PART III
Improving Health Care Systems



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Improving Birth Outcomes: Meeting the Challenge in the Developing World PART III Improving Health Care Systems

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Summary of Findings: Improving Birth Outcomes Within Health Care Systems Successful implementation of the interventions recommended in previous chapters requires an effective health care system. The essential elements in that system for improved birth outcomes include skilled birth attendants at labor and delivery; trained, supervised staff (including village health workers) for other services; and, in the event of complications, access to essential obstetric and neonatal care through an effective referral system. An effective referral system includes good communication between the referral hospital or health center and the skilled attendant, transportation to the referral facility, and access to a loan if needed. Community trials of appropriate models of reproductive and neonatal health care will be instrumental in building accessible, acceptable, cost-effective health services to improve birth outcomes. Each country should develop a strategy, a framework of activities, and the commitment of its leaders to reducing maternal, fetal, and neonatal mortality. Surveillance of birth outcomes—especially maternal, fetal, and neonatal mortality—is essential to recognizing the burden of disease associated with pregnancy and childbirth, and to providing the data needed for identifying, prioritizing, and evaluating interventions to provide those services. Each country should strengthen its public health capacity for recognizing, implementing, monitoring, and tuning interventions that meet their population needs and have been proven effective in similar populations.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World 5 Improving Birth Outcomes Within Health Care Systems The previous chapters have described a broad range of conditions that contribute to adverse birth outcomes. Most of these conditions can be addressed through affordable interventions that have been proven effective in clinical trials, and in some cases, in population-based studies. In order for these interventions to have the maximum impact on birth outcomes in large populations, however, they must be implemented within an effective health care system. As discussed in Chapters 2 and 3, the key requirements for reducing maternal, fetal, and neonatal mortality are skilled birth attendance and, for complicated deliveries, access to the appropriate level of essential obstetric and neonatal care (World Health Organization, 1999; Li et al., 1996). Building strong reproductive health care capacity both requires and contributes to a strong and equitable system for overall health care (Graham, 2002). This chapter addresses the overall process of developing and strengthening a health care system. Countries meet their specific needs by tailoring that overall process. The chapter first reviews the evidence base for strengthening health care systems, then addresses primary care and referral by reviewing current models of care for labor and delivery, and considers the limitations in access to these health care services. The next section addresses the building of health care capacity, which involves staff development and training, the role of the private sector, financing, and health care reforms. This is followed by a section on management of health care systems, which includes the roles of surveillance and evaluation. The chapter concludes

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Improving Birth Outcomes: Meeting the Challenge in the Developing World with three recommendations and the research needed to develop health care systems that support sustained and future improvements in birth outcomes. THE EVIDENCE BASE Evidence concerning the effectiveness of specific interventions to prevent adverse birth outcomes has been reviewed in earlier chapters. This chapter addresses the implementation of these interventions within primary health care systems, a process that has not been evaluated with the same methodological rigor as the effects of the component services or activities. The clinical and cost-effectiveness of interventions within a health care system would ideally be determined through randomized, controlled trials (RCTs), since they provide the most reliable evidence. However, RCTs have not been used extensively in evaluating community interventions (Smith et al., 2000) because of the cost and complexity of very large trials or because denial of services to a control group when they are widely believed to be beneficial may be considered unethical. Because maternal mortality is a relatively rare event, very large populations need to be studied. Such trials are also complex owing to their multiple components and the involvement of several levels of government (Sorensen et al., 1998) Clearly the evidence base for improving birth outcomes within the health care systems of diverse countries would be strengthened by conducting RCTs of interventions in the systems in question. It is important for future research to meet the challenges imposed by cost and complexity so that policies and programs can be based on a stronger scientific footing. For now, given the current lack of RCTs to evaluate the effectiveness of health care systems, and the urgent need to improve birth outcomes, the committee has examined less rigorous attempts to integrate interventions into health care systems and programs. This chapter therefore focuses on the feasibility of implementing systems and programs of maternal and infant care in different settings, the problems encountered, and the lessons learned. When published evidence on the overall effectiveness of these systems and programs is available, it has been reviewed. Since this evidence often consists of comparisons before and after interventions in the same geographic setting, participants versus nonparticipants in the same setting, or settings that have implemented a program versus those that have not, caution is advised in drawing inferences about the causal effects of the systems or programs of care. PRIMARY CARE AND REFERRAL The 1978 International Conference on Primary Health Care produced the Alma-Ata Declaration, a strategy promoting “health for all” that has

