12~~~~~1* 43 4% ~ ~ ~ ~~ ~~ ~~~~~~% Public Disclosure Authorized

HumanResources Development and OperationsPolicy The Wcrld Bank January 1994 HROWP21 Public Disclosure Authorized

rKFN UPTONE AFR1IA Public Disclosure Authorized

Patricia Daly Michael Azefor Boniface Nasah Public Disclosure Authorized

Papsmidnhs seaenfompublica s of theWorddBans. hp plmnyd unposhed resus of aalysis tat is cir edtoawouage discussionand cment;t and the use of suchapper shouldtake accunt dci poiia dmuaer. 7he findings preats, _ad conduions cxprssed in this paper aneenthely tose ofthe author(s)and sd not be anbued in ny mamer to the Word Bank,to its afflid orgnzaions, or to ambeof iu Boad of EeotWe Dizec r the ccuenuwthey rprst. Safe Motherhoodin FrancophoneAfrica: Some ImprovementBut Not Enough

by

PatriciaDaly MichaelAzefor BonifaceNasah Abstract

Women of Sub-SahaianAfrica face the highest risk of maternalmortality and morbidity of any region in the world. At least 150,000 African women will die of pregnancy-related complicationsevery year in Africa, and the number of maternal deaths continues to rise each year in many countries. The populationof womenof child-bearingage is now Aargerthan it was in 1989, and the number of women who die each year from pregnancy-relatedcauses has increasedeven though there may have been a slight decline in the risks of pregnancy.

In 1989 representativesfrom the Governmentsof the french-speakingcountries of Sub- Saharan Africa and internationalorganizations participated in the Niamey Conferenceon Safe Motherhoodand made a commitmentto decrease maternal mortality by 50 percent by the end of the century. The result of the NiameyConference was the "Appel de Niamey' - a solemn caU for Governments to make the reducticn of maternal mortality a multi-sectoralnational priority, develop action plans to implement safe motherhood programs, establish national committees on safe motherhood,and undertake a total mobilizationof efforts in each country to reduce maternal mortalityby 50 percent by the year 2000.

Since that time the Bank has maintainedcontact with the African technical experts who played a major role in the work of the Niamey Conference and has used them to review safe motherhoodactivities in the region. Thispaper reflects their recommendationsfor strengthening safe motherhood programs. Programs succeed best when there is substantial political commitmentand policieswhich supportan integratedpackage of services,including community- based family planning, health and nutrition services and appropriate allocation of resources. The report calls for the participation of every country, and within each country, the many governmentsectors, NGOs, communityand women's groups, and providers. While there has been some progress in the countries of french-speakingAfrica, the challengeremains to get safe motherhoodprograms rapidly in place at the country level. Contents

I. INTRODUCTION...... 1 What Is Sab Motherhood? ...... 2 What Have We Learned? ...... 3

II. SAFE MOTHERHOODIN FRANCOPHONEAFRICA ...... 4 The Regional Resource Group of Experts on Safe Motherhood ...... 4 Principles of Safe Motherhood ...... 4 Building Local and Regional Capacity for Safe Motherhood ...... 7 Strategies for ManagingRisks Associatedwith Pregnancy ...... 8 m. SAFEMOTHERHOOD ACTIVITIES IN SELECTEDCOUNTRIES ...... 8

IV. SPECIAL ISSUES:ADOLESCENT FERTILITY AND UNSAFE ABORTION ... 14

V. SUMMARY: THE PROBLEMOF EXCESSIVEMATERNAL MORBIDITY AND MORTALITY IS INCREASING AND DEMONSTRATED POLITICAL COMMITMENTTO SAFE MOTHERHOODIS LACKING ...... 17

REFERENCES ...... 20 I. IN1RODUCTION

Ih 1989 representativesfrom the Governmentsof COefrench-speaking countries of Sub-Saharan Africaand internationalorganizations participated in the NiameyConference on Safe Motherhood and madea conmmitmentto decreasematernal mortality by 50 percentby the end of the century. At this meeting,Mr. EdwardJaycox, RegionalVice Presidentof the World Bank, called upon the participantsto educateAfrican leaders and the publicabout the unacceptablyhigh levelsof maternal mortalityand morbidityin Sub-SaharanAfrica. The result of the NiameyConference was the 'Appel de Niamey' - a solemncall for Governmentsto makethe reductionof maternalmortality a multi- sectoralnational priority, developaction plans to implementsafe motherhoodprograms, establish nationalcommittees on safe motherhoodand undertakea totalmobilization of effortsin each country to reduce maternalmortality by 50 percentby the year 2000. Severalinitiatives have been started in many countriesand someprogress has been madein reducingthe currentunacceptably high levels of maternalmortality and morbidity.

The pace of progressis umevenamong and within the countriesof Sub-SaharanAfrica. The problemsare Immense:

* Womenof Sub-SaharanAfrica face the highestrisk of maternalmortality and morbidityof any region of the world. Of all human developmentindicators, maternal mortality ratei representthe greatestdisparity between industrialized and Sub-SaharanAfrica countries. At least 42,000women in french-speakingcountries of Sub-SaharanAfrica will die of pregnancy-related complicationsthis year. For every womanthat dies, at least 15 others who survivewill suffer chronicillness or physicalimpairment that will remainwith them for the rest of their lives.

* Womenform the backboneof Africaneconomies. They produce most of the food necessary for a household,cook for the family,fetch water,clean the houseand care for the children,the sick and the elderly at home. The death of a womanresults in both economicand social hardship for the family and community. At least 7 millionpregnancies worldwide result in stillbirthsor infantdeaths as a result of maternalillness. Amonginfants who survivethe death of the mother,fewer than 10 percentlive beyondtheir first birthday(Koenig and others 1988; Chen and others 1974).

* HIV infectionposes a furtherthreat to health in Africa. Studieson HIV infectionsuggest that as many as 3.5 millionwomen are alreadyinfected. Womenbetween the ages of 15 and 35 years are most vulnerable.Data from Rwanda show that the younger the age of first pregnancyor frst sexualintercourse the higherthe incidenceof HIV infecdon:over 25 percent of youngwomen pregnant at age 17 or youngerare infectedand about 17 percentof thosewho initiatesexual intercourse before age 17 are infected(Chao 1991). In a study in Bujumbura, Burundi24 percentof the womenbetween age 24 and 34 years are HIV positive. Studiesin Abidjan,COte d'Ivoire indicatethat amongpregnant women with sexually transmitted diseases (STDs),HIV infectionrates range from 11.6 percentto 17.8 percent(unpublished data).

* Adolescentpregnancy iF an explodingproblem in Sub-SaharanAfrica. Young women under age 20 in Africa are more likelyto have a childthan those in other regions. For example,by age 18 more than40 percentof the womenin Coted'Ivoire, and Senegalhave given birth already (Senderwitz1993; PopulationReference Bureau 1992). In Mali, 1 in 5 adolescent womenwill have a birth in a given year. Most of the births to teenagersare first births and womenhaving their first child carry higherrisk of seriousmedical complications. Babies who are first births face a higher infantmortality sate than higher order births and this risk is even 2 greaterfor teenagemothers. Adolescentchildbearing imposes a heavyburden on each country's health care aystem as these young mothers also need antenatal,maternal and child health services.

* A large proportionof pregnancies,both within and outsidea maritalunion, are unintended. The collapseof traditionalsocialization systems has led to an alarmingincrease in the number of womenresorting to inducedabortions to deal with unwantedpregnancies. Studiesin Sub- Saharan African countriesfound that adolescentsrepresented between 39-72 percent of all womenpresenting with abortion-relatedcomplications (Center for PopulationOptions 1992). They are not alone in seekingabortions: women in all phases of their reproductivelife-cycle experienceunwanted pregnancies and seekabortions (Senderwitz 1993).

*hat Is Safe Motherhood?

