HUMAN DEVELOPMENT NETWORK Health, Nutrition, and Population 22641 June 1999 Safe Motherhood and The World Bank Lessons From 10 Years of Experience ,~~~~~~~~~~~ Thwe WVorld Bank ~ c HEALTH,NU/TRITION.ANTDPOPULATIo T H E W ORt L D B A N K Health, Nutrition, and Population Series This publication was prepared by the Health, Nutrition, and Population division (HNP) of the World Bank's Human Development Network. HNP publications provide information on the Bank's work in the sectors of health, population, and nutrition. They consolidate previous papers in these areas, and improve the standard for quality control, peer review, and dissemination of HNP research. The publications expand our knowledge of HNP policy and strategy issues through thematic reviews, analyses, case studies, and exam- ples of best practice. They focus on material of global and regional relevance. The broad strategic themes of the publications are proposed by an editorial committee, which is coordinated by Alexander S. Preker. The other members of this committee are A. Edward Elmendorf, Mariam Claeson, Armin H. Fidler, Charles C. Griffin, Peter F. Heywood, Prabhar K. Jha, Jack Langenbrunner, Maureen A. Lewis, Samuel S. Lieberman, Milla McLachlan, Judith Snavely McGuire, Akiko Maeda, Thomas W Merrick, Philip Musgrove, David H. Peters, Oscar Picazo, George Schieber, and Michael Walton. HUMAN DEVELOPMENT NETWORK Safe Motherhood and The World Bank Lessons From 10 Years of Experience The World Bank Washington, D.C. C) 1999 The International Bank for Reconstruction and Development / THE WORLD BANK 1818 H Street, N.W Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing June 1999 2345 03020100 This report has been prepared by the staff of the World Bank. The judgments expressed do not necessar- ily reflect the views of the Board of Executive Directors or of the governments they represent. The material in this publication is copyrighted. 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Contents Foreword v Acknowledgments vi Executive Summary 1 Introduction and Overview 5 Safe Motherhood in the Development Context 6 The Link Between Safe Motherhood and the Bank's Strategies for Health, Nutrition, and Population 7 World Bank Support for Safe Motherhood 9 Country Reviews: Improving Project Implementation at the Country Level 13 Proposed World Bank Actions to Further Strengthen Safe Motherhood Programs 19 Guiding Lessons 20 Annexes 1 World Bank Lending for Population and Reproductive Health 25 2 Cost of Mother-Baby Package 31 3 Poor-Rich Inequalities in Access to Different Types of Health Care 32 4 World Bank-supported Safe Delivery Activities in 29 Countries 33 5 Countries with Highest Maternal Mortality Ratios and Selected Information Related to World Bank Assistance and Basic Indicators 34 6 ICPD Definition of Reproductive Health 35 7 Projects with Safe Motherhood Components in Country Reviews 36 8 Importance of Areas of Sectoral Emphasis for Different Income Groups 42 9 Removing Barriers to Progress in Safe Motherhood 43 Boxes 1 Safer births and a better health system in Chad 9 2 Improving maternal health in Malaysia: A success story 12 3 Expanding coverage for maternity care in Indonesia 14 4 Scarcity of data 16 5 Safe motherhood indicators 18 Figures 1 Relationship between the presence of a skilled attendant at delivery and the maternal mortality ratio 6 iii 2 Philippines: Gap in Maternity Care and Immunization Between Poorest and Richest Segments of Society 8 3 Population, Gender, and Reproductive Health-Related Impacts of Bank Operations 10 4 Number of New Projects with Reproductive Health, Safe Delivery, and Health, Nutrition, and Population Activities, Fiscal 1987-98 10 Tables 1 Essential safe motherhood interventions 7 iv Foreword In April 1998, World Health Day commemorated the reducing maternal mortality - safe delivery, especially Tenth Anniversary of the Safe Motherhood Initiative. for poor women. This review of 10 years' experience World Bank President James Wolfensohn stated that describes cost-effective strategies, discusses factors to "Safe motherhood is a human right... Our task and the be considered in program planning and implementa- task of many like us ... is to ensure that in the next tion, and recommends ways that development agen- decade safe motherhood is not regarded as a fringe cies such as the Bank can assist developing countries issue, but as a central issue." He requested that the in improving maternal health outcomes. Bank review its progress on the Safe Motherhood Reducing maternal morbidity and mortality will Initiative and recommend further actions needed. contribute to the goals of the Bank's Health, The lessons reported here are based on a review of Nutrition, and Population Sector Strategy A key ele- the World Bank's experience in providing support to ment of the strategy is to work with countries to borrowing countries for safe motherhood activities improve outcomes for the poor, especially the most over the past decade. The findings are clear: maternal vulnerable such as women and children. Another pri- death is preventable. Effective interventions are ority is to allocate scarce public resources to achieve known. Investment in safe motherhood will reduce the greatest effect. The Bank's recent report, "Popu- maternal and infant death and disability, contribute to lation and the World Bank," also recognizes the links the well-being of families and the community, and ulti- between safe motherhood and broader human devel- mately improve human development and enhance eco- opment goals. nomic growth. This report is intended primarily for the use of This report identifies opportunities for improving World Bank staff. We hope that it will also provide World Bank work in safe motherhood. In many coun- guidance to governments, other international agencies, tries more work is needed for policy dialogue and pro- and nongovernmental organizations in the design and gramming in maternal health, and more effort is par- implementation of programs to reduce maternal mor- ticularly needed on the most crucial intervention for tality and morbidity and improve the status of women. David de Ferranti J. Christopher Lovelace Vice President, Human Development Network Director, Health, Nutrition and Population v Acknowledgments This report was finalized under the guidance of the Leaders and staff were consulted on the country Population and Reproductive Health Thematic Group. reviews: Bangladesh - Phil Gowers, J.S. Kang, Tony Anne Tinker was the Task Team Leader, and she, Edna Measham, and Tom Merrick; Chad - Michelle Lioy; Jonas, and Pat Daly prepared the overview report. Peer Brazil -JeanJacques De St. Antoine and Tom Merrick; review was provided by Chris Walker, Susan Stout, and India - Indra Pathmanathan and Rashmi Sharma; Jerker Liljestrand (WHO). Joanne Epp and Kathleen Indonesia - Fadia Saadah; The Philippines - Rama Finn contributed to the data analysis, and Joanne Epp Lakshminarayanan; Romania - Richard Florescu, provided overall coordination for the final report. The Sabrina Huffman, and Olusoji Adeyi; Yemen - Gail country reviews were conducted by a team comprising Richardson and Atsuko Aoyama; and Zimbabwe - EdnaJonas, Kathleen Finn, Nancy Piet-Pelon, Marjorie Keith Hanson, Kees Koostermans, Hope Phillips, and Koblinsky and Pat Daly The following Bank Task Team Wendy Roseberry. vi Executive Summary Complications of pregnancy and childbirth are the and after pregnancy Safe motherhood is now univer- leading cause of death and disability among women of sally acknowledged as a central component of repro- reproductive age in developing countries. One in four ductive health programs, and most countries have women in these countries suffers from acute or chron- undertaken to improve and expand their maternal ic conditions related to pregnancy A woman in a health services. Many of the World Bank's borrower developed country has a one-in- 1,800 chance of dying countries have committed themselves to halving from pregnancy-related causes; the ratio for the devel- maternal mortality by 2005, and have been increas- oping world is one in 48.1 Of all the human develop- ingly willing to borrow funds to achieve this goal. ment indicators, this shows the greatest discrepancy between developed and developing countries. The implications for infants and older children are Safe Motherhood in the Development Context also serious. At least 20 percent of the burden of dis- ease among children less than five years old is attrib- A decade of research and experience in addressing utable to conditions directly associated with poor maternal health has made it clear that safe motherhood maternal health, nutrition, and the quality of obstetric initiatives are a sound investment, promising high and newborn care. social and economic returns at low cost. Interventions Most of this loss and suffering is preventable. to improve maternal health and nutrition are not only Investment in pregnancy and safe delivery programs is cost-effective but also clearly feasible, even in poor set- a cost-effective way to meet the basic health needs of tings. The potential benefits are substantial: women in developing countries. It can reduce mater- nal death and disability, contribute to the well-being of * Investments in safe motherhood not only improve a families and the community, and ultimately improve woman's health and the health of her family, but also human capital development and increase the opportu- increase the labor supply, productive capacity, and nities for economic growth. economic well-being of communities. The World Bank is a leader in promoting and sup- porting efforts to improve maternal health, and is now * The burden on women associated with frequent the largest source of external assistance for safe moth- pregnancies, poor maternal health, pregnancy com- erhood. To focus international attention on the subject, plications, and caring for sick children drains the Bank cosponsored the 1987 Nairobi Conference on women's productive energy, jeopardizes their Safe Motherhood; where only 10 Bank-financed pro- income-earning capacity, and contributes to their jects addressed maternal and child health and family poverty. planning issues by 1987, since then there have been close to 150 such projects. * Unwanted or ill-timed pregnancies can interfere The 1987 conference also saw the launch of the Safe with women's social and economic activities and Motherhood Initiative to provide access to family plan- cause emotional and economic hardship not only to ning and appropriate care for women before, during, women but also to their families. 1 2 Safe Motherhood and The World Bank * Children whose mothers die or are disabled in child- concerns. Countries that have addressed their defi- bearing have vastly diminished prospects of leading ciencies in maternal health care have improved the a productive life. health of mothers and their newborns, but more needs to be done. The most effective interventions are atten- A cost-effective intervention dance at birth by providers trained in life-saving skills, World Development Report 1993: Investing in Health, and prompt diagnosis and treatment of complications. which assessed the disease burden and the cost-effec- The focus needs to be on a continuum of care for safe tiveness of a wide range of health interventions, con- motherhood interventions, however, not just on scat- cluded that interventions for children under age five tered elements of the program. Achieving such a con- and for women of reproductive age bring the greatest tinuum requires commitment at the highest levels of benefit at lowest cost. Family planning can eliminate government, and a step-by-step approach that takes the risks of unwanted pregnancies. Good-quality pre- initial conditions and capacities into account. natal, delivery, and postpartum care to the under- Education is also needed to address the constraints on served-and particularly better management of the demand side, so that women and their families and obstetric complications-can substantially reduce the communities understand the importance of seeking death and disability associated with child bearing and proper care during pregnancy and delivery, particular- ensure that more women and their children survive, ly in the event of complications. thrive, and contribute to societal welfare. Benefits to the entire health system World Bank Support for Safe Motherhood Strengthening maternal health services can also bring benefits to the overall health system and enhance the The World Bank hosted a meeting on safe motherhood impact of a country's broader reproductive health on World Health Day in April 1998 for heads of UN program. To manage obstetric complications-the agencies, senior government officials, and representa- key life-saving component of maternity care- a facil- tives of nongovernmental organizations (NGOs). ity must have trained staff and a functional operating Following the meeting, an in-depth desk study was theater, and must be able to administer blood trans- conducted for nine countries in which the Bank cur- fusions and anesthesia. All of these resources and rently provides assistance for safe motherhood. The capabilities can also be applied to the management of countries-Bangladesh, India, Indonesia, the accidents, trauma, and other medical emergencies. Philippines, Yemen, Romania, Zimbabwe, Chad, and Pregnancy and childbirth are often the reasons for a Brazil-were chosen for their regional diversity and for woman's first contact with the health services, and the broad range of initial conditions they presented. therefore present a valuable opportunity to identify and treat other illnesses such as anemia, malaria, and tuber- Unfinished agenda culosis. The provision of antenatal care also offers a The World Bank has been a leader in safe motherhood chance to counsel women about family planning and at the country level as well as at the international level. sexually transmitted diseases. By packaging together However, there are outstanding gaps in the World pregnancy and delivery care, family planning, and man- Bank's work. In many countries, we are missing oppor- agement of sexually transmitted infections, the health tunities for policy dialogue and programming in mater- service can achieve even greater cost-effectiveness. nal health, and even where we are supporting safe motherhood, there are few projects that include the most crucial intervention-safe delivery. Policy and Program Design Bank support of other projects aimed at the broader goals of alleviating poverty and sharing Despite improvements over the past 10 years, mater- growth has also significantly improved women's nal death and disability remain major public health health and status. These projects include the Lessons From 10 Years of Experience 3 encouragement of smaller families and older age continuum of high-quality care from the communi- at marriage, the provision of widespread prima- ty to the hospital. This requires staff trained in mid- ry schooling and wider access to health facilities, wifery skills at various levels of the health system, and efforts to lower fertility and infant mortali- and well-functioning facilities accessible to clients ty. Too many women still die from causes that and equipped with essential obstetric drugs and can be cost-effectively prevented, however. supplies. * Safe motherhood interventions can strengthen Guiding Lessons the performance of the health system. The effec- tiveness of maternal health services, like that of The Bank is capable of influencing health systems and other primary health care activities, is often ham- outcomes in its member countries through its policy pered by organizational and institutional con- dialogue and projects. Lending for safe motherhood straints. In some countries, for example, links have over