The 1990 RAMOS study that focused on maternal mortality helped galvanize the efforts behind these changes: knowledge that the MMR was 182 gave the Ministry of Health a "rude awakening" (Danel 2000). Targeting regions of the country with the highest MMRs (regions 2, 5, and 6), the government, with donor assistance, built seven new rural area hospitals and, with community input, five maternity waiting homes attached to rural hospitals as well as eight new birthing centers. The number of urban medical health centers (CESAMO) and rural health centers (CESAR) also increased. While these health centers do not provide delivery care, they do offer prenatal care and referrals for hospital delivery for high-risk women.
Throughout the country, an increase in the number of health personnel, especially auxiliary nurses, accompanied the rise in facilities. More training was offered. The training of the clinical staff, along with community health workers (including the TBAs), focused on recognizing risks in pregnancy (extremes of age, first birth, more than four previous births, underlying medical problems) and danger signs in childbirth (including bleeding, hypertension, labor longer than 8 hours for multiparas and 10 hours for primiparas, premature rupture of membranes, fever, retained placenta, and malpresentation). Norms for the integrated care of women were published in 1995; they emphasized the identification and referral to hospitals of high-risk women and those with obstetric emergencies.
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