Obstetrics and Gynecology International when treatment is diﬃcult to access. Women with positive screening tests may not learn about positive results until a later clinic visit, and are often asked to travel to another site for treatment—for which they often, again, have to pay themselves. Furthermore, while most programmes collect data on maternal screening, few collect data on provision or timing of treatment, and thus programmes may be unaware of their deﬁciencies in providing prompt and appropriate treatment [22, 23]. Another increasingly reported barrier that limits programme coverage and eﬀectiveness is the provision of disease-speciﬁc antenatal care. In some settings women are required to attend diﬀerent clinics for basic ANC services, HIV testing and prevention of mother to child transmission services (PMTCT), and malaria prevention and treatment, for example [23]. 4. WHO Initiative for the Global Elimination of Congenital Syphilis 4.1. Rationale and Strategy. Taking into consideration the current challenges to congenital syphilis prevention, WHO has outlined a strategic plan of action for the global elimina- tion of congenital syphilis [20] as a public health problem. Given diﬃculties in diagnosing and monitoring syphilis- related complications, the speciﬁc goal of this elimination eﬀort is to prevent transmission of syphilis from mother to child. This can be achieved by strengthening antenatal care programmes to ensure that all women receive early antenatal care which includes universal syphilis screening, prompt and appropriate treatment, and counselling on how to prevent infection. Additionally, recommendations that partners of infected women are treated (reducing reinfection) and that all neonates born to infected mothers are treated will help reduce congenital syphilis in live borne infants. WHO has also outlined a series of guiding principles upon which the global congenital syphilis elimination strat- egy was developed: country-driven to adapt to local needs; integrated to ensure that the eﬀort strengthens existing STI, HIV, prenatal, and maternal and newborn health services; rights-based to ensure that all individuals have the knowledge to participate in decision-making about their health and access to high-quality care, and collaborative so that government bodies, donors, and communities work together to optimize use of scarce resources. At a country level, WHO outlined a strategy consisting of four pillars with corresponding speciﬁc objectives of actions to be undertaken (Figure 1). The pillars are the following: (1) ensure advocacy and sustained political commitment for a successful health initiative, (2) increase access to, and quality of, maternal and newborn health services, (3) screen and treat pregnant women and partners, and (4) establish surveillance, monitoring, and evaluation systems. The global initiative emphasizes that congenital syphilis elimination can contribute directly to three of the Mil- lennium Development Goals (MDGs) by reducing child 3 mortality (MDG4) through reductions in perinatal deaths and low-birth-weight infants; improving maternal health (MDG5) through reductions in late fetal losses and stillbirths and through a decreased burden of syphilis in pregnant women, and combating HIV/AIDS, malaria and other diseases (MDG6) through combined, systematic screening for HIV and syphilis in pregnancy with an emphasis on strengthening antenatal and postpartum health systems. 4.2. Measuring National and Local Programme Progress and Impact. Although some countries routinely monitor reports of congenital syphilis as a routine part of public health reporting, in general, case reporting of congenital syphilis is problematic as its deﬁnitive diagnosis is not easy. To address this, a WHO-led working group has identiﬁed a set of outcome and process indicators that together are feasible measures of programme progress and impact on congenital syphilis elimination. Monitoring the proportion of stillbirths attributable to syphilis was identiﬁed by the working group as the most promising outcome indicator, and it was recommended that a target for nations should be that “the proportion of stillbirths attributable to syphilis in the mother be less than 2 percent.” The stillbirth target of 2 percent was chosen because stillbirth is both the most common and most severe outcome caused by untreated maternal syphilis. Among women with active syphilis, 17 to 40 percent of pregnancies result in stillbirth, and the risk of stillbirth has been reported as ten to 18 times the background rate of stillbirth (approximately 2 percent) [4–8]. In settings with moderate to high maternal syphilis prevalence, congenital syphilis has been reported to account for more than 20 percent of all stillbirths (i.e., attributable fraction) [7, 8]. The 2 percent target was chosen as both an aspirational benchmark and one that, historically, was able to be achieved in settings adopting universal syphilis screening in pregnant women and prompt treatment of those testing positive [5, 6]. Three critical process indicators were also identiﬁed to monitor programme progress, all involving collection of local data. These are (1) the proportion of women tested for syphilis at their ﬁrst antenatal care visit, (2) the proportion of pregnant women with a positive test for syphilis, and (3) the proportion of positive women treated for syphilis, ideally by 24 weeks. These few process indicators, along with currently collected indicators on estimated number of pregnancies and coverage of antenatal screening, potentially allow countries to calculate a summary process indicator that estimates overall programme eﬀectiveness, that is “the estimated proportion of all syphilis-positive pregnant women treated by 24 weeks of gestational age.” This indicator is important for countries to ascertain since treatment suﬃciently early in pregnancy (prior to 24 to 28 weeks) is necessary to avert the adverse eﬀects of syphilis in pregnancy in most situations [8]. 5. Call to Action: An Investment Case for Eliminating Congenital Syphilis In order to raise funds for the goal of eliminating con- genital syphilis, WHO and its partners have developed