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Improving Birth Outcomes: Meeting the Challenge in the Developing World been broadly accepted. The main goal of this strategy is to make primary health care—defined as essential health care based on practical, scientifically sound, and socially acceptable methods and technology—accessible to people in every community and affordable to communities and countries at every stage of development. The Alma-Ata Declaration recognizes primary health care as the centerpiece of a country’s health system, and an important component of its overall social and economic development (World Health Organization, 1978). More recently, “close-to-client” health care has been identified as the principal vehicle for addressing the small number of conditions, including maternal, fetal, and neonatal mortality, that account for much of the excess mortality in developing countries (Jha et al., 2002). In this model of primary care, relatively simple hospitals and health centers deliver effective interventions against major causes of death and disability in poor populations. Care in these settings, which can often be provided by nonphysicians (nurses, midwives, community or village health workers, and other paramedical staff) is complemented by a referral system that provides access when needed to higher-level care (World Health Organization, 1994, 1996a). The goal of referral is to assure that patients receive effective care in an appropriate facility at minimal cost (Murray et al., 2001). Box 5-1 lists the essential features of effective referral systems. Several interventions recommended in this report, such as those for family planning, preconceptional care, and refocused antenatal care (Villar et al., 2001)—all primary care services—can be offered through community facilities linked to district hospitals. Antenatal care can be provided at a community health clinic. Skilled birth attendants can provide clean and safe deliveries and immediate postpartum care in homes or clinics. Postnatal BOX 5-1 Essential Features of Effective Referral Systems An adequately resourced referral center (see Chapter 2 and Table 2-3) Communications and feedback systems Designated transport Protocols for the identification and management of complications in specific settings Teamwork between referral levels A unified records system Mechanisms to ensure that patients do not bypass referral levels (good patient information and structured fee and exemption systems) SOURCE: Murray et al., 2001.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World care for the infant can be provided by a midwife, nurse, or possibly a village health worker (Bang et al., 1999) (see Box 3-2). Trials are needed to test this approach in other settings and determine whether a similar approach can be effective for maternal postnatal care. Local services can easily be tailored to meet community needs and local participation in decisions on the delivery of health services increases the use of services, improves patient satisfaction and knowledge, and strengthens health care capacity. Since the risks for adverse birth outcomes are so high at the time of labor and delivery and the immediate postpartum period, the quality of care at that time becomes the major focus. Reducing the significant burden of maternal, fetal, and neonatal mortality will require good-quality maternal and neonatal services along with effective referral systems (Jha et al., 2002; Murray et al., 2001; Ross et al., 2001; Kusiako et al., 2000; Fauveau et al., 1990). This can be accomplished in this “close to client” model by providing a skilled birth attendant—a midwife, doctor, or nurse—who can manage normal deliveries, recognize complications early, and promptly refer patients to the level of care needed. For complicated deliveries, referral to a basic or comprehensive essential obstetric care facility is critical. Patients who need care for complicated deliveries require a caregiver with a higher level of skill and a facility with the necessary equipment, drugs, and other materials. An enabling environment for labor and delivery includes specialized equipment, reliable supplies of drugs and other materials, and efficient transportation from the home or health facility to the referral facility (Ross et al., 2001; Graham et al., 2001). To be sustainable over time, it also requires ongoing staff development and training, adequate financing, supportive policies, and strong leadership. Models of Care for Labor and Delivery The essence of primary care and referral for labor and delivery is the presence of a skilled attendant backed up by good-quality, readily accessible emergency care. The wide range in services and settings in countries for labor and delivery can be described in terms of four models of care, based on the type of caregiver and the setting in which delivery takes place (Table 5-1) (Koblinsky et al., 1999). Each model is presented below along with examples of country programs. The models do not include one for home birth with a nonprofessional attendant and without referral for complicated cases. While this is the reality for many poor, rural populations, it is inevitably associated with high maternal, fetal, and neonatal mortality and is, therefore, in urgent need of being upgraded.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World TABLE 5-1 Models of Health Care During Labor and Delivery Model of Health Care Birth Attendant Location of Delivery Referral Capacity Country examples, each with its with Maternal Mortality Ratio (per 100,000) 1 Nonprofessional: often a community member with little or no medical training Home Referral and transport needed for complicated cases Rural China (1994): 115 Fortaleza, Brazil (1984): 120 Many barriers and may involve long distances 2 Professional: often a midwife who can recognize complications and provide basic essential care Home Referral and transport needed for complicated cases Malaysia (1970s-1980s): 50 Netherlands (1983-1992): 7 Some barriers may involve long distances 3 Professional: often a physician, alternatively, a midwife Health clinic or hospital with basic essential care Referral and transport needed for complicated cases Malaysia (1980s-1990s): 43 Sri Lanka (1996): 30 4 Professional: most often a physician Hospital with comprehensive essential care No referral needed United Kingdom: 9 United States: 12 Mexico City (1988): 114   SOURCE: Adapted from Koblinsky et al., 1999.