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INTRODUCTION Measurement of programme impact is one of the major challenges for safe-motherhood programmes. Much work has been done to develop indirect methods to measure the incidence of maternal mortality, but few evaluations use the maternal mortality ratio as an index of programme impact due to requirements of a large sample size and extended recall period (1-4). International groups have made a concerted effort to develop alternative process indicators for programme management and evaluation (5-9). The most prominent indicators include the proportion of all births that take place in essential obstetric care (EOC) facilities, the percentage of women with obstetric complications treated at the EOC facilities, the proportion of all births through caesarean sections, and case-fatality rates at the EOC facilities. The validity of these indicators depends on a number of questionable assumptions, such as the availability of accurate data on the number of deliveries occurring in the referent health service area, a 15% incidence of life-threatening obstetric conditions with little global variability, and unbiased and accurate diagnosis of complications regardless of training or availability of laboratory diagnostics (10,11).