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Title: Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works?
Author: Kwast BE.
Journal: Eur J Obstet Gynecol Reprod Biol; 1996 Oct; 69(1):47-53. PubMed ID: 8909956.
Abstract:
The purpose of this article is two-fold: (i) to lay out conceptual frameworks for programming in the fields of maternal and neonatal health for the reduction of maternal and peri/neonatal mortality; (ii) to describe selected MotherCare demonstration projects in the first 5 years between 1989 and 1993 in Bolivia, Guatemala, Indonesia and Nigeria. In Inquisivi, Bolivia, Save the Children/Bolivia, worked with 50 women's groups in remote rural villages in the Andean mountains. Through a participatory research process, the 'autodiagnosis', actions identified by women's groups included among others: provision of family planning through a local non-governmental organization (NGO), training of community birth attendants, income generating projects. In Quetzaltenango, Guatemala, access was improved through training of traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery/neonatal complications, while quality of care in health facilities was improved through modifying health professionals' attitude towards TBAs and clients, and implementation of management protocols. In Indonesia, the University of Padjadjaran addressed issues of referral and emergency obstetric care in the West-Java subdistrict of Tanjunsari. Birthing homes with radios were established in ten of the 27 villages in the district, where trained nurse/midwives provided maternity care on a regular basis. In Nigeria professional midwives were trained in interpersonal communication and lifesaving obstetric skills, while referral hospitals were refurbished and equipped. While reduction in maternal mortality after such a short implementation period is difficult to demonstrate, all projects showed improvements in referral and in reduction in perinatal mortality. This article presents an analysis of baseline data from four Mothercare projects that provided community-based maternal and child health services in rural Inquisivi, Bolivia; rural Quetzaltenango, Guatemala; rural Tanjungsari in West Java, Indonesia; and Bauchi state, Nigeria. Each project relied on different interventions. All women faced economic, psychological, sociocultural, technical, and administrative barriers in accessing services. The Safe Motherhood Initiative found that people's medical decisions were often based on nonmedical reasons and cultural appropriateness, and that the medical community needs to recognize their competitors in alternative health systems. Maternal and child survival are dependent upon recognition of the problem, decision making about care, access to care, and quality of care. A well-functioning program includes policy formulation, training, IEC, management and supervision, logistics and supplies, and research, monitoring, and evaluation. Study surveys were conducted during the early 1990s. In Bolivia, findings indicate that perinatal mortality declined during 1990-93 to 38/1000 births and fewer mothers died due to pregnancy or childbirth. Family planning use increased from 0 to 27%. The Bolivian project worked to strengthen women's groups. Findings from the Guatemalan project indicate that referrals from traditional birth attendants (TBAs) increased in both the implementation and the comparison areas, but significantly more so in the implementation area. Perinatal mortality among referred women decreased in both areas (from 22.2% to 11.8% in the intervention area). Indonesian results indicate that referrals to birthing centers by TBAs increased from 19% to 62%. Maternal mortality was halved; perinatal mortality declined to 35.8/1000. In Nigeria, maternal mortality declined among all causes.

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