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Model 1: Home birth with nonprofessional attendant and referral for complicated cases In countries with high rates of maternal and neonatal mortality, traditional birth attendants (TBAs) and relatives are the most common providers of care for mothers and infants during labor and delivery, especially in rural areas (Schaider et al., 1999; Itina, 1997; Eades et al., 1993). TBAs are typically older women who lack formal education, but are accorded social status in their communities due to their years of assisting women during childbirth (Eades et al., 1993; Itina, 1997; Abioye-Kuteyi EA et al., 2001). To begin to address the need in developing countries for skilled assistance during labor, delivery, and the postpartum period, several field projects have attempted to train TBAs in critical skills (Daga et al., 1997; Kwast, 1996; Miller et al., 1995; O’Rourke, 1995; Pratinidhi et al., 1986; Schaider et al., 1999; Smith et al., 2000). Some TBAs have learned to recognize complications and refer patients to medical facilities (Janowitz et al., 1985; Bailey et al., 2002); however, the training of TBAs has not been associated with reduced maternal and neonatal mortality rates (Jaffre and Prual, 1994; DeBrouwere et al., 1998; Graham, 2002; Smith et al., 2000). China, in one of the rare successful large-scale scenarios for Model 1 care, achieved dramatic reductions in maternal and infant mortality in the 1960s to 1980s (see Box 5-2). Over this time, most births in rural China were attended by relatives or lay persons with some training (Goldstein, 1998; Hesketh and Zhu, 1997; Young, 1990). However, the Chinese experience stands as an exception to the generally high frequency of deaths during labor, delivery, and the first 24 hours postpartum that occur in Model 1 settings. Model 2: Home birth with professional attendant and referral for complicated cases Delivery at home and care of the newborn, usually by a midwife, is available in some developing countries, generally in rural areas (see Appendix C for a detailed definition of “skilled birth attendant”). In countries where skilled birth attendants manage at least half of all deliveries, such as Sri Lanka and South Africa, maternal and neonatal mortality rates are among the lowest in the developing world (see Figures 2-5 and 2-6). Providing quality Model 2 care involves the training of competent birth attendants and provision of equipment. It also involves transportation and communication capacity for referrals. Provider and community attitudes that can be major barriers to the use of skilled birth attendants and other health care services need to be overcome (Mathur et al., 1979; The Prevention of Maternal Mortality Network, 1992). Whereas TBAs work in vil-

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Improving Birth Outcomes: Meeting the Challenge in the Developing World BOX 5-2 Model 1 Care in China In 1949, the government of the newly founded People’s Republic of China launched a massive campaign to provide basic health care to all citizens, and particularly to its underserved rural population (Goldstein, 1998; Hesketh and Zhu, 1997; Young, 1990). As part of this effort, programs were developed to educate traditional birth attendants, midwives, and obstetric nurses in “modern birth methods,” and millions of village health workers known as “barefoot doctors” were trained. All of these health care providers were connected through a three-tiered referral system. Rural birth attendants were linked to township health centers and to county maternal and child health institutes or county hospitals; these in turn were linked to specialized municipal, provincial, and national maternal and child health services and research facilities. Over the next 30 years, the campaign was able to overturn centuries of tradition regarding birthing practices and sharply reduced both maternal and neonatal mortality rates. Maternal mortality fell from approximately 1,500 per 100,000 live births in 1950 to 61 per 100,000 in 1995. A strong family planning program, introduced in the early 1970s (abortion had been legal since 1957), appears to account for nearly two-thirds of the decline in maternal mortality (Koblinsky et al.,1999). Social campaigns such as those for late marriage and women’s literacy were also associated with mortality reductions for both women and children. Since about 1980, however, maternal and neonatal mortality rates in China have shown little improvement, and wide disparities continue in both the availability of care and in mortality rates between rural and urban areas. In the mid-1980s, for example, the maternal mortality rate in Shanghai was 18 per 100,000 births, compared with 108 per 100,000 in the central province of Ningxia (Young, 1990). Moreover, the proportions of beds and of physicians remain heavily weighted toward urban areas. This rural/urban disparity can be traced to the 1978 economic reforms, which caused a virtual collapse of the cooperative insurance scheme inaugurated in the villages at the start of the revolution (Young, 1990). As a result, the demand for and availability of primary health care has declined in rural areas. Some of China’s strategies to improve birth outcomes may be applicable in other countries. The national effort to reduce maternal and infant mortality had strong political guidance. The priorities of health care reform were determined by the need and potential impact, and strategies to achieve reform goals were adaptable to local needs. Access to skilled delivery and obstetric care at the time of complications was guaranteed through a referral network that reached into communities. These efforts were complemented by social campaigns that emphasized prevention and good health care practices. lages where they are known and respected, professional care providers begin their work as strangers to a village. Partnerships with TBAs can facilitate the transition of a new midwife, who will need to show understanding and respect for local birth traditions that are not harmful (Koblinsky et al., 1999; Sibley et al., 2002).

