Pay-for-performance and the Millennium Development Goals

Only 23 countries are on course to reach Millennium Development Goal (MDG) 5: to reduce the maternal mortality ratio by 75% by 2015 [1]. One reason for this slow progress is that, in many low-income and middle-income countries, most poor women deliver at home without skilled attendance, and thus face a high rate of obstetric complications. Our recent analysis, for example, found that in sub-Saharan Africa, from 2003 to the present, 78% of births among the poorest women occurred at home, of which 56% were unattended [2]. Reasons for this high rate of unattended home births include poor availability of health facilities, and social and cultural preferences for home delivery [2,3]. Increasing the proportion of poor women receiving skilled obstetric care is a complex public health challenge that defies easy solutions. Innovative approaches are desperately needed. References 1. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23. 2. Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One 2011; 6: e17155. 3. Koblinsky M, Matthews Z, Hussein J, et al, on behalf of The Lancet Maternal Survival Series steering group. Going to scale with professional skilled care. Lancet 2006; 368: 1377–86.