Training initiatives for essential obstetric care in developing countries ...

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HEALTH POLICY AND PLANNING; 15(4): 386–393

© Oxford University Press 2000

Review article Training initiatives for essential obstetric care in developing countries: a ‘state of the art’ review SHEREEN PENNY1,2 AND SUSAN F MURRAY2 1Freelance Midwifery Consultant, 2Institute of Child Health, University College, London, UK Increased international awareness of the need to provide accessible essential or emergency obstetric and newborn care in developing countries has resulted in the recognition of new training needs and in a number of new initiatives to meet those needs. This paper reviews experience in this area so far. The first section deals with some of the different educational approaches and teaching methods that have now been employed, ranging from the traditional untheorized ‘chalk and talk’, to competency-based training, to theories of adult learning, problem solving and transferable skills. The second section describes a range of different types of indicators and data sources (learner assessments, user and community assessments, trainer assessments and institutional data) that have been used in the assessment of the effectiveness of such training. The final section of the paper draws together some of the lessons. It considers evaluation design issues such as the inclusion of medium and long term evaluation, the importance of methods that allow for the detection of iatrogenic effects of training, and the roles of community randomized trials and ‘before, during and after’ studies. Issues identified for the future include comparative work, how to keep training affordable, and where training ought to lie on the continuum between straightforward technical skills acquisition and the more complex learning processes required for demanding professional work.

Introduction The Safe Motherhood Initiative increased international awareness of the need to provide accessible essential or emergency obstetric and newborn care to any woman who might require it. This has resulted in the recognition of new training needs for maternity care providers at hospital and peripheral level, and in a number of initiatives attempting to meet those needs. This article draws upon the international experience of the last few years in the development and implementation of such training strategies and projects, particularly in resourceconstrained settings. The different educational approaches and teaching methods that can be used are reviewed and the question of how the effectiveness and impact of such training initiatives may be assessed is considered.

Methods Searches of on-line databases such as MEDLINE and POPLINE revealed that little of this experience is published as yet. This review draws on much ‘grey’ literature, proceedings from previous workshops, conference reports, nongovernmental organizations (NGOs), government, and donors’ programme evaluations. It also benefited from personal communication with key providers of training in developing countries to whom the authors are greatly indebted. Project reports and documents were analyzed for

information on their objectives, their educational approach, teaching methods used, reported outcomes and how these were measured.

Background Rosenfield and Maine (1985) were among the first to publicly challenge the assumption that maternal mortality could be tackled by classical maternal and child health (MCH) service approaches. In their 1985 Lancet article ‘Maternal mortality – a neglected tragedy: where is the M in MCH?’, they highlighted the fact that the public health community had largely ignored maternal mortality. Deborah Maine and others subsequently further elaborated the argument, demonstrating that the poor sensitivity and specificity of risk screening procedures in antenatal care mean it is not possible to adequately predict which women will, and which will not, have obstetric complications. Thus it is necessary to make emergency care available to all women (Maine 1993). The unpredictability of complications means that good quality treatment needs to be available not just in centralized referral units but at facilities within easy reach of all women. The World Health Organization (WHO) began work in the mid-1980s delineating the basic requirements for provision of emergency obstetric ‘functions’ and the Essential Elements of Obstetric Care at the First Referral Level was published in

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Training for essential obstetric care 1991 (WHO 1991a). It was recognized that these requirements, considered to be the minimum level in the provision of care at the district or sub-district hospital or health centre level, were seriously deficient in many countries where these qualities did not exist even at the teaching hospital level (Maine 1993).

Defining ‘essential’ obstetric care The terms ‘emergency’ and ‘essential’ obstetric care have been used both interchangeably and to signify quite different approaches to Safe Motherhood (Rosenfield 1995). In the Mother-Baby Package, WHO produced a list of the Essential Obstetric Care (EOC) which includes surgical obstetrics, anaesthesia, medical treatment, blood replacement, and manual procedures including labour monitoring, management of women at high risk, and a range of contraceptive methods (WHO 1994).1 More recently, when faced with the challenge of developing guidelines for monitoring the actual availability and use of obstetric care programmes, UNICEF, WHO and UNFPA (1997) took a slightly more restricted view, and used ‘Essential Obstetric Care’ to refer to ‘the short list of services that can save the lives of the majority of women with obstetric complications’. Two levels of care were defined within this: basic and comprehensive, with a list of ‘signal functions’ as shown in Table 1.

