Making pregnancy safer in least developed countries: the challenge of delivering available services.

• Author: Islam, Quazi Monirul

The international community came together 20 years ago in Nairobi, Kenya, to launch the Safe Motherhood Initiative and highlight the most striking inequity in public health. This global initiative was developed to generate political will, identify effective interventions and mobilize resources that would rectify a horrifying injustice. Yet, each year 3.3 million babies are stillborn and more than 4 million newborns die within 28 days of coming into the world. Some 536,000, often sudden, unpredicted deaths occur among women during pregnancy, childbirth or after the baby is born, leaving behind devastated families who are often pushed into poverty because of the cost of health care that came too late or was ineffective.

Although an increasing number of developing countries has succeeded in improving the health and well-being of mothers and their newborns in recent years, the countries that started off with the highest burdens of maternal and neonatal mortality and ill-health made least progress during the 1990s. In some countries, the situation has actually worsened. Worrying reversals in maternal and newborn mortality have taken place. Progress has slowed down and is increasingly uneven, leaving large disparities between regions and countries. Moreover, within individual countries, there are often striking inequities and differences between population groups. National figures often mask substantial internal variations--geographical, economic and social. Rural populations have less access to skilled care than urban dwellers; mortality is higher among slum populations within urban dwellers; rates can vary widely by ethnicity or wealth status; and remote areas often bear a heavy death burden. Unless efforts are stepped up significantly, there is little hope of eliminating avoidable maternal and newborn mortality.

There is no doubt that technical knowledge exists to respond to most of the critical problems that affect the health and survival of mothers and newborns. The strategies through which households and health systems together can make sure technical solutions are put into action for all, in the right place and at the right time, are also becoming increasingly clear. However, too often programmes have been allowed to fragment, thus hampering the continuity of care, or have failed to give due attention to professionalizing services. Technical experience and the successes and failures of the recent past have shown how best to move forward.

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