The most recent estimates developed by WHO, UNICEF and UNFPA on the maternal mortality rates world-wide relate

that: 515,000 women die each year - one every minute - from complications of pregnancy and childbirth; Of these deaths, over half (273,000) occurred in Africa, about 42% (217,000) occurred in Asia, about 4% (22,000) in Latin America and the Caribbean, and less than 1% (2,800) in the more developed regions of the world.

 Twelve countries account for 65 per cent of all maternal deaths world-wide. These include: India (110,000), Ethiopia (46,000), Nigeria (45,000), Indonesia (22,000), Bangladesh (20,000) Democratic Republic of Congo (20,000), China (13,000), Kenya (13,000), Sudan (13,000), United Republic of Tanzania (13,000), Pakistan (10,000) and Uganda (10,000). The life time risk of maternal death varies widely from one region of the world to another. For example, in Africa it varies from 1 in 11 in Eastern Africa, to 1 in 65 in Southern Africa; in Asia, from 1 in 55 in South-central Asia to 1 in 840 in Eastern Asia, and in Latin America from 1 in 85 in the Caribbean to 1 in 240 in Central America. Within specific regions of the world, it varies from country to country, and further from region to region within each country.

 Obstetrical Complications In addition to these maternal deaths, as many as 50 million women - more than one quarter of all adult women now living in the developing world - experience maternal health problems annually. These include: uterine rupture, prolapse, hemorrhage, vaginal tearing, urinary incontinence, pelvic inflammatory disease, and obstetric fistula, a muscle tear that allows urine and feces to seep into the vagina. It is estimated that as many as 300 million women more than one quarter of all adult women now living in the developing world currently suffer from short or long term illnesses and injuries related to pregnancy and childbirth.

 Adolescent girls (15-19 years of age) are at a greater risk during pregnancy and childbirth. In fact, they are twice as likely to die from childbirth as women in their twenties, and if under 15 years of age, five times more likely to die. Unwanted pregnancies, which often lead to unsafe abortions, continue to be a major preoccupation for women world-wide. It is estimated that 50 million unwanted pregnancies are terminated each year, and some 20 million of these are deemed unsafe and thus, a threat to womens health and lives. Furthermore, as with maternal deaths, approximately 95 % of unsafe abortions occur in developing countries, causing the deaths of more than 200 women daily.

 Child Survival There is a definite link between poor maternal health and the newborns chances of survival. An estimated four million babies die during the first 28 days of life - almost two-thirds of whom die within the first week and particularly during the first day. An additional four million are stillborn. It is further estimated that 75 percent of perinatal deaths, almost 8 million per year in developing countries, could be avoided with improved maternal health, adequate nutrition during pregnancy, and appropriate management of deliveries. In 2001, HIV/AIDS was considered the fourth biggest killer worldwide, and the leading cause of death in sub-Saharan Africa. In many parts of the developing world, young adults and especially young women are considered the most at risk for the infection.

 HIV/AIDS Recent antenatal clinical data show that several parts of southern Africa have now joined Botswana with prevalence rates among women exceeding 30%. Every year, it is estimated that HIV/AIDS is transmitted during pregnancy and childbirth to approximately half a million infants in the developing world. Sixty-seven percent of these infants are born in Africa and 30 percent in East Asia and India.

Main Causes of Maternal Death and Injury

The direct causes of maternal deaths are similar throughout the world. They include: haemorrhage (25%), sepsis (14%), hypertensive disorders (13%), complications due to unsafe abortions (13%) and obstructed labor (7%). An additional 20% of maternal deaths in developing countries are attributed to pre-existing medical conditions such as anemia, malaria and HIV/AIDS that are aggravated during pregnancy. Obstetrical complications can neither be predicted nor prevented, except those related to unsafe induced abortion. It is estimated that for every 100 women who become pregnant, 15 will develop life-threatening complications mostly around the time of birth.

 Birthing mothers capacity to survive complications is also influenced by a number of other factors such as: - Womens poor health and nutrition from childhood as well as during pregnancy; - Inadequate, inaccessible or unaffordable health care services; - Poor hygiene and care during childbirth; and - Socioeconomic and cultural factors, such as poverty, womens unequal access to resources - including heath care, food and preventive services, their heavy physical work load and their lack of decision-making power in families, communities and societies.

The 3 Delay Model

Delay 1: Deciding to seek care When complications arise, the decision to seek care is the first step which must be taken by the birthing mother, her family and/or her attendant(s) to ensure access to the appropriate medical care needed. This decision may be influenced by many factors such as: the ability of the birthing mother and her family or attendants to recognize obstetrical complications; who decides when to seek care: the birthing mother herself, her family (husband, mother-in-law) or the assistants; knowledge as to where to go to seek appropriate medical assistance; and cultural factors such as the way society views delivery and childbirth (e.g. women are expected to labour in silence).

Delay 2: Reaching the proper medical services Once the decision has been made to seek medical care, the issue of transportation and/or communication often comes into play. A woman who lives in a rural area, far from health facilities, can face difficulties accessing transportation to get to a health center, especially if she or her family have no means of transportation and/or little financial resources. Furthermore, once at the community clinic, the birthing mother may need to be transferred to a higher level medical facility for services such as blood transfusion or C-section. The delays in accessing transportation to ensure timely access to health services is thus extremely important to consider when trying to improve the accessibility of health care services for obstetrical complications. One question to ask when evaluating this barrier is: is there a village or sub-county plan for emergency transportation in case of obstetrical emergencies?.

