Safe motherhood initiative: 20 years and counting.

1130 www.thelancet.com Vol 368 September 30, 2006 The global campaign to reduce maternal mortality was launched in February, 1987, when three UN agencies— UNFPA, the World Bank, and WHO—sponsored the international Safe Motherhood Conference in Nairobi, Kenya. The event aimed to raise awareness about the numbers of women dying each year from complications of pregnancy and childbirth, and to challenge the world to do something. The origins of the conference dated from 1985, when two critical events focused the attention of public-health specialists on the horrifi c risks pregnancy posed for women in developing countries. In that year, Allan Rosenfi eld and Deborah Maine pointed out that maternal and child health programmes in developing countries were almost exclusively for the benefi t of the child, with almost no attention to the factors that were causing women to die. That same year, during the conference marking the end of the UN Decade for Women, women’s advocates from around the world heard WHO announce that half a million women were dying each year from obstetric complications. These two events began a groundswell of concern for key players, both institutional and individual, who came together to plan the Nairobi Safe Motherhood Conference and to launch the global Safe Motherhood Initiative. The 1987 Nairobi conference led to the formal establishment of the Safe Motherhood Inter-Agency Group (which included the three sponsors of the conference plus UNICEF, UNDP, and two international non-governmental organisations, IPPF and the Population Council), and to a series of regional and national conferences that made safe motherhood an accepted and understood term in the public-health realm. By the time of the International Conference on Population and Development in 1994, every region of the world had held a safe motherhood conference, and safe motherhood was fi rmly ensconced as a core component of reproductive health. The importance of maternal survival was reinforced in 2000, when it was included as one of the eight Millennium Development Goals. The Safe Motherhood Initiative has learned important lessons during the past 20 years. At the Nairobi conference, the framework for action in Fred Sai’s closing statement encompassed the need to improve women’s status, educate communities, and strengthen and expand core elements of maternal health—antenatal care, delivery care, and postpartum care—at the community and referral levels. The conference proceedings echoed these recommendations, but they were not always taken up by key actors. During this period, less than 10 years after the Alma Ata conference and the global commitment to primary health care, the public-health community was prioritising community-based preventive interventions. Donors, UN agencies, and governments therefore seized on two elements of the safe motherhood strategy discussed at the Nairobi conference —antenatal care, with a focus on screening women to identify those at risk of complications, and training of traditional birth attendants to improve delivery care at the community level—and poured their funding and support into these strategies. A decade later, at the conference marking the Initiative’s 10th anniversary, two of the key action messages about safe motherhood implicitly acknowledged the failure of these approaches (panel). The two messages helped shift the focus of the Safe Motherhood Initiative; many donors and governments began de-emphasising large-scale training programmes for traditional birth attendants and prioritising health-sector interventions designed to increase women’s access to professional medical care, especially for life-threatening complications. There were other strategic decisions in the Initiative’s early years that had unforeseen negative consequences, Safe motherhood initiative: 20 years and counting