The trainees The audience for training varies from project to project. ‘Skilled birth attendants’ are defined by WHO as trained midwives, nurses, nurse/midwives or doctors who have completed a set course of study and are registered or legally licensed to practice (WHO/FIGO/ICM 1992). This group is often identified as the appropriate focus for training, but Table 1. Signal functions used to identify basic and comprehensive essential obstetric care (EOC)a Basic EOC services

Comprehensive EOC

(1) Administer parenteral (2) antibiotics (2) Administer parenteral (2) oxytocic drugs (3) Administer parenteral (2) anticonvulsants for (2) pre-eclampsia and (2) eclampsia (4) Perform manual removal (2) of placenta (5) Perform removal of (2) retained products of (2) conception (6) Perform assisted vaginal (2) delivery

(1–6) All of those included in basic EOC

projects have varied in their exclusion or inclusion of different professions within their schemes, some concentrating specifically on midwives, and other offering training to different cadres of worker. It has to be said at this point that training alone is seldom sufficient for improved health services. Broader capacity strengthening may be required to promote greater support and job satisfaction for health workers in the field (WHO 1993). Management skills and health information systems inputs (Kwast 1998), and equipment, drugs, communications and transport all play vital roles. Nonetheless, the training needs remain real and merit consideration, both in terms of appropriate approaches and methods for evaluation.

Using new educational approaches It has been recognized in recent years that the pre-service training curricula often used to teach midwifery skills in developing countries have been based upon developed country models which do not reflect the working conditions, lack of resources and types of complications present in resource-constrained settings (Kwast 1990; WHO 1991b). A similar situation has existed in many medical schools in developing countries (Ratnam 1990). The educational methods used have also come into question. ‘Traditional’ style teaching focused on the handing-down of knowledge, typified in ‘chalk and talk’ sessions in the classroom, studious copying of the teachers’ notes, and a high priority given to memorization of factual information. Largely untheorized, it worked on an assumption that institutional structures and standards required replication. Knowledge in traditional education was (and is) often tested through written exams. The ability of learners to recall or recognize information, and their ability to understand it and then apply it, however, are not one and the same thing, and can be seen in discrepancies between exam performance and actual ability to deal with real patients in real situations. When the need to provide practical learning environments is not recognized, outcomes of training programmes can be disappointing. Information recall or recognition is not synonymous with understanding, nor does it automatically guarantee an ability to perform effectively (Cox 1992). One of the reasons that the safe motherhood components of the Child Survival and Safe Motherhood programme implemented by the Ministry of Health and Family Welfare in India in the early 1990s were ineffective seems to have been the lack of ‘hands on’ practical obstetric experience (Huque et al. 1996). Competency-based approaches

(7) Perform surgery (caesarean section) (8) Perform blood transfusion a

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Adapted from UNICEF, WHO, UNFPA (1997, p. 26).

The ‘competency-based’ approach to training (CBT) addresses this type of weakness because it places great emphasis on acquiring skills through repetition in ‘hands on’ practice. CBT has been widely used by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) in projects to improve the quality of clinical skills in the family planning field (Johnson and

