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Maternal Healthcare in the Developing World

January 11th, 2010

Maternal healthcare in the developing world

By:

Derick Stace-Naughton, Jess McCamy, George Roche, and Cara Swantek

Section 1: Summary

When researching the vast health inequities between the developed and developing world, one of the most glaring and unmistakable differences is in maternal healthcare–the care provided to a woman during pregnancy, childbirth and the postpartum period. Undeniably, developed countries have nearly eliminated their maternal mortality while developing nations are left with little help to save dying mothers.  Every year, 537,000 women die due to complications of pregnancy, and 99% of those are in developing countries. While the number may be viewed as small in comparison to other death tolls, its impact cannot be underestimated. In his May 2009 statement on the Global Health Initiative, President Obama said the following: “I also recognize that we will not be successful in our efforts to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems around the world, focus our efforts on child and maternal health, and ensure that best practices drive the funding for these programs.”

The solution we have developed in order to address maternal mortality in developing nations is a Global Fund for Maternal Health. The Fund will be similar in function to the Global Fund for Tuberculosis, Malaria, and AIDS in that it will act solely as a financing instrument, and not a program implementing entity. It will seek donations from governmental agencies as well as private institutions in order to fund grants awarded to program proposals.  Separate programs will be developed by individual countries and their designated Country Coordinating Mechanisms, consisting of healthcare professionals.

While the Global Fund for Maternal Health would not develop programs itself, the experts have seen extensive progress made by a few particular approaches.  In fact, these efforts have shown such great success that the Fund will set their results as a benchmark for other programs.  The use of certain drugs, specifically expanded distribution of hemorrhagic drugs, has proven to alleviate their respective complications. In addition, the increased presence of skilled birth attendants has drastically decreased the number of maternal deaths in particular countries. Thus while the Fund does not require the use of these mechanisms in any program proposed by a country, it shall require the demonstration of enhanced results effecting maternal mortality – better than those seen with these drugs and skilled birth attendants.

­­Section 2: Conceptual Map

maternal_healthcare_conceptual_map

As we examined various issues in Global health, it was clear that the maladies affecting industrialized nations were vastly estranged from the basic health needs in the developing world. Then as we were looking at those diseases which were preventable, that we could therefore have an impact on, we encountered variances between populations. It seemed that the health issues adversely effecting individuals largely depended on sex and age. Then finally as we were researching women’s health issues, we found the UN’s Millennium Development Goals and number 5 was to reduce by three-quarters maternal mortality ratios (defined below).  We knew that if the UN had assigned high importance to this matter then it was certainly an issue which demanded viable solutions.

Section 3: The Maternal Healthcare Problem

Substantial

Every minute, a woman dies from pregnancy related complications, which are almost always avoidable with proper care.  Although over 500,000 women dying each year as a result of pregnancy-related complications, the maternal healthcare problem can extends to an additional 15 to 20 million women who suffer debilitating consequences of pregnancy each year.[1] Furthermore, deficiencies in maternal healthcare and the resulting deaths create hundreds of thousands of new orphans annually.  In addition, approximately 8 million babies die during the week before or after childbirth as a result of insufficient maternal healthcare.[2] This overall number of annual deaths due to insufficient maternal healthcare is staggering, and indicative of what a substantial global problem maternal healthcare is.

Urgent

Maternal deaths are almost always preventable and, as a result, maternal mortality rates are exceptionally low in the developed world.  The overwhelming number of preventable deaths has led the United Nations to make maternal healthcare the fifth Millennium Development Goals (MDG) for 2015.  The MDG has set a goal for global leaders to lessen the maternal mortality ratio by three-fourths by 2015, but current data indicates that completion of this goal remains extremely unlikely.  In the fifteen years between 1990 and 2005, maternal mortality rates were reduced a mere 5%.[3] Noeleen Heyzer, the top UN offical for the Asia-Pacific region, recently described the situation by stating, “Maternal health and child mortality are areas where progress has been extremely slow and where urgent action is needed.”[4] As a result of this slow progress in maternal care improvements, many countries, including most of sub-Saharan Africa and Afghanistan, still experience well over 1,000 deaths for every 100,000 births.[5]

Global

maternal_healthcare_figure_1

While many poor nations suffer from these excessive maternal death rates, the Millennium Development Goal Tracker shows that most developing countries have a ratio of less than 25 deaths per 100,000 births.  Figure 1 illustrates the maternal mortality ratio, via a color-based key, for every nation on earth.  The darker regions, indicative of greater maternal mortality rates, correspond with under-developed geographic areas. This discrepancy between ratios in developing and developed countries is so drastic that as a result maternal mortality ratios are often used to determine whether a country is developed, and as a marker for government instability.[6] Overall, the average number of deaths per 100,000 births in a developing country is 450, whereas the average for developed nations is just 9 deaths per 100,000 births.[7]

Ineffective Efforts

The WHO recommends that a woman receive care throughout her pregnancy and up to a month after childbirth.  Yet in Africa and Asia, roughly half of all pregnant women do not receive any antenatal care.  Lack of maternal healthcare has been recognized as a serious problem, which is why it is one of eight Millennium Development Goals established by the UN.  According to the UN Children’s fund, more than one-quarter of all adult women in developing countries suffer from pregnancy-related illnesses [8] In addition to a lack of care throughout pregnancy, the delivery itself only occurs in the presence of a skilled attendant 53% of the time in developing countries.[9] Such practices are even more dangerous than a lack of care during pregnancy, as delivery is the most dangerous aspect of having a child.  Despite the knowledge of the dangers of lack of care, and the well-documented lack of care in developing countries, little progress has been made.  With only a 5% decrease in maternal mortality ratios from 1990 to 2005, it is clear that current efforts are falling flat.  The WHO has been working on this issue since 1987, and while they have been successful in drawing attention to the program, their efforts to reduce maternal mortality through the promotion of clinical guidance is ineffective.  Many women in developing countries either do not have access to a clinic, or are prevented by cultural barriers from seeking help at a clinic.  As such, it is important that future efforts to reduce maternal mortality be more sensitive to the circumstances and cultural issues a pregnant woman in a developing country may face.

maternal_healthcare_figure_2

Figure 2: Percentage breakdown of major causes of maternal death.