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Improving Birth Outcomes: Meeting the Challenge in the Developing World In some developing countries, birthing homes—places in the community where women can go to give birth with a skilled attendant—have been accepted as an alternative to deliveries at home or in a referral facility. Often built by community members, these homes are likely to attract skilled birth attendants by providing a central location for deliveries (Koblinsky et al., 2000). The homes can also foster partnerships between skilled birth attendants and TBAs or community health workers. In Honduras, the use of birthing homes has increased as they are relatively inexpensive and reduce overcrowding in referral hospitals (Danel and Rivera, 2002). Model 3: Hospital/clinic birth with basic essential care Deliveries attended by skilled, experienced birth attendants can be further supported when they take place in hospitals or clinics that provide basic essential obstetric and neonatal care. Model 3 services for the mother should include at least parenteral medications (antibiotics, oxytocic drugs, and anticonvulsants) and manual removal of the placenta and other retained products in basic essential obstetric care services. However, in comprehensive essential obstetric care services, provision for surgical procedures, anesthesia, and blood transfusion in addition to the above should be included (World Health Organization, 1996c). Model 3 services for the newborn include cardiopulmonary resuscitation (bag and mask ventilation, endotracheal intubation, cardiac massage), thermal management (using radiant warmers and incubations), supplemental oxygen, parenteral medications (e.g. antibiotics), nutrition management (use of feeding tubes), and fluid managment (Hesketh et al., 1994). Model 3 facilities are typically staffed by physicians, nurses, and midwives. Determining the availability of Model 3 care is difficult because documentation of coverage by health care facilities does not distinguish between basic (Model 3) and comprehensive (Model 4) care. Increased access to hospital delivery and literate female populations has been associated with reduced maternal mortality in Sri Lanka (Gunaserera and Wijesinghe, 1996) and reduced neonatal mortality in Shunyi County, China (Yan et al., 1989). Similarly, there was a reduction in maternal and neonatal mortality in Malaysia (see Box 5-3). Where there is a demand for hospital delivery, maternity waiting homes—residences near hospitals where women who live far from the facility can stay near the time of delivery—can increase access for rural women (Koblinsky et al., 1999). Unlike birthing homes, maternal waiting homes are not used for deliveries. However, use of these facilities has been limited by their expense and the need for childcare when the mother is away from home (Fawcus et al., 1996). Their value in reducing maternal mortality has not been clearly established (Chandramohan et al., 1994).

