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Globally, countries have made impressive strides toward achieving targets set by the Millennium Development Goals (MDGs) to reduce maternal mortality. The subsequent Sustainable Development Goals (SDGs) have further challenged countries to accelerate these reductions. While Indonesia invested in several initiatives to improve care for mothers and newborns and made large gains in improving skilled care at birth, the country fell short of its MDG target. This paper outlines some of the remaining challenges and highlights the role of the US Agency for International Development-funded Expanding Maternal and Neonatal Survival (EMAS) program in eliminating the barriers to improved care. Achieving the SDGs by 2030 will require strong cross-sectoral collaboration and innovative approaches, such as the recent launch of Indonesia's national health insurance program, which can accelerate reductions in mortality by reaching women most in need of services.

Accountability mechanisms help governments and development partners fulfill the promises and commitments they make to global initiatives such as the Millennium Development Goals and the Global Strategy on Women’s and Children’s health, and regional or national strategies such as the Campaign for the Accelerated Reduction in Maternal Mortality in Africa (CARMMA). But without directed pressure, comparative data and tools to provide insight into successes, failures, and overall results, accountability fails. The analysis of accountability mechanisms in five countries supported by the Evidence for Action program shows that accountability is most effective when it is connected across global and national levels; civil society has a central and independent role; proactive, immediate and targeted implementation mechanisms are funded from the start; advocacy for accountability is combined with local outreach activities such as blood drives; local and national champions (Presidents, First Ladies, Ministers) help draw public attention to government performance; scorecards are developed to provide insight into performance and highlight necessary improvements; and politicians at subnational level are supported by national leaders to effect change. Under the Sustainable Development Goals, accountability and advocacy supported by global and regional intergovernmental organizations, constantly monitored and with commensurate retribution for nonperformance will remain essential.

Objective To determine the prevalence of female genital mutilation (FGM), the common forms of FGM, reasons for the practice, associated obstetric outcomes, and how these have affected efforts to achieve Millennium Development Goals (MDGs) 3, 4, and 5 in southeast Nigeria. Methods A prospective descriptive study of parturients in southeast Nigeria was conducted from January to December 2012. All primigravid women attending delivery services at 2 health institutions during the study period were recruited, examined, and classified using the 2008 WHO classification for FGM. Results The mean age of the 516 participants was 27.24 ± 4.80 years and most (66.3%) had undergone FGM. Type II FGM was the most common form, accounting for 59.6% of cases. Most FGM procedures were performed in infancy (97.1%) and for cultural reasons (60.8%). Women who had undergone FGM had significantly higher risk for episiotomy, perineal tear, hemorrhage, cesarean delivery, neonatal resuscitation, fresh stillbirth/early neonatal death, and longer hospitalization, with higher risk ratios associated with higher degrees of FGM. Conclusion FGM is still a common practice in southeast Nigeria, where its association with adverse reproductive outcomes militates against efforts to achieve MDGs 3, 4, and 5.

Objective In 2007–2008, the Partnership for Maternal, Newborn and Child Health (PMNCH), Geneva, organized capacity-building workshops in Malawi, Burkina Faso, and Bangladesh. Their aim was to strengthen the role of healthcare professional associations (HCPAs) in national reproductive, maternal, newborn, and child health (RMNCH) planning and programs. The present cross-sectional study evaluated the outcomes of these regional workshops. Methods In 2010, a structured survey, telephone interviews of workshop participants, and a document review were used to analyze the impact of these workshops. Results Overall, HCPAs in only 2 of the 17 participating countries (11.8%) were able to increase their impact on RMNCH planning. Although all countries developed action plans, 15 (88.2%) were unable to fully implement them despite increased interactions among HCPAs and with the Ministry of Health (MOH). Nine countries (52.9%) implemented their action plans partly. Engagement of the MOH emerged as a strong indicator of HCPA contribution toward RMNCH planning. Conclusion Strong and sustained follow-up by PMNCH, a clear sense of ownership by HCPAs, designated staff, and financial resources emerged as important determinants for the implementation of action plans. These workshops were generally successful in both encouraging HCPA collaboration and marching toward Millennium Development Goals 4 and 5.

