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Strengthening maternal and child health programmes through primary health care. Guidelines for countries of the Eastern Mediterranean Region. Based on the deliberations of the Intercountry Meeting on the Integration of MCH into Primary Health Care, Amman, Jordan, 11-15 December 1988.
Alexandria, Egypt, WHO, EMRO, 1991. 75 p. (WHO EMRO Technical Publication No. 18)All countries in the WHO Eastern Mediterranean Region (EMRO) have had maternal and child health (MCH) programs for many years, yet maternal mortality and morbidity and infant mortality remain high. The EMRO office in Jordan, recognizing this dilemma, convened a meeting of national managers from the 22 EMRO member states to discuss how to integrate MCH programs with primary health care (PHC). The meeting resulted in the publication of guidelines and goals to help each country integrate MCH into PHC which would strengthen MCH services and improve MCH status. The managers noted the need to switch from a pregnancy-oriented approach to a holistic approach in which MCH/PHC programs and society consider women as more than childbearers. MCH/PHC programs and society need to be concerned about the well-being of females beginning with infancy and should place considerable health promotion for girls during the pubertal spurt and adolescence. They should also promote prevention of iron deficiency anemia in women. Since maternal mortality is especially high is EMRO, the national managers clearly laid out approaches for health services to reduce maternal mortality caused by obstetrical complications. They also recognized the need for a practical alternative to obstetric care provided by health workers--training traditional birth attendants in each village. They also provided guidance on improving prenatal care to reduce perinatal and neonatal mortality such as vaccination of every pregnant woman with the tetanus toxoid. Since the causes of death in the postneonatal period, MCH/PHC programs need to take action to reduce malnutrition and infection. For example, they must promote breast feeding for at least the first 6 months of life. The managers suggested the implementation of the Child Survival and Development Strategy which includes growth monitoring.
Amsterdam, Netherlands, WGNRR, 1991. 48 p.This report summarizes the activities of the Women's Global Network for Reproductive Rights (WGNRR), an organization that campaigns to reduce maternal mortality and morbidity, during 1991. In addition to its summary of activities, the report provides examples of local, national, and regional activities which illustrate the efforts of WGNRR's campaign. The report explains that the organization has succeeded in establishing May 28 as the Day of Action for Women's Health. For 1992, WGNRR hopes to make the issue of adolescent mothers the focus of the Day of Action. Having presented excerpts of Martha Rosenberg's paper entitled "Rethinking maternity: a women's task" (presented at the University of Salamanca, Spain on September 1990), the report goes on the describe the work done by WGNRR groups. As an example of a local initiative, the publication discusses the efforts conducted in Tanzania to end sexual harassment. This topic became the focus of the Day of Action. The Tanzania Media Women's Association held a seminar do discuss issues such as rape, media images of women, violence, and harassment in the workplace. The report goes on to describe a national campaign conducted in Chile, a campaign entitled "I am a woman. . . I want to be healthy," which focused on women's demands to humanize health care. For its regional experience, the report discusses accomplishments of the First Regional Workshop on Maternal Mortality, held in Managua in April 1991. The workshop attracted participants from Belize, Costa Rica, the Dominican Republic, Guatemala, Mexico, and Nicaragua. The report also includes an evaluation of the campaign conducted in Lima, Peru. Finally, the report presents excerpts of letters and reports of activities conducted by member groups around the world.
Safe motherhood: priorities and next steps. Forward-looking assessment on the reduction of maternal mortality and morbidity within the framework of the Safe Motherhood Initiative: (SMI).