Effortsto reducematernal mortality and morbiditylevels are a top priority, not only because of the scale of preventablesuffering, but also becauseprenatal care and deliveryservices are among the most cost-effectiveinterventions available to governmentsto improveadult and child health, accordingto the WorldDevelopment Report 1993: InvestIng In Health.

Safe motherhoodis achievedthrough a concerted set of interventionsdesigned to reduce maternalmortality and morbidityand to improvethe reproductivehealth status of women. This goal Is formally set forth in the Safe MotherhoodInitiative, which the Bank co-sponsoredwith other intenational agenciesin an effort to achieve a worldwide50 percentreduction of 1987 maternal mortalitylevels by th year 2000. Healthymothers result in fewer infantand childdeaths, improved infantand child health and nutritionstatus, and usuallygenerate higher incomes for the familyand, subsequendy,higher productivity in the community.

SafeMotherhood is achievedthrough a programof inter-linkedsteps whichstrive to provide: familyplanning services to preventunwanted pregnancies; safe abortions,where legal, and efficient managementand treatmentof complicationsof unsafe abortions;prenatal and delivery are at the communitylevel with quick accessto first-referralservices for complications;and postpartumcare, includingfamily planning services, promotion of breastfeeding, and nutritionservices. Safemotherhood services must be integratedinto !he healthdelivery system and the necessaryinputs - drugs, equipment,facilities, and properlytrained staff - supplied.

The root causesof a woman'sdeath Medial Caosmof Obstei Deaths in beginbefore her birth, are perpetuatedduring Do19ping Countries childhoodand adolescenceand continuelater in life. Experiencein both industrializedand developing countries has shown that safe motherhood is inextricably linked to the l/SA) social,cultural and economicenvironment in which women live. Therefore, while i strengtheningmedical services is the core strategy,safe motherhoodefforts shouldalso 1%) promotea comprehensiveapproach which includes education and income-generating 0%) opportunitiesfor women. 3 Maternalmortality and morbiditycan bt reducedthrough improved access to familyplanning, appropriatedelivery practices by trainedbirth attendants,and appropriatestrategies to reducethe incidenceof unsafe abortion. No matterhow effectivethe community-basedmaternity care, some womenwill die from complicationsif not deliveredor treated in a referral center. This requires efficientinteraction between the community-basedhealth post, the localhealth center, and the district hospitals.

W7atHave We Learned?

Experiencedemonstrates that community-basedapproaches, including family planningand training and deploymentof nurses and midwives,have helped reduce maternalmortality in high- mortality settings. Communityand facility-basedservices need to be linked and supportedby training, effectivelogistic and supplymanagement. An info mation,education and communications strategyis essentialto promoteawareness of the problemsand effectbehavior change of women, their familiesand healthproviders.

In Africa,over 60 percentof womendeliver with a familymember, a traditionalbirth attendant, or even by themselves. Ir Rwanda, only 18 percent of all deliveriesare attendedby trained personnel. Althoughtraditional birth attendants(TBAs) still have an importantrole during childbirth in Africa, studiesto wvaluatetheir contributionto reducingmaternal morbidity and mortalityhave shownvariable results: inBenin and EasternNh-eria, trained traditional birth attendantswith back-up support from health personnelhave contributedto a reductionin maternalmortality, while in the Gambiatrained traditional birth attendantswithout skilled back-up support did rot de-creasematernal mortality(Greenwood 1991).

In resource-poorcountries, expandingfamily planning services and cost-effectiveprenatal interventions,training midwives, and strengtheningobstetrical services at districthospitals will be a priority. A woman's survival and well-beingdepends primarilyon early detectionof actual complicationsor diseaseand appropriatemanagement of care. Thisrequires trained health providen with midwiferyskills in the community;TBAs trained to use appropriateand safe deliverypractices and to recognizewomen with demonstratedrisk factorsor dangersigns and refer them for obstetric care; and an informedcommunity.

Safe motherhoodalso requires strong nationaland local politicalsupport. From the onset, policy-makersand decision-makersmust demonstratestrong political commitmentand encourage opinionleaders and potentialprogram beneficiaries, both womenand men, to focus constantlyon efforts to improvesafe motherhood.

Upgradingthe qualityand coverageof safe motherhoodservices will have the largestpayoffs in averting deaths and reducing disability in women and children. According to the World DevelopmentReport 1993, prenatal care and deliveryservices are amongthe most cost-effective interventionsavailable to governmentsto improveadult and childhealth. The costs for a substantial reductionin maternalmorbidity and mortalityare approximatelythe equivalentof $2 per capitaper year, with half of that for maternalhealth and half for familyplanning (Tinker and others, 1993). The costs of not providingsafe motherhoodservices will be a continueddrain on the publichealth budget. The introductionof appropriatetechnology could reduce these costs sharply.For example, in KenyattaNational Hospital, Nairobi, substantial health care resourceswere beingused to manage 4 incompleteabortions. After introductionof the manualvacuum aspiration technique, clients and providersbenefitted from shorterhospital stays and costshave been re¢iucedfrom 23 to 66 percent.

II. SAFE MOTHERHOODIN FRANCOPHONEAFRICA

The Regional ResourceGr :up of Experts on Sqfe Motherhood

After the 1989 NiameySafe MotherhoodConference, the Bankand other donors foresawthe need to coordinatesafe motherhoodefforts and to monitorprogress towards attainingthese safe motherhoodgoals. In this spirit, the Bankhas maintainedcontact with the Africantechnical experts who playeda majorrole in the work of the NiameyConferezice and has used them as a consultative group to review safe motherhoodactivities in the countriesof the Region. This group represents specialistsfrom various countries who have pioneeredsafe motherhoodin francophoneAfrica since before 1987. In doing so, they have gained experiencethat is valuableto programsin the region. Composedof experts from francophoneAfrica, this group met for the secondtime in Bujumbura, Burundiin April 1993to reviewthe statusof maternalhealth and familyplanning programs currently being implementedin francophonecountries of the Region.

The objectivesof this meeting were: to review t.Weprogress to date in implementingthe recommendationsof the NiameySafe Motherhood Conference, particularly in Benin,Burkina Faso, Burundi,Cameroon, Central African Republic, COte D'Ivoire, Madagascar,Mali, Nig-r, Rwanda, Senegaland Zaire; to iden.ifythe constraintsand barriers to strengtheningand expandingfamily planningservices and prenatal,delivery and postpartumcare; and, to identifypriority measuresand reformsin each countrythat will contributeto strengtheningsafe motherhoodprograms.

Principlesof Safe Motherhood

* SafeMotherhood strategies should be integralpartsof the w'4onalhealth policy and shoud dependon demostrated leadershipand comnitment.

The policies and strategiesfor improvingwomen's health were framed by a set of guiding principles. Accordingto World Bank participants,Michael Azefor, Senior Populationand Health Specialist,AF1PH, and Patricia Daly, Public Health Consultant,PHN, the core concern in the developmentand implementationof a safe inotherhoodprogram is that it be an integralpart of a country'sprimary health care and overallpublic and privatehealth system.They stressedth' role policymakersand plannersmust play in buildingcommitment at the nationallevel and in mobilizing decision-makers,opinion leaders, and potential program beneficiaries, both women and men,to make programs succeed. Safe motherhoodalso requires local flexibilityin planning combinedwith dem-onstratednational and localpolitical support. Where this valued onstituency3 is in place, such as in Senegal,safe motherhoodis a priority program.

* Investmentsin needs assessmentand researchare importan to building consensusand effectivedelivery systems.

Successfulstrategies to achievesafe motherhooddepend on demonstratedleadership and political commitmentat the nationallevel. Achievingnational consensus on approachesto safe motherhood requiresa betterunderstanding of the demographic,epidemiological and socio-culturalsituation with respect to women's health. Governmentsshould conductresearch on practicesrelated to family 5 planning,adolescent sexual activity, abortion, childbearing practices and ne.vborncare. Womenand specificvulnerable groups, suchas adolescents,unmarried women, women in urban slums,refugees, etc., need to be asked about their needs and this informationneeds to be used to adaptprograms to these specialneeds.

