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Striking progress has been achieved in providing paid maternity leave to employed women since the member States of the ILO adopted the first Maternity Protection Convention in 1919. At that time, only nine of the 29 countries which had instituted compulsory maternity leave provided payment of allowances through some kind of insurance scheme. By 1952, some 40 countries had compulsory social insurance laws providing maternity benefits. Today, more than 100 countries worldwide recognize a woman’s right to paid maternity leave and accordingly guarantee the provision of social security benefits before and after childbirth.

This chapter focuses on the main trends observed in the provision of cash and medical benefits in recent years and calls attention to some of the fundamental issues to be considered with regard to the revision of the Maternity Protection Convention (Revised), 1952 (No. 103), including the differing approaches to coverage with regard to cash and medical benefits and the financing of benefits. These are discussed in the light of the relevant ILO instruments, which are briefly reviewed.

Equality of treatment between men and women remains theoretical if social security systems and social protection measures do not take account of women’s needs with respect to maternity.¹ Indeed, social security systems are the principal source of cash and medical benefits in many ILO member States. Substantial improvements in coverage have been noted in recent years. In most industrialized countries with a market economy, the scope of social security protection has been extended to include almost all economically active women, while at the same time maternity leave has been increased, in almost all cases, to more than the 12-week minimum period for payment of benefits set by the Maternity Protection Convention (Revised), 1952 (No. 103), and the Social Security (Minimum Standards) Convention, 1952 (No. 102). The level of benefits has increased in parallel, and is also adapted to the situation of each woman in proportion to her previous earnings. In the vast majority of industrialized countries, it is more than the two-thirds stipulated by Convention No. 103.

In many countries, the number of women entitled to maternity protection has increased mainly because of the extension of social security schemes to sectors not previously covered, such as agriculture, domestic service and self-employment. For example, maternity benefits are available to agricultural workers in Ecuador, Morocco and Tunisia and to domestic workers in Brazil, Jamaica and Peru, while domestic and agricultural workers in Trinidad and Tobago are entitled to maternity benefits.

Some countries have included self-employed women within the purview of their social security systems. In the Bahamas, Costa Rica, Finland, Philippines, Portugal, Slovakia and Tunisia, self-employed women are protected under the same qualifying conditions, at the same level of benefits and for the same period of payment as employed women.² In Albania and Denmark, cash benefits are paid at different rates for the two types of women workers, while Belgium, France, Gabon, Luxembourg and Spain have set up special systems to protect self-employed women during maternity. Self-employed women are also protected in Barbados, Germany, Greece, Hungary, Israel, Seychelles and Sweden. A voluntary coverage system for self-employed women exists in Belize, Nicaragua, Panama, Paraguay and Peru. In Thailand, such a system will start from 2 September 1998.

As women have come to play an increasing role in the economy, the question of equality of treatment for men and women has come to the fore. Efforts have been made to help women reconcile their work with family responsibilities and, in almost all countries where changes have been introduced, an attempt has been made to increase benefits by giving rights to fathers. Social security benefits for fathers are provided in Denmark, for example, where the employed or self-employed father has a right to two weekly payments within the 14 weeks after childbirth. In Sweden, the father has the right to a ten-day allowance after childbirth.

Progress has, however, not been uniform. Maternity benefits, which have traditionally been extensive in Eastern European countries, have been cut back with economic restructuring, particularly as regards cash benefits. The transition to a market economy has resulted in the deregulation of labour market institutions, social security systems and employment protection. The resultant increase in unemployment rates has particularly affected women who, under these circumstances, no longer fulfil the qualifying conditions for cash benefits.

While maternity benefits are generalized in developed countries, there are enormous disparities within and between developing countries. In newly industrialized countries, maternity protection has progressed a great deal and, in some instances, the rights granted exceed ILO minimum social security standards. For example, in Latin America and some parts of Asia, workers in the formal sector are relatively well-protected in this respect. The level of health benefits is increasing and in countries with adequate health-care infrastructure, either social security or the public health system is responsible for medical care and hospitalization during pregnancy, delivery and the perinatal period. In regions such as sub-Saharan Africa, however, protection has developed little. It is largely dependent on social welfare, rather than a social security system, and has insufficient scope, effectiveness and permanence. In Benin, for example, social security covered an estimated 5 per cent of the economically active population in 1992. In Cd’Ivoire, the figure was 7 per cent in 1995 and, in Cameroon, 10 per cent in 1994.³

A large proportion of economically active women remain unprotected because they are under-represented in the formal sector towards which social security protection is directed. This problem is particularly acute in developing countries, although it is not limited to them. In Colombia, 52 per cent of economically active women were employed in the informal sector in 1994; in Peru, the figure stood at 48 per cent in 1995; and, in Poland, the informal sector employed 10 per cent of working women in 1995.

