Investing in maternal health: learning from Malaysia and Sri Lanka

Of all the human development indicators, the greatest discrepancy between industrial and developing nations is in maternal health. Women in the developing world have a 1-in-48 chance of dying from pregnancy-related causes; the ratio in industrial countries is I in 1,800. For every woman who dies, another 30 to 50 women suffer injury, infection, or disease. Key interventions to improve maternal health and reduce maternal mortality include mobilizing political commitment in a receptive policy environment; investing in social and economic measures such as female education, poverty reduction, and improving women's status; offering family planning services, providing high-quality antenatal care, skilled attendance during childbirth, and emergency obstetric services for pregnancy complications; and strengthening the health-care system and community involvement. This volume is the first of two publications describing success stories and lessons learned in efforts to improve maternal health in developing countries. Based on the experiences of Malaysia and Sri Lanka during the past five to six decades, it describes studies that began in the two countries at a time when maternal mortality was high and discusses strategies used over the past half-century to reverse that situation. Among these strategies were the efforts to professionalize midwifery, the introduction of civil registration and a broadening of women's access to high-quality care from rural midwives with closely linked backup emergency obstetric services. The case studies of Malaysia and Sri Lanka reveal that a modest investment in maternal health services, combined with other poverty-reduction measures, led to a fairly rapid decline in maternal mortality. The two countries" strategies changed over time from an initial emphasis on expanding the provision of services, to increasing service use, and finally to improving quality of care. Removing clients' financial barriers to service use was an important step in both countries. Emergency care was developed in conjunction with gradually increased access to skilled birth attendance from clinically trained midwives, nurse / midwives, and doctors. Recording and reporting of maternal deaths was a prerequisite to addressing maternal mortality in both countries. The success of the two countries in achieving substantial reduction in maternal mortality motivated researchers to determine which of the strategies used there might be replicated in other developing coun