Editors’ choice


  • Nynke van den Broek,

  • Devender Roberts

The Millennium Development Goals (MDGs) are ‘time-bound goals’ (i.e. they are meant to happen by a set date) for global development agreed by the United Nations in 2000. MDGs 4 and 5 have well-defined and measurable indicators and targets to be achieved by 2015 (Table 1). They provide the framework for international and regional communities to work together to reduce child mortality and improve maternal health, and also allow the monitoring of progress made as a result of the implementation and scale-up of priority interventions.

Table 1.   Indicators for Millennium Development Goals (MDGs) 4 and 5
Indicators for MDG 5a
Maternal mortality ratio (MMR)
Proportion of births attended by skilled health personnel (SHP)
Indicators for MDG 5b
Contraceptive prevalence rate
Unmet need for family planning
Adolescent birth rate
Antenatal care coverage (at least one visit) and (at least three visits)
Indicators for MDG 4
Under-five mortality rate
Infant mortality rate
Proportion of 1-year-old children immunised against measles

South Asia contains one-fifth of the world’s population, and is one of the most densely populated areas in the world. It contains five of the world’s megacities, but, although there has been increasing urbanisation of the poor for economic reasons, most still live in rural areas. Although ‘human development indicators’ (a quality-of-life index—see http://www.hdr.undp.org/en/statistics/) are usually higher in cities, the urban poor are vulnerable to the effects of slum dwelling, lack of sanitation and limited access to employment, health and education.

The achievement of the MDG goals for South Asia by 2015 will be a major challenge. There is a need for sustained commitment and a focused approach, with allocation of the necessary resources. The set target for MDG 4 is to reduce the under-five mortality rate by two-thirds between 1990 and 2015.

The Countdown Coverage Writing Group reported in 2008 that 16 of 68 priority countries with 97% of the maternal and child deaths worldwide were found to be on track to meet MDG 4 (Countdown Coverage Writing Group. Lancet 2008;371:1247–58). With better nutrition, universal immunisation and the management of early childhood diseases, under-five mortality in many South Asian countries has decreased, but neonatal mortality still remains relatively high, requiring further development of appropriate strategies.

The targets for MDG 5 are to improve maternal health by reducing the maternal mortality ratio by three-quarters between 1990 and 2015 (MDG 5a) and to achieve universal access to reproductive health by 2015 (MDG 5b).

Maternal mortality ratios are still relatively high in a number of South Asian countries [World Health Organization (WHO). Maternal Mortality in 2008: Estimates Developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organization; 2010]. The reasons for this are varied, and may include a lack of availability and uptake of family planning services, inability of women to access safe termination of pregnancy services when needed, delivery without a skilled birth attendant and problems with access to, as well as a lack of, equitable distribution of essential (including emergency) obstetric services for women who have complications during pregnancy, childbirth or the postpartum period. In many cases, the quality of care for poor people is low (van den Broek and Graham. BJOG 2009;116:18–22). Care may be suboptimal because it is not ‘woman or baby friendly’, or because available staff are insufficiently knowledgeable or skilled, demotivated and work in very challenging environments, or there is a lack of infrastructure or any form of ‘enabling environment’. Good-quality care may not be available close to home or may be unaffordable.

This International Supplement focuses on five countries of southern Asia: India, Pakistan, Bangladesh, Nepal and Sri Lanka. For each of these five countries, authors have reviewed the maternal and newborn health indicators for the country and provided the measured targets for each stipulated indicator for 5-year intervals from 1990 to the current time, where these data are available. Using the framework of the continuum of care, articles describe the state of affairs with regard to antenatal, intrapartum and postpartum care, family planning, newborn care and care for children under 5 years. Causes of maternal and newborn mortality are reviewed, followed by an outline of the country’s strategy, policy and programmes that are in place to address the challenges of meeting MDGs 4 and 5. Finally, the authors highlight both the challenges and opportunities that each country faces and make an estimation of likelihood that the 2015 targets will be met.

This International Supplement to BJOG has provided a unique opportunity to document comprehensively where each country is at in 2011—<5 years from 2015—and to share lessons learnt across South Asia.

A number of regional initiatives in South Asia, such as the multi-country healthcare professional association (HCPA) workshops, aim to promote and implement plans to achieve MDGs 4 and 5, as well as share strategies to address common challenges in improving service delivery for maternal, newborn and child health (MNCH) in the region (Requejo et al. J Health Popul Nutr 2010 Oct;28(5). The main purpose of these initiatives is to enable the sharing of best practice, and the production of ‘country action plans’ to guide joint HCPA activities over a 1–2-year period. In this Supplement, Bhuiyan and Goodall give an overview of the role of SAFOG (The South Asia Federation of Obstetrics and Gynaecology) in communicating and coordinating efforts to address MDGs 4 and 5 at the regional level (pages 22–25). In a country case study from Nepal, David Nunns highlights the practical ways in which colleagues at a local level can work together to ensure that good-quality health care is available even in rural areas (pages 93–95). Ghazna Siddiqui and colleagues, in their paper, highlight the role that obstetrician-gynaecologists, originally from Pakistan, but now based in the UK, can play in improving the status and health of mothers in Pakistan.

The review of the situation in India illustrates how complex are the issues. Although the country has a rapidly expanding economy, it is still a large contributor to maternal and child mortality globally. National and state governments have concentrated efforts on the ‘High focus states’ with the poorest health outcomes. The new ‘Aisha’ and voucher schemes promoting delivery in a health facility have resulted in significantly larger numbers of women delivering with a skilled birth attendant. This has been coupled with country-wide skilled attendance at birth (SAB) training programmes, as well as training in emergency obstetric care and anaesthesia for MBBS doctors. The need to ensure that good-quality care is provided at times of such rapid scale-up is highlighted by the Commentary from Mathews Mathai (pages 12–14).