[New York, New York], United Nations Development Programme [UNDP], 1991 Apr. , viii, 40,  p.Women in Development is one of six key policy areas for the UN Development Program's (UNDP) next programming cycle. UNDP acknowledges the hazards of pregnancy and childbirth that rob society of women society at the height of their productivity. It has supported the Safe Motherhood Initiative (SMI) from its inception to reduce maternal mortality and morbidity in developing countries. UNDP reviewed its contributions at the global, regional, and national levels within the framework of SMI to determine its contributions during the 1990s. A three-person, multidisciplinary team conducted a forward-looking assessment which included interviews with 200 persons in UN and bilateral donor agencies and nongovernmental organizations, a survey of UNDP staff in developing countries, and visits to Senegal and Indonesia. The team assessed progress that has been made in policies, programs, resources, coordination, research, technical cooperation, and information. UNDP support helped initiate SMI. Its support of SMI conferences has increased awareness and political commitment. UNDP contributes funds to WHO's Safe Motherhood Operations Research Programme. Some of its SMI projects will likely achieve significant improvements in maternal health. UNDP support in Senegal and Indonesia allowed the first national needs assessments and action plans in the SMI. The team found that funding of needs assessments and action plans is constructive. It agreed with UNDP's policy of pooling its support with that of other donors. It found the present organization and structure through which UNDP funds are implemented to be appropriate. It recommended that UNDP continue to contribute to SMI. It suggested that UNDP take the lead role in establishing the International Partnership to Prevent Maternal Deaths and Disability as a mechanism to take the SMI into its next phase of translating the increased concern and technical know-how into increased safe motherhood activity at the country level.
Regional Resource Group on Safe Motherhood for Francophone African Countries. Safe Motherhood in Francophone Africa: a Review of Progress to Date, Abidjan, Cote d'Ivoire, September 10-12, 1991.
Washington, D.C., World Bank, 1991. 36 p. (Partnership for Safe Motherhood)The Regional Resource Group on Safe Motherhood for Francophone African Countries met in Abidjan, Cote d'Ivoire, in September 1991 to review the progress of safe motherhood programs in French speaking African countries. The World Bank continues to support the integration of safe motherhood efforts within existing health, population, nutrition, and other social sector programs. Participants reviewed the findings of the World Bank Survey on Safe Motherhood which included limited data on maternal morbidity, leading causes of maternal death, interconnectedness of women's health and status, and major obstacles to safe motherhood. These obstacles include lack of political commitment, limited national and local interest in reducing maternal deaths, inadequate maternal health services, and shortage of trained health personnel. The participants reached a consensus that safe motherhood interventions should meet four objectives: preventing unplanned pregnancy, managing unwanted pregnancy, reducing the likelihood of complications during pregnancy and labor, and improving the outcome of women developing such complications. Priority services should include family planning and management of abortions, essential services for safe pregnancies (prenatal, intrapartum, and postpartum care), and services for the management of obstetrical emergencies. The Resource Group agreed that each country needs to determine its own priorities and unique approach to achieving safe motherhood. The first step is a strong national political commitment for safe motherhood through the adoption of a national policy and strategy. The Group classified the countries into six different groups, the most advanced group being countries where a political commitment exists and the basic components of a maternal health care program are implemented through an integrated health service delivery system. The next meeting of the Group will be in Kigali, Rwanda, in 1992. The meeting's report has a case study of safe motherhood in Senegal.
TIDSSKRIFT FOR DEN NORSKE LAEGEFORENING. 1991 May 30; 111(14):1729-33.The 4 cornerstones of reproductive health according to the WHO are family maternal care neonatal and infant care, and the control of sexually transmitted diseases. In recent years, the AIDS epidemic has caused concern in the world. The world's population doubled to 4 billion from 1927 to 1974, and it will reach 6 billion by the year 2000. The rate of growth is 1.4% in China and 2% in India vs. .3% in Europe. Contraceptive prevalence is 15-20% in Africa, 30% in South Asia, and 75% in East Asia. Shortage of contraceptives leads to abortion in eastern Europe. In 1985 in the USSR, there were 115.7 abortions/1000 women (mostly married) aged 15-44; and 6.4 million abortions for 5.5 million births in 1989. RU-486 or mifepristone combined with prostaglandin has produced abortion in 90% of first trimester pregnancies. After approval in France in 1987, it was used in 40,000 abortions in the following year. 90% of the estimated annual 500,000 maternal deaths occur in developing countries. In Norway, the rate is fewer than 10/100,000 births vs. 100/100,000 in Jamaica. In the mid-1980s, 26% of rural women in Thailand, 49% in Brazil, 54% in Senegal, and 87% in Morocco went without maternal care. In Norway, infant mortality is 6-8/1000 live births vs. 75-150/1000 in developing countries. A WHO investigation on causes of infertility in 25 countries found a 31% rate of tubal pathology in 5800 couples. In Africa, over 85% f infertility in women was infection related. Venereal diseases and infertility are associated with premarital sexual activity in young people. Various donor agencies and the WHO Special Program of Research, Development, and Research Training in Human Reproduction are providing help and resources including AIDS research.
