attending to 136 million births, every year 67 the registration of midwives was stepped up with 18 314 new registrations. Midwives ecame key figures in many villages, proud of their professional and social status Mortality dropped steadily and caught up with Sri Lanka by 1980. The main effort then went into strengthening and equipping district hospitals. Within 10 years, from 1977 to 1987, the number of beds in small community hospitals quadrupled, from 2540 to 10 800, and the number of doctors in these districts rose from a few hundred to 1339. By 1990 the maternal mortality ratio was below 50 per 100 000 births(see Figure 4.2) More recently, Egypt reduced its maternal mortality by more than 50% in eight years, from 174 in 1993 to 84 per 100 000 live births in 2000: major efforts to promot safer motherhood doubled the proportion of births attended by a doctor or nurse and improved access to emergency obstetric care (41). Honduras brought matemal deaths down from 182 to 108 per 100 000 between 1990 and 1997 by opening and staffing seven referral hospitals and 226 rural health centres and by increasing the number of health personnel and skilled attendants (42) These examples illustrate that long-term initiatives and efforts to provide skilled professional care at birth produce results; unfortunately, the converse is true as well. Breakdowns of access to skilled care may rapidly result in an increase of unfavour ble outcomes, as in Malawi or Mongolia(see Chapter 1). In Tajikistan too, economic upheaval following the break-up of the Soviet Union and newly won independence in 1991, compounded by civil war, led to a startling erosion of the capacity of the health care system to provide accessible care and a dramatic tenfold increase in the proportion of women giving birth at home with no skilled assistance (43 ) Maternal Some countries are trying to make good the shortfall in the number of midwives. This picture of lurse-midwifery graduates was taken on the day of their graduation from the University of Malawi amuzu College of Nursingattending to 136 million births, every year 67 the registration of midwives was stepped up with 18 314 new registrations. Midwives became key figures in many villages, proud of their professional and social status. Mortality dropped steadily and caught up with Sri Lanka by 1980. The main effort then went into strengthening and equipping district hospitals. Within 10 years, from 1977 to 1987, the number of beds in small community hospitals quadrupled, from 2540 to 10 800, and the number of doctors in these districts rose from a few hundred to 1339. By 1990 the maternal mortality ratio was below 50 per 100 000 births (see Figure 4.2). More recently, Egypt reduced its maternal mortality by more than 50% in eight years, from 174 in 1993 to 84 per 100 000 live births in 2000: major efforts to promote safer motherhood doubled the proportion of births attended by a doctor or nurse and improved access to emergency obstetric care (41). Honduras brought maternal deaths down from 182 to 108 per 100 000 between 1990 and 1997 by opening and staffing seven referral hospitals and 226 rural health centres and by increasing the number of health personnel and skilled attendants (42). These examples illustrate that long-term initiatives and efforts to provide skilled professional care at birth produce results; unfortunately, the converse is true as well. Breakdowns of access to skilled care may rapidly result in an increase of unfavour￾able outcomes, as in Malawi or Mongolia (see Chapter 1). In Tajikistan too, economic upheaval following the break-up of the Soviet Union and newly won independence in 1991, compounded by civil war, led to a startling erosion of the capacity of the health care system to provide accessible care and a dramatic tenfold increase in the proportion of women giving birth at home with no skilled assistance (43). Maternal Some countries are trying to make good the shortfall in the number of midwives. This picture of nurse-midwifery graduates was taken on the day of their graduation from the University of Malawi Kamuzu College of Nursing. R.M. Kershbaumer/University of Pennsylvania School of Nursing