Much progress has been made in the last 10 years towards a better understanding of the problem of maternal mortality. However, despite heightened international awareness and commitment, only a few countries have adopted national programmes of sufficient magnitude to make a major impact on the level of maternal mortality. There is an urgent need for immediate action if the goals of the Safe Motherhood Initiative are to be achieved by the year 2000.
The Programme of Action of the International Conference on Population and Development, adopted by consensus in September 1994, has recognized that meeting the reproductive health needs of women and men is a critical requirement for human and social development. The Conference affirmed that reproductive health care is an integral component of primary health care and should be provided in that context. Reproductive health care includes, at the very minimum, prevention and management of sexually transmitted diseases (STDs); family planning information and services that permit people to choose the timing, spacing and number of their children; and safe motherhood to ensure women are able to go safely through pregnancy and childbirth and have a healthy infant. These elements have a profound impact on the course and outcome of pregnancy, and the health service requirements for addressing them are closely related. The Mother-Baby Package addresses all these aspects of reproductive health and thus provides an opportunity to develop an integrated approach to service delivery.
The Mother-Baby Package does not focus solely on maternal mortality. It is clear that the factors that cause the more than 500 000 maternal deaths a year overlap with those that cause maternal morbidity, stillbirths and neonatal mortality and morbidity. What will reduce maternal mortality will certainly reduce the others as well. Moreover, it is impractical to separate maternal care from care of the newborn. In this Package, mother and baby are treated as one entity - a dyad.
The Mother-Baby Package is based on a number of underlying principles which are intrinsic elements of primary health care.
• Interventions must be based on the best scientific information available and must use only those methods that have been scientifically demonstrated to be valid.
• There must be equity in access to care for all, including the poor and disadvantaged.
• Services should be provided at the lowest level of the health care system capable of performing them adequately.
• Resources, both human and material, must not be concentrated at the apex of the health care system but must be redistributed to the periphery and to the communities where people live (decentralization).
• There should be delegation of responsibility and of authority, coupled with supportive supervision.
• Quality of care is as important as access to care and implies the existence of the skills and equipment that are necessary, as well as client-provider relationships that are appropriate.
• There should be appropriate use of technologies, avoiding high-technology interventions when equally effective alternatives are available.
• Communities should be involved in developing, implementing and evaluating the services that are provided for them.
• Health care providers should work together in a spirit of teamwork and collaboration.
• Health interventions must be cost-effective and sustainable.
This Mother-Baby Package is intended to facilitate national strategies and plans of action. It is addressed to national decision-makers and those responsible for health planning. It is also intended to be used by the staffs of United Nations and bilateral agencies and nongovernmental organizations (NGOs) concerned with maternal and neonatal health. However, it is not limited to “strategic” issues; components of the Package and its annexes give details on the “what” and “how” of the required actions. Detailed managerial guidelines and other support materials are available, or are in preparation, to facilitate the implementation of the interventions.
The problems of maternal and neonatal mortality are complex, involving women’s status, education, employment opportunities and the availability to women of basic human rights and freedoms. While interventions in these areas should start now, it would not be realistic to expect to make major changes in less than a generation. Thus it is necessary to identify interventions that will make a visible impact in the immediate term.
This document is intended to allay apprehensions that safe motherhood is just another “vertical” programme. The nature of the core elements of the Mother-Baby Package is such that they cannot operate on their own. They must be integrated with and operate through existing health systems. The strategies depend on augmenting and making the best use of existing resources. For this reason, the cost of implementing the Package may be less than anticipated, especially in countries where the infrastructure already exists. Moreover, as the World Bank’s World Development Report 1993 implies, safe motherhood is a reliable, cost-effective investment.
The basic principles of the Mother-Baby Package are neither new nor controversial - they are considered the “four pillars” of safe motherhood:
1. Family Planning - to ensure that individuals and couples have the information and services to plan the timing, number and spacing of pregnancies;
2. Antenatal Care - to prevent complications where possible and ensure that complications of pregnancy are detected early and treated appropriately;
3. Clean/Safe Delivery - to ensure that all birth attendants have the knowledge, skills and equipment to perform a clean and safe delivery and provide postpartum care to mother and baby;
4. Essential Obstetric Care - to ensure that essential care for high-risk pregnancies and complications is made available to all women who need it.
Fig. 1 The “four pillars” of safe motherhood
These four strategic interventions must be delivered through primary health care and rest on a foundation of greater equity for women.
Even though the five major causes of maternal death are common to all developing countries, there are considerable variations between countries and even within individual countries. These variations make regional and national adaptation essential. The value of this Package can be determined only through its adaptation, its wide dissemination and, above all, its use.
The Mother-Baby Package is the product of extensive consultation. The World Health Organization (WHO) received valuable feedback from its partners in safe motherhood, especially UNDP, UNFPA, UNICEF and the World Bank, as well as governments, universities, NGOs and bilateral agencies. Their comments have been carefully taken into consideration in preparing this version. The World Health Organization is most grateful to all who have contributed to this initiative to reduce the tragic damage and loss caused by maternal and neonatal mortality.
The World Health Organization welcomes comments on the Mother-Baby Package, especially from those working to alleviate the burden of maternal deaths and disabilities in developing countries. Please complete the form at the end of the document and send it to:
Maternal Health and Safe Motherhood Programme
Division of Family Health
World Health Organization
20 Avenue Appia
CH-1211 Geneva 27