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Lewison 1996). It is also used in the ‘Life Saving Skills’ curriculum devised by the American College of Nurse Midwives (ACNM), probably the most influential EOC training programme for developing country use to be developed so far. The ACNM manual, now in its third edition, comprises a 10part modular education programme for qualified midwives in the identification, stabilization and treatment of emergencies or potential emergencies in obstetrics (Buffington and Marshall 1998). CBT is based upon higher order behaviourist theory, with its stimulus-response approach to learning, and uses behavioural objectives, programmed texts, modelling, and self-assessment tasks. It aims at the mastery of specific knowledge and skills (Sullivan and McIntosh 1996). It is more learner-centred than the traditional educational system, because it allows the learner’s progress through the course to be self-paced. The ACNM process involves pre-testing knowledge and practical skills, introduction of obstetric protocols (where necessary), course delivery through interactive and participatory methods and practising the skills taught following particular steps until a level of competency is obtained (Marshall and Buffington 1998). Other important features in the ACNM and JHPIEGO models are the training of trainers and the use of ‘Master Trainers’ (Johnson and Lewison 1996). Emergency skills courses designed to enable the practitioner to respond quickly in an emergency have also been developed in industrialized countries such as the US and UK. The London Fire Brigade uses CBT (personal communication 1998), as does the Advanced Life Support in Obstetrics (ALSO) Course. ALSO began in 1990 in the US and was ‘designed to assist health professionals in developing and maintaining the knowledge and skills they will need to effectively manage the emergencies which arise in obstetrics’ (Taylor 1996, p. 696). ALSO draws upon educational theory such as Bloom’s work on the different domains of learning: the cognitive, psychomotor and the affective domains. Bloom attributes the qualities of knowledge, comprehension, application, analysis-synthesis and evaluation to the cognitive domain, and those of receiving, responding, valuing, conceptualizing and organizing to the affective domain (Bloom 1965). Learning on the ALSO course occurs through syllabus reading and didactic lectures, the use of ‘hands on’ workstations and mannequins and memorization of easy to remember mnemonics. Assessment methods include a written test and a ‘megadelivery’ testing exercise, as well as long term follow-up on ‘comfort with’ the procedures and on self-reported changes in practice. The course is usually spread over two whole days and student numbers are kept small. The preference is to have one instructor to every five students. Adult learning, transferable skills and generalizable competencies In Learning Theory and Professional Life, Roy Cox makes the point that professionals are rarely asked to simply reproduce knowledge, they are asked to put it into use in certain situations where it can help to solve problems (Cox 1992). This seems particularly true for nurses and midwives working at community level who need to respond in a proactive and

creative way when confronted with an unexpected emergency situation. Most of the accounts of training programmes we reviewed, while not making explicit reference to the theories of learning on which they were based, seemed to recognize this, often making some reference to ‘adult learning’ or ‘andragogy’. Knowles’ conceptualization of andragogy fundamentally challenged traditional educational approaches by presenting the adult learning process as essentially collaborative, by recognizing the learners as rich resources, by taking a problem-centred rather than subject-centred orientation to learning, and by using experiential techniques of inquiry (Knowles 1978). Participatory methods have been used in health sector education in some countries. The training of Mother and Child Health nurses in Mozambique in the early 1980s, for example, used ‘active participation which included discussion of first hand experiences and different life situations and emphasized respect for the traditions and cultures of the trainees’ (Loprestti 1997). The WHO Task Force Team on Human Resources Development for Maternal and Newborn Health at the Health Centre Level (1993) emphasizes the ‘problem solving’ approach in training (WHO 1993). The ‘problem solving’ approach has its roots in cognitive psychology and androgogy. It is intended to facilitate what Entwhistle describes a as ‘deep’ rather than ‘surface’ approach to learning on the part of the student (Entwhistle 1987). The emphasis is on learning related to situations similar to those faced in the field and which takes an integrated (rather than subject-based) approach to the complexities of real life situations. Ideally these assist the students towards gaining more generalizable competencies – life skills such as problem solving, the ability to work collaboratively and to take a creative approach to an unfamiliar task. The WHO Safe Motherhood educational material for nursemidwives is designed for ‘problem-solving’ training in the five major causes of maternal mortality and was pre-tested in a number of developing countries (Maclean and Tickner 1992). The modules incorporate aspects of community involvement, prevention, treatment and follow-up (WHO 1996). Various teaching methods are used including lectures, clinical demonstration and practice, and role-play, as well as written and oral tests. The ACNM Life Saving Skills curriculum includes some problem-solving teaching techniques as well as CBT methods. In doing so it attempts to cover both the analytical and creative skills and the practical clinical skills required for maternity care. There are, however, real limitations to the possibilities for building up the sort of generalizable competencies mentioned above within the time span of most inservice training courses, particularly if they have been lacking in the participants’ previous educational experiences. Contextualizing EOC training within a wider change process A newer, related development for EOC training has been the move to locate the training innovation within theories related to motivation and human resource development management and the management of change. The Nepal Safer

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Training for essential obstetric care Motherhood Project funded by the UK Department for International Development, for example, is, at the time of writing, implementing a participatory method based upon the COPE approach (‘client-oriented provider-efficient services’) developed by Access to Voluntary and Safe Contraception (AVSC) (AVSC International 1998; Department for International Development 1998). The aim is to affect changes in behaviour in staff working within a number of hospitals in three districts in Nepal, and in doing so to improve the quality of emergency obstetric care. Training is preceded by a needs assessment in which competency checklists were used based upon observation checklists and knowledge questionnaires. The trainers in this context act as facilitators, and the approach taken is that all change can be threatening, whether good or bad. This type of training is based upon the individual’s own professional and personal needs, and involves as many of the team as possible.

