Report for Governance and Poverty seminar, 2013.

1. Interventions, Innovations and Investment in Improving Maternal Health: Summary of MDG 5
Significance, Progress, Challenges and Strategy with a Focus on Skilled Birth Attendance
Solveij Rosa Praxis
Governance and Poverty, POLISCI 247G
Professor Beatriz Magaloni-Kerpel
March 18, 2014

2. 1
1. Millennium Development Goal 5: Improve Maternal Health
a. Background
Maternal health improvement is a development goal of immense significance,
complexity, and potential. The international community prioritized maternal health as the fifth of
the eight targets, the Millennium Development Goals, of a global development agenda, the
United Nations Millennium Declaration, committed to in partnership by the United Nations in
September of 2000 with a deadline of 2015.[1] Target A of MDG 5 is the reduction maternal
mortality by three quarters, based on the 1990 maternal mortality ratio (MMR), by the 2015
target date.[2] Maternal mortality is defined as “the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from
any cause related to or aggravated by the pregnancy or its management but not from accidental
or incidental causes.”[3] Critical indicators of target 5A are the maternal mortality ratio and the
percentage of births attended by skilled health personnel. Target 5B, the achievement of
universal access to reproductive health, including family planning, was added in 2007 as a
culmination of powerful discourse establishing the importance of reproductive health in
development progress.[4] Indicators for this target are the total fertility rate (TFR), contraceptive
prevalence rate (CPR), adolescent birth rate, antenatal care coverage, and unmet need for family
planning. Contraceptive prevalence rate refers to the use of modern contraceptive methods
among married women of reproductive age (15-49).[5]
b. Progress and Present Conditions
Globally, the maternal mortality ratio has declined from 1990 levels of 400 maternal
deaths per 100,000 live births, over half a million maternal deaths annually, to the 2010 MMR of
210 maternal deaths per 100,000 live births. This reduction by 47% is significant, but fails to
reach the goal of a 75% decrease. The percentage of births attended by skilled health personnel

3. 2
in developing nations increased from 55% in 1990 to 66% by 2011.[2] Of the estimated 210
million pregnancies each year, [6] 90% occur in the developing world. [7] 8 million women
experience life-threatening complications related to pregnancy or childbirth and between 15 and
20 million girls and women suffer from maternal morbidities every year[8]. In 2010, 287,000
women died of maternal causes. [2] 99% of maternal deaths are endured by developing
countries, a striking health disparity between rich and poor countries and populations. [2]
Women’s deaths in the process of giving life are devastating losses in the family and community.
The great burden on developing nations is represented in economic terms by $15 billion of
annual lost productivity due to maternal and newborn death. [9]
From 1995 to 2008, pregnancy rates fell by a notable 17% worldwide; from 108 to 90 per
1,000 in the developed world and from 173 to 173 in developing areas. Unintended pregnancy
also decreased over this period, though to a significantly “greater extent in the developed world
(29%) than in the developing world (20%).” [7] The overall proportion of unintended
pregnancies remained high, at 41% in 2008. [7] At present, a conservatively estimated 86 million
pregnancies, over a third and up to half of all pregnancies annually, are unintended. [7] Of these
unintended pregnancies, 41 million are terminated in abortion, 33 million result in unplanned
births, and 11 million are ended in miscarriage. [7] 97 percent of unsafely performed abortions
occurring in less developed countries [10] In developing countries, 82% of these unintended
pregnancies occur among the 215 million women who desire to avoid pregnancy but have unmet
need for modern contraception. [11] Worldwide, unmet need for family planning was at an
estimated rate of 12.3% in 2010, a reduction by about 3 percent from 1990 levels (15.4%). [12]
The worldwide contraceptive prevalence rate increased from 54.8% in 1990 to 63.3% in 2010.
[12] However, this rate is based on a definition excluding unmet need for non-married women of

