Starting maternity care programmes in developing countries to reduce maternal mortality

This paper provides a descriptive summary of the MotherCare project experience in collaboration with the Ministries of Health and non-governmental organizations in Bolivia, Guatemala, Indonesia and Nigeria. In accordance with the global safe motherhood initiative, MotherCare's purpose is to improve pregnancy outcomes for women as well as newborns in diverse settings from a resource-poor to a resource-rich environment with concomitant reductions in maternal and perinatal mortality. The three major intervention strategies are affecting behaviours, improving services and policy reform. Quantitative and qualitative research prior to start-up directs the relative emphasis of each intervention depending on the strength and limitations of access of care. During 1989-93, training efforts were directed at traditional birth attendants (TEA), midwives and physicians, information, education and communication strategies were developed and, in Indonesia, the referral chain was strengthened with radio communication and ambulance services. A decrease in perinatal mortality either at community or hospital level was achieved in most projects. However, the implementation period was too short to achieve a significant reduction in maternal mortality. Improvements in labour and delivery management at the hospital level in Nigeria showed a reduction in maternal morbidity. While recognition of complications by women and TEA improved after training information, education and communication campaigns, this was not necessarily followed by an increase in compliance with referral and hospital admission. It is clear that in societies with strong preference for home delivery, the willingness to break with deeply valued cultural and traditional norms in the event of obstetrical complications, will require long-term strategies and solutions which harmonize the traditional and biomedical approach to maternity care.