Reducing maternal mortality in the developing world: sector-wide approaches may be the key

Reducing the rate of maternal mortality by 75 per cent by 2015 is one of the development targets endorsed at numerous international meetings. The technical interventions needed to prevent maternal deaths are well understood. The problem is how an environment can be created which will enable interventions to be made in a setting with few resources. The obvious way to provide this environment is to create a functioning health system. This discussion paper, published in the British Medical Journal, reviews the three main options available to governments and donors for funding large-scale activities aimed at improving maternal health.

The authors believe that the launch of the Safe Motherhood Initiative by the Interagency Group on Safe Motherhood offers real opportunities for countries to make progress in providing effective health care. They argue that for the best results the initiative should be linked to financial support mechanisms designed to improve the quality of the health sector as a whole. The authors review the opportunities and risks associated with a vertical project approach and a reproductive health programme approach, and finally focus on sector-wide approaches (SWAps) which they believe are the key to sustaining affordable improvements in maternal health in the long term.

Findings include the following:

• Despite the drawbacks of vertical funding, many safe motherhood projects initiated in the past few years exhibit a number of vertical design features. Typically, they also rely on government health infrastructure and health personnel and have been hampered by sector-wide deficiencies, including the poor performance of health staff.
• The concept of reproductive health covers a wide range of issues, and the strong focus needed to improve maternity care may be lost in an integrated approach.
• In a reproductive health initiative supported by the United Nations Population Fund and the European Commission, only 11 out of 40 projects mention any aspect of maternal health.
• SWAps were developed and applied to health care as they were thought to offer better prospects for success compared with piecemeal projects financed separately.
• There seem to be no donor supported SWAps that have emphasised safe motherhood as an indicator condition or goal.

Conclusions drawn are as follows:

• Tactically it makes better sense for maternal health programmes to be linked with, and tap into, the greater funds available for health sector development.
• The dependence of initiatives for promoting safe motherhood on health systems means that health sector reforms have huge implications for these programmes. Linking safe motherhood programmes to SWAps at an early stage may mean that the implications of proposals for providing better care can be tested and considered.
• Donor agencies that support SWAps need to be aware that some key activities that are essential to improving maternity care might not be covered by broad approaches to funding. Training in specific techniques, such as manual vacuum aspiration, will need focused technical assistance and funding.
• Improvements in maternal health can be used to measure the performance of SWAps. If performance was made a condition of funding, the position of maternal health services at the centre of the sector could be assured.