Objective To assess the availability of prenatal care and basic emergency obstetric care services at primary healthcare (PHC) facilities in rural Nigeria. Methods In total, 652 PHC facilities enrolled in the Midwives Service Scheme, a government-funded program designed to reduce the national shortage of skilled birth attendants, were surveyed. Results In all, 44.0% of the PHC facilities evaluated did not provide all components of prenatal care, and only 39.0% of all pregnant women nationwide attended prenatal care clinics 4 or more times. In addition, 52.2% of the facilities were not distributing insecticide-treated nets to pregnant women, while only 36.8% of the PHC facilities provided services to prevent mother-to-child transmission of HIV. By contrast, 70.0% of the PHC facilities had access to antibiotics for the treatment of uncomplicated sepsis. Only 11.0% of clinics reported the use of vacuum extraction during labor and 36.8% provided post-abortion care services. Treatment for pre-eclampsia and eclampsia was initiated at 40.0% and 28.0% of PHC facilities, respectively, prior to referral. Conclusion The present study provides useful information on the state of prenatal and basic emergency obstetric care in rural Nigeria. The data obtained indicate that changes are needed to achieve related Millennium Development Goals.

Background Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped. Objectives A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa. Search strategy MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa. Results Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better. Conclusion Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5.

Objective To achieve Millennium Development Goals 4 and 5 in Nigeria, a quality assurance project in obstetrics in 10 hospitals in northern Nigeria was established to improve maternal and fetal outcome. Methods The project commenced in January 2008 with assessment and improvement of the structure of the 10 hospitals. Continuous maternal and fetal data collection and analysis were conducted from 2008 to 2009 by means of a maternity record book and structured monthly summary form. The quality of hospital infrastructure and equipment was also assessed. Results The mean maternal mortality ratio (MMR) was reduced from 1790 per 100 000 births in the first half of 2008 to 940 per 100 000 births in the second half of 2009. The average fetal mortality ratio (FMR) decreased slightly from 84.9 to 83.5 per 1000 births. There was an inversely proportional relationship between the total number of deliveries in a hospital and MMR and FMR. There was a close correlation between the MMR and the equipment status and hygiene conditions of the hospitals. Conclusion Continuous monitoring of quality assurance in maternity units raised the awareness of the quality of obstetric performance and improved the quality of care provided, thereby improving MMR.

Objective To document an innovative public–private partnership between the government of Gujarat, India and private obstetricians in rural areas that provides delivery care to the poor. Methods This is a descriptive analysis of the scheme and analysis of secondary data. We estimate the lives of mothers and newborns potentially saved because of the scheme. Results More than 800 obstetricians have joined the scheme and more than 269 000 poor women have delivered in private facilities in 2 years. We estimate that the percentage of institutional deliveries among poor women increased from 27% to 48% between April 2007 and September 2008. In addition, there are fewer reported maternal and newborn deaths among the beneficiaries compared with the number of deaths expected in the absence of the scheme. Conclusions This innovative program shows that, at least in some areas of India, it is possible to develop a large scale partnership with the private sector to provide skilled birth attendance and emergency obstetric care to poor women at a relatively low cost. This is one way of addressing the human resource deficit in the public sector in rural areas of low-income countries to achieve Millennium Development Goals 4 and 5. We also conclude that the skilled care thus provided can reduce maternal and neonatal mortality among the poor.

The maternal mortality ratio in Pakistan remains high at between 350 and 500 per 100 000 live births, while the neonatal mortality ratio is 50 per 1000 live births. This paper examines the trends in maternal and neonatal mortality in Pakistan and looks at why slow progress has been made in attempts to achieve safe motherhood. Despite numerous initiatives, it is uncertain whether Pakistan will achieve Millennium Development Goals 4 and 5 by 2015.

Nigeria harbors an estimated 40% of all the women affected with obstetric fistulas today, and at the current rate of treatment in this country, it would take about 300 years to treat them if no new fistulas occurred. This situation obviously runs contrary to the ideals of the United Nations Millennium Development Goals and needs to be reversed. We reviewed the literature on fistula treatment in Nigeria to identify strategies and practices that, if adopted, would likely accelerate the pace of fistula repair and improve postoperative fistula care in this country. A comprehensive nationwide survey, a stronger political will and commitment of resources, a systematic postoperative care and follow-up, more fistula centers, and more fistula campaigns are necessary. Technically, the involvement of all surgeons trained in fistula repair and an experience-based postoperative management protocol will relieve the disease burden carried by women living with fistulas in Nigeria.

