Rating maternal and neonatal health services in developing countries.

Rating maternal and neonatal health services in developing countries Rodolfo A. Bulatao1 & John A. Ross2 Objective To assess maternal and neonatal health services in 49 developing countries. Methods The services were rated on a scale of 0 to 100 by 10–25 experts in each country. The ratings covered emergency and routine services, including family planning, at health centres and district hospitals, access to these services for both rural and urban women, the likelihood that women would receive particular forms of antenatal and delivery care, and supporting elements of programmes such as policy, resources, monitoring, health promotion and training. Findings The average rating was only 56, but countries varied widely, especially in access to services in rural areas. Comparatively good ratings were reported for immunization services, aspects of antenatal care and counselling on breast feeding. Ratings were particularly weak for emergency obstetric care in rural areas, safe abortion and HIV counselling. Conclusion Maternal health programme effort in developing countries is seriously deficient, particularly in rural areas. Rural women are disadvantaged in many respects, but especially regarding the treatment of emergency obstetric conditions. Both rural and urban women receive inadequate HIV counselling and testing and have quite limited access to safe abortion. Improving services requires moving beyond policy reform to strengthening implementation of services and to better staff training and health promotion. Increased financing is only part of the solution. Keywords Maternal health services; Perinatal care; Health services accessibility; Delivery of health care; Family planning; Program evaluation; Comparative study; Developing countries (source: MeSH, NLM ). Mots cle´s Service sante´ maternelle; Soins pe´rinatals; Accessibilite´ service sante´; De´livrance soins; Controˆle naissances; Evaluation programme; Etude comparative; Pays en de´veloppement (source: MeSH, INSERM ). Palabras clave Servicios de salud materna; Atencio´n perinatal; Accesibilidad a los servicios de salud; Prestacio´n de atencio´n de salud; Planificacio´n familiar; Evaluacio´n de programas; Estudio comparativo; Paı´ses en desarrollo (fuente: DeCS, BIREME ). Bulletin of the World Health Organization 2002;80:721-727. Voir page 727 le re´sume´ en franc¸ais. En la pa´gina 727 figura un resumen en espan˜ol. Introduction Experts in developing countries have rated family planning programme efforts (1–3), thus facilitating useful comparisons between countries (4) and allowing the effects of programme services on outputs to be analysed (5). Expert ratings for HIV/ AIDS programmes have also recently been introduced (6). Such indicators of programme and service adequacy that are comparable across countries can be useful in identifying deficiencies, interpreting morbidity patterns and planning improvements. On the basis of judgements made by experts, we have obtained indicators for maternal and neonatal health services in 49 developing countries. The indicators, designed after a review of existing indicators for maternal health services (7–12), cover both routine and emergency care The present paper describes overall patterns across services and makes preliminary comparisons between countries. Methods The Futures Group International conducted the study in 1999 and early 2000, identifying individual consultants or consultant institutions for each of 49 developing countries and working with them to identify and recruit expert raters. Of the 10 to 25 raters selected in each country, at least two were from each of the following sources: the ministry of health (working in maternal and child health, hospitals, training, management information or elsewhere); private health care providers, including nongovernmental and community organizations; resident staff of international donors and related agencies; and medical schools and universities, associations of obstetricians and gynaecologists, nurses andmidwives, and similar groups of knowledgeable observers. Service providers comprised 42% of the 1037 raters; 61% of all the raters were physicians. The average country rater had eight years of experience at the national level and at least as much additional experience at the provincial, district or community level. There was no evidence of substantial systematic biases in ratings associated with the training or experience of raters (13). The experts were asked to rate services on an 81-item questionnaire, the Maternal and Neonatal Programme Effort Index. The items in the questionnaire covered antenatal care, treatment for complications of delivery, neonatal care, immunization, the control of sexually transmitted infections, and many other areas. The items were grouped not by medical condition but with reference to different stages involved in 1 Independent Consultant, 8201 16th Street, Silver Spring, Maryland, MD 20910, USA (email: Bulatao@erols.com). Correspondence should be addressed to this author. 