Issues Paper No. 9

"A TORA MOUSSO KELE LA": A CALL BEYOND DUTY
OFTEN OMITTED ROOT CAUSES OF MATERNAL MORTALITY IN WEST AFRICA
Alpha Boubacar Diallo

Endnotes
Acknowledgements
Biographical Note

It is one of the merits of the Nairobi (1987) and Niamey (1989) conferences on Safe Motherhood to have brought to the attention of the international community the true dimension and nature of the long neglected and tragic problem of maternal mortality. Their call for action has produced an encouraging mobilization of international and national institutions and organization, with new studies of the problem being undertaken and new national programmes being developed.

While there is a consensus that the most appropriate approach to solving the problem of maternal mortality has to be multisectoral and multidisciplinary, most of the strategies developed so far have put the major emphasis on a medical solution, with sometimes limited socio-economic supporting interventions. By contrast, the socio-cultural dimension has so far received very little attention in both referenced studies and in the development of national programmes. In most cases, socio-cultural conditions have been lumped in with the socio-economic factors.

 One of the reasons for this situation could be the bias of research towards quantitative methodologies. Another reason is the understandable caution required in handling cultural values, together with a judgment that these are difficult to change.

 Is the omission of the socio-cultural dimension justified for any understanding of such a sensitive, intimate, complex but also important phenomenon as is human reproduction? In doing so, are we running the risk of overlooking some key primary causes in the pursuit of symptoms and secondary causes? This has serious implications for the effectiveness of strategies designed to bring about the conditions essential and necessary for assuring safer motherhood for millions of women, particularly in the developing world.

 It was during a 6000 km journey through rural Senegal in 1989 to collect data for a study on maternal mortality that the importance of the socio-cultural dimension was clearly illustrated. We were privileged to a wide spectrum of rich experiences. Some were unusual, many were dramatic and most were deeply moving. From this mass of data, impressions and feelings, two critical impressions stand out.

 First, a strong connection was established with the women we met. The success of our approach was thus predicated on an ability to explain the purpose of the study (1), and consequently to gain the active support of the host community through an equal partnership. One outcome was our strong sense of moral obligation to improve the fate of these women, and to help them avoid the tragedy of maternal mortality, a risk they face during each and every pregnancy.

The second observation is that, while the team felt that the findings of the study had made some significant contribution to the understanding of factors affecting maternal mortality through a systematic investigation of factors contributing to maternal death in both the health system and the community; including the modelling of demand and supply for obstetric services; the development of an index of obstetric risks; the correlation between risk and knowledge; the distance from a health centre, etc., our Report could only capture a small fraction of the reality that we had experienced.

 Beneath the reality open to study with the tools and methodologies generally used to analyze the phenomenon of maternal mortality lie other crucial determinants. Understanding these could be essential if one is ever to develop effective strategies which reduce rates of maternal mortality in West Africa.

 Let us explore the nature and consequences of these determinants and their implications for the development of effective strategies for substantially reducing maternal mortality.

 These determinants are best summarized by the expression: "a tora mousso kele la", which in Bambara is an expression used for the loss of life of a woman in childbirth. The equivalent is: "she fell on the battlefield in the line of duty".

 The internal logic and corresponding concepts embodied in this expression are an integral part of a larger reality, namely a system of societal beliefs developed through the ages to manage a major event: the procreation process. As with any such system, society also develops a related set of practices, customs, and normatively sanctioned behaviours within its accepted values which become elements of its culture.

 From the onset and throughout the field trip we were to discover the importance of the socio-cultural dimension.

The initial indication came from our first community interview. To compensate for the small size of our sample and improve the reliability of our results, we chose to collect the data from three independent sources. For data on maternal deaths we used the local government official census documents, the health services statistics, and the community official records, and then carried out our in-depth interview of community leaders. We then checked for inconsistencies and discrepancies.

 We soon discovered that for the collective memory of the community (2) that maternal death was a "non event". We could not get data from a direct question such as, How many maternal deaths occurred during a given time period? We had to devise a four-step approach. We started with the total number of deaths for the period. From this total we got the number of deaths to women. Then from the latter the number of deaths within the age bracket 15 to 45. Finally we correlated this number to known pregnancies and births.

 Many significant determinants of maternal mortality can be attributed to a large extent to the "logical" implications of the Bambara expression.

