“Every day we hear about the
dangers of cancer, heart disease and
AIDS. But how many of us realize
that, in much of the world, the act of
giving life to a child is still the
biggest killer of women of child-
– Liya Kebede
Objective of the Seminar:
Review global strategies on
• Online Search by using Key words:
– Global strategy on maternal health,
– Global/International health conventions on maternal
health and reproductive health,
– Global/International conventions/declarations on
women’s health and right.
Web search: PubMed, Medline, who.int, Google Scholar.
• Grey-literature and desk review: For published and
• For referencing: Zotero Standalone
–A plan of action
designed to achieve a vision or putting a plan
into operation in a skilful way.
– Derived from the Greek "στρατηγία"
(strategia); which means command or
–Defined as "…the direction and scope over
the long-term: which achieves advantage
through its configuration of resources
within a challenging environment, to meet
the needs and to fulfil expectations". 
–In gist: an approach that has to be followed
to achieve a goal.
Why Need Global Strategy?
• More than 7 million pregnancy- related deaths:
mothers, newborns and stillbirths occur
• 99% deaths occur in developing countries,
• Out of the total deaths 75% can be prevented-
by access of SBA care and EmOC,
• Deaths are more common in
rural, illiterate, poor and remote communities,
• Reduce maternal deaths and achieve MDG 5 by
Causes of Maternal Deaths- 
Direct Causes – 80%
Haemorrhage - 24%, Obstructed labour- 8%,
Eclampsia -12%, Sepsis - 5% ,
Unsafe abortion -13%, Other direct causes – 8%
(ectopic pregnancy, embolism and anaesthesia-related causes)
Indirect causes - 20%.
(E.g. Anaemia, TB, Malaria, HIV/AIDS etc )
–There was lack of global and regional
strategies for health including maternal
–After establishment of United
Nations, there was felt and generated
global effort for health.
–WHO was established in 1948.
Universal Declaration of Human
• Article -25
1. Everybody has health and well-being
2. Motherhood and childhood are
entitled to special care and
First time, maternal mortality
estimates by WHO- 1984 [ 11]
–WHO first time released maternal
mortality estimates. During this
time, the main strategies for reduction
of maternal mortality were-
• Trained TBAs,
•Identified high risk pregnancy.
The First International Safe
Motherhood Conference, Nairobi-
–Defined and developed the concept of
–Launched safe motherhood initiatives
with aim to reduce the burden of
maternal death and ill-health in low
Safe Motherhood Strategies
mainly consisted of-
–Family planning and access to other
reproductive health services including
–Skilled care during pregnancy and
–Emergency Obstetric Care, and
–Postnatal Care. 
The “Four Pillars” of Safe Motherhood
1st 2nd 3rd 4th
Three Delays in Maternal Care 
1st delay: Delay in decision to seek care
– Failure to recognise complications
– Acceptance of maternal death
– Low status of women
– Socio-cultural barriers, etc
2nd delay: Delay in reaching care
– Poor roads, mountains,
islands, rivers, etc
3rd delay: Delay in receiving care
– Inadequate facilities, supplies and personnel
– Poor training and de-motivation of personnel
– Lack of financial resources, etc
Source: Family Care International
International Conference on
Population and Development-1994 
Highlighted points of Maternal Health-
• Reduce maternal mortality, …
• Ensure universal access to RHC-FP,
• Assisted childbirth,
• Prevention of STIs including HIV/AIDS
Note: Maternal health should be seen with in the
Sexual and Reproductive Health issues.
The 10th Anniversary Meeting of Safe
Motherhood Initiatives in Sri Lanka-1997 
Three core action messages were developed, for
shaping the future work:
1. Shift from “High Risk Approach” to “Every
Pregnancy Faces Risks”;
2. Shift from TBA to “Ensure skilled attendants at
3. Improve quality and access of maternal care;
EmOC is the utmost importance .
Before pregnancy: emphasis on empowerment of women and
strengthening of sexual and reproductive health.
Prioritised Safe Abortion within
Programs of Maternal Health-
Reproductive health care and unmet
need for contraception including safe
abortion for maternal mortality
The WHO, UNICEF, UNFPA and World Bank
Joint Statement on the Reduction of
Maternal Mortality, 1999 
–Recommend to reduce Maternal and Child
Health problems/mortality by-
1. A societal commitment to ensuring safe
pregnancy and birth.
2. Improve access to the quality health care.
3. A commitment to the special needs of girls
and women throughout their lives.