Sri Lanka’s focused ‘Health and education for all’ policy has led to the most dramatic improvement in maternal mortality in the region. The country is cited as a model for nonindustrialised countries, not least as it has managed the change on a relatively small budget. The skilled birth attendance rate is high and essential obstetric care is available to almost all who need it. In contrast with other countries in the region, Sri Lanka has been able to ensure a confidential enquiry into almost all maternal deaths in the country. A number of countries in South Asia are also gradually implementing this practice, it having been performed previously so successfully at, for example, state level in India (Tamil Nadu) or as a subnational assessment (Bangladesh). Counting each death and understanding why it occurred will ensure that concrete steps can be taken to prevent subsequent deaths. It is hoped that, when a new classification of the causes of maternal deaths is finalised and disseminated, this will make a more accurate attribution of the causes of maternal deaths easier, and allow for comparison across the region (pages 79–87).

In Nepal, although it has been difficult to achieve the skilled birth attendant rate target of 60%, the Government is committed to strengthening the healthcare system, and there is a real sense that maternal mortality and under-five mortality targets will be met by 2015. Amit Bhandari and colleagues (pages 26–30) describe the Safe Motherhood Program in Nepal, an example of government commitment and focused strategy and the role of bilateral aid.

Bangladesh, similar to Nepal, has made significant inroads into reducing maternal and child mortality. Many national strategies have been implemented to target the MDGs and, surprisingly, a reduction in maternal mortality ratio has been achieved despite a very limited increase in skilled birth attendance rates. A reduction in fertility rates and relatively good coverage with essential (including emergency) obstetric care are thought to (at least in part) have accounted for the improvement in the maternal mortality ratio in Bangladesh. However, as in other countries, the neonatal mortality rate remains high, despite a reduction in under-five mortality and good immunisation coverage. The importance of family planning in South Asia is further highlighted in the Commentary by Howarth and Walker (pages 31–35).

Pakistan, a country troubled by conflict and natural disaster, has the additional challenge of addressing cultural norms which hinder access to health care for women and children. Perhaps there is no other country in the region with as diverse a population as Pakistan. There is a dearth of appropriate policies to address female education and health services for the poor—particularly the rural poor—in hard-to-reach places. Recent decentralisation of health care to the provincial level has yet to be implemented. Colleagues reporting from Pakistan conclude that this country is unlikely to meet the MDGs 4 and 5 targets set for 2015.

Reading the reviews in this Supplement, it becomes apparent that countries in South Asia do not always have good systems for collecting data to monitor their progress. In addition, there is often a lack of research and publications in peer-reviewed journals when it comes to the more public health aspects of maternal and newborn health. The evaluation of programmes that are in place to address maternal and newborn health needs is rarely systematic and may lack the rigorous approach usually seen in conventional research. The Lassi and Bhutta Commentary reviews the evidence for community-based interventions to improve newborn health and highlights some of the challenges faced (pages 18–21).

On a global scale, South Asian countries do not rank in the top 13 countries with the highest maternal mortality or in the top ten countries with least progress in under-five mortality. Change is occurring, therefore, although, in some countries, it may not be as much as was hoped and expected at the time of setting the MDG targets. The Reviews and Commentaries in this Supplement represent a collation of all the strategies implemented by these countries to try to meet these goals, and give us some insight into why some strategies are effective, whilst others are difficult to achieve despite the continued efforts of some incredibly committed healthcare professionals to improve outcomes for mothers and children. High-level advocacy for better maternal and child health services is much needed, as well as continuing ‘grass root level’ efforts. We must celebrate what has been achieved, but encourage even greater efforts in the future, and our hope is that this Supplement has been a positive contribution to that process.

Disclosure of interests

Nynke van den Broek is the Director, Royal College of Obstetricians and Gynaecologists/Liverpool School of Tropical Medicine (RCOG/LSTM) International Partnership and Head of the Maternal and Newborn Health Unit at LSTM. She is the principal investigator for the Making it Happen Programme funded by the Department for International Development-UK (DFID-UK) Aid. Devender Roberts is a Member of the British Maternal Fetal Medicine Society, Deputy Chair Pregnancy Outcome Group, a Member of the Wellbeing of Women Research Advisory Committee, a Member of the British Maternal Fetal Medicine Society and the Fetal Medicine Clinical Scientific Group. She is principal investigator on the AMIPROM trial—a pilot randomised controlled trial of serial amnioinfusion versus expectant management for very early preterm premature rupture of membranes, funded by the Health Technology Assessment (HTA) [International Standard Randomised Controlled Trial Number (ISRCTN)—8192589]. She has occasionally received honoraria for lectures/presentations in the UK and overseas. She also undertakes expert witness work in fetal medicine. Devender Roberts is a Member of the BMFMS Fetal Medicine Clinical Scientific Group, Deputy Chair Pregnancy Outcome Group, a Member of the Wellbeing of Women Research Advisory Committee, Member of the British Maternal Fetal Medicine Society and the Fetal Medicine Clinical Scientific Group. She is principal investigator on the AMIPROM trial – a pilot randomised controlled trial of serial amnioinfusion versus expectant management for very early preterm premature rupture of membranes, funded by the HTA. ISRCTN – 8192589. She has occasionally received honoraria for lectures/presentations in the UK and overseas. She also undertakes expert witness work in fetal medicine. ▮