 Let us examine some of these implications and their consequences for maternal mortality. Finally we can see how these elements will affect the choices for an effective set of strategies for the development of programmes for safer motherhood.

 The implicit assumptions underlying the expression are:

 1) Childbirth is assimilated to a battle.

2) Any battle, in essence, has inherent and unavoidable associated risks. Among the risks are casualties and deaths.

3) It is the duty, not to say destiny, of women to have to go through this battle in order to achieve the ideal family size required by the norms of society.

4) As a "warrior", the pregnant woman is valued for her bravery, expressed in terms of stoicism.

5) In preparation for the battle, the major emphasis is centered around psychological coping strategies for achieving the stoic stance.

6) Society, for its part, develops strategies to transcend the adversity of an eventual casualty; in this instance, maternal death.

7) The phenomena of both is beyond our power to understand: being supernatural.

8) It is also beyond our abilities to defend ourselves against this phenomenon through ordinary measures.

9) Thus traditional interventions will be on the plane of metaphysics.

In most of West Africa many key issues related to the ways devised by society to manage the phenomenon of reproduction have serious impact on a number of determinants of maternal mortality. A fuller understanding of the problem would thus require consideration of the socio-cultural context. From this perspective, a key cultural parameter is the importance given to the continuation of lineage. It is deeply rooted in the world view of the society and shapes its value system.

 Using a battle as a metaphor for childbirth emphasizes the recognition by society of the high level of risk associated with giving birth. The women are called upon to fight this risky battle as a matter of DUTY. The fate of women is thus subordinated to the realization of the requirements for the continuation of the lineage.

 The first requirement for the continuation of the lineage is the value placed on childbearing. In the scale of social values childbearing is elevated to a virtue which confers high social status. On the other hand, a stigma is attached to a childless woman who is often regarded as tainted with sin and, at worst, with evil. In parts of West Africa, where funeral rites play an important function in social relations, the ultimate punishment is reserved for barren women and for those losing their life in childbirth. They are denied normal funeral rites and are buried secretly at night outside the village. It is a case of the society reserving its harshest punishment for its innocent victim.

 By focussing on fertility to satisfy the continuity of the lineage, women are under strong pressures to bear children. Most studies have shown that it is only after 6 to 8 surviving offspring that a substantial majority of African women wish to stop childbearing. But under prevailing conditions of high infant mortality, to insure the probability of survival of the desired optimum family size condemns women to repeated and frequent pregnancies. In part, this may explain the high fertility rates still observed in most of Africa and the associated high maternal mortality.

 I was recently alerted to the strength of the value attached to childbearing even in a non-traditional urban environment. A well-traveled and western educated professor of social sciences at an institution of higher learning, out of sympathy for the "desperate" situation of her sister who has been unable to bear children, decided to get pregnant for her sister. This is viewed as a proof of deep love. Her sister will raise the child as her own.

 The consequences of numerous and frequent pregnancies in order to attain a socially determined ideal family size expose African women to a higher lifetime risk of maternal death (1 in 21) compared with women in northern Europe (1 in 9.850).

 The responsibility for the fulfillment of the requirements for the continuation of the lineage is vested in the clan. This exclusive social organization is characterized by a strong interrelationship of mutual support and obligations binding the members together. It is governed by the principle of subordination of individual interests to those of the group. The notion of duty is toward the group: the extended family. The role of women in the reproduction process is subordinated to the requirement of maintaining the "viability" of the extended family. She is a passive actor called upon to fulfill with "dignity" and "modesty" her ascribed duties.

 I have often been baffled by the extravagance of naming ceremonies in West Africa. Even in periods of deep economic crisis, these are grandiose festive events requiring lavish expenditure way beyond what the majority of the population could afford. In this always well-attended event, the mother of the newborn is conspicuously anonymous in the group of women. What is being celebrated is not even the newborn but first and foremost the lineage and, secondly, its strengthening through the name given. This is amplified by the "griot" (3) in his litany on the pedigree of the extended family. This glorification calls for lavish rewards to the benefit of the griots.

 While preparing this paper, I had a discussion with a medical doctor friend. She related a recent incident and how hurt and angry it made her. While recuperating from a cesarian section in a private clinic, the aunts of her new-born burst into her room. She was barely greeted and all the attention was focussed on the baby. They had come to take the baby for the naming ceremony. She was left by herself to endure both physical and emotional pain. "She was only doing her duty"!

