Global Issue Two Decades of the Safe Motherhood Initiative Time for Another Wooden Spoon Award? Alan T. N. Tita, MD, PhD, Jeffrey S. A. Stringer, MD, Robert L. Goldenberg, MD, and Dwight J. Rouse, MD, MSPH After two decades of the Safe Mother- hood Initiative, meaningful reductions in maternal mortality and disability during pregnancy and childbirth in de- veloping countries have not been real- ized. Herein, we present an overview of the Initiative and review the reasons for this lack of impact, focusing on the issue of strategic effectiveness. An ap- praisal of strategies that are currently recommended reveals a lack of strong evidence to support their effectiveness. Drawing from the Initiative’s history, we propose that, among essential ele- ments to achieve safe motherhood, recommended public health strategies should be supported by good evidence of effectiveness, through (cluster) ran- domized trials when feasible, before their widespread implementation. (Obstet Gynecol 2007;110:972–6) T his year marks the 20th anniver- sary of the Safe Motherhood Ini- tiative to redress the neglected and disproportionate problem of pre- ventable maternal mortality in devel- oping countries. 1–2 Strategies origi- nally formulated to achieve the stated goal to reduce maternal mor- tality by 50% within one decade in- cluded the provision of appropriate prepregnancy care, family planning, good prenatal care (including ade- quate nutrition and detection and referral of high-risk patients), the as- sistance of a trained attendant at birth, and access to essential obstetric care for women at risk of complica- tions. 3 Government commitment, community mobilization, and ongo- ing research and program evaluation were also emphasized. Since the Initiative was launched, interval and current estimates of ma- ternal mortality and other complica- tions of childbirth reveal that the situation for mothers in developing countries is as dire as 20 years ago. Although in many settings, accurate measurement of maternal mortality is difficult to make, owing to incom- plete ascertainment of both births and maternal deaths, it is estimated that about 530,000 women continue to die annually as a complication of pregnancy and child birth. 4 About 99% of these deaths are in develop- ing countries. In Sub-Saharan Africa, on average, about one woman dies for every 100 live births compared with 1 out of 5,000 births in the developed countries. The magnitude of this disparity is further amplified by generally higher birth rates in developing countries: a woman’s life time risk of maternal death is 1 in 16 in Sub-Saharan Africa versus only 1 in 2,800 in North America and Eu- rope. Even worse is that for each maternal death, thousands of moth- ers suffer preventable morbidity such as hemorrhage, sepsis, and ob- structed labor, which frequently re- sults in long-term disability such as infertility, urinary and/or fecal in- continence, and fistulae. Even in this era of the human immunode- ficiency virus (HIV)/acquired im- munodeficiency syndrome (AIDS) pandemic, maternal mortality re- mains the public health indicator with the highest discrepancy, in relative terms, between developing and developed countries. Further- more, maternal mortality is directly associated with perinatal and early childhood mortality, which are also disproportionately higher in devel- oping countries. See related editorial on page 968. From the Center for Women’s Reproductive Health and Maternal–Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; and Department of Obstetrics/Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania. Dr. Tita was funded by the National Institutes of Health Framework Program for Global Health, UAB Sparkman Center for Global Health. The authors thank A. Metin Gulmezoglu, MD, PhD, (UNDP/UNFPA/WHO/World Bank Special Pro- gramme of Research, Development and Research Training in Human Reproduction, World Health Organization) for contributing to earlier drafts of this manuscript. Corresponding author: Alan Thevenet N. Tita, MD, MPH, PhD, Department of Obstetrics and Gynecol- ogy (MFM Division), University of Alabama at Birmingham, 618 20th Street South, Birmingham, AL 35233; e-mail: Alan.Tita@obgyn.uab.edu. Financial Disclosure The authors have no potential conflicts of interest to disclose. © 2007 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/07 972 VOL. 110, NO. 5, NOVEMBER 2007 OBSTETRICS & GYNECOLOGY