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SafeMotherhood

A Review

The Safe Motherhood Initiative 19872005


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The Safe Motherhood Initiative 19872005

SafeMotherhood

A Review


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Acknowledgments 3

I. Introduction 4

II. A Historical Review o Sae Motherhood: 20 Years and Counting 8

III. International Advocacy and Agreements or Sae Motherhood 13

IV. Media Trends in Sae Motherhood 17

V. Development and Donor Agency Commitment 23

VI. Financial Trends or Sae Motherhood 30

VII. National Programs, Policies, and Budgetary Commitments or Sae Motherhood 35

VIII. Conclusion 83

List o Abbreviations 86

Agencies and Organizations 87

Annexes 88

Table of Contents


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This report is the result o collaborative eorts and contributions rom a range o individualsand partner agencies.

Family Care International is grateul to the World Bank or its inancial support, with specialthanks to Elizabeth Lule or initiating the development o this report.

Ann Starrs, Executive Vice-President, FCI and Rahna Reiko Rizutto, Consultant, kicked o thisproject with a wealth o ideas, insights, and inspiration.

Rebecca Casanova, Communications Consultant, carried out in-depth interviews with expertsand the review o international agreements or sae motherhood (section III) and conducted the

media analysis rom 20002005 (section IV).

Karuna Chibber, Consultant, developed the country questionnaire guide or the nationalreports (section VII) and carried out in-depth interviews with development and donor agencyrepresentatives (section V).

National consultants carried out the research at the country level and drated the reports:Alexia Escobar, Alberto De La Galvez Murillo Camberos, and Oscar Viscarra (Bolivia)Widi Wibisana (Indonesia)Rebecca Ramos (Lao Peoples Democratic Republic)

Valentino Lema (Malawi)Mountaga Toure (Mali)Nikubuka Shimwela (Tanzania)

Researchers at the Netherlands Interdisciplinary Demographic Institute (NIDI) providedinvaluable support and assistance in the analysis o inancial data related to sae motherhood(section VI). Special thanks to UNFPA or permission to use the UNFPA/UNAIDS/NIDI resourcelows database.

FCI sta contributed critical technical eedback, suggestions, and support throughout theresearch and writing process: Jill Sheield, Ann Starrs, Martha Murdock, Cristina Puig, Ellen

Brazier, Ellen Themmen, Fatima Maiga, Rehema Mwateba, and Lauren Goddard. The reportwas coordinated by Shaia Rashid and designed by Patricia Quintero. Adrienne Atiles, withassistance rom Luz Barbosa, managed the design and production o the publication.

FCI also wishes to thank the many colleague agencies who contributed their time andthoughts to this project.

Acknowledgments


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The year 2007 will mark 20 yearssince the launch o the global Sae

Motherhood Initiative (SMI), an internationaleort to raise awareness o the scope anddimensions o maternal mortality and togalvanize commitment among governments,donors, UN agencies, and other relevantstakeholders to take steps to address thispublic health tragedy. The orthcomingtwentieth anniversary o the SMI providesa timely opportunity to take stock o how

sae motherhood has ared within the healthand development agenda, and assess theInitiatives achievements and shortalls.

In 1987, when health experts, developmentproessionals, and policymakers gathered inNairobi to inaugurate the global Initiative,maternal mortality was not a major nationalor international priority. In act, it was otenthe overlooked component o maternal-

child health programs, as noted by Maineand Rosenield in their seminal 1985 article,Where is the M in MCH?1 At the Nairobimeeting, a group o international agencieslaunched a global movement, the SaeMotherhood Initiative, whose aim was toreduce the burden o maternal death andill-health in developing countries. Later thatyear, the Sae Motherhood Inter-Agency

Group (IAG)2

was established to realize thegoals o the Initiative. As a group and asindividual organizations, these agenciesraised international awareness about saemotherhood, set goals and programmaticpriorities or the Initiative, stimulatedresearch, mobilized resources, and sharedinormation to make pregnancy andchildbirth saer.

In the 21st century, sae motherhood

has achieved greater prominence on theinternational agenda, with increasing visibilityresources, and attention being directedtoward it. Many agencies and organizationsnow have dedicated programs ocusing onmaternal health; donors have prioritizedsae motherhood in their unding programs;governments have developed nationalstrategies and programs to reduce maternalmortality; and there is greater knowledge andawareness o the problem and how to addressit. There is broad agreement that good-qualitymaternal health services need to includeskilled care or both routine and complicatedcases, including emergency obstetric servicesor lie-threatening complications, and aunctioning reerral system to ensure timelyaccess to appropriate care.

IntroductionII

1 A Roseneld and D. Maine, Where is the M in MCH? Maternal Mortality: A neglected tragedy. LancetJul 13; 2(8446):83-5, 1985.

2 The ounding members o the IAG were the World Bank, World Health Organization, UNFPA, unice, and UNDP. In October1987, the group expanded to include the International Planned Parenthood Federation (IPPF) and the Population Council.In 2000, the International Conederation o Midwives, the International Federation o Obstetrics and Gynecology (FIGO),the Regional Prevention o Maternal Mortality Network (Arica), and the Sae Motherhood Network o Nepal joined theIAG. Family Care International served as the secretariat until January 2004, when the Partnership or Sae Motherhoodand Newborn Health was established.


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Progress has been achieved on a numbero key indicators, including the proportiono pregnant women receiving antenatal

care, and the proportion o births attendedby a skilled birth attendant. Since 1990,coverage o antenatal care in developingcountries has increased by 20%, and morethan 50% o women receive at least the ourrecommended antenatal visits.3 Between 1990and 2003, the presence o a skilled attendantat delivery increased signiicantly, rom 41%to 57% in the developing world as a whole.4

Despite these achievements, the SaeMotherhood Initiative has allen short o thegoal that it set almost 20 years ago: to reducematernal mortality by 50% by the year 2000.While a ew countries have experiencedsustained reductions in maternal mortality,little or no progress has been achieved inthose countries with the highest levels omortality,5 and in some countries, it appearsthat they have worsened. Maternal mortalityremains high even in some countries where

utilization o maternal health care (such asantenatal and delivery care) has improved;this underscores the importance o improvingnot just the availability o care, but its quality.6

Why has the Initiative not achieved its goals?Faltering political commitment, inadequateunding, and a lack o clear technical prioritieshave hampered progress.

Safe Motherhood in Perspective

Each year, more than hal a millionwomen die during pregnancy and

childbirthmaking pregnancy-relatedcomplications among the greatest killers owomen o reproductive age in developingcountries.7 O all the health data monitoredby the World Health Organization, maternalmortality demonstrates the greatest disparitybetween poor and rich countries: the lietimerisk o a woman dying during pregnancyor childbirth is much higher in the poorest

countries than in the richest (one in 12 orwomen in east Arica compared with one in4,000 in northern Europe). Within countries,poor, uneducated, and rural women suerdisproportionately compared to theireducated, wealthy, and urban counterparts: inKenya, or example, just over 23% o womenin the lowest wealth quintile have access toskilled assistance during childbirth, whilealmost 78% o women in the highest wealthquintile are attended by a doctor or a nurse/

midwie.8 Urbanrural dierences also aect

...[M]aternal health rarely gets the priority orattention that it deserves. Partly thats becausethe victims tend to be faceless, illiteratewomen who carry little weight in their ownfamilies, let alone on the national or worldagenda.

3 State o the World Population 2004 Report, The Cairo Consensus at Ten: Population, Reproductive Health, and the GlobalEort to End Poverty. New York: UNFPA, 2004.

4 State o the World Population 2005 Report, The Promise o Equality: Gender Equity, Reproductive Health and the MillenniumDevelopment Goals. New York: UNFPA, 2005. At the regional level, the most marked improvements took place in South-Eastern Asia (rom 34 to 64%) and Northern Arica (rom 41% to 76%). In sub-Saharan Arica and Western Asia, the indicatorincreased by only 1 percentage point between 1990 and 2003.

5 The Millennium Development Goals Report 2005. New York: United Nations, 2005.6 Personal communication, Khama Rogo, World Bank.7 Make Every Mother and Child Count, World Health Report 2005. Geneva: WHO, 2005.8 Davidson R. Gwatkin, Beyond the Averages, Countdown 2015 Sexual and Reproductive Health & Rights or All.

Washington, DC: IPPF, PCI, FCI, 2004.

Nicholas D. Kristo, New York Times, March 20, 2004


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whether a woman receives adequate careduring pregnancy and childbirth: in Peru, over80% o urban women have a skilled provider

attend their delivery, whereas less than 20%o rural women receive such care.9

In addition to the risk o dying duringpregnancy and childbirth, women cansuer rom short- and long-term maternaldisabilities and illnesses. According tothe 2005 World Health Report, 20 millionwomen each year will experience maternaldisability, which can range rom ever and

depression to severe complications suchas obstetric istula and uterine prolapse.10The exact magnitude and scope o maternalmorbidity is unclear, due to underreporting,poor recordkeeping systems, and deinitional/classiication problems.