the past decade has indicated that borrower coun- had to be established between separate family plan- tries are willing to borrow funds for safe motherhood ning and health programs. Improving access to activities. From its experience with safe motherhood good-quality maternal health care also remains a projects over the past decade, the Bank has learned challenge in many countries because it requires a much about how to work with countries to develop functioning primary health care system in the com- more effective and sustainable safe motherhood pro- munity and a referral system to a health facility capa- grams. To achieve the Bank's poverty, equity, and ble of providing emergency obstetric care. Safe human development objectives, considerably more motherhood interventions designed to integrate needs to be done to improve women's access to mater- these different sectors of the health service can thus nal health services. Countries that fail to institute the bring about improvements that more broadly affect necessary changes will fall further behind other coun- the health system. tries in human capital development. Several key lessons emerge from the review of World * Bank-financed safe motherhood programs Bank experience in safe motherhood over the past need to adapt to local conditions and do what decade: is feasible. Competing demands on resources may make it difficult to simultaneously address • Safe motherhood is a vital social and economic every component of an effective safe motherhood investment. Safe motherhood interventions are program, but every country can make a start. among the most cost-effective in the health sector. Initial measures in the poorest countries should They contribute to women's health and well-being start by expanding family planning, promoting and that of their children, to women's role within the good nutrition and hygienic births, training family, and ultimately to societal welfare. Countries more health providers in midwifery skills, and (and areas within a country) where poor women improving the capacity of district hospitals to lack access to basic family planning and maternal manage obstetric complications. Increasing the health services should receive priority attention. number of female health workers can improve service quality and use, particularly in cultures * Improving maternal health requires a continuum that discourage women from consulting male of services, including, in particular, referral health providers. In more developed borrower capacity for the management of complications. nations, efforts should focus on improving the The Bank-assisted projects that are designed to quality of case management and counseling in address safe motherhood most effectively, such as family planning and maternity care and pay spe- those in Bangladesh, India, Indonesia, and the cial attention to marginalized groups such as Philippines, are designed from the start to provide a adolescents. 4 Safe Motherhood and The World Bank - Effective programs promote awareness of * High-level government commitment and part- maternal health services as well as improve the nerships are essential to effective safe moth- quality of services. Activities to promote aware- erhood programs. Bangladesh, Chad, India, ness of maternal and reproductive health services and Indonesia have all been able to advance are needed to increase the demand for those ser- their safe motherhood programs because of the vices. In Indonesia, for example, more than strong commitment of their national leaders, 50,000 village midwives have been trained, but supported by consistent and coordinated exter- they continue to be underutilized. Well-informed nal assistance. For safe motherhood programs to and educated families and communities will take be effective, the Bank needs to promote dialogue responsibility for the health of women in their between governments, policymakers, health community by supporting and encouraging them providers, NGOs, and other assistance agencies. to seek good maternal health and nutrition, and The consortium of development partners in by helping them to recognize danger signs in preg- Bangladesh, for example, has coordinated its nancy. Bank support is being used to increase this planning in partnership with the government. awareness among women, families, and providers. The Bank is well-positioned to support this sort of policy dialogue, to mobilize resources, and to * Sector work is important for policy reforms and facilitate the work needed to link investments setting program priorities, especially since data made in different sectors and by different related to maternal health are scarce. Projects donors. need indicators that measure the variables affecting maternal health, such as the percentage of births * Both the borrower country and the Bank must attended by skilled providers and the proportion of have a sustained commitment to reducing district hospitals able to provide essential obstetric maternal mortality. There is no shortcut for care. More information about maternal mortality reducing maternal mortality. Better maternal and morbidity is also needed. In India, sector work health is a cost-effective and achievable objective, on reproductive health supported the government's but progress in reducing maternal death and dis- shift from a target-driven family planning program ability has been slow, often because interventions to a reproductive-health-centered approach. After are not properly phased or focused. Changes may a sector analysis in Bangladesh showed that mater- be needed both in the health system itself and in nal health lagged far behind achievements in fertil- the understanding of maternal health issues at the ity and infant mortality reduction, the government household, community, and national levels to pro- made a determined commitment to make similar vide an effective continuum of care. Countries achievements in maternal health. In Brazil, sector should not try to achieve too much in too short a work contributed to a better understanding of how time. Behavioral change is an important element fee structures provided incentives for hospitals and of an effective healthy pregnancy and safe delivery doctors to encourage cesarean sections, most of program, but achieving that change can take a which were unwarranted. long time. Safe Motherhood and The World Bank: Lessons From 10 Years of Experience Introduction and Overview Tanzania also found a detrimental effect on chil- dren's education, especially at the secondary level. Nearly 99 percent of the more than 500,000 maternal deaths each year occur in the developing world. A The World Bank has been a leader in promoting and woman in the developing world has a one-in-48 supporting efforts to improve maternal health, and chance of dying from pregnancy-related causes, com- today it is the largest single source of external assistance pared to a one-in-1,800 chance in the developed for safe motherhood. In 1987, the Bank cosponsored the world.2 That makes maternal mortality the human Nairobi Conference on Safe Motherhood, which development indicator showing the greatest discrep- launched the Safe Motherhood Initiative, the first glob- ancy between developing and developed countries. al commitment to issues of this type. In the 10 years The means to narrow the gap are now well known, and since then, the number of projects that include safe maternal health interventions are among the most cost- motherhood-related activities has increased substantial- effective in the health sector. So why does the gap per- ly. By 1987 the Bank's lending program included 10 pro- sist? Consider these further findings: jects with family planning and maternal and child health components; today, almost 150 projects include such * Complications of pregnancy and childbirth are the components. Overall lending for population and repro- leading cause of death and disability among women ductive health has totaled $385 million a year since of reproductive age. 1992, or 30 percent of the Bank's total lending for health, nutrition, and population, although only a portion of * One in four adult women in the developing world this amount supports safe motherhood (Annex 1). suffers from acute or chronic conditions related to In the decade since 1987, knowledge of the causes pregnancy. of maternal disability and death and of the appropriate interventions in poor settings has increased consider- * Twenty percent of the burden of disease among chil- ably. With that new understanding has come a broad- dren under the age of five is attributable to perina- er recognition of the importance of interventions tal conditions-low birthweight, birth asphyxia, aimed specifically at pregnancy and childbirth. It has and birth-related trauma-directly associated with become clear that life-threatening complications of poor maternal health and poor quality of obstetric pregnancy (prenatal and postpartum hemorrhage, and newborn care. These same conditions are infection, eclampsia, obstructed labor, and complica- responsible for more than 3 million deaths of new- tions of abortion) are responsible for nearly three-quar- borns each year. ters of maternal deaths, and that risk-screening methodologies cannot reliably predict which women * Research from Bangladesh shows that children up to will experience these complications. The most effective the age of 10 whose mothers die have three to five interventions are attendance at delivery by providers times the mortality rate of children whose mothers skilled in midwifery and prompt diagnosis and treat- are alive or whose fathers die. A recent study from ment of complications (figure 1).3 5 6 Safe Motherhood and The World Banh Borrower countries have demonstrated an increas- initiatives are a sound investment, promising high ing commitment to safe motherhood. So too has much social and economic returns at low cost. Interventions of the international community, which confirmed its to improve maternal health and nutrition are not only support for safe motherhood initiatives at the cost-effective but also clearly feasible, even in poor set- International Conference on Population and tings. The potential benefits are substantial: Development (ICPD) and at the International Conference on Women. It is important now to take * Unwanted or ill-timed pregnancies can interfere stock of the safe motherhood experience, to distill the with women's social and economic activities, and lessons learned, and to prepare recommendations for cause emotional and economic hardship not only to the future. women but also to their families. This paper examines the Bank's work in safe moth- erhood, based largely on a review of experiences in * Children whose mothers die or are disabled in child- nine countries in which the Bank provides substantial bearing have vastly diminished prospects of leading assistance in maternal health and family planning. a productive life. These countries-Bangladesh, Brazil, Chad, India, Indonesia, the Philippines, Romania, Yemen, and * The burden on women associated with frequent Zimbabwe-bring regional diversity and a range of pregnancies, poor maternal health, pregnancy com- maternal health conditions to the study The projects plications, and caring for sick children drains their reviewed were selected for their different approaches productive energy, jeopardizes their income-earning to maternal mortality and disability, the lessons they capacity, and contributes to their poverty offer on program experience over the past decade, and their contribution to the identification of critical inter- * Investments in women's health not only improve a ventions for future work in safe motherhood. woman's health and the survival and health of her family, but also increase the labor supply, productive capacity, and economic well-being of communities. Safe Motherhood in the Development Context A cost-effective investment A decade of research and experience in addressing World Development Report 1993: Investing in Health, maternal health has made it clear that safe motherhood which assessed the disease burden and cost-effective- ness of a wide range of health interventions, concluded that interventions for children under age five and for Figure 1 Relationship between the presence of a skEed women of reproductive age bring the greatest benefit at attendant at delivery (percentage of deliveries) and the lowest cost. Family planning can reduce the risks of maternal mortality ratio (1990 data) unwanted pregnancies. Good-quality prenatal, delivery, and postpartum care to the underserved-particularly 0 s-oo _ _ better management of obstetric complications-can O^ 1600I- + I I I _ _ substantially reduce the death and disability associated 1400 T- E 1200 ---- with child bearing and ensure that more women sur- .6 1000 i oo … vive, thrive, and contribute to societal welfare. 8 .> s600 ----~--n …- ˘-- ----- The World Bank and the World Health Organization -~6001- 400 zzzzz- -- (WHO) have estimated that providing a standard pack- 200 0…70 _ _ age of maternal and newborn health services would 0 lO 20 30 40 50 60 70 80 90 l0 cost approximately $2.60 per person per year in a low- % skilled attendant at delivery income country. These costs are predominantly for Source: WHO Discussion Paper. Prepared for United Nations ICPD+5 maternal health services (68 percent), but also include PrepCom Meetings, New York, March 24-31, 1999. postpartum family planning and basic neonatal care, as Lessons From 10 Years of Experience 7 well as condom promotion to prevent sexually trans- with life-saving skills are key to reducing maternal mor- mitted infections (Annex 2). Delivering effective tality. maternal health services requires better infrastructure At the community level, the needs are for health and maternity care hospitals, but does not usually providers trained in first aid who can stabilize and refer require new facilities. In most countries, the greatest complications and for readily accessible referral sites. impact could be achieved through interventions to At the referral level, the package requires timely treat- improve existing community health centers and dis- ment in appropriately equipped and staffed facilities. trict hospitals; for example, by training health providers, especially midwives, and purchasing essen- Synergy with health services tial obstetric supplies and equipment. Strengthening Safe motherhood efforts can provide the groundwork the infrastructure would also benefit the population by for broader progress in strengthening health systems. improving the delivery of other services. To manage obstetric complications-the key life- Safe motherhood involves changes at the household, saving component of maternity care-a facility must community, and health system referral levels (table 1). have trained staff and a functional operating theater, Within households it requires changing the behavior and must be able to administer blood transfusions and and practices of women, their husbands, and families anesthesia. All of these resources and capabilities can so they can recognize danger signs in pregnancy and be also be applied to the management of accidents, trau- more responsible for good health practices in pregnan- ma, and other medical emergencies. Indeed, one way cy In the least-developed settings, properly trained and to evaluate the performance of a country's health sys- supervised traditional birth attendants may help to tem is to examine the functioning of its prenatal and improve hygiene during home deliveries and the refer- delivery care system. The success of a country's mater- ral of women with complications. However, even with nal health program also reflects its performance in training, traditional birth attendants cannot treat seri- meeting other development objectives, such as infant ous complications, and