overview xvii Reaching all children with a package of essential child health interventions neces- sary to comply with and even go beyond the MDGs is technically feasible within the next decade.In the 75 countries that account for most of child mortality this will require USS 52.4 billion,in addition to current expenditure,of which USS 25 billion represents additional costs for human resources.This USS 52.4 billion corresponds to an increase as of now of 6%of current median public expenditure on health in these countries,rising to 18%by 2015.In the 21 countries facing the greatest constraints and where a long lead time is likely,current public expenditure on health would have to grow by 27%as of 2006,rising to around 76%in 2015. For maternal and newborn care,universal access is further away.It is possible to envisage various scenarios for scaling up services,taking into account the specific cir- cumstances in each of the same 75 countries.At present,some 43%of mothers and newborns receive some care,but by no means the full range of what they need even iust to avoid maternal deaths.Adding up the optimistic-but also realistic-scenarios for each of the 75 countries gives access to a full package of first-level and back-up care to 101 million mothers (some 73%of the expected births)in 2015,and to their babies.If these scenarios were implemented.the MDG for maternal health would not be reached in every country,but the reduction of maternal and perinatal mortality globally would be well on the way.The costs of implementing these 75 country sce- narios would be in the region of USS 39 billion additional to current expenditure.This corresponds to a growth of 3%,in 2006,rising to 14%over the years,of current me- dian public expenditure on health in these countries.In the 20 countries with currently the lowest coverage and facing the greatest constraints,current public expenditure on health would have to grow by 7%in 2006.rising to 43%in 2015. Putting in place the health workforce needed for scaling up maternal,newborn and child health services towards universal access is the first and most pressing task.Making up for the staggering shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. The extra work required for scaling up child care activities requires the equivalent of 100000 full-time multipurpose professionals,supplemented,according to the sce- narios that have been costed,by 4.6 million community health workers.Projected staffing requirements for extending coverage of maternal and newborn care assumes the production in the coming 10 years of at least 334 000 additional midwives-or their equivalents-as well as the upgrading of 140 000 health professionals who are currently providing first-level maternal care and of 27 000 doctors who currently do not have the competencies to provide back-up care. Without planning and capacity-building,at national level and within health districts, it will not be possible to correct the shortages and to improve the skills mix and the working environment.Planning is not enough,however,to put right disruptive histories that have eroded workforce development.After years of neglect there are problems that require immediate attention:first and foremost is the nagging question of the remuneration of the workforce. In many countries,salary levels are rightfully considered unfair and insufficient to provide for daily living costs,let alone to live up to the expectations of health profes- sionals.This situation is one of the root causes of demotivation,lack of productivity and the various forms of brain-drain and migration:rural to urban,public to private and from poorer to richer countries.It also seriously hampers the correct functioning of services as health workers set up in dual practice to improve their living conditions or merely to make ends meet-leading to competition for time,a loss of resources for
overview xvii Reaching all children with a package of essential child health interventions necessary to comply with and even go beyond the MDGs is technically feasible within the next decade. In the 75 countries that account for most of child mortality this will require US$ 52.4 billion, in addition to current expenditure, of which US$ 25 billion represents additional costs for human resources. This US$ 52.4 billion corresponds to an increase as of now of 6% of current median public expenditure on health in these countries, rising to 18% by 2015. In the 21 countries facing the greatest constraints and where a long lead time is likely, current public expenditure on health would have to grow by 27% as of 2006, rising to around 76% in 2015. For maternal and newborn care, universal access is further away. It is possible to envisage various scenarios for scaling up services, taking into account the specific circumstances in each of the same 75 countries. At present, some 43% of mothers and newborns receive some care, but by no means the full range of what they need even just to avoid maternal deaths. Adding up the optimistic – but also realistic – scenarios for each of the 75 countries gives access to a full package of first-level and back-up care to 101 million mothers (some 73% of the expected births) in 2015, and to their babies. If these scenarios were implemented, the MDG for maternal health would not be reached in every country, but the reduction of maternal and perinatal mortality globally would be well on the way. The costs of implementing these 75 country scenarios would be in the region of US$ 39 billion additional to current expenditure. This corresponds to a growth of 3%, in 2006, rising to 14% over the years, of current median public expenditure on health in these countries. In the 20 countries with currently the lowest coverage and facing the greatest constraints, current public expenditure on health would have to grow by 7% in 2006, rising to 43% in 2015. Putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task. Making up for the staggering shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. The extra work required for scaling up child care activities requires the equivalent of 100 000 full-time multipurpose