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Nearly 30 per cent of all maternal deaths are caused by post-partum haemorrhage. This calls for increased skilled attendance at birth and the universal availability of the necessary commodities. However, in the ESA region skilled birth attendance exceeds 80 per cent in only five countries, i.e. Botswana, Comoros, Namibia, South Africa and Swaziland.

It has been found that by increasing the proportion of births with a skilled health attendant, there is a related decrease in maternal death rates (UN Statistical Division analysis).

Rwanda and Angola, for instance, more than doubled the proportion of skilled birth attendants and as a result, maternal mortality is reducing.

However, challenges remain. For instance, spatial and income inequalities make it difficult to increase access to skilled birth attendants for many countries. In rural areas, the number of trained and skilled health providers is in general much lower than in urban areas. In addition, skilled birth attendants in rural areas have limited access to essential drugs, supplies and equipment. Another challenge for women, in rural areas in particular, is meeting the costs of giving birth with a skilled health attendant. The costs are related not only to medical care, but also for transport and care for their children. Countries that have made maternal health care free of charge – Rwanda and Malawi, for instance – have enabled rural low-income women to access skilled assistance.

Challenges remain

Human resources shortages remain a critical gap in the health sector in the ESA region, affecting availability, access and quality of health care services. Countries have, however, made considerable progress in implementing comprehensive midwifery programmes. The majority of countries in the region has adapted the International Confederation of Midwives (ICM) competencies and has midwifery associations in place. However, while most countries have conducted midwifery needs assessments there is a need to strengthen midwifery strategies in the majority of cases.

Due to the many challenges faced by countries in implementing midwifery programmes, UNFPA has developed the Midwifery Services Framework, which aims to identify bottlenecks in midwifery improvement and propose actions to respond effectively to these types of issues. It provides strategic and practical guidance that countries may use to address issues related to their context in the three midwifery improvement pillars.