O Healtheducation and communicationstrategies are neededto strengthenpublic involvement In safe motherhood.

This qualitative and quantitativeresearch can be used to convince policymakersof the importanceof safe motherhoodand to persuade governmentsto allocate resources for these programs. A constituencyto supportsafe motherhoodcan then be built throughdiscussions with governmentofficials, legislators,women's associations,local interestgroups, professionalhealth associationsand communitygroups. Organizationalprocesses can be modifiedto establishsafe motherhoodcommittees at the nationaland local levelscomposed of these groups. Thesegroups cantnen persuade government officials to translatetheir commitmentto nationaland localbudgetary supportfor programsand to generatecommunity interest and demandfor safe motherhoodservices.

* Programquality requires training, supervision and logiscal supportsystems.

During the planning and implementationof safe motherhoodprograms, it is importantto recognizethat the componentsof the safe motherhoodsystem are inte.r-related.Program strategies needto ensurethat the healtl.care systemhas the capacityto providematernity care servicesand that healthstaff are appropriatelytrained and supportedto providethese services. Qualityof care must be improvedat both the communityas well as the fist-referral level if there is to be a substantial reductionin maternal mortality. The developmentof one componentwithout the simultaneous development- or carefullydesigned phasing - of related componentscould increase costs and diminisheffectiveness. Servicesmust be based on establishednorms and proceduresand mustbe acceptableand perceivedto be importantby the client. For ex&'-ple, standardtreatment practices, suchas the partogramthat has been shownto be effectivein pre'vuiJngprolonged labor, in reducing operativeintervention, and in improvingneonatal outcome should be used. Supportsystems to guaranteetimely and periodicsupervision as well as adequatesupplies of medicineand equipment are essential. For example, ensuring the collectionand availaAilityof safe, reliable blood for transfusionposes particularproblems at health care facilitiesin many parts of Africa, whereblood and blood products need to be refrigeratedor frozen until needed. "Walkingblood banks' may enhanceavailability. Theseare individualsin the communitywho are identifiedas blood donors, ready to donate directlyto a patient in need - with the blood "stored"at body temperate in the donor until the momentof need. This interventiondoes not automaticallyovercome the risks of ,which still need to be addressed. The responsibilitiesof each level of care have to be clearlydefined, staff appropriately trained, and norms, skillsand proceduresfor the maintenanceof buildings,equipment, and vehiclesestablished and carefullymonitored.

O Monitoringand evaluationmust provide inputfor programdecision-makers.

The effectivenessof inputs to safe motherhoodcan also be better monitoredby policymakers and health providers. Where possible, gender-baseddata shouldbe gathered. Governmentsand donorsneed to investin the local researchcapacity of individualsand institutionsand be willingto provide support to those institutionsin their developmentalstage. In addition, analysis of health outcomesfrom the perspectiveof the health provider and the householdshould be a priority of 6 Africangovernments. The effectiveuse of servicestatistics and researchdata shouldbe emphasized at the districtand facilitylevel, particularly by thosedirectly responsible for clinicaland management decisions. Reportingshould be limitedto data which are routinelyneeded by decision-makersto assess the approachand effectivenessaf programdelivery and to monitorprogranms.

4 Decentralizationcan improvethe efficiencyand responsivenessof safe motherhoodservices.

In Africa, politicalupheavals have had negativeimpact on the health care system,in general, and on servicesto mothersand children, in particular.In countrieswhere there have been stronger initiativesin effectivedecentralization, the negativeimpact of such upheavalsare reducedas local authoritiestakt initiativesto ensurea minimumlevel of care. Iniereasinginterest in decentralization among most governmentsis encouragingfor safe motherhood. However, each country should recognizethat a satisfactorylevel of investment,training and organizationof decentralizedunits are prerequisitesfor success. Decentralizationshould also involvethe sharingof budgetplanning and executionpowers between the center and decentralizedunits. Thoughgovermment decentralizatio 1. and devolutioncan increaseefficiency where there is adequatecapacity and accountabilityat the district level, these actions can result in problemsif takentoo hastily. In some countries,such as Zaire and Madagascar,the pathwayto better health may involvea rethinkingand planningof the healthcare system. In other countries,such as Benin,C6te d'Ivoire, and Senegal,the path is likely to be one of buildingon the experiencesto date and strengtheningfamily planning and maternitycare serviceswithin the overallhealth care system.

* Africangovernments and donorsmust work togetherto build local capacityto managethe healthsector.

In Africa, aid contributesan averageof 15 percent of nationalhealth spending(World Bank 1993). In most of the francophoneAfrican countries, however, external assistance accounts for all investmentsin the health sector. All too often, donorassistance drives the developmentprogramn of a countryand in many instancesdoes not reflect the prioritiesof the countrynor the capacityof a governmentto sustainthese programs. Manydonors have respondedto this low capacityto sustain programs by sbarply increasingtechnical assistancepersonnel who substitute for weak health ministriesand have paid inadequateattention to the local capacityto plan or managethe program.

Africanpolicymakers need to developtheir own nationalhealth policies and strategiesto direct donor assistance and examineopportunities for collaborationin program developmentand co- finacing of safe motherhoodactivities. While African policymakersneed to take the lead in preparinghealth strategies,donor agenciesneed to seek greater beneficiaryinput in setting their prioritiesand allocatingfunding. Countriesthat show a willingnessto plan and managehealth and populationsector programs and to improveaccess to health servicesfor womenshould be candidates for aid.

* Empoweringwomen Is essendalto improvingtheir health and that of theirfamilies.

Finally,African governments need to fosteran enablingenvironment for woinen. In manyparts of Africa, womenperform an estimated60-80 percent of all agriculturallabor and female-headed householdsare becomingincreasingly more common. Studieshave shown that increasingfemale educationand literacypositively impacts children's chancesof surviving. The centralrole played by womenin food preparation,nutrition, household tasks, home finances,and fertility choicehas 7 a powerful influenceon the health of hcuseholdmembers. Removinggender discriminationcan boost women'searnings and financialsecurity. In addition,women need to be healthythemselves so as to fulfilltheir roles as mothersand householdmanagers.

BuildingLocal and RegionalCapacity for Safe Motherhood

Local and Regional Research Capacity: BonifaceNasah, M.D., Director of the Regional Centre for Training and Researchin Family ,underlined the importantrole of Africanresearch institutions in researchand trainingfor programsto reducematernal morbidity and mortalityas well as the promotionof women'shealth. Previousworkshops at the RegionalTraining Center in Kigaliidentified the need for countriesto determinetheir researchpriorities in health and family planning, includingthe importanceof socio-culturaland formativeresearch in these areas. Severalcountries, including Cote d'lvoire, Camercon,Rwanda and BurkinaFaso, have alreadyheld nationalworkshops defining their nationalpriorities for familyplanning and maternalhealth. Dr. Nasahstated that donorsupport to Africanresearch institutions could strengthen the capacityof _aese institutionsto conducttheir own trainingand researchprograms. Supportof regional institutions may be the most effectiveway to build localor regionalcapacity for safe motherhoodresearch and programmanagement. This institutionaldevelopment strategy is stronglyendorsed by the World Bank. Mr. EdwardJaycox, World Bank RegionalVice Presidentfor Africa, recently calledfor greater effort to build local capacityand reduce Africa's dependenceon "expatriatetechnical- assistancemanaged" programs. Africaninstitutions must be strengthenedand used for trainingand retrainingpolicymakers and providersin the healthsector and managersand donoragencies need to be flexiblein supportingthese researchinstitutions in their early stages of development.