professionals, supplemented, according to the scenarios that have been costed, by 4.6 million community health workers. Projected staffing requirements for extending coverage of maternal and newborn care assumes the production in the coming 10 years of at least 334 000 additional midwives – or their equivalents – as well as the upgrading of 140 000 health professionals who are currently providing first-level maternal care and of 27 000 doctors who currently do not have the competencies to provide back-up care. Without planning and capacity-building, at national level and within health districts, it will not be possible to correct the shortages and to improve the skills mix and the working environment. Planning is not enough, however, to put right disruptive histories that have eroded workforce development. After years of neglect there are problems that require immediate attention: first and foremost is the nagging question of the remuneration of the workforce. In many countries, salary levels are rightfully considered unfair and insufficient to provide for daily living costs, let alone to live up to the expectations of health professionals. This situation is one of the root causes of demotivation, lack of productivity and the various forms of brain-drain and migration: rural to urban, public to private and from poorer to richer countries. It also seriously hampers the correct functioning of services as health workers set up in dual practice to improve their living conditions or merely to make ends meet – leading to competition for time, a loss of resources for
xviii The World Health Report 2005 the public sector,and conflicts of interest in dealing with their clients.There are even more serious consequences when health workers resort to predatory behaviour:finan- cial exploitation may have catastrophic effects on patients who use the services,and create barriers to access for others;it contributes to a crisis of trust in the services to which mothers and children are entitled. There is an urgent need to invent and deploy a whole range of measures to break the vicious circle,and bring productivity and dedication back to the level the popula- tion expects and to which most health workers aspire.Among these,one of the most challenging is rehabilitating the workforce's remuneration.Even a modest attempt to do so,such as doubling or even tripling the total workforce's salary mass and benefits in the 75 countries for which scenarios were developed,might still be insufficient to attract,retain and redeploy quality staff.But it would correspond to an increase of 2%rising,over 10 years,to 17%of current public expenditure on health,merely for payment of the MNCH workforce.Such a measure would have political and macro- economic implications and is something that cannot be done without a major effort. not only by governments but by international solidarity as well.On the eve of a decade that will be focused on human resources for health,this will require a fundamental debate,in countries as well as internationally,on the volume of the funds that can be allocated and on the channelling of these funds.This is all the more important because rehabilitating the remuneration of the workforce is only one part of the answer:estab- lishing an atmosphere of stability and hope is also needed to give health professionals the confidence they need to work effectively and with dedication. At the same time,ensuring universal access is not merely a question of increasing the supply of services and paying health care providers.For services to be taken up, financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care,and particularly against the catastrophic payments that can push households into poverty.Such catastrophic payments occur wherever user charges are significant,households have limited ability to pay,and pooling and prepayment is not generalized.To attain the financial protection that has to go with universal access,countries throughout the world have to move away from user charges,be they official or under-the-counter,and generalize prepayment and pooling schemes.Whether they choose to organize financial protection on the basis of tax-generated funds,through social health insurance or through a mix of schemes,two things are important:first,that ultimately no population groups are excluded;second. that maternal and child health services are at the core of the health entitlements of the population,and that they be financed in a coherent way through the selected system. While it can take many years to move from a situation of a limited supply of services. high out-of-pocket payments and exclusion of the poorest to a situation of universal access and financial protection,the extension of health care supply networks has to proceed in parallel with the construction of such insurance mechanisms. Financing is the killer assumption underlying the planning of materal,newborn and child health care.First,increased funding is required to pay for building up the supply of services towards universal access.Second,financial protection systems have to be built at the same time as access improves.Third,the channelling of increased funds, both domestic and international,has to guarantee the flexibility and predictability that make it possible to cope with the principal health system constraints-particularly the problems facing the workforce. Channelling increased funding flows through national health insurance schemes-be they organized as tax-based,social health insurance,or mixed systems-offers the best avenue to meet these three challenges simultaneously.It requires major capacity-
