Research capacity building through North-South-South networking: towards true partnership? An exploratory study of a network for scientific support in the field of sexual and reproductive health.

BACKGROUND: We explored the perceptions of members of the Network for Scientific Support in the field of Sexual and Reproductive Health (NetSRH) on North-South-South networking and on constraints and perspectives for South-led research. METHODS: An exploratory qualitative study was conducted 18 months after the network was launched. In-depth interviews were carried out with NetSRH members (n = 15) affiliated to southern research institutions. A thematic analysis was done and N-Vivo 10 software used. RESULTS: A number of barriers to South-led research were identified, the most important being a lack of time, resources and research skills, and donor influence for the choice of research topics. Although the level of technical skills, such as writing proposals and scientific papers, differed among NetSRH members, all welcomed additional research capacity building. All members have deplored the lack of research management skills such as project cycle management as well as how to communicate with and get funds from donor agencies. International (local or regional) donor agencies had their own agenda with a budget already reserved for other purposes, thus priorities identified by national researchers were less taken into consideration. Systemic dependencies on external funds lead southern research partners to respond to calls for proposals mostly initiated by partners from northern institutions, leaving limited leeway for local initiatives. Southern NetSRH members perceived coaching done by the northern partners in scientific writing positively. South-South collaboration was minimal within NetSRH at this stage of the project, mainly due to time and resources constraints. CONCLUSION: NetSRH members unanimously concluded that sustainable financing of southern research centres is a necessary condition for them to initiate their own research projects. We recommend reserving funds within the international donor agencies for South-led research in order to break the vicious circle of running behind money provided by northern donors, thereby missing out on time and resources for reviewing research gaps and/or conducting needs evaluations required to initiate relevant own research.

Effectiveness of demand generation interventions on use of modern contraceptives in low- and middle-income countries.

OBJECTIVES: To synthesise evidence on the implementation, costs and cost-effectiveness of demand generation interventions and their effectiveness in improving uptake of modern contraception methods. METHODS: A Cochrane systematic review was conducted. Searches were performed in electronic databases (MEDLINE, EMBASE) and the grey literature. Randomised controlled trials, cluster randomised trials and quasi-experimental studies, including controlled before-after studies (CBAs) and cost and cost-effectiveness studies that aimed to assess demand interventions (including community- and facility-based interventions, financial mechanisms and mass media campaigns) in low- and middle-income countries were considered. Meta-analyses and narrative synthesis were conducted. RESULTS: In total, 20 papers meeting the inclusion criteria were included in this review. Of those, 13 were used for meta-analysis. Few data were available on implementation and on the influence of context on demand interventions. Involving family members during counselling, providing education activities and increasing exposure to those activities could enhance the success of demand interventions. Demand generation interventions were positively associated with increases in current use (pooled OR 1.57; 95% CI: 1.46-1.69, P < 0.01). Financial mechanism interventions (vouchers) appeared effective to increase use of modern contraceptive methods (pooled OR 2.16; 95% CI: 1.91-2.45, P < 0.01; I2 = 0%). Demand interventions improved knowledge (pooled OR 1.02; 95% CI 0.63-1.64, P = 0.93) and attitudes towards family planning and improved discussion with partners/husbands around modern contraceptive methods. However, given the limited number of studies included in each category of demand generation interventions, the dates of publication of the studies and their low quality, caution is advised in considering the results. Very limited evidence was available on costs; studies including data on costs were old and inconsistent. CONCLUSION: Demand generation interventions contribute to increases in modern contraceptive methods use. However, more studies with robust designs are needed to identify the most effective demand generation intervention to increase uptake of modern contraceptive methods. More evidence is also needed about implementation, costs and cost-effectiveness to inform decisions on sustainability and scaling-up.

[Quality of caesarean delivery: A cross-sectional study in 12 hospitals in Benin]. / La césarienne de qualité : étude transversale dans 12 hôpitaux au Bénin.

