Adopted in 1987 by the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), and WHO, the International Safe Motherhood Initiative seeks to reduce maternal deaths by at least one-half by the end of the century (113, 185). The Initiative does not specifically mention migrants, refugees, or internally displaced persons, nor have many studies focused on safe motherhood practices among migrants. A study in Bolivia found that migrants were less likely than others to have had prenatal care or a trained attendant during delivery (27). In Sabah, Malaysia, poor access to reproductive health services, as well as lack of interest, helped explain why migrants were much less likely than the general population to have prenatal care. Migrants who received any prenatal care at all received it later than the general population (345).

Data do not exist on safe motherhood practices among refugees or even on refugees' morbidity and mortality related to pregnancy and childbirth (299, 320). Observers have reported, however, that pregnancy and complications of delivery are leading causes of illness and death among refugee women of childbearing age when maternal care is unavailable (195, 302). When complications of pregnancy occur, for example, camp medical provisions are likely to prove inadequate, and hospitals may be too far away (222). Two recent publications, drafted following the Symposium on Reproductive Health in Refugee Situations in 1995, draw attention to safe motherhood for refugees 242, 299, 310) (see sidebar International Relief Agencies).

Except for emergency obstetrics, safe motherhood initiatives may not be too difficult to organize in refugee camps. It is often possible, for example, to find traditional birth attendants (TBAs) among refugees who could be included in a safe motherhood system working together with trained midwives (32). Among refugees in Kenya, TBAs were trained in safe motherhood care, while refugee health workers were trained by the International Rescue Committee (IRC) to provide family planning (12). In three camps in Baluchistan, TBAs among the refugees received training and were able to provide better services (207).