Maternal death and the Millennium Development Goals.

Maternal health is one of the main global health challenges and reduction of the maternal mortality ratio, from the present 0.6 mio. per year, by three-quarters by 2015 is the target for the fifth Millennium Development Goal (MDG 5). However this goal is the one towards which the least progress has been made. There is not a simple and straight-forward intervention, which by itself will bring maternal mortality significantly down; and it is commonly agreed on that the high maternal mortality can only be addressed if the health system is strengthened. There is a common consensus about the importance of skilled attendance at delivery to address the high, maternal mortality. This consensus is also reflected in the MDG 5, where the proportion of births attended by skilled health personnel is considered a key indicator. But even if countries invest massive efforts to increase skilled care, there will be a time lag. In addition, there is a need of major investment in human resources to counter the present momentum of emigration of qualified personnel from low income countries. To address the lack of skilled attendance, alternative strategies should therefore be developed and incorporated within the existing health system. One plausible solution could be to involve lower level providers such as community health workers to provide health facility based care under close supervision of authorized midwives. Upgrade of midlevel staff to provide life-saving obstetric surgery may also be an important innovative strategy. Along with the strategy of aiming at increasing the number of health facility based deliveries and the empowerment of non physicians to provide obstetric surgery, some preventive functions of basic care targeting women who prefer to deliver outside the health facilities should be developed. Finally, political leadership, openness to discuss women's rights, including abortion, and involving the community i.e. MDG 3 is essential to attain MDG 5.