 One consequence of this subordination of the individual to the "greater good" of the group, the extended family, is that the major decisions during the reproduction process which affect the whole life of women are outside their control. Society is depriving them of the authority for autonomous decision making in this vital event in their lives. They are powerless in making the decisions that shape their fate. During our field trip we came across over and over again cases requiring an urgent medical evacuation to a nearby health center being unduly delayed or not acted upon because the husband, whose consent for such a decision was required, was either working in the field or absent.

 While this could be expected in a traditional social setting, women do not fare better in the modern health delivery system. Here they are subjected to mutually reinforcing sets of unfavorable circumstances. While the health providers have acquired the medical skills based on scientific knowledge, their behaviour is shaped by the prevailing traditional social values that they have retained. They operate in a health structure model inherited from the former colonial power in which the decision making process is the exclusive, unchallenged privilege and prerogative of health providers. It should be remembered that the bulk of expatriate medical personnel was then made up of military health providers. Finally the maze of bureaucratic hurdles with unpredictable rules changing according to the mood, personality or personal interest of each agent can severely limit the access of health services in emergencies for those without connections or wealth.

 It has been estimated in a major urban center that in the great majority of the SMI (MCH centers) it took only six minutes for most of the midwives to conduct a normal prenatal consultation with a predominance of one-way communication (4). It is also not uncommon to see visiting teams being taken through the delivery room while a woman is in labor without ever seeking her prior permission or consent.

 The study project offices were located in a major urban SMI. I once witnessed the heroic efforts of a caring resident doctor to secure admission for an emergency case patient into the hospital. The patient had been shuttling back and forth between health facilities. Finally, as a last resort, the supervisor advised the doctor to deposit the patient at the entrance of the hospital and hope for a miracle, so that she could at least attend to her heavy case load at the SMI.

 In order to fulfill their ascribed "duty" to the extended family, the whole life cycle of women is affected. From childhood she will be prepared to play her roles of wife and mother. At a very tender age she will be initiated to demanding domestic work while her brothers are spending most of their time playing children's games. In any compound it is common to see little girls helping their mothers while the little boys are roaming free of responsibilities. In most cases she will be eating with the women. A well-bred wife is expected to reserve the best portions for her husband. The little girl will share the meals with the women and most probably receive less in terms of nutrition than her brothers. Because her destiny is first and foremost to be a good wife and mother, she will have less chance for formal education or training than boys. In our study, only 7% of the women could read. Because of the very strong social stigma attached to the status of unmarried women, the family is under strong pressure to marry her to the first convenient party. In most cases, this will be at an age when her body is not yet ready for childbearing. In our study, 7 women out of 10 had their first birth before they reached 17 years. Because of the dishonor on the family name attached to pregnancies outside marriage, unwanted pregnancies are kept secret and preferably terminated through clandestine abortion under less than optimal sanitary conditions -- a major cause of maternal deaths.

The preparation of young women for safe motherhood is totally inadequate. In terms of acquisition of a useful knowledge base, this is most often limited to reassurances about the menstrual process along with advice on personal hygiene. Pregnancy, delivery and care of the newborn is seldom explored in detail. If it is, it will be in the form of metaphors requiring guesses at the true meaning. Further, the code of behaviour set up by society does not allow for frank discussion between a mother and daughter on reproductive matters. Even if this was possible, its usefulness would be limited because the society does not seem to have accumulated a practical knowledge base to systematically pass on from one generation to the next. The information transmitted takes the form of "stories" among peers or parables from the older generation which are very difficult to decipher for a young woman with little life experience.

 In our study we attempted to determine the knowledge base of our target population on indications of a normal pregnancy, complications during pregnancy and delivery. On the scale of the knowledge index we developed, 58% scored low, 36% average and only 7% high. We did find a correlation between a higher score and having experienced the event themselves and also being at a greater distance from a health center. When presented with facts indicating a probability of a severe hemorrhage some of the women we interviewed indicated that they believed this to be a good sign because the body was eliminating the bad blood to be replaced by new blood.