Investing in maternal health saves individualwomens lives and saeguards their well-being. It also aects the health and well-beingo entire societies. Research indicates that

the health o newborns is closely linked withthe health o their mothers. About 3040%o neonatal and inant deaths result rompoor maternal health and inadequate careduring pregnancy, delivery, and the criticalimmediate postpartum period. Data alsosuggest that a mothers death aects theoverall well-being o her surviving children:in Bangladesh, the surviving children o adeceased mother are three to ten times more

likely to die within two years.

11

In Tanzania,children living in homes in which an adultwoman died during the previous 12 months

spent hal as much time in school as otherchildren. The impact on childrens health andsurvival was not signiicant when an adult

male died.12

In addition to the impact on inants andchildren, a womans death aects her amilyswell-being and society as a whole. Ater awoman dies, her amily is less able to careor itsel, and oreits any paid/unpaid wagesshe contributed to the household. Her deathincreases the chances o her amily acingpoverty and malnutrition. Data suggest

that the death o an adult woman has asigniicant eect on household consumptionin the poorest households or at least a yearollowing her death.13

Investing in maternal health provideslong-term beneits or the entire healthdelivery system. Elements that are essentialor eective maternal health care, suchas adequate human resources, eectivecommunications and reerral mechanisms,

and an eicient supply o equipment, drugs,and consumable goods such as gloves andsyringes, also have a positive impact on arange o non-obstetric services, includingthe handling o accidents, trauma, and otheremergencies. In addition, pregnancy andchildbirth are oten the irst point o contactor a woman in the health system; antenatalcare can provide an opportunity to addressother reproductive health concerns, such as

amily planning and STIs, as well as otherillnesses or conditions including tuberculosis,malaria, and HIV/AIDS.

9 Presentation by Ana Langer, Countdown 2015 Global Roundtable, London, 31 August2 September 2004.10 Obstetric stula reers to holes in the birth canal caused by prolonged or obstructed labor. Consequences include: vaginal

incontinence, pelvic and/or urinary inections, pain, inertility, and early death. The social repercussions are oten severe,resulting in abandonment and ostracization. Uterine prolapse is the alling or sliding o the uterus rom its normal position inthe pelvic cavity into the vaginal canal.

11 M.A. Strong, The Health o Adults in the Developing World: The View rom Bangladesh, Health Transition Review2(2):21524, 1992.

12 Ainsworth M. and Over M., AIDS in Arican Development, Research Observer9(2): 203240, 1994.13 Margaret E. Greene and Thomas Merrick, Poverty Reduction: Does Reproductive Health Matter? World Bank HNP

Discussion Paper, July 2005. World Bank: Washington, DC.


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Finally, sae motherhood investments arecost eective. According to the 1993 WorldBank World Development Report, sae

motherhood is among the most cost-eectivestrategies or low-income countries. In 2005,researchers assessed the costs and beneitso interventions or maternal and newbornhealth, and determined that strategies atthe community and primary care levels(community-based newborn care, antenatalcare, and skilled care during childbirth) tolower maternal and newborn deaths arehighly cost-eective.14

Sae motherhood is undamentally a mattero human rights; all women are entitled togood health and high-quality health services.Maternal deaths are linked to womens lowstatus in society, and their lack o decision-making ability and economic power. In orderor women to be able to enjoy sae pregnancyoutcomes, they need to be accorded thesame opportunities to health, education, andemployment as their male counterparts.

What This Report Contains

This report reviews the impact o theglobal Sae Motherhood Initiative, andassesses progress in the sae motherhoodield since its launch in 1987. Speciically, thereport examines how the ield has evolved interms o international advocacy and mediaattention; development agency and donor

commitment to sae motherhood; inancialtrends and allocations; and the developmento national policies and programs orsae motherhood.

International advocacy and media relations:

The report reviews how media attentionor sae motherhood has changed over

time, and analyzes how and why maternalmortality has been identiied as a keypriority in international meetings and

processes. The analysis reviewed relevantpress coverage o sae motherhood toidentiy trends in coverage and regionalor topical trends. In addition, in-depthinterviews were conducted with keyactors rom select international meetingsto ascertain the inluence o global saemotherhood events.

Development and donor agency

commitments:To assess shits in emphasis,priority, and commitment within selecteddonor and development agencies, a serieso in-depth interviews were carried out withprogram representatives (see Annex I or alisting o agencies included in the analysis).

Financial trends for safe motherhood:Financial trends since 1987 were analyzedusing three dierent data sources: a WorldBankcommissioned report on unding or

sae motherhood ollowing the launch othe SMI; the UNFPA/UNAIDS/NIDI inancialresource lows database o donor undsvia bilateral, multilateral, and oundationchannels; and interviews with selecteddonor oicials on trends within theiragencies and in the ield as a whole.

National policies, programs, and budgetary

commitments:In order to examinethe development o national maternal

health priorities/programs and allocationsin several countries in Arica, Asia, andLatin America, in-country consultantsconducted document research and carriedout interviews with government oicials,donor representatives, and NGOs. Countrieshighlighted in this analysis include: Bolivia,Indonesia, Lao Peoples DemocraticRepublic, Mali, Malawi, and Tanzania.

14 Adam T., Lim S.S., Mehta S., Bhutta Z.A., Fogstad H., Mathai M., Zupan J., and Darmstadt G.L. Cost eectiveness analysis ostrategies or maternal and neonatal health in developing countries British Medical Journal. Nov. 12, 331(7525), 2005, http://

bmj.bmjjournals.com/cgi/content/ull/bmj;331/7525/1107

Introduction


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The past 20 years have witnesseddramatic shits in how maternal

health is ramed and conceptualized at theinternational level. Sae motherhood hasevolved rom a neglected component inmaternal and child health programs to anessential and integrated element o womenssexual and reproductive health. In the late1970s through the mid 1980s, while saemotherhood was acknowledged as a keypriority area or attaining the health and

development o women, it was neglected inthe development priorities o governmentsand unding agencies, and maternal and childhealth programs tended to ocus on the needso the child and not the mother. In 1987, inan eort to redress this situation, a globalmovement was launched to bring attentionto the silent tragedy o women dying duringpregnancy and childbirth.

Over the next 15 years, largely a result othis landmark worldwide initiative, saemotherhood became a central componentor the achievement o womens health andrights. At the International Conerence onPopulation and Development (ICPD), maternalmortality was identiied as a core componento womens sexual and reproductive health,and at the Millennium Development Goal(MDG) Summit it was situated within thebroader context o poverty reduction eorts

and overall development eorts.

This section traces how maternal health hasigured within the broader developmentramework and identiies key events thatshaped its role at the international level.

The UN Decade for Women (19761985)

At the irst conerence on women heldin Mexico City in 1975, the UnitedNations declared the period 19761985 asthe United Nations Decade or Women in aneort to raise international attention on thehealth, rights, and development prioritieso women. In July 1985, at the third UN

conerence on women, a series o ForwardLooking Strategies or the Advancement oWomen was adopted by delegates to reviewand appraise the achievements o the UnitedNations Decade or Women.

Focusing on the themes o equality,development, and peace, the consensusdocument ramed maternal health within thecontext o womens health and rights, andsupported a reduction o maternal mortalityby the year 2000.15 The Strategies alsocalled or: equal access to health services. adequate health acilities or mothers

and children. every woman's right to decide on the

number and spacing o her children, andaccess to amily planning or every woman.

discouragement o childbearing atan early age.

improvement o sanitary conditions,including drinking water supply.16

15 AbouZahr, C. Sae Motherhood: A Brie History o the Global Movement 19472002, British Medical Bulletin 67:1325, 2003.

16 Paper presented at the Nation Convention on Empowerment o Women: Nairobi (1985) to Beijing (1995) held on1618 March, 1995, organized by Women or Women, Dhaka, Bangladesh.

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17 See note on page 4.18 AbouZahr, C. Sae Motherhood: A Brie History o the Global Movement 19472002, British Medical Bulletin 67: 1325, 2003.

The Launch of the SafeMotherhood Initiative (1987)

In 1987, when the Sae MotherhoodConerence was held in Nairobi, Kenya,the scope and dimensions o maternal healthwere not well known or understood. Therewas little evidence available concerning thetechnical and programmatic interventionsmost eective or improving maternal health.

To generate awareness and stimulatecommitment among governments andunding agencies to address this publichealth problem, WHO, the World Bank,and UNFPA brought together a range ostakeholders, including government oicials,NGO representatives, health providers, anddonor representatives at a conerence inNairobi. The conerence underscored therelative neglect o maternal mortality inthe development priorities o governmentsand unding agencies, and urged concerted

action to prevent women rom dying duringpregnancy and childbirth.

The conerence situated maternal healthwithin the context o improving womensstatus in the economic, social, and politicalspheres, and outlined speciic strategies orsaer motherhood: strengthening community-based health care

by improving the skills o community healthworkers and traditional birth attendants,and screening high-risk pregnant women orreerral or medical care;

improving reerral-level acilities to treatcomplicated cases and serve as a back-up tocommunity-level care;

developing an alarm and transport systemto serve as a link between community andreerral care.