Millennium Development Goals
Goal 5: Improve maternal health
reduce the maternal mortality ratio by
three-quarters between 1990 and 2015,
–Maternal mortality ratio
–Proportion of birth attended by skilled
“Working with Individuals, Families and
Communities to Improve Maternal Health
–Published, Department of Making Pregnancy
–Edited by Carlo Santarelli - consultant,
Making Pregnancy Safer focuses on –
1) Advocacy, 2) Technical support to countries,
3) Partnership building, 4) Norms, standards and
tools development, 5) Research, and
6) Monitoring and evaluation of global efforts.
Prioritized Areas For Organizing
1. Developing capacities
2. Increasing awareness
3. Strengthening linkages
4. Improving quality
Making Pregnancy Safer-
Interventions in the Priority
1. Developing Capacities-
–Self-care (nutrition, rest, plan for
delivery, hygiene …)
–Birth and emergency preparedness
2. Increasing Awareness-
–Human and reproductive rights
–The role of men and other influentials
surveillance and maternal-perinatal
(needs, diseases and deaths) ...
3. Strengthening Linkages-
–Community financing and transport
schemes to reduce second delay
–Maternity waiting homes for hard-to-reach
areas to reduce second delay
–Roles of TBAs within the health system
• Improve hygiene during delivery
• Recognize complications & refer
• Provide emotional support to mother ...
4. Improving Quality
–Community involvement in the quality
–Social support during childbirth
–Inter-personal & inter-cultural
competency of health care providers
–To promote universal access to safe,
–To support women's autonomy to
make their own decision.
International Campaign for Women's
Right to Safe Abortion, May- 2012,
Global Players: Maternal Health
WHO, UNICEF, UNFPA, UNAIDS and World Bank
UNDP, IPPF (International Planned Parenthood
Federation),Population Council, DFID, FCI, Dutch
Ministry of Foreign Affairs, Norwegian Agency for
Development Corporation, The Partnership For
Maternal, Newborn and Child Health … [13 and 18]
Content and quality of care?
• In spite of all the efforts being put on
maternal health, still, it seems that the quality
of maternity care in poor-resource settings is
often very low.
• Essential interventions are not carried out in a
timely and there are many problems with
Vignette of 3rd delay
• For the improvement of maternal and
reproductive health outcomes, there is
need to focus and take account the
macroeconomic environment efforts in
national as well as international level by
government and non-governmental
• Need to address cross-cutting issues for the
succeeding of strategies. 
• According to Marge-2012, In the poorest
countries, women may have more pressing
health needs even than for maternity care-
– access to any affordable health care,
– Enough food to eat,
– Sanitation and potable water, …
• Lesson Learnt from: Sweden, Sri-Lanka
, Malaysia, … [38, 40]
For addressing the maternal health
challenges and issues there should
strategically address cross-cutting
issues, like -
• Gender empowerment/ independence,
• Political commitment/willingness
• Women’s rights
Maternal Care Model in Sri Lanka
Source: Repot of High Level Consultant Meeting on MDG 4&5 , India 2008
Midwife with client
When should strategies focus?
Source: Based on New Model of ANC, WHO
Maternal Health Strategies:
Identification of high risk pregnancy by
Every pregnancy faces risk and
Cross- cutting issues
Social determinants of health
Identification of high risk pregnancy by
Remaining Challenges and Issues
• MDG -5 is further off-track than any of the other
MDGs. Only 12 out of the 68 identified countries
seem on track.
• Increase political commitment and willingness
among the under developing countries.
• Raising inter- sectoral co-ordination to address
the cross-cutting issues of maternal health. 
• Establish up to date databank in low income
countries . 
• Making agreement between socio-cultural and
religious practices with maternal health care.
e.g. use of FP services and abortion practices
• Maternal health care of affected and displaced
women during conflicts and wars.
• Continuation of financial incentives/support
and the involvement of private-sector in
maternal health care.
Remaining Issues [cont..]:
• Inequalities in the risk of maternal death exist
everywhere, both between and within
• Single strategy will not be enough to optimize
maternal health worldwide.
• Urgently required public health strategy to
reduce maternal mortality, particularly in under
• International consensus and multi-
sectoral efforts are inevitable parts of
global maternal health strategy.
• Need to establish data-bank, particularly
in developing countries to formulate
• Prevention of unwanted pregnancies by family
planning & safe abortion,
• Provision of institution delivery and EmOC,
• Antenatal and postnatal quality care: to detect
and treat complications early,
• Investigations into maternal deaths,
• Ensure 24 hour professional care at all levels,
• Strengthen financing schemes including case
transfer initiatives by inter-sectoral involvement.
• Writers, editors and publishers of the
reviewed literature & Kirti Iyengar,
• Doctorial Advisory Committee (DAC) Members
for their consistent guidance from the
inception of this presentation.
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