POPULATION AND DEVELOPMENT REVIEW. 1991 Dec; 17(4):749-51.The report of the Secretary General of the UN on the social and economic conditions in Africa notes the worsening of conditions during 1986-90. Declines were apparent in education, health, nutrition, employment, and income. Government spending on health declined from 6% in 1985 to 5% in 1990 and on education from 15% to 11%. School enrollment declined from 77% in 1980 to 72% in 1987 and 70% in 1990. Primary school enrollments were also affected; i.e., only 65% of those enrolled in 1986 were still in school in 1990. Illiteracy rates dropped from 59.1% in 1985 to 52.7% in 1990, but the absolute numbers rose from 133.6 million to 138.8 million. Female illiteracy is very high at 66% compared to 46% for males. Government funding cuts have also had an impact on nutrition. There were 70 million more severely undernourished Africans in 1989 than in the mid 1970s (80 million), and 40% of preschool children suffered from acute protein energy deficiency, which is an increase of 25% from 1985. There was evidence of large numbers of underweight (26.6%), wasting (10.2%), and stunted children )53.3%). Diseases such as malaria, trypanosomiasis, and schistosomiasis, which had been under control or eradicated reappeared. The <5 years mortality rate remained stable and high at 182/1000. Improvements have been made in expansion of immunization, 22 countries achieved 75% immunization in 1990. There were fewer deaths from measles and diarrheal diseases. Maternal mortality remains high at 1120/1000. AIDS is a serious social problems. By 1991, 6 million people had been infected with HIV including 3 million women an increases are expected. 900,000 HIV-infected babies were born as of 1990. The number of AIDS orphans is increasing. Real wages declined by 30% during the 1980s, and unemployment grew an average of 10%/year between 1986-90. Formal sector employment stagnated, and informal sector employment showed tremendous increases. Substance farming became a survival strategy. Poverty has affected as much as 50% of the African population. Brain drain emigration has resulted in the loss of an estimated 50-60,000 people. For Africa, the future emphasis will be on efficacy, tough minded realism, self-reliance, and grassroots initiatives.
Geneva, Switzerland, WHO, 1991. vii, 72 p.Members of WHO's Technical Working Group on Essential Obstetric Functions at First Referral Level have prepared a book geared towards district, provincial, regional, national, and international decision makers, particularly those in developing countries, whose areas of expertise include planning, financing, and organization and management of obstetric services. The guidelines should allow them to improve referral services' standards at the district level. They should also help them decide how far and by what means they may possibly expand some of these services to more peripheral levels, e.g., renovating facilities and improving staff. When developing these guidelines, WHO took in consideration that many countries confront serious economic obstacles. The book's introduction briefly discusses maternal morbidity and mortality in developing countries and maternity care in district health systems. The second chapter, which makes up the bulk of the book, addresses primary components of obstetric care related to causes of maternal death. This chapter's section on surgical obstetrics examines cesarean section and repair of high vaginal and cervical tears among others. Its other sections include anesthesia, medical treatment, blood replacement, manual procedures and monitoring labor, family planning support, management of women at high risk, and neonatal special care. The third section provides guidelines for implementation of these services, including cost and financial considerations. It emphasizes the need at the first referral level to have the least trained personnel perform as many health care procedures as possible, as long as they can do so safely and effectively. Other implementation issues are facilities, equipment, supplies, drugs, supervision, evaluation, and research. Annexes list the required surgical and delivery equipment, materials for side ward laboratory tests and blood transfusions, essential drugs, and maternity center facilities and equipment.
Rapid anthropologic assessment: applications to the measurement of maternal and child mortality, morbidity and health care.
