In 1996-97, the Lebanese Family Planning Association (FPA) conducted a survey to identify the remaining traditional birth attendants (TBAs) in the country and determine their level of education and what services they offer. Most of the TBAs are over age 50, illiterate, and completely untrained. Only 26% ever observed or assisted a trained midwife or physician in a delivery. Just over half (54%) accepted only normal deliveries, more than 75% used traditional instruments or outdated methods, and most employed powerful medications. The TBAs attended 12% of all births in Lebanon (a higher percentage in rural than in urban areas). It was impossible to determine what percentage of Lebanon's maternal mortality rate (164/100,000 live births) was attributable to TBAs, and more than 60% of the TBAs indicated that they are not interested in training. The FPA recommended that the government regulate the practice of the TBAs by giving them work permits, forcing them to accept training, limiting their work to normal deliveries only, and banning them from prescribing medicines. The FPA also proposed that the government phase out TBA deliveries within 10 years, finding alternative work for the remaining TBAs and equipping rural areas with professionally staffed maternity care units.
In order to reduce preventable maternal mortality, it is necessary to go beyond ensuring the development and availability of effective health interventions. What is needed is a recognition that maternal mortality is caused by women's inferior social status and that women's disempowerment from birth represents a cumulative social injustice that governments are obliged to remedy through application of their political, health, and legal systems. The challenge of effectively applying such a human rights perspective to safe motherhood is similar to that required in efforts to eliminate slavery or racial discrimination: the necessary reforms threaten conventional practices and value systems. The claim that safe motherhood is a human right will gather legitimacy when it is understood that denying this claim creates an injustice within the standards of fairness that societies hold dear. In addition, countries must recognize that this human rights claim arises from their own cultural values. Then, governments must be held accountable. Advancing safe motherhood through human rights will require a diagnosis of laws, policies, and social norms. The task must include inquiries into the nearly 600,000 annual maternal deaths, and it must meet the challenge of translating human rights into the rights of each person to be human. As 1998 celebrates the first 50 years since the 1948 UN Universal Declaration of Human Rights, the next phase in human rights development must focus on the previously neglected interests of women.
At 143/1000 women aged 15-19, sub-Saharan Africa has the highest rates of births to adolescents in the world, and the maternal mortality rate is equally high in this age group. In response to this situation, the Planned Parenthood Association of Ghana (PPAG) created a prototype Mothers Project that seeks to improve the sexual and reproductive health status of young mothers. The project has its origins in the 1972 Family Life Education program established at the Presbyterian Training College for young students. PPAG took over this program in 1984 and, realizing that girls who had dropped out of school because of pregnancy also needed attention, created a companion community-based Teens Project. The Teens Project seeks 1) to provide adolescent mothers with maternal-child health/family planning services; sexual and reproductive health information, education, and counseling; and employable skills and 2) to lobby for other support services for the adolescent mothers. In 1996, the project received a prize for innovation from the Ghana Chapter of the Forum for African Women's Education because the project had been instrumental in 1) reducing the number of adolescent pregnancies from 30% in 1991 to 12% in 1995; 2) helping young women gain self-esteem; 3) facilitating the return of young mothers to school; and 4) advocating for provision of services tailored to meet the needs of adolescent mothers.
The accessibility of maternal health care services depends on more than their mere existence. While access to routine prenatal care can be increased through use of mobile outreach clinics or peripheral health facilities, access to care for delivery is complicated by the unscheduled nature of labor, by women's other responsibilities, and by fears for women's safety during night travel. Current modes of service delivery must be changed to make care accessible. Physical barriers posed by lack of communication and transportation must be overcome. Possible strategies include establishment of maternity waiting homes, emergency transport and referral mechanisms, and enhanced communications systems. Another strategy is to authorize health care workers at the lowest level of the health care system to perform emergency obstetric services, such as Cesarean sections. Cost is also a barrier, and institution of user fees has prevented many women from seeking care. There are even hidden costs when services are provided free or for a nominal charge. Efforts to overcome these economic barriers include health insurance schemes. In the long term, communities must be educated to recognize and respond to obstetric emergencies, and the quality of health care offered to women must be improved. In addition, communication must be improved between formal and informal health care systems, between communities and health care facilities, and between women and providers.
Dr. Ouk Vong Vathiny is the first director of the Reproductive Health Association of Cambodia (RHAC), the International Planned Parenthood's newest affiliate. Dr. Vathiny's interest in reproductive health began with her first position in a clinic serving women working in Phnom Penh's commercial sex district. Today, she works with RHAC staff to provide a full range of reproductive health services to a wide variety of rural and urban women. Under the direction of Dr. Ping Chutema, the RHAC clinic provides a standard package of safe motherhood services and highlights provision of birth spacing counseling and methods. Although it operates in only three of 22 provinces, the RHAC now distributes between a fourth and a third of all contraceptives dispensed by government services. Dr. Vathiny and Dr. Chutema note that the biggest problem they face is the fact that most women in Cambodia have very little education and that rumors spread faster than real information. Efforts to insure safe motherhood are challenged by high rates of sexually transmitted diseases and by a high prevalence and rate of increase of HIV infection, both of which are exacerbated by the popularity of commercial sex among married men. Domestic violence and women's low nutritional status are also problems. RHAC considers education and counseling essential elements of its safe motherhood package and even trains community-based contraceptive distributors to counsel women on ways to negotiate with their husbands.