GreaterUse of ProfessionalAssociations: Another important priority area is to strengthenthe collaborationwith health protessional associations and to elicit their participationin safe motherhood throughtraining, research,and improvementsin the qualityof services. Professionalassociations, in particular the African Society of Gynecologyand Obstetrics and the national midwifery associations,can undertakea varietyof activitieseither with their ownfinancial resources or through raisingsupport from international associations. The professional associations need to be fullpartners in the developmentof safe motherhoodpolicies and strategiesand in developingquality assurance toolsand trainingprograms. Gainingtheir supportand participationin the development,monitoring, and evaluationof safe motherhoodprograms can influencehealth policiesand strategiesand the effectivenessof these programs.

Strengthen Regional Information Dissemination: Better health requires that African policymakersdetermine health sectorpriorities and seek ways to use resourcesmore effectively. Equally importantis for developingcountries to play a larger role in establishinginternational priorities. In order to do this, developingcounitries need to strengthentheir resourcebase. Dr. SambeDuale, Research Manager of the Projectto SupportAnalysis and Researchin Africa(SARA), describedthis USAID-financedproject which aims to increasethe utilizationof researchanalysis and informationdissemination in support of improvedhealth, nutrition,education and family planning policies, strategiesand programsin Sub-SaharanAfrica. Dr. Duale describedseveral ways this regionalapproach can promote research: (i) cross-country,cross-sectoral, and comparativeanalyses on importantissues; (ii) economiesof scale in analyzingissues common to many Africancountries; (iii) translationof research findingsinto policy and programrecommendation and guidelinesfor African leaders and other decision makers; and (iv) innovativedissemination of information, includinganalytical tools to help decision-makersunderstand the policy and programimplications 8 of data. The programwill developlinks with Africanresearch Institutions to strengthenthe capacity of these institutionsand to ensure Africanparticipation in both the researchand disseminationof results. S6rttgliesfor MenagingRisks Associated with Pregnancy

For womenin Sub-SaharanAfrica, the risks of complicationsin pregnancyare much higher. A signi&cantnumber of Africanwomen possess one or more of the broad characterisdcswhich are frequentlyused to deflnematernal risk, such as thosewomen who get pregnantunder age 15 or over age 40, have multiplepregnancies or previouscomplications, or have otherhealtl problemssuch as , hypertension,stunted growth or ma:nourishment.However, because recent studieshave focusedon differentand varyingoutcomes of maternalmortality, others perinatal or infantmortality, it is difficult to conclude on the predictivevalue of "risk factors" for maternal mortality in developingcountries.

Becauseof the issuesof accessand availabilityto healthservices in Africa, someAfrican health and family planningprofessionals still see the risk approach as an evolvingprocess and have identifiedit as an importantarea for continuedresearch in Africa. The socioeconomicstatus of most womenin Africaand the barriers to accessto care createan environmentin which it is important to screenwomen for early indicationsof complicationsand to refer them to trainedhealth providers. In Africa, the lack, or poor management,of transportationto the first-referralcenter, shortaps of and inadequatelytrained health personnel, poorly equipped and mainta!ned health facilities, and flaws in the patient managementsystem, all serve to create barriers to appropriateand timelyobstetric care. While it is essentialto reduce these problems,the Groupconsiders it a priority to carry out furtherresearch on risk assessmentin the Africanenvironment in order to developguidelines for health providersto screenwomen for the most commonand importantcomplications.

III. SAFE MOTHERHOODACIlVITIES IN SELECTED COUNTRIES

Participantsat the meetingpresented status reports describing the needsand piloritiesof many of the francophoneSub-Saharan African countries. Drawingupon the informationin these reports and the experienceof the group, practical,realistic recommendations for action were developed. Thesecountry findings are summarizedbelow.

Benin: High maternalmortality and fertility contributejointly to the poor health status of womenand childrenin Beninwhere onlya third of all deliveriesare attendedby trainedpersonnel. Hospitaldata indicatethat over halfof all maternaldeaths are due to hemorrhage.The abilityof the health systemto deal effectivelywith these problemswas hinderedduring the 1970sand 1980sby an over-centralizedmanagement system, poor infrastructureand acute shortageof drugs, supplies, equipmentand appropriatelytrained personnel at the servicedelivery level.

A comprehensivereform of the healthsystem initiated in 1987gives high priority to improving basic health services,including maternal health and familyplanning services. Key componentscf this programinclude early detectionand managementof high-riskpregnancies, improved prenatal, labor and delivery care, and the creation of trained teams of health providers to manage the identification,referral and treatmentof pregnancy-relatedcomplications. The programwill also developnorms and standardsfor care and provide supplementaltraining for midwivesin each 9 district. The reformshave initiatedan effectiveessential drugs procurement and distributionsystem that has reducedthe shortageof suppliesand drugs. Delaysin the implementationof the proposedsafe motherhoodprogram, a major component of the project, result from inadequatepolitical commitment and a highlycentralized and inefficiently managedhealth ministry. The grouprecommended that politicalauthorities at the nationaland local levels,MOH officials, and localassociations support a moreaggressive family planning and maternal health program which could reducethe country'shigh maternalmortality and fertilitylevels. The Group also recommendedthat the Governmentestablish a coordinationmechanism for integrating safe motherhoodservices into the familyplanning and maternaland childhealth (FP/MCH) program.

Burkina Faso: Maternalmortality remains high in BurkinaFaso withmaternal mortality rates ranging from 350 to 650 per 100,000live births. Less than 23 percentof the deliveriestake place in a health facility and less than 30 percent of deliveriesare assisted by a trained attendant. Accordingto Mme.Josephine Ouedrago even thosewomen who recognize the needto go to a health facilityfor antenatalcare are often treatedrudely and forcedto wait for longperiods of time before they are seen. Oftenwomen wait only to be told that there is no blood or drugs are lacking.

The Governmentof Burkina Faso has developedan integratedfamily planningand maternal health programwith the aim of reducingmaternal mortality rates by 5 percent. The programwill establisha continuumof care from the communityto the district-levelhospital which will be based on clearlydefined national norms and standards.

Researchis an importantpart of the safe motherhoodagenda. A community-basedmaternal mortalitystudy as well as a study examiningthe role of communityhealth workers as agents to promotefamily planning and maternalhealth servicesare presentlyongoing. A nationalcommittee on women'sreproductive health has been establishedto determinethe prioritiesin this area for the country.

Burundi: Burundiis the secondmost densely populated country in Africa. Persistentlyhigh fertility is reflectedin the youthfulstructure of the population;46.5 percentof the populationis under age 15. Althoughthe governmenthas recentlygiven high priority to slowingthe population growth,contraceptive still remains at only 1.6percent. Burundi'snational health policy, which is firmlygrounded in the principleof primaryhealth care, aims to providebasic health care to all thereby: (i) increasingoverall life expectancy;(ii) reducingmorbidity and mortalityof infants and children; and (iii) reducingmaternal mortality and morbidity. Governmentstudies estimate maternalmortality rate to be 300 per 100,000live births.

A site visit to the KigamaHealth Center in the Provinceof Muramvyaallowed the Groupto examinefrst hand some of the difficultiesfaced by the health systemin Burundi. Healthservices in Burundisuffer from poor infrastructureand a lack of drugs, suppliesand equipmentand trained health personnel. Referral systemsare weak and norms and standardsfor the monitoringand assuranceof qualitycare are only now being formulated.

The nationalhealth policyplaces more emphasison the major systemicconcerns in the health sector, including:(i) decentralizingplanning, programming and administrationof health servicesto improveefficiency and responsiveness;(ii) accordingmanagerial autonomy to health facilities; (iii) strengtheningfamily planning services; and (iv) involving communitiesin the financingand 10 managementof health services. The Government'spopulation policy is to reduce the rate of populationgrowth through the nationalFP/MCH program.

A review of recent data on fertilityshowed a relativelydelayed age of marriage(23 years for girlsj and indicationsof low abortionrates amonggirls below this age, yet an extremelyhigh fertility rate for Burundianwomen. The data suggestthat delayedage of first marriageis not a sufficient measurefor reducingfertility. The Group proposedthat researchbe undertakento examinethe socio-cultural factors influencing fertility practices, traditional contraceptivemethods and managementof unwantedpregnancies. Using the results of this research, program strategies integratingwomen's reproductivehealth into the servicedelivery system can be developed.