Delay 3: Accessing quality care Once the birthing mother arrives at the health center, it is thus just as important that she accesses the required emergency care services. Access to care delays are usually dependent on a number of factors, such as the number and skill level of staff, availability of drugs, supplies and blood and the general condition of the facility. They may also include: delay in the arrival (time wise) of the nurse, midwife or physician attending the patient; delay in accessing, in a timely fashion, the needed medical procedure (e.g. c-section, blood transfusion). A good way to gain insight on the quality of this care is to survey the patients on their perception of the care they received.

It is internationally recognized that the impact of maternal death on families and communities are the following: In developing countries, a mothers death during childbirth means almost certain death for a newly born infant and severe consequences for her surviving children. Studies have shown that there is an increased probability of older children, especially daughters, dying and of their absenteeism from school. Without education, the cycle of poverty continues. Women are more likely than men to spend their income on family welfare. Consequently, when a mother dies during childbirth, the family may lose an important, or its only, financial contributor.

 Within the family, the mother usually assumes the main responsibility for maintaining the home and caring for societys dependents children and the elderly. The loss of a mother thus affects the well-being of the family as a whole. When a mother dies, the community loses a vital member whose unpaid labor is often central to community life.

Safe Motherhood: A Matter of Social Justice and Womens Human Rights

ICPD further recognized reproductive rights to include the rights of couples and individuals to: Decide freely and responsibly the number, spacing, and timing of their children, and to have access to the information, education, and means to do so; Attain the highest standard of sexual and reproductive health and make decisions about reproduction free of discrimination, coercion, and violence,

and sexual rights to include the rights of all people to: Decide freely and responsibly on all aspects of their sexuality, including protecting and promoting their sexual and reproductive health; Be free of discrimination, coercion or violence in their sexual lives and in all sexual decisions, and Expect and demand equality, full consent, mutual respect, and shared responsibility in sexual relationships.

The Cairo accord clearly specifies that sexual and reproductive health includes: Family planning information, counseling and services Prenatal, postnatal and delivery care Health care for infants Prevention and treatment of sexually transmitted diseases (STDs) and reproductive tract infections (RTIs) Legal, safe abortion services and management of abortion-related complications Prevention and treatment of infertility Information, education and counseling on human sexuality, reproductive health and parenthood. Family Care International. Sexual and Reproductive Health Briefing Cards. ICI, 2000.

 Womens empowerment is deemed absolutely necessary in all efforts to prevent maternal death and injury. Only when women are empowered and their sexual and reproductive rights are guaranteed will they be able to attain a certain level of equality in society. Furthermore, this will enable them to: Express their health needs and concerns; Access services with confidence and without delay; Seek accountability from service providers, health program staff and from governments for their reproductive health policies; Fully participate in social and economic development in their communities; and finally Enhance their familys opportunities and have healthier families.

What You Can Do to Ensure Sexual and Reproductive Rights

1. Essential Services for Safe Motherhood In light of the above, much has also been learned as to Safe Motherhood programming. It is internationally recognized that the essential services for Safe Motherhood include: Community education on safe motherhood; Antenatal care and counseling, including the promotion of maternal nutrition; Skilled attendance during childbirth;

 Care for obstetric complications, including lifethreatening emergencies; Post-partum care; Services to prevent and manage complications due to unsafe abortion; Family planning counseling, information, and services; and Reproductive health education and services for adolescents.

2. Role of Health Professionals in Safe Motherhood Initiatives Health professionals - obstetricians, general practioners, midwives and nurses - have an important role to play in ensuring that women have access to the needed services for safe and healthy pregnancies and deliveries. They also have an essential role to play in ensuring access to the necessary health services when complications arise during labor and delivery. In fact, it is well recognized that the single most critical intervention for safe motherhood is to ensure that a skilled attendant - someone with midwifery skills (e.g., doctors, midwives and nurses) is present at every birth. Such a strategy will ensure that birthing mothers are attended by health professionals who have the training and skills necessary to manage normal deliveries and diagnose or refer complications to higher levels of care.

3. Access to Quality Maternal Health Services: WomenFriendly Health Services According to UNICEF, poor quality of care and deficient services are the most common reasons women and their families give for not using available services, even if they are accessible. It is well understood that if given a choice, women and their families will use facilities and providers that offer what they perceive as the best care. Among others, they seek: Respect, friendliness, courtesy, confidentiality and privacy; Understanding, on the part of the providers, of each womans situation and needs;

 Complete and accurate information; Technical competence: Women judge the cleanliness of the clinics, the thoroughness of examinations and the types of medication they are given, and ultimately whether their needs are met or their problems resolved; Access and continuity of care and supplies; Fairness: Information and services for everyone regardless of class or ethnicity. Results: women dislike being told to wait, come back on a different day, or having their complaints dismissed as unimportant.

Women-Friendly Health Services are services that meet established criteria for quality. They are health facilities where: Quality of care standards and guidelines are implemented, followed and revised periodically; The necessary supplies and equipment, including medication, are available for the provision of the needed health services; The necessary transportation and communication links are accessible when referral to a higher functioning facility is required, whether living in an urban or rural area. The services are affordable to all women, and if not, that measures are put in place to ensure access to services for the poorest. The health services are available to all women: For example, that women are not left waiting hours for consultations, that emergency care be made available in an acceptable time frame, that social factors be accounted for when necessary (e.g., female health workers). Health professionals respect women and childrens rights.