The Lancet Maternal Survival Series
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Making sure women throughout the world can give birth in a health facility, in the presence of a midwife, is the best strategy for substantially reducing maternal mortality worldwide, according to a landmark series of papers. The authors are calling on governments and donors to prioritize this strategy over alternatives, such as home births with a relative, traditional birth attendant, community health worker or midwife, to save the lives of over half a million women who die in pregnancy or childbirth each year. The five papers that form the The Lancet maternal survival series present the evidence for adopting the health centre strategy worldwide and detail the action required for its roll-out, including immediate priorities for governments and donors. The authors warn that without political commitment and investment into this approach, substantial declines in maternal mortality are unlikely in the next 10-20 years, and the fifth Millennium Development Goal-to reduce maternal mortality by 75 percent by 2015-will not be met. Maternal survival is closely linked to newborn and child survival, which is the fourth MDG.

Maternal mortality: who, when, where, and why
Ronsmans C, Graham WJ, on behalf of The Lancet Maternal Survival Series steering group (Vol. 368, Issue 9542, pages 1189-1200)
The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world compared with about one in 30,000 in Northern Europe. Such a discrepancy poses a huge challenge to meeting the fifth Millennium Development Goal to reduce maternal mortality by 75 percent between 1990 and 2015. Some developed and transitional countries have managed to reduce their maternal mortality during the past 25 years. Few of these, however, began with the very high rates that are now estimated for the poorest countries-in which further progress is jeopardized by weak health systems, continuing high fertility, and poor availability of data. Maternal deaths are clustered around labor, delivery, and the immediate postpartum period, with obstetric hemorrhage being the main medical cause of death. Local variation can be important, with unsafe abortion carrying huge risk in some populations, and HIV/AIDS becoming a leading cause of death where HIV-related mortality rates are high. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable-rural populations and poor people-is essential if substantial progress is to be achieved by 2015.

Strategies for reducing maternal mortality: getting on with what works
Campbell OM, Graham WJ, on behalf of The Lancet Maternal Survival Series steering group (DOI: 10.1016/S0140-6736(06)69381-1)
The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations of such a strategy and, using the best available evidence, prioritize one strategy based on delivery in primary-level institutions (health centers), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fifth Millennium Development Goal is to be achieved, then what needs to be prioritized is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal.

Going to scale with professional skilled care
Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, Achadi E, Adjei S, Padmanabhan P, van Lerberghe W, on behalf of The Lancet Maternal Survival Series steering group (DOI: 10.1016/S0140-6736(06)69382-3)
Because most women prefer professionally provided maternity care when they have access to it, and since the needed clinical interventions are well known, we discuss in their paper what is needed to move forward from apparent global stagnation in provision and use of maternal health care where maternal mortality is high. The main obstacles to the expansion of care are the dire scarcity of skilled providers and health-system infrastructure, substandard quality of care, and women's reluctance to use maternity care where there are high costs and poorly attuned services. To increase the supply of professional skilled birthing care, strategic decisions must be made in three areas: training, deployment, and retention of health workers. Based on results from simulations, teams of midwives and midwife assistants working in facilities could increase coverage of maternity care by up to 40 percent by 2015. Teams of providers are the efficient option, creating the possibility of scaling up as much as 10 times more quickly than would be the case with deployment of solo health workers in home deliveries with dedicated or multipurpose workers.

Mobilising financial resources for maternal health
Borghi J, Ensor T, Somanathan A, Lissner C, Mills A, on behalf of The Lancet Maternal Survival Series steering group (DOI: 10.1016/S0140-6736(06)69383-5)
Coverage of cost-effective maternal health services remains poor due to insufficient supply and inadequate demand for these services among the poorest groups. Households pay too great a share of the costs of maternal health services, or do not seek care because they cannot afford the costs. Available evidence creates a strong case for removal of user fees and provision of universal coverage for pregnant women, particularly for delivery care. To be successful, governments must also replenish the income lost through the abolition of user fees. Where insurance schemes exist, maternal health care needs to be included in the benefits package, and careful design is needed to ensure uptake by the poorest people. Voucher schemes should be tested in low-income settings, and their costs and relative cost-effectiveness assessed. Further research is needed on methods to target financial assistance for transport and time costs. Current investment in maternal health is insufficient to meet the fifth Millennium Development Goal (MDG), and much greater resources are needed to scale up coverage of maternal health services and create demand. Existing global estimates are too crude to be of use for domestic planning, since resource requirements will vary; budgets need first to be developed at country-level. Donors need to increase financial contributions for maternal health in low-income countries to help fill the resource gap. Resource tracking at country and donor levels will help hold countries and donors to account for their commitments to achieving the maternal health MDG.

Maternal health in poor countries: the broader context and a call for action
Filippi V, Ronsmans C, Campbell OM, Graham WJ, Mills A, Borghi J, Koblinsky M, Osrin D (DOI: 10.1016/S0140-6736(06)69384-7)
In this paper, we take a broad perspective on maternal health and place it in its wider context. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women's empowerment. We also consider outcomes beyond mortality, in particular, near-misses and long-term sequelae, and the implications of the close association between the mother, the fetus, and the child. We make links to a range of global survival initiatives, particularly neonatal health, HIV, and malaria, and to reproductive health. Finally, after examining the political and financial context, we call for action. The need for strategic vision, financial resources, human resources, and information are discussed.

Comments
Healthy motherhood: an urgent call to action
Horton R
(Vol. 368, Issue 9542, page 1129)

Safe motherhood initiative: 20 years and counting
Starrs AM
(Vol. 368, Issue 9542, pages 1130-1132)

Meeting MDG-5: an impossible dream?
Rosenfield A, Maine D, Freedman L
(Vol. 368, Issue 9542, pages 1133-1135)

Where is maternal and child health now?
Lawn JE, Tinker A, Munjanja SP, Cousens S
(DOI: 10.1016/S0140-6736(06)69387-2)

An alternative strategy to reduce maternal mortality
Costello A, Azad K, Barnett S

Women's wisdom-a source of knowledge for medicine
Malterud K - 30 September 2006
(Vol. 368, Issue 9542, pages 1139-1140)