|02. Of Blind Alleys and Things that Have Worked: History's Lessons on Reducing Maternal Mortality|
It has taken the international community up to the 1990s to realise that the important thing is that deliveries are far safer with professional assistance, and that when a serious problem appears a pregnant woman should have access to an appropriately equipped health service.
Antenatal care or delivery attendance by TBAs without professional obstetric care cannot achieve the same. If the necessity of referral level obstetric care has now become obvious, the need for professional assistance to all deliveries - essential obstetric care - still meets only with limited support, and the medical assistance model clearly is favoured over midwifery. The end result is that some countries have invested all in institutionalisation and medicalisation of childbirth. Others, still put their hopes in antenatal screening and TBAs. Only a minority is investing in the now - at last - WHO-recommended essential obstetric care. EOC is much more credible for and readily accepted by the medical community than the ANC-TBA strategies of the 1970s. Where resources are available EOC expands rapidly and maternal mortality drops. The downside is that it also easily gets translated into institutionalisation and technologisation of delivery. In Thailand, for example, the midwifery association has ceased to exist in the early 1990s, and as a rule deliveries now take place in hospitals: 28% through caesarean section.
In countries with severe resource constraints, however, there remain major problems in implementing these strategies. First, because huge investments in time and money are necessary to train the required numbers of professionals: midwives are scarce, 1 per 300,000 inhabitants in a 1990 estimate (Kwast 1991), especially outside the capital cities. Huge investments in time and money are necessary also to provide the necessary referral facilities able to complement a still to be created network of professional assistance to normal deliveries. Resources are not enough, though. Accessibility also has financial, cultural and psychosocial aspects (Jaffré & Prual 1994). Perhaps the most intractable and important issue is that of the accountability of professionals: for the quality of what is done in the hospital, and for what is not done outside (Nasah 1992, Derveeuw et al. 1999).