Identifying practices and ideas to improve the implementation of maternal mortality reduction programmes: findings from five South Asian countries J Hussein, a D Newlands, a L D’Ambruoso, a I Thaver, b R Talukder, c G Besana a a Immpact/Ipact, University of Aberdeen, Aberdeen, UK b Mustashaar, Social Development Advisors, Ahmed Centre, Islamabad, Pakistan c Golpark, Kolkata, India Correspondence: J Hussein, Immpact/Ipact, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK. Email j.hussein@abdn.ac.uk Accepted 30 October 2009. Published Online 15 December 2009. Objective The successful implementation of programmes to reduce maternal mortality is constrained by a ‘know–do’ gap: the disparity between what is known and the application of that knowledge in policy and practice. This study identified innovations, practices and ideas aimed to improve project and programme implementation. Design Cross-sectional. Setting Five South Asian countries: Afghanistan, Bangladesh, India, Nepal and Pakistan. Sample Sixteen projects and programmes, and 100 key informants. Methods In-depth review of documents, key informant interviews and focus-group discussions. Main outcome measures Innovations and ideas to improve programme implementation, and their perceived effects. Results Delegation of duties to intermediate-level health workers, incentivisation of health workers, providing the means to overcome financial barriers for accessing care, quality improvements and knowledge transfer were examples of ideas put into practice to improve programme implementation. There was a perception that these improved service use and availability, but objective evidence was lacking. Conclusions Some innovations, practices and ideas are supported by evidence of effect, and could be replicated, whereas others have not been formally evaluated. Testing of these innovations is required before more widespread adoption can be recommended, although experiences should be shared to narrow the ‘know–do’ gap, even though the evidence on beneficial effects remains unclear. Keywords Good practices, maternal mortality, programme implementation. Please cite this paper as: Hussein J, Newlands D, D’Ambruoso L, Thaver I, Talukder R, Besana G. Identifying practices and ideas to improve the implementa- tion of maternal mortality reduction programmes: findings from five South Asian countries. BJOG 2010;117:304–313. Introduction Since the launch of the global safe motherhood initiative in 1987, much experience in implementing maternal mortality reduction programmes has accumulated, although there is still substantial ground to be covered before the stated objectives are reached. 1 Investment, political commitment and further research are needed, alongside efforts to bridge the ‘know–do’ gap – the disparity between what is known and the application of that knowledge in policy and in practice. 2–4 The aim of this paper is to share practices and ideas identified as part of an assessment of maternal mortality reduction programmes in five countries in South Asia: Afghanistan, Bangladesh, India, Nepal and Pakistan, thereby contributing to closing the ‘know–do’ gap. A quarter of the world’s population resides in the five countries included in this study. The population is pre- dominantly poor and rural, with both geographical and financial problems limiting access to maternity care. An estimated 188 000 maternal deaths take place in these countries every year, making up 35% of global maternal deaths. 5 There are major gender disparities: female literacy is below 50%, with two- or three-fold differences between men and women. 6 This affects women’s capacity to work 304 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology DOI: 10.1111/j.1471-0528.2009.02457.x www.bjog.org General obstetrics