Traditionally, decisions about program design have 'Jeen based on assumptions regarding the potertial impact of alternative strategies. Maximizing the benefit of scarce health resources, however, requires that cost be considered along with effectiveness in program design. Resource constraints, existing infrastructure, the skill levels of health personnel, and other issues will also affect the ideal balance of further investments. In particular, it is essential that Safe Motherhood goals be united with broader health sector objectives, and that related remedial strategies be integrated with existing programs.

The goal of this workshop was to lay the groundwork for incorporating cost data into the decision-making process. However, one of the major barriers to designing programs on the basis of cost-effectiveness is lack of accurate knowledge of the effectiveness of many interventions, as well as lack of knowledge of their costs. At its simplest, a costing methodology would provide guidelines for estimating the costs of prospective programs, once designed. When combined with information on effectiveness, it could be used to give planners an indication of the potential results achievable through a variety of Safe Motherhood program options or combinations of interventions, subject to the resources at their disposal.

The first step in the development of a cost-effectiveness model is to attempt to define the relationship between the resources used and program outcomes, (reductions in maternal mortality, for example.) This relationship is difficult to define in the health sector, and perhaps more difficult in Safe Motherhood. The most important direct causes of maternal mortality are hemorrhage, pregnancy-related hypertension, infection, obstructed labor and the sequelae of unsafe abortion. These problems stem not only from inadequate health and family planning services, but also from the social, cultural and economic environment in which women live. As a result, the largest reductions in maternal mortality could be achieved through a combination of socioeconomic change and direct health sector interventions. The relative effectiveness of health-sector interventions and non-health sector interventions, of different levels of the health care system, and of different interventions, however, is a subject that generates continued debate. There is now growing consensus that direct maternal health care and family planning interventions will have the most impact in the short term, though changes in women's status are important long-term goals. Accordingly, efforts should focus on ensuring the availability of a carefully coordinated set of interventions at the community and referral levels, to prevent pregnancy, to prevent matemal complications, and to recognize and efficiently treat them when tLey occur.

There is little consensus, however, on which matemal care interventions are most effective, nor on the ideal balance between them. Indeed, the efficacy of many interventions is not yet proven. If matemal health care is indeed the most effective means of reducing maternal mortality, to what extent should resources be concentrated on providing emergency obstetric care to women suffering complications during delivery, or on preventing or managing these complications through improved, routine pre-natal and delivery care and community-level education on the issues surrounding pregnancy? What are the components of an ideal pre-natal care program? To what extent should resources be concentrated on training traditional birth attendants, increasing the number of trained midwives, or on improving the distribution of 4