For the irst time ever, the internationaldevelopment community ocused on theplight o women dying during pregnancy

and childbirth, and issued a speciic goalor maternal mortality reduction: to reducematernal mortality by 50% by the year 2000.From here on, sae motherhood was coinedas the catch phrase or maternal health.

Following the Nairobi conerence, a serieso regional and national meetings washeld in Arica, the Arab region, Asia, andLatin America in an eort to generate

recognition o poor maternal health andstimulate commitment to address this publichealth problem among national decision-makers, health providers, and NGOs. AnnexII provides a summary o the meetingsand conerences the Inter-Agency Group17organized, and the publications and reports itproduced since 1987.

The Childrens Summit

(1989)

In 1989, world leaders, joined by the headso UN agencies and senior representativeso the international development community,gathered in New York to attend the WorldSummit or Children. The conerencereviewed key areas related to the survival,protection, and development o children andissued a plan o action or the next ten years.Maternal mortality was identiied as critical

to the health and survival o children, andas one o the major goals o the Summit,which speciically called or a reduction omaternal mortality by hal between 1990 and2000. Maternal health was ramed largely asa means to ensure childhood survival, ratherthan an end in itsel.18


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10

The International Conferenceon Population and Development(1994)

The International Conerence onPopulation and Development (ICPD),held in Cairo, Egypt, was a watershed eventor womens health and rights. Reramingpopulation and development rom a ocus onmeeting demographic goals to securing thereproductive health and rights o men andwomen o all ages, the ICPD put orward a

ar-reaching plan or achieving progress inhealth and development.

Maternal health was situated within thecontext o the comprehensive approach toreproductive health. Speciically, the ICPDProgramme o Action called or:

Governments agreed to cut the number omaternal deaths by hal by the year 2000,and in hal again by 2015. In 1995, the FourthWorld Conerence on Women (FWCW) inBeijing gave substantial attention to maternalmortality and reiterated the commitmentsmade at the ICPD.

The ICPD and Beijing commitments alsoreinorced the position that maternal deathsand disability are violations o womens

human rights, and are strongly tied towomens status in society and economicdependency.19 At a undamental level, womenhave a right to health services that promotetheir health and survival during pregnancyand childbirth.

Tenth Anniversary of the SMI(19971998)

To commemorate the tenth anniversaryo the Initiative, the members o

the Sae Motherhood Inter-Agency Groupexecuted a wide-ranging program with theollowing objectives: invigorate national and international

commitment and action or saemotherhood among a range o audiences,including policymakers, donors, and healthproviders; and

bring together existing knowledge andresearch on the most eective interventionsinto a set o clear technical messages orguiding programs and policies onthe ground.

The Sae Motherhood Tenth Anniversaryprogram consisted o a comprehensive set oactivities, including a technical consultationheld in Colombo, Sri Lanka in October 1997to orge consensus on the most cost-eective

strategies or sae motherhood; a WorldHeath Day media event in April 1998 togenerate high-level attention to the problemo maternal mortality among developingcountry policymakers and donors; and a ar-reaching media strategy and communications

19 State o the World Population 2004 Report. The Cairo Consensus at Ten: Population, Reproductive Health, and the GlobalEort to End Poverty. New York: UNFPA, 2004.

[Maternal health] services, based on theconcept of informed choice, [which] should

include education on safe motherhood,prenatal care that is focused and effective,maternal nutrition programmes, adequatedelivery assistance that avoids excessiverecourse to Caesarian sections and

provides for obstetric emergencies; referralservices for pregnancy, childbirth andabortion complications; post-natal careand family planning


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campaign to widely disseminate the indingsand messages to interested parties all overthe world.

The Tenth Anniversary program has beenby ar the single largest eort to advancesae motherhood within the internationaland national arenas. Selected products andoutcomes included: increased media attention on the

dimensions and consequences omaternal mortality.

a set o ten priority action messages

relecting consensus on the key policy andprogram strategies or improving maternalhealth (see Annex III or a summary o theten action messages or sae motherhood).

a range o communications tools andresources, including a Web site, act sheets,public service announcements, a brochure,and a pocket card.

The ten priority action messages prooundlytransormed the conception, design,

and implementation o sae motherhoodprograms and policies. Two programinterventions that the Initiative itsel hadadvocated ten years earlier at the Nairobiconerence (training o traditional birthattendants and risk screening or pregnantwomen to identiy those most likely todevelop obstetric complications) weredeemed to be ineective or reducingmaternal mortality, and not to be promoted

as priority strategies. Instead, the ten actionmessages emphasize the need to address thebroad social, economic, and political contextthat contributes to womens risks o dyingduring pregnancy and childbirth, and promoteaccess to essential obstetric care to preventor treat serious obstetric complications.20

Millennium Development Goals(2000)

In 2000, at the UN Millennium GeneralAssembly in New York, 189 countriesrom around the world adopted speciicinternational development goals with theaim o reducing poverty and promotinghuman development. Building upon theagreements and commitments made at theseries o world conerences held in the 1990s,the Millennium Development Goals (MDGs)oer a blueprint or reducing poverty andhunger, and addressing poor health, genderinequality, lack o education, lack o access toclean water, and environmental degradation.Millennium Development Goal 5 calls oran improvement in maternal health and areduction in maternal mortality by 75% by2015 rom 1990 levels.

The identiication o maternal health as oneo the eight MDGs irmly situates it as central

to poverty reduction and overall developmenteorts. Its inclusion has resulted in increasedinternational attention to maternal mortality,and provided a mechanism or monitoringprogress on maternal health and improvingaccess to skilled attendants at deliveries(the key indicator or measuring progressor Goal 5). With the MDGs now widelyaccepted as the ramework or assessingprogress on overall health and development

at the national and international levels, saemotherhood can igure more prominentlyin country programs and in developmentagencies priorities.

20 Sae Motherhood at Ten, Final Report on the Program to Mark the Tenth Anniversary o the Sae Motherhood Initiative,January 1997April 1999. New York: Sae Motherhood Inter-Agency Group, 1999.

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12

For each o the Goals and targets, a task orcewas established to provide governmentsand members o civil society with a concrete

plan or achieving progress on health anddevelopment. The Task Force on Child Healthand Maternal Health issued a set o ninerecommendations or realizing improvementsin maternal health and child mortality (Goal4 calls or a reduction by two-thirds o theunder-ive child mortality rate).

In its report, the Task Force outlined thecentral challenge or maternal and child

health: developing and strengtheningunctioning health systems through whichevidence-based interventions can bedelivered and scaled-up to the ull population.In particular, the report highlighted theunequal distribution o power and resources,and a range o social, economic, cultural, andpolitical inequities, as the main impedingactors or achieving progress in maternal andchild health.

An Expanded GlobalPartnership for Maternal Health(2005)

In September 2005, a partnership bringingtogether three existing global healthcoalitions on maternal, newborn, and childhealth (the Partnership or Sae Motherhoodand Newborn Health, which itsel evolvedrom the Sae Motherhood Inter-AgencyGroup; the Healthy Newborn Partnership;and the Partnership or Child Survival) was

launched. The Partnership or Maternal,Newborn, and Child Health (PMNCH) aims tostrengthen global advocacy and leadership inan eort to raise the proile and visibility omaternal, newborn, and child health; developand promote a continuum o care or mothersand children; and coordinate country-levelsupport and action. It builds on the expertise,experience, lessons learned, and membershipo the predecessor partnerships, with a majorocus on working eectively at the country

level to achieve improvements in maternal,newborn, and child health.


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Beginning in the 1990s, the UnitedNations sponsored a series o

international conerences to develop aramework or achieving progress onpopulation, health, and development. Saemotherhood, including maternal mortalityreduction, has been consistently identiied asa key development goal at all o these majorglobal conerences.

In order to examine how sae motherhood

came to be highlighted as a critical areaor action at the international level, and thereasons underlying its inclusion, a set o keyinormant interviews were carried out withindividuals rom multilateral organizationsand NGOs who played a role in negotiatingor otherwise inluencing the outcomeso international declarations. The majormeetings and outcomes included in thisanalysis are: the International Conerence

on Population and Development (1994); theFourth World Conerence on Women (1995);the Millennium Declaration (2000); and theChildrens Summit (2002). What ollows is asummary o the indings.

The International Conferenceon Population and Development(1994) and the Fourth WorldConference on Women (1995)21

The 1994 International Conerenceon Population and Developmentrepresented a paradigm shit on approachesto population, womens rights, and sexual

and reproductive health. Prior to the ICPD,most leaders in the population communitywere concerned primarily with achievingdemographic targets, rather than meetingindividuals needs or health servicesand inormation.

