Maternal mortality at the end of a decade: signs of progress?

Maternal mortality is an important measure of women's health and indicative of the performance of health care systems. Several international conferenc es, most recently the Millennium Summit in 2000, have included the goal of reducing maternal mortality. However, monitoring progress towards the goal has proved to be problematic because maternal mortality is difficult to mea sure, especially in developing countries with weak health information and v ital registration systems. This has led to interest in using alternative in dicators for monitoring progress. This article examines recent trends in tw o indicators associated with maternal mortality. the percentage of births a ssisted by a skilled health care worker and rates oi caesarean delivery. Gl obally, modest improvements in coverage of skilled care at delivery have oc curred, with an average annual increase of 1.7% over the period 1989-99. Pr ogress has been greatest in Asia, the Middle East and North Africa, with an nual increases of over 2%. In sub-Saharan Africa, on the other hand, covera ge has stagnated. In general, caesarean delivery rates were stable over the 1990s. Countries where rates of caesarean deliveries were the lowest - and where the needs were greatest showed the least change. This analysis leads us to conclude that whereas there may be grounds for optimism regarding tr ends in maternal mortality in parts of North Africa, Latin America, Asia, a nd the Middle East, the situation in sub-Saharan Africa remains disquieting .