xviii The World Health Report 2005 the public sector, and conflicts of interest in dealing with their clients. There are even more serious consequences when health workers resort to predatory behaviour: financial exploitation may have catastrophic effects on patients who use the services, and create barriers to access for others; it contributes to a crisis of trust in the services to which mothers and children are entitled. There is an urgent need to invent and deploy a whole range of measures to break the vicious circle, and bring productivity and dedication back to the level the population expects and to which most health workers aspire. Among these, one of the most challenging is rehabilitating the workforce’s remuneration. Even a modest attempt to do so, such as doubling or even tripling the total workforce’s salary mass and benefits in the 75 countries for which scenarios were developed, might still be insufficient to attract, retain and redeploy quality staff. But it would correspond to an increase of 2% rising, over 10 years, to 17% of current public expenditure on health, merely for payment of the MNCH workforce. Such a measure would have political and macroeconomic implications and is something that cannot be done without a major effort, not only by governments but by international solidarity as well. On the eve of a decade that will be focused on human resources for health, this will require a fundamental debate, in countries as well as internationally, on the volume of the funds that can be allocated and on the channelling of these funds. This is all the more important because rehabilitating the remuneration of the workforce is only one part of the answer: establishing an atmosphere of stability and hope is also needed to give health professionals the confidence they need to work effectively and with dedication. At the same time, ensuring universal access is not merely a question of increasing the supply of services and paying health care providers. For services to be taken up, financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care, and particularly against the catastrophic payments that can push households into poverty. Such catastrophic payments occur wherever user charges are significant, households have limited ability to pay, and pooling and prepayment is not generalized. To attain the financial protection that has to go with universal access, countries throughout the world have to move away from user charges, be they official or under-the-counter, and generalize prepayment and pooling schemes. Whether they choose to organize financial protection on the basis of tax-generated funds, through social health insurance or through a mix of schemes, two things are important: first, that ultimately no population groups are excluded; second, that maternal and child health services are at the core of the health entitlements of the population, and that they be financed in a coherent way through the selected system. While it can take many years to move from a situation of a limited supply of services, high out-of-pocket payments and exclusion of the poorest to a situation of universal access and financial protection, the extension of health care supply networks has to proceed in parallel with the construction of such insurance mechanisms. Financing is the killer assumption underlying the planning of maternal, newborn and child health care. First, increased funding is required to pay for building up the supply of services towards universal access. Second, financial protection systems have to be built at the same time as access improves. Third, the channelling of increased funds, both domestic and international, has to guarantee the flexibility and predictability that make it possible to cope with the principal health system constraints – particularly the problems facing the workforce. Channelling increased funding flows through national health insurance schemes – be they organized as tax-based, social health insurance, or mixed systems – offers the best avenue to meet these three challenges simultaneously. It requires major capacity-
overview X building efforts.but it offers the possibility of protecting the funding of the workforce in public sector and health sector reform policies and in the forums where macroeco- nomic and poverty-reduction policies are decided.It offers the possibility of tackling the problem of the remuneration and the working conditions of health workers in a way that gives them long-term,credible prospects,which traditional budgeting or the stopgap solutions of project funding do not offer. While the financing effort seems to be within reasonable reach in some countries. in many it will go beyond what can be borne by governments alone.Both countries and the international community will need to show a sustained political commitment to mobilize and redirect the considerable resources that are required,to build the in- stitutional capacity to manage them,and to ensure that maternal,newborn and child health remains at the core of these efforts.This decade can be one of accelerating the move towards universal coverage,with access for all and financial protection. That will ensure that no mother,no newborn,and no child in need remains unattended -because every mother and every child counts. CHAPTER SUMMARIES Chapter 1.Mothers and children matter-so does their health This chapter recalls how the health of mothers and children became a public health priority during the 20th century.For centuries,care for mothers and young children was regarded as a domestic affair,the realm of mothers and midwives.In the 20th century this purely domestic concern was transformed into a public health priority.In the opening years of the 21st century,the MDGs place it at the core of the struggle against poverty and inequality.as a matter of human rights.This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries. The chapter summarizes the current situation regarding the health of mothers,new- borns and children.Most progress has been made by countries that were already in a relatively good position in the early 1990s,while countries that started with the highest mortality rates are also those where improvements have been most disap- pointing. Globally.mortality rates in children under five years of age fell throughout the latter part of the 20th century:from 146 per 1000 live births in 1970 to 79 in 2003.Towards the turn of the millennium,however,the overall downward trend started to falter in some parts of the world.Improvements continued or accelerated in the WHO Regions of the Americas,South-East Asia and Europe,while the African,Eastern Mediter- ranean and Western Pacific Regions experienced a slowing down of progress.In 93 countries,totalling 40%of the world population,under-five mortality is decreasing fast.A further 51 countries,with 48%of the world population,are making slower progress:they will only reach the MDGs if improvements are accelerated significantly. Even more worrying are the 43 countries that contain the remaining 12%of the world population,where under-five mortality was high or very high to start with and is now stagnating or reversing. Reliable data on newborns are only recently becoming available and are more dif- ficult to interpret.The most recent estimates show that newborn mortality is consid- erably higher than usually thought and accounts for 40%of under-five deaths:less than 2%of newborn deaths currently occur in high income countries.The difference between rich and poor countries seems to be widening