Assessing the effectiveness of training Assessment of the effectiveness of training initiatives is not a particularly simple matter, but it is an essential one in which advances are being made. With the realization that maternal mortality ratios were not viable indicators to use for measuring the impact of Safe Motherhood programmes (Graham et al. 1996), there has been renewed interest in process indicators (Campbell 1999; Wardlow and Maine 1999). It has been suggested that Safe Motherhood programme process indicators might include programme inputs, such as number of midwives trained, and programme outputs, such as the proportion of births attended by trained health providers (Koblinsky et al. 1994). It is widely accepted that the evaluation of the training programmes themselves requires something more than an account of the numbers of midwives ‘trained’. If we are to invest funds and human resources in this area we need indicators that tell us something about outputs such as improved provider knowledge, improved competence, behavioural change or improved service performance. From the projects reviewed we identified four main sources of information that have been used to assess the effectiveness of EOC training: • learner assessments of their own learning; • service users/community assessments of quality of service; • trainer assessments of skills acquisition/competency measures; • proxies for health outcomes derived from routine service delivery statistics. Learner assessments To have satisfactorily met the trainees’ needs, as defined by the trainee, is often considered an important measure of success in educational enterprises. The MotherCare project in Indonesia, for example, asked participants whether they would be prepared to pay for such a course and used positive responses as an indicator of learner satisfaction (Putney 1996). Simple satisfaction ratings conducted at the end of the

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course of training are of limited value by themselves, given that they are dependent upon the initial levels of expectation and can be bound by courtesy conventions. Open-ended questions, however, can provide useful information on learner motivation and on specific aspects of course content and method. There have been some more sophisticated attempts to measure the learning that took place as translated by the affective domain of the individual, and to chart the longer term impact of the training as reported by the learner. Taylor’s (1998) evaluation of the impact of the ALSO course on the performance of former students used a Likert Scale measure of ‘comfort with’ the procedures surveyed at 6 months and at a 1-year follow-up, and correlated with changes in reported practice patterns. Critical incident analysis is another method in which the usefulness of training for real life practice can be charted. Learners might be asked at 6 months or 1 year post-training, for example, to give detailed examples of three incidents in their work in which they were able to respond to an emergency or a complicated case more effectively as a result of what they had learned on the course (Rich and Parker 1995). Importantly they can also be asked to relate critical incidents that have occurred for which the course did not provide them with adequate training, thereby providing information on which additions to the training might be made. Service users’/community assessments Increased service acceptability to users and to the community as a result of the training may also be used as a measure of effectiveness of training interventions. Exit interviews or community surveys are the usual means of gathering this type of information. MotherCare used a proxy measure in their evaluation of a Safe Motherhood project in Guatemala in 1995. The training had involved 40 hours of instruction in standards of care for managing obstetrical and neonatal patients, the introduction of protocols, plus training of TBAs in when, and how, to refer women. A pre-intervention study had shown considerable fear of admission to hospital among the public in general, and poor attitudes of health professionals to clients. As well as looking at ‘hard’ indicators, such as peri-natal mortality rates, the evaluators used the increased rates of TBA referrals to the hospital as a behavioural indicator of increased acceptability of the service to the community (O’Rourke 1995; Gilson and Goldman 1998). Trainer assessments of skills acquisition/competency measures The cognitive domains of learning are often tested in written examinations or in practical tests towards the end of courses (Taylor 1998). Competency-based training programmes typically have skills acquisition as their measure of success and use observed competency checklists which are applied by the trainers (Sullivan and McIntosh 1996). A MotherCare training project in Bolivia, for example, undertook an evaluation nine months after the training took place. The three objectives of the training covered aspects of quality of care, interpersonal