BACKGROUND: Caesarean section (CS) is a major obstetric intervention, widely recognized as an effective means to reduce maternal and perinatal mortality, when appropriately performed. CS numbers and rates are regularly published but quality is rarely taken into account. This study aims to describe the quality of caesarean delivery in selected hospitals in Benin. METHODS: A cross-sectional study was performed among women who had undergone a CS between 18 December 2013 and 8 February 2014 in one randomly selected hospital in each of the 12 administrative districts of Benin. The quality of CS was defined according to the analytical framework of Dujardin and Delvaux (1998) with its four pillars (access, diagnosis, procedure, postoperative care). Data were collected from hospital files and questionnaires from women and hospital directors. Data analysis was performed using Epi Info 3.5.1. RESULTS: Six hundred and thirty-two women delivered by CS during the period and 579 were eligible for the study. They were aged 26.5±6.3 years, 73.2% living more than 5km from the hospital, 63.0% referred to a health facility of whom 46.0% and 21.8% were transported by motorcycle and by ambulance respectively. The median expenditure by family was FCFA 30 000, ranging from 0 to FCFA 200 000. The admission examination was complete in 12.6% of women and the partograph used in 32.6%. The average CS rate was 37.6%, the average response time, 124minutes. Emergency CS was performed in 80.7%, for absolute maternal indications in 48.0% and under spinal anesthesia in 84.2% (98.3% of which were conducted by a nurse or midwife anesthetist). Maternal mortality was 2000 maternal deaths per 100 000 deliveries, while perinatal mortality was 7.4% (88.4% due to stillbirths). CONCLUSION: CS in Benin hospitals partially fulfilled quality criteria. However access to CS remains difficult and errors of diagnosis or excessive delay are too frequent. Quality CS is not yet a reality in Benin hospitals.

Implementing a maternal mortality surveillance system in Morocco - challenges and opportunities.

OBJECTIVE: To describe the development of the maternal death surveillance system (MDSS) in Morocco and discuss the initial results. METHOD: The nationwide MDSS was implemented in 2009 with the involvement of health professionals and local authorities. It comprises (i) notification of all deaths of women of reproductive age (from 15 to 49 years); (ii) a preliminary survey to identify pregnancy-related deaths; (iii) a confidential enquiry into all pregnancy-related deaths. The information thus obtained describes socio-demographic characteristics of the women, their obstetric and medical history, the mode of delivery, its follow-up and the medical cause of death. RESULTS: From 1st of January 2009 to 31st of December 2009, 3814 deaths of women of reproductive age were recorded, and a total of 436 pregnancy-related deaths were identified, with 73.4% of those occurring in health facilities. Among the 313 reviewed records, 80.8% were direct obstetric deaths, and 13.5% were classified as indirect. Haemorrhage was the first direct obstetric cause of death (33%). Heart disease was the main indirect obstetric cause of death (39% of indirect causes). CONCLUSION: The Moroccan MDSS is a powerful tool for understanding the causes and circumstances of maternal deaths. However, challenges remain regarding the full coverage of the system, the decentralisation of the data entry and analysis and the completeness of medical records.

The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso.

OBJECTIVE: To describe the implementation of facility-based case reviews (medical audits) in a maternity unit and their effect on the staff involved. DESIGN: Cross-sectional descriptive study. SETTING: A 26-bed obstetric unit in a district hospital in Ouagadougou, Burkina Faso. SAMPLE: Sixteen audit sessions conducted between February 2004 and June 2005. Thirty-five staff members were interviewed. METHODS: An analysis of all the tools used in the management of the audit was performed: attendance lists, case summary cards and register of recommendations. The perceptions of the staff about the audits were collected through a questionnaire administrated by an external investigator from 10 June 2005 to 16 June 2005. MAIN OUTCOME MEASURES: Session participation, types of problems identified, recommendations proposed and implemented and staff reaction to the audits. RESULTS: Only 7 midwives from a total of 15 regularly attended the sessions. Eighty-two percent of the recommendations made during the audits have been implemented, but sometimes after a delay of several months. Interviewed personnel had a good understanding of the audit goals and viewed audit as a factor in changing their practice. However, midwives highlighted problems of bad interpersonal communication and lack of anonymity during the audit sessions, and pointed out the difficulty of practising self-criticism. CONCLUSIONS: A lack of staff commitment and the resistance of maternity personnel to being evaluated by their peers or service users are reducing acceptance of routine audits. The World Health Organization must take all these factors into account when promoting the institutionalisation of medical audits in obstetrics.

Quality cesarean delivery in Ouagadougou, Burkina Faso: a comprehensive approach.