The ICPD Programme o Action was awatershed or sae motherhood: or the irsttime, a UN document deined a time-boundand measurable goal or maternal health: to

reduce maternal deaths by 75% by the year2015.22 The sae motherhood commitmentincluded in the ICPD Programme o Actionhas been reairmed by several major globalagreements negotiated since the ICPD,including the Platorm or Action o the FourthWorld Conerence on Women, the outcomedocuments rom the UN General AssemblySpecial Session on HIV/AIDS, the UN GeneralAssembly Special Session on Children, and

the Millennium Declaration.

21 NB: The overwhelming majority o content in this section discusses the ICPD. With the exception o one sub-paragraph oneliminating punitive measures or women who obtained illegal abortions, the FWCW documents sae motherhood languagewas basically identical to that o the ICPD. Additionally, the inormants noted that the group o countries that opposedlanguage on amily planning and unsae abortion at the ICPD made the same objections at the FWCW and, as at the ICPD,eventually joined the consensus, albeit with reservations.

22 While the 1990 World Summit or Children Plan o Action or Implementing the World Declaration on the Survival,Protection and Development o Children in the 1990s included a goal to reduce maternal mortality by 50% by 2000, it didso in the larger context o a set o quantitative goals ocused primarily on child and inant health and well-being. The ICPDProgramme o Action placed maternal health in the reproductive health ramework; in addition, at the ICPD, the internationalcommunity pledged nancial and other resources to realize this promise.

International Advocacy and Agreementfor Safe MotherhoodIIIIII


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1

The inormants reported unanimously thatthe inclusion o an explicit goal on saemotherhood was a precedent-setting event

that elevated sae motherhood rom anoverlooked public health problem to a centraldevelopment goal. This section discussesthe actors that led to the inclusion o saemotherhood in the ICPD Programme oAction and how this commitment has beenreairmed and expanded upon in subsequentinternational agreements.

Regional conerences organized by the

Sae Motherhood Initiative in the Arabregion, Southern and Francophone Arica,South Asia, and Latin America in the late1980s and early 1990s, as well as a rangeo national workshops and conerences,raised the proile o sae motherhood, andhelped to pave the way or the inclusiono a holistic approach to sae motherhoodin the ICPD Programme o Action. Becauseo these meetings, there was amiliaritywith and support or sae motherhood

when the preparatory ICPD meetings tookplace. For example, many o the ICPDPreparatory Committee and regionalmeeting governmental delegations includedministry o health sta and parliamentarianswho had participated in the SMI regionalmeetings, and they were strong advocatesor sae motherhood. Further, the SMIswide dissemination o messages andother outcomes rom the regional SMI

meetings helped to raise awareness o saemotherhood among policymakers, NGOs,and the media.

The leadership o the ICPD secretariat(UNFPA) and key individuals played acritical role in securing commitment to sae

motherhood at the Cairo Conerence. Oneinormant noted that, since its irst decade,UNFPA has been involved in eorts to

improve maternal health and that UNFPAdedicated a signiicant portion o the timeallocated to the ICPD regional preparatorymeetings to discussions o the centrality osae motherhood to reproductive health anddevelopment. In addition, Dr. Fred T. Saisstrong leadership as ICPD Chair and his longhistory o involvement in maternal healthplayed a critical role in securing the saemotherhood goal.

During the ICPD preparatory process, a largecoalition o NGOs ocused on sexual andreproductive health, eventually numberingmore than 1,000 organizations rom allregions o the world, concentrated itseorts on lobbying or strong commitmentsto a comprehensive approach to sexualand reproductive health, o which saemotherhood was an intrinsic element.One inormant noted that much o the

drat language contained in the coalitionsproposals was incorporated verbatim intothe ICPD Programme o Action. The NGOcoalition, along with European and Aricangovernmental delegations, worked withthe conerence secretariat to highlight theimportance o a strong agreement that tooka lie-cycle approach to reproductive health,population, and development.

All inormants reported that, given theawareness o sae motherhood that wasraised prior to the ICPD, the Programmeo Actions sae motherhood goal enjoyednear-universal support.23 However, achievingconsensus on addressing a leading causeo maternal deathunsae abortionwas

23 One inormant recalled the Holy See being the only delegation that opposed the goal to reduce maternal deaths by 75% by2015. This was based on the Catholic Churchs long-standing proscription against articial methods o amily planning,which were recognized as being key to reducing unintended pregnancies and, by extension, maternal deaths.


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among the most hotly-contested issues at theICPD and FWCW. Several inormants recalledthat a small, vocal minority o delegations

rom conservative member states made asustained eort to prevent consensus onlanguage calling or action on unsae abortionand on making reproductive health servicesavailable on a universal basis.

Finally, it was noted that sae motherhoodserved an important political purpose oraddressing some o the more controversialissues in the Programme o Action. Framing

the reproductive health agenda as critical toreducing maternal mortality made it possibleto discuss and achieve agreement on issuesthat were sensitive or controversial, suchas unsae abortion, and enabled delegatesto embrace the comprehensive approach toreproductive health.

The Millennium Summit andMillennium Development Goals

Sae motherhoods inclusion in theMillennium Development Goals wasboth a recognition o its centrality to povertyalleviation and a compromise.

The UN Secretary Generals document thatcreated a ramework or the MillenniumSummit, We the Peoples: the role o theUnited Nations in the 21st century, did notcontain a reerence to maternal health. Itwas noted that the omission o the saemotherhood goal rom We the Peopleswasan oversight rather than intentional neglect omaternal health, which was later inserted intothe text o the Millennium Declaration.

One inormant noted that there had beenso much good will on sae motherhood

built by the SMIs 1997 and 1998 activitiesthat improving maternal health was widelyviewed as being key to alleviating poverty

and ensuring sustainable development. Thisinormant noted that, by keeping the ocus onsae motherhood and articulating clear goals,the Initiative helped establish the oundationor the MDGs. In addition, an inormant notedthat the 1999 WHO/UNFPA/unice/WorldBank joint statement on sae motherhood24was important or building support o a saemotherhood goal.

Second, the sae motherhood goal wasseen by some as a substitute or thereproductive health goal. One inormantrecalled that the dynamic o the MillenniumDeclaration process was markedly dierentrom that o the ICPD and FWCW. Unlikethe conerences o the mid-1990s, NGOswere provided little access to the Summit,limiting the possibility o advocacy.Another dierence was the ormat o thenegotiations: the overwhelming majority o

the Declarations text had been negotiatedthrough inormal diplomatic discussionswell in advance o the Summit itsel, urtherlimiting advocacy eorts. A small minority oconservative governments threatened that, ithe reproductive health goal was included asone o the Millennium Development Goals,they would block the consensus. However,these governments also indicated that a goalon maternal health would be an

acceptable substitute.

Thus, the inclusion o an explicit MillenniumDevelopment Goal on improving maternalhealth was driven by the recognition oits centrality to development and povertyalleviation in general, as well as bypolitical compromise.

24 Reduction o Maternal Mortality: A Joint WHO/UNFPA/unice/World Bank Statement. Geneva: WHO, 1999.

International Advocacy and Agreements for Safe Motherhood


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The UN General AssemblySpecial Session on Children

The UNGASS on Children, held in 2002,was a ten-year review o the WorldSummit or Children. It aimed to assessprogress on improving childrens lives and toidentiy additional interventions necessary toachieve the goals o the World Summit.

One inormant recalled that commitmentsto sae motherhood were included in thedrat outcome document drat preparedby unice (the UNGASS secretariat). Thedrat document ramed sae motherhood asnecessary or improving womens health andinant and child survival, and included keyactions on priority areas such as increasingaccess to skilled care during childbirth. Thiswas a very eective strategy: although themost powerul governmental delegationthato the United Statesattempted to weakenthe discussion o maternal health by equating

sae motherhood with abortion, all otherdelegations reiterated their commitment tosae motherhood, leading the United Statesto retreat. The inormant recalled that, by

the time o the UNGASS on Children, saemotherhood was widely accepted as akey development goal; governments were

ocused on identiying and implementingmaternal health interventions and werenot interested in revisiting old debates.Additionally, the inormant recalled that anumber o delegates reerenced materialsprepared by the SMI when making statementson recommending strong sae motherhoodlanguage in the document.


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This section assesses how mediaattention or sae motherhood has

changed over time, speciically analyzingthe impact o the Sae Motherhood TenthAnniversary media campaign. In addition,trends in press coverage between 2000and 2005 were analyzed to ascertain howsae motherhood has ared in national andinternational media outlets.

Safe Motherhood at 10

As part o the Sae Motherhood TenthAnniversary programme, a mediacampaign was carried out to reach inluentialmedia in donor and developing countries.Elements o this campaign, which waslaunched ollowing the Technical Consultationin October 1997, included: development o story ideas, press releases,

and eatures;

media training or potential saemotherhood spokespeople in bothdeveloped and developing countries;

identiication o a circle o 100 journalistsrom important print and broadcast outlets;

a media-only Web site or inormation (alsocalled a virtual press oice);

event-related press relations; a master press kit to help partners in

developing countries extend the media

attention on key sae motherhoodissues; and development and distribution o public

service announcements (PSAs).