Cameroon:The maternalmortality ratio in the Cameroonis estimatedas 420 per 100,000live births. Accessto health care is limited for most of the predominantlyrural population,with one physicianfor every 17,466people. Contraceptiveprevalence is approximately5 percent. Morethan 21 percentof the femalepopulation is betweenthe ages 10and 19, and early marriageand pregnancy are the norm. Teenagersaccount for more than 21 percent of all annual births, and nearly 18 percent of teenage pregnanciesend in inducedabortion, which is legally restrictedand usually unsafe. The total fertility rate is six, and the averageage for grand multiparityis 27 seriously affectingmaternal depletion. Teenagepregnancy and grand multiparityaccount for 67 percentcf complicationsin labor and the puerperium. (Leke1991; Nasahand others 1991).

The CentralMaternity, University Hospital Center and 18 privatematernities in Yaoundehave adoptedthe risk approach, which requires that all pregnantwomen be screenedfor risk factors during the prenatal, intrapartumand postpartumperiods. Those identifiedas being at high risk receive special surveillanceand care. Studies have shown that inadequatecare of hospitalized motherscontributed to 54 percentof all deaths. In additionto ensuringthat all womenat high risk receiveappropriate surveillance, all womenin labor in the teachinghospitals are monitoredusing the partogram,which can be used to detect intrapartumrisk.

Dr. RobertLeke of the CentralHospital of Yaoundeand Mme. SimoneDormont of the Centre Internationalde l'Enfance in Paris presentedthe results of a researchproject conductedin one provinceof Cameroon. The studyfound that femalesunder age 20 eccountfor 21 percent of the births and that there is a low frequencyof abortionsin this age group. It wasrecommended that this studybe expandedto one or two other provincesso that the resultscan be extrapolatedto a national level. A review of the national program indicatesthat the lack of a central coordinatingbody responsiblefor safe motherhoodhas resultedin the fragmentationand diffusion of maternityservices. It is recommendedthat programmanagement and service deliveryfor safe motherhoodservices be decentralizedto the program level and that norms and standardsfor safe motherhoodservices be strengthenedto improvethe qualityof care. Professionalassociations, in particularthe National Associationfor Obstetrician-Gynecologists,must be more activelyinvolved in safe motherhood activitiesat the nationaland locallevels. To encouragethis involvement,the groupagreed to invite representativesfrom the relevantmedical professional associations to participateat the next meeting of this Groupwhich is scheduledto be held in Cameroon.

C8te d'Ivoire: Despite considerableprogress over the years in improvingthe health care system,health conditionsin the C0te d'Ivoire are not significantlybetter than many poorer African countries. Life expectancyremains at 53 years and infantand maternalmortality are high. A recent maternalmortality study conductedin Abidjanfound maternalmortality rates in three first-level 11 referralcenters in Abidjanto be abnormallyhigh in 1992.(Hospital maternal mortality rates of 2548, 2979 and 888 were recordedin Cocody,Treichville and Yopougon,respectively.)

Althoughthere existsa publichealth care networklinking primary health care servicesprovided at the communitylevel with first-levelreferral care, this pyramidof services does not function effectively. Hospitaltertiary care has been favored over primary health care and first-referral services. Lack of financesand poor managementof availableresources have furtheraggravated the system. There is an oversupplyof specialistsin somefields and an acuteshortage of primaryhealth care providers for family planning and maternal and child health care. Patient care practice standardsare unacceptablylow and not basedon establishednorms and clinicalguidelines. Although there is no national safe motherhoodstrategy, political interest and commitmentfor reducing maternalmortality and morbidityand reducingthe populationgrowth is more evident. Two local NGOs, AssociationIvoirienne pour la MaterniteSans Risques and l'AssociationIvoirienne pour le Bienttre Familiale,have integratedsafe motherhood services into their programmingstrategy in the urban areas.

The Group recommendsthat a dialoguebe openedwith the Government,through the formal mechanismof this Group, to sensitizegovernment officials to the high levelsof maternalmortality and morbidityin the country and the need to take urgent action. In addition,the Groupproposes sendinga missionto Abidjanto assistthe Govermnentin organizinga nationalworkshop to develop a programto manageemergency obstetric care at the first-referrallevel facilities both in Abidjanand elsewherein the country.

Miadagascar:In 1976Madagascar was one of the first countriesto adopta primaryhealth care strategywhich emphasizedbasic preventivehealth services. Despitethis statedpriority to health care, however,budgetary allocations to the MOHwere low and conditionsof the healthsystem have progressivelydeteriorated. Maternal mortality in Madagascaris estimatedin the range of 250400 deathsper 100,000live births. Themajor causes of maternalmortality are reportedto be postpartum complications(29 percent), abortions(16 percent)and hemorrhage(7 percent). Accessto quality prenataland deliverycare is limited. Accessibilityand availabilityof familyplanning services is also low; contraceptiveprevalence is estimatedat less than 3 percent.

A s'.bstantialamount of inducedabortion is reportedin Madagascar.One hospital-basedstudy in Antananarivofound that over 15 percent of all maternaldeaths were attributableto unsafe abortion. A study in the rural areas reportedthat 30 percentof maternaldeaths are attributableto complicationsfrom unsafeabortion. In anothersurvey in the capitalarea, 36 percentof the women of childbearingage who were not pregnantreported that they would seek an abortionshould they becomepregnant. There is an urgent need to make safe and effectivemethods of contraception availableand to improveearly treatmentand referralof complicationsfor unsafe abortionand other emergencyobstetric services.

In 1987, UNFPA sponsoreda three-yearsafe motherhoodproject which emphasizedfamily planning and maternity care services in the rural areas. The project trained family planning providersbut did not successfullyintegrate these servicesinto MCHactivities. The lessonslearned from this pilot safe motherhoodproject have encouragedthe Governmentto pursue an integrated packageof family planningand MCH servicesby the MOH. 12 At present,the Governmentof Madagascaris givingpriority to rehabilitatingthe publichealth sectorto deliverbasic health services. Througha World Bank loan, the Governmentwill reform its health service deliverysystem based on the health districtapproach.

Althoughreducing maternal morbidity and mortalityand moderatingfertility levels are priorities of the Government,insufficient human resources and health infrastructureseverely limit the capacity of the systemto provide services. In order to assurethat safe motherhoodbecomes an integrated part of this system,the Group proposessharing technical expertise on safe motherhoodwith the governmentand assistingthem to developa nationalsafe motherhoodprogram.

Mali: Quality family planningand maternitycare is not readily accessiblein Mali. Only 1 percentof womenof reproductiveage use a moderncontraceptive method and 38 percentof women receivedprenatal care. Childbearingis high amongteenage women,with almost one-halfof all womenunder the age of 19 givingbirth (PopulationReference Bureau 1992). Ihis meansthat on average, one in five adolescentwomen will have a birth in a given year. A 1987 report by the Ministryof Healthestimated the maternalmortality rate to be between1,750 and 2,900.

Althoughthe health systemhas been plaguedwith a lack of financesand poor managementof availableresources, the country'snetwork of district-basedhealth centers now providesaccess to care for 45 percentof the populationand this is expectedto increase. There is an insufficientsupply of health manpowerand existing staff are not adequatelyprepared to provide obstetric services. There is an oversupplyof providers in Bamakoand an acute shortage of primary health care providersat the periphery. Healthservices are not fullyutilized because of the poor qualityof health care. Facedwith longwaits, staff who are not responsiveto clientsneeds and a shortageof drugs, Maliansare forcedto use more expensiveprivate clinics, where they exist, or traditionalhealers for care. In recentyears, the Govermnenthas givenincreased priority to the promotionof primaryhealth and, particularly,strengthening family planningand maternaland child health care. There is now greatercollaboration between the publicand privatesectors, NGOs and donorsto integrateFP/MCH servicesand to developan IEC programto promotethese services. Community-basedand referral- level facilitiesare being enhancedto increaseboth the coverageand qualityof health services.