Leading Causes

The most common causes of maternal mortality are all preventable through either drug treatments or the care of a skilled attendant.  The leading cause of death each year is hemorrhage, or massive blood loss, which is responsible for 31% of maternal deaths.  Hemorrhagic deaths can be prevented with appropriately administered drugs, or by suturing by skilled attendants.  Sepsis and hypertensive disorders, which often lead to eclampsia and seizures, are other common causes of death that can be prevented through medication and skilled care.  The proportion of deaths that various causes are responsible for can be seen in Figure 2.

Section 4: Medical Systems Interventions

Drugs to treat post-partum hemorrhaging

Hundreds of thousands of hemorrhage-related maternal deaths occur annually, simply because effective hemorrhagic treatment regimens are unavailable in much of the developing world.  The World Health Organization consistently lists post-partum hemorrhage as the single greatest cause of maternal death; hemorrhage-oriented health interventions have a vital role in the improvement of maternal healthcare outcomes.  Both due to the prevalence of this often fatal complication of pregnancy and because it is treatable with routine medicines, post-partum hemorrhage is an ideal target for health intervention programs.  The charitable augmentation of maternal healthcare options in developing nations depends upon the consistent, reliable availability the medications used to treat post-partum hemorrhage.

In order to increase the availability of hemorrhagic drugs, intervention programs must first identify the most effective option from a range of hemorrhagic medications offered by pharmaceutical companies.  Research and experience has led global health organizations to accept misoprostol and oxytocin as the most useful drugs in the treatment of post-partum hemorrhage worldwide[10].

Misoprostol

Misoprostol, which has been available for purchase since 1985, functions biologically as an E1 prostaglandin analoguein.  Prostaglandin is an endogenously produced compound with physiological functions including contraction and relaxation of smooth muscle.  The drug has current uses ranging from prevention of gastric ulcers, to a variety of obstetric applications; one of these ancillary benefits of misoprostol is its ability to induce labor.  Like other drugs which work to start the labor process, misoprostol causes the ripening of the cervix.  The cervix typically remains firm, keeping the baby in the uterus.  The baby can only be delivered when the cervix thins, as in women taking misoprostol.  Most cases of post-partum hemorrhage are related to uterine atony which is that loss of uterine muscle contraction.  The muscle contractions augment coagulation and aid in bleeding prevention.  Misoprostol causes uterine contractions, which both induce labor and help prevent bleeding[11].

Advantages of Misoprostol

85 nations have approved the medical use of misoprostol[12],[13].  This widespread acceptance facilitates the use of misoprostol in international aid programs.  Furthermore, researchers have categorized misoprostol as a “heat-stable drug,” meaning that it remains medically effective even after exposed to high temperatures.[14] Because international transportation, the temperate climates of much of the developing world, and a lack of easily accessible cooling devices in very poor nations, misoprostol’s heat-stable property is a vital qualifier for use in aid-based healthcare interventions.  In addition to misoprostol’s ability to tolerate heat, this drug’s method of administration enhances its appeal to third-world healthcare workers.  Patients take misoprostol in tablet form.[15] Because the medication can be taken orally, as a pill, intervention programs need not cope with the complications and challenges of sanitary intravenous delivery.  Administration of misoprostol does not require the presence of somebody familiar with the process and hygienic requirements of intravenous shots.  Effective delivery and increased accessibility of this drug in resource-deprived regions is therefore far more feasible than with medications dispensed in shot form.

Disadvantages of misoprostol

Misoprostol, significantly more than oxytocin, causes side effects such as shivering and pyrexia, or fever[16].   This shivering is not physically damaging, and typically persists for fewer than 24 hours.  However, physicians recognize pyrexia as a troubling, medically significant side effect of misoprostol.  The risk of pyrexia causes many doctors to hesitate to endorse misoprostol for use in the absence of a medical professional.  Although misoprostol-induced fevers do eventually dissipate, trained health workers should be present to monitor pyrexia[17].

Due to misoprostol’s published health side effects, the drug’s manufacturer and patent-holder, Pfizer, hesitates to market misoprostol for use in the treatment of post-partum hemorrhage.  Pfizer believes the drug is outdated for obstetric and gynecological purposes.  Consequently, in 2006, Pfizerceased selling Cytotec (a branded version of misoprostol) in Germany[18].  Pfizer’s cautious approach to misoprostol may also stem from the drug’s decreasing profitability.  As market values of the drug have declined, the OB/GYN medication manufacturers have also assumed greater liability for their products.  Pfizer recently decided not to even apply for licenses that would allow the sale and use of misoprostol for maternal health problems.  That decision is indicative of perceived barriers, both economic and medical in nature, to the increased production of the drug[19].

Oxytocin

Despite misoprostol’s acceptance and widespread use in healthcare intervention programming, it is not universally recognized as the best treatment of post-partum hemorrhage. As recently as 2009, the WHO stated publicly its belief that oxytocin—not misoprostol—acts as the most effective post-partum hemorrhage medication[20].  Clinical research has documented oxytocin’s potential to reduce post-partum hemorrhage rates by up to 50%, with negligible side effects4.  However, although it may reduce post-partum hemorrhage more than misoprostol when both are effectively administered, oxytocin has a unique set of challenges to delivery that make it a much less viable option for use in international aid programs.

Disadvantages of oxytocin

The current best-practices medical guidelines for administration of oxytocin state that a trained healthcare professional must be present at treatment, using sterilized syringes for injection of the medication4.  The requirement for some type of healthcare worker adept at administering intravenous medication immediately hinders use in poor, rural areas where the maternal health problem is most prevalent.  Healthcare intervention programs could try to address this problem through administration of oxytocin at a central, regional clinic with an experienced healthcare worker.  However, since post-partum hemorrhage is an immediately life-threatening situation for mothers, transportation to a hospital or clinic facility after the onset of hemorrhage is seldom a viable option.  Just during unanticipated, short-distance transportation, mothers can lose enough blood to die.  Post-partum hemorrhage medications must be administered quickly, but the intravenous nature of oxytocin severely impedes sterile, appropriately dosed, timely administration of this drug in the developing world.

Furthermore, injectable uterotonics such as oxytocin are unstable in high temperatures, and require cold-chain storage. [21] Because oxytocin requires refrigeration during transport and administration, administration can be particularly challenging in areas with little infrastructure.  For instance, according to a study published by the Derman Lab, oxytocin—despite its clinical success—is not a feasible treatment for post-partum hemorrhage in resource-poor areas, where a significant portion of births occur in individual homes[22].  Oxytocin is therefore least effective as a treatment for post-partum hemorrhage in the regions that need it most.  The use of oxytocin is not yet feasible in much of the developing world, where deliveries still take place in rural areas without the wealth for refrigeration capacity or the knowledge base for effective use of intravenous syringes.