 Contrary to the inadequacy of preparing young women for safer motherhood in terms of useful factual information, the psychological preparation receives a major emphasis. The desired outcome is to increase the threshold of tolerance to physical pain. This is to be demonstrated through stoic behaviour. A common example is the advice given to young women to be prepared to endure a level of effort equal to that which would be required to produce water by pressing hard enough on a stone. The pains of delivery are endured in expectation of harder moments to come. One is surprised and relieved after delivery not to have gone through the dreaded anticipated level of pain. The desirable heroic stance is usually rewarded by lavish praise for the demonstrated courage and admiring compliments from the women attending the new mother and also from the family members and the community. A less than "heroic" behaviour is the subject of verbal abuse and scorn. At this point a paradox is worth exploring. The midwives in maternity wards are notorious for their ill treatment of their patients. One would have expected a more supportive behaviour because of their training, the ethics of the medical profession and the fact that they also are mothers. On close examination one can see that their behaviour is quite similar to that of the traditional birth attendants when confronted with similar situations. Their behaviour is culturally determined and is guided by the norms requiring the mother to maintain a stoic stance. Because of this stoicism, vital life threatening signals that require urgent and immediate action are suppressed and not communicated until too late, leading to tragic loss of life.

 In place of a body of practical knowledge capable of insuring safer motherhood, traditional society has developed a supernatural set of explanations for the phenomenon of reproduction. This has led to the attitude that the phenomenon is beyond the power of rational understanding. This being so, there are no concrete steps that can be taken to modify a predetermined outcome. the interventions to secure a favorable outcome will be in the realm of metaphysics and call for traditional para-psychological therapy. 

The consequence of these attitudes is a large number of non-assisted births. Our findings indicate that only 2 out of 5 women received assistance from a qualified birth attendant during delivery. It is worth noting that traditional birth attendants usually intervene only during the last phase of delivery -- the expulsion. Further if they intervene in case of complications, they are more likely to increase the risk to the life of the mother and baby by ill-timed, unsafe and intrusive interventions to speed up the process.

 Society has developed coping strategies of "denial" for dealing with maternal mortality which is treated as a "non-event" in the collective memory of the community. This attitude of "denial" is also found among health providers at all levels of the health services. As pointed out by Pr Fadel Diadhiou of the Dantec Teaching Hospital, maternal death is too often viewed as "daily occurrence dramatically common" (5). He has been working with great dedication to bring about a change in this prevailing attitude. He keeps emphasizing to his students and staff that each maternal death should be regarded as a dramatic event which should mobilize the conscience of each health provider so as to make it an event as rare as possible.

 Those who are advocating caution on the ground of sensitivity or respect for the integrity of the host culture have to weigh this against the fact that any delay in ACTING NOW is to condone the avoidable cruel and unjust death of millions of innocent women (one death every minute).

A closer examination will show that methodological considerations are not a real obstacle to the inclusion of socio-cultural variable in our study of maternal mortality.

 These quantitative methodologies do not necessarily always lead to effective policies and programmes, and qualitative methods can yield valuable results in terms of effective strategies. While quantitative methods demonstrate possible relationships between dependent and independent variables, as well as the strength or significance of the relationship, qualitative methods allow a more general understanding of the phenomena under investigation by analyzing it within the sub-system of which it constitutes an element. This requires first an understanding of the internal logic of the sub-system along with its relation to the larger system. Only then can the logical sequencing of the chain of causality be established. From this chain the key variables can be identified along with their relative significance in explaining phenomena. In our case study, we focussed on the dominance of the centrality of the continuity of the lineage in the socio-cultural value system as a key element in understanding maternal mortality.

 The results of our analysis of the system can be used for programme development. Identification of key parameters permits the design of effective strategies so as to affect events along the chain of causality in order to achieve desired outcomes. Programme effectiveness will be enhanced by testing the consistency of a selected strategy with the internal logic of the system.

 For example, in the case of socio-cultural values affecting some important determinants of maternal mortality in West Africa, we can for the purpose of programme design consider two enabling factors. These are the moral duties of children toward their mother, and the web of mutual obligations required from the members of the extended family.

 While society in West Africa confers status to women bearing children, this translates into worship of mothers by their children. As a rule of thumb, insulting a peer could lead to a quarrel; if it is someone's father, this could escalate to a serious conflict. Insulting someone's mother, he will have to fight if he is a man of honour, even if he is sure of loosing the battle. The implied moral foundation of mother worship is the debt of gratitude owed to the one who has given us the gift of life. Mother worship is an important element of the values system. Since society requires a fight to preserve the honor of one's mother, to be consistent it cannot require less to preserve her life particularly when she is giving the gift of life. Therefore, society will have to promote safer motherhood. This, in turn, implies the need to remove the "denial" surrounding the tragedy of maternal mortality. This will necessitate that society finally come to terms with this tragedy and give it the too long overdue priority it deserves. Only then can we have genuine community mobilization of conscience, will and resources to address the problem.