OBJECTIVE: To assess the effects of a comprehensive intervention (staff training, equipment, internal clinical audits, cost sharing system, patients-providers meetings) in improving cesarean delivery access and quality in an urban district of Burkina Faso. METHODS: We conducted a before-after study in the health district sector 30 in Ouagadougou between 2003 and 2006. We measured cesarean delivery quality (accessibility, diagnosis, procedure, postoperative follow-up) and maternal and neonatal health in 1371 sections. RESULTS: The number of cesarean deliveries performed increased each year, from 42 in 2003 to 630 in 2006. This increase happened without increase in maternal and perinatal post-cesarean mortality (respectively 1.1% and 3.6% in 2006). The cesarean delivery rate for women of the district increased from 1.9% to 3.3% of expected births between 2003 and 2005. CONCLUSION: To improve access to quality cesarean delivery, we have shown that it was necessary to have a systemic approach combining technical, operational, sociocultural, and political factors.

Assessment of appropriate child care at district level: how useful are mortality rates?

PIP: Where financial resources are sharply limited, routine process and health care output data could be used to assess district level child health care system appropriateness better than mortality data. The rural district health system serving Kasongo, Zaire was studied in reaching these conclusions. Appropriate systems were defined as affordable, acceptable, flexible, and effective. Each of these four characteristics should be met where a primary health care package of techniques and activities truly meets the needs of a given sociocultural setting. The authors do not accept mortality rates as the most suitable tools needed to determine if a system meets these criteria for appropriateness. Particular attention is called to the complexity of measuring system effectiveness. A decline in mortality rate may be an implicit system objective, but not the only goal of the program recognized by its users and workers. There is also a clear need for immediate care and relief from suffering in the community. Use of mortality rates as principle indicator of system effectiveness would not fully reflect positive steps in meeting the broader objectives of the system. Moreover, mortality rates lack sensitivity and specificity, lack relevance to indicators needed by decision-makers at the district level, and are otherwise costly and complex to accurately obtain. Instead of mortality rate determination and analysis, the authors call for a comparison of hospital admission rates between regions which do and do not have properly functioning rural health units accordingly. If health unit operations are conducted as effectively and efficiently as designed, hospital admission rates for illnesses readily treated at the rural level should decline over time. this information is readily and cheaply examined, and allows local decision makers to respond quickly and accurately to local needs.^ieng

The strategy of risk approach in antenatal care: evaluation of the referral compliance.

The main goal of antenatal care in developing countries is to identify women whose pregnancy or delivery is likely to raise problems and to refer them at the appropriate time to a hospital facility where the necessary medical equipment and expertise (vacuum extractors, cesarian sections, human skill, etc.) is available. This approach, which is known as the Risk Approach (RA) strategy, is expected to significantly reduce maternal morbidity and mortality. However, the RA will function properly only if the women identified at risk agree to give birth in a hospital on the one hand, and if they can indeed reach this hospital on the other hand. In this article the authors assess to what extent women with a risk of difficult labor (nulliparous or primiparous women under 150 cm, history of previous difficult delivery or stillbirth, women with transverse lie) agreed to give birth in a hospital. This descriptive survey, which covered 5060 pregnancies monitored in the Kasongo District, Maniema, in eastern Zaire, showed that the referral success rate in this socioeconomically very disadvantaged region was only 33%, despite some favorable conditions, such as a strong emphasis on community participation, a complementarity of health centers and hospital, and the absence of financial barriers within the health services system. Of the various hypotheses tested, the geographic accessibility of the hospital and the parturient's perception of the risk status were the two most important factors determining the compliance rate. A stratified analysis shows that the intensity of the parturient's perception has a different impact on compliance whether rural or urban situations are considered.(ABSTRACT TRUNCATED AT 250 WORDS)

[Estimation of need for obstetrical interventions in Morocco. An approach based on the spatial analysis of deficits]. / Estimation des besoins en interventions obstétricales au Maroc. Une approche fondée sur l'analyse spatiale des déficits.