Which hemorrhagic drug is best for healthcare intervention programs?

Misoprostol does not suffer from the problems associated with oxytocin.  Studies have been conducted to show the success misoprostol in regards to post-partum hemorrhage, demonstrating oral misoprostol’s ability to reduce acute hemorrhaging by as much as 50%, and acute-severe hemorrhaing by as much as 80%, equivalent in effectiveness to oxytocin[23].  The cost of misoprostol is very low, making it particularly attractive for health ministries.  It is possible to manufacture misoprostol for as little as 4 cents a tablet.  In many developing nations a three tablet dose can go for as little as 1 USD[24].

Given the advantages and disadvantages of both oxytocin and misoprostol there is an inherent difficulty in stating the best possible course of treatment.  However, keeping current research and doctor recommendations in mind, oxytocin should remain the gold standard for addressing post-partum hemorrhage.  Due to its lack of side effects, success rate comparable to that of misoprostol, and low cost, oxytocin should be used where the existence of cold-storage infrastructure permits.  However, the current limitations in terms of distribution and administration of oxytocin, misoprostol should be used in rural areas and areas inaccessible to skilled birth attendants.  Misoprostol can serve as a near term solution to mitigate the deaths occurring in these regions until further health systems strengthening occurs.

Addressing professional guidelines

Professional guidelines often suggest that only trained medical staff handle the allocation of proper drug doses4.  Of course, these professional medical recommendations are created by and for healthcare professionals in developed countries.  The weak, or even nonexistent, health systems of underdeveloped countries lack the human resources associated with these standards.  It would simply be unrealistic to expect that professionals with the knowledge and training of, for instance, American nurses, allocate and administer all hemorrhagic drugs in third world nations.  Developing countries must thus use first world medical guidelines as a goal, but not a prerequisite, for post-partum hemorrhagic drug administration.

As stated by Lilly Kak of USAID, the World Health Organization’s current guidelines do not recommend the administration of misoprostol by local health workers.  According to these recommendations, misoprostol should only be taken under the supervision of a trained birthing attendant or the trained workers at health facilities.  Even with sufficient supplies of misoprostol pills, these guidelines would inhibit the accessibility of misoprostol in resource-deprived locations, where doctors and skilled birth attendants are seldom available. Many maternal deaths occur with pregnancies in rural homes, beyond the reach of WHO-approved health officials.  There is thus a need for delivery of drugs by persons on site in the rural areas.

Future change to the WHO guidelines on misoprostol is on the horizon.  According to Lilly Kak of USAID there has been a call for randomized sampling studies proving the proficiency of community health workers in regard to giving proper dosage and timing of misoprostol.  Studies have been published showing potential safety of distribution at the local health worker level.  However, there is a dearth of studies conducted using random sampling methods to scientifically prove the workers effectiveness.  As such, the WHO remains hesitant to change their guidelines for distribution until data proving local health work proficiency is conducted.  When this research is published, the WHO would likely change its guidelines for distribution allowing broader scale access to misoprostol and therefore alleviating the bottleneck for distribution.

Further work needs to be done to address the problems with current distribution outlets and methods for oxytocin and misoprostol.  It is imperative to have these drugs, which are vital to saving lives, be readily available to mothers in need.  As a health system strengthening occurs and more skilled birthing attendants can work with mothers, the accessibility of post-partum hemorrhage drugs to these workers is crucial.  Additionally, skilled birthing attendants, who can work with mothers in their homes, should have access to supplies and proper equipment in order to lower at-home death rates.   Similar measures need to be taken with oxytocin because it requires intravenous administration and refrigeration which is not always possible.

Should proper equipment, such as sterile hypodermic needles and refrigeration, be accessible, misoprostol is not the best choice of drug.   Oxytocin, because of its lack of side effects and comparable affect on hemorrhage, is an ideal treatment.  Misoporostol, however, may also be identified by Global Fund proposals as an appropriate choice, since misoprostol can easily be transported and taken orally to treat post-partum hemorrhage.  However, under current guidelines and given the side effects of use, misoprostol should be taken with care and under the guidance of a SBA.  Shivering and fever are both dangerous and, if uncontrolled, can have serious consequences.  Only if a given Global Fund proposal demonstrates that local health workers are proficient in distribution of misoprostol and the handling of side effects, should supplies be readily accessible to these local workers.  One of the main dilemmas with addressing the problem of post-partum hemorrhage is the inaccessibility of treatment to remote, resource-poor regions.  If distribution of misoprostol in these places areas then post-partum hemorrhage prevalence with decrease accordingly.

Skilled Birth Attendants

What are birth attendants?

Increasing both the portion of births attended by a skilled professional and the quality of training for these workers is, along with increasing hemorrhagic drug use, one of the most effective maternal healthcare interventions.  A skilled birth attendant (SBA) is “an accredited health professional–such as a midwife, doctor or nurse–who has been educated and trained to…manage normal…pregnancies, childbirth and immediate postnatal period” (4).  Although doctors and nurses technically qualify as SBAs, in the developing world these attendants are most often narrowly trained around the experience of childbirth.  The exact duties of SBAs vary widely with region, but typically include delivering of infants during childbirth, counseling and training new mothers to breast feed, and caring for newborn children immediately following birth.  Despite the myriad health risks associated with labor and delivery, a full third of births worldwide take place in private homes, without the assistance of SBAs (1).  Periodic prenatal check-ups with a skilled healthcare professional, as well as the presence of a skilled birth professional during delivery, would provide women in the developing world with a much safer maternal experience.

The vast majority of human communities, whether or not they are within or strongly connected to the developed world, are familiar with the concept of birth attendants.  Even regions without substantial healthcare infrastructure as well as communities that have a traditional reluctance towards formal healthcare typically recognize the value of SBAs.  Consequently, in these developing areas where the maternal health problems are particularly prevalent and new healthcare delivery systems are particularly challenging, preexisting SBA networks represent a unique, well-positioned option for healthcare improvements.  Unfortunately, although SBAs provide a valuable service for pregnant women and new mothers, these existing SBA networks often lack the medical resources and knowledge necessary to truly maximize potential SBA impact maternal health outcomes.  Birth attendants in under-developed countries can, ideally, mediate between outdated local health practices and the scope of current medical knowledge and procedures.  Existing SBA frameworks have unique potential to enhance maternal healthcare outcomes.