ILO standards relative to social security

Because most countries provide maternity benefits through social security, it is important that any revision of the Maternity Protection Convention (Revised), 1952 (No. 103), take into account the minimum standards prescribed for social security coverage. The four principal social security instruments to be considered are the Social Security (Minimum Standards) Convention, 1952 (No. 102), the Income Security Recommendation, 1944 (No. 67), the Medical Care Recommendation, 1944 (No. 69), and the Medical Care and Sickness Benefits Convention, 1969 (No. 130). These address the question of maternity protection within a wider framework of health-care provision and income security.

The Social Security (Minimum Standards) Convention, 1952 (No. 102), recognizes maternity benefits as one of the nine branches of social security. Part VIII, which refers to maternity benefit, provides for medical care and periodical payments in respect of suspension of earnings. As of 31 December 1996, Part VIII of Convention No. 102 had been ratified by 26 countries: Austria, Belgium, Bolivia, Bosnia and Herzegovina, Costa Rica, Croatia, Czech Republic, France, Germany, Greece, Italy, Libyan Arab Jamahiriya, Luxembourg, Mexico, Netherlands, Niger, Peru, Portugal, Senegal, Slovakia, Slovenia, Sweden, the former Yugoslav Republic of Macedonia, Turkey, Venezuela and Yugoslavia.

The Income Security Recommendation, 1944 (No. 67), advocates as one of its guiding principles that “income security schemes should relieve want and prevent destitution by restoring, up to a reasonable level, income which is lost by reason of inability to work”. Paragraph 10 of the Recommendation states that the particular contingency for which maternity benefits should be paid is the loss of earnings resulting from women’s abstention from work during prescribed periods before and after childbirth.

The Medical Care Recommendation, 1944 (No. 69), stresses that the availability of medical care constitutes an essential element of social security. Paragraph 21 specifies that the medical care afforded should comprise both general practitioner and specialist out- and in-patient care, including domiciliary visiting; dental care; nursing care at home or in hospital or other medical institutions; the care given by qualified midwives and other maternity services at home or in hospital; maintenance in hospitals or other medical institutions; and, so far as possible, the requisite dental, pharmaceutical and other medical or surgical supplies. Paragraph 29 notes the diagnostic and treatment facilities, the specialist advice and care, and the nursing, maternity and pharmaceutical services which should be at the disposal of the physician for the use of patients.

Provision of benefits

Whether provided through social insurance, public funds, or a mixed system of public and private funding, maternity benefits in ILO member States generally include medical care and some form of income replacement during leave.⁴

An examination of social security systems reveals two basic types. The first provides cash and medical benefits to all insured women, as in Austria, Belgium, Cameroon, France, Germany, Iran, Lebanon, Pakistan, Poland, Slovakia, Spain and Thailand (only in enterprises with more than ten workers), as well as the countries of Central and South America. The second covers all residents, but may have a different scope for the provision of health care or for cash benefits. Iceland provides both types of benefits to all resident women, whereas Australia, Canada, Cuba, Denmark, Finland, Georgia, Ireland, Latvia, Norway, Portugal, Sweden, United Kingdom and Uzbekistan, among others, protect all resident women for medical benefits, but only insured women for cash benefits. Indeed, universal health-care systems financed by public funds provide medical benefits in a large number of countries.

The Maternity Protection Convention, 1919 (No. 3), makes no mention of the conditions of access to maternity benefits, whereas the Maternity Protection Convention (Revised), 1952 (No. 103), states that women who comply with prescribed conditions shall be entitled to the medical and cash benefits. It is up to national law and practice to prescribe the qualifying conditions. Article 4, paragraph 5, of Convention No. 103 further provides that women who do not qualify for benefits granted as a matter of right shall be entitled to adequate benefits out of social assistance funds, subject to a means test.

Qualifying conditions vary significantly from country to country according to whether such benefits take the form of health care or cash. They may include proof of residence, required contribution periods or required periods of employment. In Spain, for example, no conditions are prescribed for access to health benefits; however, compliance with a contribution period of 180 days in the last five years is required for entitlement to cash benefits. Canada, Iceland and New Zealand require proof of a period of residence for access to medical benefits.