Considerable coverage was generated by theSae Motherhood Tenth Anniversary events(the Call to Action on World Health Day inparticular) and by the PSAs, which weredisseminated to over 350 TV and 200 radiooutlets in more than 80 countries. The PSAswere shown requently by such outlets asCNN International, CNBC Europe, Star TV, andMTV (North and South), as well as nationaltelevision stations in Malaysia, Bangladesh,the Czech Republic, Lesotho, Pakistan,

Zimbabwe, and Uganda. In a survey ocountry-level participants rom the TechnicalConsultation, 70% o respondents elt thatlocal media coverage about sae motherhoodhad increased during the campaign, thoughno ormal country-by-country evaluationwas conducted.

The impact o the campaign was assessedthrough an analysis o press coverage

generated around World Health Day 1998events in Washington, DC and around theworld. Press coverage was tracked or theperiod covering September 1997 to October1998, which encompassed the TechnicalConsultation on Sae Motherhood in SriLanka and World Health Day, on April 7,1998.25 One hundred ourteen articles wereanalyzed across 15 markets: Australia,Canada, China, France, India, Israel, Malaysia,Russia, Singapore, South Arica, Sri Lanka,

Thailand, Turkey, the United Kingdom, andthe United States. Key indings are presentedon the ollowing page.

25 The media analysis was limited to articles eaturing the World Health Organization within the context o the IAGs WorldHealth Day activities, since World Health Day coverage was extensive and beyond the nancial means and study o thecommunications analysis.

Media Trends in Safe MotherhoodIVIV


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Story Placement:

The greatest number o articles appearedin the United States (55) and the United

Kingdom (17). India ollows with ten articles,Sri Lanka with eight, then Malaysia andSouth Arica with our each. Reasons orthe heightened interest in these countriesinclude: the location o the World Health Dayevents and the Technical Consultation, useo local speakers and local issues, and theattendance o national igures at the events.

A variety o wire services covered saemotherhood; they were responsible or

29% o the press. Most prominent wereAssociated Press, PressWire, Agence FrancePresse, and Reuters.

National print was responsible or 43% ocoverage. The Daily News(Sri Lanka) hadthe most articles (three) ocused on theColombo conerence. The UK publicationsthe Daily Telegraph and the FinancialTimesalso contributed one item each.Other national print channels includedthe Jerusalem Post, the New Straits

Times(Malaysia), and the Straits Times(Singapore).

Story Sources: Seventy-our o the published articles

analyzed were news items, 36 were opinionpieces, three were editorials, and one wasa letter. The source o the coverage wasbroken down as ollows: interviews orpress brieings (62%); third party (i.e., WHO,

unice) (19%); press releases (11%); andspontaneous coverage (3%). Press brieings and interviews with key

spokespeople proved to be very eective;they generated good coverage o keymessages both in terms o volume andavorability. Each market took a keeninterest in their own leading igures, andalso in the keynote igures at World HealthDay in Washington.

Story Focus and Content: Media attention overwhelmingly cited World

Health Day (66%). Family planning was

the ocus o 19 articles (driven by HillaryClintons call or amily planning to preventunsae abortion); there were also tenmentions o unding (again driven by Mrs.Clintons criticisms o the U.S. Congress).

The most common messages mentioned inthe media coverage were: sae motherhoodis a human right (26); sae motherhood is avital economic investment (13); and greaterunding is required (6).

Oering acts and igures in press releasesand other materials helped ensure clearand consistent reportage o the extent andthe medical causes o maternal mortality.Coverage o the socioeconomic and politicalactors was much more diverse, relectingdiering political and economic contexts oreach media market.

Media Coverage Since 2000

This section analyzes how the mediahas covered sae motherhood issuessince 2000, and identiies regional as wellas issue-based trends in press coverage.Media reporting rom January 2000 to June2005 was reviewed or coverage o saemotherhood issues. Research was limitedto English-language press sources includedin the NEXIS academic universe database.To identiy coverage addressing sae

motherhood issues in developing countries,keyword searches were conducted usingthe ollowing search terms: maternal health,maternal death, Sae Motherhood Initiative,and sae motherhood. In addition, moredetailed searches were conducted or articlesthat had the terms maternal health andMillennium Development Goals within 25words. The ollowing NEXIS news libraries


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were examined: Major Papers; World News:European sources, North and South Americansources, Asia and Paciic Sources, and Arica

and Middle East Sources. Additionally, acompilation o news coverage on the BushAdministrations decision to withhold the U.S.governments contribution to UNFPA wasreviewed or sae motherhood content.

Observations and Trends

Increase in Maternal Health Coverage and

the Impact of the MDGs

Perhaps the most striking inding in thisanalysis was a progressive increase, duringthe irst ive years o the new millennium, inthe number o articles reerencing maternalhealth. This trend, which holds or mediaoutlets in each region, is strongly correlatedwith the adoption o the MDGs in late 2000.In years 2001 through 2005, MDG reportingincreased reerences to maternal health by asigniicant margin.

From January 1, 2001 until June 1, 2005,maternal health was mentioned in 561 articlesrom Middle Eastern and Arican sources in

the World News library (see graph below).Two hundred thirty-one (41%) o thesearticles ocused on the MDGs (the remaindero the articles reported on a range o saemotherhood issues such as new maternalmortality estimates, the impact o unsaeabortion on women in the region, and donorunding or national or regional maternalhealth interventions). In comparison, romJune 30, 1996 until December 31, 2000,

maternal health was mentioned in just 172articles rom Middle Eastern andArican sources.

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Media Trends in Safe Motherhood


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As the graph below illustrates, similar trendsappear in the Asia and Paciic region. FromJanuary 1, 2001 until June 1, 2005, maternal

health was mentioned in 813 articles; 212(26%) o which were ocused on the MDGs(the Asia and Paciic region includes Australia;89 o the non-MDG articles identiied inthis search discussed domestic Australianmaternal health issues). In comparison, romJune 30, 1996 until December 31, 2000 just290 articles rom the Asia and Paciic regionmention maternal health.

While the MDG-related articles werenumerous, most o them did not dedicatesigniicant attention to maternal health.Frequently, maternal health appeared merelyin a summary o goals within an article thatexamined a countrys eort to achieve one othe other goals, such as reducing poverty orincreasing primary school enrolment.Overwhelmingly, MDG-ocused articles

that were maternal health speciic eitherlauded a countrys success in improving saemotherhood or lamented the likelihood that

the country would ail to meet the maternalhealth goal by 2015. Regional dierences inwhether the coverage was slanted towardlauding or lamenting maternal healthwere striking.In Asia, in sae motherhood success storycountries such as Sri Lanka and Malaysia,the governments garnered media attentionor their assertion that they had met the

goal o reducing maternal mortality by75%. Interestingly, the Chinese governmentasserted that, while progress had beenmade, they needed to work harder to meettheir MDG on maternal health and notedthat expanding access to skilled care duringchildbirth was key to achieving a 75%reduction in maternal mortality by 2015.

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In Arica, most o the maternal health-speciicMDG coverage lamented the prospect thatkey countries would not achieve the maternal

health MDG by the 2015 target. Country-speciic coverage included articles romZambia, Kenya, and Ghana. Additionally,several articles rom Arican (Pan-AricanNews Agency) and other regional pressoutlets (such as Deutsche Press-Agenturand Xinhua News) reported that maternalmortality was increasing in countries aectedby civil unrest and/or armed conlict such asZimbabwe and Sierra Leone.

Overall, while the MDG process appearsto have raised the medias awareness omaternal health issues, much o the coverageto date has been supericial. This suggeststhat there is a need or press outreach thatemphasizes the centrality o the maternalhealth goal to the achievement o povertyalleviation and sustainable development asa whole.

Other Trends

Reframing of Maternal Health IssuesMedia coverage o maternal healthhas generally ocused on the numbers orrates o women who die each year rompregnancy-related causes, with the releaseo maternal mortality estimates by the UNagencies approximately every ive yearsgarnering signiicant press attention. In

the last 56 years, media coverage hasbroadened to discuss eective interventions,in part relecting eorts by the press oiceso technical and unding agencies (such asWHO, unice and UNFPA) to rame maternalmortality as a problem with known solutions,requiring political will and resources. Forexample, 14 o 15 articles on UNFPAseorts in October and November 2001 toprovide health care to women reugees rom

Aghanistan mentioned either sae birthingkits or the importance o giving birth with askilled attendant.

Mothers DayThe use o Mothers Day as a news hookhas helped generate coverage when coupledwith the release o new inormation or data.For example, in the United States in 2000and 2001, just two columns ocused on saemotherhood; once Save the Children beganto release its Save the Mothers report onMothers Day, Mothers Day press coverage

o sae motherhood issues increasedsigniicantly. In 2003, 2004, and 2005, 20Mothers Day articles eaturing the Savethe Mothers report were identiied. Thisreport ocuses on a dierent aspect o saemotherhood every year and also includes thepopular Mothers Index, a compilation ocountry-level data on key maternalhealth indicators.