How do skilled birth attendants impact maternal mortality?

According to Joy Phumaphi, Assistant Director-General of Family and Community Health at WHO, “Life-threatening complications occur in 15% of all births…[and] a skilled birth attendant can make the difference between life and death.”[25] In response to the immense potential of expanded skilled birth attendant networks to reduce maternal mortality, the United Nations Millennium Declaration included the strengthening of SBA networks as a core aspect of its maternal healthcare Millennium Development Goal (MDG).  In particular, the MDG specifies that 90% of births should occur in the presence of a skilled attendant by 2015.[26] Ideally, skilled birth attendants should have the knowledge to identify pregnancy-related medical conditions as they develop, the resources to address those issues, and the ability to spend time with mothers periodically throughout pregnancy and for at least several hours after birth.  In a joint statement, the World Health Organization, International Midwife Coalition, and International Federation of Gynecology and Obstetrics expressed the importance of an “enabling environment” that provides these conditions necessary to the success of skilled birth attendants . [27] A high-functioning, robust network of SBAs can not only “recognize and prevent medical crises on the spot, but…can refer women for life-saving care when complications arise”. [28]

maternal_healthcare_figure3

Figure 3: Maternal mortality in Thailand, Sri Lanka and Malasia by year with increasing midwife prevalence.

It has been shown that increased prevalence of skilled birth attendants at childbirth greatly decreases maternal mortality.[29] Industrialized nations experienced this impact in the early twentieth century when they halved their maternal mortality ratios by providing professional midwifery care at childbirth.[30] This effect has also been seen in developing countries. Malaysia, Sri Lanka and Thailand all halved their maternal mortality ratios within ten years in the 1960s and 1970s.  The dominant health systems intervention in each of these cases was a vast increase in the number of midwives, and each of these nations attributed their improvements in maternal care to the increases in SBA availability.  The association between enhanced SBA availability and decreased maternal mortality is illustrated in Figure 3. As the graph indicates, the number of hospital beds needed decreased as the number of SBAs increased, because their presence decreased the need for emergency care. Egypt provides another example of drastic maternal death reductions via SBA system improvements.  During the years 1983 through 2000, Egypt both doubled its proportion of deliveries assisted by skilled birth attendants and reduced its maternal mortality ratio by fifty percent.[31]

Quality of SBAs through training programs

SBA-related health intervention programs should both increase the portion of births attended by SBAs, and the knowledge with which these SBAs handle the atypical pregnancy and childbirth scenarios that cause maternal deaths.  In particular, SBAs must be able to quickly identify a problem which would require referral to a health facility.  The World Health Organization’s SBA instruction model addresses maternal health complications most effectively, and should serve as a template for subsequent SBA-related health programs.  The WHO provides 6 modules for midwifery education, with the assumption that students already have the basic abilities to monitor blood pressure, conduct a normal delivery, and infection prevention.[32]

The first module is considered the foundation, and outlines economic and cultural as well as medical factors that put a woman at risk of having a complicated pregnancy. In addition, it discusses the dangers in delaying seeking medical care, and outlines ways to reduce a woman’s risk factors.  In the second module, students focus on post-partum hemorrhage, which is a severe loss of blood. It first details the physiology of the entire third stage of labor and when it is most likely to occur.  Students learn what hemorrhage is, risk factors for it, how to identify it, and basic steps to control it.  The focus is on prevention of postpartum hemorrhage through active management of the third stage of labor which includes massaging the uterus, basic suturing, as well as drug treatments.  The third module focuses on prolonged and obstructed labor, and begins by reviewing the anatomy and physiology related to such occurrences. In addition to being able to identify major risk factors, the third module teaches how to assess both the pelvic and baby positions, and how to perform vacuum extractions in the case of an emergency.

The WHO education program for midwives then moves onto the fourth module which addresses puerperal sepsis, a severe uterine infection after childbirth.  It explains how to identify this condition as well as how to differentiate it from other infections.  There is also a focus on proper procedures to lessen exposure to potential infections, as well as a discussion on how to provide the proper drugs should sepsis occur.  This module also contains a small chapter devoted to minimizing mother-to-child HIV transmission. The fifth module teaches how to manage eclampsia, or non-neurological seizures in pregnant women. It discusses the pre-eclampsia and eclampsia conditions and how to identify them.  A strong focus is placed on prevention and identification of risk factors, however the proper approach to caring for someone during a seizure is included as well.  The sixth module is related to abortion and how it affects maternal mortality.  The module explains abortion and the various types and stages.  However, it also discusses stress the laws and regulations related to abortion, and explores social and religious opinions on abortion.  In addition, means of preventing unwanted pregnancy are detailed so that the midwives can help women from wanting an abortion in the first place.  However, emergency abortion procedures are detailed so as to preserve the mother’s life.

While the WHO’s training program does not leave the midwife equipped to independently handle any emergency, it does enable the midwife to prevent a majority of the most common complications, and control the problems that lead to preventable maternal deaths.  This training module encompasses the major complications without overestimating the medical knowledge of the midwives, and countries implementing training programs should be encouraged to utilize it, or create a similar program. Ideally the program would be taught by midwives, possibly centralized at the nearest health clinic, who would be accredited by the WHO to provide the course. An apprenticeship program which would complement the coursework could be highly beneficial to inexperienced students and should be considered by CCMs. As the WHO modules and texts have already been created after careful study and are readily accessible, organizations creating training programs could use these to more rapidly begin training rather than devote resources to creating new education modules. However, the Global Fund would not require the usage of the WHO modules, as it is important to leave room for creativity and cultural sensitivity in both training and implementation.  In addition, evaluation of the modules has found that while they were developed for in-service education, they can also be utilized in pre-service education programs.[33] However, the outcome of an attendant who is skilled in preventing and identifying major complications, would still be desired.