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Improving Birth Outcomes: Meeting the Challenge in the Developing World BOX 5-3 Labor and Delivery Care in Malaysia: From Model 1 to Model 3 When Malaysia became independent in 1957, the maternal mortality rate was 320 per 100,000 and the reported neonatal mortality rate was 75.5 per 1,000 births (Pathmanathan and Dhairiam, 1990). Free health services were made available to rural populations. Professional midwives and nurses were trained and assigned to villages, where they were supported by an expanding network of local health units (one for every 50,000 people) linked to regional clinics and, by referral, to district hospitals (Koblinsky et al., 1999). Between the mid-1970s and mid-1980s, most births still took place at home, but were attended by a professional midwife (Koblinsky et al., 1999). During this period, the maternal mortality rate dropped to 50 per 100,000. Midwives in Malaysia are salaried civil servants who provide maternal health care including home visits in the prenatal and postpartum periods, normal deliveries, risk screening, referrals with transport to a maternity home or hospital, family planning, and child health services (Koblinsky et al., 1999). They can administer certain drugs, including oxytocin, but rely on a nurse to provide antibiotics, sutures, or intravenous fluids. Midwives use checklists to recognize the signs and symptoms of complications and make timely referrals. In the mid-1990s, the formal training course of study for midwives was expanded to a two-and-a-half year program for high school graduates with hands-on learning in hospital and community settings. As the presence of and demand for professional midwives increased, the role of TBAs in Malaysia gradually moved from birth assistant to provider of family support (Koblinsky et al., 1999). This transition was encouraged by government initiatives to limit their role in labor and delivery, while training, registering, and supervising their provision of traditional massage and postpartum care. By 1996, 95 percent of all home births were assisted by midwives and less than 1 percent by TBAs (National Population and Family Development Board/Ministry of Health, 1998). Although Malaysia had achieved relatively low levels of maternal and neonatal mortality through home deliveries with a skilled midwife, the coverage of births was uneven. A survey at the end of the 1970s revealed many areas of underserved mothers, inadequate communication between rural maternal and child health services and obstetric and pediatric services, and too many inadequately attended high-risk pregnancies (Pathmanathan and Dhairiam, 1990). Concerned by these findings, the Malaysian government encouraged women to give birth in facilities providing basic essential obstetric care (includes all essential obstetric functions except surgery, anesthesia, and blood transfusion). The transition from home birthing to hospital birthing moved relatively rapidly, and by 1998, more than 90 percent of women with high-risk pregnancies, and 80 percent assigned moderate risk, delivered in a hospital. Deliveries by skilled personnel had risen from 51 percent in 1980 to 95 percent in 1996. By 1996, the maternal mortality rate had declined to 43, the perinatal mortality rate was 11, and neonatal mortality rate was 7 (National Population and Family Development Board/Ministry of Health, 1998). The goal of moving from home birthing to facility-based birthing was achieved in Malaysia by convincing women and their families that it is safer to deliver with skilled providers in a facility with backup support (Koblinsky et al., 1999). To further promote this goal, services and transport were provided at no cost for families, and significant improvements in the quality of hospital care were accomplished through quality assurance efforts.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World event of complications, to a facility where the appropriate level of essential obstetric and neonatal care can be obtained. Where resources for reproductive health care are limited, these goals should be given highest priority. Strong systems of referral will be necessary to overcome the many physical and financial barriers to obtaining good-quality essential obstetric and neonatal care in developing countries. Establishing health services that reduce maternal, fetal, and neonatal mortality will require national leadership, support, and oversight. The Ministry of Health or another national health agency could coordinate the training of health staff, the organization and management of community health services, the surveillance and analysis of birth outcomes, the evaluation of established interventions, and the implementation of new and revised interventions to target priority outcomes. Support for maternal and neonatal health care policy and services should be sought through community participation, as well as through national, regional, and international collaborations. Recommendation 5. Each country should develop a strategy to reduce maternal, fetal, and neonatal mortality, a framework of activities by which this can be accomplished, and the commitment of health leaders to accomplish these goals. A crucial first step in improving health outcomes is the identification of priority outcomes. These must be measured with the precision needed to determine their present status and establish a basis for evaluating progress toward improvement. For health systems and maternal and child health programs, surveillance of maternal, fetal, and neonatal mortality provides the foundation for identifying, selecting, and evaluating interventions to improve birth outcomes. Fetal, early neonatal, and late neonatal, as well as maternal deaths must each be clearly defined to address the distinct causes of mortality for each of these populations. Where vital statistics are inaccurate or nonexistent, pregnancy-related data can be collected on a periodic basis or in sentinel districts or other representative areas and extrapolated to a larger time or geographic scale. Intermediate process data such as the use of specific maternal and neonatal services can also be monitored. However, priority should be given to improving vital statistics, while other data collection should be tailored to match specific conditions and resources. Recommendation 6. To determine the true burden of disease associated with adverse birth outcomes and measure the effectiveness of interventions to address these problems, basic epidemiological and surveillance data must be collected, analyzed, interpreted, and acted upon. Each country should, as resources permit, incrementally develop complete

