Die Lebensqualität der Frauen hat in den letzten 20 Jahren Fortschritte insofern gemacht, als sie länger leben, weniger Kinder bekommen, besser ausgebildet sind und ihnen moderne Antikonzeptiva zugänglicher geworden sind.

The MotherCare Project has as its goal the reduction of maternal and neonatal mortality and related morbidities, and the promotion of the health of women and newborns. To achieve these goals, maternal and family planning programs were strengthened in both rural and urban settings through three intervention strategies - policy reform, affecting behaviors and improving services. The fundamental premise in each project was to strengthen the weakest part of the maternity care pyramid, ensuring linkages among all levels of service - from community through to the referral hospital level. In rural Andean populations of Bolivia, knowledge of danger signs and women's response to them improved, increasing in use of prenatal and family planning services through a participatory problem-solving and community-based strategy. In West Java, Indonesia, bringing professional midwifery services and facilities closer to women together has resulted in a positive response to their use. Augmenting this intervention with a transport and intercommunication system together with improved hospital practice through perinatal mortality meetings and in-service training for doctors and midwives has reduced the maternal and perinatal mortality over a four year period. Hospital practice has improved in Uganda and in two states of Nigeria, maternal mortality and morbidity have been reduced in the training facility where seminars for physicians, training of midwives in life saving midwifery and interpersonal communication skills have taken place, and equipment and supplies have been improved. Furthermore, in rural Guatemala, implementation of norms and protocols, expert supervision and sensitization of hospital staff to the needs of the community has increased referral by traditional birth attendants (TBAs) to the hospital and reduced perinatal mortality.

During a 2-year period, there were 71 patients whose fistula repair was unsuccessful at the first attempt, at the Addis Ababa Fistula Hospital. All the obstetric fistulas resulted from obstructed labor, and in 17.1% the uterus had ruptured. There was a previous history of at least one unsuccessful attempt at repair in 18.3%; all the fistulas were complicated. Forty-one of the 71 patients were cured by a further operation; spontaneous cure occurred in 3 patients. Failed repair was associated with a history of ruptured uterus, a history of previous unsuccessful attempts at repair, and more patients whose general condition was poor, whose fistula was complicated and required complicated operative procedures. The majority of the failures were cured by a further operation.

Three hundred and nine patients (a 1:10 random sample) treated at the Addis Ababa Fistula Hospital during the years 1983 to 1988 were studied for biosocial factors, obstetric history, previous attempts at repair, the condition of the patient and the extent of injury to the genitourinary tract, as well as treatment and results. Sixty-five percent of patients were under 25 years. The cause of the fistula was obstructed labor in 97.4%; in 62.7% it was the patient's first labor; the outcome for the baby was a stillbirth in 92.7%. The fistula was complicated in 69.4%; a Martius graft was used in 73.6%; 88% were cured; 5.8% of repairs failed and in 6.2% the patient had stress incontinence. Obstetric fistulas in Ethiopia result from obstructed labor, mostly in a first pregnancy in young women, and it is rare for the baby to survive. Prevention will involve improved education, communication, transport and health care measures. With good preoperative and postoperative care and attention to surgical detail many of these women can be cured.

The most acceptable and attainable rural health worker for maternity care is frequently the traditional birth attendant or other personnel lacking clinical skills to treat life-threatening emergencies. When first referral level facilities are also poorly staffed and illequipped to deal with these emergencies, this again points to the need for training of and delegation to the trained midwife in rural areas. Unfortunately, their number is declining in rural areas of some countries most in need, e.g., Tanzania. Elsewhere, midwifery skills and knowledge have been integrated into basic nursing education, but practical skills are only developed postbasically when midwife educators are expert clinicians. The graduates of such training could be delegated responsibility for many lifesaving procedures in obstetric care. Successful clinical experience in use of these responsibilities will earn the midwife's needed community reputation as a trusted health worker.

The principal way of achieving maternal health and safe motherhood is to expand the specific functions and/or categories of midwifery personnel. This includes strengthening knowledge and skills to improve the quality and quantity of care. Success would ensure that for millions of women the prospect of childbirth would be one of joy rather than misery.

Objective: to describe the lived experiences of autonomous midwives working in Angolan midwifery-led maternity units.Design: a qualitative approach using semi-structured, audiotaped interviews, in Portugese. Data were analysed in a six-step process.Setting: three midwifery-led maternity units in the most densely populated suburbs in the capital of Angola, Luanda. The average number of deliveries per unit was 2500 per year.Participants: 11 midwives from the three maternity units.Findings: four main areas emerged: society/culture, significant others, personal self and professional self. Sub-areas, concepts and supporting statements were defined in each area.Key conclusions: the midwives served within a population living in rough circumstances but which maintained strong traditional roots. The midwives did not support homebirths, but did assist when needed. The midwives described their professional role as a ‘calling’, which was very independent. Cure, was considered more important than care, and strong emotions were expressed when discussing cases of failure. The partograph was viewed as an important instrument and continuous learning as crucial in their role as autonomous midwives.Implications for practice: the model of a midwifery-led delivery unit described in this study may be used in other countries facing the same problems as Angola. Difficulties concerning transfer should be seriously considered as well as adequate education for the midwives. A pre-requisite in order for peripheral maternity units to have any impact on maternal morbidity and mortality, is a well-organised first-referral level.

