prenatal and delivery care at the community level need to bc combined with essential obstetric care and alarm and transport systems to ensure that women receive this care in time. It is not an issue of prenatal versus referral level mare. Because indivi;dual program components operate synergistically, it is important to look at the cos -effectiveness of a variety of packages reflecting different balances of all components, rather than determine the cost-effectiveness of individual components. Some workshop participants argued that the entire package must be implemented simultaneously. Others felt that if a choice between components had to be made, emergency obstetrics should receive priority. Still others felt that while the whole package was desirable, a phased approach beginning with prevention and management at the community level would provide significant benefits even in the context of poorly developed referral-level care. A recent program in the Matlab district of Bangladesh, for example, where trained midwives were posted in the community, brought about a 68% reduction in matemal mortality in only three years.

This discussion of program components and priorities was supplemented by the presentation of an "epidemiological program-level model" of maternal mortality based on the five leading direct causes of death (hemorrhage, infection, abortion, obstructed labor, and eclampsia), which is being developed at WHO. The model relates maternal d.eaths from a specific cause to the following: demographic indicators (e.g. population, married women of reproductive age); indicators of pregnancy rates, wanted and unwanted (e.g. proportion of sexually active women, abortion ratio); rates of pregnancy-related complications (e.g. severe anemia); proportion of births attended by different categories of health care providers; prenatal care coverage indicators; indicators of mortality by cause of death; and relative risk of mortality for women with specific risk factors (e.g. relative risk of mortality for women suffering cephalopelvic disproportion).

Preliminary results from the WHO clinical model emphasize the important link between screening and referral, suggesting a need to move essential obstetric care (EOC) closer to the community level. Not only is quality EOC only available at the pinnacle of the health system in many settings, the essential link between communities and the district level (the health center level) is often weak, making it difficult to ensure that complicated cases and emergencies are effectively referred even when EOC is available. The number of midwives, in both absolute and relative terms, is falling, making this link less functional. It must be reiterated, however, that certain complications of pregnancy and childbirth could be prevented and/or managed at the community level.

Each cause of maternal death has many potential underlying causes. Sound program design and resource allocation decisions are impaired by the fact that we do not know the proportion of hemorrhage deaths, for example, that are attributable to severe anemia, abortion, retained placenta, placenta previa, etc. Some of these conditions can be prevented or dealt with effectively by non-physicians at the community level. Others require more sophisticated equipment and the attention of a physician, and must be dealt with at higher levels of the health system. Lack of informatio.: on the proportion of deaths attributable to each underlying cause impairs our ability to determine where limited resources should be concentrated to achieve maximum impact.

7