Safe Motherhood Initiatives: Critical Issues.

Based on the sobering fact that motherhood is just as unsafe for women living in the poor world as it was 13 years ago when the Safe Motherhood Initiative was launched, this clear and authoritative book pulls no punches. After more than a decade of getting it wrong in a myriad of ways we can now be a lot clearer about what does not work when it comes to preventing maternal death, as our understanding both of the problem and of effective solutions has matured greatly in that time. Among the interventions highlighted as largely ineffective are such central tenets as the provision of antenatal care, the training of traditional birth attendants, and the use of ‘risk’ screening to predict which women will develop complications. Conversely, success in reducing maternal mortality and morbidity has followed from the strengthening of primary care (including contraception services), provision of safe, legal abortion and the upgrading of emergency obstetric services. The contribution that epidemiology plays in tackling safe motherhood needs, according to several of the chapter authors, to be completely rethought. Asserting that ‘the values and limitations of different forms of measurement of levels and trends in maternal mortality have only recently become clear’ they argue that ‘the time has come to shift the focus from measurement to analysis, from trying to understand the size of the problem to seeking to understand its underlying causes and determinants’. For those who like their epidemiology action-orientated, the first few chapters will make rewarding reading. The focus ranges from asking what it is we need to know when measuring maternal mortality, through advocating the use of process indicators and on to the limitations of health outcome indicators. The chapter authors are from a wide range of disciplines and an impressive array of countries. What they have in common is a very readable style and a strong belief, based on their own experience, that it is time to throw out the rule book, stop repeating the mistakes which we have all been making since 1987 and develop a fresh approach. Of what this new approach might consist is mapped out in some detail, making this book one of the most valuable contributions yet made to the Safe Motherhood literature.