The Safe Motherhood Initiative calls for improved maternity care for all women, essential obstetric services at the nearest place possible, and access to and acceptance of family planning services adapted to the needs of individual couples. Central to this effort is the midwife, who can serve as a link between community health workers and physicians. However, an International Planned Parenthood (IPPF) review of 29 countries that utilize midwives in their health systems found that half had a shortage and that a collective total of 61,000 additional midwives is needed to create a midwife:live birth ratio of 1:200. The regions with the worst ratios are generally those with lowest prenatal coverage and contraceptive prevalence rates and the highest incidence of maternal mortality. This situation could be remedied, in part, by greater utilization of auxiliary nurse midwives or specially trained traditional birth attendants. In countries where trained community health workers are permitted to distribute condoms, barrier methods, and the pill, an intermediate-level health worker should be authorized to provide injectables and IUDs. In many countries, even midwives are not permitted to provide family planning services, and their education does not include family planning content. Experiments in Indonesia, Turkey, Thailand, and the Philippines have demonstrated that midwives can be trained to insert Norplant and IUDs, and even perform sterilizations, as effectively as physicians. In Chile, a core of 300 physicians and midwives were selected for training in family planning methods and education and went on to train others. It is important that midwives themselves take the lead in restructuring and upgrading their profession and form strong partnerships with women's organizations at the grass-roots and policy-making levels.

The hospital of Attat in central Ethiopia serves 300,000 people. In 1987 there were 777 deliveries in the hospital, maternal mortality was 21.2/1000 live births, and the rate of stillbirths was 212/1000 total births. In 1976 a residence or tokul with 15 beds was inaugurated for pregnant women with obstetrical problems to mitigate obstetrical emergencies because of the difficulty of transportation to the hospital. Average stay was 15 days with prenatal care by a hospital nurse visiting the tokul once a day. There were 15 villages around the hospital with 15,000 inhabitants, and a 5-member development committee met with a public health matters. In 1987 a total of 151 pregnant women were admitted, most with a history of obstetrical problems. 34 had caesareans (19 of 25 with previous caesareans), 7 had assisted delivery, and 30 had spontaneous delivery. Only 7 of 15 with previous uterine rupture gave birth via the abdominal route, the others delivered vaginally. There were 635 deliveries of women who entered the hospital directly. Only 142 out of 151 women who stayed at the tokul gave birth in the hospital: 9 of them went home. Many of the direct hospital cases had severe problems: 45 suffered uterine rupture and 23 had craniotomy of the stillborn fetus. 88 (25%) of 348 abnormal deliveries required caesarean section, while there were 44 (72%) caesareans in 61 abnormal deliveries in the tokul group. 13 women died in the direct admission group vs. none in the tokul cases. The maternal mortality rate was 21.2/1000 live births. Rupture of the uterus caused 5 deaths, eclampsia 3, hepatic coma 2, grave sepsis 2, and placenta previa 1. There were 161 fetal deaths in 635 pregnancies of the direct referral group. The stillborn rate was 253.5 vs. 28.2/1000 births in the tokul group.

As a way of preventing maternal and perinatal deaths the Attat region of Central Ethiopia has established a maternity waiting home. Evidence shows that areas with difficult access to hospitals see a high rate of maternal mortality. The Attat region with a population of 1.5 million people has one 55-bed rural hospital at its service. But for many in the region getting to the hospital proves to be a difficult journey so a tukul a maternity waiting home was opened in 1976. The tukul provides a place where pregnant women at high risk can be observed prior to delivery. The waiting home constructed with the labor and materials of the community is a building in the style of a local house that contains 15 beds. On the advice of outreach antenatal clinics at primary health centers women come to the tukul where they stay an average length of 15 days. Once a day a nurse from the nearby hospital comes to observe the women. In 1987 the Attat hospital performed 777 deliveries. 635 of the women were admitted directly to the hospital and 142 were admitted via the maternity waiting home (the tukul saw 152 women that year but 9 returned home before the delivery). While there were 13 maternal deaths among the direct admissions there were none among the women admitted via the tukul. Furthermore women admitted directly to the hospital had a stillbirth rate 10x higher than the women who stayed in the tukul. These figures show that a maternity waiting home can be very effective in preventing obstetric disasters in areas where women have to travel long distances and where transportation is poor. But the authors stress that a successful waiting home requires antenatal care and community involvement.

About two-thirds of the world's population live in areas where registration of vital statistics is unsatisfactory (Tietze, 1977), and in many countries such statistics from rural areas are unavailable or grossly underestimated (WHO, 1971). Most of the women who die in pregnancy and childbirth are poor and live in remote areas or city slums. Their deaths are accorded little importance and fail to enter registers.

Causes of maternal mortality were investigated in Addis Ababa, Ethiopia, from September 1981 to September 1983. Viral hepatitis ranked third among the leading causes of maternal mortality behind septic abortion and puerperal sepsis. There were 26 deaths from viral hepatitis during the 2-year study period for a hospital maternal mortality rate of 91.0 per 100,000 live births. Although 30% of women who died of all maternal causes received antenatal care in Addis Ababa, only 13% of women who died from viral hepatitis in our hospital study received antenatal care. Low socio-economic status (SES) has been shown to be associated with low antenatal care utilization and with an increased risk of protein malnutrition. Malnutrition is considered a predisposing factor for liver damage. Suggestions for reducing hepatitis transmission and maternal mortality through education, better hygiene, and improved sanitation are discussed.