In countries where universal health care is not available, medical benefits are subject to contribution periods. This is the situation in Brazil, Colombia, Dominican Republic, Ecuador, Egypt, Greece, Nicaragua, Peru, Philippines (for non-pensioners), Senegal and Thailand. In Algeria, Guinea and Tunisia (non-agricultural employees), a certain period of employment is required, while in France and Mauritania, the criterion is a period of employment with contributions.

As far as qualifying conditions for cash benefits are concerned, provision is often subject to required contribution periods, as in Albania, Belgium, Cd’Ivoire, Czech Republic, Germany, Greece, Guatemala, Honduras, Islamic Republic of Iran, Ireland, Israel, Mexico, Nicaragua, Paraguay, Peru, Philippines, Spain, United Kingdom and Zambia. In other countries, a specified period of employment is required, as in Algeria, Argentina, Bangladesh, Canada, France and Norway. In the Central African Republic, Gabon, Guinea, Madagascar, Mali and Tunisia, qualifying conditions for maternity benefits are a certain period of insured employment. In Australia and New Zealand, cash benefits for maternity are subject to a means test.

Cash benefits

The need for cash benefits has been recognized in all ILO standards concerning maternity protection. Cash benefits provided during maternity leave are intended to replace a portion of the income lost due to the interruption of the woman’s professional activity. Without such financial support, the woman’s loss of earnings during her absence on leave, coupled with increased expenditures associated with pregnancy and birth, would pose financial hardship for many families. In such circumstances, women might feel compelled to return to work before their entitlement to leave was exhausted and, perhaps, before it was medically advisable to do so. Cash benefits give substance to the right to leave and, as a general rule, the duration of cash benefits coincides with the length of leave, although this is not always the case.

Convention No. 3 (1919) provides that during maternity leave, the woman will receive cash benefits for 12 weeks. The level of these benefits is not stated, leaving it up to individual States to set the exact amount. The Convention stipulates only that the provision must be sufficient for the full and healthy maintenance of the woman and her child. The Convention adds that no mistake on the part of the medical adviser in estimating the date of confinement shall preclude a woman from receiving benefits from the date of the medical certificate up to the date of the actual confinement.

Convention No. 103 (1952) provides that benefits will be paid throughout the absence prescribed by law, i.e. at least 12 weeks, as well as any extensions of leave accorded for a birth which occurs after the expected date or in the event of illness resulting from the pregnancy or childbirth or its complications.⁵ As regards the amount, this Convention reproduces the terms of the 1919 Convention, stating that the benefits shall be fixed by national laws or regulations “in accordance with a suitable standard of living”. However, with regard to benefits provided under social insurance systems, the Convention stipulates that the benefits must not be less than two-thirds of the previous earnings taken into account for the purpose of computing benefits.

Recommendation No. 95 (1952) suggests that, wherever practicable, cash benefits should be fixed at a higher rate than the minimum standard provided in the Convention and should, to the extent possible, equal 100 per cent of the woman’s previous earnings taken into account to calculate benefits.

The Social Security (Minimum Standards) Convention, 1952 (No. 102), states that cash maternity benefits will consist of a regular payment calculated on the basis of previous insured earnings, which will be at least 45 per cent of the salary which the woman earned before she stopped work. The regular payment may be subject to variations, provided that they do not involve a reduction in the average amount of the sum mentioned above. This benefit, which will replace income, must, according to Recommendation No. 67, be such that it restores to a reasonable level the resources lost owing to inability to work. The international instruments under examination consider that the concept of “reasonable” should be understood in relation to the beneficiary’s previous remuneration. Appended to Part XI of Convention No. 102 is a schedule of periodic payments which provides a set of substitute rates considered to be desirable by the International Labour Conference for the various circumstances. In the case of maternity benefits, it would be the rate already mentioned of 45 per cent of the insured salary of a typical beneficiary. As noted above, Maternity Protection Convention No. 103 increases this level to two-thirds of the salary taken into account for social security purposes.

In practice, cash benefits provided under social security systems do not wholly replace the shortfall in income due to an interruption of work. They are generally paid as a percentage of insured earnings, or as a percentage of earnings taken into account for the purpose of computing benefits. Because earnings are rarely totally insured and benefits are usually computed on the basis of only a portion of the total salary, cash benefits may represent only a relatively small fraction of actual earnings. In Canada in 1995, for example, maternity benefits were based on a rate of 55 per cent of previous average insured earnings up to the maximum pensionable earnings level, but a benefit ceiling of CAN$ 1,792 per month meant that the effective individual replacement rate could be a far smaller percentage of actual income. Benefit ceilings exist in a number of countries, including Austria, El Salvador, France, Gabon, Ireland, Morocco and Thailand.

