Despite recent improvements in some countries, progress towards reducing maternal mortality rates in sub-Saharan Africa overall lags considerably behind that of other developing country regions.

Recent evidence indicates that Rwanda has made impressive progress in this area, particularly in the rural locations. This report presents research findings from a project concerned with identifying the institutional arrangements which have enabled Rwanda to achieve significant improvement in ensuring safe motherhood for growing numbers of women in the rural districts of Nyamagabe and Musanze.

Ethnographic research conducted over several months explored how actors, institutions and resources have been combined to overcome the key bottlenecks which might otherwise have undermined the provision of the key services which contribute to good maternal health outcomes. Initial analysis indicates that the coherence of the policy environent has been a key element. In addition to aiding in the clear definition oflines of responsibility, it has facilitated the avoidance of the sorts of overlapping mandates which usually encourage actors to pass the buck for service delivery failures. Laxity in professional standards and related problems ensuing from lack of motivation have been overcome by accountability mechanisms which serve as strong deterrents against misconduct by all actors responsible forservice provision.

Accompanying performance pressures based on consistent incentives comprising rewards and punishment ensure that all actors work toward the same objective of providing high-quality services. A crucial element in all this has been the facilitation of collaboration through which different actors, including users, can work together to overcome key bottlenecks.

Historically, indigenous peoples’ access to health services in Latin America has been limited due to a variety of social, economic and cultural factors. The misunderstanding of indigenous peoples’ world view and their definition of health makes it more difficult to design and implement public policies that reflect their real needs. This Brief presents the progress at the regional and country level, discusses advances in the design and implementation of intercultural health policies in areas with indigenous communities.

Key Lessons:

• the Latin American experience shows that regional health organisations can play an important role by defining the elements of an intercultural policy and the pathway for implementing it. This provides important support and inspiration for individual countries within the region
• constitutional acknowledgement of the right to intercultural health can be a first step to guaranteeing this right and ensuring its implementation
• the visibility of the struggle coming from the non-recognition and implementation of an intercultural health policy that has been brought by social movements and CSOs can produce substantive changes, such as the creation of agencies

• Session 1: The Scale of the Problem
  
• Session 2: Causes and Consequences of Undernutrition
• Session 3: Methods of Nutritional Assessment
• Session 4: International Landscape for Nutrition Programming

• Session 5: Basic Epidemiology: Evaluating Quality of Evidence
• Session 6: Introduction to Emergencies: Nutritional Assessment and Early Warning Systems
• Session 7: Food Based Strategies for Enhanced Nutritional Status: Dietary Diversification and Biofortification
• Session 8: Maternal Nutrition
• Session 9: Infant and Young Child Feeding
• Session 10: Infant and Young Child Feeding in Emergencies
• Session 11: Social Protection for Nutritional Outcomes
• Session 12: Agriculture and Nutrition
• Session 13: Climate Change and Nutrition
• Session 14: Nutrition and Infection
• Session 15: Nutrition and Health in Emergencies
• Session 16: Gender Equality and Nutrition
• Session 17: Nutrition and Education

In sub-Saharan Africa, the unprecedented population growth that started in the second half of the twentieth century has evolved into unparalleled urbanisation and an increasing proportion of urban dwellers living in slums and shanty towns, making it imperative to pay greater attention to the health problems of the urban poor. In particular, urgent efforts need to focus on maternal health. Despite the lack of reliable trend data on maternal mortality, some investigators now believe that progress in maternal health has been very slow in sub-Saharan Africa.

This study uses a unique combination of health facility- and individual-level data collected in the slums of
Nairobi, Kenya to:

• describe the provision of obstetric care in the Nairobi informal settlements
• describe the patterns of antenatal and delivery care, notably in terms of timing, frequency, and quality of care
• draw policy implications aimed at improving maternal health among the rapidly growing urban poor populations.

It finds that:

• the study area is deprived of public health services, a finding which supports the view that low-income urban residents in developing countries face significant obstacles in accessing health care
• despite the high prevalence of antenatal care (ANC), the proportion of women who made the recommended number of visits or who initiated the visit in the first trimester of pregnancy remains low compared to Nairobi as a whole and, more importantly, compared to rural populations
• bivariate analyses show that household wealth, education, parity, and place of residence were closely associated with frequency and timing of ANC and with place of delivery
• there is a strong linkage between use of antenatal care and place of delivery.

The authors call for urgent attention by Kenya’s Ministry of Health and local authorities to the void of quality health services in poor urban communities and the need to provide focused and sustained health education geared towards promoting use of obstetric services.