2 Senior Fellow, Futures Group International, Glastonbury, Connecticut, USA. Ref. No. 00-0972 721Bulletin of the World Health Organization 2002, 80 (9) organizing and delivering care, from setting policy to attending to patients (Fig. 1). Also included, although not represented in the diagram, was the provision of family planning, the one substantive area separately covered. Taken together the elements represented programme effort as distinct from health outcomes. The experts rated services from 0 to 5. For example, in relation to the statement ‘‘All pregnant women have their labour monitored’’, a rating of 5 indicated that this was completely true whereas a rating of 0 indicated this was completely false. The ratings were multiplied by 20 to give a range of 0 to 100. A slightly different scale was employed for the assessment of access to services, indicating the percentage of pregnant women with adequate access to each service. Thus a range of 0 to 100 was again used. The experts were expected to give their own opinions but were free to consult with colleagues or refer to available health system or household survey data. Of the 49 countries, 23 were in Africa, 13 were in the Americas and 13 were in Asia (Table 6). They included the largest developing countries as well as countries of special policy interest, comprising 84% of the population of the developing regions. Partly because of its size, India was treated inmore detail than the other countries: programmeswere rated separately for each of 14 states containing some 85% of the national population. Population-weighted averages of the ratings for the states were used as national ratings. Results Capacity of health centres and district hospitals to provide maternal health services The mean ratings across countries of the capacity of health facilities and the rankings by item are shown in Table 1. That a health centre had adequate antibiotic supplies was about equally likely to be true or false (mean rating = 52). A health centre was more likely to have the capacity to administer antibiotics intravenously (mean rating = 61), but there was only a 52% probability of the antibiotics being available. Health centres tended not to use the partograph or to have transportation available in the event of obstructed labour and were especially unlikely to be able to offer manual vacuum aspiration or electric suction. District hospitals scored somewhat better than health centres. Hospitals were best at doing the things that health centres were supposed to do (rated 67), but their capacity to provide blood transfusions was, on average, close to even odds. Variation between countries in the capacity of facilities was largest with regard to the use of the partograph, as indicated by the standard deviations across countries per item (not shown). This simple tool had apparently been easily assimilated into the procedures of health centres in some countries whereas it was still largely unknown in others. Although the above ratings appear low, the question arises whether they, and others indicated below, are higher than they should be. A comparison of selected items with household survey data (see below) reveals no substantial discrepancies in ratings. There were few systematic differences between raters and there was no particular reason to distrust any category of raters (13). The ratings given are averages, and many countries indeed have much lower ratings. In addition, the ratings apply only to existing facilities. Ratings may be high in a situation where facilities are too few. Access to services in rural and urban areas The raters indicated the proportion of pregnant rural and urban women with adequate access to each service (Table 2). On average across eight items, their ratings imply that 68% of urban women and 39% of rural women had such access. For access to a 24-hour district hospital, the figures for urban and rural women were 81% and 58% respectively. For antenatal care, the figures were similar. For delivery care by a trained professional attendant, the figure was also similar for urban women, but for rural women it was lower, under 50%. Treatment for postpartum haemorrhage, obstructed labour and complications of abortion was accessible to slightly more than two-thirds of urban women but to only one-third of rural women. Fewer than half of urban women and only one-fifth of rural women had access to safe abortion, the least accessible service. Table 1. Capacity of facilities to provide maternal health services Meana Rankb At health centres, trained staff can . administer antibiotics intravenously 61.4 30 . manage postpartum haemorrhage 52.0 54 . call on adequate antibiotic supplies 51.8 55 . manually remove retained placenta 48.6 60 . use partograph to determine when to refer 45.4 65 . arrange transport in cases of obstructed labour 43.4 68 . perform manual vacuum aspiration or electric suction 24.3 80 At district hospitals, trained staff can . provide all functions listed for health centres 66.8 20 . perform caesarean sections or other operative deliveries 64.1 25 . perform blood transfusions 52.5 52 a Mean ratings for 49 developing countries on a scale of 0 to 100. b Ranks for the 81 items in Tables 1–5. 