National legislation nonetheless attempts to ensure payment of a benefit which may not fall below a certain level, even if a beneficiary’s previous earnings are low. Replacement rates lower than 100 per cent may not necessarily result in a loss of a certain standard of living.

Cash benefits granted by social security systems can be calculated either on the basis of the insured earnings of the woman on the expected birth date, or her average insured earnings for the previous months or year. With regard to Europe, for example, the following benefits apply for the normal period of maternity leave: Turkey (66.66 per cent of earnings); Belgium (82 per cent of earnings for the first month for salaried employees, 75 per cent thereafter); Austria, Israel and the Russian Federation (100 per cent of earnings); France (100 per cent of basic daily wage); Hungary (100 per cent of daily average net earnings if 270 days of insurance within last two years, or 65 per cent, if at least 180 days of insurance); and Spain (100 per cent of the daily salary on which contributions were paid during the months preceding maternity leave).

In Latin America, 100 per cent of earnings is paid in Argentina, Brazil and Uruguay, while in Mexico, payments equal the average earnings. In Chile, 100 per cent of net earnings is paid for public employees; for private sector employees, the benefit equals the average monthly net earnings in the last three months. In Africa, countries such as Benin, Cameroon and Senegal grant a provision equivalent to 100 per cent of the woman’s earnings. In Asia, India pays 100 per cent of average earnings, and the Philippines provides for 100 per cent of the average daily wage for the best six months of the 12 months preceding the birth. Japan pays 60 per cent of the basic salary, as well as a lump sum birth grant; Thailand, 50 per cent of salary. In Australia and Zambia, women are paid a lump sum. These examples are taken from the legislation of the countries examined, but it should be remembered that, in many cases, the reality is different, since these benefits are subject to the influence of other factors, such as taxation or the application of benefit ceilings.

In many countries, paid maternity leave is increased in the event of a multiple birth. In Armenia and Turkmenistan, women are entitled to cash benefits for 180 days instead of the 140 days paid under normal circumstances. In Iceland, cash benefits are paid for one additional month per child beyond the six months’ paid leave provided for the birth of a single child. In Luxembourg, the benefit is paid for 20 weeks instead of the 16-week period. In Estonia, Georgia and Uzbekistan, the postnatal leave period is extended from eight to ten weeks in case of a multiple birth. In Poland, the leave period is extended from 16 to 26 weeks; in Slovakia, from 28 to 37 weeks; and, in Spain, from 16 to 18 weeks. In Afghanistan and China, paid leave is extended by 15 days, and in Viet Nam, by 30 days.

Some countries increase the period of payment of benefits for large families. For example, in France, the cash benefit is paid for eight weeks before and 18 weeks after childbirth for the third and subsequent children, compared to the six weeks before and ten weeks after childbirth for the first and second child. As far as the question of limiting the number of children in relation to whom maternity benefits are granted, any such limitation raises ethical concerns, since social security is a human right to which women and children are entitled as members of society.⁶

Medical benefits

The international standards relating to maternity protection state that the woman has the right to medical care as well as to cash benefits. Convention No. 3 (1919) stipulates that the pregnant woman is entitled to free attendance by a doctor or qualified midwife.

Convention No. 103 (1952) is more precise. It states that medical benefits shall include prenatal, confinement and postnatal care provided by qualified midwives or medical practitioners, as well as hospital care if necessary. Freedom of choice of doctor and freedom of choice between a public and private hospital shall be respected.

Recommendation No. 95 (1952) lists, in Paragraph 2 (2), the medical benefits to be granted. Wherever practicable, these should comprise “general practitioner and specialist out-patient and in-patient care, including domiciliary visiting; dental care; the care given by qualified midwives and other maternity services at home or in hospital or other medical institutions; maintenance in hospitals or other medical institutions; pharmaceutical, dental or other medical or surgical supplies; and the care furnished under appropriate medical supervision by members of such other profession as may at any time be legally recognized as competent to furnish services associated with maternity care”. These provisions recall those of the Medical Care Recommendation, 1944 (No. 69), cited above.