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interaction and communication with the women, and improvement through training of the medical team functions. Physicians, nurses and nurse auxiliaries had been included in the 4-week training programme. The evaluation included a review of patient case notes, competency checklists and interviews with the staff (Gilson and Conover 1998). Proxy measures for health outcomes, derived from routine service delivery statistics Despite the very real difficulties in evaluating the complex packages of interventions that are put in place when a training programme is implemented, an imperative to demonstrate impact on health outcomes is often felt. This is particularly the case where resources are scarce and where funders wish to see evidence that their funds are well directed. While the ‘super goal’ of all EOC training projects would be a reduction in maternal and perinatal mortality and morbidity rates, these are not practical indicators for measuring the impact of training projects (Koblinsky et al. 1994; Graham et al. 1996; Campbell 1999). Some projects, however, have used routine service delivery data to develop proxy measures of the health impact of their training interventions. The Strengthening of Emergency Obstetric Care project in Bangladesh, for example, which involved training in emergency obstetric care provision for medical officers, nurses, family welfare visitors and medical technologists, chose case fatality rates and caesarean section rates, as measures of impact (Bhuyian 1997). Such indicators are relatively crude measures of performance (a helpful discussion of their value and limitations can be found in Wardlow and Maine 1999), and therefore are most useful when used in combination with other types of data from maternal death audits and other qualitative studies. Where detailed perinatal and maternal death audits have been introduced as part of the package of interventions, as in the Nepal Safer Motherhood project funded by DFID, and the South African Perinatal Education Programme (Theron 1997), midwives and doctors can participate in an ongoing process of self evaluation that can identify improvements in care and any weaknesses in provider skills and service provision.

Discussion It is clear from our review that international experience now exists in the field of in-service training for EOC and some lessons have been learnt. Approaches to training in some recent projects have certainly become more thoughtful and more grounded in research-informed education theory. Competency-based training, problem-solving approaches and management of change all represent important advances in the techniques of training. In the evaluation area things have moved on apace from the days when a written test of knowledge and perhaps a final day student evaluation form were all that one could expect to find as tools for judging the value of such courses of training. The criteria and indicators for assessing the effectiveness of its impact are advancing in sophistication. Medium- or long-term follow-up is now built into an increasing number of course evaluations and a wider range of indicators is drawn upon in measuring the effectiveness of the training intervention.

Methods that also allow for the detection of iatrogenic effects and of missing elements in the training are a valuable and important addition. The Safe Motherhood Demonstration Projects in Ghana and Vietnam provide a good example. These projects evaluated the use of Life Saving Skills training using the ACNM modules, along with the introduction of new equipment. They found that the detection of life-threatening obstetric conditions improved at the primary and secondary health facility level, but that management of such conditions improved only at secondary level. Because indicators of negative effects of the training intervention were included in the evaluation, it was also revealed that, in some cases, increases in confidence accompanied by a poor level of understanding had resulted in mis-management (Sloan et al. 1998). Despite the advances, a number of challenges still remain. Personal communications from those active in the field often revealed frustration over insufficient time and resources to perform rigorous and scientific evaluations of training programmes. Donor timetables, the growing pressure to implement in the face of some 12 years of a Safe Motherhood Initiative which has seen little impact on global maternal health statistics, plus a tradition within the health care sector of intuitive rather than evidence-based assessment of educational impacts, have all compounded this situation. Secondly, we found that direct comparisons between the training initiatives and the differing educational approaches were difficult to make because of the diversity of contexts and of evaluation mechanisms used. The ‘ideal type’ of rigorous scientific evaluation of training remains elusive. Community randomized trials may be the desirable gold standard for evaluation of these sorts of interventions, but few randomized trials have actually been attempted in the area of EOC training, probably because of the considerable cost of such large scale undertakings, as well as concerns about context specificity (Campbell 1999). The pragmatic choice may often have to be the descriptive non-experimental designs of the type Campbell (1999) calls ‘before, during and after studies’ (studies that use a wellchosen selection of qualitative and qualitative process indicators). These may not prove causality but importantly they can provide interpretation of changes that are observed over the period of the intervention. The Safe Motherhood Demonstration Projects in Ghana and Vietnam are examples of this sort of approach, drawing data from house-to-house surveys, community-based interviews and institutional information systems (Sloan et al. 1998). Thirdly, to reiterate a point made earlier in the paper, EOC training in under-resourced settings is not a straightforward matter. Shortcomings such as poor pre-service training, lack of good equipment and lack of obstetric protocols in the workplace, can substantially hinder the positive learning process that EOC in-service training courses are designed to offer. Where pre-service training has not encouraged the development of analytical ability or teamwork, nor provided sufficient clinical training, projects have discovered that there is often a need to bring the health workers up to an