Coverage of Unsafe Abortion

During the analysis period or mediacoverage (January 1, 2000 through June1, 2005), unsae abortion was cited morerequently than any other single cause omaternal death and disability. Unsae abortionwas cited in 993 news articles rom theWorld News library in NEXIS. Twenty-eightpercent o these articles discussed the causalrelationship between unsae abortion andmaternal death, many citing the toll o unsae

abortion in a speciic country (such as Kenya,the Philippines, and Colombia). Additionally,17% o the coverage ocused on the impacto the Bush Administrations policies onreproductive health and reerenced how suchpolicies were having a negative eect oneorts to reduce unsae abortion.

Media Trends in Safe Motherhood


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Additionally, the Sae Motherhood Inter-Agency Group meeting on unsae abortion,held in Kuala Lumpur in September 2003,

generated national attention in Malaysia,where Bernama (the Malaysian National PressAgency) published an article that was madeavailable via the Financial Timess GlobalNews Wire and reprinted in at least ournewspapers around the world.

Lessons Learned

The prominence o the MDGs inthe media presents an important

opportunity to ensure that MDG-related presshighlights sae motherhood. To this end, itis important to consider special MDG pressoutreach ocused on maternal health. Suchoutreach could include media-riendly casestudies o success and challenge countries.


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Since the launch o the SMI in 1987,the landscape o agencies working

in the ield o maternal and child healthhas changed signiicantly. The numbero development agencies with dedicatedsae motherhood programs has growndramatically, and sae motherhood hasreceived increasing priority. Donor agenciesunding commitments to sae motherhoodhave also risen, in response to internationalmandates such as ICPD and the MDGs.

However, unding remains inadequate toachieve the Initiatives goals.

A review o organizations and agenciesworking in health and development justprior to the launch o the Sae MotherhoodInitiative in 1987 revealed that ew(approximately six agencies) had speciicprograms ocusing on maternal health. In1992, ive years ater the SMI launch, the

number o agencies with sae motherhoodas a priority increased to 26 (includingmultilateral organizations) as part o ananalysis conducted in preparation o ameeting o Partners or Sae Motherhood,which reviewed progress and prospects orsae motherhood between 1987 and 1992.26

The agencies that had identiied saemotherhood as a priority issue around the1987 conerence included:

The World Bank:As one o the longest andmost consistent supporters o the globalInitiative, the Bank has used its inancialclout to increase investment in maternalhealth policies and programs. In the tenyears ollowing the SMI launch in Nairobi,

World Bankunded projects or saemotherhood increased substantiallyromten to 150 projects.27 The Bank has also beena critical partner in the Sae MotherhoodInter-Agency Group, through its periodicrole as chair and its inancial support othe secretariat.

The World Health Organization:As oneo the co-sponsors o the Nairobi SaeMotherhood Conerence, the World Health

Organization (WHO) has long identiiedsae motherhood as a core priority area.WHO has provided technical leadership inthe design, implementation, and evaluationo programs to governments, and hasworked in collaboration with NGOs andhealth proessional groups, among others,to strengthen the provision o maternalhealth services. The clinical guidelines,policy bries, training modules, and research

reports and methodologies it has producedon maternal health have been widely usedand adapted.

UNFPA:Following the ICPD in 1999,UNFPAs ocus on maternal health increaseddramatically. Its current strategy orpreventing maternal mortality includesamily planning to reduce unintendedpregnancies; skilled care at all births; andemergency obstetric care or women who

develop complications. At the country level,sae motherhood eatures prominentlyin UNFPAs programs, and the agencysexperience working in sae motherhood inover 140 countries has provided a wealtho programming lessons or the maternalhealth community.

Development and Donor AgencyCommitmentVV

26 Otsea K. Progress and Prospects: The Sae Motherhood Initiative 19871992. Washington, DC: The World Bank, 1992.27 Sae Motherhood and the World Bank: Lessons rom 10 Years o Experience. Washington, DC: The World Bank, 1999.


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Family Care International:Family CareInternational (FCI) was one o the earliestNGOs to situate maternal health as central

to its organizational mission. At the saemotherhood conerence in Nairobi, FCIplayed a critical role in setting the agenda,coordinating the meeting logistics, anddocumenting and disseminating theconerence indings. In its role as secretariatto the Sae Motherhood Inter-AgencyGroup (IAG, 19872004), FCI helped shapethe global landscape or sae motherhood;the materials produced with and on behal

o the IAG, as well as the conerences itorganized, inluenced the policy agenda atthe global and national levels, set technicalpriorities, and raised awareness around thispublic health tragedy.

MotherCare (a USAID-funded project

implemented by John Snow International):From 1990 to 2000, MotherCare wasUSAIDs lagship project on maternalhealth (subsequently superseded by the

Maternal & Neonatal (MNH) Program andACCESS). With the aim o improving thehealth, nutrition, and survival o womenand newborns through a continuum o care,it provided evidence-based programmaticapproaches through needs assessments,monitoring and evaluation, and policydialogue. The lessons and experiencesgleaned rom MotherCares work in over 25countries had a signiicant inluence on the

design, planning, and implementation osae motherhood programs in the decadesto come.

The Safe Motherhood Inter-Agency Group:

Founded in 1987 ollowing the Nairobiconerence, the Sae Motherhood Inter-

Agency Group was launched in an eortto redress the gross neglect o maternalmortality and morbidity in the priorities odevelopment agencies, within the nationalplans o developing country governments,and in the mindsets o the general public.Bringing together UN agencies andcivil society partners, the IAG was anunprecedented partnership o organizationsunited by a common goal: to halve the

maternal mortality ratio. While its impacton the global SMI is diicult to determine inquantitative terms, it is clear rom inormaleedback and a general assessment otrends that the IAG has made substantialinroads or maternal health on the policy,advocacy, and technical ronts.

Columbia University, Prevention of

Maternal Mortality Program:From 1988 to1996 researchers at Columbia University,

New York, collaborated with a network oeleven multi-disciplinary teams in WestArica (based in Ghana, Nigeria, and SierraLeone), called the Prevention o MaternalMortality (PMM) Network. These teamscarried out operations-research projectson maternal mortality, collected a body oinormation on the design and evaluationo such programs, and produced analyticalwork that signiicantly inluenced program

design (such as the three delays model,which analyzed the actors that preventwomen rom receiving essential care, andtheir ocus on the importance o emergencycare or lie-threatening complications).Their experiences have provided the saemotherhood community with solid evidenceon the types o interventions that have thegreatest impact on reducing maternal deathand disability.


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Beginning in the 1990s and continuing intothe new millennium, a number o large,visible, and relatively well-unded projects

and programs aiming to reduce maternalmortality were launched. These includedthe Averting Maternal Death and Disability(AMDD) program, implemented by ColumbiaUniversity and partner agencies; theInitiative or Maternal Mortality ProgrammeAssessment (IMMPACT) project whichis coordinated through the University oAberdeen; FCIs Skilled Care Initiative; and theUSAID-sponsored MNH Program and ACCESS

housed at JHPIEGO. These projects/programsare a testament to the increasing visibility andimport accorded to sae motherhood as anissue area over the last decade.

AMDD was launched in 2000 as a large-scale demonstration project ocusing onimplementing emergency obstetric careinterventions in low resource developingcountries through a human rightsbasedapproach. Implemented in over 50 countries,

the program has achieved high impact,high visibility, and is well-regarded bygovernments, international developmentagencies, and civil societies.

IMMPACT is a global research initiative thataims to provide rigorous evidence o theeectiveness and cost-eectiveness o saemotherhood interventions, speciically interms o equity and sustainability. Funded

by a range o development aid agencies,IMMPACT plans to develop a series o toolsand methodologies, among other activities,by the end o 2007.

FCIs Skilled Care Initiative is an innovativeive-year project being implemented in threerural, underserved districts in Burkina Faso,

Kenya, and Tanzania to improve womensaccess to skilled care during pregnancyand childbirth. The project examines theeasibility, cost, and impact o implementinga comprehensive approach to skilled careduring childbirth in low-resource settings.

ACCESS is USAIDs lagship program onmaternal health. Building on the work othe MotherCare and MNH projects, ACCESS

aims to improve the availability, access,and use o maternal health and newbornservices in select countries around theworld. ACCESS works at the clinical andcommunity levels (rom the acility to thehousehold) in an eort to bring care as closeas possible to women and their amilies.

Agency Trends in Policy andFunding for Safe Motherhood

In order to assess how sae motherhoodhas ared at the policy, program, andbudgetary levels within development anddonor agencies, interviews were held withselected representatives between May andJuly 2005. The objectives o the researchwere to: Assess agency trends in policy commitment

to sae motherhood over the last ten years. Track agency trends in unding or sae

motherhood/maternal health over the pastten years.

Identiy the main actors that have shapeddevelopment agencies commitment to andinvestment in sae motherhood.

Evaluate general trends and events thathave inluenced unding or and progresstoward achieving sae motherhood goals.