In Paragraph 2 (3), Recommendation No. 95 notes that the medical benefit should be afforded with a view to maintaining, restoring or improving the health of the woman protected and her ability to work and to attend to her personal needs. Paragraph 2 (4) additionally provides that the institutions or government departments which administer medical benefits should encourage the women protected to use the general health services placed at their disposal by the public authorities or by other bodies recognized by the public authorities. In this, it echoes the provisions of Article 49 (4) of the Social Security (Minimum Standards) Convention, 1952 (No. 102).

Thus, maternity protection meets a broader aim of social integration than “classic” social security protection, to the extent that it not only provides a substitute income, and thereby protects against need, but also places appropriate health services at the disposal of individuals. Such services might include mother and child health-care programmes, for example. In addition, national legislation in many countries considers the provision of prenatal care allowances and birth allowances, which take into account the expenses which the woman will have to meet owing to her pregnancy (prenatal checkups) as well as those she incurs as a result of the birth (postnatal benefits). Milk and clothing allowances often also supplement the regular benefits. Such benefits in kind and in cash are mentioned in Paragraph 2(6) of Recommendation No. 95.

Provision of health services varies from country to country. The general expansion in public health systems and social security hospitals has led to improvements in many countries. In English- and French-speaking Africa, medical care is often provided in public health system hospitals whereas, in Latin America, health care is generally provided by social security institutions in their own facilities and with their own personnel. The choice of doctor and hospital to which the patient has access may be limited. Some countries contract services from either state-owned or private sector medical facilities when social security medical services have not yet been installed. In some instances, the social security authorities deliberately refrain from creating their own infrastructure when they are able to make use of good quality services already available in the public or the private sector.

Special agreements may affect the services provided in particular countries. In France, for example, the insured person pays for services and is reimbursed by local health funds according to the rules established in the conventions subscribed for this purpose. A list of the hospitals is available for the beneficiaries. In Germany, there is free choice among health fund doctors, whose fees, along with the cost of hospitalization and medicines, are paid by the health funds.

Financing of maternity benefits

Conventions No. 3 (1919) and No. 103 (1952) specifically state that maternity benefits (medical care and cash benefits) will be provided by means of an insurance system or public funds. Convention No. 103 accordingly provides in Article 4, paragraph 8, that in no case shall the employer be individually liable for the cost of the maternity benefits to which women employed by him are entitled. Underlying this provision is the desire to eliminate the costs of maternity protection as a disincentive to the employment of women.

As regards the methods used to fund costs deriving from maternity benefits, Article 4, paragraph 7, of Convention No. 103 provides that any contributions due under a compulsory social insurance scheme providing maternity benefits, and any tax based upon payrolls which is levied with the aim of providing the benefits mentioned above, “shall, whether paid both by the employer and the employees or by the employer, be paid in respect of the total number of men and women employed by the undertakings concerned, without distinction of sex”.

In many countries, the methods for meeting the cost of maternity benefits appear to conform in general to the provisions of ILO instruments. In most countries in Europe and Latin America, as well as several in Africa and Asia, maternity benefits are provided within the framework of social insurance, which is generally compulsory. In a large portion of these, benefits are funded by contributions paid by both employers and workers of both sexes without distinction as to age. In more than a third of the countries surveyed, however, employers were principally, if not solely, responsible for contributions to social insurance. Governments sometimes covered administrative costs as well as any deficits. Many countries also use tax revenues to meet the costs of benefits.

In a number of countries, maternity benefits are financed by the State, generally as part of a welfare-based system. Whereas insurance systems that rely on specifically allocated financial resources and medical services are generally able to guarantee effective cover, systems based on welfare, when applied to broader sectors of the population, can offer only modest benefits. This gives rise to different levels of health care according to whether women gain access to this care as employees coming within the scope of social security coverage or whether they seek care under universal public health systems.

Maternity benefits provided by a public welfare system are sometimes used to supplement those funded by social insurance. They may be granted to workers who have no right to social insurance or may be added to social insurance benefits to extend protection. This is the case in Austria, Denmark, Finland, France, Germany, Luxembourg, Netherlands, Norway and Sweden.

Workers not included in the scope of social security legislation may gain access to maternity benefits through collective agreements. In Pakistan, for example, an agreement reached between Eastern Federal Union (EFU) General Insurance Limited and EFU Insurance Workers Union provides that female employees shall receive 4,000 rupees for a normal delivery and 7,000 rupees for a surgical delivery. In a number of countries, collective agreements simply echo the provisions of the law regarding leave and benefits.

