Las amenazas leves del art 171.4 CP y las coacciones leves del art 172.2

In countries where maternal mortality is meas- ured using household surveys, the margins of uncertainty are such that it is not possible to draw firm conclusions about the direction of trends. For assessing progress in these countries, process in- dicators are needed for regular monitoring. The percentage of births attended by skilled health personnel is one potential process indicator, and there is evidence of a strong association between that indicator and the levels of maternal mortality (World Health Organization, 1999; De Browere, Tonglet and Van Lerberghe, 1998). Despite con-

cerns about definitions and comparability both between countries and over time, the indicator has a number of advantages for monitoring purposes, including the wide availability of data for devel- oping countries up to and including the year 2000. The source of the information is generally the Demographic and Health Surveys, the Pan Arab Project for Child Development (PAPCHILD) or reproductive health surveys that provide a stan- dardized methodology and sampling framework along with strict criteria regarding the mainte- nance of data quality. For estimates by the World Health Organization and the United Nations Chil- dren’s Fund, the skilled health-care personnel category comprises only the first two groups,

namely, doctors and nurses/midwives who have the necessary midwifery skillsi (World Health Or- ganization, 1999).

Trend data on skilled attendants are available for 53 countries that have a minimum of two data points derived from sources using similar estima- tion methods, generally Demographic and Health Surveys. Overall, these countries account for 76 per cent of live births, although this figure varies

considerably by region. Table 38 shows the trend in the proportion of deliveries assisted by skilled attendants for major regional groupings. Because data are available for different years and cover a different period for each country, adjustments to a common ten-year period, 1989 to 1999, have been made. The observed rate of change was used to project data for the end points 1989 and 1999. The regional averages are weighted by the numbers of live births.

TABLE 38. TRENDS IN THE PERCENTAGE OF DELIVERIES ASSISTED BY SKILLED ATTENDANTS FOR 53 COUNTRIES,

1989-1999 Number of

countries with trend data a

Percentage of births in the region cov-

ered by the data

Percentage of births assisted by skilled attendants Annual average rate of change b (Percentage) Region 1999 1999 1989 1999 1989-1999 Sub-Saharan Africa... 17 59 44 44 0.1

Western Asia and Northern Africa... 9 56 49 63 2.5

Asia... 7 89 39 48 2.2 Latin America and the Caribbean ... 18 74 74 81 0.9

Total ... 53c ₇₆ d ₄₅ d ₅₂ c _1.7 c

Source: C. AbouZahr and T. Wardlaw, “Maternal mortality at the end of a decade: signs of progress?”, Bulletin of the World Health Organization, vol. 79, No. 6 (2001).

a _{Data published up to April 2001.}

b _{Weighted average of individual country data. Regional averages were weighted by the numbers of live births.} c _{Including two countries from Central and Eastern Europe and the Commonwealth of Independent States.}

d _{Data for developing countries only.}

The evidence shows that in general only mod- est improvements in coverage of care at delivery have occurred, with an average annual increase of 1.7 per cent over the period 1989 to 1999. In sub- Saharan Africa, there has been barely any percep- tible change over the decade. However, countries of Asia, Western Asia and Northern Africa show significant improvements, with annual average increases of 2.2 per cent and 2.5 per cent respec- tively.

In Brazil, Jamaica, Jordan, Kuwait, Oman, Pa- nama and South Africa, there are relatively high levels of coverage with modest improvements. By contrast, in Bangladesh, Burkina Faso, Haiti and Mali, very low proportions of deliveries are as-

sisted by skilled attendants; moreover, trends in care at delivery in those countries are stagnant or even declining. Niger and Yemen, though starting from a low baseline, have shown some improve- ments in coverage over the period. Significant improvements can be observed in Bolivia, Egypt, Indonesia, Morocco and Togo, countries charac- terized in recent years by a determined and high- level commitment to address maternal mortality. In Egypt, for example, coverage by skilled atten- dants at delivery increased from 35 per cent to 61 per cent from 1988 to 2000. In Indonesia, cover- age by skilled attendants increased from 36 per cent in 1987 to 56 per cent in 1999. In Morocco, coverage increased from 24 per cent in 1984 to 40 per cent in 1995. In Honduras, institutional deliv-

eries increased from 41 per cent in 1987 to 54 per cent in 1996. Significant increases are observed in other countries such as Argentina, Ecuador, Hon- duras and Mexico (AbouZahr and Wardlaw, 2001).

Countries with already high levels of coverage by skilled attendants at delivery (such as Costa Rica, Cuba, Jordan, and Kuwait) appear to be making continuous progress in terms of the use of skilled birth attendants. Countries with intermedi- ate levels of coverage (such as Guinea, South Af- rica, Togo, Tunisia and Zimbabwe) show ongo- ing, slow improvements. However, some countries, such as Burkina, Faso, Cameroon, Kenya, Madagascar, Mali, the United Republic of Tanzania, and Zambia, appear to have lost ground over the period. Of the 17 sub-Saharan countries for which trend data are available, only six— Ghana, Guinea, Niger, Nigeria, Senegal and Togo—have increased levels of coverage signifi- cantly since 1988. While acknowledging that the apparent declines may be an artefact of the data collection methods, the apparent fall in coverage recorded in some countries should alert national authorities to the possibility of a problem (AbouZahr and Wardlaw, 2001).

If the validity of using the percentages of births attended by skilled health personnel as a process indicator to monitor trends in maternal mortality is accepted, it can be concluded that while there have been modest improvements in Asia, Western Asia and Northern Africa, it is likely that levels of maternal mortality in sub- Saharan Africa have remained unchanged or even deteriorated.

In 1999, at the twenty-first special session of the General Assembly for an overall review and appraisal of the implementation of the Programme of Action of the International Conference on Population and Development, it was agreed that all countries should strive to ensure that 80 per cent of deliveries be assisted by skilled attendants by 2005 (General Assembly resolution S-21/2, annex, para. 64). Based on current trends, only the countries of Latin American and the Caribbean will attain this goal. Countries in Western Asia and Northern Africa will not attain the goal until around 2010, and Asian countries as a whole will fall short of the goal even in 2015. In sub-Saharan Africa as a whole, no progress towards the goal is

F. CAUSES OF MATERNAL MORTALITY AND