higher-level health providers and child mortality reduction, gender equity, and reduced fertility. Pregnancy and childbirth services are often an entry point or first contact with the health system for Table I Essential safe motherhood interventions women, and therefore provide a valuable opportunity Prevention and management of uvnwanted pregnancies to identify and treat women for illnesses such as ane- * Family planning mia, malaria, and tuberculosis, for which early treat- * Termination of pregnancy where not against the law - ment during pregnancy is critical. Antenatal care is also the health service women are most likely to use, and as Pregnancy-related services such offers a chance to counsel women about family Prenatal care * Birth planning planning and sexually transmitted infections, includ- * Prompt detection, management and referral of ing HIV/AIDS. Maternal health services-pregnancy pregnancy complications and delivery care, family planning, and the manage- * Tetanus toxoid immunization * Nutrition promotion, including iron and folate supplements ment of sexually transmitted infections-can be even * Iodine supplements, where warranted more cost-effective when offered as a package. * Management and treatment of sexually transmitted infections, malaria, and tuberculosis Safe delivery, * Hygienic, normal delivery The Link Between Safe Motherhood and the * Detection, management, and referral of obstetric Bank's Strategies for Health, Nutrition, and complications Population • Facility-based essential obstetric care Postpartum care * Monitoring for infection and hemorrhage In recent years, the Bank has greatly increased its fund- . Child spacing ing for health, nutrition and population (HNP) pro- 8 Safe Motherhood and The World Bank grams in developing countries. It is important to tal-based services. A minimum package of safe moth- understand the links between safe motherhood and the erhood services requires governments to provide Bank's objectives and strategies in the sector. Moreover, essential community-based services and to upgrade the Bank has recognized the central role of maternal support systems such as clinical training, medicine and and infant health outcomes in the context of a com- equipment supply systems, safe blood supply, and prehensive development framework. institutional capacity Safe motherhood programs can make a critical con- In countries where the health infrastructure is bet- tribution to achieving the three primary goals of the ter developed, there can be more emphasis on quality World Bank's stated strategies for health, nutrition, and assurance and client satisfaction. These countries population: should also encourage greater diversity in the ways that health services are provided, by improving public-sec- * Improving health, population, and nutrition out- tor performance and increasing the participation of the comes for the poor private sector and nongovernmental organizations in health. New facilities and regulatory mechanisms for * Strengthening the performance of health care sys- providers, both public and private, may be needed. tems Improved access to family planning and maternity care services also requires working with the ministries of i Securing sustainable health care financing education, women's affairs, planning, and finance, as well as with the ministries of health and population. The most vulnerable groups, women and children, It is important that countries secure sustainable are most likely to suffer where scarce public resources health-care financing for their maternal health services, are not used to protect the poor. As a result, the Bank's and they should take advantage of the different ways of senior managers in HNP have identified maternal and doing this. The Bank project in Indonesia is introduc- child health and nutrition as one of five sectoral ing a new approach for financing referral services for emphases for Bank assistance. essential obstetric care, for example, which pools the Low consumption of maternal health services is risk of a major health expenditure. The welfare gains most marked among lower-income groups. In the for risk pooling are greatest for risks that are relatively Philippines, and in developing countries in general, rare but involve high costs, such as life-threatening the gap between the poorest segment of the popula- obstetric complications. This use of demand-side tion and the richest for women whose delivery is attended by an appropriately trained provider is even wider than the gap for other basic services (figure 2 Figure 2 Philippines: Gap in Maternity Care and and Annex 3). Poor women make less use of skilled Immuntization Between Poorest and Richest Segments providers during delivery, and their access to referral of Society services during obstetric emergencies is limited by 10 transport costs, fees for service, and opportunity costs, t 7 7 as well as social factors. Strengthening maternal health > 75 - _ _ c _ _ - - 75 care can provide greater access to health services for 50 674.6 70.5 the poor, and can improve the allocation of scarce 432 public resources to programs that have the greatest 2 25- impact on health, particularly among those unable to 24.5 pay Poorest 20% 2nd 3rd 4th Richest 20% As already mentioned, maternal health services can Percentage of people in the country $ i--- atterdanse (%) Births assisted by docto, nure, or rained midwife also provide the groundwork for better performance of =4,i a-nzatiion (%). Chdidre- 12-23 moths ere,ving BCG, measles, and the health system, since these interventions require an three doses of DPT and polio Source: World Bank. HNP Health and Poverty Thematic Group Analysis. effective continuum of care from community to hospi- March 1999. Lessons From 10 Years of Experience 9 financing of emergency obstetric care is consistent with tional agencies and nongovernmental organizations. the trend toward self-financing hospitals in Indonesia. Most of the projects have included matemal and child The Bank's population and reproductive health strat- health-which historically has focused primarily on egy also emphasizes that population and reproductive child health, and family planning activities; far fewer pro- health programs need to be location-specific, and jects include activities to ensure safe delivery, particular- adapted to the demographic, economic, and geograph- ly the management of obstetric complications (figure 4). ic conditions of each country (box 1). This strategy rec- Of the 77 countries where the Bank has supported safe ognizes the links between safe motherhood interven- motherhood activities since 1987, only 29 countries have tions and broader human development goals (figure 3). had projects that include safe-delivery interventions It notes that high maternal mortality is part of the unfin- (Annex 4). Although the number of projects that include ished agenda for the Bank and its borrower countries, safe motherhood-related activities has increased sub- and calls for the Bank to support borrower countries in stantially over the decade, safe delivery still lags behind implementing safe motherhood programs. other areas of health, nutrition, and population. The unfinished agenda World Bank Support for Safe Motherhood Assessment of the Bank7s work in safe motherhood shows that a substantial number of women remain at The Bank has been a leader in promoting and support- risk. Twenty-nine countries have maternal mortality ing efforts to improve maternal health. Today it is the ratios of 600 or more deaths per 100,000 live births. largest single source of external assistance for safe moth- The Bank finances safe motherhood-related activities erhood. Projects supported by the Bank employ a variety (family planning or maternity care) in 22 of them, but of strategies, including health-sector reforms, multisec- safe delivery activities are supported in only seven toral approaches, and partnerships with other intema- (Annex 5). Box I Safer blith ad a betterhea in Chad World spporedpr tsin d the Hethodt ltiond AIDS Control Proj, re w to p repucte t s d to g ea s e i an effective entrypointbothW fhir lpoen t rid fr Xttehe oeall h se irues- fusflnn heat servce at al leei of c -r.I"' ' :. -;--'--.--.--.. The pojecus are, buiding inotiwtoal apenft decenrledpla ne ser- vices, and bg access ii basic heas lh ser*es. one. of p y d cu es. Lessthan 25 pcent of women deiver Xwih a skll birth atteridant and approxImately 2-6 pretir of adults have 'AS About 20 percent''f women e ge m on. The Safe Motherhoo Project emergencies, ensring a to drug an eg h h cation to encurage all women to seek terhealth cae. During iplementation became clear that Imprving trortion and training paramedics to recognize and mawge bctric and newborn -problem were ctl to bettef pregnany outcomes, The BHak ararraed for a supplemental credit t addirs t is iity. Pr pars- medics with the support they nteedrugs, radios, mnoorcyces, and referral backuip--reur a ln-term co!mtment. The Populaion and AIDS Control Project is working to increas ;h ue ofuso,de contraceptive methodsand to slow the spread of lY inc by promoting behavIoral change and ncreasing anenat caf The projet is bu u natoio ac-. ity forpopulation-related ativies through better infomation and r h, IV screenig of pregnant womgn, a soal mar-. keing programfor condom use, and establshment of a soca find to provide grts for pp a AD nrol effor Both pojects had to adapt their avities to loal conditions. They neede to build the institution capacity of the health system to provie services and add ess neg d Ise related to highfertilitya high naena mortality, and the NV/ADS epi-: demlc~ Vital linkages between co ity-e servie providrs and referal oi, and between seri provoni du- catio at are ke} elerfmts of safe motherhood program that work to strengthen the oeral penforance of the health sy,stemL,,,.,,,,-,............................... 10 Safe Motherhood and The World Bank Figure 3 Population, Gender, and Reproductive Health-Related Development Impacts of Bank Operations Operations Sector Outcomes Human Development Impacts Gender-focused Higher income Redced desired K components of - lhrncms edcdele 9 micro-enterprise and J better jobs for familysize Increased women's j < ~~autonomy ncreased enrollments ( Girls' education ) _ ( completion rates, G -w y < reduced gender Source: Adapted from World Bank, Population and The World Bank, 1998. Country-assistance strategies rarely mention mater- out an attendant trained in midwifery skills, and about nal mortality and disability concerns, even for countries one-third of pregnant women have no prenatal con- with the most serious maternal health problems. Only tact with an appropriately trained health provider. nine of 24 country-assistance strategies for countries Conditions vary widely by region, country, and even with very high maternal mortality ratios mention the locality Sub-Saharan Africa, South Asia, and the issue as part of the country strategy (Annex 5). For Middle East and North Africa account for 90 percent example, despite unacceptably high maternal mortality of maternal deaths. In these regions, women have lim- ratios in most of Sub-Saharan Africa, the most recent ited access to prenatal, delivery, and postpartum care, country-assistance strategies for countries in the region fail to mention this as a problem. Among the few coun- Figure 4 Number of New Projects with Reproductive Health, try-assistance strategies that do consider maternal Safe Delivery, and Health, Nutrition, and Population Activities, health, those for Bangladesh and Guinea both address Fiscal 1987-98 maternal mortality ratios as a serious problem that affects poverty alleviation as well as women's health. Both use data on the attendance of skilled practitioners , 25 at delivery as a measure of progress. There is scope in OA all country-assistance strategies for more detailed analy- 20 sis of how maternal health care fits into the overall s15i country program, particularly in countries with high E maternal mortality ratios. It is also important to identi- z 10 fy links with other sectors-education, gender, and infrastructure development-to show how they affect matemal health and how better matemal health con- o0 tributes to a multisectoral development agenda. 87 88 89 90 91 92 93 94 95 96 97 98 Fiscal year -_- HNP - Reproductive Health e, Safe Delivery Strategies tailored to local conditions Source: World Bank Staff Appraisal Reports and Project Appraisal Half of women in developing countries deliver with- Documents. Lessons From 10 Years of Experience 11 and treatment for obstetric complications and the to the setting for a project to successfully achieve the quality of care are generally poor. In Latin America and following outcomes: the Caribbean, East Asia and the Pacific, and Europe and Central Asia, maternal mortality ratios are lower. * Families, communities, and providers informed In these regions, the priority concerns are complica- about good maternal health and nutrition practices tions from unsafe abortion and limited access to qual- and about the danger signs of complications ity care for the poor. To be most effective, safe motherhood initiatives * Well-functioning facilities accessible to clients and need to consider the country context and develop a equipped with essential drugs and supplies to man- roadmap based on level of development. For example, age complications a country like Cambodia, which has an estimated maternal mortality ratio of 900 per 100,000, also has * Staff trained in midwifery skills at all levels of the other urgent needs in the health sector, including the health system control of communicable diseases such as tuberculosis and malaria. With the need so great and capacity still * Different levels of the system linked to ensure a con- low, there is a risk of trying to do everything at once, tinuum of care from community to hospital, includ- and failing. The Bank's initial work has therefore ing alarm and transport for emergency cases. focused on strengthening general health services and controlling communicable disease. Interventions in In resource-poor countries such as Chad and areas such as maternity care will be phased in later, as Yemen, where fertility and mortality rates are high, it capacity grows. However, it is useful for policymakers is most important to expand family planning services and program managers to develop a framework which and introduce cost-effective prenatal interventions; to lays out the sequencing of interventions to achieve train midwives; and to strengthen obstetric services at long-term goals. the district hospital. Programs to educate women and There can also be substantial differences within a influential family members about the importance of country For example, the national maternal mortali- pregnancy and delivery care, healthy practices during ty ratio in Indonesia is 390 per 100,000, but the ratio pregnancy, and recognition of danger signs in preg- varies from 150 per 100,000 in parts of Java to more nancy are also important. than 1,000 in Eastern Indonesia. This differential is Education programs also need to address demand- much greater than that for other basic health indica- side factors, and especially to advise families and tors such as infant and child mortality. In cases such providers about the importance of seeking health care as this, flexible project designs may be needed that during pregnancy and delivery Depending on the pol- allow for location-specific interventions for materni- icy environment, a first step may be to increase aware- ty care. Also, because of the difficulty of accurately ness among policymakers of the extent, dimensions, measuring maternal mortality, these statistics should and development implications of maternal death and be complemented by others when designing safe disability