One of the indicators of health system effectiveness with regard to maternal health is the maternal mortality ratio. Measuring this ratio in developing countries is, however, not an easy task since reliable information on mortality is rarely available. An alternative to the maternal mortality ratio measurement, as an indicator of effectiveness, is the assessment of the coverage of obstetrical intervention needs. The authors chose to restrict the notion of "needs" to the obstetrical interventions carried out in order to save a mother's life. Using data from a survey by the Ministry of Health of the Moroccan Kingdom on all the obstetrical interventions carried out in 1989, obstetrical intervention rates for "absolute maternal indications" are analysed according to the mother's origin, by province and urban/rural environment. The spatial analysis of these rates showed large variations in each of the environments (0 to 2.14 % of the expected births in urban areas and 0 to 1.25 % in rural areas) and a significative difference between the rural and urban distributions (median 0.80 % in urban areas versus 0.30 % in rural areas). Applying a reference rate of 1 %, deficits between the expected numbers of needed obstetrical interventions and the observed numbers were calculated for every province in both urban and rural areas. In the whole of Morocco, intervention rates are markedly below what is expected. The spatial analysis of the deficits helps to identify the provinces where the problem is the most prominent in terms of numbers of women whose intervention needs have to be covered. The authors discuss the validity of the reference rate and suggest several strategies to solve the problem. They conclude that the deficits map is a useful tool to decide on priorities for planning and monitoring of strategies to be implemented. The spatial analysis of obstetrical intervention deficits seems to be an instrument both cheaper and more relevant than a maternal mortality estimates survey.

[Hospital deliveries in Morocco or how to reconcile different logics]. / Accouchement à l'hôpital au Maroc ou comment concilier des logiques différentes.

BACKGROUND: In Morocco, the majority of maternal deaths and severe obstetrical complications occurs outside a health structure. If accessibility to a referral hospital is clearly a problem, this problem can be exacerbated by the perception that women and their family have of the quality of care received in these maternity services. The objective of this article is to explore how women who went through a severe obstetrical complication experienced their hospitalisation and to confront this experience with the caregivers'perception. METHODS: This study was carried out in Tetouan and Sidi Kacem between July 1999 and January 2001. Semi-structured individual interviews were held with 94 women who underwent an episode of severe morbidity, 91 family members, as well as 4 focus groups and 53 interviews with health staff members. RESULTS: Though all show gratitude towards the hospital staff for having saved their life, half of the women and their relatives reported problems of behaviour and attitude of the staff: verbal violence, baksheesh, patronage, lack of empathy and discrimination against certain categories of the population. These result from a complex interplay of factors: the stress-load within the profession, the institutional context which by its failures leads to or allows these behaviours and the representations peculiar to each of the players, the providers and the users. CONCLUSION: In order to be professionally more effective, it would be in the caregivers'interest to set up a system of communication that would place the patient back in the centre of hospital care.

[Why patients do not comply with reference decision made by general practitioners?]. / Pourquoi les patients n'adhèrent-ils pas à la décision de référence faite par le médecin généraliste?

SUBJECT: A health system's efficacy depends on the efficacy of its different components (first-level health services and hospitals). It also depends on the system's ability to ensure the continuity of care among the various levels of the system. Health care officials in Settat Province, Morocco, found continuity in this province to be unsatisfactory. Depending on the health centre involved, only 31 to 52% of patients referred from the first to the second level of care reached the hospital. METHODS: The study was conducted in two rural and two urban health centres (HCs) covering a total population of around 94,000. The methodology consisted of two steps. First we analysed retrospectively various determinants (age, gender, distance, time until appointment) that might influence the compliance of patients referred by the four health centres in 1994. Then we observed curative medical consultations conducted in each of these health centres over a three-day period; the 38 patients referred to the hospital over this period were interviewed and the organisation of the hospital used on was analysed. RESULTS: The results revealed low compliance: only 43% (782/1807) of the patients referred actually consulted the hospital's departments. The compliance rates varied from one HC to the other and were lower in rural than urban areas taken as a whole (34% (207/607) versus 48% (575/1200), respectively). The interviews revealed that patients did not trust the last-year medical students who staffed the emergency rooms. Another organisational problem in the hospital was identified: patients referred to the hospital to consult a specialist were not seen immediately but given appointments at later dates, and these waiting times influenced the final success of the referral process. Thus, if the patients were seen immediately, compliance increased from 48 to 77% in the case of the urban HCs and from 34 to 67% in the case of the rural HCs. CONCLUSION: The most important determinants of compliance were above all associated with the way health services were organized and the quality of communication between health professionals and patients.

[Utilization of hospital emergency service for primary care (study at the Children's Hospital of Rabat, Morocco)]. / L'utilisation d'un service hospitalier d'urgences pour les soins de première ligne (étude à l'Hôpital d'Enfants de Rabat, Maroc).