Quantity of SBAs through Community Health Organizations

There is currently a 50% shortfall of the estimated 700,000 midwives needed to ensure universal coverage of maternal care.[34] On a broader scale, there are 4.3 million health workers lacking worldwide.[35] Thus, not only must SBAs receive more thorough training in maternal healthcare, they must be employed more efficiently, to provide services at more births.  SBA networks must also be increased in size.  It is imperative that resources be dedicated to recruitment, training, and retention of professionals with midwifery skills.         Of course, the services of a SBA are less costly than maternal health services provided through a regional clinic or hospital.  For instance, in Berega, Tanzania, a birthing attendant’s services cost about $2 USD per birth. At an area hospital, an uncomplicated birth would cost $6 USD, while an emergency Caesarean procedure costs $15 USD.[36] A Global Fund for Maternal Health would pay SBAs through regional grant programs, making SBA care much more affordable for impoverished populations, and incentivizing both the training and use (through those lower costs) of the use of birth attendants.

This new Global Fund could also fund proposals designed to support increasing the establishment of small, formal schools dedicated to providing midwifery education, thereby increasing the chance that a person could attend such a program. It could not only act as an opportunity to those already interested, but as an attractive agent to those who may not have considered the option previously. The fund strongly suggests incorporating and enticing individuals from a community in need. By keeping individuals near or within their own communities, more mothers are guaranteed skilled maternal care.  These professionals will have the personal incentive to remain within their own communities and provide the necessary extended care to women who have given birth.  So often is the case that birth attendants cannot monitor the vulnerable period following childbirth, and some complications go undetected

One Organization which has shown immense success with enticing participants is Rural Expansion of Afghanistan’s Community-Based Healthcare, or REACH. REACH, funded in part by USAID, offers an 18-month midwife training program, which had 20 applicants for 20 available spots in 2003; however, due to improved living arrangements during the course and the potential for a vastly increased salary after graduation, by 2006 there were 1300 applicants.[37] The responsiveness of the program to the needs of women for better living arrangements so that their families would permit them to attend, as well as the spread of their enthusiasm about the benefits of being a midwife contributed to the success of the program.  Afghanistan has also approached the issue through an increase in the number of Community Health Organizations, which are efforts at the village level to improve post-natal and basic care[38]. As these organizations do not deal with delivery itself, workers require less skilled training. The program could then produce a larger volume of these community health workers and a greater percentage of mothers would receive the necessary extended postnatal care.  In addition, a community-based program gives a sense of ownership over maternal healthcare, which helps ensure continuing participation in programs aimed at decreasing maternal mortality.

Importance of providing resources for SBA to perform duties

Skilled birth attendants must be able to act upon the solutions and preventions they identify.  As such, the full efficacy of increasing the number of skilled birth attendants will not be reached until there is an increase in the number of well-equipped health centers, primarily for referral in an emergency.  To complement the knowledge being applied, pharmaceutical drugs as well as tools should be accessible to the attendants.  Every country should also have a national system in place for licensure and accreditation.  Uniform standards for knowledge and protocol ensure the safety and reliability of someone who is properly referred to as a skilled birth attendant. Continuing education as well as performance auditing protocols should also be considered.

Section 5: Advantages and Disadvantages

Please find Section 5 throughout Sections 4 and 6.

Year Amount
1985 132.2
1986 155.6
1987 184.5
1988 172.6
1989 203.3
1990 185.6
1991 251.1
1992 269.0
1993 281.5
1994 240.3
1995 296.8
996 360.9
1997 338.3
1998 380.9
1999 363.0
2001 361.1
2002 391.7
2003 389.7
2004 442.9
2005 458.7

Section 6: Addendum

Addendum 1: The Structure of a solution

USAID and Maternal Care

About one half of one percent of America’s annual federal budget is spent by the United States Agency for International Development (USAID), the government’s primary mechanism for foreign assistance.[39] USAID disburses American aid, in the form of financial assets, material goods, and human resources, in support of a variety of international causes.  Although the Secretary of State ultimately dictates USAID’s priorities and policies, USAID consistently promotes such causes as agricultural and economic development, global health, and humanitarian relief.  Both through its own global health programming, and via some collaboration with international, national, governmental, and private sector partners, USAID works to improve maternal healthcare around the world.  USAID health interventions can take a range of different forms, from community-level interventions to broad health-systems strengthening.  USAID’s maternal care programs focus on a set of interventions designed to target specific, high-mortality complications of pregnancy and birth.  Those target complications coincide with Figure 2, and include post-partum hemorrhage, hypertension and eclampsia, and infections, among others.  USAID also directs some of its work on maternal healthcare improvements directly to improving the prevalence and quality of SBA-attended births.

Disadvantages of USAID work on maternal health

Although USAID recognizes the potential to enhance maternal health through programs that improve healthcare options throughout both pregnancy and the post-partum period, its programs have not fully addressed the maternal healthcare problem.

As depicted in Table 1, USAID has spent more than $6 billion on global child survival and maternal health efforts since 1989.  Despite these efforts, the global maternal mortality count has remained for years at about 500,000 deaths annually.  Due to global population growth, the consistent 500,000 maternal death count does represent a progressively smaller portion of annual births, and therefore some slight degree of improvement in maternal healthcare over the past two decades.  This constancy of the global maternal death count does not render USAID intervention programs unsuccessful, but it does mean that USAID efforts can absolutely not be treated as a sufficient response to maternal healthcare deficiencies.

USAID is clearly committed to improving maternal healthcare, but it seems to view this problem primarily through the lens of child death.  For instance, when USAID describes and motivates the maternal health problem on its website, it claims that to “combat illness in children and create a safer future for the world, USAID has to care for newborns [and] train midwives.” (CITE).  This statement, though completely accurate, is indicative of USAID’s approach to maternal care as a means to improved child survival rates, rather than a worthwhile end in itself.  Indeed, the expenditures that USAID characterizes as investments in child survival/maternal health are in large part geared towards child programs.  Though USAID’s approach to the maternal health improvements principally in terms of their potential to enhance child health is not necessarily inappropriate, the maternal healthcare problem would benefit from the efforts of an organization focused specifically on the health of mothers.