Multisectoral approaches can also be taken motherhood interventions, such as the percentage of to improve women's status, including girls' education, births attended by skilled providers or the proportion raising the age of marriage, and ending female genital of district hospitals offering essential obstetric care mutilation. services. In countries with more health infrastructure, such The mix of strategies supported by the Bank reflects as Indonesia and the Philippines, competency-based the variations in local settings. The World Bank training and quality assurance systems should be Discussion Paper, Making Motherhood Safe, identifies strengthened to ensure that normal deliveries are safe factors across all levels of institutional capacity that and complications appropriately managed. Communi- need to be considered in any project attempting to cation and counseling skills for providers may also improve maternal health. The means must be tailored need attention to improve the quality of care. More 12 Safe Motherhood and The World Bank W;;eAi000;*cadsaire a;tdno* i a:\SS S;tkiWfSX0: \ff efort 2hu Imgovingmtera honelthg fain alaysiato sueeo s Wtory h elhifatucuei etrdvl contintenc plans fos deliver ed at hm assisted byed, suntai in birthi aegindans,o Mrazil, morta ity pee into eivpreing governeto hostals, pircen in privateb h ita o tyo homes, and 12 percentathome. By 1996t fully Suseaned piticalffe 24mtmenu or four de aied catlicraing t acenptsai of apubltic pdovd heltsora- necessavcesormuricalpoo and rat imporon aemss te thos sem cszt of r Inth eat secor evolut0ion has ben stead, thoughgradual *\EShw; C_licalmiwies out hm eieries. Thebackbone oftherual eath srvcs isastrngneworkofgovrnmentt raidwivs suerie by puli helt nuses Rural midie hae 18 mots of cinical midwifr trang, an pub- 0C? an 90 ocsdo stbihn this0f0 network. Th push F formrerradotors came onl in th mid-90s omuite nw rfe ciicl iw ivs In th 197'4 0s,0 litrt trdtoa birth attedant wer reitrdanrie the00000 trdtionl> brWR0th a62ttedn ha los iaperd Sic the 10s theSS districtmtra adcidhelhcmites edd by a dstric hostl-bse obteriia and: priate treatment. efor Carel goystem pcounsjoint reposiility ton teveldsrithoptapn Whreural health sricerat reuetur mabeterna deaths. Vitigncllagehelt ommdeittees litedwhn thee hospital-based obsetrisciasn viedrtoepain hegowns unowaBrdzl evenrty cul an Every im atering dceathis reviewed. Hopialprcices wi h ave e hanged to becoe moremp usrfindl Nursne trid tmves over suly equpedn lprgace and ctfed2 onuct nord al adeliveris aloigtotrsteocs complications. Obteri pracbrtoad ticeiscoareg neesregomulaly cpated,nand earl-arningr systems. aecn inualteg thenoed. dclzto f btti ae Lessorns From 10 Years of Experience 13 Expanding access to a variety of contraceptive meth- ject supporting health programs; others have had a ods can provide good results, and making maternity series of such projects (Annex 7). The reviews were care more efficient as well as client-centered is also guided by a set of questions and included analysis of an important issue for many of the more developed the key project documents.4 borrower nations, including Romania. In these coun- Bank assistance to clients with population projects tries, efforts should focus on improving the quality shows a common pattern: initial faltering evolving into of support-such as case management and counsel- an effective program several years later. Bangladesh, ing-for family planning and maternity care, and India, and Indonesia provide examples of how a deep- should pay special attention to marginalized groups ening relationship between Bank and government has such as adolescents. The private sector and NGOs coincided with a remarkable increase in contraceptive have an increasing role in providing pregnancy and prevalence and a dramatic change in the approach to ser- delivery care, and as consumers are able to choose vice provision. This has produced a strong foundation from a variety of providers-public, private non- that will enable the transition from a target-driven fami- profit, and private for-profit-regulation of these ly planning program to one based on the reproductive providers will be critical for maintaining quality, health approach. The Indonesian Government, building on its successful family planning program, launched ini- tiatives to improve reproductive health, including reduc- Country Reviews: Improving Project ing maternal mortality (box 3). Implementation at the Country Level In another example, an initial health and family plan- ning project in Zimbabwe stimulated institutional devel- A review of selected Bank-financed projects with sub- opment in the sector. By project's end in 1994, 48 per- stantial maternal health activities was recently con- cent of couples were using contraceptives, more than 90 ducted to assess the Bank's work over the past 10 years, percent of all women received prenatal care, and 70 per- to identify what works and what doesn't, and to under- cent had a facility-based delivery. A second project was stand what has contributed to the improved quality of able to build on the gains made to enhance the capacity projects. The review covered the operational and tech- to deliver maternal, child, and nutrition services and to nical aspects of project design and implementation. It give top priority to addressing the AIDS epidemic. was designed to track the Bank's work in a country over Bank assistance in Brazil and Romania took a broader time, rather than to focus on a particular project. This sectoral approach. For example, the Health approach was important because some of the countries Rehabilitation Project in Romania was designed to were in transition from target-driven family planning reverse a long decline in health indicators, including programs to a broader reproductive health approach, maternal health. The project included funds to improve following the 1994 International Conference on maternal health services at rural dispensaries and hospi- Population and Development (Annex 6). tal referral centers and to increase the availability of con- The review covered nine countries that had projects traceptives at local family planning units. During this with safe motherhood components or activities that period, maternal mortality declined substantially were approved by the Board before the end of fiscal The review examined experience with sector analy- 1998: Bangladesh, Brazil, Chad, India, Indonesia, the sis and project preparation, design, and implementa- Philippines, Romania, Yemen, and Zimbabwe. These tion. Each project had successful aspects as well as countries were selected to ensure representation of all problems from which to learn. The most comprehen- geographic regions and all different stages in the estab- sive projects were based on careful sector review, espe- lishment of a continuum of services for improved cially of institutional issues and the linkage between maternal health. World Bank lending in these nine supply characteristics and client demand. Lasting com- countries accounts for 40 percent of its total lending in mitment at the highest levels by the Bank and borrow- the health, nutrition, and population sector since er agencies was very important, especially during 1987. Some countries have had only a single Bank pro- implementation. 14 Safe Motherhood and The World Ban1k Sector analysis and project preparation and Safe Motherhood Project and the Population and Several lessons relate to the early planning stages of the AIDS Control Project. These projects focus on project cycle for safe motherhood projects: strengthening the overall health system as well as improving reproductive health services. Originally a Institutional constraints can present barriers to single project whose activities were to be managed by achieving safe motherhood objectives the Ministry of Public Health, the Chad project was split into two when it became clear that the project Safe motherhood programs involve a continuum of would exceed the limited capacity of the Ministry of care. It is therefore important to identify beforehand Public Health. The two projects were managed by any institutional constraints, to avoid attempting pro- separate ministries (Ministry of Public Health and jects that are too ambitious for their institutional set- Ministry of Planning and Coordination), with a sin- ting. Divided institutional responsibilities can be gle Bank task leader providing overall coordination. another obstacle. In Indonesia, for example, different In Bangladesh and Indonesia, an analysis of the insti- ministries manage family planning and health pro- tutional constraints made it clear that the project grams, making it difficult to create a coherent would have to include components to develop link- approach to strengthening maternal health services at ages between the separate family planning and health all levels. arms of the government, in coordination with the There are also cases where efforts have been made ministries responsible for women's affairs and edu- to optimize existing capacity, as in the Chad Health cation. Althuham ostpercentofndoneianwomenreceivesom eantenta carmore tan two out of thrw n stld at and place m nore than54,000 villag midwivesin alosti evr vllae inthe countr Th midwvs whot comlete a0 forya trin in rga i usn an midi fey r ire 7onthree-year renewabl contrazcts o or iX7An vilages throghot Indonsi. Often,;i ;f they are thepimr suc of basicheathc readmtrnalanidt child he˘alt ae. in Is 5addistion0 t o managin nona p5reganciesz00 ;; an eieie,te r trained tod< iagos an tret rng f pregnanc-reate coplicatios, to Cstaiie aes before referrl,; 00 an to prvd ai aeo ebrn.Bcues ayoe delivr aLtŁ home, th miwies are enorgd toonuc hoe0it MESt;ini07stry o Hel5thi is oseperd wok; Wing toimpr To7ve klsfrolt ; th; oug adiioa inservic training andS0:i on-theob tranngi f;W0;WA;t;dSi;s-0S Sf? c ialyaogtepo.Hwvrt nube ofy su0X t t ( pply and dmad-eated obsacls kep heprogra 7mfrombeomngsel00f-sus- midifeserics.The orl Bnk-ianePrne+pf rship o Sf othe rhoodProectiupoting goenet && effortsto ernore 2 P0io0 in erveAn3tionsinclue targtd pe ormncebasdcontrcts to5compestevlage mik|dwivsfr rvdigaclearlydefied 00 pakgeo eriest hepor nthe i dmn-c, thercetecon.om5ic criss ndneiaha brought rnwe oncernabou Noe simtso maternal mortalseity re ;influened b tesize and Stype ;of the! sampte,l and; vary5' from A343to fi78 per 100,000.o5 The figureio f t0390 e 00,00057*;0f is frm h 19 Idneia emgapi and000 Health0300fS0002000X00000zZ0\kX0000000000300f Survey0; Lessons From 10 Years of Experience 15 Demand-side analysis is especially important for * Strong government commitment and agreement on maternity care services priority interventions are important for the success of safe motherhood programs, particularly because Although stakeholder participation in project prepara- of the low status of women in many countries tion is increasing, client-centered, demand-side analy- sis is still often lacking, along with examination of the Government ownership and high-level support are interdependence of supply-side factors. It is important important to successful safe motherhood programs. In to know how social constraints, such as the low status the Philippines, strong initial interest by the Department of women in many societies, may affect demand for ser- of Health during preparation of the Women's Health and vices. Assessment of staffing requirements for health Safe Motherhood Project soon gave way to increasing facilities and of plans for training in counseling and ambivalence about the project as the government sought technical skills, especially for female health care to introduce broader institutional reforms and to providers, is similarly important. devolve program and budget responsibility to local-gov- Innovative ways to address demand-side constraints ernment units. The project was weakened by the lack of were applied in Bangladesh, Iran, and Pakistan5 Mlost national leadership for the program, and it is only women in these countries are forbidden to receive recently that the new leadership of the Department of health care from men. To overcome this barrier, pro- Health has shown a commitment to the safe motherhood grams have implemented training programs for program, within the context of women's health. women and deployed them at the community and In countries where resources are limited and many household levels. In Indonesia, the Population V health problems demand attention, a common practice Program had shown that increasing the number of vil- is to fund those activities that have highly visible lage midwives would not have the desired impact if results, such as building new hospitals and purchasing women were not informed about the benefits of using ambulances, rather than to fund maternity care, which services. The Safe Motherhood Project thus included has a low profile in part because of the low status of an education component aimed at strengthening the women. Furthermore, in many Bank-assisted projects counseling and communication skills of the village that include lower maternal mortality ratios as a goal, midwives to encourage mothers to adopt safer birthing the choice of specific interventions is not always strate- practices. gical]y sound. There is a tendency to incorporate some elements of antenatal care into the project without pro- * Project preparation can assess the multisectoral viding support for safe deliveries, particularly manage- dimensions of maternal health issues ment of complications, the most important interven- tion for reducing maternal deaths. Maternal death and disability are also influenced by social factors, particularly those that are consequences e Sector work is important for policy reforms and of a woman's perceived role in society, such as educa- setting program priorities, especially where data tion, access to income and resources, and degree of on maternal death and morbidity are scarce isolation. Sometimes these intermediate factors need to be addressed before real progress can be made in Research related to maternal health status and services maternal health. For example, in Yemen, women have has been very limited (box 4). Baseline data and infor- little power to make decisions about their own repro- mation on program performance and impact are not ductive health, and men pay little attention to routinely collected. To supplement available data, sec- women's reproductive health needs. The Bank pro- tor analysis is important for providing country-specif- gram uses a multisectoral approach that incorporates ic information about population and reproductive activities aimed at raising the status of women and health issues. In India, sector work on reproductive alleviating poverty, in addition to strengthening health supported the government's shift from a narrow maternal and child health. family planning program to a reproductive health and 16 Safe Motherhood and The World Bank client-centered approach, and led to the Reproductivy effective care. In contrast, few projects have included and Child Health Project. The Bangladesh program interventions to ensure skilled assistance at delivery, a Teas based on the government's sector analysis and key element of safe mothen hood. Incomplete project strategy, which defined priorities, including maternal designs have missed vital linkages between communi- health, that had lagged far behind achievements in fer- ty-level service providers and referral points, and tility and infant mortality reduction. between service provision and the education that makes known the availability of those services. Well- Project design designed projects-for example, the Indonesia Safe Every country, regardless of institutional or financial Motherhood Project, Indiafs Reproductive and Child constraints, has the capabiliti to work toward a con- Hiealth