4. 3
reproductive age who are sexually active. [13] The Guttmacher Institute reports that, among
women in developing countries who are of reproductive age, sexuality active and fertile, but do
not want a child in the next two years 26%, or 222 million women, have unmet need for modern
contraceptive methods. [14]
Maternal health development, of all of the MDGs, has made the least progress and is the
most underfunded of the health-related goals. [9] The low prioritization and funding from the
development world is the result of the same inequalities causing maternal disparities and deaths;
women’s low social and actual capital. Even when children, in their vulnerable state, are the
focus of resources and support, their mothers are neglected and invisible.
c. Challenges Causing Progress Lag
The progress lag is not only the product of neglect. Engagement with the issue requires
intensive interventions, complex in their multi-system implementation and complicated by
intersecting economic, cultural and institutional inequalities and injustices. These realities with
oppressive consequences are serious challenges that must be addressed by effective maternal
health interventions in the developing world. Economic injustice is clear in evidence that
women fulfill 66% of the world’s work for only 10% of income and ownership of a dismal 1% of
property globally. [15] By some estimates, 70% of people in poverty are women, suggesting the
phenomenon of the feminization of poverty. [15] As discussed, economic inequity engenders the
health divide in maternal mortality and newborn mortality, virtually all of which occurs in the
developing world. The low prioritization of women is an extension of gender inequality and
discrimination with significant consequences for women’s health. Lack of education, social and
economic dependency on male partners or family members, and threats of violence for behavior
challenging male dominance severely limit women’s options and ability to make personal

5. 4
decisions for their own and their family’s health. Women’s education and health are intimately
linked, highlighted by evidence such as a study showing that women with no education were
nearly three times more likely to die during pregnancy and childbirth than women who
completed secondary school.[16]
Discriminatory expectations for women’s reproductive and childrearing roles reinforce
unhealthy behaviors, such as early marriage, low contraceptive use, and high fertility rates. [17]
Institutional, or political, dimensions of women’s experiences are also significant for maternal
health issues. Violence and conflict stemming from civil war or criminal activity may restrict
access to basic health care for affected populations. Sensitive health issues, such as reproductive
health, are particularly impacted in conflict situations. Finally, the history and present political
reality of anti-democratic external and internal hierarchies exercising control and exploiting
vulnerable populations, especially women and the poor, harm the agencies of women and their
advocates. This may damage trust in development relationships between the developed world
and developing world partners.
Interwoven in maternal health, intersecting injustices and inequalities complicate and
define the issue. Improvement in maternal health is inherently an issue of not only health, but of
social justice and human rights advancement.
d. Significance of Maternal Health as Foundation for Development
This insight points to the heightened significance of maternal health development as an
issue upon which many other development areas in need of progress are contingent.
Development and women’s health, as well as empowerment, are interdependent. The relationship
is deeper than that, for family planning is the foundation upon which human development is
built. [18] Poverty and hunger are addressed by birth spacing and small families, which decrease

6. 5
low birth weight and poor maternal nutrition. Smaller families also put less pressure on
environmental resources because consumption of land, food and water is decreased. Girls have
greater opportunity to take advantage of education when unintended pregnancy or the need to
care for new children in the family do not encourage low attendance and dropping out of school.
Women’s empowerment and equality are rooted in women’s agency over their reproductive
potential and family size. Prevention of unintended pregnancy also reduces the complications
and deaths associated with pregnancy, as well as the incidence of mother-to-child HIV
transmission. [19] None of these development and social justice goals, from hunger alleviation
and environmental preservation to gender equity and disease prevention, will be achieved or
sustained without progress in women’s reproductive health, rights, and empowerment. The
contributions family planning shares delivers to all development goals and economic growth is
known as the “demographic dividend,” a benefit that only family planning and maternal health
improvement can provide. [20]
2. Interventions
a. Introducing General Interventions, Health Interventions and Maternal Health
Interventions
i. Guiding Principles and Frameworks
Ethical and effective interventions are founded on several principles: community-based
development and implementation; community empowerment through ownership, collaboration
and in the practice of the intervention; and a model oriented towards aligning incentives to make
adoption as easy as possible, just as an efficient business is structured. Health interventions are
delivered on five levels: counseling and education, clinic interventions, protective interventions,
enabling environment and socioeconomic interventions.[21] Maternal health strategies require
multi-tiered, complex systems involving public education and training of health promoters,

