Safe Motherhood Case Studies: Learning with Stakeholders in South Asia—An Introduction

The international community resolved in 1987 to reduce maternal mortality around the world. This resolution was strengthened in 2001 when 189 countries signed the Millennium Declaration, committing themselves to Millennium Development Goal (MDG) 5 towards improvement of maternal health. To accelerate national progress towards achievement of MDG 5, a deeper understanding of what works at scale is needed. This demands a common framework for measuring progress within and across countries and learning processes that engage national stakeholders in using local evidence for programmatic decision-making, identifying critical bottlenecks in scaling up, and generating context-specific implementation solutions (1,2). However, progress has been slow and uneven. Now, as two decades ago, more than 500,000 women die each year from pregnancy-related complications—nearly half in South Asia. “Getting on with what works”—the Lancet subtitle of an article on strategies for reduction of maternal mortality—states that we know what works to reduce the number of maternal deaths (3). The recommended priority strategy is quality intrapartum care where women deliver in health facilities staffed with a team of midwives available 24 hours a day, with a medical team at a referral hospital for back-up support in the case of life-threatening complications. This strategy has the potential to impact not only to reduce the number of maternal deaths but also mortality of newborns (4). Achieving equitable access may require innovative financing mechanisms to increase participation of care providers and women's access (5). With leadership of the World Health Organization (WHO), the importance of such intrapartum care is now acknowledged worldwide. Countries have responded positively but implementation has varied. Many countries focus only on a part of the intrapartum care strategy: in Bangladesh, intrapartum care presently focuses on the midwifery component; in India, it is the facility component. Country and subcountry-level efforts are hampered due to lack of data to guide implementation, with even less data available to tailor strategy selection to the local context and assure active coverage and good quality (2,6). Through the case studies in this issue of the Journal, we have initiated a response to the growing call for evidence to support improved local implementation, gathering lessons from practice within and across more and less successful areas of South Asian countries. The aim is to build a body of knowledge by looking at patterns of problems and solutions to improve safe motherhood implementation at the national and subcountry levels.