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Improving Birth Outcomes: Meeting the Challenge in the Developing World national demographic data and ongoing surveillance of maternal, fetal, and neonatal mortality and morbidity. Once priority outcomes have been identified, interventions to address them must be selected and their impact assessed and improved through continuing surveillance and rigorous, evidence-based evaluation. Recommendation 7. Each country should strengthen its public health capacity for recognizing and implementing interventions that have proven effective in reducing maternal, neonatal, and fetal mortality in similar populations. This also involves monitoring and tuning interventions for clinical- and cost-effectiveness in the local setting. RESEARCH NEEDS Rigorous research is needed to strengthen the evidence base on the effectiveness of interventions to reduce maternal, fetal, and neonatal mortality in the health care systems of developing-country populations. High-priority topics for study include: Implement randomized controlled trials to measure, in a range of settings, the clinical- and cost-effectiveness of interventions likely to reduce maternal, fetal, and neonatal mortality. Based on country needs (from surveillance) and resources and using rigorous evaluation, determine the optimal model of labor and delivery care for a particular country or a region of the country along with strategies to provide broad access to that level of care. Identify appropriate mechanisms for financing reproductive care and measuring the impact of these financing methods on the use and effectiveness of maternal and neonatal services. CONCLUSION Health care systems vary widely among developing countries, but every system can be adapted or expanded to provide the fundamental services that reduce maternal, fetal, and neonatal mortality. These include a skilled attendant at every birth; access to essential obstetric and neonatal services for every complicated delivery; and preconceptional, antenatal, and postpartum care that is affordable and effective. Additional maternal and neonatal health services can be added to an effective basic program according to the priorities and resources of countries. Accurate information from population-based surveillance and from clinical and community-based studies is necessary to guide the identification and development of priority services and to improve the effectiveness of new and ongoing interventions.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Historically, governments have achieved significant reductions in maternal and neonatal mortality once they have recognized, through surveillance, the magnitude of the problem and the importance of skilled childbirth assistance in prevention. Policymakers can safeguard the success of such initiatives by monitoring the quality of care provided and ensuring professional accountability. Similar leadership is now needed in developing countries with high maternal and neonatal mortality. Mortality can be lowered most effectively by implementing the evidence-based interventions described in this report, addressing priority needs in underserved populations, and identifying and correcting inefficiencies in the delivery of maternal and neonatal health care services. Adverse birth outcomes cannot be eliminated, even in countries with large health budgets. However, experience in virtually all industrialized countries—and in many developing nations as well—indicates that maternal, fetal, and neonatal deaths can be reduced considerably. REFERENCES Abioye-Kuteyi EA, Elias SO, Familusi AF, Fakunle A, Akinolayan K. 2001. The role of traditional birth attendants in Atakumosa, Nigeria. Journal of Research in Social Health 121(2):119–124. AbouZahr C. 1999. Disability adjusted life years and reproductive health: a critical analysis. Reproductíve Health Matters 7(14):118–119. AbouZahr C, Wardlaw T. 2001. Maternal mortality at the end of a decade: signs of progress? Bulletin of the World Health Organization 79(6):751–758. Adams I, Burn R. 2000. Optimizing health funds—planning for reproductive health services in Kenya and Zambia. MotherCare Matters 9(1):3–5. Adeloye A. 1993. Surgical services and training in the context of national health care policy: the Malawi experience. Journal of Tropical Medicine and Hygiene 96:215–221. Asowa-Omorodion FI. 1997. Women’s perceptions of the complications of pregnancy and childbirth in two Esian communities, Edo state, Nigeria. Social Science and Medicine 44(12):1817–1824. Bailey PE, Szaszdi JA, Glover L. 2002. Obstetric complications: does training traditional birth attendants make a difference? Revista Panamericana de Salud Pública 11(1):15–23. Bang AT, Bang RA, Tale O, Sontakke P, Solanki J, Wargantiwar R, Kelzarkar P. 1990. Reduction in pneumonia mortality and total childhood mortality by means of community-based intervention trial in Gadchiroli, India. Lancet 336(8709):201–206. Bang AT, Bang RA, Sontakke PG. 1994. Management of childhood pneumonia by traditional birth attendants. The SEARCH Team. Bulletin of the World Health Organization 72(6):897–905. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. 1999. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 354(9194):1955–61. Berry RJ, Li Z, Erickson JD, Li S, Moore CA, Wang H, Mulinare J, Zhao P, Wong LY, Gindler J, Hong SX, Correa A. 1999. Prevention of neural-tube defects with folic acid in China. China-U.S. Collaborative Project for Neural Tube Defect Prevention. New England Journal of Medicine 341(20):1485–1490.

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