Project, and Bangladesh's Health and winuum of care for safe motherhood. It is important that Population Project-included the key elements of safe project planners envision from the start how the pro- motherhood programs that strengthen the overall per- gram should ultimately look, even if a country can ini- formance of the health system. tially undertake only such basic measures as expand- ing access to family planning, promoting good fIn countries where providingintegrated maternal nutrition and hygienic births, training more female health services is new, the Bank could advise paramedics in midwifery skills, and improving capac- borrowers to include an operations research and ity to manage obstetric complications at major hospi- evaluation component in their national programs tals. lew Bank projects are designed to ensure this con- to test new approaches tinuum of care, however. The Indonesia Third Community Health and Nutrition paSafe motherhood requires a continuum of care Project inciuded an operations research component from the community to the referral facility that financed pilot studies proposed by district health officials to test local approaches to strengthening safe Well-designed projects have a logical and coherent motherhood interventions. In the Philippines, new ser- framework of objectives, interventions, and indicators. vices, such as screening for cervical cancer and sexual- Many Bank projects have proposed numerous activi- ly transmitted infections, are being tested in some ties but failed to include those necessary to achieve provinces. A quality assurance system is also being their stated objectives. Others have included some ad introduced at hospitals to reduce maternal infections hoc antenatal care, but not necessarily the most cost- and to review adverse obstetric events. In Zimbabwe, Lessons Fr-om 10 Years of Experience 17 a project-supported study of user fees found a 23-30 attended by skilled providers and health service uti- percent drop in attendance at facilities charging fees, lization rates (box 5). Quantitative indicators such as with many women delaying antenatal care because of these should be supplemented, where possible, with the requirement that they pay delivery fees on their first survey information, including qualitative measures, antenatal visit. and maternal death audits. In Indonesia, maternal and In each of these instances, valuable information was perinatal death audits are used as a kind of verbal autop- learned before the program was expanded nationwide. sy to determine the causes of death-both medical and The Bank's new adaptable lending instruments (learn- nonmedical. These reviews trace events from the health ing and innovation loans and adaptable program loans) facility back to the community in an effort to uncover can address issues of uncertainty such as these and the medical, institutional, and sociocultural factors that facilitate the testing of new services. At the same time, led to a mother's death. A good maternal or perinatal the new instruments enable the Bank to offer a long- death review involves health providers and members of term financial commitment to subsequent expansion. the community, and seeks to identify avoidable factors and to educate health providers and the community Appropriate indicators to measure project about these factors. progress are critical, especially to measure atten- dance by skilled providers at delivery * Reducing maternal mortality requires sustained, long-term commitment and partnership The projects that devised an appropriate and compre- hensive set of indicators for measuring project Countries are often expected to achieve too much in progress-in Bangladesh, India, Indonesia, and the too short a time. In the Philippines, the technical Philippines-were usually devoted primarily to safe design of the project was strong, but it was too ambi- motherhood and included support from a maternal tious, and when institutional changes were introduced health specialist. Indicators chosen for the other pro- into the health system the project faltered. Neither the jects vary in appropriateness and comprehensiveness. donors nor the government had conducted the insti- A few projects whose goal is reducing maternal mor- tutional analysis during project preparation that might tality have no indicators for measuring maternal have resulted in a more realistic assessment of imple- health, for example. In some projects, indicators are mentation capacity, and therefore have guided policy- more of a "to do" list than a means of measuring makers to make the necessary program adjustments. progress. Other projects have proposed indicators for Such an assessment is now part of the restructuring which there are no baseline data or means of measure- plan for the project. ment. Since the start of its project, Romania has seen In countries where the Bank makes a commitment remarkable drops in the maternal mortality ratio (from to work for at least 10 years-through an adaptable 169 per 100,000 in 1989 to fewer than 40 per 100,000 program loan, for example-expectations tend to be in 1997) and the abortion ratio (from more than three more realistic. Projects are also more successful when per 1,000 live births in 1990 to less than two per 1,000 they are designed in partnership with other donors and in 1997). Had process or outcome indicators been NGOs, in addition to national and local officials. The established at the start of the project, they could have consortium of development partners in Bangladesh provided important information on the factors con- and Romania, for example, has enabled coordinated tributing to this achievement. planning in partnership with the government. Other Many projects propose using maternal mortality partners may have specialized skills that are needed by ratios as an impact indicator, but these are not an appro- the country to deal with technical or institutional priate or practical indicator of project outcomes or issues. For example, the United Nations Population progress. Projects should use process and output indi- Fund (UNFPA) is often best situated to provide tech- cators that measure the intervening variables affecting nical assistance and procurement for family planning maternal health, such as the proportion of births services. In Chad, where there is also effective donor 18 Safe Motherhood and The World Bank collaboration, NGOs are actively involved in the pro- recent economic crisis, when the project was modi- gram. A social fund provides grants to NGOs for fam- fied to assist the government in procuring contracep- ily planning and AIDS control. tives. Mid-term reviews and surveys conducted by the borrower, followed by supervision missions, have Project implementation also been used in countries such as Indonesia and the The review of safe motherhood projects strongly con- Philippines to strengthen projects during implemen- firms the importance of the quality of supervision to tation. project performance. Project outcomes can be enhanced by a supervi- * PSafe motherhood projects can be strengthened, sion strategy that includes monitoring of the even those with initially poor designs, through maternal health component of broader health pro- intensive supervision and restructuring jects, and that maintains continuity of team lead- ers and the supervision team Regular supervision that focuses on the maternity- care component of safe motherhood projects results Most supervision budgets are inadequate to cover the in the most effective project implementation. cost of all the specialists needed. As a result, many Supervision can make possible the early identifica- supervision missions fail to assess the status of mater- tion and removal of constraints to good project per- nal health activities that are part of broader health pro- formance. In Chad, project supervision helped to jects. To address this, the Zimbabwe project included identify transportation as a barrier to womens access a maternal health specialist in all supervision missions; to services, and to show that centralized paramedic local staff can also participate to provide this expertise. training was leading to delays in staffing peripheral Even when a specialist is not available, however, the sites. The Bank arranged for a supplemental credit to supervision team should Teport on the progress of address these issues immediately Circumstances may maternal health activities. In Romania, the project had also change during the course of a project, and the been consistently rated unsatisfactory, including an Bank may need to modify some project components unsatisfactory rating for the reproductive health com- accordingly. This happened in Indonesia during the ponent. In 1997, project supervision was moved from Lessons From 10 Years of Experience 19 headquarters to the field office, and the more frequent Contributions of sector managers and task team field-level monitoring immediately improved project leaders performance. Maternal and child health and nutrition is an impor- tant emphasis of the Bank's Health, Nutrition, and Population Sector, particularly to improve health out- Proposed World Bank Actions to Further comes for the poor (Annex 8). Making sure that safe Strengthen Safe Motherhood Programs motherhood activities receive full attention at the Health, Nutrition, and Population Sector Board and Making motherhood safer is fundamental to the health regional sector-head level can help to improve their and human resources agenda of the World Bank and to effectiveness. its view of strategic initiatives such as poverty reduc- tion and a comprehensive development framework. In * Sector heads can help ensure that the technical con- response to continued high maternal mortality and tent of projects with safe motherhood components morbidity, the Bank is able to influence health systems is closely monitored through supervision missions and outcomes through its sector work, policy dialogue, and midterm reviews. Sector heads and task-team and projects. leaders can also use the Implementation Completion Report as a tool for addressing mater- Bank leadership nal health, by including lessons learned in materni- There must be strong, visible demonstration from Bank ty care services and formulating recommendations senior management, from the president to each coun- for further work in safe motherhood. try director, that reducing maternal mortality is an inte- gral part of meeting the Bank's objectives of human * The Sector Board should ensure that enough trained development, equity, and poverty reduction. It also staff or consultants are available to provide techni- needs to be clear that the Bank has a long-term com- cal expertise in safe motherhood and to implement mitment to safe motherhood. this action plan. e Recent country-assistance strategies include mater- * Sector heads and task-team leaders also need to see nal mortality ratios as one of their human develop- that sector strategies address the problem of mater- ment indicators; they also need to add skilled atten- nal mortality as well as other areas of HNP sector dance at delivery, which is more easily measured emphasis. Effective sector strategies will recognize over short periods of time. the importance of strengthening the continuum of care, including hospital-based obstetric services, in * Bank assistance to countries with maternal mortal- a coherent, step-by-step manner according to each ity ratios (greater than 300 per 100,000) should country's particular circumstances. include efforts in health, population, and nutrition programs as well as other sectors to address the * Health system reform projects should use as a mea- problems of unwanted fertility and maternal mor- sure of performance skilled attendance at delivery tality as well as critical gender-related issues, such and, over the longer term, the maternal mortality as girls' education. ratio. * If the Bank is not providing support for safe moth- Contributions of the Population and Reproductive erhood programs in a country with a high maternal Health Thematic Group mortality ratio, the country-assistance strategy The Population and Reproductive Health Thematic should note that the issues were considered and Group, a part of the Bank's Human Development explain why the decision was made to not address Network, is central to strengthening safe motherhood them now. within the Bank's programs. It will monitor safe moth- 20 Safe Motherhood and The World Bank erhood and related activities in Bank projects to Partnerships enhance the quality of this work. The Population and The Bank strongly supports collaboration among Reproductive Health Thematic Group has several donor agencies and NGOs on safe motherhood important population and reproductive health initia- issues: tives underway or planned: - The Bank will continue as a member of the Safe Safe motherhood concerns will be included on the Motherhood Interagency Group that includes Population and Reproductive Health Policy Watch UNICEF, UNFPA, WHO, the International Planned List. The watch list was established to ensure that key Parenthood Federation, and the Population documents such as the country-assistance strategy Council. The Bank will also work with the relevant and analytical economic and sector work include a UN agencies on the Safe Motherhood Working population perspective. Countries with maternal Group of the UN Coordinating Committee on mortality ratios greater than 300 per 100,000 live Health, as well as nongovernmental organizations births, at either the national or regional level, will be such as the International Federation of placed on the watch list and monitored to ensure that Obstetricians and Gynecologists and the Bank-financed programs include effective interven- International Confederation of Midwives. tions to reduce maternal deaths and disability Additional knowledge-management support will be * Internationally, and in the countries where we work, provided to regions with countries on the watch list there is a critical shortage of technical experts who to support studies of critical gaps in safe mother- can help plan, design, and monitor maternal health hood. Countries on the watch list that are preparing programs. No agency has an adequate stable of country-assistance strategies or economic and sector experts to assist governments in obstetrics and work will be eligible for support from the Thematic nurse-midwifery. There is more expertise available Group to prepare a brief summary of the country's in many other areas of health and family planning. maternal health status. We will need to work with our partners to develop this expertise and to help make it available to our * The Thematic Group will post information and doc- clients. uments about Bank-financed safe motherhood pro- grams on the Human Development Networks Web * Collaboration at the country level is needed to max- site and will provide links to other safe motherhood imize participation of local stakeholders, focus sites. It will also disseminate information about safe scarce resources on priority areas, and make the best motherhood to Bank professional staff through peri- use of donors with a specialized focus or a particu- odic training activities or information sessions. lar expertise. * The Population and Reproductive Health Thematic * The Bank should continue to use the Develop- Group will develop cooperative activities in mater- ment Grant Facility to address critical areas in nal and child health and nutrition and will collabo- safe motherhood and reproductive health that rate with other thematic groups such as the Public cannot be addressed through the lending pro- Health, Indicators, Health Reform, Gender, and gram. Education Groups. * A Safe Motherhood subcommittee of the Thematic Guiding Lessons Group will be established to guide and monitor