BACKGROUND: Utilisation of emergency department (ED) for non-urgent problems, usually dealt with in first line health services (FLHS), has an impact both in terms of efficiency (ED care is more expensive than primary health care) and in terms of quality of care (due to ED overcrowding). This study describes the utilisation pattern of the ED at the Children's Hospital of Rabat (CHR) and assesses the appropriateness of ED utilisation. METHODS: During a whole week in September 1991, 24 h/24, information about every child admitted in the ED was collected by outside investigators, using a questionnaire. This questionnaire was divided into two sections. One section, filled out at admission of the child, consisted of the following items: time of arrival, health problem, health seeking pattern and identification of child (name, age, gender and address). The second section was filled out at the medical consultation and consisted primarily of a judgement about the relevance of ED utilisation (urgent/non-urgent condition, need for hospital-based equipment, subjective assessment of delay). RESULTS: During the week under study, 1,544 children were admitted at the ED: 904 at the medical ED and 640 at the surgical ED. At the medical ED, the proportion of urgent cases was 38%; among them, 65% needed hospital-based equipment and among the latter 72% arrived on time. It means that only 18% of the children utilised the ED in an appropriate way. At the surgical ED, the proportion of urgent cases was 56%; among them, 41% needed hospital-based equipment and among the latter 86% arrived on time. It means that only 20% of the children appropriately utilised the surgical ED. Appropriate utilisation is not associated with gender. The proportion of cases judged as urgent was associated neither to hour of admission--at least for the medical ED--nor to distance (less than 15 km). However, the proportion of urgent cases varied according to the day of the week. CONCLUSION: Results confirmed the opinion of the CHR staff: most children admitted to the ED had health problems that should have been cared for at FLHS. Rationalisation of ED utilisation will depend on the health system's ability to supply acceptable and accessible care at FLHS.

[Between scientific management and research-action: the problem of overconsumption of drugs in Kasongo (Zaire)]. / Entre gestion scientifique et recherche-action: le problème de l'hyperconsommation des médicaments à Kasongo (Zaire).

A Primary Health Care (PHC) system may be effective and efficient to the extent that essential drugs are available in health services and financially accessible to the population. In developing countries, besides the difficulties related to supplying health services with adequate amounts of drugs, the control of drug consumption is one of the frequent problems encountered by health authorities. Literature is relatively abundant in the field of rationalization of the diagnosis and drug prescription processes, and also in the field of drug financing mechanisms; publications are however rather scarce when topics related to corruption or drug misappropriation are concerned. The case study submitted hereafter reports a drug overconsumption problem in the health centres (HC) of the Kasongo district (Zaire). Despite the existence of direct control mechanisms as well as indirect ones (monitoring of drug consumption by HC), the problem has been identified belatedly. The district staff then used a step-by-step analysis of the HC drug consumption profiles; this analysis allowed to demonstrate that misappropriation would be the most plausible hypothesis. In order to solve the misappropriation problem-the consequences of which jeopardized the functioning of the very health system-the district staff chose to involve the nurses, in charge of the HC, in the entire problem-solving process. This participative approach, involving different actors as partners, allowed to deepen the situation analysis and to elaborate solutions congruent with PHC principles and acceptable to all concerned.

The global health financing revolution: why maternal health is missing the boat.

The first decade of the new millennium saw an upsurge in global financing for health. When the world took stock of progress on the Millennium Development Goals in mid-2010 the one addressing maternal health showed the least progress. Did maternal health miss the boat? In mid-2010 the Secretary-General of the United Nations launched a "Global Strategy for Women's and Children's Health", also known as the "Every Woman Every Child" initiative. Has the tide now turned in favour of maternal health? The authors try to answer this question by first examining whether maternal health really missed out with respect to increased global funding and why this may have occurred. They then assess whether the new initiative will make a difference by comparing several elements of the approach taken by HIV/AIDS activist to that of maternal health activists. They suggest that real progress requires international financing, thus pledges must become robust and reliable commitments. They conclude that the absence of an organisational structure in the current initiative means the global maternal health financing revolution will probably not happen.

Reducing financial barriers to emergency obstetric care: experience of cost-sharing mechanism in a district hospital in Burkina Faso.