7. 6
health facilities with quality care and appropriate equipment, as well as mechanisms for client
access to services. Interventions for maternal health are delivered to women in need of services
on the community-level, in first-level health facilities, and referral facilities. The distinction
between first-level and referral health facilities is made by the facilities’ difference in resources.
On the community level, services may be made accessible through programs connecting clients
to the clinic, through direct transport, for example, or by bringing services a clinic would offer
directly to women without easy access to clinics. Comprehensive policies and strategies are the
underlying frameworks ensure this health infrastructure is supported, sustainable and effective by
framing of priorities, guiding interventions and outlining how resources needed to deliver results
will be mobilized and deployed. [21]
ii. Challenges in Developing Maternal Health Interventions
Developing interventions with empirical support is challenging in the maternal health
area because of the inherent sensitivity and indeterminable value of related factors, such as
women’s empowerment. In many instances, randomized controlled trials and safe motherhood
are not compatible. The wellbeing of women and children cannot be experimented with in a risky
manner. Another issue in determining intervention impact is that critical impacts, such as
women’s empowerment or social consciousness change, are not objective or easily quantifiable.
As a result, holistic programs with these impacts may be overlooked and under-supported. The
complexity of maternal health interventions results in difficult identification for specific causes
of changes in maternal mortality and other targeted indicators. Even the specifics, such as
maternal mortality, have proven to be extremely difficult to measure at the local level. Consider
that only a third of countries are characterized as having a complete civil registration system with
good attribution of cause of death. This serious flaw in data collection has led WHO to issue a

8. 7
recommendation that, by 2015, all countries commit to establishing coordinated, accurate health
information systems. [21] Despite these challenges and limitations, there is sufficient literature
and evidence to define an effective maternal health development interventions strategy.
b. Maternal Health Background
i. Causal Pathway of Maternal Mortality
Women’s health, which can also be understood as sexual and reproductive health, is
categorized in the stages of life before pregnancy, during pregnancy, at birth, after birth
(postpartum health), and during motherhood (maternal health). These are the life stages targeted
by maternal health interventions. Along the stages from pregnancy to birth, a causal pathway for
intensive care, near-misses, and maternal death is identified. The five central causes of maternal
death are postpartum hemorrhage (PPH; 24%), infection and sepsis (15%), eclampsia and
hypertensive disorders (12%), unsafe abortion (13%) and obstructed labor (8%). [22] Addressing
the causal pathway is central in reducing maternal mortality.
ii. Challenges for Resource-Poor Settings
Resource poor, socioeconomically disadvantaged settings face unique challenges in
maternal health development. The first is the “inadequate number of health care facilities staffed
with trained providers in emergency obstetric care (EmOC).” [23] The lack of trained providers
is a complication that is difficult address for socioeconomically disadvantaged areas for various
reasons, including the trend that medical professionals will emigrate from poor areas for their
own financial stability. Secondly, socioeconomically disadvantaged clients have financial
barriers to expensive maternal health care services as well as the unofficial costs of access to
care, such as costs of medications, supplies and transportation. Finally, these settings lack
appropriate technology for management of birthing complications in the home-setting. This is an

9. 8
extraordinary challenge for resource-poor areas because, in these settings, the majority of
deliveries occur in the home. Women in these poor, often rural areas are most vulnerable to
maternal mortality and complications.
c. Maternal Health Interventions
i. Goal of Safe Motherhood and Protected Birth; Revised Strategy of
Community- and Home-Based Interventions
The goal of establishing quality obstetric care with trained providers and access to this
care appears, at first, to be straightforward. The standard intervention approach has been to
support and fund existing models to increase and expand services. Normative, clinic-based health
services do not reach at-risk women and may not for quite a long time. Given the challenges for
resource-poor, socioeconomically disadvantaged settings where women are most at risk of
maternal mortality, this strategy must be reevaluated. Establishing quality clinics and extensive
infrastructure is a long-term commitment. For the near future, however, challenges of inaccess
are prohibitive barriers to care for poor, rural women. A new, short-term strategy which
addresses the need for protected births in the home is essential to the goal of safe motherhood.
This alternative strategy is necessarily community- and home- centered.
ii. Intervention Areas and Effective Interventions
Innovative interventions are aimed at the goal of safe motherhood, address the causal
pathway of maternal mortality and are developed with an understanding of the barriers at-risk
women encounter. Within three interventions areas, there are three high-impact interventions.
The first areas is family planning, including counseling, services and supplies. The first specific,
high-impact intervention is within this area: access to contraceptive services for all women to
prevent unwanted pregnancies and complications associated with pregnancies. [9] The second