Payments by the employer

Employers pay all or a major portion of maternity benefits in a large number of countries, and in particular in developing countries where social security systems are not adequately developed. The employer is legally responsible for maternity payments in the Democratic Republic of Congo, Malaysia, Malta, Mauritius, Mozambique, Nepal, Pakistan, Rwanda, Saudi Arabia, Singapore, Solomon Islands, Somalia, Sri Lanka, Sudan, Syrian Arab Republic, United Republic of Tanzania, Thailand, Uganda, United Arab Emirates, Zambia and Zimbabwe. In Botswana, the employer in designated areas is required to pay 25 per cent of the woman’s salary. In Mexico, Panama and Sao Tome and Principe, the employer must pay the woman’s salary during leave if she does not fulfil the conditions for social security. As mentioned previously, in a number of countries, the employer finances the contribution to social insurance for cash maternity benefits without worker participation.

Employer liability has long been viewed as a disincentive to employers to employ women of child-bearing age, and thus detrimental to the promotion of equal treatment for men and women.⁷ It is widely held that it is only through collective financing and the redistributive function of social security that the proper balance between fairness and solidarity can be achieved. In Burkina Faso, as a result of pressure from the unions which manage the National Social Security Fund, it is this fund which is now responsible for paying the salaries of mothers during the three months of maternity leave. In China, employer liability is currently under review with the aim of moving towards a system of social insurance.

Despite the principle that employers should not be held individually liable for payment of benefits, nothing prevents employers from raising the level of benefits provided by supplementing the social security benefits with additional payments. This type of compensation - whether voluntary, based on collective agreement, included in the employment contract or provided in legislation - exists in a number of countries. In Sao Tome and Principe, for example, the employer must pay the difference between the social security benefits and the woman’s actual salary for the total duration of leave. In Benin, Burundi, Congo and Togo, employers pay 50 per cent, with the remainder provided by the system of national insurance. A similar approach is taken in Trinidad and Tobago, where national insurance replaces 60 per cent of earnings and employers must pay the remaining 40 per cent in certain sectors, such as catering, or for certain occupational groups, such as shop assistants, household assistants and teachers.

In France, for example, collective agreements valid in 1997 in the insurance sector (general agencies) and in the retail sector (department stores) provide that the difference between the benefits paid under social security and the woman’s actual salary shall be paid to women with at least one year of service in order to maintain their full salary during maternity leave. In Canada, supplementary payments for teaching personnel provide compensation during the two-week statutory period during which no other indemnity is paid. The rate varies from 60 to 100 per cent of salary, depending on the province and the school jurisdiction. In the United Kingdom, a recent survey found that 149 of the 243 establishments examined provided a higher rate of cash benefits than those provided under the law. Improved benefits were often related to time in service.⁸

The principle of providing cash and medical benefits to women workers on maternity leave is strongly supported in ILO member States, but the paths towards this objective vary greatly. The degree of success in achieving the goal depends on a number of factors, including the country’s level of economic development, the strength or weakness of the social security system, the quality and extent of the medical infrastructure, and the political will to bring practice into line with law. The organization and funding of health services and the manner of providing income replacement vary widely from country to country.

Mixed systems of public and private health services are found in many countries. The costs of health care are met through a combination of public funds, compulsory insurance, voluntary insurance and direct payment by the employer or worker. In many countries, improvements in medical benefits have developed in line with the general expansion in public health systems and social security hospitals. Where resources are scarce, this approach makes possible the provision of prenatal, confinement and postnatal care to a larger portion of the female workforce, but may limit the choice of doctor and hospital available to the patient.

Most ILO member States provide some form of income replacement during maternity leave with the aim of securing the full and healthy maintenance of the woman and her child and a suitable standard of living. A large number of developing countries, however, whose social insurance schemes are not yet fully developed, are unable to do this through compulsory social insurance. The narrow scope of application and the low level of benefits paid have led to mixed systems of partial payment through insurance schemes with the remainder provided by employers. In many countries, employers may be required to pay the worker’s salary directly during her maternity leave and, in some, employers are also liable to cover the cost of medical care. Where social insurance systems operate, benefits may be calculated at a level below the two-thirds of insured earnings required in Convention No. 103, yet still provide income replacement to ensure against financial hardship during the leave period. In some countries, the divergence between law and practice is such that collective agreements play a major role in securing benefits for workers. Those who work outside of collective agreements may thus face the prospect of maternity without effective protection.

The variety of circumstances pertaining to the provision of medical care and income replacement and, in particular, the differing means and capacity of member States at different levels of development to provide benefits require a realistic assessment of how the common goal of maternity protection may best be reached.