722 Bulletin of the World Health Organization 2002, 80 (9) Research In some particulars, the ratings of health services accessibility and of the capacity of facilities are in agreement. Overall, however, they do not correspond to one another. The wordings of items differ, and comparison is further compli- cated by the absence of information on the geographical distribution of pregnant women in relation to that of facilities. Maternal and neonatal health care received Ratings were obtained for maternal care received at antenatal visits, at delivery and for neonates (Table 3). These ratings were somewhat higher than those for the capacity of facilities and for access, indicating better than even odds that care would be received. This was partly because the items placed proportion- ally less emphasis on obstetric emergencies and more on routine types of care. The best odds for receiving care related to immunization. This probably reflected the vigour of the worldwide immunization effort. Nevertheless, the ratings of 76–78 sug- gested that many children were not covered. Very poor ratings were obtained for voluntary HIV counselling and testing (rated 30). HIV was not regarded as a pressing problem in a number of the countries covered, but evenwhere it should be so regarded, the ratingswere low.At 51 the rating for examination and treatment for syphilis was also low. Care for sexually transmitted infections appeared to be a serious weakness, lagging well behind other areas. Various other types of care fell between immunization and sexually transmitted infections. In general the care of neonates appeared somewhat better than antenatal or delivery care. The weakest aspect of neonatal care was prophylactic eye treatment. With regard to antenatal care, tetanus immunization was the most frequently available type of care, while counselling on HIV and sexually transmitted infections was the least frequently available. Hypertension received slightly more attention at antenatal visits than iron folate supplementation, which in turn received more attention than counselling on danger signs in pregnancy. Thus, even during antenatal visits, there was an apparent bias towards medical interventions as opposed to nutritional supplementation and simple counselling. At delivery, the odds of having a trained professional attendant were slightly better than even (rated 56). The odds were better for the encouragement of breast feeding, counselling on care of the umbilical cord, and checking for hypertension, anaemia and other conditions, presumably performed by a less trained person. The odds for receiving care in an emergency were also better than even (rated 55), but labour was less likely to be monitored in order to provide warning of an emergency (rated 52). Any monitoring may not be up to standard, given that the capacity to use the partograph had a lower rating (Table 1). The item with the lowest rating was a scheduled check-up within 48 hours after delivery. Family planning provision Ratings of family planning provision combined elements of the capacity of facilities, access and care received (Table 4). These ratings, ranging from 36 to 71, were not particularly high relative to other items despite substantial previous donor assistance in this area. District hospitals performed better than health centres and best in regard to the insertion of intrauterine devices (rated 71). They also tended to have contraceptive pills in stock, although health centres performed just as well in this connection. The worst result for health centres concerned the availability of progestin-only pills for breast feeding women Table 2. Percentages of pregnant women with access to maternal health services Rural areas Urban areas Mean Rank Mean Rank Adequate access to . district hospitals open 24 hours 57.7 37 81.3 1 . antenatal care 56.3 41 79.9 2 . delivery care by trained professional attendant 43.9 67 75.5 6 . postpartum family planning services 36.4 73 60.8 31 . treatment for postpartum haemorrhage 34.8 76 68.6 15 . management of obstructed labour 33.1 77 69.0 14 . treatment of complications of abortion 32.0 78 68.0 17 . provision of safe abortion services 21.1 81 44.7 66 Table 3. Maternal and neonatal health care received Care received Mean Rank Antenatal visits Tetanus injections as required 78.4 4 Examination and treatment for hypertension 70.2 13 Iron folate tablets for anaemia 65.8 22 Information