10. 9
area is quality care for pregnancy and childbirth, consisting of “antenatal care, skilled attendance
at birth including emergency obstetric and neonatal care, and immediate postnatal care for
mothers and newborns.” [9] Within the category of skilled birth attendance, is the second high-
impact intervention: access to care by a skilled attendant for pregnancy and childbirth alone. The
third is also within this category: access to emergency obstetric care for all women and newborns
with complications. The third major intervention area is safe and legal abortion services. [9]
3. Innovations
a. Midwives (MOMS, TBAs, etc.) as Community-Based Health Promoters
i. Background
Midwives and Others with Midwifery Skills (MOMS) are community-based maternal
health promoters with access to women in poor, rural areas who are most at-risk for maternal
mortality. MOMS trained as skilled health workers are ideally situated to address the short-term
goal of protecting births in the home. This capacity-building for skilled birth attendance is the
second of the three high-impact interventions. Effective midwives serve women and
communities by overseeing and providing personal, quality care that is culturally appropriate at
the critical stages of maternal health in homes of at-risk women and, ideally, with access to
emergency care if needed. They also build the skills of other health promoters and promote
health education and empowerment. [24] Most women in poor, rural settings rely on community
members such as MOMS, traditional birth attendants (TBAs), health extension workers (HEWs),
community-based reproductive health agents (CBRHAs) and others for pregnancy care. [24]
These workers relieve overburdened health facilities by managing care for women without
severe complications, allowing care facilities to provide specialized care for women with serious
risks. MOMS and other community-based reproductive health workers are predominantly

11. 10
female. Because they are women working with women, they are highly valued by the women
they serve. [25]
ii. Challenges
This fact, however, also causes midwives to be devalued, ignored, and dismissed within
the health profession and as key actors in development by the international community. [25]
Midwives are under-supported by health institutions, which fail to fund training and employment
of midwives, create incentives to cultivate human resources for health, or even recognize
midwifery as a legitimate profession. As a result, midwives lack numbers and, in many cases,
have low-quality training. This poor quality of training is compounded by the phenomenon of
diminishment and loss of midwifery identity. [25] Initial studies of the impacts of community-
based pregnancy health promoters, conducted in the early years of the Millennium Development
initiative, found that “decades of training traditional birth attendants (TBAs) ha[d] made little or
no significant impact on maternal mortality” to the great disappointment of midwifery advocates.
[23] However, there is a clear distinction to be made between traditional birth attendants and
professional midwives. [26] The former had no systematized training or skill set. Furthermore, it
is widely recognized midwifery programs were under-supported and undermined by
contradictory policies. Finally and crucially, midwifery strategies lacked the implementation of
appropriate technology that would enable midwives, women who often have little formal
education and are illiterate, to address the causes of maternal mortality in the home. [23]
b. Training MOMS with Appropriate Technology for Addressing Causal Pathway
i. Study: Training MOMS in Misoprostol and Referral for PPH
Compelling evidence from recent years suggests that this situation has been drastically
altered. Studies have been conducted for the purpose of training community-based pregnancy

12. 11
health workers, such as Midwives and Others with Midwifery Skills (MOMS) and traditional
birth attendants (TBAs), as skilled health workers. The training, supported and of high quality, is
meant to address the causal pathway for maternal mortality and paired with appropriate
technology to enable the health providers. Between 2005 and 2007, an intervention trial was
conducted in the Tigray region of Ethiopia with 966 participants.[27] The study asked whether
midwives can be trained to use appropriate technology to safely address the causal pathway of
maternal mortality at home births. In this case, the technology traditional birth attendants (TBAs)
were trained in was the use of was misoprostol for prophylaxis treatment of postpartum
hemorrhage (PPH). [27]
Postpartum hemorrhage is the leading cause of maternal death globally. The correct
diagnosis and management of PPH “in a timely manner […] determine[s] the level of maternal
deaths in poor settings.” [23] However, the drug used in developed nations, oxytocin, is
administered by injection and needs refrigeration, barriers for rural, poor settings without the
necessary resources and skilled attendance. The technological innovation that is appropriate in
this situation is misoprostol. Misoprostol is a “proven uterotonic increasingly used in obstetrical
and gynecological practice including the control of PPH.” It is an “inexpensive tablet, [that] is
easy to store, stable in field conditions,” and also has an “excellent safety profile with multiple
routs of administration.” [27] Thus, misoprostol is an extremely useful and appropriate
technology for the rural, poor settings in which most maternal deaths happen. [27]
In the study, traditional birth attendants (TBAs) were trained in the usage of misoprostol
for PPH prevention to administer 600mcg of oral misoprostol, in the visual perception of
approximately 500mL and 1000mL of blood loss, and to know when to safely refer women to
emergency-care facilities for additional treatment. This training was critical to build capacity and