Even thoughthe FP/MCH programis now providingIn-service training in safe motherhood, much remainsto be done to reducematernal mortality and morbidityin the country.Several of the constraintswhich are blocking the developmentof a safe motherhoodprogram are: (i) lack of involvementof obstetrician/gynecologistsin safe motherhood;(ii) lack of national researchon maternalmortality and morbidity;(iii) limitedcollaboration with private clinics in providingsafe motherhoodservices; (iv) poor inderstandingof and knowledgeabout adolescent fertility and abortionin the country;and (v) recentpolitical instability which has disruptedthe Ministryof Health.

Inproving women'shealth status in Mali meansthat policy-makers,health care providersand clientsmust focusboth on the household'scapacity for self-careand community-basedand referral level health services. The Group suggestedthe followingrecommendations to strengthensafe motherhood:

(i) There is a need to developnational norms and standardsfor deliveringfamily planning and maternitycare services. 13 (ii) The complexityof health manpowerissues in Africa coupledwith the need for servicesto be availablein the communitynecessitate that Mali promotethe conceptof districthealth teams. Districthealth teams can influencedecision-making, set localstandards, and monitorperformance and, thereby,have an importantrole to play in guaranteeingan essentialpackage of services.

(iii) Health professionalassociations and local NGOs need to be. involvedin the planning, implementationand monitoringof safe moeherhoodactivities.

(iv) Trainingprograms should be revisedto adaptmedical curricula to publichealth needs and reorient in-serviceFPIMCH training to focuson safe motherhoodinterventions.

(v) The Government,donors and regional institutions need to invest in the long-term developmentof the researchcapacity in safe motherhoodand women'shealth in Mali.

Senegal: Studiesin Senegalestimate the maternalmortality rate to be 933 deathsper 100,000 live births. Most births in Senegaltake place at home and, as a result, it is estimatedthat three out of four maternaldeaths are not registered. Manywomen die in route to a health facilityor, once they reach the facility, obstetric care may be delayed due to the absence of qualifiedmedical personnelor the lack of drugs and supplies. Becauseof theseproblems, Mrs. ThereseKing, former Ministerof Healthof Senegal,told the Groupthat the Governmentof Senegalhas chosena proactive strategywhich mobilizesboth human and financialresources to reduce the levels of maternal mortalityin the country.

The Government of Senegal has established a national safe motherhood program and coordinatingbody to ensurethe implementationof programactivities. The safe motherhoodprogram emphasizeseducating women and providersat the peripheryabout family planningand promotion of healthypregnancies. At the level of the health center, the programwill improveservices for familyplanning, prenatal and deliverycare and the screening,management and referralof high-risc pregnancies. Emergencyreferral systemswill be strengthenedby encouraginglocal counitwes to organizeto providethese services. At the first-referrallevel, districthospitals are beingupgraded to provideemergency obstetrical services.

At present, the safe motherhoodprogram is beingimplemented in the Regionof Tambacounda and providesa range of familyplanning, prenatal, delivery and postpartumservices at all levelsof the health pyramid. The Governmentplans to expandthis programto a secondregion as fumds permit. The Senegalprogram offers some excellentlearning opportunities for other countriesand the Group is encouragingsite visits from neighboringcountries.

Zaire: Dr. Alexis Ntabona,of the Schoolof Public Health in Zaire and Dr. SambeDuale describedsome of the maternalhealth problems and the constraintsto improvingfamily planning and maternal health services in Zaire. Womenin Zaire suffer a disproportionateamount of health problemsdue to problems associatedwith pregnancy,infertility, STDs, and AIDS. Matenal mortalityrates are estimatedto be above 800 per 100,000live births. The increasingincidence of STDs and HIV seroprevalence,estimated to vary from 6 to 8 percentin Kinshasa,and AIDSadds another dimensionto the problemsfacing women.

In Zaire, the government'sshare of health expendituresis less than 5 percent (WorldBank 1993). Most services are deliveredin collaborationwith NGOs and religiousmissions. At the 14 districtlevel, 50 percentof 306 health zonesestablished between 1982-86 are beingmanaged by, or in close collaborationwith, NGO assistance. Unfortunately,broader societalconditions, such as politicalinstability and financialmismanagement, have disruptedthe health system. Todaythere is neithera nationalsafe motherhoodprogram nor a nationalcoordinating body for safe motherhood in Zaire.

Thepolitical situationin Zaire has resultedin a lack of central coordinationof health services and fragmentationof servicesdelivered at the districtlevel. Until the currentpolitical situation is improved,sector specialists, both withinand outsideof Zaire, shouldbe encouraged(and supported) to use this opportunityto generatedialogue with beneficiaries, professional associations, and health providerson approachesfor integratingsafe motherhoodservices into the FP/MCHprogram.

IV. SPECIAL ISSUES: ADOLESCENTFERTILITY AND UNSAFE ABORTION

In Sub-SaharanAfrica, adolescentsmake up 19 percentof the total populationand are part of the group at greatestrisk of maternalmortality and morbidity.Many femaleadolescents have had some sexualexperience: some studieseven suggestthat more than one-halfof womenaged 15-19 had experiencedsexual intercourse (Senderwitz 1993). A majorityof these womenwill have had a birth by age 20 and an unknownnumber will have terminatedtheir pregnanciesthrough unsafe abortion. The result is that in somecountries births to mothersunder 20 years old accountfor close to 20 percentof total birth.

The rates of sexualintercourse vary greatly among countries according to premaritaland marital socialnorms. In somecountries, such as Mali where76 percentof womenunder age 20 had sexual intercourse,the majority(99 percent)of these teenagersare marriedby the time their babieswere born. In other societies,such as Kenya and Botswana,sexual intercoursetakes place prior to marriageand most girls remain singleafter childbirth. Burundiis the only countryin an eleven country DHS study of Sub-SaharanAfrica where teenage childbearingis relativelyuncommon (PopulationReference Bureau 1992).

In some African societiesadolescents are sexuallyactive within culturallyapproved unions, which may take place outside of marriage, but conformto norms of many traditionalAfrican societiesthat approveof early marriageand childbirth. Today's adolescentsin contemporaryAfrica are also facing vast pressures:increased opportunities for sexualactivity because of urbanization, higher female enrollmentis secondaryschools, changes in the family structure, peer pressure, availabilityof drugs and alcohol, and mediainfluence. A younggirl may provide sexualfavors to an older man, commonlyknown as the "sugardaddy," in return for materialfavors or in the role of the youngerwife. Thesegirls are oftenignorant or fearfulof seekingfamily planning counseling and STD treatnent and control.

The health risks of teenagechildbearing for boti. ' mother and child are serious, including pre-eclampdc toxemia, anemia, , cephzt 1vic disproportion, obstetric fistulae, obstructedlabor, lowbirth weightand perinatalmortality. However,most adolescents do not protect themselvesagainst unwantedpregnancies; more than 30 percent of currentlymarried teenagers in 8 of the 11 Sub-SaharanAfrican countries looked at in the DHS studyhave an unmetneed for family planning(Population Reference Bureau 1992). Thesocial costs of teenagepregnancies are alsohigh: teenagegirls who are pregnantare threatenedwith schoolexpulsion and ostracismby their families and often seek to terminatetheir pregnancies. 15 It is often difficult for adolescents to find appropriate family planning and reproductive health services because: (i) few teenagers are knowledgeable about sexual behavior; (ii) few services are designed to meet the needs of adolescents at a cost affordable to them; (iii) health providers are not trained to provide counseling and services to adolescents; and (iv) government policies and legislation often work at odds with promoting family planning and reproductive health services and education programs for adolescents.