on danger signs 59.6 33 Examination and treatment for syphilis 51.5 56 Voluntary HIV counselling and testing offered 29.8 79 Delivery Encouragement to start breast feeding immediately 74.3 7 Counselling on care of umbilical cord 65.9 21 Checking for hypertension, anaemia, infection 59.9 32 Seen by trained professional attendant 56.0 44 Can receive emergency obstetric care 55.5 45 Monitoring of labour 52.5 53 Scheduled for check-up in 48 hours 41.2 72 Neonates Scheduled for subsequent immunizations 78.5 3 Diphtheria-tetanus-pertussis injection at 3 months of age 76.5 5 Umbilical cord cut with clean blade 72.7 9 Dried and kept warm 72.5 10 Mouth and nasal passageways cleared 68.5 16 Prophylactic eye treatment 57.3 38 723Bulletin of the World Health Organization 2002, 80 (9) Rating maternal and neonatal health services in developing countries (rated 49). Hospitals performed even worse in the provision of male sterilization (rated 36). The likelihood of postpartum family planning being routinely offered was rated 56 for district hospitals and 51 for health centres. Table 2 showed that 61% of urban women had access to postpartum family planning services, suggesting that, proportionally, urban facilities offering this service attended to more deliveries than facilities not offering it. However, only 36% of rural women had such access, indicating that, whatever services health centres and hospitals provided, substantial proportions of rural women did not have access to the facilities themselves, or at least to those facilities that were adequately staffed and equipped. Policy and support services Ancillary services were divided into five areas (Table 5). Of these, broad policy was generally the strongest. Having a basic policy and a service director with a high rank in the bureaucracy were rated 72 and 67 respectively. Similarly, such other policy items as authorizing appropriate personnel to provide services, consulting interested groups on policy development, and issuing frequent public statements of support were better rated than most other ancillary services. The lowest ratings for policy items were given to official approval for treating complications of abortion and to active policy implementation through high-level reviews and action plans. Table 4. Family planning provision Health centres Hospitals Mean Rank Mean Rank Trained staff . have contraceptive pills consistently in stock 65.7 23 67.3 18 . routinely offer family planning after delivery 59.3 34 61.5 29 . can insert intrauterine devices 56.7 40 70.7 12 . routinely offer family planning after abortion 51.4 57 56.1 43 . have progestin — only pills for breast feeding women 48.7 59 – – . can offer sterilization to females – – 61.9 28 . can offer sterilization to males – – 35.7 74 – No data available. Table 5. Policy and support services Mean Rank Policy Adequate health ministry policies 72.5 11 Service director at high administrative level 66.9 19 Appropriate personnel allowed to provide services 63.6 26 Policies developed through adequate consultation 63.6 27 High ranking officials issue frequent statements of support 58.3 36 Policies favour treatment of complications of abortion 54.8 47 High-level policy reviews and action plans 53.9 49 Resources Active private sector 58.5 35 Adequate budget 48.1 64 All services and drugs free 35.0 75 Monitoring and research Surveys provide data on maternal events 64.1 24 Statistical reporting system 56.9 39 Statistics used for decisions and strategy 56.2 42 Central monitoring and analysis of statistics 54.0 48 Updated listing of facilities 52.9 51 Each hospital reviews maternal deaths 49.8 58 Health promotion Ministry supplies educational materials 48.4 61 Community organizations educate public 48.4 62 Media-based education on complications 48.3 63 Media-based education on harmful practices 42.6 69 Training Medical curricula include hands-on training 72.8 8 Midwife and nurse refresher training within five years 55.3 46 Doctor refresher training within five years 52.9 50 New midwives and nurses trained in six months 42.6 70 New doctors trained to manage normal deliveries 41.3 71 724 Bulletin of the World Health Organization 2002, 80 (9) Research The weakness of implementation was also reflected in poor scores for resources. The odds were essentially even that the budget for public services would be adequate. In contrast the odds were better that the private sector would be active. Active monitoring is required in order to ensure that policy is effective. Item ratings varied in this area. They were best for surveys of maternal events (rated 64), followed by statistical reporting systems (and their use for monitoring and decision-making) and then by centralized listings of facilities. Hospital reviews of all their maternal deaths was the item with the lowest rating. This was unfortunate, since such reviews could trigger immediate improvements in practices. In