[Unpublished] 1991. Presented at the International Union for the Scientific Study of Population [IUSSP] Committee on Population and Health and Cairo University Institute of Statistical Studies and Research, Center for Applied Demography Seminar on Measurement of Maternal and Child Mortality, Morbidity and Health Care: Interdisciplinary Approaches, Cairo, Egypt, November 4-7, 1991. 14 p.University Nations University (UNU) leaders requested rapid anthropological assessment procedures (RAP) guidelines in the early 1980s to examine health-seeking behavior in 16 developing countries. They were not content with the expense, time, and poor accuracy of standard survey techniques to study health care. UNU project researchers studies 42 communities in these countries. They used triangulation to assess the validity of their data and found the data to be accurate. RAP involves applied medical anthropologists and other social scientists with appropriate training to pass about 6 weeks in a community where a supposed effective primary health care (PHC) programs operates to learn the household and community perspective on PHC services. 6 weeks constitute a long time for health planners and policymakers, but for anthropologists this time period tends to be too. Yet the required time hinges on the amount and complexity of data needed. It is important that the anthropologists and/or other social scientists already know the language and the culture because they interview biomedical and indigenous health providers. RAP depends on limited objectives and on existing data and prior research. Research designers should modify the limited objectives or data collection guidelines to fit each culture and each project. RAP data collection techniques include formal and informal interviews, conversations, observation, participant observation, focus groups, and data collection from secondary sources. Indeed researchers should be able to adapt these various techniques during the project. Obstacles which RAP research designers must consider are: some anthropologists do not feel at ease with RAP; not all cultures are comfortable with an outsider coming into their community asking questions, thus highlighting the importance of using an anthropologist already known and trusted in the community; and the topic may not be appropriate for discussion in a community.
Maternal mortality and the right of the child to survival, protection and development. Perspectives on southern and eastern Africa in light of international law.
In: The effects of maternal mortality on children in Africa: an exploratory report on Kenya, Namibia, Tanzania, Zambia, and Zimbabwe, [compiled by] Defense for Children International-USA. New York, New York, Defense for Children International-USA, 1991. 97-143.How international law documents such as the Convention on the Rights of the Child establish a legal framework within which to promote child survival in Southern and Eastern Africa, emphasizing the documents' significance for maternal mortality, the most important factor affecting child survival, is examined. In November 1989, the UN General Assembly unanimously adopted the Convention, a comprehensive treaty that establishes the rights of children and their families, outlining the responsibilities of governments and adults in securing those rights. By September 1990, most countries in Southern and Eastern Africa had ratified the treaty; the remaining countries had pledged to approve it. The Convention not only obligates governments to allocate greater resources to the most vulnerable members of society, but also requires a higher level of international cooperation, including greater commitment from industrialized countries and greater participation at the grassroots level. The economic, social, and cultural dimensions of maternal mortality and its impact on child survival are discussed, as well as the maternal and child survival issues addressed by the Convention: 1) maternal-child health services; 2) traditional practices harmful to the mother and child (in this case, female circumcision and child marriage); and 3) survival and development through international cooperation. The implications of the Convention on the primary health care model are also discussed. The impact of other international documents on maternal mortality and child health is examined.
[Unpublished] . 100 p. (WHO/MCH/MSM/91.6)The Maternal Health and Safe Motherhood Programme under WHO's Division of Family Health has compiled maternal mortality data in its 3rd edition of Maternal Mortality Ratios and Rates. The report contains data up to 1991. These data come from almost all WHO member countries. 1988 estimates reveal that 509,000 women die each year from causes related to pregnancy and childbirth. Most die from preventable causes such as aseptic abortions and lack of adequate health care. 4000 of these maternal deaths occur in developed countries. Thus developing countries, where 87% of the world's births occur, experience 99% of maternal deaths. In fact, the lifetime risk of death from causes related to pregnancy and childbirth in developing countries is 1:57 compared to 1:1825 in developed countries. Women in countries of western Africa have the greatest risk (1:18) and those in North America the smallest risk (1:4006). Even though the maternal mortality ratio for developing countries fell from 450-520 per 100,000 live births between 1983-1988, it increased in western African countries (700-760). This report consists mainly of tables of maternal mortality estimates for each country and in some cases certain areas of each country, for the world and various regions and subregions, and changes in maternal mortality since 1983 for the world and various regions and subregions. The world comparison table includes live births, maternal deaths, maternal mortality ratios and rates, lifetime risk, and total fertility. Country tables list year, data sources, maternal mortality ratio, indication if abortion deaths were included or not, and reference.