Development and Donor Agency Commitment


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Development Agency Trends

Sixteen representatives rom majorinternational development agencies28

based in the U.S. and Europe wereinterviewed or this report. Responding toa pre-set questionnaire, representativesshared inormation regarding their agenciescommitment, unding, and technical prioritiesrelated to sae motherhood.

The majority o development agencyrepresentatives (13 out o 16) participating

in the survey reported that over the pastten years sae motherhood has remained aconsistent priority within their agency. Saemotherhood was oten classiied as oneo the priorities within the larger gamut osexual and reproductive health or broaderdevelopment issues such as gender andviolence, and many representatives identiiedspeciic aspects o sae motherhood (skilledcare during childbirth, postabortion care, and

malaria in pregnancy) as key priority areasover the past ten years.

The actors that contributed to the inclusiono sae motherhood as an agency prioritywere varied. For some agencies, it wasdriven entirely by internal push actorsindividuals interested in promoting saemotherhoodwhile others were inluencedby external actors such as research,evidence rom the ield, and global

conerences on maternal health.

The majority o agencies elt that maternalhealth would continue to be a priority inthe uture in some capacity or the other: 13

o the 16 respondents explicitly identiiedmaternal health as a uture priority areaor their agency. The clear trend wasintegrating sae motherhood with other areasspeciically, agencies planned to developlinkages between sae motherhood andHIV/AIDS, given the increasing importanceo preventing mother-to-child transmission.Another proposed area o integration ismaternal health and newborn health.

One representative noted that newborn

health programs typically have dierentstrategies and priorities than those ocusingon maternal health. For example, they placeconsiderable emphasis on community-based care, including hygienic delivery, cordcare, breasteeding, kangaroo care, etc.;emergency obstetric care, abortion-relatedcare, and addressing obstetric istula are nottypically part o newborn care programs.With more and more donor unding ocusing

on integrating newborn and maternal health,it may become challenging to marry thevarying priorities.

28 Participating agencies included: Academy or Educational Development; Alan Guttmacher Institute; American College oNurse Midwives; Care International (USA); EngenderHealth; Family Health International; Global Health Council; InternationalPlanned Parenthood Federation; Ipas; International Rescue Committee; IntraHealth International; Pathnder International;Population Reerence Bureau; Program or Appropriate Technologies in Health; Save the Children; Womens Commission orReugee Women and Children.

Safe motherhood will become a bigger

part of our work in the next few years.One reason for this change is the newapproach to working with mothers andnewborn care.With new money fromfoundations, there is a lot of energyaround newborn health.


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The trend toward integrating saemotherhood with other development issuesstems rom addressing the entire continuum

o womens health issues. In addition, severalrepresentatives noted that sae motherhoodis gaining greater prominence with otherrelevant development issues:

Representatives were asked to relect onshits in programmatic and technical areaswithin their agencies over the past ten years.Commonly recurring themes includethe ollowing: A shit rom primarily emphasizing acility-

level work to building capacity at thecommunity level.

Focusing on the entire health system,which involves strengthening capacity atall levels o the health care inrastructure,rom primary to reerral levels, andengaging community members in serviceprovision. Speciic programmatic areaso ocus include: improving reerral andtranser to higher-level acilities; improving

communication systems; strengtheningskills in emergency obstetric care atall levels.

Increased advocacy or all sexual andreproductive health issues, includingincreasing womens access to sae abortionservices (where not against the law) and the

health consequences o unsae abortion. Onerespondent noted that advocacy eorts needto be supported by clear, evidence-based

interventions with demonstrated impact. Increasing emphasis on the rights

ramework which situates saemotherhood as an essential human right,and includes the right to receive basichealth care services.

Emphasizing skilled assistance at childbirthand emergency treatment or complications

Representatives noted that there has beengrowing consensus that skilled care at the

time o childbirth, along with emergencyobstetric care to handle complicatedcases, is a critical intervention or reducingmaternal mortality.

These changes in programmatic and technicalemphasis were attributed to two broad areas:

The impact o international conerences anddiscussions, global partnerships, and globaladvocacy initiatives or maternal health:

Lessons learned rom the ield:

The role of safe motherhood is evolving

within HIV/AIDS; for example, looking atthe safety of contraception and preventionof unwanted pregnancy for HIV-positivewomen is increasingly being encompassedin HIV/AIDS work. So aspects of safemotherhood are expanding to cover newareas.

International dialogue tells us what

is important. We are constantly informedby what is happening internationally. Forexample, recently WHO has emphasizedsafe motherhood and newborn care tobe looked at collectively, and this hasinfluenced our thinking.

We are influenced by programming inthe field. The lessons learned are adaptedinto our programs.



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Representatives emphasized the importanceo operations and ield research in providingevidence or the design and development

o program interventions. For example, therecent ocus on neonatal mortality reductionrose in large part rom evidence illustratingthat simple, home-based interventions canreduce neonatal deaths. Research in particularcan identiy what the gaps are and what canbe done to address them.

Some representatives also discussed theinluence o donors and speciically noted

that agencies programming priorities wereshaped by what donors wanted and werewilling to und.

Data on annual health expenditure wasavailable rom 12 o the 16 representativesinterviewed or this survey. Among the 12,only ive agencies speciically earmarkedunds or maternal health, and their maternalhealth budgets ranged rom 1060% o theirtotal annual health budget; seven agencies do

not earmark unds by topical area, or they nolonger allocated speciic parts o their healthbudget to maternal health activities. O thelatter, some agency representatives explainedthat they did not receive unds speciicallyor sae motherhood (or other areas), butrather unding was country-speciic andor a speciic project or program. Anotheragency representative said that until 2000they received unding speciically or sae

motherhood; this is no longer the case, andnow they receive lump sum unds or a rangeo reproductive health issues, with maternalhealth programs included in this package.

Among those who reported expenditureinormation, the majority (7 out o 12representatives) reported that their agencies

maternal health budget as a proportion othe total annual health budget had increased.They attributed this increase to a recentheightened emphasis on sae motherhoodand other reproductive health issues, as wellas the rise in unding or speciic aspectso sae motherhood such as postpartumcare, skilled assistance, etc. Further, with theintegration o sae motherhood and newbornhealthan area o growing importance

more unding was becoming available orsae motherhood activities.

Donor Agency Trends

All donor agency representativesparticipating in the survey29 reportedthat over the past ten years, sae motherhoodhad consistently been a priority area or theiragency. Reasons cited or its inclusion as a

priority area included: the inluence o the1987 Sae Motherhood conerence and theICPD conerence in 1994; the identiication omaternal health as a goal in the MDGs; andthe belies o individual members withinthe agency.

29 Donor agencies participating in this review included: The Bill & Melinda Gates Foundation; Department or InternationalDevelopment (DFID), UK; Department or Development Aid Cooperation, Finland; MacArthur Foundation; SwedishInternational Development Cooperation Agency (Sida); United Nations Population Fund (UNFPA); United States Agency orInternational Development (USAID); The World Bank; and World Health Organization.

Reaching the MDGs and poverty

reduction is our first goal, yet maternalhealth has become increasingly importantsince it has become a milestone in the

MDGs.


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All but one representative elt that saemotherhood would continue to be a priorityarea in the uture, and the majority (ive out

o nine respondents) elt that its importancewould increase. With the MDG goals oimproving maternal health and reducingchildhood mortality, many representativeselt that sae motherhood was now back onthe map and gradually regaining importance.Some respondents also pointed out thattheir agencies were integrating maternaland newborn health, and hence in terms opriority and budgets sae motherhood would

become increasingly important in the uture.

Many o the representatives interviewedidentiied a dramatic shit in undingstrategies and priorities in the health ield ingeneral, and sae motherhood speciically.Most agencies are now shiting rom apiecemeal approach to a health systemsapproach. This encompasses all aspectso the health system such as upgradingcommunications systems, strengthening the

capacity o health workers, setting up reerralsystems, etc. Since maternal health dependsupon a working health system, many donorsidentiy sae motherhood as a barometer othe overall health system.

With the identiication o maternal health asone o the MDGs, donors eel their energyis invested less on unding service delivery

programs or projects, but on scaling-upoperations in an eort toward achievingbroad development goals.

There is increased emphasis on inancingmechanisms. Donors now consider itimportant to have a public health systemwith detailed data on costs or each healthservice. This level o detail is consideredcritical or eicient und allocation, and

in order to measure success. Sector-wideapproaches (SWAps) are increasingly beingpushed and endorsed by more donors, andthey are aiming to advocate or increasedmaternal health allocation in SWAp budgets.

A discussion o inancial trends or saemotherhood is provided in section VI.

We, unlike other agencies, which may

say they work on emergency obstetriccare, are working at improving national-level health systems. We are also trying

to influence technical reform anddecentralization of health care delivery.



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0

To provide an assessment o inanciallows or sae motherhood since 1987,

several data sources were used:

A World Banksponsored report, SupportingSae Motherhood: A Review o Financial

Trends, assessed unding levels relatedto oicial development assistance (ODA)or three years (19861988). The reviewemployed data sets rom this time period,supplemented with interviews with donor

representatives and oicial annual reportsrom bilateral and multilateral agencies.

