SummaryThis study assesses the performance of maternity care and its specific service components (preventive interventions in antenatal care, antenatal screening, referral, obstetric care) in Banke District, Nepal, using a set of structure, process, and output/outcome indicators. Data sources included health service documents in 14 first level health units and two hospitals, covering 1378 pregnancies and 1323 deliveries, structured observations, antenatal exit interviews (n ϭ 136) and interviews with maternity users (n ϭ 146). Coverage of antenatal care (28%) and skilled delivery care (16%) was low. In antenatal care, preventive interventions were only partially implemented (effective iron supplementation in 17% of users). On average one minute was spent on individual counselling per consultation. 41% of pregnancies were identified as high risk and 15% received referral advice, which was followed in only 32%. Hospital deliveries accounted for 9.8% of all deliveries. Hospital-based maternal mortality was 6.8/1000 births and the stillbirth rate 70/1000. High rates of stillbirth were observed in breech delivery (258/1000 births), caesarean section (143/1000) and twin delivery (133/1000). The risk of stillbirth was higher for rural women (RR 2.3; 95% CI 1.51-3.50) and appeared to be related to low socio-economic status. Emergency admissions were rare and accounted for 3.4% of hospital deliveries or only 0.4% of all expected deliveries. There was hardly any accumulation of high-risk pregnancies at hospital. The population-based rate of caesarean section was 1.1% (urban 2.3%, rural 0.2%). The estimated unmet obstetric need was high (82 cases or 61% of expected live-threatening maternal conditions did not receive appropriate intervention). The limited effectiveness of maternity care is the result of deficiencies of all service components. We propose a two-pronged approach by starting quality improvement of maternity care from both ends of maternity services: preventive interventions for all women and hospital-based obstetric care. Antenatal screening needs to be rationalized by reducing inflated risk catalogues that result in stereotypical and often rejected referral advice. keywords safe motherhood, health systems research, maternity care, quality of care, Nepal correspondence Dr Albrecht Jahn,

A rabid wolf attacked 12 humans and six animals in six villages in the course of a day before it was surrounded and killed. Of the 12 human victims, three had severe wounds to the face and head, five had severe lacerations, two had less severe wounds on the trunk and limbs, and two had minor wounds or scratches. Nine of these victims received antirabies treatment with Semple vaccine (preceded by immune serum in one case). No persons with trunk and limb bites died. All three patients with head wounds died. One of these patients received vaccine and serum, one received vaccine, and the third had no treatment. Neutralizing antibodies were demonstrated in blood samples drawn 58 days after the incident from five survivors who had received a full course of treatment, but such antibodies were absent from the blood of one untreated survivor (who had only minor scratches and had refused treatment) and of the wife of one man who died, who had been in close contact with her husband throughout his illness. All severely bitten animals died of rabies. A dog that the carcass of a pig which had died of rabies itself developed rabies 12 days later. This event raised the possibility of infection by the oral route.

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SUMMARY In a prospective community based study of the distribution and determinants of stillbirths in a rural area of Maharashtra, India, that was carried out for two years, 3129 singleton and 22 twin births were recorded in a population of 47 000. Of the 3173 babies, 85 singletons and five of the twins were stillborn giving a stillbirth rate of 28 4/1000 births. The causes of stillbirths are analysed and the possibility of reducing the unacceptably high stillbirth rate by adequate training of grassroot level workers in screening pregnant women for detection of "at risk" mothers and their timely referral is discussed.

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