In: Disease and mortality in Sub-Saharan Africa, edited by Richard G. Feachem, Dean T. Jamison. Oxford, England, Oxford University Press, 1991. 31-6.This article is an overview of 4 chapters of part I of the 1991 World Bank publication entitled Disease and Mortality in Sub-Saharan Africa. It discusses what the health community currently knows about the levels, trends, and patterns of mortality in Sub-Saharan Africa. In fact, it points out that only limited data are currently available. Demographic techniques have evolved to overcome data limitations, however. These chapters also identify important information gaps that must be filled to plan interventions. These chapters reveal that mortality levels are higher in Sub-Saharan Africa than in other developing regions. Mortality of children <5 years old has decreased since the 1940s in most Sub-Saharan African countries, except for countries who have experienced war and civil unrest. Further Sub-Saharan Africa exhibits a specific mortality pattern: higher levels of infant, young child, and adult mortality exist in western Africa than in eastern or southern Africa. Nevertheless adult mortality in western Africa fell considerably between the 1950s-late 1970s, but it did not fall much in eastern African countries (their levels were lower initially though). This article suggests that donors could greatly contribute to developing planning ability in Sub-Saharan Africa by supporting the establishment of a vital registration system. Health planners often have access to hospital record and community survey data, however, but these data are biased. Further these chapters show that interventions to reduce mortality do not necessarily result in a reduction in morbidity. Rapid population growth and high fertility pose further problems for health planners.
[Unpublished] 1991. Presented at the 119th Annual Meeting of the American Public Health Association [APHA], Atlanta, Georgia, November 11-14, 1991. 7,  p.Maternal health affects child survival in many ways. For example, and infant in Bangladesh whose mother has died during childbirth has a 95% chance of dying in the 1st year. Further children <10 years old in Bangladesh, especially girls, who have lost their mother are 4 times as likely to also die. In addition, there is a relationship between protein energy malnutrition in mothers and low prepregnancy weight and meager wait gain during pregnancy which retards fetal growth resulting in a low birth weight (LBW) infant, LBW infants die at a rate 30 times that of adequate weight infants. In fact, child survival depends on maternal health even before the mother is able to conceive. Daughter as well as mothers in developing countries often eat last and smaller amounts of food than male family members. Females who remain poorly nourished often experience obstructed labor which causes several complications for the infant such as respiratory failure. Maternal infections such as malaria and sexually transmitted diseases are also closely linked to LBW. Some can also bring about preterm birth and congenital infections. Pregnancy and labor complications are responsible for about 500,000 maternal deaths annually. Hemorrhage, sepsis, eclampsia, and obstructed labor cause most of these deaths. A woman's fertility pattern also contributes to child survival. The high risk birth categories include too young, too old, too many children, and too closely spaced. In fact, the median mortality rate for infants born <2 years after the older sibling is 71% greater than that for those born 2-3 years apart. The World Bank recommends improved community based health care, improved referral facilities, and an alarm and transport system to improve maternal health. The World Bank, UNDP, UNFPA, UNICEF, WHO, IPPF, and the Population Council support the Safe Motherhood Initiative which aims to reduce maternal morbidity and death by 50% by 2000.
Weekly Epidemiological Record / Releve Epidemiologique Hebdomadaire. 1991 Nov 22; 66(47):345-8.Recent community studies and better information systems have made it possible for WHO to reassess maternal mortality and calculate new estimates. These new estimates indicate that pregnancy and childbirth are somewhat safer for women in parts of Latin America and most of Asia than they were in 1983. In Sub-Saharan Africa, however, a rise in births have resulted in an equal rise in maternal deaths. Further, it is in Sub-Saharan Africa where the only real increases in maternal mortality occurred since 1983. Thus deteriorating economic and health conditions in Sub-Saharan Africa have resulted in maternal mortality here being the worst in the world. Like in 1983, >500,000 women still die annually from pregnancy related causes and childbirth because there has been about a 7% increase in the number of births, but the risks are around 5% lower than in 1983. In developed countries, maternal mortality and number of maternal death have decreased 13% since 1983. In the Caribbean, the rise in maternal mortality is actually due to better information. In Latin America, maternal mortality in most countries, except Haiti and Bolivia, stand <200/100,000 live births. In fact, the number of maternal deaths has declined by almost 25%. A recent nationwide study in China reveals that the former maternal mortality figure of 50 was inaccurate and was actually almost 100. Except for China, however, declines in risks or pregnancy and number of deaths have occurred in all subregions of Asia. Country specific data, estimates, and explanations of how statisticians arrived at estimations appear in either 1 of 2 WHO reports entitled Maternal Mortality; A Global Factbook (US$45) and Maternal Mortality: A Tabulation of Available Information (free).