13. 12
dispel misinformation. For example, some TBAs initially were under the misperception that
heavy bleeding is an expected part of birthing that does not require medical professionals or
intervention. In following years, properly trained traditional birth attendants (TBAs) would fall
under the umbrella-term of MOMS. Though this study was an experimental trial, ethical
standards were met by ensuring that the trial would be stopped if deaths were to be attributed to
the intervention.
The results were that “women in intervention areas were significantly less likely to be
referred for additional treatment related to excessive bleeding (8.9%) compared to women in
non-intervention areas (18.9%).” [27] Though distinguishing excessive bleeding from PPH was
not feasible, the outcome that half of referrals were addressed by trained TBAs with misoprostol
in the home demonstrates that the intervention decreases the risk of maternal death by PPH.
Intervention safety was determined by “comparing the frequency of reported symptoms after
delivery between the two study areas; the need for further treatment for these symptoms; and the
report of serious adverse events due to failure to follow study protocol.” [27] Without notable
reports or discrepancies in symptoms, it was ultimately found that “prophylactic use of
misoprostol in home births is a safe and feasible intervention.” [27]
ii. Implications
1. Intervention Strategy Methodology
A major finding of this study in terms of the broader maternal health development
strategy is the effectiveness of community-based interventions and the utilization of MOMS and
TBAs with quality training and enabling technology. If skilled birth attendants are trained to
address the causal pathway of maternal mortality and given the effective tools to safely do so,
they can be greatly successful in preventing maternal death. On a fundamental methodological
level, the efficacy of bottom-up, grassroots interventions that focus on the empowerment of

14. 13
marginalized people with potential, in this case formerly disregarded midwives and the
vulnerable women they serve, is exceptionally reinforced by these findings.
2. Initial Expansion and Adoption, Scaling-Up Impact
Nigeria and India approved misoprostol distribution for PPH prevention in 2006,
followed by Tanzania in 2007. [23] Finally, in 2011, Misoprostol was added for prevention of
PPH to an updated WHO list of Essential Medicines. [28] Now, the great majority of countries
have approved misoprostol for PPH prevention. [29] The Bixby Center for Population Health
and Sustainability at UC Berkeley and Venture Strategies Innovations are key actors funding
similar interventions implementing training for community-providers with misoprostol for PPH
prevention. [30] Sustainable scaling-up of the intervention requires significant commitment and
financial resources. Strategies for investment must be coordinated by governments and donors.
3. Challenges for Misoprostol Adoption
Though misoprostol is increasingly adopted as a safe and effective tool for preventing
maternal death by PPH, it is also relatively safe and effective for the self-inducement of abortion.
[31] Due to this fact, some special interest groups are attempting to ban the sale of misoprostol,
with varying success. In Turkey, the government banned misoprostol from sale in pharmacies as
it prepared to ban abortion entirely. [32] The abortion stigma, creating the fear that women will
use misoprostol to induce abortion, is a major challenge for the expansion of misoprostol use for
PPH prevention. [31] Additional challenges include the fear of misuse in the home by providers
or delivering women, the worry that protecting home deliveries discourages facilities deliveries,
the issue that “registration of misoprostol for obstetric indications is time consuming,” and the
problem that “some countries do not have a drug distribution network that can reach poor women
in the remote areas at affordable prices.” [23] These barriers, in respect to the alternative, are
minimal. If the goal of safe motherhood is to be met, supporting protected births in the home