 This would be a major area of strategy design for programme development. Some immediate outcomes of this social mobilization would be a substantial reduction in the workload presently required from pregnant women, the removal of food taboos for better nutrition and reallocation of financial resources from name giving ceremonies to pre-natal and natal care. An example is the practice on the island of Gorée for friends and family to contribute for every pregnant woman toward acquiring a layette. The island is linked with the mainland by a ferry boat only during the day. The maternity is lacking the bare essentials, as is often the case. The layette is meant to solve these problems; it will usually have the minimum required supplies for safe delivery and post natal care for the newborn. As far as accessibility is concerned, the great majority of the rural population in West Africa lives on "islands".

 The web of mutual obligations characteristic of extended family translates in the area of health into a system of continuous support through physical presence of relatives and friends. In sharp contrast to the western need for privacy in such circumstances, in West Africa this would be perceived as a form of punishment through isolation and exclusion from the group. With some exceptions, the layout of health services has not yet come to terms with the reality that the family will move in with the patient.

 Curiously, a notable exception to providing this network of support through physical presence is with birthing. Tragically it is when the woman is most in need of physical, material and emotional support that she is left by herself to cope with the challenges of childbearing. This is even more tragic with the case of a large number of inexperienced young women with their first child. 

A second major area of strategy design for programme development could be the extension of this support system to childbearing. Again, society, to be consistent with the value accorded to childbearing cannot deny the necessary support required to achieve the desired outcome. To this end, two basic premises in the belief system which hold that the phenomenon of childbearing is beyond our understanding and, secondly, that it is beyond our power to modify the course of events, have to be shown to be no longer valid. The realization by society of the possibilities for ACTION which would enhance favorable outcomes will give the necessary purpose to extending the support system to childbearing and safer motherhood.

 This new knowledge and understanding of the attitudes of the community could impact now on several determinants of maternal mortality. Thus, identifying the web of the family support system could promote a more systematic follow-up of each pregnancy and an earlier identification of problems. It provides a mechanism for more rapid decision making in case of emergencies, even in the absence of the husband. Most importantly, it could drastically reduce the number of unattended deliveries. Finally, the positive psychological impact on pregnant women cannot be underestimated.

 A major element for the success of the extended support system would be the role to be played by traditional birth attendants since they are already an integral part of the community. The experience of Professor Fall in Khombole, Senegal has shown that trained and supervised birth attendants over a period of years have achieved significantly better results in reducing maternal mortality than midwives in the formal health service. This opens up the possibility of solving the problems resulting from unattended deliveries in a very short time period. The role of traditional birth attendants in this strategy should not be one of an inexpensive substitute for para-medical personnel but should be that of an active agent of social change within their community.

 One important result of the Nairobi and Niamey conferences is the Safe Motherhood Initiative. Since then, there has been an increase in interest for the problem of maternal mortality. More research has been undertaken. Some countries have initiated programme development activities. A broad approach was recommended in recognition of the fact that a combination of factors: medical, socio-economic and cultural, affect maternal mortality.

 So far, most of the studies and corresponding programmes have put most of the emphasis on strategies based on medical solutions. This bias can partly be explained by the choice of variables. These studies are centered around intermediate and proximate factors affecting maternal mortality but underlying factors such as socio-cultural parameters have been notably neglected. This approach has serious shortcomings and inevitably limits the effectiveness of the corresponding public policy strategies. Analyzing only some elements of a phenomenon in isolation can lead to erroneous conclusions when used as a basis for decisions affecting the whole system.

 An illustration is the study by Harrison in Northern Nigeria (6) on the effect of the health care and intensive nutrition programme for pregnant women in relation to operative delivery due to fetopelvic disproportion. He concluded that, for a generation or more, for small women (150cm or less) there will be a rise of the operative delivery rate for fetopelvic disproportion due to gain in weight of the foetus. The absence of a programme to treat the increase in obstetric complications could lead to an increase in maternal mortality.

 For programme development does this mean that health care and intensive nutrition only benefit the foetus? Unless there are adequate health services capable of treating the obstetric complications, should the nutrition programme be abandoned for small women?