overview xix building efforts, but it offers the possibility of protecting the funding of the workforce in public sector and health sector reform policies and in the forums where macroeconomic and poverty-reduction policies are decided. It offers the possibility of tackling the problem of the remuneration and the working conditions of health workers in a way that gives them long-term, credible prospects, which traditional budgeting or the stopgap solutions of project funding do not offer. While the financing effort seems to be within reasonable reach in some countries, in many it will go beyond what can be borne by governments alone. Both countries and the international community will need to show a sustained political commitment to mobilize and redirect the considerable resources that are required, to build the institutional capacity to manage them, and to ensure that maternal, newborn and child health remains at the core of these efforts. This decade can be one of accelerating the move towards universal coverage, with access for all and financial protection. That will ensure that no mother, no newborn, and no child in need remains unattended – because every mother and every child counts. CHAPTER SUMMARIES Chapter 1. Mothers and children matter – so does their health This chapter recalls how the health of mothers and children became a public health priority during the 20th century. For centuries, care for mothers and young children was regarded as a domestic affair, the realm of mothers and midwives. In the 20th century this purely domestic concern was transformed into a public health priority. In the opening years of the 21st century, the MDGs place it at the core of the struggle against poverty and inequality, as a matter of human rights. This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries. The chapter summarizes the current situation regarding the health of mothers, newborns and children. Most progress has been made by countries that were already in a relatively good position in the early 1990s, while countries that started with the highest mortality rates are also those where improvements have been most disappointing. Globally, mortality rates in children under five years of age fell throughout the latter part of the 20th century: from 146 per 1000 live births in 1970 to 79 in 2003. Towards the turn of the millennium, however, the overall downward trend started to falter in some parts of the world. Improvements continued or accelerated in the WHO Regions of the Americas, South-East Asia and Europe, while the African, Eastern Mediterranean and Western Pacific Regions experienced a slowing down of progress. In 93 countries, totalling 40% of the world population, under-five mortality is decreasing fast. A further 51 countries, with 48% of the world population, are making slower progress: they will only reach the MDGs if improvements are accelerated significantly. Even more worrying are the 43 countries that contain the remaining 12% of the world population, where under-five mortality was high or very high to start with and is now stagnating or reversing. Reliable data on newborns are only recently becoming available and are more dif- ficult to interpret. The most recent estimates show that newborn mortality is considerably higher than usually thought and accounts for 40% of under-five deaths; less than 2% of newborn deaths currently occur in high income countries. The difference between rich and poor countries seems to be widening
xx The World Health Report 2005 Over 300 million women in the world currently suffer from long-term or short-term illness brought about by pregnancy or childbirth.The 529000 annual maternal deaths, including 68 000 deaths attributable to unsafe abortion,are even more unevenly spread than newborn or child deaths:only 1%occur in rich countries.There is a sense of progress,backed by the tracking of indicators that show increases in the uptake of care during pregnancy and childbirth in all regions except sub-Saharan Africa during the 1990s,but the overall picture shows no spectacular improvement,and the lack of reliable information on the fate of mothers in many countries-and on that of their newborns-remains appalling. Chapter 2.Obstacles to progress:context or policy? This chapter seeks to explain why progress in maternal and child health has appar- ently stumbled so badly in many countries.Slow progress,stagnation and reversal are clearly related to poverty.to humanitarian crises,and,particularly in sub-Saharan Africa,to the direct and indirect effects of HIV/AIDS.These operate,at least in part. by fuelling or maintaining exclusion from care.In many countries numerous women and children are excluded from even the most basic health care benefits:those that are important for mere survival. The specific causes,manifestations and patterns of exclusion vary from country to country.Some countries show a pattern of marginal exclusion:a majority of the population enjoys access to service networks,but substantial groups remain excluded. Other countries,often the poorest ones,show a pattern of massive deprivation:only a small minority,usually the urban rich,enjoys reasonable access,while an overwhelm- ing majority is excluded.These countries have low density,weak and fragile health systems. The policy challenges