implementation of the Bank's activities to strength- The Bank has done much to increase attention to safe en safe motherhood programs and improve the motherhood within the Bank, among borrower coun- quality of our work. tries, and among its partners. The Bank has also Lessons From 10 Years of Experience 21 learned much from project experience over the past ness of maternal health services, like that of other decade about what constitutes an effective safe moth- primary health care activities, is often hampered by erhood package, and this knowledge is being used to organizational and institutional constraints. In some help borrower countries develop more effective and countries, links have had to be established between sustainable safe motherhood programs. separate family planning and health programs. There are nonetheless gaps in the World Bank's Improving access to good-quality maternal health work. In many countries we are lacking efforts for pol- care remains a challenge in many countries because icy dialogue and programming in maternal health. it requires a functioning primary health care system Even where we are supporting safe motherhood, there in the community and a referral system linked to a are few projects that include the most crucial inter- health facility capable of providing essential obstet- vention for reducing maternal deaths-safe delivery ric care, particularly for emergencies. . Safe mother- There are many health issues competing for resources, hood interventions can thus bring about improve- and safe motherhood is seldom accorded high priority ments that affect the health system more broadly in country programs. This is despite the fact that it is one of the most cost-effective health-sector interven- * Bank-financed safe motherhood programs need to tions, with the potential to bring about broad improve- adapt to local conditions and do what is feasible. ments throughout the health sector. Competing demands for resources may make it dif- The key lessons for improving safe motherhood pro- ficult to simultaneously address every component of grams include: an effective safe motherhood program. But every country can work toward a continuum of care from * Safe motherhood is a vital social and economic the start. Initial measures in the poorest countries investment. Safe motherhood interventions are should start with expanding family planning, pro- among the most cost-effective in the health sector. moting good nutrition and hygienic births, training They contribute to women's health and well-being more health providers in midwifery skills, and and to that of their children; to the performance of improving the capacity of district hospitals to man- women in their roles within the family and society; age obstetric complications at district hospitals. and ultimately to societal welfare. Countries and Increasing the number of female health workers can local areas where poor women lack access to basic improve service quality and use, particularly in cul- family planning and maternal health services should tures that discourage women from consulting male receive priority attention. health providers. In more developed borrower nations, efforts should focus on improving the qual- * Improving maternal health requires a continuum of ity of case management and counseling in family services, including in particular, referral capacity planning and maternity care and pay special atten- for management of complications. The Bank-assist- tion to marginalized groups such as adolescents. ed projects that are designed to address safe mother- hood most effectively, such as those in Bangladesh, * Increasing the demand for maternal health ser- India, Indonesia, and the Philippines, are designed vices can be as important as improving the quali- from the start to provide a continuum of high-quali- ty of services. Activities to promote awareness about ty care from the community to the hospital. This maternal and reproductive health services are also requires staff trained in midwifery skills at various lev- needed to increase the demand for services. Well- els of the health system, as well as well-functioning informed and educated families and communities facilities, accessible to clients and equipped with all take responsibility for the health of women in their essential obstetric drugs and supplies. community by encouraging and supporting all women to seek good maternal health and nutrition * Safe motherhood interventions can strengthen the and to recognize danger signs in pregnancy In performance of the health system. The effective- Indonesia, more than 50,000 village midwives were 22 Safe Motherhood and The World Bank trained, but they continued to be underutilized. programs because of the strong commitment of Bank support is being used to increase awareness national leaders, supported by consistent and coor- among women, families, and providers. dinated external assistance. For programs to be effective, the Bank needs to promote dialogue and Sector work is important for policy reforms and program planning in safe motherhood with gov- setting program priorities, especially where data ernments, policymakers, health providers, NGOs, related to maternal health are scarce. In addition and other assistance agencies. The consortium of to maternal mortality ratios, projects need indica- development partners in Bangladesh, for example, tors that measure intervening variables that affect has enabled coordinated planning in partnership maternal health, such as the percentage of births with the government. The Bank is well positioned attended by skilled providers and the proportion of to support policy dialogue, mobilize resources, and district hospitals able to provide essential obstetric facilitate work that links investments made in dif- care. In India, sector work on reproductive health ferent sectors or by different donors. supported the government's shift from a target-dri- ven family planning program to a reproductive * Both the borrower country and the Bank must health-centered approach. After a sector analysis in have a sustained commitment to reducing mater- Bangladesh showed that maternal health lagged far nal mortality. There is no shortcut for reducing behind achievements in fertility and infant mortal- maternal mortality Better maternal health is a cost- ity reduction, the government made a determined effective and achievable objective, but progress in commitment to make similar achievements in reducing maternal death and disability has been maternal health. In Brazil, sector work contributed slow, often because interventions are not properly to a better understanding of how fee structures pro- phased or focused. To provide an effective continu- vided incentives for hospitals and doctors to um of care, changes may be needed both in the encourage cesarean sections, most of which were health system and in the understanding of maternal unwarranted. health issues at the household, community, and national levels. Countries should not try to achieve * High-level government commitment and partner- too much in too short a time. Behavioral change is ships are essential to effective safe motherhood an important element of an effective healthy preg- programs. Bangladesh, Chad, India, and Indonesia nancy and safe-delivery program, but behavioral have all been able to advance their safe motherhood change can take a long time. Lessons From 10 Years of Experience 23 Notes are beyond their competence or not possible in the particular setting. Depending on the setting, other healthcare providers, 1. WHO. 1996. Revised 1990 Estimates of Maternal such as auxiliary nurse/midwives and community midwives, Mortality: A New Approach by WHO and UNICEF may also have acquired appropriate skillls if they have been spe- 2. The first estimate of the extent of maternal mortality cially trained. These individuals frequently form the backbone around the world, made in the late 1980s, indicated that some of maternity servies at the periphery, and pregnancy and labor 500,000 women die each year from pregnancy-related causes. outcomes can be improved by making use of their services, This estimate was revised by WHO and UNICEF in 1996, based especially if they are appropriately supervised. WHO, 1999. on the availability of additional information, to 585,000 mater- Reduction of Maternal Mortality: A Joint WHO, UNFPA, nal deaths each year. New global estimates are now being made UNICEF, and World Bank Statement. which will be reported before the end of 1999 and are expect- 4. Country Assistance Strategy, economic and sector work, ed to be around 500,000. appraisal documents of closed and active projects, supervision 3. The term "skilled attendant" refers exclusively to people and completion reports, and mid-term reviews. Aide memoirs who have been trained in midwifery skills (for example, doc- and more detailed mission reports were not included. Team and tors, midwives, nurses). Skilled attendants must be able to man- task leaders' views were also solicited. age normal labor and delivery, recognize the onset of compli- 5. Pakistan and Iran were not included in the review. These cations, perform essential interventions, start treatment, and interventions are used as examples that show an innovative supervise the referral of mother and baby for interventions that approach to the problem. Lessons From 10 Years of Experience 25 Annex 1 World Bank Lending for Population and Reproductive Health FY 1987-98 (US$ millions)a Fiscal Year Region/Project IBRD/IDA Lending P/RH Lending 1987 Africa The Gambia-National Heath Development Project 5.6 0.6 Guinea Bissau-Population Health and Nutrition Project 4.2 0.5 Malawi-Second Family Health Project 11.0 4.8 Zimbabwe-Family Health Project 10.0 2.0 Subtotal 30.8 7.9 Latin America and the Caribbean Jamaica-Population and Health Project 10.0 6.8 Subtotal 10.0 6.8 Total 40.8 14.7 1988 Africa Burundi-Population and Health Project 14.0 4.4 Ethiopia-Family Health Project 33.0 3.3 Kenya-Third Population Project 12.2 22.2 Subtotal 59.2 29.9 Latin America and the Caribbean Brazil-Northeast Endemic Disease Control 109.0 n.a. Subtotal 109.0 n.a. South Asia India-Bombay and Madras Population Project 57.0 57.0 Sri Lanka-Health and Family Planning Project 17.5 5.3 Subtotal 74.5 62.3 Total 242.7 92.2 1989 Africa Benin-Health Services Development Project 18.6 0.3 Mozambique-Health and Nutrition Project 27.0 0.1 Subtotal 45.6 0.4 Middle East and North Africa Yemen, Rep.-Second Health Development Project 4.5 0.4 Subtotal 4.5 0.4 South Asia India-Family Welfare Training and Systems Development Project (Sixth Population Project) 124.6 124.6 Subtotal 124.6 124.6 Total 174.7 125.4 1990 Africa Kenya-Fourth Population Project 35.0 35.0 Lesotho-Second Population, Health, and Nutrition Project 12.1 1.2 Tanzania-Health and Nutrition Project 47.6 9.5 Subtotal 94.7 45.7 Latin America and the Caribbean Brazil-Second Northeast Basic Health Services Project 267.0 13.4 Haiti-First Health Project 28.2 1.6 Subtotal 295.2 15.0 Middle East and North Africa Morocco-Health Sector Investment Loan Project 104.0 10.4 Yemen, Rep.-Health Sector Development Project 15.0 1.5 Subtotal 119.0 11.9 (Continued on next page.) 26 Safe Motherhood and The World Bank Annex 1 (continued) Fiscal Year Region/Project IBRD/IDA Lending P/RH Lending South Asia India-Seventh Population Project 96.7 96.7 Subtotal 96.7 96.7 Total 605.6 169.3 1991 Africa Ghana-Second Health and Population Prcject 27.0 4.9 Madagascar-Health Sector Improvement Project 31.0 4.4 Malawi-Population, Health,and Nutrition Sector Credit 55.5 5.8 Mali-Second Health, Population, and Rural Water Supply Project 26.6 3.0 Nigeria-National Population Project 78.5 78.5 Rwanda-First Population Project 19.6 19.6 Senegal-Human Resources Development Project: Population and Health 35.0 14.8 Togo-Population and Health Sector Adjustment Project 14.2 4.3 Subtotal 287.4 135.3 Eastern Asia and Pacific Indonesia-Fifth Population 104.0 104.0 Subtotal 104.0 104.0 Latin America and the Caribbean El Salvador-Social Sector Rehabilitation Project 26.0 1.5 Haiti-Economic and Social Fund 11.3 0.5 Honduras-Social Investment Fund 20.0 0.2 Mexico-Basic Health Care Project 180.0 3.5 Venezuela-Social Development Project 100.0 5.0 Subtotal 337.3 10.7 Middle East and North Africa Tunisia-Population and Family Health Project 26.0 26.0 Subtotal 26.0 26.0 South Asia Bangladesh-Fourth Population and Health Project 180.0 61.5 Pakistan-Family Health Project 45.0 13.5 Subtotal 225.0 75.0 Total 979.7 351.0 1 992b Africa Niger-Population 17.6 17.6 Mauritania-Health and Population 15.7 6.9 Equatorial Guinea-Health Improvement 5.5 0.7 Subtotal 38.8 25.2 East Asia and Pacific China-Infectious Disease Control 129.6 0.5 Subtotal 129.6 0.5 South Asia India-Family Welfare 79.0 63.2 India-Child Survival and Safe Motherhood 214.5 96.5 India-AIDS Control 84.0 84.0 Subtotal 377.5 243.7 Europe and Central Asia Poland-Health 130.0 6.5 Romania-Health Services Rehabilitation 150.0 40.1 Subtotal 280.0 46.6 Lessons From 10 Years of Experience 27 Latin America and the Caribbean Honduras-Second Social Investment Fund 10.2 0.1 Guyana-Health, Nutrition, Water, and Sanitation 10.3 2.2 Subtotal 20.5 2.3 Total 846.4 318.3 1993 Africa Burundi-Social Action 10.4 0.5 Guinea Bissau-Social Sector 8.8 0.9 Angola-Health 19.9 1.2 Zimbabwe-STI Prevention and Care 64.5 64.5 Subtotal 103.6 67.1 Middle East and North Africa Iran-Primary Health Care and Family Planning 141.4 59.5 Jordan-Health Management 20.0 6.6 Yemen, Rep.-Family Health 26.6 13.3 Subtotal 188.0 79.4 East Asia and Pacific Papua New Guinea-Population and Family Planning 6.9 6.9 Phihppines-Urban Health and Nutrition 70.0 35.0 Indonesia-Third Community Health and Nutrition 93.5 37.4 Subtotal 170.4 79.3 South Asia India-Social Safety Net Sector Adjustment Program 500.0 40.0 Pakistan-Second Family Health 48.0 19.2 India-ICDS 194.0 19.4 Subtotal 742.0 78.6 Latin America and the Caribbean Honduras-Nutrition and Health 25.0 1.0 Chile-Health Sector Reform 90.0 0.9 Ecuador-Second Social Development: Health and Nutrition 70.0 23.1 Columbia-Municipal Health Services 50.0 10.0 Guatemala-Social Investment Fund 25.0 1.0 Subtotal 260.0 36.0 Total 1,464.0 340.4 1994 Africa Burkina Faso-Health and Nutrition 29.2 7.5 Burkina Faso-Population and AIDS Control 26.3 26.3 Chad-Health and Safe Motherhood 18.5 6.1 Comoros-Population and Human Resources 13.0 4.3 Guinea-Health and Nutrition Sector 24.6 2.5 Uganda-Sexually Transmitted Infections (STI) 50.0 50.0 Subtotal 161.6 96.7 East Asia and Pacific China-Rural Health Workers Development 110.0 8.9 Malaysia-Health Development 50.0 0.5 Subtotal 160.0 9.4 South Asia India-Family Welfare (Assam, Rajasthan, Karnataka) 88.6 70.9 Nepal-Population and Family Health 26.7 21.4 Social Sector-Pakistan-Social Action Program 200.0 40.8 Subtotal 351.3 133.1 Latin America and the Caribbean Argentina-Maternal and Child Health and Nutrition 100.0 12.0 (Continued on next page.) 28 Safe Motherhood and The World Bank Annex 1 (continued) Fiscal Year Region/Project IBRD/lDA Lending P/RH Lending Brazil-AIDS and Sexually Transmitted Diseases 160.0 160.0 Nicaragua-Health Sector Reform 15.0 .06 Peru-Basic Health and Nutrition 34.0 10.5 Peru-Social Sector-Social Development and Compensation Fund 100.0 1.4 Subtotal 409.0 184.0 Total 1,045.9 423.2 1995 Africa Benin-Health and Population 27.8 13.9 Burundi-Second Health and Population 21.3 8.0 Cameroon-Health, Fertihty, and Nutrition 43.0 21.5 Chad-Population and AIDS Control 20.4 20.4 Kenya-Sexually Transmitted Infections (STI) 40.0 40.0 Senegal-Community Nutrition 18.2 1.8 Uganda-District Health Services Pilot and Demonstration 45.0 11.3 Zambia-Health Sector Support 56.0 28.0 Zambia-Second Social Recovery 30.0 0.9 Subtotal 301.7 145.8 Middle East and North Africa Lebanon-Health Sector Rehabilitation 35.7 8.9 Subtotal 35.7 8.9 East Asia and Pacific China-Comprehensive Maternal and Child Health 90.0 45.0 China-Iodine Deficiency Disorders Control 27.0 2.7 Indonesia-Fourth Health Project: Improving Equity and Quality of Care 88.0 22.0 Lao PD.R.