[Unpublished] 1991. Presented at the Demographic and Health Surveys World Conference, Washington, D.C., August 5-7, 1991. 8 p.The maternal and child health/family planning (MCH/FP) program at WHO specifies the priorities for MCH/FP in the 1990s. Results of the Demographic and Health Surveys (DHS) in many, but not all, developing countries have shown overall improvement in fertility and maternal and child health, especially in the family planning and child survival movements. Maternal mortality did not change, however. Moreover, maternal mortality in some countries exceeded natural maternal mortality. These elevations sparked a 3rd movement in the late 1980s, safe motherhood. These results confirm that the public health community cannot become complacent. Indeed it must strengthen the infrastructure, management, and performance of the health system to maintain gains. This involves identifying a novel strategy to priority setting and program development which are adapted to the changing needs and circumstances of each country, and even within each country. In fact, firm program strategies and policies need to concentrate on maternal health and morbidity, newborn care, breast feeding, perinatal infections, and HIV/AIDS. Based on DHS data and on evaluations of MCH/FP programs, WHO lists crucial principles for successful programs. The 1st principle includes equity in access and use of social resources which includes disaggregating data according to geographic and population subgroups to find appropriate strategies to close the widening gap within and between countries. The next principle is community and health care provider participation and ownership. Indeed successful MCH/FP programs are those where the community identifies problems and needs and evaluates the program. The 3rd principle encompasses quality data collection to assess quality of care and program effectiveness. WHO has proposed 5 priorities for organization and management of MCH/FP programs. 1 priority which WHO suspects will generate the most debate is integration of family planning, child survival, and safe motherhood programs.
NEW AFRICAN. 1991 Sep; (288):43-4.This article, which explains the severe need for family planning in Africa, serves as an introductory piece to a supplement dealing the problems faced by the medical community in dealing with the health of families in the continent. The articles in the supplement are written by medical staff workers of the Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ) GmbH, an agency of the German government designed to assist in the planning and execution of health development projects. As the article explains, Africa has the highest maternal mortality in the world, ranging anywhere from 400/100,000 live births to 1000/100,000 live births. The risk is greatest among very young or very old women. Maternal mortality rate among women aged 15-19 is twice that of women 20-24. And for girls under 15, the risk is 5x to 7x greater. The risk is also very high among women over 35. Furthermore, a high frequency of birth endangers the health of the mother and infant. Unwanted pregnancies often result in illegal abortions, which can cost the life of the mother. Many couples in Africa say that they would like to limit family size to 2 or 3 children. Also, knowledge of modern contraceptive methods runs as high as 80-90%. Yet most couples do not have access to family planning services, and in the instances when they do have access, services are often ill-equipped to handle the demand. In order to address these concerns, GTZ has supported family planning programs throughout Africa.
BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY. 1991 Apr; 98(4):345-8.Discusses dual concerns of the Royal College of Obstetricians and Gynaecologists (RCOG): that a widening gap between obstetric standards in Britain and those in the developing world exists and that the RCOG is unable to meet the needs of Third World doctors who come to the RCOG for postgraduate study. A meeting sponsored by Birthright and held at the Royal College of Obstetricians and Gynaecologists (RCOG) in June 1989 which explored aspects of Third World obstetric care reflects these concerns. The proceedings of the meeting have been published and verbatim recordings of the discussions are available on tape from the RCOG. Reports on maternal mortality/morbidity in the Third World indicate persistence of poor obstetrical practices and of common obstetrical complications. Suggestions for improvement include the redeployment of and the replanning of services within countries and an increase in health education for women. Access to care at the first referral institution level is seen as the key to the improvement of care. Problems of transport and communication create serious obstacles to the link between community care and the first referral institution. The goal of the World Health Organization (WHO) is to cut the Third World maternal mortality in half by the year 2000. To reach this goal WHO plans to field obstetric teams in Latin America, Africa and South Asia; to train nurse-midwives to perform life saving measures on their own initiative; and to employ community resources by training indigenous midwives to function as extensions of the health team. The RCOG will sponsor training designed for doctors who will work in developing countries.