we look at the history of recent improvements in global maternal health, say over the past quarter century, several characteristics really stand out. One is the massive and recent reduction in the number of maternal deaths around the world, which has happened at the same time that social and political attention to maternal health and well-being has really been on the rise. But for a very long time before that, maternal mortality was seen as a stubborn or unfixable problem. The deaths of women, stillbirths, newborns somehow seen as inevitable. Something to be lamented, but surely not important enough to tackle.
But in the past 25 years from 1990 to 2015, a really tiny slice of history, there’s been a huge reduction in the number of maternal deaths around the world– by nearly half, 44%. Every region of the world, whether it’s sub-Saharan Africa, West Asia, Latin America, has experienced rapid improvements, although some greater than others. So what’s behind this? Why did decision makers now see maternal health is an urgent issue, one that can be solved through policy and investment? And why has maternal health been in the limelight when there are other global health issues with bigger mortality burdens– road accidents, or diabetes, cancer?
And one answer to this is partnerships and advocacy– how partners concerned with maternal health decide to work together, how they agree on evidence and ideas, how they deliberately reframe public perceptions, and how they really pursue open windows of opportunity for joint action. Those together can make a massive difference in global health. Because it was only a few decades ago that technical experts, donors, programme managers, others argued ferociously about which strategies and approaches would really drive maternal health. Was it traditional birth attendants or professionalised maternity care? Did antenatal screening make a difference, or did it not? Would investing in child health neglect the rights and health of women who delivered those babies?
But as evidence continued to be gathered and partners continued to meet, the safe motherhood movement in the 1990s and early 2000s began to explore common ground with reproductive, newborn, and child health advocates, and agreed that a continuum of care approach would serve the interests of all. What’s good for women’s health is good for their children and vice versa. Important agreements on women’s health established at the Cairo Conference on Population and Development in 1994, also with the Beijing Women’s Conference in ‘95, served as a platform for creating consensus among different partners. Governments, NGOs, the UN really drove the idea that maternal health is intimately related to reproductive health, to child health.
The goals, targets, and indicators agreed at such conferences proved to be a successful basis for advocacy that could be taken forward into the Millennium Development Goals (MDG). In the early 2000s MDG 4 on child health and MDG 5 on women’s maternal health became the centrepiece of the MDG approach for poverty reduction. What we learned from this is that when partners from different backgrounds, different geographies come together with common ideas, when they find ways to frame their ideas in persuasive ways, political attention tends to follow. One measure of this as investment. Development aid for maternal health more than doubled in the MDG era.
Aid for maternal health has risen more than 200% since 2004, faster indeed than almost every other global health issue apart from malaria, and remarkably has continued to rise even where other issues, like HIV, have levelled off. So how we use evidence to frame certain issues really matters to the results we get. How partners come together into networks and advocate together matters. How we identify windows of opportunity like the MDG and now the Sustainable Development Goals, the SDGs, matter. But we need more than that. We also need guiding institutions, champions and roadmaps to keep us on track and to hold us accountable for action.
In 2005, those who had championed maternal and child health in the MDGs– governments, donors, health professional groups, NGOs, academics, UN agencies, and others– came together to form a new institution to scale up global advocacy. The Partnership for Maternal Newborn and Child Health, PMNCH, was built from three different partnerships– one on safe motherhood, one on newborn health, and one on child survival. Important actors and partnerships in maternal health since then have included Countdown to 2015; Women Deliver; the White Ribbon Alliance; the Campaign for the Accelerated Reduction of Maternal Mortality in Africa; and, of course, Every Woman, Every Child; and the Global Strategy for Women’s, Children’s and Adolescents’ Health. Arguably, global advocacy for maternal health was at its zenith.
Never before had so much attention, so much money, so much policy work been directed at improving maternal health outcomes. The consensus represented in the global strategy developed by the UN pushed all partners in all constituencies to work together for results and to be accountable to each other in doing so. When the 2030 Sustainable Development Goals took over from the MDGs in 2015, maternal health remained prominent in the framework, with a clear target of no more than 70 maternal deaths per 100,000 live births to be achieved by 2030. Yet, in an SDG era, the future of maternal health advocacy does not rely on technical approaches to maternal mortality reduction alone.