The Millennium Development Goals (MGD) represent a commitment of 189 member states that adopted them during the Millennium Summit in September 2000. This UN General Assembly recognized that gender equality and women's empowerment are both central to achieving sustainable development by means of combating poverty, hunger and disease. Neither reproductive nor sexual health was explicitly articulated in the original MDGs and indicators-a critical omission, as globally women are more disadvantaged than men. However, a clear link exists between all of the MDGs and the reproductive and sexual health of women, who cannot contribute to sustainable development, unless their right to health is met through improved access. The FIGO 2006 World Report on Women's Health addresses many issues critical to the success of the MDGs, with a focus on how partnerships have become a crucial vehicle to improve access to health for women.

Violence against women is a serious health and development concern, as well as a violation of women's human rights. Violence against women has a devastating effect on women's sexual and reproductive health, as well as the health of their children, and is rooted in gender inequality. Reducing violence against women is therefore a key strategy for the achievement of the Millennium Development Goals. Key lessons have emerged from more than two decades of experiences dealing with violence against women within the health sector. Interventions must go beyond training and curricula reform and utilize a system-wide approach, including changes in policies, procedures and attention to privacy and confidentiality. Providers must work together with other sectors, particularly at a community level, to strengthen local networks for support of survivors of violence. Prevention activities are critical, particularly those that seek to change cultural norms and laws that encourage violence and discriminate against women and girls.

The Millennium Development Goals set ambitious targets for women's health, including reductions in maternal and child mortality and combating the spread of HIV/AIDS. The law, which historically has often obstructed women's access to the health care they require, has a dynamic potential to ensure women's access that is being progressively realized. This paper identifies three legal principles that are key to advancing women's reproductive and sexual health. First, law should require that care be evidence-based, reflecting medical and social science rather than, for instance, religious ideology or morality. Second, legal guidance should be clear and transparent, so that service providers and patients know their responsibilities and entitlements without litigation to resolve uncertainties. Third, law should provide applicable measures to ensure fairness in women's access to services, both general services and those only women require. Legal developments are addressed that illustrate how law can advance women's equality, and social justice.

The present paper provides an overview of the Safe Motherhood Initiative, Healthy Newborn Partnership, and Child Survival Partnership and their eventual merge into the Partnership for Maternal, Newborn and Child Health (PMNCH) in 2005. The promise and past successes of the PMNCH are highlighted, with a particular focus on the PMNCH's partner-centric approach showing the importance of collaboration for progress. The aims of the strategic framework for 2012-2015 are presented within the context of the Global Strategy for Women's and Children's Health, launched in 2010, and growing political momentum to achieve Millennium Development Goals 4 and 5 (reduce child mortality and improve maternal health, respectively). The next 4 years leading to 2015 are critical, and the global community must continue to work together to ensure all women and children are reached with key interventions proven to reduce mortality.

After the International Conference on Population and Development (ICPD) in 1994 and the Fourth World Conference on Women in 1995, sexual and reproductive health and rights (SRHR) have improved in many countries, and been supported by awareness raised by women's health advocates, increasingly by youth groups, and also by organizations of health professionals. In the HIV/AIDS area, involvement of organizations of people living with HIV/AIDS is crucial to improve prevention and care. However, after victories during the 1990s, combating opposition by social and political conservatives has taken up much energy in recent years. Continuous advocacy to broaden acceptance of the fundamental importance of SRHR, their role in meeting the Millennium Development Goals, and the imperative to increase funding, is essential.

Health statistics relating to Millennium Development Goals 4 and 5 are poor for most low-resource countries. Professional societies can assist governments to improve these health indicators. For an effective collaboration, the Society of Gynaecologists and Obstetricians Cameroon (SOGOC) and the Ministry of Public Health signed a memorandum of understanding on reproductive health. A major consequence of this collaboration was the ease of transfer of competence associated with SOGOC adopting a monitoring and evaluation role, which has improved quality of care. The impact of this collaboration for the Society has been significant; SOGOC is recognized as a partner and has an opportunity to play a leadership role in issues concerning reproductive health.

