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# **1.** INTRODUCTION

At the February 1987 Conference on Safe Motherhood in Nairobi', Herz and Measham (1987) presented a paper on 'The Safe Motherhood Initiative,* in which they proposed a new approach to reduce maternal mortality and morbiditv in developing countries. Herz and Measham noted that in spite of progress toward child survival and improvements in life expectancy, an estimated 500,000 women, 99 percent of them from the developing world, die each year from pregnancy-related causes-.

**About** three quarters of these deaths are the direct result of obstetrical complications -- hemorrhage, infection, toxemia, obstructed labor, and abortion (under primitive and illegal conditions). An estimated equivalent number of infants do not survive their mother's death. For surviving mothers, the consequences of pregnancy have a severe impact on health and family economics.

The proposed strategy for safe motherhood is based on two approaches. First, the encouragement of activities that indirectlv improve maternal health. These include education, policies to improve women's rights and working conditions, health care and nutrition, transportation and communication systems, water and sanitation facilities, and increases in family income and food production.

The second approach, which serves as the core strategy for the Safe Motherhood (SM) Initiative targets activities to reduce maternal deaths. These activities include reducing unwanted pregnancies through the provision of family planning services, and through national policies that recognize the importance of this issue (although Maine (1985) estimates that even if all unwanted pregnancies were avoided, only a fourth to two fifths of maternal mortality would be avoided).

A second objective is to reduce the risks of pr.gnancy through providing community-based family planning and prenatal services to identify high-risk cases' adequate referral services for the womplications of pregnancy, and communication and transport systems to support patient referral procedures.

Given the long history of support for maternal health by international bilateral, multilateral, and nongovernmental organizations (NGOs), the conference recognized that the limited progress in reducing maternal mortality and morbidity required moving to a svstems approach utilizing selected, targeted, core activities.

# II. TERMS OF REFERENCE

## A. _Purpose_

In response to a request from the Meeting of Interested Parties, which serves as the international forum for monitoring the Safe Motherhood Initiative, the World Bank has undertaken this study to measure aid flows for this program since the 1987 conference. The study is designed to measure financial trends and new initiatives in support of the program's objectives; identify issues of statistical methodology that may constrain the analysis, and establish a baseline fir 1988 against which to measure future financial trends.

A second objective of the study is to identify SM policies and programs among the major official sources of external financing. In view of the four-month timetable to cor.mplete this study, it concentrates on Official Development Assistance (ODA) and does not include nongovernmental and private contributions except for official contributions to nongovernmental organizations (NGOs)<sup>3</sup> .