vary according to the different patterns of exclusion.Many countries have organized their health care systems as health districts,with a back- bone of health centres and a referral district hospital.These strategies have often been so under-resourced that they failed to live up to expectations.The chapter argues that the health district model still stands as a rational way for governments to organize decentralized health care delivery,but that long-term commitment and investment are required to obtain sustained results Chapter 3.Great expectations:making pregnancy safer This chapter reviews the three most important ways in which the outcomes of preg- nancies can be improved:providing good antenatal care,finding appropriate ways of preventing and dealing with the consequences of unwanted pregnancies,and improv- ing the way society looks after pregnant women. Antenatal care is a success story:coverage throughout the world increased by 20% during the 1990s and continues to increase in most parts of the world.Concem for a good outcome of pregnancy has made women the largest group actively seeking care.Antenatal care offers the opportunity to provide much more than just pregnancy- related care.The potential to promote healthy lifestyles is insufficiently exploited,as is the use of antenatal care as a platform for programmes that tackle malnutrition, HIV/AIDS,sexually transmitted infections,malaria and tuberculosis and promote fam- ily planning.Antenatal consultations are the ideal occasion to establish birth plans that can make sure the birth itself takes place in safe circumstances.and to help mothers prepare for parenting
xx The World Health Report 2005 Over 300 million women in the world currently suffer from long-term or short-term illness brought about by pregnancy or childbirth. The 529 000 annual maternal deaths, including 68 000 deaths attributable to unsafe abortion, are even more unevenly spread than newborn or child deaths: only 1% occur in rich countries. There is a sense of progress, backed by the tracking of indicators that show increases in the uptake of care during pregnancy and childbirth in all regions except sub-Saharan Africa during the 1990s, but the overall picture shows no spectacular improvement, and the lack of reliable information on the fate of mothers in many countries – and on that of their newborns – remains appalling. Chapter 2. Obstacles to progress: context or policy? This chapter seeks to explain why progress in maternal and child health has apparently stumbled so badly in many countries. Slow progress, stagnation and reversal are clearly related to poverty, to humanitarian crises, and, particularly in sub-Saharan Africa, to the direct and indirect effects of HIV/AIDS. These operate, at least in part, by fuelling or maintaining exclusion from care. In many countries numerous women and children are excluded from even the most basic health care benefits: those that are important for mere survival. The specific causes, manifestations and patterns of exclusion vary from country to country. Some countries show a pattern of marginal exclusion: a majority of the population enjoys access to service networks, but substantial groups remain excluded. Other countries, often the poorest ones, show a pattern of massive deprivation: only a small minority, usually the urban rich, enjoys reasonable access, while an overwhelming majority is excluded. These countries have low density, weak and fragile health systems. The policy challenges vary according to the different patterns of exclusion. Many countries have organized their health care systems as health districts, with a backbone of health centres and a referral district hospital. These strategies have often been so under-resourced that they failed to live up to expectations. The chapter argues that the health district model still stands as a rational way for governments to organize decentralized health care delivery, but that long-term commitment and investment are required to obtain sustained results. Chapter 3. Great expectations: making pregnancy safer This chapter reviews the three most important ways in which the outcomes of pregnancies can be improved: providing good antenatal care, finding appropriate ways of preventing and dealing with the consequences of unwanted pregnancies, and improving the way society looks after pregnant women. Antenatal care is a success story: coverage throughout the world increased by 20% during the 1990s and continues to increase in most parts of the world. Concern for a good outcome of pregnancy has made women the largest group actively seeking care. Antenatal care offers the opportunity to provide much more than just pregnancyrelated care. The potential to promote healthy lifestyles is insufficiently exploited, as is the use of antenatal care as a platform for programmes that tackle malnutrition, HIV/AIDS, sexually transmitted infections, malaria and tuberculosis and promote family planning. Antenatal consultations are the ideal occasion to establish birth plans that can make sure the birth itself takes place in safe circumstances, and to help mothers prepare for parenting
overview XXi The chapter sets out critical directions for the future,including the need to improve the quality of care and to further increase coverage. Even in societies that value pregnancy highly,the position of pregnant women is not always enviable.In many places there is a need to improve the social,political and legal environments so as to tackle the low status of women,gender-based violence, discrimination in the workplace or at school,or marginalization.Eliminating sources of social exclusion is as important as providing antenatal care. Unintended,mistimed or unwanted pregnancies are estimated to number 87 million per year.There remains a huge unmet need for investment in contraception,informa- tion and education to prevent unwanted pregnancy,though no family planning policy will prevent it all.More than half of the women concerned,46 million per year,resort to induced abortion:that 18 million do so in unsafe circumstances constitutes a major public health problem.It is possible,however,to avoid