African governments must do much more to promote legal and social change regarding adolescent fertility and to implementprograms that are tailored to the fertility and reproductive health needs of adolescen. . Family life education in schools and communities can help teenagers make informed choices about sexual behavior and family planning services should be available for those sexually-active adolescents. Some suggestions offered by the Group to reduce adolescent fertility rates are:

'9 Promote policies aimed at increasing the age of marriage, delaying childbearing, and increasing female enrollment in secondary schools.

* Provide more reproductive health programs aimed at increasing the knowledge and changing the reproductive behavior patterns of adolescents.

* Provide family planning counseling and services to adolescents, regardless of age and marital status.

* Provide family planning and maternal health services to adolescentsin a multiservice center which is attractive to teenagers and serves their health and social needs.

* Design service delivery strategies in collaboration with adolescents who are the expected beneficiaries.

* Encourage wider public discussion of adolescent health needs and educate the public and adolescents, both males and females, about the advantages of delaying the first birth and marriage, staying in school, and practicing safe sex to avoid pregnancy and STDs, including HIV.

Misinformation or lack of knowledge about the socio-cultural factors surrounding adolescent fertility is widespread in most African countries. Promising approaches to delivering services and changing behavior through health education programs will need to be examined in each country.

Unsafe abortion is another cause of maternal mortality. Reliable data on abortion in Africa is lacking and the hospital-based data which is available is likely to underestimate the extent of the problem since information does not reflect those clandestine abortions which occur without any complication. Recent data from a study in Kenya estimated that there were approximately75,000 abortions in Kenya in 1990. Extrapolating this to Sub-Saharan Africa suggests that there was an estimated 1.5 million abortions in the region (Rogo 1991). In Ethiopia and Nigeria, aLmost50 percent of the maternal deaths result from complications due to abortion. In Kenyatta National Hospital in Nairobi, approximately 100,000 beds each year, or 27 beds each day, are occupied by patients with complicationsrelated to unsafe abortion. Treatment for abortion-relatedcomplications can consume significant resources. 16 Althoughadolescents account for a disproportionatenumber of abortioncomplications given their greatertendency to obtainan unsafe abortionand their delayin obtainingthe procedures,they are not alone in seekingabortions: women in all phases of their reproductivelife-cycle experience unwantedpregnancies and seekabortions (Senderwitz1993). Dr. ColetteDehlot, fromthe Nairobi Officeof the PopulationCouncil, reported on a knowledge,attitude and practicestudy among Masai womenwho have obtainedunsafe abortionswhich foundthat no matter the age or marital status, whenconfronted with an unwantedpregnancy, the first reactionfor all womenis to seekan abortion.

The vast majorityof womenin Africa do not have accessto safe abortion. Where abortion servicesare not availableor becausewomen seek anonymityor do not have the moneyto pay for services,they abort themselvesor resort to unsafeabortion by peoplewho have no medicaltraining. Womenoften delay seekingtreatment for complicationsof illegalabortion for fear of revealingthe abortionor due to the lack of accessto health services. Even where abortionis legal, such as in Zambia, problemswith access continue. A 1988 study using data from the UniversityTeaching Hospitalin Lusaka showedthat, for every one abortionperformed legally, twenty-fiveabortion- related complicationswere treated.

A KAP studyon health personnelwhich was also reportedon by Dr. ColetteDehlot found that clandestineand unsafe abortionis practicedby both health professionals,including physicians and nurses, as weUas traditionalhealers and non-medicalpersonnel who work in healthcenters. Often, these abortionstake place outsideof clinic hours and are done to supplementtheir monthlyincome (Phillipps1991). Manyare performedunder unsanitary conditions, using elementary techniques and inadequateinstruments - all of which may lead to severecomplications.

Throughoutfrancophone Africa, there are examplesof governmentlegislation and policies which createbarriers to improvingwomen's social status. Themajority of countriesmaintain former colonial laws prohibitingabortion unless the mother's life is in danger and restrictingthe sale of contraceptivesto marriedwomen who havetheir husband'sapproval. In manyfrancophone African couitries, the 1920 French law prohibitingthe sale and distributionof contraceptivesis still in existence. Accessto familyplanning services for adolescentsand singlewomen is severelylimited.

The recognitionof abortionas a severehealth problem in Sub-SaharanAfrica is just beginning, however,there are a few examplesof successfulprograms: in KenyattaNational Hospital, Nairobi, manual vacuum aspirationtechnique has been introducedto terminatepregnancies in the first trimester. After introductionof the manualvacuum aspiration technique, clients and providershave benefittedfrom shorterhospital stays, better results, and costs that have been reducedby 23 to 66 percent. BothBotswana and Burundihave familylife educationprojects which focus on adolescents. The programin Burundiis a sexualeducation program conducted in the secondaryschools. The objecdveof the Botswanaprogram is to provideeducation, counseling and familyplanning services to boys.

Reducingunsafe abortion should be a priority for achievingsafe motherhood. The economicand socialcosts of unsafe abortionin Africaare tremendous.Unfortunately, however, the problemhas not been given the attentionit deservesin Africa. Legalizingabortion, as in Zambia, is insufficient to improvewomen's health where accessto health servicesis limited. Africangovernments need to documentand recognizethe extent of the problemof unsafe abortionand to focus resourceson Improvingaccess to and quality of family planningservices as well as services to manage the complicationsfrom unsafeabortion. This requires:(i) traininghealth providers to ensure technical 17

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S.w.e: PoplIattonRaftronce Burv. 1992 competenceand appropriatetreatment of complicationsfrom abortion; (ii) involving women's organizationsin the developmentand implementationof programsfor women's reproductivehealth; and (iii)promoting health education and communicationprograms to educatewomen to the dangers of unsafeabortion. In addition,government policy and legislationhave a criticalimpact on women's reproductivehealth. Restrictionswhich createbarriers to family planninguse, such as restriction on the availabilityof contraceptiveservices because of age and marital status or expulsionof adolescentgirls who becomepregnant from secondaryschooling, need to be modified. Inproving women'saccess to familyplanning services and providingsaf} abortion services as well as services to managethe complicationsfrom unsafeabortion requires tremendous political will and a concerted effort from local communities,governments, international agencies and NGOs.

V. SUMMARY: THE PROBLEM OF EXCESSIVE MATERNAL MORBIDlTY AND MORTALITYIS INCREASINGAND DEMONSTRATED POLITICAL COMDTE TO SAFE MOTHERHOODIS LACKING.

The numberof maternaldeaths continuesto rise each year in many countriesin Sub-Saharan Africa. The populationof womenof childbearingage is now larger than it was in 1989,and the numberof womenwho die eachyear frompregnancy-related causes has increasedeven thoughthere mayhave been a slight declinein pregnancyrisks. Yet, in spite of this fact, the RegionalResource Groupof Expertson SafeMotherhood for FrancophoneAfrican countries believes that there is cause for hope in the progressof the francophoneAfrican countries toward reducing maternal mortality by half by the year 2000. There is now more recognitionand support for safe motherhoodat the international,regional and countrylevel, some governments have developed strategies and programs aimed at reducingthe levelof maternalmortality and morbidityand, in some instances,community 18 activitiesto promotesafe motherhoodhave been initiated. There is causefor hopebut much remains to be done. The Grouprecognizes that althoughindividual circumstances require each countryto determine their owtapriorities and strategies, certain critical factors, essentialto improvingand expanding maternalhiealth and family planning, are not receivingappropriate and urgent attention. These include:

Inadequatepolitical commitment at national level. Evidencefrom statementsand activities of politicalleaders do not reflect a sense of nationalpriority in addressingmaternal and women's health issues.The apparentlack of demonstratedpolitical commitment in this area is most reflected in the limitedor, in some casesnon-existent, allocations in the government'sbudget for non-wage operatingexpenses that are neededat the levelof health facilitiesto effectivelyprevent and manage high risk pregnancies. Few countries have establishedor rendered effective mechanismsfor coordinatingstrategies and programson safe motherhood.Even in countrieswhere substantialwork has been done to developprograms that will improvematernal and women's health, the lack, or ineffectiveoperation, of coordinationmechanisms contributes to duplicationof efforts by various donors acting bilaterallyand independentlywith the government.The positive effects of strong countrycommitment are almostuniversally recognized as one of the main factorsbehind program success.