 Another shortcoming of an exclusively medical solution is an implicit assumption that an effective demand exists and that the problem is primarily from the supply side. This is often not verified by the field realities. In our study, the analysis of demand and supply for obstetric services gave the following results: 83% felt the need for the services, 79% wanted them but only 39% actually sought the services.

 We visited 43 health facilities, including a newly built regional hospital. None could compare in cleanliness and comfort for the patient to a community built health post run by a dynamic group of women's organizations but we were surprised to find out that it was seldom used. The reason was that the door was in full view of a regular meeting place for men. This lack of privacy discouraged many women from using the facility. After a meeting of community leaders, it was decided to move the meeting place.

 This is not to imply that the medical solution is not essential to the solution of the problem of maternal mortality. It is a necessary but not sufficient condition. Medical and non-medical solutions are not mutually exclusive; in fact, they are complementary and allow synergy among activities. Without strategies dealing with the socio-cultural constraints and involving the active partnership of the community, health services even if they are appropriate and adequate, which is often not the case, will continue to be overwhelmed by the scope and complexities of the problem. For any programme to be effective, there is need for an optimum mix of strategies taking into consideration all the major factors in the chain of causal events that affect maternal mortality.

 In the West African context, the problem of maternal mortality is deeply rooted in the socio-cultural value system of society. Since along the path all the factors that contribute to maternal health are interrelated, a viable programme has to take these into consideration for strategies to be effective. It is therefore essential not to omit the root causes. As one moves down the path, opportunities for effective interventions are missed while the probabilities of unfavorable outcomes increase. Unfortunately, this is too often the case with a great number of women reaching the health facilities too late to be saved, as is shown by higher maternal mortality ratios from most hospital service statistics.

 "A tora mousso kele la"! If society is going to send the women to battle, then it must remove the mines from the battlefield. The necessary knowledge about the nature of the mines, their location and how to remove them is now available. It must also provide full support: material, physical and emotional. Finally, it should honor those who have been willing to give the precious gift of life sometimes at the risk of their own. It is a moral obligation for society to minimize casualties on the "battlefield" of motherhood. One fundamental human right is the right to life. Safe motherhood is a fundamental human right. There is no democracy without fundamental human rights being respected. The new hope for democratization in Africa will never be fulfilled as long as half of the population is denied a fundamental right: safe motherhood.

 AND THE TIME FOR ACTION IS NOW!

Endnotes

1. DIA, A., et al, "Rapport de la Deuxieme Mission D'Identification Pour la Reduction de la Mortalite Maternelle au Senegal".

 2. The collective memory of the community is significant, particularly in societies with oral traditions. It constitutes a driving force of most social events.

 3. Griot: Caste of traditional musician-entertainers of West Africa. They have an uncommon mastery of the spoken word. They are the depository of the history and traditions of the clan as well as the genealogies of important extended families.

4. Aissatou Lo, "Impact of Surveillance of High Risk Pregnant Women in Urban Areas".

5. Dia, A. et al. Op. Cit.

 6. Harrison, K.A. "Predicting Trends in Operative Delivery for Cephalopelvic Disproportion in Africa". Lancet, April 7, 1990.

Acknowledgements

 This paper was prepared for The Center For Population and Family Health, Columbia University for Safer Motherhood, 1991. I would like to express my sincere gratitude to the mission team: Medecin Colonel Amadou Dia, Dr. Abdoulaye Gueye, Mme Khady Ndiaye Fall, Mlle Salimata Ba and Dr. Patrick Kelly; also to Ms. Mina Mauerstein-Bail.

My most profound gratitude to the women we met and, through them, the African women: our daughters, wives and mothers, for their modesty, courage and caring. They generously give the best of themselves to sustain the viability of our family, community and society while receiving so little!

Biographical Note

 Alpha Boubacar Diallo is a development economist. He is currently the Coordinator of UNDP's Regional Project: "Socio-Economic Impact of HIV/AIDS in Sub-Saharan Africa". He was the Coordinator of the Second Mission of Identification for Safer Motherhood in Senegal. Mr. Diallo has also worked as a Senior Economic Advisor with the Ministry of Economic Development and Planning in his native country, Guinea. His professional expertise includes: organizational oevelopment, experiential training methodologies, management training for public health officers, programme development and operational research.

Home