-Health Systems Reform and Malaria Control 19.2 4.8 Philippines-Women's Health and Safe Motherhood 18.0 18.0 Cambodia-Social Fund 20.0 1.0 Subtotal 262.2 93.5 South Asia India-Andhra Pradesh First Referral Health System 133.0 26.6 Pakistan-Population Welfare Program 65.1 65.1 Bangladesh-Integrated Nutrition 59.8 14.9 Subtotal 257.9 106.6 Europe and Central Asia Croatia-Health 40.0 1.6 Estonia-Health 18.0 0.2 Turkey-Second Health Project: Essential Services and Management Development in Eastem and Southeastern Anatolia 150.0 37.5 Subtotal 208.0 39.3 Latin America and the Caribbean Panama-Rural Health 25.0 4.0 Mexico-Program of Essential Social Services 500.0 50.0 Subtotal 525.0 54.0 Total 1,590.5 448.1 1996 Africa COte d'lvoire-Integrated Health Services Development 40.0 13.5 Sierra Leone-Integrated Health Sector Investment 20.0 1.3 Lessons From 10 Years of Experience 29 Mozambique-Health Sector Recovery Program 98.7 35.9 Subtotal 158.7 50.7 Middle East and North Africa Egypt-Population 17.2 17.2 Morocco-Social Priorities Program: Basic Health 68.0 20.3 Subtotal 85.2 37.5 East Asia and Pacific Indonesia-HIV/AIDS and Sexually Transmitted Diseases (STD) Prevention and Management 24.8 24.8 Vietnam-National Health Support 101.2 39.6 Vietnam-Population and Family Health 50.0 50.0 Subtotal 176.0 114.4 South Asia India-Second State Health Systems Development 350.0 56.0 Pakistan-Northem Health Program 26.7 26.7 Subtotal 376.7 82.7 Europe and Central Asia Bulgaria-Health Sector Restructuring 26.0 9.5 Georgia-Health Project 14.0 8.1 Kyrgyz Republic-Health Sector Reform 18.5 4.2 Russian Federation-Medical Equipment 270.0 90.0 Subtotal 328.5 111.8 Latin America and the Caribbean Mexico-Second Basic Health Care 310.0 111.8 Subtotal 310.0 111.8 Total 1,435.1 508.9 1997 Africa Niger-Health Sector Development Program 40.0 1.7 Subtotal 40.0 1.7 East Asia and Pacific Indonesia-Intensified Iodine Deficiency Control 28.5 1.9 Cambodia-Disease Control and Health Development 30.4 6.1 Subtotal 58.9 8.0 South Asia India-Reproductive and Child Health 248.3 124.1 Sri Lanka-Health Services 18.8 7.6 Subtotal 267.1 131.7 Europe and Central Asia Turkey-Primary Health Care Services 14.5 4.4 Bosnia-Herzegovina-Essential Hospital Services 15.0 2.0 Russia-Health Reform Pilot 66.0 19.7 Subtotal 95.5 26.1 Latin America and the Caribbean Argentina-Matemal and Child Health and Nutrition 100.0 33.3 Paraguay-Maternal Health and Child Development 21.8 16.2 Argentina-AIDS and Sexually Transmitted Diseases Control 15.0 15.0 Subtotal 136.8 64.5 Total 598.3 232.0 1998 Africa Eritrea-National Health Development 18.3 9.9 The Gambia-Participatory Health, Population and Nutrition 18.0 5.8 Guinea-Bissau-National Health Development Program 11.7 9.3 Madagascar-Community Nutrition 11 Project 27.6 5.0 (Continued on next page.) 30 Safe Motherhood and The World Bank Annex 1 (continued) Fiscal Year Region/Project IBRD/IDA Lending P/RH Lending Mauritania-Health Sector Investment Project 24.0 8.0 Senegal-Integrated Health Sector Development Program 50.0 20.0 Ghana-Health Sector Support Program 35.0 7.0 Subtotal 184.6 65.0 Middle East and North Africa Egypt-Health Sector Reform Program 90.0 33.0 Tunisia-Health Sector Loan 50.0 5.0 Subtotal 140.0 38.0 East Asia and Pacific China-Basic Health Services Program 85.0 6.1 Indonesia-Safe Motherhood Project 42.5 42.5 Philippines-Early Childhood Development Project 19.0 2.0 Subtotal 146.5 50.6 South Asia Bangladesh-Health and Population Program Project 250.0 84.0 India-Orissa Health Systems Development Project 76.4 7.0 India-Woman and Child Development 300.0 80.0 Subtotal 626.4 171.0 Europe and Central Asia Armenia-Health Financing and Primary Health Care Development Project 10.0 2.7 Subtotal 10.0 2.7 Latin America and the Caribbean Dominican Republic-Provincial Health Services Project 30.0 14.4 Ecuador-Health Services Modernization Project 45.0 7.8 Nicaragua-Health Sector Modernization Project 24.0 6.0 Mexico-Health Systems Reform 700.0 70.0 Subtotal 799.0 98.2 Total 1,906.5 425.5 a. Includes P/RH activities in some social sector projects. b. Starting in FY92, the World Bank broadened its definition of Population to Population and Reproductive Health (P/RH) Source: Staff Appraisal Reports and Project Appraisal Documents Lessons From 10 Years of Experience 31 Annex 2 Cost of Mother-Baby Package, by intervention and input Cost of Mother-Baby Package, by intervention (low-income scenario) Eclampsia Syphilis Gonorrhea & Clamydia 1% \ 1 1% / 1% Abortion complications Severe Anemia 4% ~\ 1% Caesarean section 5%- Sepsis l _ - Antenatal Care 6% 25% Haemorrhage 9% Neonatal- complications 13$10% ~"Normal Delivery 20% Family Planniing 14% Source: Lissner, C. and E. Weissman. How much does safe motherhood cost? World Health, WHO, 5SLtYear, No. ijanuary-February 1998, pages 10-1 1. Cost of Mother-Baby Package, by input (low-income scenario) IEC and Social Blood Supplies Transport (Petrol) Marketing I % % Support Salaries I i Laboratory SUpplieS 3% 1 Supervision 1 3% _0 Bed/Hotel Costs 4% Maintenance and Clinicab Persowm c i Utilities -39 CiialPrsne 6% Supplies - 10% 12ktig2% /1 /%\ Dup rugalris \ ILbrtoySple 12%/HolCapital Cost 16% Source: Lissner, C. and E. Wejissman. "How much does safe motherhood cost?" World Health, WHO, 51st Year, No. 1 January-February 1998, pages 10-11. 32 Safe Motherhood and The World Bank Annex 3 Poor-Rich Inequalities in Access to Different Types of Health Care (unweighted average of 10 developing countries) 90 - 80 - 70 - 60 - 50 - 40 ' 30 - 0- l l 1st 3rd 5th Quintile Quintile Quintile (Poorest) (Richest) - Attended Deliveries - Diarrhea Treatment (in Health Facility) - ARI Treatment (in -- Immunizations (All) Health Facility) Source: World Bank. HNP Poverty Thematic Group Analysis. May 1999. Lessons From 10 Years of Experience 33 Annex 4 World Bank-supported Safe Delivery Activities in 29 Countries between 1987 and 1998 World Bank Regions Countries where World Bank health projects include safe delivery activities Sub-Saharan Africa Chad Gambia, The Ghana Rwanda Madagascar Zimbabwe South Asia Bangladesh India Pakistan East Asia and the Pacific China Indonesia Philippines Vietnam Middle East and North Africa Egypt, Arab. Rep. Morocco Turkey Jordan Tunisia Yemen, Rep. of Latin America and the Caribbean Argentina Brazil Dominican Republic Haiti Honduras Paraguay Peru Nicaragua Europe and Central Asia Bosnia and Herzegovina Romania Source: Staff Appraisal Reports and Project Appraisal Documents 34 Safe Motherhood and The World Bank Annex 5 Countries with Highest Maternal Mortality Ratios (600-1,500 maternal deaths per 100,000 live births) and Selected Information Related to World Bank Assistance and Basic Indicators Active World Bank Latest CAS health mentions project with Maternal % of births any Safe Family Safe mortality/ attended Motherhood planning delivery Maternal 1997 by trained Country activities included included health MMR TFR health staff 1. Angola No - - N/A 1,500 6.8 17 2. Nepal Yes Yes No No 1,500 4.4 9 3. Ethiopia No - - No 1,400 6.5 8 4. Yemen, Rep. Yes Yes Yes Noa 1,400 6.4 43 5. Burundi Yes Yes No No 1,300 6.3 24 6. Rwanda Yes Yes Yes No 1,300 6.2 26 7. Mozambique Yes No No Yes 1,100 5.3 44 8. Gambia, The Yes Yes Yes Yes 1,050 5.7 44 9. Eritrea Yes No No No 1,000 5.8 21 10. Nigeria Yes Yes No N/A 1,000 5.3 31 11. Burkina Faso Yes Yes No No 930 6.6 41 12. Guinea-Bissau Yes Yes No Yes 910 5.8 25 13. Cambodia Yes No Yes No 900 4.6 31 14. Congo,Rep. No - - No 890 6.1 50 15. Guinea Yes Yes No No 880 5.5 31 16. Congo, Dem. Rep. No - - N/A 870 6.4 17. Bangladesh Yes Yes Yes Yes 850 3.2 8 18. Chad Yes Yes Yes Yes 840 6.5 15 19. Cote d'lvoire Yes Yes No No 810 5.1 45 20, Mauritania Yes Yes No Yes 800 5.5 40 21. Ghana Yes Yes No Yes 740 4.9 44 22. Central African Rep. No - - N/A 700 4.9 46 23. Lao PDR Yes Yes No Yes 660 5.6 30 24. Kenya No - - No 650 4.7 45 25. Zambia Yes No No No 650 5.6 47 26. Togo Yes Yes No N/A 640 6.1 32 27. Malawi Yes Yes No No 620 6.4 55 28. Lesotho No - - No 610 4.8 50 29. Haiti Yes No Yes Yes 600 4.4 20 a. Yemen 1999 CAS in process refers to maternal mortality Note: The table indicates the following safe motherhood activities supported through Bank projects = safe delivery, family planning, and maternal health care or services. Other donors may be providing assistance for safe motherhood activities, especially for family planning. Source: World Bank. World Development Indicators 1999 and various Bank project documents. Lessons From I0 Years of Experience 35 Annex 6 ICPD Definition of Reproductive Health Reproductive health care in the context of primary health care should, inter alia, include: family-planning coun- selling, information, education, communication and services; education and services for prenatal care, safe deliv- ery and post-natal care, especially breast-feeding and infant and women's health care; prevention and appropri- ate treatment of infertility; abortion as specified in paragraph 8.25, including prevention of abortion and the management of the consequences of abortion; treatment of reproductive tract infections; sexually transmitted dis- eases and other reproductive health conditions; and information, education and counselling, as appropriate, on human sexuality, reproductive health and responsible parenthood. Referral for family planning services and fur- ther diagnosis and treatment for complications of pregnancy, delivery and abortion, infertility, reproductive tract infections, breast cancer and cancers of the reproductive system, sexually transmitted diseases, including HIV/AIDS should be available, as required. Active discouragement of harmful practices, such as female genital mutilation, should also be an integral component of primary health care, including reproductive health-care pro- grammes. Source: From the October 18, 1994 Report of the International Conference on Population and Development, Cairo, Egypt, September 5-13, 1994. 36 Safe Motherhood and The World Bank Annex 7 Projects with Safe Motherhood Components in Country Reviews, 1986-1998 Country Project Name and Cost Project Objectives Key Safe Motherhood Components Bangladesh Third Population and Family Health * Help government achieve a 38%- * Strengthening delivery of and Project 40% contraceptive prevalence rate demand for family planning and and a reduction in the total fertility maternal/child health services Projects cost: $213.8 million rate to 4.8 through improved management FY 86-FY 92 * Reduce matemal and child mortal- and training; deployment of addi- ity tional personnel; provisions of drugs, medicines, and supplies; and infrastructure Improving childbirth practices by training traditional birth atten- dants and family welfare visitors, providing delivery kits, and improving the referral capabilities of field workers Bangladesh Fourth Population and Health Project * Strengthen family planning ser- * Training traditional birth atten- vices delivery dants Project cost: $ 601.4 million * Strengthen health services delivery * Screening and referring high-risk FY 91-FY 98 * Improve supportive activities to pregnancies the delivery of family planning and * Strengthening delivery of and health services demand for antenatal, delivery, * Continue women's work and nutri- and postpartum services tion programs * Supporting a special matemal and neonatal health care project * Strengthening obstetric and gyne- cological services at health centers and district hospitals - Strengthening nursing and medical education and introducing medical assurance Bangladesh Health and Population Program Project * Improve access to services for the * Provision of essential and emer- (10 poor gency obstetric care * Lower maternal mortality and * Strengthening referral system Project cost: $2,895.9 million morbidity * Proposing a Behavior Change BY 98-FY 04 * Improve child health and family Communication initiative to planning address those behaviors related to pregnancy and childbirth Brazil Northeast Basic Health Services Project * Improve the organization and use * Training health personnel in of resources for delivering a pack- maternal and adolescent health Project cost: $129.7 million age of three programs of essential FY 88-FY 96 basic health services, including: (i) a program of comprehensive care for women and children (includ- ing family planning), (u) a pTO- gram of infectious diseases control, and (iii) a program of walk-in as well as hospital-based medical care Lessons From 10 Years of Experience 37 Country Project Name and Cost Project Objectives Key Safe Motherhood Components * Improve and expand the network of basic health facilities * Strengthen the institutional capa- bilities of the State Secretariats of Health and the Ministry of Health * Prepare a second-phase project for the other six states of the Northeast. Brazil Second Northeast Basic Health Services * Strengthen basic health services * Comprehensive care for women Project * Support investment in health facil- and children, including family ities in previously underserved planning Project cost: $610.6 million areas * Infrastructure development, FY 90-FY 97 * Strengthen federal and state man- including 81 obstetric and delivery agement of the health sector units * Training 60,000 personnel in maternal and adolescent health Brazil Health Sector Reform (REFORSUS) . Estabhsh an investment fund to * Increasing antenatal visits to 80% finance rehabilitation, equipment, * Aiming to reduce maternal mortal- Project cost: $750 milhon and improved management of the ity, but no other specific safe FY 97-FY 01 Unified Health System motherhood components included D Institutional development to improve health care financing and management Chad Health and Safe Motherhood Project * Enhance capability at the central * Strengthening capacity in IEC level to support regional health (Information, Education and Project cost: $25.7 million services Communication) for maternal FY 94-FY 00 * Improve access to basic and mater- health nal health services in two regions * Enhancing the capacity of health (Guera and Tandjile) centers to provide obstetric ser- * Ensure that the population has vices access to low-cost essential drugs * Training physicians and other health providers in basic emer- gency care * Improving transport and commu- nication system for emergency care * Conducting research related to maternal mortality Chad Population and AIDS Control Project * Advance the onset of fertility * Promoting information and educa- decline by increasing the use of tion in family planning and Project cost: $27.2 milhon modern methods of contraception HIV/AIDS FY 95-FY 01 * Slow the spread of HIV infection * Promoting family planning ser- by promoting behavioral change vices, especially condom use * Estabhshing activities to improve identification and treatment of sex- ually transmitted infections (Continued on next page.) 38 Safe Motherhood and The World Bank Annex 7 (continued) Country Project Name and Cost Project Objectives Key Safe Motherhood Components India Child Survival and Safe Motherhood * Enhance child survival * Providing prenatal care by distrib- Project * Prevent matemal mortality and uting iron foliate tablets, tetanus morbidity toxoid immunization, and training Project cost: $329.6 million * Increase the effectiveness of service in clean delivery techniques FY 92-FY 97 delivery * Establishing First Referral Units by upgrading subdistrict hospitals and community health centers with equipment for essential obstetric care and safe mother- hood technical guidelines India Population XI: Family Welfare * Strengthen and improve the func- * Construction of subcenters and (Assam, Rajasthan