all of the 68000 deaths as well as the disabilities and suffering that go with unsafe abortions.This is not only a ques- tion of how a country defines what is legal and what is not,but also of guaranteeing women access,to the fullest extent permitted by law,to good quality and responsive abortion and post-abortion care. Chapter 4.Attending to 136 million births,every year This chapter analyses the major complications of childbirth and the main causes of maternal mortality.Direct causes of maternal mortality include haemorrhage,infec- tion,eclampsia,obstructed labour and unsafe abortion.Childbirth is a moment of great risks,but in many situations over half of maternal deaths occur during the postpartum period.Effective interventions exist to avoid most of the deaths and long-term dis- abilities attributable to childbirth.The history of successes in reducing maternal and newborn mortalities shows that skilled professional care during and after childbirth can make the difference between life and death for both women and their newborn babies.The converse is true as well:a breakdown of access to skilled care may rapidly lead to an increase of unfavourable outcomes. All mothers and newborns,not just those considered to be at particular risk of de- veloping complications,need skilled matemal and neonatal care:close to where and how they live,close to their birthing culture,but at the same time safe,with a skilled professional able to act immediately when complications occur.Such birthing care can best be provided by a registered midwife or a professional health worker with equivalent skills,in midwife-led facilities.These professionals can avert,contain or solve many of the largely unpredictable life-threatening problems that may arise dur- ing childbirth and thus reduce maternal mortality to surprisingly low levels.But they do need the back-up only a hospital can provide to help mothers who present problems that go beyond their competency or equipment.All women need first-level maternal care,and only in a minority of cases is back-up care necessary,but to be effective both need to work in tandem,and have to be extended simultaneously.In many coun- tries uptake of postpartum care is even lower than of care at childbirth.This is an area of crucial importance with much scope for improvement. Chapter 5.Newborns:no longer going unnoticed Until recently,there has been little real effort to tackle the specific health problems of newborns.A lack of continuity between maternal and child health programmes has allowed care of the newborn to fall through the cracks
overview xxi The chapter sets out critical directions for the future, including the need to improve the quality of care and to further increase coverage. Even in societies that value pregnancy highly, the position of pregnant women is not always enviable. In many places there is a need to improve the social, political and legal environments so as to tackle the low status of women, gender-based violence, discrimination in the workplace or at school, or marginalization. Eliminating sources of social exclusion is as important as providing antenatal care. Unintended, mistimed or unwanted pregnancies are estimated to number 87 million per year. There remains a huge unmet need for investment in contraception, information and education to prevent unwanted pregnancy, though no family planning policy will prevent it all. More than half of the women concerned, 46 million per year, resort to induced abortion: that 18 million do so in unsafe circumstances constitutes a major public health problem. It is possible, however, to avoid all of the 68 000 deaths as well as the disabilities and suffering that go with unsafe abortions. This is not only a question of how a country defines what is legal and what is not, but also of guaranteeing women access, to the fullest extent permitted by law, to good quality and responsive abortion and post-abortion care. Chapter 4. Attending to 136 million births, every year This chapter analyses the major complications of childbirth and the main causes of maternal mortality. Direct causes of maternal mortality include haemorrhage, infection, eclampsia, obstructed labour and unsafe abortion. Childbirth is a moment of great risks, but in many situations over half of maternal deaths occur during the postpartum period. Effective interventions exist to avoid most of the deaths and long-term disabilities attributable to childbirth. The history of successes in reducing maternal and newborn mortalities shows that skilled professional care during and after childbirth can make the difference between life and death for both women and their newborn babies. The converse is true as well: a breakdown of access to skilled care may rapidly lead to an increase of unfavourable outcomes. All mothers and newborns, not just those considered to be at particular risk of developing complications, need skilled maternal and neonatal care: close to where and how they live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when complications occur. Such birthing care can best be provided by a registered midwife or a professional health worker with equivalent skills, in midwife-led facilities. These professionals can avert, contain or solve many of the largely unpredictable life-threatening problems that may arise during childbirth and thus reduce maternal mortality to surprisingly low levels. But they do need the back-up only a hospital can provide to help mothers who present problems that go beyond their competency or equipment. All women need first-level maternal care, and only in a minority of cases is back-up care necessary, but to be effective both need to work in tandem, and have to be extended simultaneously. In many countries uptake of postpartum care is even lower than of care at childbirth. This is an area of crucial importance with much scope for improvement. Chapter 5. Newborns: no longer going unnoticed Until recently, there has been little real effort to tackle the specific health problems of newborns. A lack of continuity between maternal and child health programmes has allowed care of the newborn to fall through the cracks