The SDGs put a clear emphasis on equity and human rights, including those related to sexual and reproductive rights and health, which means tackling contentious issues such as abortion rights, access to family planning and contraceptive use, domestic violence, and comprehensive sexual education. These are not easy issues for many countries in the world where abortion remains illegal, where laws and regulations limit the capacity of women and adolescent girls to protect themselves from early marriage or from genital mutilation, from unwanted pregnancy or from the pain and stigma of stillbirths and newborn deaths. Without a doubt, we have moved away as a world focused mainly on supply-side, technical inputs to health.
Today, the SDGs recognise barriers to community uptake of health services and endorse universal health coverage and financial protection. We are also far more focused on community demand and greater accountability for the provision of quality care. Quality health care, equity of access, dignity of care, QED, have become a clarion call for maternal and newborn health advocates all over the world. Women have a right to expect respectful care during pregnancy and delivery regardless of their marital status, their social background, their geography. This is fundamental to human dignity and the vision of the SDGs.
First of all, we can strengthen our partnerships by reframing the way we talk about maternal health– not as a product of health services alone, but as a determinant and a consequence of sustainable development, including access to education, employment, water and sanitation, nutrition, and social inclusion. We’re only at the beginning of using the SDGs as an integrated framework for action in this way. It’s not very easy at the beginning. We’ve come from an era with very different incentives and signals. The Millennium Development Goal framework, for instance, really rewarded changes in mortality measures and looked at health through a relatively narrow telescope of quantifiable targets and biomedical drivers of change. “What gets measured gets done”, as the saying goes.
Although human rights have always been understood as implicit to maternal health, it’s only in recent years that such principles have begun to be more fully discussed and considered, as seen recently in the recommendations of the health and human rights working group launched at the World Health Assembly this year. Secondly, we need greater accountability for partnerships and the advocacy we undertake– not only for results, but for the resources we invest in such platforms and processes. These partnerships can often be overlapping and duplicative, with each issue wanting its own space, its own visibility, especially in this era of the SDGs with 17 goals, a huge expansion from the eight goals of the MDGs.
The global health space has grown tremendously in the last 15 years of the MDGs. More money for health has fueled more actors, more platforms. We’re no longer in the era of state-led health, and privatisation brings energy, innovation, resources. But it’s a challenge to work together in this crowded space. It’s sometimes easier to avoid the difficult process of consensus building and compromise and simply create more indicators, more reports, more working groups. In relation to maternal health advocacy, partners have struggled over the years to find common ground with newborn advocates, reproductive health advocates, child and adolescent health advocates. Partners have sometimes fought for dominance.
And sometimes, this has even been productive, such as when reproductive health advocates forced greater attention to family planning through initiatives such as FP2020, responding to what they felt was a lack of due attention in the global strategy. Yet, in other ways, issue competition may be less productive. When global health itself is no longer a rising star in the global development sky, such as it was the MDG era, partners may stagnate and split apart to protect their own interests.
What is good is that the Every Woman, Every Child movement has been a pathfinder for accountability, with an independent accountability panel issuing an annual report of recommendations for action, based on a synthesis of evidence submitted by partners from across the reproductive, maternal, newborn child, and adolescent health space. That report will be issued in September this year (2017) at the time of the UN General Assembly. When global partners need to be told hard truths about issue competition, duplication, and complexity that slows down country progress, the IAP report can be expected to do that. Third, and finally, we need more investment in research and advocacy strategies and tools that work and produce results for communities themselves.
In some ways, we’re still at the beginning of understanding maternal health as a political process rather than a biomedical one. We’re yet to fully invest in policy and implementation research that reveals power and politics and how they influence health outcomes. This type of evidence helps us understand how the behaviours of global networks influence outcomes at community level, but also vice versa. Women who experience inaccessible care, poor quality care, abusive care should be able to access partnerships and tools that help them realise their capacity or power to complain, to join in solidarity with others, and to use partnerships to protect them from sanctions.
The global community can support women in strengthening their voice by supporting evidence-based strategies and investments for greater accountability and joint advocacy, such as the rather impressive citizen hearing processes on maternal and newborn health sponsored by global NGOs such as the White Ribbon Alliance, Save the Children, and the International Planned Parenthood Federation. Here, the media, too, including social media, can play an important role in ensuring that voices are heard and promises are upheld and that the feedback loop from community level to global level is functioning well.
In this era of fake news that we live in, we need evidence to travel up and down these feedback loops to inform action at all levels, but we also need stories of complaint and stories of success told by those most affected. If we can better understand how global policy and partnerships influences community action and vice versa, we can make better progress in maternal health.