between 1750 and 1980, with two-thirds of the decrease occurring in the eighteenth and nineteenth centuries. This decline, not reported in other European countries, has been attributed to home-assisted births by trained midwives and the use of aseptic techniques. The decline in the maternal mortality ratio in Sweden in the twentieth century was attributable to the same factors as in the rest of Europe and United States (Hogberg and Wall, 1986; Hogberg, Wall, and Brostroin, 1986).

Implementation of some elements of essential care of obstetric complications in a few developing countries have also resulted in substantial declines in maternal mortality (World Health Organization, 1995). Sri Lanka's maternal mortality ratio dropped dramatically: from 555 per 100,000 live births in 1950-1955 to 239 in the 1960s and to 95 in 1980. A nationwide extension of the health center system and expansion of midwifery skills are credited with this rapid decline. A major shift toward birth with trained personnel occurred over this 30-year period, with a major impact on the proportion of deaths attributed to sepsis.

MATERNITY CARE AND SURVIVAL

Use of Maternity Care

The use of medical services for delivery lags far behind use of prenatal care in most developing countries. Home birth, either alone or with someone from the community, remains a strong preference. WHO estimates that only 37 percent of births in developing countries take place in a health facility; more than 60 percent of births—or 55-60 million infants annually—take place with only the help of traditional birth attendants, family members, or no assistance (World Health Organization, 1993a).

The reasons for the widespread acceptance of prenatal care throughout developing countries were captured nicely by Bolivian women who stated, ''because you're in a delicate condition," "to see if the baby's okay" (The Center for Health Research, Consultation and Education and MotherCare/John Snow, Inc., 1991). In 39 of 43 countries covered by DHS surveys between 1985 and 1994, coverage for prenatal care was found to be higher than for delivery care from a trained health provider (doctor, nurse, or nurse-midwife) (Macro International, Inc., 1994). In sub-Saharan Africa, for example, 15 of 22 countries surveyed had achieved over 75 percent prenatal care coverage (women's own definition of prenatal care was used), and only 2 had below 50 percent coverage (Macro International Inc., 1994). But only one country, Botswana, achieved over 75 percent of deliveries with professional health care providers. Between 50-75 percent of pregnant women in one-half of the other countries used



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