general, review and follow-up were particular weaknesses of maternal health programmes. As earlier noted, the odds were barely even, or worse than even, that other reviews of services would take place, whether high-level reviews or the equivalent at the client level, scheduled client check-ups. Providers were possibly too busy with clients or too absorbed in competing activities to review their work with a view to improvement. Educating the public about pregnancy complications, safe places to deliver and harmful practices, an important adjunct to the provision of services, received relatively little attention. All the items on health promotion were in a tight cluster of ratings below 50. For staff training, on the other hand, the spread in ratings was quite large. Hands-on training as part of medical curricula was rated relatively highly, whereas training for new medical staff received one of the lowest ratings. Refresher training within the preceding five years was given intermediate ratings. As might be expected, doctors were less likely to receive either new-provider or refresher training than nurses and midwives, but the difference in each case was only 2 points. Variation between countries Variation between countries was substantial. Table 6 shows one indicator of this, a rating of national access tomaternal care obtained by averaging all the urban and rural access ratings, weighted by population. Over 80% of women were estimated to have access to services in Jamaica and the Islamic Republic of Iran; under 30% had such access in Ethiopia, Nepal, Pakistan, and the Republic of Yemen. This large difference primarily reflected differences in rural access. Urban access also varied but the gap was smaller. For other non-access items (not shown) the gaps tended to be somewhat smaller even between these two extreme groups of countries. In particular the gaps were only half as wide for ratings of average policy and budget adequacy. Africa had a preponderance of countries with very weak access ratings, but here, and evenmore so on other continents, the variation in ratings was wide. There were some extreme contrasts between neighbouring countries, e.g., between the Islamic Republic of Iran and Pakistan and between the Dominican Republic and Haiti. Table 6. National ratings for access to maternal health servicesa Americas Asia Africa Moderate (70–89) Jamaica 83.1 Islamic Republic of Iran 80.9 Egypt 74.5 Dominican Republic 72.9 China 75.4 South Africa 73.3 Peru 72.1 Viet Nam 73.9 West Bank and Gaza Strip 72.9 Weak (50–69) Mexico 66.1 Philippines 69.2 Algeria 66.4 Brazil 64.1 Myanmar 57.1 Zimbabwe 65.5 Paraguay 58.1 India 56.2 Ghana 56.6 Ecuador 53.4 Indonesia 52.4 Malawi 53.9 Nicaragua 50.6 Sudan 52.4 Republic of the Congo 51.9 Very weak (30–49) Honduras 49.7 Cambodia 33.0 Benin 48.9 El Salvador 47.9 Bangladesh 31.5 Madagascar 48.1 Guatemala 40.4 United Republic of Tanzania 47.2 Bolivia 39.1 Rwanda 44.3 Haiti 31.6 Kenya 42.5 Mali 42.4 Mozambique 42.2 Nigeria 40.4 Uganda 40.3 Guinea 40.0 Senegal 39.7 Democratic Republic of the Congo 39.4 Zambia 37.3 Angola 35.4 Extremely weak (10–29) Yemen 29.4 Ethiopia 27.5 Pakistan 24.6 Nepal 16.9 a Rural and urban access weighted by population. 725Bulletin of the World Health Organization 2002, 80 (9) Rating maternal and neonatal health services in developing countries Conclusions How credible are expert ratings of reproductive health programmes? Such measures obtained over three decades for family planning programmes, based on similar types of questions and using expert groups recruited by the same procedures, have proved useful for research and policy purposes. They have been essential in analyses of the contribution of family planning programmes to contraceptive use and fertility transition and have been used by persons arguing both for and against such a contribution (14, 15). The ratings have also been used as a means of drawing attention to weaknesses in these programmes in particular countries and of mobilizing and focusing national efforts. Two decades after their introduction, ratings of family planning programmes were validated against objective data for two countries (16). Similar detailed validation of ratings of maternal health programmes is not possible at present, but limited comparisons can be made with household survey data to show that the experts are generally accurate. The Demographic and Health Surveys (DHS) asked national samples of women who their attendants were at any birth in the previous five years and whether the women had received tetanus injections beforehand. Responses are available for surveys conducted between 1994 and 1998 for 27 of the 49 countries considered in this paper (17). The proportions of births in the presence of a trained attendant, as indicated by the DHS, agree well with the current ratings for attended births, which generally refer to 1999. The correlation