with a remarkable drop in avoidable factors assigned to the staff, emphasizing the pediatric staff's improved response to newborn problems (Schieber et al., 1995).

Audits themselves can provide an internal mechanism to monitor and change provider practices. Where they have been implemented, as in India (Bhatt, 1989) and Egypt (Ministry of Health, 1994), they have proved a powerful tool, going beyond raising awareness of the problems. Factors determined to be avoidable can be used in monitoring on-going services. Using both audits and obstetric rounds for on-going services, and bringing together all levels of providers responsible for emergency obstetric clients might suffice to prevent future maternal deaths due to avoidable factors.

Governments, in consultation with private-sector providers, need to establish a regional or national framework for maternity care, including the allocation of resources for each level of care. Many previous efforts to reduce maternal mortality in developing countries have foundered because they relied on attempts to train traditional birth attendants and screen high-risk pregnancies and refer women to expensive, distant, and ineffective sources of treatment. To save lives and reduce morbidity will require expenditures to upgrade facilities and train and supervise providers, as well as efforts to raise awareness at a community level of the signs of obstetric complications and how and where to seek appropriate care.



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