Conclusions
In 2001, maternal and perinatal conditions represented the single largest contributor to the global burden of disease, at nearly 6 percent of total DALYs (Mathers and others 2004). Reducing that burden is widely stated as a priority at both national and international levels, but the track record of translating the rhetoric into action on a sufficiently large and equitable scale to make a difference at the population level remains disappointing. The literature abounds with examples of this disappointment (see, for example, Maine and Rosenfield 1999; Weil and Fernandez 1999). Many reasons account for the limited progress, especially in the poorest regions of the world, and researchers offer many interpretations of the bottlenecks. Lack of evidence on the size of the burden and on the effectiveness of alternative intervention strategies figures prominently in these interpretations.
The modeling in this chapter is, therefore, based on imperfect knowledge and needs to be supplemented with data from primary evaluations. The findings do, however, provide some tentative insights into programmatic options that may represent the optimal use of resources in South Asia and Sub-Saharan Africa. In this context, three issues deserve emphasis. First, for intervention packages to achieve the degree of cost-effectiveness shown here, improvements are needed across health systems, and both the supply and the demand sides need to be addressed. Second, crucial entry points to this system can be achieved at the primary level, particularly through prenatal care. The effect of increasing the volume of women in contact with these services is likely to manifest itself in an increased proportion of deliveries with skilled attendance and of deliveries in which women obtain access to emergency obstetric care. Finally, the quality of these services is crucial, and even with only 50 percent uptake of care, benefits can still be achieved in terms of overall DALYs averted and of reduced maternal and perinatal mortality.
Initiatives to improve the quality of care, particularly at a primary level, thus appear to be cost-effective options for the poorest regions of the world. Overall those findings appear to lend support to a safe motherhood and newborn health strategy that is close to the client and boosts community confidence in health systems.