The Global Fund to Fight TB Malaria and AIDS

Three other global health problems have been approached successfully via a different method of intervention program development and aid disbursement.  Since 2002 the Global Fund for Tuberculosis, Malaria, and AIDS has effectively combated these three contagious diseases.   As a funding—but not an implementation—mechanism, the Global Fund’s purpose is to collect and appropriately distribute monetary assets in a way that most reduces the burden and prevalence of tuberculosis, malaria, and AIDS.  The Global Fund structure takes the form of an international partnership between a number of public and private organizations, both donating and receiving the financial resources of the Global Fund.  Thus, the Global Fund works with national governments, private corporations and individuals, non-governmental organizations, and civil society to raise money and facilitate health intervention programs.  This organization was originally designed “to serve as a catalyst for the generation of additional funds, and to complement already existing sources.”[40] When the Global Fund entered the arena of charitable, international health intervention programming, it was meant to attract new financial contributions, and not to detract from organizations and funding sources with similar goals.  The Global Fund model has proven itself successful; since 2002, Global Fund staff have raised and spent US$ 18.7 billion on 572 different programs.  In addition to bringing supplemental resources to its target issues, the Global Fund has made investments in tuberculosis, malaria, and AIDS interventions more effective, by helping unify and focus the efforts of its many partner organizations.

The Global Fund does not directly implement the healthcare programs that it funds, but instead relies on a Country Coordinating Mechanisms (CCMs) to supply the knowledge and will to develop healthcare solutions.  CCMs that have conceived and developed health intervention program ideas may propose these interventions to the Global Fund administrators.  The Global Fund uses a comprehensive review system to select and enhance promising proposals, and then provides the proposing CCM with a grant to implement its intervention concept.  By leaving program design and implementation to CCMs, the Global Fund model allows recipient organizations and countries to act on their own healthcare priorities, and makes certain that all funded programs are designed with an awareness and acknowledgement of the unique concerns of the beneficiary population. Because of its emphasis on centralized funding and local program design, the Global Fund’s grant program represents a new way of responding to international healthcare challenges.

USAID vs. Global Fund for Maternal Care

The establishment of a Global Fund for Maternal Health is the best way to address the maternal healthcare crisis.  The Global Fund for Tuberculosis, Malaria, and Aids has undergone several periodic evaluations since its inception, and independent evaluations of the Global Fund have consistently articulated the unique strengths and advantages of the Global Fund’s approach to healthcare improvements.  These strengths in large part stem from the structure of the Global Fund, not from the particular details of tuberculosis, malaria, or AIDS interventions.  Many of the existing Global Fund’s advantages would thus extend to a new Global Fund for Maternal Health.  One of those advantages involves the Global Fund’s ability to bring completely new funding sources to international efforts to control tuberculosis, malaria, and AIDS.  For instance, David Wilkinson’s appraisal of Cambodia’s Global Fund CCM notes that “The Global Fund, through the establishment of the CCM, has provided new opportunities for a range of stakeholders to work together more effectively.”[41] Steve Radelet’s independent evaluation of the Global Fund’s progress in 2004 corroborates this perspective, and also points out that the Global Fund “has successfully raised global awareness about the three diseases.”  [42] Of course, the Global Fund structure has a number of other benefits, beyond its ability to increase participation in the fight against its three target diseases.

The use of CCMs to carry out the conception and implementation of programs, as opposed to USAID’s practice of conceiving, funding, and implementing its own disease-based health interventions, provides important benefits for the Global Fund structure.  Different regional populations have unique religious perspective, cultural values, and traditions that sometimes affect the type of healthcare interventions needed to improve maternal care.  For instance, most Afghan mothers may seek out medical attention only “with the permission of their families (husbands, but often parents-in-law, and sometimes village religious leaders as well).”[43] Afghan women must also receive treatment only from female health workers.  In other cases, the influence of culture on healthcare intervention effectiveness is more subtle, but the situation of Afghan women demonstrates a typical type of barrier to maternal health improvements.

The locality of program development and implementation would strengthen the cultural sensitivity of Global Fund interventions, ensuring that programs are built with an awareness of a given region’s social norms.  Any given Global Fund program would be designed and administered, at least in part, by individuals native to the region targeted by that program.  All project will therefore be designed with an understanding and acknowledge of those ideological practices which would traditionally act as barriers to health systems improvements.  Regional CCM project administrators will not propose projects which they know to conflict heavily with social values in their respective areas.  Because the Global Fund supports local projects, cultural awareness is built into health interventions.

The political situation of USAID also contributes to the selection of a Global Fund structure for support of SBA system strengthening, increased hemorrhagic drug use, and other intervention programs targeting maternal health.  USAID core goals and missions are ultimately subject to the foreign policy agenda of the Secretary of State and, by extension, the ideological perspective of the President of the United States.  While it seems fitting that the leader elected by the American people dictates the use of American tax dollars overseas, this model can interfere with the otherwise effective programs of aid workers.  Each change of administration—and each shift in one given administration’s approach to foreign policy—can emphasize or devalue certain global challenges, and certain types of programs.  Long term planning and development programs are particularly challenging for organizations, like USAID, that do not know what their own, exact goals will be in just a few years’ time.  Even changes within Congress, occurring every two years, can alter USAID’s expectations for funding reauthorization.  Because Congress must, presumably, justify its appropriations to the American people, so must USAID justify its expenditures to Congress.  USAID’s position within the federal government of the United States forces it to think, and act, in the short-term.

Given USAID’s necessary focus on verifiable short-range problem solving, it is not surprising that this organization favors output-based, rather than outcome-based, metrics of success.  Output-based metrics, although easier to measure than outcome-based metrics, are less indicative of the actual health improvements of intervention programs.  A measure of a program’s success (or failure) in output metrics will provide quantitative information about the degree to which financial resources were able to create possibilities for healthcare improvements.  Outcome-based measurement will instead provide information regarding the extent to which healthcare interventions actually improved the overall health of a population.

For instance, a program designed to reduce hemorrhagic deaths may measure output in terms of the number of misoprostol tablets distributed in a given area.  However, outcome-based metric would provide data regarding how many of those pills were actually received—at the right time and in the appropriate dose—to women in labor, and how many maternal deaths the drug prevented.  Health outcomes clearly function as a better indicator of a given program’s value.  Unfortunately, outcome-based metrics of success take longer and are more challenging to obtain than output data.  Organizations oriented towards annual goals and in need of data justifying their programming, such as USAID, consequently favor output-based measurements.  A Global Fund for Maternal Health, because it would be less dependent on any one source of funding, could thus enjoy a greater degree of political and financial consistency than USAID.  This ultimately makes a Global Fund structure more capable of long-term planning and improvements, and would allow a Global Fund for Maternal Health to place greater value on outcome-based data.

