What will be the space for personal choice? Who will decide as to where and how women should deliver? Will this decision for every woman in the developed as well as developing countries be made by the professionals and policy makers alone or will women and their families have a choice?
Who will finance the enormously costly professional model of maternal-neonatal care? Will the people be willing to pay the cost because the “experts” want them to be served only by the professionals? At the current maternal mortality ratio (MMR) of 5 per 1000 deliveries, people in many developing countries may consider a pregnancy and delivery to be 99.5% safe. Will they like to put their money for making it safer?
Is saving mothers by the SBA approach the most cost-effective option to save mothers? A country may like to put its scarce resources in TB or malaria control or tetanus immunization to save mothers. Has a rigorous comparison of the cost-effectiveness of different approaches been made?
The inference that the training of traditional birth attendants (TBAs) did not succeed in reducing maternal mortality is a half-truth. The other half is that TBAs were not backed by emergency obstetric care. In the absence of referral linkages to manage the complicated deliveries the training of TBAs did not succeed in isolation. Not surprising. Even the skilled birth attendance may not result in the reduction of maternal mortality in the absence of access to emergency obstetric care. The disappointment about TBAs is due to a wrong expectation. When the unskilled birth attendants were backed by the access to referral care (Model I), the maternal mortality ratio reduced in rural China and Brazil to 115 and 120, respectively (Table 5-1 in the report).
The report assumes that what is best for mothers is also the best for neonates. Hence SBA + referral care is recommended as the main strategy for neonates as well. This may not be true. The current level of MMR and the causes of maternal deaths may necessitate access to hospital-based professional care for preventing maternal deaths. But neonatal deaths can be prevented and NMR brought down without dependence on hospitals. In 1996 Sri Lanka achieved an NMR of 12.5 per 1000 live births when the entire country had only 40 neonatal intensive care incubators, 54 pediatricians (1:34,000 population) and 77 obstetricians (1:24,000) (de Silva, 1999). The Gadchiroli (India) trial, described in this report (Box 3-1) has shown that training village level functionaries to deliver home-based neonatal care (including some skilled functions) reduced the NMR by 62 percent at a very low cost of $5.30 per neonate, and $97 per averted fetal/neonatal death. Since nearly 60 percent of neonatal deaths occur after the first day of delivery, when the neonates are usually at home, and since prevention of neonatal deaths needs simpler technology, most of the neonates can be managed at home as well. The NMR can be reduced at a very low cost