The study included the ollowing project/program categories: those speciicallylabeled sae motherhood activities;projects categorized as maternal healthprograms; amily planning and populationprograms; general health system projectswith components that contribute to improving

maternal health; nutrition programs; IECprograms; women in development projects;and intersectoral programs that beneitwomen o reproductive age throughimprovements in education, employment,rural development, or agriculture.

The UNFPA/NIDI resource lows database,covering a time span o 19962002,was developed ollowing ICPD to trackresources or the costed package, a set

o reproductive health interventions andservices (including amily planning, basicreproductive health, STD and HIV/AIDSprevention, and research policy analysis).Maternal health care is included underthe basic reproductive health category.The database assesses inancial lows orpopulation via bilateral, multilateral, andprivate-sector channels, as well as romdevelopment banks.

A series o interviews with key saemotherhood bilateral and multilateraldonors to assess changes in undingpriorities or reproductive health generallyand sae motherhood speciically, and toidentiy uture unding directions orsae motherhood.

While these sources provide a snapshot ohow unding or sae motherhood has aredover time, they do not yield a complete

analysis o inancial trends since the launcho the Initiative. Since the data sets are notcomparable, inormation rom one sourcecannot be used in conjunction with the other,resulting in data and time gaps. Eorts tocollect data rom individual donor agenciesregarding sae motherhood expenditureswere problematic, primarily or two reasons: lack o electronic inormation systems (and

dedicated sta) that have kept track o

unding data since the mid-1980s; tendency to aggregate sae motherhoodinto broader reproductive health and/orpopulation programs, thereby making itdiicult to isolate how much is actuallyspent on sae motherhood projectsand programs.

Funding for Safe MotherhoodFollowing the SMI

In May 1990, the World Bank commissioneda report to assess how inancial lows ormaternal health changed since the launcho the global Sae Motherhood Initiative.Focusing speciically on ODA (and not otherunding sources, such as oundations orNGOs), the analysis estimated trends inexternal inancing or sae motherhood indeveloping countries.

Financial Trends for Safe MotherhoodVIVI


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According to the report, or the 17 bilateralsources, assistance or sae motherhoodincreased rom US$691.5 million in 1986 to

US$818.8 million in 1988 (in current dollars);or the six multilateral agencies, spendingincreased as well, rom US$396.7 million(1986) to US$477.7 million (1988).30

Interviews with the major bilateral andmultilateral agencies were held to assessindividual agencies commitment to saemotherhood and respective undingexpenditures to developing countries.

Covering the period rom 1985 to 1988, all17 bilateral donor representatives and sixmultilateral agencies included in the surveyreported a gradual increase in currentdollars or sae motherhood and indicatedplans to increase inancial support or saemotherhood in the uture.

Funding for Safe Motherhoodfollowing the ICPD

As noted above, the ICPD provided costestimates or the implementation o aset o services needed to achieve universalaccess to reproductive health by 2015 (theICPD costed package), and initiated amechanism or tracking donor expenditurestoward this goal. Initially, the majority oexpenditures (70%) were on amily planningand reproductive health services, with thelatter including inormation and routineservices or prenatal, delivery, and postnatalcare; abortion and postabortion care; andcomplications o pregnancy and delivery.Trends in the ICPD categories over time, asoutlined in the graph below, point to a sharpincrease in expenditures toward STIs andHIV/AIDS in response to the escalating AIDScrisis. Expenditures or basic reproductiveservices, which include maternal health,appear to have remained airly constant

between 19962004, with small spikes anddeclines rom one year to the next.

Donor Expenditures on ICPD Costed-Population Package Categories

(in US$), 19962004 (Figures or 2003 and 2004 are estimates)

30 Since bilateral data can include government contributions to multilateral and United Nations agencies, expenditures rom

both categories cannot be summed to yield an annual total. The nancial data represent donor allocations or a specic year

Accessed: http://www.resourcelows.org/index.php/articles/c78/ 10 August, 2005.

Family Planning STD/HIV/AIDS

US

Dollars

(In

hundred

ofthousands)

Reproductive Health Basic Health

0

500

1000

1500

2000

2500

200420032002200120001999199819971996


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2

In addition to examining trends in broadcategories o the ICPD costed package, a wordsearch o sae motherhoodrelated terms was

conducted to obtain expenditures speciicto maternal health between 19962002. Theanalysis revealed that the total amount ounds spent on sae motherhood projectsincreased steadily rom US$74.75 millionin 1996 to US$182.63 million in 1999; rom1999 to 2002, however, there was a gradualdecline in the amount o unds, to US$177.93million. It is interesting to note that theamount o unding peaked in 1999, the period

corresponding with the tenth anniversary othe Sae Motherhood Initiative.

As the next graph outlines, the number osae motherhood projects and programsillustrates a rising trend, with an increaserom 366 programs in 1996 to 468 in 2002.

Geographic distribution o unds or saemotherhood between 1996 and 2002 providesinsight into how donor priorities have shitedover time: in 1996, the region receiving thelargest number o unds was Asia and thePaciic, ollowed by Global/Inter-regional,with Western Asia and North Arica roundingout the top three. In 2002, regional prioritiesrelated to sae motherhood shited, such thatGlobal/Inter-regional received the largestshare o donor unds, Asia and Paciic thesecond largest share, and sub-Saharan Arica

the third largest. With data unavailable or2003 and 2004 at the time o publication, itis unknown how these regional allocationshave changed; however, there are indicationsthat more unds are being directed towardsub-Saharan Arica, in large part a resulto stagnating, and even rising, maternalmortality levels.

Donor Funding Trends for

Safe Motherhood

Interviews were carried out with ninekey sae motherhood donor agencies,representing bilaterals, multilaterals, andoundations31 (see Annex I or ull list oagencies), in an eort to assess past and

31 Donor agencies participating in this review included: The Bill & Melinda Gates Foundation; Department or InternationalDevelopment (DFID), UK; Department or Development Aid Cooperation, Finland; MacArthur Foundation; SwedishInternational Development Cooperation Agency (Sida); United Nations Population Fund (UNFPA); United States Agency orInternational Development (USAID); The World Bank; and World Health Organization.

0

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

140,000,000

160,000,000

180,000,000

200,000,000

2002200120001999199819971996

U

S

Dollars

Total US$ amount spent per year on

Sae Motherhood projects

0

100

200

300

400

500

600

2002200120001999199819971996

Numberofprojects

Number o Sae Motherhood projects

ound per year


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uture unding trends or sae motherhood.Data on annual health investments (rom 2004or the last iscal year or which data were

available) were made available by all donorrepresentatives interviewed or this survey:most indicated that unds or maternal healthhad increased in their agencies in the pastten years.

With regard to overall trends in maternalhealth unding, donors had mixed views as towhether unding has increased or decreased.Hal the respondents elt that the total unds

available or maternal health had increasedin the recent past with additional undscoming in rom new donors such as theGates Foundation and DFID. Representativesnoted that, as a result o the identiicationo maternal health as one o the MDGs,donor commitment and collaboration hadincreased. They hoped that this wouldtranslate into more money or maternalhealth in the near uture.

Others elt that there had been no change inunding or maternal health, and i anything,

unds had slightly decreased. Althoughoverall donor commitment to reproductivehealth seems to have increased, it wasdiicult to tease out the impact on maternalhealth. Measuring unding levels or maternalhealth is likely to become even more diicultin the uture, with donors and oundationsmoving toward a more integrated or basketapproach to unding using channels suchas SWAps and Poverty Reduction StrategyPapers (PRSPs).

Donor agency views on whether globalconcern about HIV/AIDS has resulted in undsbeing shited rom sae motherhood varied,

relecting at least in part dierent internalmechanisms and unding lows. Four donorrepresentatives stated that in their view theimpact has been negative, since in theiragencies unds or maternal health and HIV/AIDS were drawn orm the same pool.

In cases where HIV/AIDS unds do notnecessarily come rom the same pool, donorrepresentatives indicated that it wouldbe incorrect to say that HIV/AIDS is takingmoney away rom maternal health. Onerepresentative noted that, The whole pie hasincreased, so not sure it is an issue o suckingunds away rom one area to the other.

A handul o donor representatives also eltthat despite the luctuations in the past, thingswere beginning to change, and that moneywould be coming back to maternal health.

Donor representatives were asked tocomment on whether the current-levelunds were adequate or meeting the ICPDand MDG goals or maternal health, andto suggest how to augment unding levels.While all representatives agreed that undswere inadequate to meet stated maternalhealth goals, they proposed a wide range osolutions, including the ollowing:

We can say that with the MDGs,

maternal health is now on the map andit has now become an issue of knowingwhat to do and how to scale it up. It isless about getting peoples attention, but ofactually setting things in place.

donors need to fund the

Global Fund initiative, and this is normallyquoted as the reason why funding in other

areas is not going.

The fund committed to HIV/AIDS hasalready been allocated, and now new moneyis available to maternal health.

Financial Trends for Safe Motherhood


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Central to incr

sm a review full report final

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