Global Fund Guiding Principles

Like the Global Fund for Tuberculosis, Malaria, and AIDS, the Global Fund for Maternal Health would attract, manage and disburse resources to improve maternal healthcare.  It will act solely as a financial instrument and not an implementing entity.  The Global Fund for Maternal Health would seek out donations from the same types of national governments and private firms which have historically donated to the Maternal Fund for TB, Malaria, and AIDS.  Our approach to obtaining donations will be outlined below, in the section titled ‘Shaping Public Opinion.’ Disbursement of funds would take place in the form of a grant program.  Maternal healthcare intervention grant proposals will be conceived, developed and submitted by the Country Coordinating Mechanisms (CCM) of individual countries. Proposals will be evaluated through independent review processes, designed to identify proposals which would most effectively and efficiently address unmet maternal healthcare needs.

CCMs would typically be composed of representatives from the private and public sectors, such as governments, bilateral and multilateral agencies, non-governmental organizations, academic institutions, private businesses and people working in the country’s healthcare system.  A given CCM, having developed an intervention concept, may formally propose that project to the Global Fund at any time.  Following approval, each program will be operating locally, administered, potentially revised, and monitored almost exclusively by the CCM.  Local involvement in both decision-making and decision-implementation fosters a sense of empowerment and ownership of Global Fund projects.  The CCM structure is also necessary because unique cultural outlooks, often stemming from religious perspective, can detract from the ability of American-designed programs to flourish in developing countries.  For areas, such as Afghanistan, with particularly challenging cultural barriers to maternal care, the Global Fund for Maternal Health’s administrators would require grant proposals to outline and address popular attitudes towards maternal health.  The Global Fund would only fund grant proposals that both recognize these barriers, and pinpoint a means of overcoming them.

The Maternal fund will ensure effectiveness through performance based funding. All CCMs will have project goals, developed in conjunction with the Global Fund administrators, to measure project success and identify shortcomings.  Time-based and results-based goals will be set at the outset of each newly funded program.  In evaluating the goals, the Maternal Fund will prioritize metrics measuring outcome over those measuring output.  The Global Fund’s use of an independent Technical Review Panel ensures that limited resources are invested in technically sound programs with the greatest chances of success. The panel includes disease experts, as well as experts in the field of development who are able to assess how proposed programs complement ongoing health and poverty reduction efforts at the country level.  Because it leaves project implementation to CCMs, the Global Fund need only to monitor these feedback mechanisms in order to make funding decisions during periodic reauthorization processes.  Every program must be able to account for their use and dispersal of resources granted by the Maternal Fund.

Funding priority will be given to interventions that have demonstrated scientific and technical merit, as determined by the panel of experts in the field of medicine, business administration, economics, public health policy, and others.  For instance, (as discussed above) two specific medical systems interventions have been identified as particularly effective ways to reduce a region’s maternal mortality rate.  Distribution of hemorrhagic drugs and antibiotics, as well as the strengthening of skilled birthing attendant systems, set a benchmark of maternal mortality rate reduction.  Funding decisions will therefore favor these types of projects, unless a grant proposal can demonstrate equivalent or greater potential success for a different intervention.  Potential success may be demonstrated through historical data on a given intervention (preferably data which employs outcome, not output-based metrics) or intervention outcome modeling algorithms.  Projects not focused on either skilled birthing attendants or drugs distribution will be started small and, potentially, scaled up.

Addendum 2: Shaping Public Opinion

A Global Fund for Maternal Health can only function as long as national governments and large private donors choose to contribute financially to the organization.  Founders of a Global Fund must thus consider popular attitudes, particularly in rich nations, towards maternal health.  Unfortunately, because wealthy countries already have highly effective maternal healthcare systems, these potential donor countries tend not to appreciate the extent of the global maternal healthcare problem.  The nature of the maternal health crisis as an issue unique to the developing world heightens the challenge of altering public perspective in developed areas of the world.  Here, we will briefly discuss ways in which proponents of the Global Fund may shape the American public’s opinion towards maternal health improvements.

The United States has pledged almost US$6 billion to the Global Fund for Tuberculosis, Malaria, and AIDS.  These three diseases do have both a significantly greater affected global population and a more explicit link to international security concerns than the maternal health problem.  Consequently, a United States contribution to the Global Fund for Maternal Health would not—and need not—reach as high as US$6 billion.  Still, advocates of this new Global Fund would ultimately shape public opinion in order to secure as much funding as possible.  Thus, the ultimate purpose of altering opinions towards maternal healthcare is not necessarily to inform average Americans on the topic, but rather to secure  an appropriation, from Congress, for this new Global Fund.  Advocates need only make average Americans value global maternal care improvements enough to leverage support from federal officials.

Several different approaches to the maternal healthcare issue will help convince specific American Members of Congress (MCs) to support a substantial contribution to the Global Fund for Maternal Health.  For instance, Global Fund advocates may target MCs who represent stake-holding Congressional districts.  Congressman Rodney Frelinghuysen, of New Jersey’s 11th Congressional district, represents many employees of pharmaceutical companies, which could potentially benefit for an increased demand for maternal healthcare medications.  That aspect of his constituency would, for example, hopefully make Representative Frelinghuysen empathetic to a Global Fund appropriate. By identifying and utilizing these types of relationships between MCs and the maternal healthcare issue, advocates can increase support for a large American donation to the Global Fund.

The attitudes of MCs towards the Global Fund for Maternal Health can also be shaped simply through case-appropriate framings of the maternal care issue.  Again, this discussion will provide only examples of the types of reasoning that Global Fund advocates can use.  With liberal and progressive CMs, Global Fund supporters may frame maternal health as a women’s rights issue.  When shaping the opinions of more conservative CMs, advocates may have more success by explaining the way in which maternal care improvements can prevent unnecessary abortions worldwide.  Of course, these are both broad generalizations.  The point is that the maternal healthcare message can—and should—change with the message’s audience.

Although many altruistic individuals may value maternal health improvements as a worthy humanistic cause, a treatment of maternal health problems as a global security threat has the potential to affect even more Americans.  A country of orphans will not grow into a stable government; by emphasizing the relationship between maternal mortality and governmental instability, Global Fund advocates can transform expenditures on maternal healthcare improvements into an investment in America’s safety.

