Learning from low income countries

Editor—Costello et al addressed important issues for poor countries to achieve the millennium development goals.¹ We share their view that community based interventions are crucial to reduce maternal and child mortality by 50% in 2015. In Yemen, the only country with low income and high mortality in the Arabian peninsula, all rural births are home deliveries attended by traditional attendants.

Maternal mortality for Yemen has been estimated at 850/100 000 births.² I recently reported that perinatal characteristics (low birth weight, breech presentation, obstructed labour, and abnormal intrapartum bleeding) in a community health survey and the main walk-in maternal and children hospital in Sana'a city were comparable.³ A 12 year, hospital based study showed that perinatal mortality remained unchanged at 95/1000 births and is probably lower than that in the community.⁴ In 2003, 596 newborn infants who were delivered at home needed special care at this hospital, and 140 (23.5%) died, compared with 177 (16.3%) of the 1089 newborn infants delivered in hospital who needed the same care. Both accounted for 52.5% of the total hospital's child mortality.

Traditional birth attendants live in their communities, which are usually the poorest of the population. Training them about safe delivery and immediate basic care of newborn infants, and instructing them to refer to the nearest essential obstetric care unit if any danger signs become obvious, may prove to be an important, cost effective strategy to reduce maternal and neonatal mortality in communities. They can also contribute in terms of health education and encouraging breast feeding.

The advantage of such training is its sustainability. A trained attendant will train the next family member that takes her position when she retires. Investing in such training should be considered by policy makers and donor agencies.