across countries is 0.70. The correlation is even stronger, at 0.83, with ratings as of three years previously, i.e. effectively for 1996. For the proportion receiving at least two tetanus injections the correlations are also strong at 0.62 for current ratings and 0.74 for ratings as of three years previously. The level of ratings is also of interest. For the countries covered by the DHS, the mean percentage of births in the presence of a trained attendant was 55, virtually identical to the mean current rating of 56 for these countries and higher than the rating of 43 for three years previously. The DHS indicated the mean percentages receiving at least one and at least two tetanus injections to be 69%and 46% respectively, these values being below the currentmean rating of 77 for ‘‘needed’’ tetanus injections in the same countries but encompassing the mean rating of 66 for three years previously. The complications of these comparisons cannot be explored here. The important point is that expert ratings match, to some degree, data derived from large, representative household surveys, providing a quicker method of obtaining an overall programme evaluation. What do the ratings imply for policy in this area? Clearly, there is a need for greater programme effort. With only a 56% likelihood that a typical service item is adequate, maternal health programmes in developing countries have serious deficiencies. The wide range in mean country ratings shows that some countries face much greater challenges than others. The need to improve services is greater in rural areas. Only 39% of rural women were estimated to have adequate access to the average service item, as opposed to 68% of urban women. Rural womenwere especially disadvantaged in respect of the treatment of emergency obstetric conditions. Since rural access ratings are among the most variable between countries, the lower ratings may be remediable. What services most require improvement? Emergency obstetric services are a possible choice, being much less adequate than many routine services for pregnant women, such as antenatal care, nutrition supplementation during pregnancy and the care of neonates. Raising less concern are such services as immunization and the encouragement of breast feeding at delivery, whose ratings are among the best. Nevertheless, some services that could be considered routine received even lower ratings than emergency care. Among these were HIV counselling and testing (rated 30), safe abortion in both urban and rural areas (ratings 45 and 21 respectively), and the scheduling of a postnatal check-up within 48 hours (rating = 42). However, it is not possible to conclude that the weakest services should have top priority. This analysis has not considered why particular ratings are low, the interactions between them, the epidemiological implications, and the costs of remedies. Such issues would have to be taken into account if ratings were to be used to justify focusing on the weakest areas, or on the weakest country programmes, which would also require attention to government commitment and capacity. Arguably, however, national policy reform should not be the main focus. Ratings of official maternal health policies are better than many of the ratings for actual services. Implementa- tion is clearly the crux of the matter, and increased financing is only part of the answer. The likelihood of an adequate budget is rated close to 50%. While not good, this is not substantially worse than other ratings. Between countries at opposite extremes, moreover, the contrasts in budget adequacy are substantially weaker than the contrasts in access to services. The improvement of training must be another part of the answer. The training of new providers is uncommon, and refresher training occurs only slightly more frequently. The adequacy of training has not been ascertained. Health promotion is another problematic area. All media-related items are rated, on average, below 50. Whether this is due to inattention, a lack of resources or a lack of skills in health promotion, the weakness in this area suggests substantial needs. One cannot rely on the private sector to compensate for inadequate public services. Where service ratings are weak, ratings for private sector activity may also be weak. This is especially true for South Asia generally. The picture may seem bleak, but there are indications that maternal health care services have improved since the 1994 Cairo conference. Raters estimated that adequacy improved by 10 points on the typical item over three years. Assuming this to be reliable, such performance, if sustained, could eventually lead to substantial progress. n Acknowledgements The data were provided by 1037 raters, who cannot be acknowledged individually. They were recruited by consultants in each country, who also made important contributions. Advice on the design of the study and on the questionnaire was received from Carla Abou-Zahr, Wendy Graham, Marge Koblinsky, Deborah Maine, Cindy Stanton, Patricia Stephen- son, Amy Ong Tsui and others. Katherine Abel and Katharine Cooper-Arnold assisted with data processing. TheMEASURE Evaluation project and the Rockefeller Foundation provided financial support. Conflicts of interest: none declared. 