Use of a ‘simple truth’ in conversations with MCs, or in communications targeted towards the entire American public, will also help strengthen American support of a Global Fund for Maternal Health.  For instance, the statement, “It costs less than one dollar to save a mother’s life,” although based on a number of assumptions made by the Commission for Macroeconomics and Health regarding appropriate maternal healthcare interventions, succinctly juxtaposes a small requisite investment with a large, compelling outcome.  Global Fund advocates must learn to transform dense facts into convincing statements.

National publicity efforts on the maternal healthcare issue and on the Global Fund for Maternal Health should note that America only spends approximately 1% of its annual federal budget on foreign assistance.  Recognition of this fact could help preempt suggestions that America’s aid costs are already too high.  Intensive efforts to shape public opinion in America should also take place near Mother’s Day, in order to utilize the sentiments and values expounded by this holiday.


[1] USAID. “Saving the Lives of Women and Children. (http://www.usaid.gov/our_work/global_health/mch/mh/index.html, accessed 8 December 2009).

[2] UNICEF. “Improve Maternal Health.” (http://www.unicef.org/mdg/maternal.html, accessed 8 December 2009).

[3] “Maternal Care”. World Health Organization.. (http://www.who.int/topics/maternal_health/en/, accessed 19 September 2009).

[4] “UN Urges Greater Investment in Maternal, Child Health in Asia-Pacific Region”

Voice of America 16 September 2009.
[5] Millenium Development Goal Monitor. (http://www.mdgmonitor.org/map.cfm?goal=4&indicator=0&cd=, accessed 20 September 2009).

[6] Cole, Elizabeth.  “Maternal Health in Afghanistan: A Security Issue?”  2008.

[7] “Maternal Care”. World Health Organization.. (http://www.who.int/topics/maternal_health/en/, accessed 19 September 2009).

[8] [8] UNICEF. “Improve Maternal Health.” (http://www.unicef.org/mdg/maternal.html, accessed 8 December 2009).

[9] “Reduction of Maternal Mortality.” A Joint WHO/UNFPA/UNICEF/World Bank Statement. 1999.

[10] Villar J, Gulmezoglu AM, Hofmeyr J, Forna F. Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage. Obstet Gynecol. 2002;100:1301-1312.

[11] Weeks, Andrew. “Misoprostol in Obstetrics and Gynaecology”. November 30, 2009 <http://www.misoprostol.org/>.

[12] Weeks, Andrew. “Misoprostol in Obstetrics and Gynaecology”. November 30, 2009 <http://www.misoprostol.org/>.

[13] Reproducitve Health Supplies Coaliton, http://www.path.org/files/RH_caucus_new_underused_med-abort_br.pdf

[14] Pagel, C., Lewycka, S., Colbourn, T., Mwansambo, C., Meguid, T., Chiudzu, G., Utley, M., and Costello, A. Estimation of potential effects on improving community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness  model. The Lancet 2009. 374: 1441-1448

[15] Ibid.

[16] Hoj, L., Cardoso, P., Bruun, B., Hvidman, L., Nielsen, J., Aaby, P. Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial. BMJ 2005: 331: 723.

[17] Hoj, L., Cardoso, P., Bruun, B., Hvidman, L., Nielsen, J., Aaby, P. Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial. BMJ 2005: 331: 723.

[18] Weeks, Andrew. “Misoprostol in Obstetrics and Gynaecology”. November 30, 2009 <http://www.misoprostol.org/>.

[19] Weeks, A., Fiala, C., Safar, P. Misoprostol and the debate over off-label drug use. BJOG 2005: 112: 269-272.

[20] Villar J, Gulmezoglu AM, Hofmeyr J, Forna F. Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage. Obstet Gynecol. 2002;100:1301-1312.

[21] Derman, R., Kodkany, B., Goudar, S., Geller, S., Naik, V., Bellad, M.B., Patted, S., Patel, A., Edlavitch, S., Hatwell, T., Chakraborty, H., Moss, N. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. The Lancet 2006: 368: 1248-1253.

[22] Ibid.

[23] Ibid.

[24] Grossman, Amy. “A Birth Pill”. The New York Times 05/09/09: 10.

[25] Skilled attendants vital to saving lives of mothers and newborns. World Health Organization. 15 November 2004. (http://www.who.int/mediacentre/news/notes/2004/np23/en/)

[26] Millenium Development Goal 5. World Health Organization. (http://www.who.int/making_pregnancy_safer/topics/mdg/en/index.html

[27] Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva, World Health Organization, 2004

[28] Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva, World Health Organization, 2004

[29] Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva, World Health Organization, 2004

[30] Skilled attendants vital to saving lives of mothers and newborns. World Health Organization. 15 November 2004. (http://www.who.int/mediacentre/news/notes/2004/np23/en/)

[31] The world health report 2005 – Make every mother and child count. Geneva, World Health Organization, 2005 (http://www.who.int/whr/2005/en, accessed 2 December 2009).

[32] Midwifery Education Modules. The World Health Organization, 2006. (http://www.who.int/making_pregnancy_safer/documents/9241546662/en/index.html, accessed 8 December 2009).

[33] Prevention of Postpartum Hemorrhage Initiative. “Evaluation of the Training Strategies for the Management of Third Stage of Labor.” 2007.

[34] The world health report 2005 – Make every mother and child count. Geneva, World Health Organization, 2005 (http://www.who.int/whr/2005/en, accessed 2 December 2009).

[35] The world health report 2006 – Working together for health. Geneva, World Health Organization, 2006 (http://www.who.int/whr/2006/en, accessed 14 August 2008).

[36] Grady, Denise. “Where Life’s Start is a Deadly Risk.” The New York Times. (http://www.nytimes.com/2009/05/24/health/24birth.html?_r=2&sq=May, accessed 2 December 2008).

[37] Cole, Elizabeth. “Maternal Mortality in Afghanistan as a Security Issue?” 2008

[38] Ibid.

[39] Offical USAID Website, http://www.usaid.gov/about_usaid/

[40] DR. Anne Peterson, ACVFA Briefing on Global Fund, October 9th, 2002.

[41] Wilkinson, David.  A Case Study on Cambodia CCM.  February 2004.

[42] Steven Radelet’s (Center for Global Development) June 2004 report on The Global Fund to Fight AIDS, Tuberculosis and Malaria: Progress, Potential, and Challenges for the Future

[43] Cole, Elizabeth  “Maternal care in Afghanistan”  2008.

Global Health, Global Health Projects


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