OBJECTIVE: To describe the implementation of a cost-sharing system for emergency obstetric care in an urban health district of Ouagadougou, Burkina Faso and analyse its results after 1 year of activity. METHODS: Service availability and use, service quality, knowledge of the cost-sharing system in the community and financial viability of the system were measured before and after the system was implemented. Different sources of data were used: community survey, anthropological study, routine data from hospital files and registers and specific data collected on major obstetric interventions (MOI) in all the hospitals utilized by the district population. Direct costs of MOI were collected for each patient through an individual form and monitored during the year 2005. Rates of MOI for absolute maternal indications (AMI) were calculated for the period 2003-2005. RESULTS: The direct cost of a MOI was on average 136US$, including referral cost. Through the cost-sharing system this amount was shared between families (46US$), health centres (15US$), Ministry of Health (38US$) and local authority (37US$). The scheme was started in January 2005. The rate of cost recovery was 91.3% and the balance at the end of 2005 was slightly positive (4.7% of the total contribution). The number of emergency referrals by health centres increased from 84 in 2004 to 683 in 2005. MOI per 100 expected births increased from 1.95% in 2003 to 3.56% in 2005 and MOI for AMI increased from 0.75% to 1.42%. CONCLUSIONS: The dramatic increase in MOI suggests that the cost-sharing scheme decreased financial and geographical barriers to emergency obstetric care. Other positive effects on quality of care were documented but the sustainability of such a system remains uncertain in the dynamic context of Burkina Faso (decentralization).

Hands-on training in health district management.

PIP: In 1985 in Zaire, a 12-week training course began in Kasongo district to prepare physicians to use sound management of primary and secondary health services, supervision of health centers, and commitment to team work to operate districts in an integrated way. Only 1 new physician trainee was accepted every 4 weeks. During the first week, trainees observed work at an outpatient clinic for 2-3 hours/day to learn about the links between the primary and secondary levels of health care. During the second week, they observed staff at an urban health center in Kasongo city so they could become familiar with strategies for diagnosis and treatment in curative consultations and with instructions for follow-up. During the third week, the trainees returned to the outpatient clinic to practice interviewing patients. During the fourth week, they observed work in a rural health center and in remote villages. During the second 4-week period, trainees worked in a hospital department of their choice to learn how to use files and to evaluate quality of care. They visited health centers 1-2 times/week to examine supervisory techniques of different resident physicians. Trainees were part of the health team during the third 4-week period. They were responsible for a hospital department and supervised health centers under a resident physician. The trainees also attended management committee meetings addressing quality of care, staff management, and feedback from health center supervisions. The cost for this health district management training was US $100/trainee. Between mid-1985 and mid-1988, 18 physicians underwent this training. 12 of these physicians are now working in health districts in Zaire. A follow-up survey in 1995 showed that most trainees were applying the requisite skills and knowledge acquired during the training. Further supervision or self-training, involving team analysis of problems and possible solutions, are needed. Factors contributing to the course's success include: an integrated health system under the direction of a health team, a large enough team to do student training but small enough to maintain communication, and active participation of trainees.^ieng

Hospitals in sub-Saharan Africa: why we need more of what does not work as it should.

This paper analyses the origins of today's crisis in the hospital sector in sub-Saharan Africa. Present trends in availability of hospital services are extrapolated to the future in order to provide a low-end estimate of the need for expansion of first referral level hospitals, This will not be possible without giving due priority to this sector, a commitment to considerable investments and reorientation of resources from tertiary to first referral level hospitals. It is to be feared that if this is not done, the backlog will increase, and, given the time lag before investments translate into operational services, there will be a major shortage of hospital services in sub-Saharan Africa within a decade.

Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?

Ten years of Safe Motherhood Initiative notwithstanding, many developing countries still experience maternal mortality levels similar to those of industrialized countries in the early 20th century. This paper analyses the conditions under which the industrialized world has reduced maternal mortality over the last 100 years. Preconditions appear to have been early awareness of the magnitude of the problem, recognition that most maternal deaths are avoidable, and mobilization of professionals and the community. Still, there were considerable differences in the timing and speed of reduction of maternal mortality between countries, related to the way professionalization of delivery care was determined: firstly, by the willingness of the decision-makers to take up their responsibility; secondly, by making modern obstetrical care available to the population (particularly by encouragement or dissuasion of midwifery care); and thirdly, by the extent to which professionals were held accountable for addressing maternal health in an effective way. Reduction of maternal mortality in developing countries today is hindered by limited awareness of the magnitude and manageability of the problem, and ill-informed professionalization strategies focusing on antenatal care and training of traditional birth attendants. These strategies have by and large been ineffective and diverted attention from development of professional first-line midwifery and second-line hospital delivery care.