726 Bulletin of the World Health Organization 2002, 80 (9) Research Re´sume´ Notation des soins de sante´ maternelle et ne´onatale dans les pays en de´veloppement Objectif Evaluer les services de sante´ maternelle et ne´onatale dans 49 pays en de´veloppement. Me´thodes Dans chaque pays, les services ont e´te´ note´s de 0 a` 100 par 10 a` 25 experts. Pour e´tablir la note, divers e´le´ments e´taient pris en compte : services d’urgence et services courants (y compris les services de planification familiale) dans les centres de sante´ et les hoˆpitaux de district, acce`s a` ces services pour les femmes des zones rurales et urbaines, probabilite´ pour les femmes de recevoir certains soins ante´natals et obste´tricaux, et e´le´ments d’appui (politiques, ressources, surveillance, promotion de la sante´ et formation). Re´sultats La note moyenne n’e´tait que de 56, mais avec de grandes variations d’un pays a` l’autre notamment au niveau de l’accessibilite´ des services dans les zones rurales. Des notes relativement bonnes ont e´te´ obtenues pour les services de vaccination, les soins ante´natals et le conseil en matie`re d’allaitement au sein. Elles e´taient particulie`rement faibles pour les soins obste´tricaux d’urgence en milieu rural, les services d’interruption de grossesse et le conseil relatif au VIH. Conclusion Les efforts consacre´s a` la sante´ maternelle dans les pays en de´veloppement sont nettement insuffisants, surtout dans les zones rurales. Les femmes des zones rurales sont de´savantage´es a` de nombreux e´gards, mais plus particulie`rement en ce qui concerne le traitement des urgences obste´tricales. Dans les zones rurales comme dans les zones urbaines, le de´pistage et le conseil en matie`re de VIH sont insuffisamment propose´s aux femmes, qui n’ont en outre qu’un acce`s limite´ aux services d’interruption de grossesse. Pour redresser la situation, il faut aller au-dela` de la re´forme des politiques pour renforcer la mise en œuvre des services et ame´liorer la formation des personnels et la promotion de la sante´. L’augmentation du financement ne repre´sente qu’une partie de la solution. Resumen Evaluacio´n de los servicios de salud materna y neonatal en los paı´ses en desarrollo Objetivo Evaluar los servicios de salud materna y neonatal en 49 paı´ses en desarrollo. Me´todos Unos 10–25 expertos puntuaron el funcionamiento de los servicios con arreglo a una escala de 0 a 100 en cada paı´s. La evaluacio´n abarco´ los servicios de urgencia y los servicios ordinarios, incluida la planificacio´n familiar, de los centros de salud y los hospitales de distrito, el acceso a esos servicios por las mujeres, tanto rurales como urbanas, la probabilidad de que las mujeres recibieran determinadas formas de atencio´n prenatal y obste´trica, y elementos de apoyo de los programas tales como las polı´ticas, los recursos, la vigilancia, la promocio´n de la salud y la capacitacio´n. Resultados La puntuacio´n media fue so´lo de 56, pero con amplias diferencias entre los paı´ses, especialmente en lo referente al acceso a los servicios en las zonas rurales. Se asignaron puntuaciones comparativamente buenas a los servicios de inmunizacio´n y a los aspectos de la atencio´n prenatal y los consejos sobre la lactancia materna. Obtuvieron en cambio una puntuacio´n particularmente baja la atencio´n obste´trica de urgencia en las zonas rurales, el aborto y los consejos relacionados con el VIH. Conclusio´n Las actividades de los programas de salud materna emprendidos en los paı´ses en desarrollo adolecen de graves deficiencias, especialmente en las zonas rurales. Las mujeres de estas zonas esta´n desfavorecidas en muchos aspectos, sobre todo en lo tocante al tratamiento de los problemas obste´tricos urgentes. Tanto las mujeres rurales como las urbanas carecen de servicios suficientes de asesoramiento y pruebas sobre el VIH y tienen un acceso muy limitado a la posibilidad de abortar sin riesgos. A fin de mejorar los servicios, es necesario rebasar el marco de las reformas de polı´tica para reforzar la implantacio´n de servicios y mejorar la formacio´n del personal y la promocio´n de la salud. El aumento de la financiacio´n es so´lo una parte de la solucio´n. References 1. Mauldin WP, Lapham RJ. 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Egypt Demographic and Health Survey 1995. Cairo: National Population Council; 1996. Calverton, Maryland: Macro International Inc.; 1996. 727Bulletin of the World Health Organization 2002, 80 (9) Rating maternal and neonatal health services in developing countries