The Safe Motherhood Initiative and beyond.

In 2007, the Safe Motherhood Initiative is celebrating its 20th anniversary. Many countries have been able to improve the health and well-being of mothers and newborns over the last 20 years. However, countries with the highest burdens of mortality and illness have made the least progress, and inequalities between countries are increasing. In many places, inequalities within countries are increasing too, between those who live in better conditions and have access to care, and those who for a variety of reasons are excluded. Globally, the numbers remain staggering: each year there are at least 3.2 million stillborn babies, 4 million neonatal deaths and more than half a million maternal deaths. The majority of these deaths are avoidable. HIV/ AIDS and malaria in pregnancy are having an impact on maternal mortality and could reverse the progress that has been made. A total of 11–17% of maternal deaths occur during childbirth itself; 50–71% occur in the post-partum period. The time spent in labour and giving birth, the critical moments when a joyful event can suddenly turn into an unforeseen crisis, needs more attention, as does the often-neglected post-partum period. These periods account not only for the high burden of post-partum maternal deaths, but also for the associated large number of stillbirths and early newborn deaths. A total of 98% of stillbirths and newborn deaths occur in low-and middle-income countries: obstetric complications, particularly in labour, are responsible for perhaps 58% of them. The care that can reduce maternal deaths and improve women's health is also crucial for newborns' survival and health. During the early years of the 20th century, standard maternity care in Europe, North America and Japan consisted of a home delivery with regular, frequent visits by an obstetric specialist. The advent of modern obstetric care in the late 1930s did not alter this practice, but gradually moved the process to institutional settings, with post-partum follow-up and care by a skilled health-care provider. Antenatal care is a relatively new concept, and pregnant women in most developed countries now receive an integrated package of antenatal, childbirth and post-partum care. This contrasts with the situation in developing countries, where antenatal care tends to be the first service to receive resources and is commonly widely implemented within maternal health programmes. Most pregnant women in developing countries visit antenatal care services at least once. Far less available and accessible is provision of professional childbirth care, either …