and Karnataka) tioning of the Government of Primary Health Centers to serve as Project India's Family Welfare Program first referral units for obstetric with the objective of lowering cur- emergencies Total project cost: $103.8 million rent levels of fertility and maternal * Strengthening outreach and com- FY 94-FY 02 and child health in the three states munity linkages by setting up mobile clinics and establishing volunteer networks. India Reproductive and Child Health Project * Improve management performance * Improving the performance of by nationwide implementation of Family Welfare Program in reduc- Project cost: $309.0 million policy change referred to as the ing maternal mortality and mor- FY 97-FY 03 "target-free approach," and institu- bidity tional strengthening for timely, * Fixing the systems that deliver coordinated utilization of project women's health services, including resources the planning and implementation * Improve the quality, coverage, and systems as well as those for moni- effectiveness of Ffmily welfare ser- toring and evaluation vices. * Conducting rigorous district-level * Progressively expand the scope surveys. and content of existing family wel- fare services to include more ele- ments of a definedessential pack- age of reproductive and child health services * In selected disadvantaged districts and in cities, expand access by strengthening family welfare infra- structure while improving its qual- ity Indonesia Fifth Population Project * Help the government intensify * Implementing policies to allow efforts to lower fertility midwives to practice with and Project cost: $148.4 million * Reduce maternal mortality by without supervision FY 91-FY 97 improving the effectiveness of * Contributing to the development community midwives and training of standards and protocols for an additional 16,000 during the midwives 1990s Lessons From 10 Years of Experience 39 Country Project Name and Cost Project Objectives Key Safe Motherhood Components Indonesia Third Community Heafth and Nutrition * Elevate infant, child, and maternal Building provincial and kabupaten Project health status by improving the capacity to plan, implement, and effectiveness of community health evaluate safe motherhood (includ- Project cost: $ 164.1 million and nutrition interventions in five ing family planing), child survival, FY 93-FY 00 provinces (West Java, Central Java, and nutrition interventions East Nusa Tenggara, Maluku, and * Training traditional birth atten- Irian Jaya) dants and BDDs (Bidan di Desa: village midwives) Providing essential equipment and supplies, matemity huts, and health centers Indonesia Safe Motherhood Project: A * Improve demand for and utihza- * Improving supply and demand for Partnership and Family Approach tion of high-quality maternal maternal health services health services. * Strengthening sustainability of Project cost: $61.9 million * Strengthen the sustainability of maternal health services at the FY 98-FY 03 matemal health services at the vil- * village level lage level * Increasing demand for and access * Improve quality of family planning to high-quality family planning services services * Prepare adolescents to lead a * Giving the government the oppor- healthy reproductive life tunity to develop and test alterna- tive strategies for addressing ado- lescent reproductive health issues. Philippines Health Development Project * Achieve improvements in the con- * Increasing the number of mid- trol of major communicable dis- wives who provide family plan- Project cost: $108.4 million eases ning services and antenatal, deliv- FY 89-Fy 97 * Reduce infant and child deaths, ery, and postpartum care in rural maternal mortality and fertility areas - Upgrade institutional capacities of * Financing the revision of training the Department of Health at all curricula for midwives and other levels to improve the program health staff effectiveness and managerial effi- ciency - Promote health equity by targeting high-risk groups according to degrees of risk and/or disease prevalence * Strengthen partnerships among the Department of Health, local governments, and nongovemment organizations * Establish improved planning mechanisms and consultation mechanisms for longer-term health policies and programs (Continued on next page.) 40 Safe Motherhood and The World Bank Annex 7 (continued) Country Project Name and Cost Project Objectives Key Safe Motherhood Components Philippines Women's Health and Safe Motherhood * Improve women's health, focusing Strengthening maternal health care Project on women of reproductive health, services, including family plan- thereby supporting the govern- ning, diagnosis and treatment of Project cost: $136.44 million ment's long-term goals of reducing reproductive tract and sexually FY 95-FY 02 fertility transmitted infections, and detec- * Improve the quality and range of tion and treatment of cervical can- maternal health and safe mother- cer hood services * Training health workers in provid- * Strengthen the capacity of local ing new services, information, government units to manage the education and communication provision of these services, and the techniques, and in using the new Department of Health to provide logistics system policy, technical, financial, and * Fostering community partnerships logistical support with nongovernment and local * Enhance the effectiveness and sus- government organizations tainability of health interventions * Conducting policy and operations through the participation of local research on women's health. communities and nongovernment organizations in the project * Expand the knowledge base upon which to draw policy and techni- cal guidance for women's health programs Romania Health Services Rehabilitation Project * Assist the government in rehabili- * Procurement and distribution of tating and upgrading the primary contraceptives Project cost: $207.5 million health care delivery system * Support and training in identifica- FY 92-FY 99 * Lay the groundwork for a major tion and treatment of high-risk restructuring of health system pregnancies, neonatal intensive financing, and management in the care, and cervical cancer screening medium term * Establishing a family planning and sex education unit * Establishment and provision of equipment and training for a net- work of family planning reference centers * Provision of equipment and train- ing of maternities * Rehabilitation of rural dispensaries Yemen Health Sector Development Project * Improve health services and facili- * Building three new regional nurs- tate their extension to under- ing and midwifery institutes, Project cost: $19.1 million served communities by strength- expanding an existing one, and FY 90-FY 99 ening the administrative, human rehabilitating another. resources, and support services * Developing a maternal and child health emergency unit and blood bank to support ongoing efforts to improve essential obstetric ser- vices. Lessons From 10 Years of Experience 41 Country Project Name and Cost Project Objectives Key Safe Motherhood Components Yemen Family Health Project * Reduce maternal mortality, mor- * Strengthen management of obstet- bidity and fertility rical emergencies, blood banking Project Cost: $30.2 million * Improve management effectiveness and operating theaters at the dis- FY 93-FY 01 in the health sector trict hospitals * Improving patient referral system * Providing fellowships for mid- wifery training Zimbabwe Family Health Project * Increase the availability and use of * Training for health workers in maternal and child health care and family planning and midwifery Project cost: $52.6 million family planningservices * Raising the contraceptive preva- FY 87-FY 94 * Improve the health status of moth- lence rate ers and children * Increasing the percentage of * Strengthen the government's insti- women receiving antenatal care tutional capacity to plan and having attended deliveries Zimbabwe Second Family Health Project * Improve maternal and child health * Increasing the percentage of and nutrition status women receiving antenatal care Project cost: $116.9 million * Reduce the population growth rate and delivering in health facilities FY 91-FY 99 * Ensure that target district house- * Increasing the percentage of holds have access to basic health women of reproductive age using services modern contraceptives and the * Improve training for health work- percentage of married women ers in family planning, midwifery, using permanent or semiperma- nutrition, and management skills nent methods of contraception * Enhance management capacity of * Training doctors and nurses in the Ministry, Zimbabwe National family planning Family Planning Council, and * Training nurses in midwifery in select nongovernment organiza- district and rural areas tions Source: Staff Appraisal Reports, Project Appraisal Documents, and Discussions with Task Team Leaders. 42 Safe Motherhood and The World Bank Annex 8 importance of Areas of Sectoral Emphasis for Different Income Groups, 1990 (Percent of total deaths in different income groups attributable to diseases indicated) 50 50 - MCH+Nutrition 40 30- Smoking-related diseases 30- Tuberculosis 20 Malaria 10 - AIDS Poorest 20% Middle 20% Richest 20% Global Population Note: WHO current estimates of overall AIDS deaths have increased since 1990. How this increase has been distributed among nch and poor is unknown. Source: World Bank. HNP Poverty Thermatic Group Analysis. May 1999. Annex 9 Removing Barriers to Progress in Safe Motherhood Problems Strategic Objectives Interventions Indicators Unplanned and poorly timed pregnancies Poorly timed and unplanned pregnan- Reduce unwanted fertility by ensuring Expand family planning services through Total fertility rate. Contraceptive preva- cies contribute to maternal mortality access to high-quality, client focused fami- community-based distribution, social mar- lence rate. and morbidity. ly planning information and services. keting, and health facilities. Complications and death from unsafe Reduce complications from unsafe abor- Ensure safety of abortion where permitted Total admissions for abortion-related abortions contribute to a high risk of tion by providing timely and appropriate and provide post-abortion care and family complications. Case fatality rate for injury or death. treatment of abortion complications, as planning information and services. post-abortion complications. well as providing postcoital contraception and safe termination of pregnancy, where not against the law. Family planning services are available Improved women's access to a full range Strengthen providers' skills and establish Percent of women who receive contra- but quality of services is likely to of family planning services and broader quality assurance approach for family plan- ceptive counsehng. remain poor. reproductive health services. Improved ning. the quahty of family planning services and method choice. Poor maternity care, especially for obstetric complications Large number of preventable deaths Reduce matemal morbidity and mortality Ensure prompt detection, management, and Matemal mortality ratio. Percent of continue to occur among women dur- through skilled attendance at delivery and referral of complications. Train staff in mid- deliveries with skilled attendant. ing childbirth. management of obstetric complications, wifery skills at all levels of the health system. Maternal and perinatal death reviews. including emergencies. Access to maternal health services is Strengthen institutional capacity of health Ensure early contact with health provider for Percent of pregnant women receiving limited. Obstetric services at health system to increase access to and availabih- appropriate care, counseling, and birth plan- antenatal care at least once. Percent of centers are unavailable or of poor ty of maternity care services. Ensure ning. Improve skills and supervision of com- pregnant women who are anemic. quality appropriate micronutrient supplementa- munity-based and health center staff in rou- Number and distribution of basic tion and management of malaria, tubercu- tine maternal and neonatal care, managing or essential obstetric care facilities. losis, STIs. referring complications, and first aid. Adopt competency-based training approach. Poor women most needing maternity Ensure that public spending on maternity Promote private services for those who can Percent of poor women who deliver care are least likely to get it. care benefits the poorest women. afford it and assure pubhc funds are used to with skilled attendant. finance care for the poor. (Continued on next page.) - Annex 9 (continued) Problems Strategic Objectives Interventions Indicators District hospitals lack capacity-skills, Strengthen institutional capacity of health Staff and equip district hospitals to manage Number and distribution of district hos- equipment, and supplies-to respond system to link community-based materni- obstetric complications, assure 24-hour ser- pitals which can appropriately manage to obstetric complications. ty care services and health centers with vice, and accountability postpartum hemorrhage and cesarean functional district hospital obstetric ser- section. Ratio of complicated cases to all vices. obstetric admissions. Institutional case fatality rate. Referral is difficult because of lack of Organize an effective alarm and transport Mobilize communities to organize for trans- Percent of women with complications transportation and/or communications system, by improving roads, transport, port and referral for emergencies. referred to essential obstetric care ser- from the community to the referral and communication. vices in a timely manner. facihty Risky/harmful practices that under- mine maternal health Unwanted pregnancies and unsafe Increase awareness of knowledge of fami- Educate women and youth about family Proportion of pregnancies not intended. sexual practices among adolescents ly planning services among youth. planning and provide a variety of methods Percent of sexually active adolescents jeopardize their health. that can be obtained at community level. who use family planning. Limited services are available to Use maternity care as an entry point to Ensure availabihty of services for RTls/STIs Percent of pregnant women screened address prevention and treatments of provide broader reproductive health ser- and treatment for other health conditions. and treated for STIs. Percent of pregnant STIs, including HIV/AIDS, elimination vices, such as services for RTIs/STIs/AIDs Provide appropriate laboratory equipment women seropositive for HIV infection. of harmful practices such as female and infertility as well as other health con- and drugs. genital mutilation, and other women's ditions such as tuberculosis, malaria, etc. health services. Lack of political commitment to Safe Motherhood National and community leaders do Increase political awareness and commit- Prepare sector work or local research on safe Demonstration of national and local not promote safe motherhood. ment to address safe motherhood. motherhood for national leaders and pro- commitment to safe motherhood. gram managers. Conduct national and local Existence of a safe motherhood strategy. level meetings to raise interest and commit- ment. Low status of women in society Women's status in society is limited by Reduce high desired fertility by increasing Improve education for girls and better Percent of females enrolled in secondary low education levels, limited employ- child survival, education girls, and reduc- employment opportunities for women. school. ment opportunities, and other socio- ing gender bias in employment, credit, Improve health communications capacity. cultural factors. laws, etc. Support involvement of women's groups. 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