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The Inter-country meeting entitled 'The Safe Motherhood Initiative in the Eastern Mediterranean Region: A decade after Nairobi' was held in Sanaa during 3-6 May. The purpose was to review what has been achieved of the commitments made in the Nairobi conference in 1987.
Participants came from Egypt, Iran, Iraq, Jordan, Lebanon, Libya, Oman, Pakistan, Palestine, Saudi Arabia, Sudan, Syria, Tunisia, the UAE, and Yemen. From outside the region, participants from Sweden, the USA and representatives of the World Health Organization (WHO) joined in. The issues addressed included maternal and neo-natal mortality, morbidity, and other aspects of reproductive health. At the end of the gathering, possible solutions were suggested.

The Nairobi Conference in 1987 is regarded as a historic milestone in the global attempt to bring the tragedy of maternal mortality under control. The Safe Motherhood Initiative generated global hope that its outcome will be a turning point in controlling the most deplorable tragedy of maternal mortality. Today, despite all efforts, safe motherhood is not assured for a large percentage of women in the countries of the Eastern Mediterranean Region. However, there is still hope, that with political will at the highest level of commitment, with social mobilization and strengthened strategy, the goal will be reached.
Some of the key participants told Yemen Times the following:

1) Minister of Health, Dr. Abdullah A. Nasher:
"The Nairobi conference of 1987 launched the Safe Motherhood initiative. Its declared target is to reduce maternal and infant mortality by 50% by the year 2000. As a result, countries in the region have taken exceptional steps to implement appropriate policies and strategies to attain the target.

"About 99% of maternal mortality is in developing countries. Since there are no national statistics in Yemen, estimates indicate that infant mortality ranges between 800 to 1,400 deaths per 100,000 births.
"It is also estimated that one woman in eight dies from complications during pregnancy and/or delivery or shortly afterwards."

2) Dr. Cynthia Myntti, Ph.D. MPH, American University of Beirut:
"Yemen, like other countries of the Middle East, places the highest value on motherhood. Mothers are the heart, the soul, the moral core, of society. This value is reinforced in prophetic tradition (Hadith al-Nabawi) with verses such as "Heaven is at the feet of mothers".

"Yet motherhood - that is, in this case specifically pregnancy and childbirth - is not safe in many parts of the world. In this region alone, an estimated 68,000 women die each year of maternity-related causes. Unfortunately Yemen has one of the highest levels of maternal mortality in the region and in the world. An estimated 1400 women die for every 100,000 live births in Yemen.
"We know that approximately 15% of all pregnancies will develop complications that are life threatening. We also know that it is very difficult to predict who these 15% will be. Therefore essential obstetric services must be in place to offer all women the life-saving care they need.
"We need to also address socio-cultural factors that affect the situation. Until now, much of the analysis has focused on the inner most circle - the pregnant woman: her beliefs, practices, perceptions, attitudes, preferences, and priorities. But we also need to examine these same issues at all levels of the social system, including within the family, community, health care system, and national political institutions.
"To move ahead, now in the second decade of the safe motherhood initiative, it is my recommendation that we:
1- focus on this 15% of women we are failing, and
2- concentrate on the two outermost layers of the social system. Specifically, this means giving more resources to ensuring better coverage and improved quality of obstetric services."

3) Dr. Abdul-Majeed Bu Aliu from Morocco:
"We participated with a number of documentary films and a theatrical play dealing with maternal mortality and mother and child health. We in Morocco have a rich experience in this field, and we are eager to share it with others. I am sure this conference was a good opportunity for that purpose."

4) Dr. Carla Abu Zahar of the WHO, Geneva:
"There are three main reasons for holding this conference in Sanaa:
- The Yemeni government, represented by the Ministry of Health, expressed readiness to improve mother and child health conditions in Yemen;
- There are numerous challenges facing those who are pushing for change in this country; and
- There is a large group of health workers in Yemen who could benefit from such a gathering.
"This has made the organization of the conference at a high level and has contributed to an excellent presentation. Discussions concentrated on what has been achieved during the last 10 years since the Nairobi conference. Some countries in the region such as Jordan, Tunisia and Morocco have witnessed great improvements in mother and child health and a marked decrease in maternal and infant mortality. Other countries are still in need of more attention, including Yemen."

5) Ms. Shaheenaz Mandhoor, Director of Mother and Child health Care, Pakistan:
"Although maternal mortality in Pakistan is low, compared to other countries in the region, it is quite high by international standards. This conference has provided us with a great opportunity to meet other experts and discuss with them relevant issues.
"I hope the next conference will be held in Pakistan, where only 1% of the national revenue is allocated to health; while, it is more than 4% in Yemen. It is clear that the people and government of Yemen are strongly committed to implementing a comprehensive health program."

6) Dr. Ghada Hafidh, Director of the Health Enhancement and Protection at the WHO Eastern Mediterranean Bureau:
"The aim of this conference is to save mothers from death, disease and other complications during pregnancy, delivery and shortly thereafter.

"Yemen was chosen because it is an Arab country that has the desire to catch up with the rest of the world. There is a challenge. The Minister of Health indicated that delivery and other maternity services are provided free of charge at public hospitals.
"Yemen needs its women to be in good health so as to be able to fully participate in the development process. So this country should be supported with education and expertise. Yemen was also chosen because it has not been able yet to reduce or control maternal mortality rates.

"Many experts have come to Yemen to discuss health risks and problems. Their ideas will be presented to the Minister of Health and the President of the Republic because safe motherhood is vitally important for the development of the country.
"The WHO, of which Yemen is a member, is implementing several programs and providing experts to help formulate plans and train staff in this country. We are now trying to form a working committee to be named the Safe Motherhood Committee. It will be formed by people from different sectors, including the media and information which is very important for raising public health awareness."