15. 14
through the training of skilled birth attendants in the use of life-saving technology, such as
misoprostol to prevent maternal death by PPH, is imperative.
4. Conclusion: Moving Forward for Maternal Health Improvement (MDG 5)
a. Lessons
Specific lessons responding to the major challenges in maternal health development faced by
poor, rural women most vulnerable to maternal death in the developing world are the following:
 Community-Based Access: Interventions must be delivered with the goal of access for
clients. For the target population most at-risk of maternal death, this requires community-
based support and services. Skilled attendants, such as MOMS or TBAs, overcome
challenges care access, such as financial barriers associated with clinics, by reaching
women where they are at—their homes.
 Quality Training of Skilled Attendants: Training community-based health providers is a
central strategy in overcoming the under-supported, underfunded health care facilities
and inadequate number of professional health care providers, at least in the short term.
Attendants must receive sufficient training and support, such as recognition and the
provision of enabling technologies, to deliver quality services with results.
 Appropriate Technological Innovation: Appropriate, effective technology, such as
misoprostol, can manage complications in home births, where most of the deliveries
occur in poor settings. The development of contextual, need-based technologies is
essential to address the causal pathway of maternal mortality. [23]
b. Strategy
Family planning, quality care with skilled health providers and emergency care, and safe
abortion services must all be supported and delivered to improve maternal health development. A
strategy committed to the fulfillment of these goals is based on the needs and empowerment of
the community, family and individual women. Long-term goals of sustainable health services
infrastructure are complemented in the short-term by practical, community-based solutions
circumventing barriers. To this end, the importance of skilled maternal health providers,
specifically the intervention of training skilled attendants for pregnancy and childbirth, has been
emphasized throughout this report.

16. 15
c. Investment Needed for Skilled Births Attendance and General Targets
Investing in midwifery has become a priority of the international strategy in maternal
health development. In a 2011 UNFPA report that focused on the centrality of midwives in
maternal health development, governments are strongly recommended to promote midwifery
through professional recognition, centrality of status in health services, and the potential for a
career in national policy. Government policy must also include midwifery in health systems and
budgets, provide funding to support emergency care facilities and supplies midwives need to be
effective, and incentivize greater midwifery expansion and quality through training, regulation,
and funding. [33] An estimated 700 thousand more midwives are needed to achieve MDG 5. [25]
The total annual funding needed to dramatically improve maternal and newborn health is estimated to be
$24 billion. [8] In 2010, $40 billion in resources was pledged by stakeholders to women’s and children’s
health following renewed commitment by the international community. [8] As we count down to 2015, it
remains to be seen whether the investment, in both commitment and funding, has been enough to reach
MDG 5 targets.
d. Potential Benefits
The impacts of investing in the health of women radiate from the individual woman to
her family, community, the nation and the world. If family planning need were met, that
voluntary access is estimated to reduce maternal deaths by a third. If all women had skilled
attendance at their deliveries alone, with emergency obstetric care when necessary, maternal
deaths would be reduced by 75% and MDG 5 would be far surpassed. With skilled health
workers supporting them during pregnancy, childbirth and postpartum, 90% of women would no
longer die in the process of giving life. [8] Women’s health and dignity must be the foundational
priorities for human development.

