Maternal mortality accounts for a large proportion of the deaths occurring among women of childbearing age in most of the developing world. Each year, about half a million women die from causes related to pregnancy and childbirth, and 99% of these deaths occur in developing countries. International concern over this appalling situation has greatly increased in recent years and has been emphasized in the conclusions and recommendations of both the International Conference on Population in 1984 and the World Conference to Review and Appraise the Achievements of the UN Decade for Women in 1985. A major international meeting, the Safe Motherhood Conference, held in Nairobi in 1987, was devoted to the subject.
The World Health Organization has recently intensified its efforts to improve maternal health care, focusing specifically on the reduction of maternal mortality. With the support of the United Nations Population Fund, WHO has initiated a worldwide programme on the collection, analysis and dissemination of information on maternal mortality and on the improvement and extension of coverage of maternal health care.
As part of this programme, a WHO Interregional Meeting on Prevention of Maternal Mortality was held in Geneva in 1985. Experts from many parts of the developing world reviewed the results of more than 20 studies on maternal mortality from all regions of the world. They then considered the medical, health service, reproductive and socioeconomic factors responsible for the very high maternal death rates in developing countries and outlined a series of actions needed,1 concluding that a reduction of maternal mortality and morbidity required the following:
• improved living standards, through general socioeconomic development;
• trained supervision of pregnancy and labour at the primary health care level, and recognition and referral of women at high risk;
• better access to referral facilities for the management of complications of pregnancy and childbirth; and
• universal availability of appropriate family planning methods.
1Prevention of maternal mortality: report of a WHO Interregional fleeting, Geneva, 1985. Geneva. World Health Organization, 1986 (unpublished document FHE/86.I; available on request from the Division of Family Health, World Health Organization, Geneva, Switzerland).
Improvement in the quality and coverage of primary health care will do much to reduce the risks of childbearing, but the major complications of pregnancy, labour and the puerperium require skills and facilities which should be made available at the first referral level - the district or subdistrict hospital or a suitably staffed and equipped health centre - as well as at the secondary referral level of care. Many maternal deaths occur at first referral level, either because women come from too far and arrive too late, or because the essential obstetric care they urgently need is not available.
In 1986, WHO convened a Technical Working Group (Annex 1) to define the essential obstetric care necessary at first referral level for the reduction of maternal mortality and morbidity, and to describe the staff, training, supervision, facilities, equipment and supplies needed (Annexes 2-5). Dr. R. Cook (formerly Division of Family Health, WHO, Geneva) was Secretary to the group and subsequently arranged for its report1 to be reviewed by some 50 experts in maternal health from many parts of the world. The present publication is based on this report, revised to take account of the comments received. It has been prepared by Dr M. Fathalla (Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva), Dr K. A. Harrison (University of Port Harcourt, Nigeria) and Dr B. E. Kwast (Maternal and Child Health, WHO, Geneva), with the collaboration of Dr G. Stott (formerly WHO, Geneva).
1Essential obstetric functions at first referral level: report of a WHO Technical Working Group, Geneva, 1986. Geneva, World Health Organization, 1986 (unpublished document FHE/86.4; available on request from the Division of Family Health, World Health Organization, Geneva, Switzerland).
The book is intended for those responsible at district, provincial, regional, national and international levels for the planning, financing, organization and management of maternity care services, in particular in developing countries. The guidelines provided should not only make it possible to raise the standards of referral services at the district level to those required, but also help decision-makers to determine how far and by what means it may be possible to extend some of these services to more peripheral levels. This may involve upgrading both staff and facilities, where feasible and affordable, or may only require the extension of the skills of certain categories of health personnel, together with quite a modest addition of equipment and supplies and redeployment of space.
The severe economic constraints faced by many countries have been a major consideration in the preparation of this publication. Every effort, therefore, has been made to include only those requirements considered indispensable in assisting health authorities to reduce maternal mortality and morbidity by bringing competent obstetric care within the reach of all who need it. For certain procedures and techniques that are not at present in widespread use at first referral level in developing countries, points of technical relevance have been included in the text.
The World Health Organization acknowledges with gratitude the financial contribution of the United Nations Population Fund, which since 1984 has supported the WHO interregional project on the prevention of maternal mortality. It is as part of this project that this publication has been prepared.