Organization, and the World Bank. The Center for Population and Family Health at Columbia University, Family Care Intemational, the London School of Hygiene and Tropical Medicine and the MotherCare Project of John Snow, Inc., have also been very active in the initiative, through advocacy and information dissemination, research efforts related to the development of rele; an. policy and programs, and national-level technical assistance.

Among the documentation for the Nairobi conference was The Safe Motherhood Initiative: Proposals for Action, by Barbara Herz and Anthony Measham. This seminal document set out possible configurations for Safe Motherhood programs with varying components and assumed impacts, and attempted to determine their costs. This paper was developed as an advocacy tool for policy makers as well as a preliminary framework for technical/project level personnel, to encourage the collection of the basic data, and promote further work toward incorporating cost considerations into the program design process.

A number of other activities are underway which aim to generate more information for the development of programs. WHO manages the Safe Motherhood Operations Research Program (SMOR), for example, which seeks to identify ar.u ev--;iate ways to strengthen existing maternal health and related services. Columbia University has compiled a chartbook reviewing the evidence on pregnancy-related mortality and the efficacy of proposed remedial strategies, to help guide policy and program development and identify remaining research needs. Numerous other individuals, governments, NGOs and intergovernmental organizations are involved in research, advocacy, education, and policy and program development activities in the field.

# III. COMPONENTS OF A SAFE MOTHERHOOD PROGRAM

A concepwual framework for Safe Motherhood programs, incorporating efforts to address women's status (education, employment, changes in law and cultural practices), family planning, mratemity care, community mobilization and education, abortion, and health care for women, was presented as a general guide. There was considerable discussion on the extent to which the Initiative should focus on family planning as opposed to specific maternity care, as well as on the relative efficacy of the preventive and curative components of maternity care. The point was made that if the primary goal of the Initiative is to reduce maternal mortality, then in most settings maximum benefit will be derived from concentrating on the provision of matemity care. That is, programs should focus on reducing the risks associated with pregnancy and childbirth, thereby ensuring successful completion of desired pregnancies. In areas where contraceptive prevalence is low, however, the provision of family planning will have considerable impact on levels of maternal mortality by reducing the numbers of high risk and unwanted pregnancies and, especially, the incidence of unsafe abortions. This discussion highlighted the importance of identifying the goals (and the effectiveness measures) of a program prior to costing exercises.

Maternity care interventions are likely to work best when provided ,ointly. In other areas of the health field, such as Child Survival, much can be achieved through single interventions such as Oral Rehydration Therapy (ORT) and immunizations; in family planning, much can be accomplished by providing contraceptive supplies. In the case of maternal mortality, however, 6