7) Dr. Abdul-Wahab Makki, Prof. of Mother and Child Health at the College of Medicine, Sanaa University, and WHO Program Officer in Yemen:
"This conference was very important given its concern with safe motherhood in Yemen. Infant mortality in this country is around 80 deaths per 1,000; while, it is 7 per 1,000 in developed countries.

"Essential suggestions were made by the participants regarding decision making, improving doctors' abilities, and increasing societal participation in enhancing mother and child health."

8) Dr. Jane Haile, Deputy Regional Director of the UNICEF Eastern Mediterranean and North Africa Bureau, Jordan:
"I visited Yemen several times before. My paper deals with discrimination against women in civil rights, education, marriage, etc.

"I stressed that safe motherhood does not merely mean good health services and facilities. It includes various other aspects such as social concerns.
"Yemen has signed the Woman's Convention, so the UNICEF regularly receives evaluations of the decisions and policies taken in this regard. There are special programs in this country working towards safe motherhood. A joint project, with the Ministry of Health, brings together many local and international experts."

9) Dr. Tomris Turman, Executive Director of Family and Reproductive Health, WHO:
"More than 1,600 women die every day - one woman per minute - worldwide because of pregnancy or delivery complications. That is, 580,000 women die every year because of these complications. In addition, 85 million infants also die during or after delivery due to lack of hygiene and proper health services. Mortality rates in developing countries are 18 times higher than in developed ones.
"Moreover, around 18 million women become affected with handicaps and serious diseases due to lack of good health services."

10) Dr. Brian McCarthy, Director of the Atlanta Institute, USA:
"I presented a pper entitled 'Use of maternal and pre-natal surveillance in the management of safe motherhood programs.' I concentrated on three important points:

1- The importance of managing and directing mother and child health services;
2- Researching the causes of maternal mortality in society so that they can be avoided in the future by providing the necessary health facilities and training for health workers; and
3- Establishing a system of constant surveillance to monitor maternal mortality in society, follow-up the progress made, and make sure that health care measures taken are the appropriate ones, and to look for better measures in case of no improvement.
"This conference will have positive reflections on the rates of maternal mortality not only in Yemen, but in the rest of the region as a whole. The most important area of cooperation is technical surveillance and establishing a program to research case of maternal and infant mortality.
"The Atlanta Institute intends to organize a national workshop for the staff of the Ministry of Health. It is very important that the Ministry should seriously consider the recommendations of this conference."

11) Dr. Najeeba Abdulghani, Director of Reproductive Health at the Ministry of Health:
"This conference has been very successful. I hope our policy/decision-makers will use the discussed strategies and plans.

"A national action plan must be adopted by this country in view of the conclusions and recommendations of this conference. Emergency health services must be available in all parts of the country.
"Midwives and health staff must be fully trained so as to be more capable in dealing with emergency situations. Facilities must also be provided to look after women during their pregnancy term.
"WHO should control funds, the network of experts, monitoring and evaluation so that it will be able to allocate the necessary funds to each country according to its needs. Less developed countries such as Yemen can then have better financial allocations. Individual governments should also chip in, and do not rely exclusively on donor countries and organizations."

MAJOR CONCLUSIONS
The conference issued the following conclusions:

1. During the decade that has passed, our knowledge about the dimension of maternal mortality, its major causes and socio-economic and cultural determinants has significantly increased. At the same time, unsafe motherhood dominates the life of millions of women in our region, especially among those who are socio-economically deprived.

2. A positive aspect of the existing maternal and child health promotion measures is the parallel efforts to reduce infant and under-five child mortality in most countries of the region. These have yielded satisfactory results in most cases. However, maternal and neo-natal mortality rations have not shown a comparable response.

3. Measuring maternal mortality is a difficult and complex task, especially in those countries where vital registration system is either absent or not fully developed. It is for this reason that reliable estimates of the dimension of the problem of maternal mortality is not generally available nor is it possible to assess the impact of interventions in order to reach set goals.

4. During the past decade, several tested and simple technologies have been put into operation in most countries to ensure safe motherhood, mainly through ante-natal care.

5. The two powerful steps to cut down maternal and neo-natal mortality are Essential Obstetrical Care and Mother-Baby Package.

6. The major constraint in establishing Essential Obstetric Care is the inadequacy of persons with appropriate training in obstetric and gynecology in peripheral areas of many countries.

7. To a large extent, Traditional Birth Attendants, assist deliveries in most countries of the region, especially in the rural sector. Efforts are constantly being made to have them appropriately trained.

8. Referral services is an essential component of the Safe motherhood Strategy. Responding to the urgent need of pregnant women at the time of delivery with obstetric complications, will need a hierarchy of supportive services-inter-linked with each other.

9. Maternal mortality, morbidity and unsafe motherhood, are clear examples of social injustice, and at the root of which is discrimination against women.

10. Creating awareness of the tragedy of maternal mortality among the women themselves, their families, the communities and policy and decision-makers, will be an urgent step to initiate collaborative efforts for ensuring safe motherhood.

11. Considering maternal mortality as a health problem, and that ameliorative actions taken by the health sector will overcome the tragedy, is not a justified approach to ensure safe motherhood for all women.

12. There are some countries in the region which have good vital registration system, but there are others with inadequate or no system at all.

GENERAL RECOMMENDATIONS:
The conference announced the following recommendations:

1- There must be a network of experts with members from the Eastern Mediterranean region to be able to assist all countries concerned with formulating policies and strategies to reduce maternal mortality levels.

2- There must be a special fund to support safe motherhood in the region to provide safe motherhood projects with the necessary finances.

3- There must be continuous surveillance, follow-up and evaluation of safe motherhood indicators so that each country can assess its successes.

Ahlam Al-Mutawakil, Yemen Times.