17. 16
Citations:
[1] United Nations Millennium Declaration. Rep. UN General Assembly, 18 Sept. 2000. Web.
[2] Trends in Maternal Mortality: 1990 to 2010. Rep. WHO; UNICEF; UNFPA; World Bank,
n.d. Web.
[3] "Maternal Mortality Ratio (per 100 000 Live Births)." WHO. N.p., n.d. Web.
[4] Millennium Development Goals Report 2013. Rep. United Nations, n.d. Web.
[5] "World Contraceptive Use 2012." UN News Center. UN, n.d. Web.
[6]Unsafe Abortion Incidence and Mortality Global and Regional Levels in 2008 and Trends
during 1990 –2008. Rep. WHO, n.d. Web.
[7] "Rates of Unintended Pregnancy Remain High In Developing Regions." Rates of Unintended
Pregnancy Remain High In Developing Regions. Guttmacher Institute, n.d. Web.
[8] Giving Birth Should Not Be a Matter of Life and Death. Rep. UNFPA, n.d. Web.
[9] "Focus on 5: Women’s Health and the MDGs." UNFPA. N.p., n.d. Web.
[10]Reducing Unintended Pregnancy and Unsafely Performed Abortion Through Contraceptive
Use. Population Reference Bureau, n.d. Web.
[11] "Facts on Induced Abortion Worldwide." Facts on Induced Abortion Worldwide. N.p., n.d.
Web.
[12] Alkema, Leontine, Vladimira Kantorova, Clare Menozzi, and Ann Biddlecom. "National,
Regional, and Global Rates and Trends in Contraceptive Prevalence and Unmet Need for Family
Planning between 1990 and 2015: A Systematic and Comprehensive Analysis : The Lancet." The
Lancet. N.p., 12 Mar. 2013. Web.
[13] Sonfield, Adam. "Working to Eliminate the World's Unmet Need for
Contraception."Guttmacher Institute. N.p., 2006. Web.

18. 17
[13] "Combating Discrimination against Women." Combating Discrimination Against Women.
Web.
[14] Costs and Benefits of Investing in Contraceptive Services in the Developing World. Rep.
Guttmacher Institute; UNFPA, June 2012. Web.
[15] "Women, Poverty & Economics." Women, Poverty, Economics. UN Women, n.d. Web.
[16] "Rich Mother, Poor Mother: The Social Determinants of Maternal Death and Disability."
UNFPA, Dec. 2012. Web.
[17] "Healthy Women, Better World UNICEF." UNICEF Presents: Youth and Maternal Health
Portal. N.p., n.d. Web.
[18] Cutting-Edge Leadership in Family Planning. Rep. Fhi360, Oct. 2013. Web.
[19] Cates, Willard, Jr. Thesis. N.d. Family Planning: The Essential Link to Achieving All Eight
Millennium Development Goals. Family Health International, 5 Jan. 2010. Web.
[20] Gribble, James, and Jason Bremner. "The Challenge of Attaining the Demographic
Dividend."Population Reference Bureau. N.p., Nov. 2012. Web.
[21] Accelerating Progress Towards the Health-Related Millennium Development Goals. Rep.
WHO, Feb. 2010. Web.
[22] “Maternal Mortality: Who, When, Where, and Why.” The Lancet, Maternal Survival, Sep.
2006. Web.
[23] Prata, N., M. Graff, A. Graves, and M. Potts. Avoidable Maternal Deaths: Three Ways to
Help Now. Routledge, 26 May 2010. Web.
[24] "Can We Reduce Maternal Mortality with Community-based Interventions? | Bixby Center
for Population, Health & Sustainability." Can We Reduce Maternal Mortality with Community-
based Interventions? | Bixby Center for Population, Health & Sustainability. Bixby Center for
Population, Health and Sustainability, n.d. Web
[25] Towards MDG 5: Scaling Up the Capacity of Midwives to Reduce Maternal Mortality and
Morbidity. Rep. UNFPA, Mar.-Apr. 2006. Web.
[26] The World Health Report 2005: Make Every Mother and Child Count. WHO, 2005. Web.

19. 18
[27] Prata, N. "Prevention of Postpartum Hemorrhage: Options for Home Births in Rural
Ethiopia."African Journal of Reproductive Health / La Revue Africaine De La Santé
Reproductive 13.2 (2009): 87-95. JSTOR. Web. 01 Mar. 2014.
<http://www.jstor.org/stable/20617115>.
[28] "Latest News." Misoprostol. N.p., n.d. Web.
[29]"Gynuity Health Projects." » Resources » Map of Misoprostol Approval. N.p., n.d. Web.
[30] "Programs." Venture Strategies Innovations. N.p., n.d. Web.
[31] Wilson, Katherine. Misoprostol Use and Its Impact on Measuring Abortion Incidence and
Morbidity. Guttmacher Institute, n.d. Web.
[32] "Press Release: Turkey Bans Medicines Used for Safe Abortion from Pharmacy in Move to
Further Restrict Access." Women on Waves. N.p., 16 July 2012. Web.
[33] The State of the World's Midwifery 2011. Rep. UNFPA, 2011. Web.