Health professional associations, including national associations of obstetrics and gynecology, can have a leading role in influencing and developing health policy and practice. However, in low- and middle-resource countries, the organizational capacity to facilitate this role is often insufficient. The International Federation of Gynecology and Obstetrics LOGIC (Leadership in Obstetrics and Gynaecology for Impact and Change) Initiative has been developing the capacity of national associations in Africa and Asia. Through this work, an electronic resource of materials (http://figo-toolkit.org/) has been brought together to support organizational capacity development, addressing domains such as culture, strategic planning, human resources, project and financial management, performance, external relations, membership services, and the development and revision of clinical guidelines.

In my inaugural address in Cape Town, South Africa, in October 2009, I called for a change that, in addition to ensuring faster achievement of health-related Millennium Development Goals (MDGs), will make the International Federation of Gynecology and Obstetrics (FIGO) more visible to obstetricians and gynecologists around the world, particularly those in low-income countries [1]. Key to this change is improving the quality of health care for women and newborns through education, training, and capacity building. One way to pursue such a change, and to strengthen FIGO's ties with its member societies and regional federations, was tomove the Executive Board meeting from its traditional venue in London, UK, to Africa, with a view to holding the meeting in different parts of the globe— particularly in countries and regions that would benefit most from FIGO's assistance. FIGO was very pleased that the Association of Gynaecologists and Obstetricians of Tanzania (AGOTA) agreed to host the Officers’ and Executive Board meetings on June 24–26, 2010, in Dar es Salaam. Africawas chosen as the site of the first Executive Boardmeeting to be held outside London for several reasons. In Sub-Saharan Africa, there is a pressing unfinished agenda on reproductive and sexual health—particularly family planning, and maternal/newborn mortality and morbidity. The fertility rate averages more than 5 children per woman, ensuring a population growth that will continue well into the 21st century [2]. There is a shortage of more than 1 million healthcare workers in Africa, where 3% of the global healthcare workforce provides health services to 24% of the global burden of disease [3]. The “brain drain” of Africa's healthcare workforce further weakens the continent's already fragile reproductive and sexual health services, and significantly impedes the achievement of health-related MDGs. Tanzania is typical of Sub-Saharan Africa, where levels of maternal and newborn deaths and diseases remain unacceptably high. The country's health statistics are appalling: the maternal mortality ratio is 790 per 100 000 live births and the lifetime risk of maternal death is

The Alliance for Womens Health is a FIGO-based interagency consortium comprising the World Health Organization United Nations Population Fund World Bank UNICEF International Planned Parenthood Federation International Confederation of Midwives and International Pediatric Association. In conjunction with the XVIII World Congress of Gynecology and Obstetrics in Kuala Lumpur in November 2006 the Alliance held a precongress workshop examining access in five priority emerging issues: human papillomavirus vaccine/cervical cancer screening emergency contraception adolescent reproductive health emergency obstetric care and sexually transmitted infections. Reports from the five working groups published in this and subsequent issues of the International Journal of Gynecology and Obstetrics provide current evidence-based recommendations on improving access to sexual and reproductive health services supported by applicable rights. The World Bank presented a framework for the discussion during theopening plenary session. The importance of sexual and reproductive health services is well recognized and was articulated in the Programme of Action of the International Conference on Population and Development which was held in Cairo in 1994. However the inclusion of universal access to reproductive health as a target for the Millennium Development Goals (MDGs) only occurred in October 2006 after prolonged negotiations reflecting the reluctance in circles of influence to provide support where there are certain sociopolitical sensitivities. (excerpt)

Recent articles in these pages have referred to the Millennium Development Goals (MDGs). These goals were set in 2000 by the General Assembly of the United Nations to be achieved by 2015. While aimed primarily at development and poverty reduction 3 goals refer to measures of health. Of the 8 goals the one of interest to this section of IJGO is MDG5 which refers to maternal health: Reduce by three-quarters between 1990 and 2015 the maternal mortality ratio; Achieve by 2015 universal access to reproductive health care; A related goal is MDG4 which is to: Reduce by two-thirds between 1990 and 2015 the under-five mortality rate. (excerpt)