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The Safe Motherhood Initiative has successfully stimulated much interest in reducing maternal mortality. To accelerate programme implementation, this paper reviews lessons learned from the experience of industrial countries and from demonstration projects in developing countries, and proposes intervention strategies of policy dialogue, improved services and behavioural change. A typological approach with three hypothetical settings from resource poor to resource rich environments is used to address the variability in health behaviours and infrastructure encountered when programming for safe motherhood.Safe Motherhood programs have been expanded over the past six years, but funding and evaluation are still insufficient to meet needs in a cost effective manner. Process indicators may be appropriate qualitative and quantitative indicators of how well programs are functioning and of the underlying mechanisms influencing maternal health outcomes. Three important dimensions of the Safe Motherhood Initiative are policy dialogue, improved services, and behavior change. The World Bank/MotherCare Workshop on Guidelines for Safe Motherhood Programming and the World Bank Discussion Paper on Making Motherhood Safe provide guides to action. Many features of the reports are summarized in this paper (a definition of the problem, the lessons learned, essential features of an effective motherhood program, strategies appropriate for specific settings, policy issues, costs of interventions, and measurement of progress). The problems of maternal mortality stem from septic abortion, postpartum hemorrhage, eclampsia, hypertension, obstructed labor, and sepsis/infection. Community-based family planning has been instrumental in rapidly reducing maternal mortality in Bangladesh. Community-based maternity care programs with trained midwives, medical supplies, and a referral system can reduce the risk of dying by 66%. Trained traditional birth attendants alone do not reduce the risk of maternal mortality. Essential, accessible obstetric care has had an impact in Zaire. Community-based maternity waiting homes, referrals, and prenatal screening prevent maternal mortality in Ethiopia. Safe Motherhood begins with a healthy environment (women's status, political commitment, and socioeconomic development), which is influenced by women's health and nutritional status, reproductive and health behavior, and access to family planning and maternal care services. Immediate determinants of maternal mortality are 1) exposure to pregnancy and 2) complications and their management. Important program elements are services, skilled assistance, referrals, and communication.

The wide gap in maternal mortality ratios worldwide indicates major inequities in the levels of risk women face during pregnancy. Two priority strategies have emerged among safe motherhood advocates: increasing the quality of emergency obstetric care facilities and deploying skilled birth attendants. The training of traditional birth attendants, a strategy employed in the 1970s and 1980s, is no longer considered a best practice. However, inadequate access to emergency obstetric care and skilled birth attendants means women living in remote areas continue to die in large numbers from preventable maternal causes. This paper outlines an intervention to address the leading direct cause of maternal mortality, postpartum haemorrhage. The potential for saving maternal lives might increase if community-based birth attendants, women themselves, or other community members could be trained to use misoprostol to prevent postpartum haemorrhage. The growing body of evidence regarding the safety and efficacy of misoprostol for this indication raises the question: if achievement of the fifth Millennium Development Goal is truly a priority, why can policy makers and women's health advocates not see that misoprostol distribution at the community level might have life-saving benefits that outweigh risks?

This paper illustrates a method of planning the geographic distribution of health facilities in order to maximize the social benefits achievable from the investment. Data from Bangladesh have been used to determine the optimal distribution of emergency obstetric care (EOC) facilities in the country using the estimates of average social cost per woman. Costs incurred by households, including the costs associated with maternal mortality, tend to increase with increasing radius of a facility's catchment area. The average facility-based costs tend to decline with increasing radius due to lower per capita capital expenditures. The summation of these two average cost functions generates a U-shaped curve. In this research, the minimum point of the aggregated average cost curve defines the 'optimal' radius of a health facility. The catchment area defined by the optimal radius minimizes the average social cost of providing EOC services in a region. The empirical analysis suggests that the optimal radius for the 20 regions of Bangladesh varies from about 6 to 12 km. If the optimal radius of the catchment area is used in planning health centre locations, Bangladesh will need to set up 450 EOC facilities; currently there are only 90 such facilities.

It is widely accepted that substantial reductions in maternal mortality and severe morbidity are impossible to achieve without an effective referral system for complicated cases. Early detection and referral to higher levels of care might also substantially reduce neonatal deaths due to the complications of childbirth. The general goal of such a referral system is that patients are dealt with in the right place with effective treatment provided at the minimum of cost. There are real challenges however in monitoring the effectiveness of such referral systems once put in place. This paper describes some of the tools used to review pregnancy-related referrals in Lusaka Zambia. The tool-mix used provided information for monitoring five different aspects of the referral system: the distribution of births across levels of facility and population coverage; the use of essential obstetric care (EOC) level facilities by women with complications; the progress towards a reduction of maternal mortality at referral facility level; inappropriate use of EOC level facility; and perinatal outcomes at peripheral facility level. Apart from the information on coverage the data came from routinely collected facility statistics registers and medical notes. Findings for Lusaka are reported. Consideration is given to issues of interpretation of specific indicators and to how such tools might be used in conjunction with others in order to help district managers to monitor the effectiveness of district maternity referral systems. (authors)

India accounts for about one-quarter of maternal deaths world wide, with the most recent statistics showing an average maternal mortality ratio of 407 per 100 000 live births at the national level. The government had hoped to reduce maternal mortality to 200 by 2000, but it is clear that this was not achieved. This paper explores the reasons why the most populous state of Uttar Pradesh continues to have one of the highest reported maternal mortality ratios in India. Data from two districts of Uttar Pradesh on mother and child health-care utilization and the readiness of the public sector to provide antenatal and emergency obstetric services are used to illustrate the reasons why maternal mortality has not declined. While blueprints for safe motherhood programmes exist, the equipment and technical competence to provide services is weak at the present moment. Reductions in maternal mortality would require interventions to improve service delivery as well as community mobilization to improve utilization of services, especially in life-threatening situations.