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Training for essential obstetric care acceptable skills and knowledge level before new skills may be taught (J McDermott, personal communication, 1998). A major challenge, therefore, is how to keep EOC training affordable for developing country contexts. The experiences of some of the projects we reviewed demonstrate that even where training has been confined to a specific set of skills over a short 2- or 3-week period, the resource implications can be considerable. Costs mount as more preparatory and evaluatory phases are included; yet without them the entire investment might be wasted. The Life Saving Skills training developed by ACNM and used by MotherCare in Ghana, Nigeria, Uganda and Indonesia, involved considerable preparation prior to the training itself. This included a needs assessment, site preparation, and the introduction of necessary equipment to augment the training, and Training of Trainers courses. The economics of EOC training initiatives is something that will need consideration in the future. One less costly approach, designed for workers in isolated settings, which might need to be explored further, is that of self-directed distance learning. It has been argued that this method is well suited for maternal health teams because ‘the instruction takes place at their health stations and the learning materials move to them’ (Parry 1992). The costs are concentrated in the development of good materials and the budget required for itinerant facilitators. The Perinatal Education Programme in Eastern Cape Province, South Africa (Theron 1999), for example, was developed in recognition of the reality that providing courses in academic centres or during visits to individual towns was only reaching a small proportion of midwives. Focusing on common and important problems in primary maternity care, the remit of the 15-unit course is rather broader than that of Emergency Obstetric Care. Their Maternal Care Manual uses distance learning principles, with knowledge acquisition and skill development as part of the programme, and skills workshops attached to the units. Whatever ‘hands-on’ experience is gained can be expected to be close to the real work context and with the level of resources that is actually available to these personnel. The potentially serious disadvantage of running EOC training away from high turnover referral units, however, is that actual ‘hands-on’ experience of the full range of obstetric complications is likely to be impossible. Creative simulation and role play may have to substitute for real life practice. The Eastern Cape project was one of the few that we found that was run as a prospective trial (Theron 1999). Unfortunately, the measurement of impact seems to have been confined to short term cognitive knowledge, as demonstrated by scores in multiple choice question tests administered in a post-test conducted 6 weeks after the course was finished. The actual impact on midwifery skills and practice can therefore only be inferred.

Concluding comments It is widely accepted that the application of existing technology could greatly reduce the number of maternal deaths. A rapid

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decline in maternal mortality has occurred in many countries with the introduction of antibiotics, blood transfusions, management of pregnancy induced hypertension and timely caesarean section (WHO 1993; Louden 1997). The ability of maternity care workers to provide such services skillfully, and in a timely fashion, needs to be enhanced, and in-service training would seem to have an important part to play. In this paper we have outlined some of the failings of ‘traditional’ training, and have identified a range of interesting approaches to learning and behaviour change being taken by different EOC training projects. We have also outlined some of the strengths and weaknesses of different ways of assessing the effectiveness of such training. The absence of assessment of long term impacts on behaviours, practice or health outputs was a serious limitation to many of the EOC training programmes we considered. It is to be hoped that funders in the future will be more prepared to accept (indeed demand) extended evaluation periods as requisites of training projects. The range of assessment criteria across the projects we reviewed also make it almost impossible to directly compare the effectiveness of different approaches. There is still little evidence from which to judge, for example, how far is it sufficient and sensible in the resource constrained realities of many developing countries, to confine EOC training to relatively straightforward technical skill acquisition (epitomized in the competency-based approach), and how far it is necessary to try to address the more complex learning processes that are required for understanding, internalization and ‘generalizable competencies’ (where problem solving approaches become more appropriate). Where should EOC training sit on the continuum between straightforward technical skills acquisition and the more complex learning required for the demands of challenging professional work? There is a need for comparative studies to set about trying to answer such questions – and such work will need to encompass economic as well as educational evaluation.

