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The World health report 2005 provides a powerful analysis of the global scandal of mothers’ and children’s ill-health (1). Every year over half a million women die from pregnancy-related causes and over 10 million children die under five years of age. These deaths are largely preventable. The report correctly identifies the causes as lying primarily in failures within health systems to provide appropriate frameworks and resources to deliver the technical interventions and in broader social and cultural factors. Evidence on technical interventions is well covered. Midwifery-led care at the first level of services with accessible back-up in hospitals is essential for reducing maternal and neonatal mortality. The report is crystal clear on this acknowledging past failures of training traditional birth attendants and problems of over-medicalization of childbirth. Universal access both financial and geographical to care by skilled attendants is emphasized although a description of the requirements of referral systems to ensure timely access to obstetric care would have been helpful. Issues too often ignored are included: violence discrimination and marginalization during pregnancy sex selection and the need for evidence to develop policy on postpartum care. (excerpt)

Exclusion, inequity and health system development: the critical emphases for maternal, neonatal and child health.