of the strategies recommended in this report can be undertaken simultaneously. Highest priority should then be accorded the report’s first two recommendations, which call for skilled attendance at delivery and, in the event of complications, timely access to good-quality essential obstetric and neonatal care. These interventions address key weaknesses in the health services of many countries that result in high maternal, neonatal, and fetal mortality. These strategies can be further supported through programs of effective antenatal and postpartum care, as specified in two subsequent recommendations. These four recommendations have the potential to greatly improve birth outcomes and can be implemented now.

The challenge for developing countries, given their limited resources and important health care needs, is how to most effectively and widely undertake these interventions. The implementation of interventions and development of next steps is addressed in the committee’s final three recommendations, which establish a framework for long-term improvement of birth outcomes based on promising strategies and committed leadership, surveillance of pregnancy- and birth-related mortality and morbidity, and the public health capacity for implementing interventions and monitoring them for clinical- and cost-effectiveness. Surveillance of adverse birth outcomes enables the identification, prioritization, and evaluation of interventions based on evidence of their effectiveness. This process is key to making wise choices among alternative interventions and programs to improve birth outcomes, and is even more crucial where resources are limited. Each country will also need to conduct operational research, as its resources permit, to identify and improve interventions to meet specific needs and expectations.

THE SKILLED BIRTH ATTENDANT

In this report a “skilled birth attendant” is defined as a midwife, physician, or nurse who has completed nationally recognized professional training and is proficient in basic techniques for clean and safe delivery; recognition and management of prolonged labor, infection, and hemorrhage; and recognition and resuscitation of neonates who fail to initiate respiration at birth. In countries with sufficient resources, the most effective way to reduce maternal, neonatal, and fetal mortality is through education, training, and oversight on clean and safe labor and delivery for qualified health staff and recognition and referral of complicated deliveries. It is important to recognize that past efforts to train and supervise traditional birth attendants (TBAs) have generally not produced birth attendants with the knowledge, skills, and caseload required to manage a normal delivery safely or the ability to promptly address complications by referral to appropriate medi-



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