Endnote 1 This list includes surgical obstetrics (caesarean delivery, treatment of sepsis, repair of high vaginal and cervical tears, laparotomy, removal of ectopic pregnancy, evacuation of the uterus, intravenous oxytocin, amniotomy, craniotomy, syphysiotomy); anaesthesia; medical treatment (of sepsis, shock, eclampsia, anaemia); blood replacement; manual procedures (removal of placenta, labour monitoring, repair of episiotomies and perineal tears, vacuum extraction, partography); management of women at high risk (intensified antenatal care); and a range of contraceptive methods including female sterilization, vasectomy, Norplant, IUD, and oral contraceptives) (WHO 1994).

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Acknowledgements The authors would like to thank the following individuals for their assistance during the search for published and unpublished material for this review. We are grateful for their time and for their insights. The authors however take sole responsibility for the views expressed in this review article. Yusuf Ahmed (University of Zambia), Deborah Armbruster (ACNM, USA), Staffan Bergstrom (Sweden), Jennifer Brown (UNDP, USA), Judith Bruce (Population Council, USA), Sandra Buffington (USAID), Suzanne Cunningham (Bournemouth, UK), Rumona Dickson (Liverpool School of Tropical Medicine, UK), France Donnay (UNICEF, New York), Maureen Dunphy (WHO, Geneva), Frances Foord (The Gambia), Judith Fortney (FHI, USA), Charlotte Gardiner (UNFPA, USA), Paul Garner (Liverpool, UK), Julia Gibson (ALSO, UK), Cathy Green (DFID/Options, UK), KM Raul Haque (CARE Bangladesh), Jane Hughes (Rockefeller Foundation, USA), Janet Hyde (DFID/Options, UK), Edna Jonas (World Bank, UK), Asa Jonsson (FCI, USA), Angela Kamara (PMM Ghana), Marjorie Koblinsky (MotherCare, USA), Barbara Kwast (Holland), Ruy Laurenti (Sao Paulo), Margaret Leppard

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(Bangladesh), Paul Lewis (Bournemouth, UK), Dana Lewison (JHPIEGO, USA), Gaynor Maclean (UK), Deborah Maine (Columbia University, USA), Merkle (GTZ, Germany), Jeanne McDermott (MotherCare, USA), Sandra McDonagh (NSMP, Nepal), Georg Nachtigal (GTZ, Germany), Jim Neilson (Liverpool, UK), A Nirmalamma (India), Anne Peat (Sheffield, UK), Pat Pettigrew (UK), Catharine Pownall (NSMP, Nepal), Bishnu Rai (Nepal), Carine Ronsmans (LSHTM, UK), Tamara Rusinow (CARE, UK), Kamla Saini (India), Pramilla Senanayake (IPPF, UK), Della Sherratt (UWE, UK), Natalie Short (Cook Islands), Laura Shrestha (World Bank, USA), Anne Stokes (Malawi), Harry Taylor (US Navy, USA), Gerhard Theron (PEP, South Africa), Anne Thompson (WHO, Geneva), Ann M Thomson (Manchester, UK), Allison Trenholm (FCI, USA), Carlos Ugarte (PATH, USA), Joan Walker (ICM, UK), Diana Winslow (ALSO, USA), Rose Zambezi (CARE, Zambia) and Christina Zampas (Carnegie, USA).

Susan F Murray is Lecturer in International Maternal Health at the Institute of Child Health, University College London. She has a background in midwifery and in the social sciences, and has worked in the Safe Motherhood field since 1987. She is editor of Midwives and Safer Motherhood and Baby Friendly/Mother Friendly published by Mosby. She is Programme Director for the Institute’s MSc/Diploma Programme in Mother and Child Health.

This review was funded by the Department For International Development (DFID) of the United Kingdom. However, DFID can accept no responsibility for any information or views expressed.

Correspondence: Susan F Murray, CICH, Institute of Child Health (University College London), 30 Guilford Street, London WC1N 1EH, UK.

Shereen Penny is a freelance midwifery consultant and at the time of writing was working as a researcher within the Safer Motherhood and Newborn Care Group at the Institute of Child Health, University College. She holds a Masters degree in Mother and Child Health, and has previously worked as a midwife trainer in relief and development in Pakistan and Tanzania.