Over-centralizationof decision-makingprocesses within health ministries. The efficiency and responsivenessof servicesto communityneeds for improvingmaternal and women'shealth are being hamperedby an over-centralizationof decision-makingwithin the central units of health ministries. Resistanceto decentralizationof the crucial planning, managementand supervision functionsfor familyplanning, maternity care and other priorityhealth programs constitutes a major obstaclein FrancophoneAfrican countries toward Se reductionof high levelsof maternalmorbidity and mortality. Experiencein Africa, as well from other regionsof the world, demorstratethat wherethe day-to-daymanagement of primarycare centersis decentralizedto the locallevel and local accountabilityfor servicesexist, serviceshave improved.

The need for a nationalpolicy and strategic frameworkfor safe motherhoodactivities. Externaldonor interest in assistingAfrican countriesin strengtheningservices that promote safe motherhoodhave inadvertentlyhindered effective progress because donors have often worked in isolation without much real coordinationof efforts and strategies. This has sometimesled to conflictinggoals, duplicationof efforts and results whichare not commensurateto expendedeffort and resources. Agenciessupporting safe motherhoodactivities must work within the contextof nationalprograms to avoid fragmentationof programsand misappropriationof scarce resources.

Trainingof healthproviders. The Groupstressed the need for revisingand streamliningbasic and in-servicetraining for physicians,nurses and midwivesto ensure the contentand technicalskills for providingcare that promotessafe motherhoodand ensuresbetter women's health status.

Inadequateinvolvement of professional bodies in safe motherhoodactivities. Safe Motherhoodprograms will be more effectiveif representativesof the healthprofessions -physicians, surgeons,midwives, and nurses-- whoseroles are criticalfor tacklingsafe motherhoodproblems, are involvedin planningand implementation. 19 Monitoring performanceand progress. An adequatemonitoring and evaluationsystem is an integral part of program implementationand essential to building appropriatemodifications into ongoingprograms and determiningwhether they achievetheir objectives. Countriesshould give greaterpriority to the developmentof servicestatistics and monitoringand evaluationof FP/MCH services. A better empiricalstatistical base is necessaryfor improvedsector analysis,better socio- cultural and epidemiologicalstudies and better evaluationof cost-effectiveapproaches to safe motherhood. Servicestatistic data shouldenable countriesto evaluateappropriateness of facilities, equipment,staff and operationalstrategies for managingobstetrical complications and effectiveness and qualityof care, as well as providefeed back mechanismsfor programmanagers.

Healtb education and communication strategies. Improved health education and comnmunicationstrategies are needed to ensure the involvementof beneficiariesin program developmentand implementation.The absenceof coordinatedhealth education and communication strategieshas tendedto send mixedmessages, excluded adolescents and singleadult women and men, and neglectedthe involvementof community-basedgroups in the developmentof IEC messagesfor promotingsafe motherhood. There is growingevidence that involvingbeneficiaries in program developmentand implementationcontributes to better results.

Many Afri=ancountries now recognizethat accessto familyplanning can improvewomen's health and stem rapid populationgrowth which jeopardizeseconomic growth and development. However, current rates of populationgrowth are slowly stretchingto their limit existingskeletal health, education,housing and transportsystems. This could contributeto a poorer qualityof life and furtherenvironmental degradation even for countriesthat have developedotherwise effective economicgrowth strategies.

Althoughall pregnanciescarry some health risks to the mother and child, family planming servicescan help to reduce the health risks from mistimedand unwantedpregnancies, particularly anong adolescents. There is a need for increasedgovernment effort to promotefemale secondary educationand to expandfamily planning services to all women,regardless of age or marital status. Anotherissue deserving more attentionis the growingproblem of unsafe abortionswhich currendy result in the deathof so manyAfrican women, a large proportionof whomare under the ageof 20. Withrespect to maternitycare, the prioritieswhich emergefrom researchand programassessment are preventionat the communitylevel ( and nutritioneducation) and early detection,transport and referral of complicatedcases to facility-basedobstetric services.

This report signals the World Bank's willingnessto support countries committedto safe motherhoodand to work in concertwith other donors to assist countriesthat accord a priorityto improvingwomen's health status. The Bank will continueto support investmentsin the health infrastructureand to strengthenthe publicand privatesector capacity to providefamily planning and maternalhealth services.

SafeMotherhood in Africawill require continued technical, human and financialresources. The ResourceGroup for Safe Motherhoodin FrancophoneAfrica calls for the participationof every countryand within each countrythe many governmentsect^rs, NGOs, communityand women's groups, and health care providers. The Group will continueadvocacy and researchefforts to mobilizegovernment participation and to monitorprogram activities. Halvingmaternal deaths by te year 2000 is a concrete,achieveble goal, providedsufficient commitment, resources and effort are dedicatedto it. 20 REFERENCES

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Washington- Achievementin Primary ErnestoSchiefelbein Diallo Education:A Reviewof the JorgeValenzuela 30997 Literaturefor LatinAmerica and the Caribbean HROWP3 SocialPolicy and Fertility ThomasW. Merrick May 1993 0. Nadora Transitions 35558 HROWP4 ,Social Sector NormanL. Hicks May 1993 J. Abner Developmentand the Roleof 38875 the WorldBank HROWP5 IncorporatingNutrition into F.James Levinson June 1993 0. Nadora Bank-AssistedSocial Funds 35658 HROWP6 GlobalIndicators of RaeGalloway June 1993 0. Nadora NutritionalRisk (II) 35558 HROWP7 MakingNutrition DonaldA.P. Bundy July 1993 0. Nadora Improvementsat LowCost Joy MillerDel Rosso 35558 ThroughParasite Control HROWP8 Municipaland Private Sector DonaldR. Winkler August1993 E. De Castro Responseto Decentralization TarynRounds 89121 andSchool Choice: The Case of Chile,1981-1990 HROWP9 Povertyand Structural lshratHusain September1993 M. Youssef Adjustment:The AfricanCase 34614 HROWP10 ProtectingPoor Jamaicans MargaretE. Grosh September1993 M.E.Quintero from CurrencyDevaluation Judy L Baker 37792 M. Rodriguez 30407 HROWP11 OperationalEducation George September1993 L. Malca Indicators Psacharopoulos 37720 HROWP12 The RelationshipBetween the John Clark October1993 P Phillip Stateand the Voluntary 31779 Sector HROWP13 Obstaclesto Women's JosephKutzin October1993 0.Shoffner Access:Issues and Options 37023 for MoreEffective Interventionsto Improve Women'sHealth HROWP14 LaborMarkets and Market- Arvil V. Adams October1993 S. Khan OriantedReforms in Socialist 33651 Economies HumanResources Development and OperationsPolicy Working Paper Series Contactfor Title Author Date paper HROWP15 ReproductiveTract , May T.H.Post October1993 0. Shoffner HIV/AIDSand Women's 37023 Health HROWP16 Job Securityand Labor RicardoD. Paredes November1993 S. Khan MarketAdjustment in 33651 DevelopingCountries HROWP17 The Effectsof Wage LuisA. Riveros November1993 S. Khan Indexationon Adjustment, 33651 Inflationand Equity HROWP18 PopularParticipation in PhilipR. Gerson December1993 L. Malca EconomicTheory and Practice 37720 HROWP.9 EconomicReturns ffom EdwinMansfield January1994 I. Dione Investmentsin Researchand 31447 Training HROWP20 Participation,Markets and DeepakLal January1994 L. Malca Democracy 37720 HROWP21 SafeMotherhood in Patricia:)aly January1994 0. Shoffner FrancophoneAfrica MichaelAzefor 37023 BonifaceNasah