The problem stream
This section addresses the emergence of maternal mortality as a human rights problem that is grounded broadly in international human rights law through an historical overview of key developments in its evolution from condition to problem. As we are interested in exploring where EmOC fits into this picture we highlight it where relevant.
Kingdon notes that “Conditions become defined as problems when we come to believe that we should do something about them” (p 109) . Getting preventable maternal mortality on the global agenda was of differing priority to the two key overlapping advocacy and policy communities, namely the maternal health community and the sexual and reproductive health and rights community. Kingdon suggests that indicators, focusing events and feedback are key to this stage of the journey and our discussion highlights how each played a part.
The emergence of maternal mortality as a (global) human rights problem
Abou Zahr highlights that “Maternal mortality was a neglected issue during the 1970s and early 1980s, less because health professionals in developing countries were unaware of the problem than because they lacked the tools to quantify and analyse it ”. It was only in the mid-1980s that the World Health Organization (WHO) released its first estimates of the annual global maternal mortality death toll as exceeding half a million women per year, with the vast majority occurring in low-income countries . The reporting of this indicator helped raise awareness of the scale of the problem and the global inequity it exposed . It also became the basis of much advocacy and the over half a million annual deaths in childbirth or pregnancy was a figure that came to be associated with this problem until evidence of a decline was finally reported in 2010 .
Several key focusing events also helped push maternal mortality from a condition to a global problem. The 1985 Lancet article by Rosenfeld and Maine entitled “Maternal Mortality – a neglected tragedy. Where is the M in MCH?” played a big role in bringing the issue of preventable maternal mortality to the attention of the international health policy community . Rosenfeld and Maine argued forcefully for increased attention to the mother, not just the child, and challenged the traditional focus on antenatal risk screening and traditional birth attendants presenting compelling arguments for the importance of access to EmOC; the significance of which we shall explore below.
A key focusing event in the emergence of a maternal health community was the 1987 launch of the global Safe Motherhood Initiative (SMI) in Kenya aiming to increase awareness of the over half a million annual maternal deaths and to reduce maternal mortality levels by half by 2000 . The SMI launch was supported by the World Bank, WHO and United Nations Population Fund (UNFPA) and this broad based support meant the concept and name had to be acceptable for communities that opposed what they perceived as political or feminist implications of terms like reproductive health . The important role of the SMI in shaping the current policy agenda on maternal health will be examined in the policy community section.
In parallel with these developments another key factor was the rise of the women’s movement which helped draw attention to the consequence of the global neglect of women’s human rights, including women’s health needs. A key focusing event included the landmark 1979 Convention on the Elimination of Discrimination against Women, which mainly framed women’s health in the context of reproductive health focusing on family planning . The 1994 United Nations Cairo Conference on Population and Development (Cairo) and the follow-up 1995 Beijing World Conference on Women (Beijing) anchored sexual and reproductive rights as broader human rights claims . With respect to maternal health governments made a key commitment at Cairo to reduce maternal mortality by one half of the 1990 levels by the year 2000 and half again by 2015 . As Alicia Yamin notes the language of Cairo and Beijing went beyond focusing on women’s health and maternal health as simply issues of health and biology recognising that it is a matter of power relations . For example the Beijing Platform recognised that “A major barrier for women to the achievement of the highest attainable standard of health is inequality; both between men and women and among women in different geographical regions, social classes and indigenous and ethnic groups ”. Thus while maternal health and maternal mortality remained important issues, for the sexual and reproductive health and rights movement they were not the priority, rather broader based holistic goals addressing structural impediments to realising rights were the focus.
The international human rights response to these developments further clarified the different human rights obligations of states with respect to maternal mortality. In 1999 the Committee on the Elimination of Discrimination against Women, issued General Recommendation 24 proclaiming “it is the duty of States parties to ensure women's right to safe motherhood and emergency obstetric services and they should allocate to these services the maximum extent of available resources ”.
The 2000 General Comment on the right to the health (General Comment) clarified the nature of the right to health obligations enshrined in Article 12 of the Covenant [2, 30]. It added precision to the right to health dimensions of sexual and reproductive health further bringing attention to maternal health as a rights issue. It makes clear that the Covenant articles on women’s health require measures to improve sexual and reproductive health services… including access to emergency obstetric services (paragraph 14)b. The framing of maternal health as an obligation of comparable priority to a core obligation has important funding and priority setting implications for the national government and the international community; specifically that states in a position to assist must help those that cannot fulfil their core maternal health obligations, including access to EmOC. The work of the United Nations Special Rapporteurs on the Right to Health; Paul Hunt (2002–2009) and Anad Grover (2009-present), has helped to keep maternal mortality high on the international human rights agenda .
It can be argued that maternal mortality moved from a condition to a global health problem when its reduction was included in the MDGs, as agreed in 2001. However its inclusion was a double edged sword. It exposed the tension around the framing of the issue among the different policy communities while further raising global awareness of the problem, if not significantly increased funding. For the maternal health community ‘their issue’ was on the global agenda which was a victory, albeit the indicator was not one they would have chosen. Much of the sexual and reproductive health and rights community were appalled that the Millennium Declaration omitted any language about sexual and reproductive rights, viewing the MDG agenda as undermining the progress made in Cairo and Beijing . The late addition of MDG target 5B in 2005 relating to universal access to reproductive health, including family planning was received more positively by the sexual and reproductive health and rights community.
It is also important to note that although maternal mortality was now being framed as a human rights problem by diverse policy and advocacy communities, each community’s understanding of and approach to addressing this frame was different. As one interviewee noted, “The people in maternal and child health are not human rights advocates so they do not have the tools for such advocacy.” (Interview 8) For the sexual and reproductive health and rights community, maternal mortality was a reproductive health rights issue requiring a broad based structural response addressing gender discrimination and the power imbalances within and between countries. For the maternal health community maternal mortality was primarily a health issue requiring the appropriate medical interventions guaranteed in a well-functioning health system. This overlapping, but increasingly disparate framing of their agendas led to fragmentation in the policy community as shall be discussed below.
2009 saw a landmark resolution adopted by the United Nations Human Rights Council recognizing maternal mortality as a human rights violation and follow-up resolutions and work led to the 2012 UN Technical Guidance on Preventable Maternal Mortality and Morbidity and Human Rights, (Technical Guidance) which will be examined below . It provides operational guidelines on program design and policy implementation that are consistent with human rights standards as well as highlighting the importance of accountability mechanisms and the role of the international community in addressing maternal mortality and morbidity.
To summarize; only since the new millennium, and the publication of General Comment 14, has the international human rights framework developed sufficiently clear guidance with respect to health related obligations and priority setting for national governments and the assistance and cooperation obligations for the international community (extra-territorial obligations), although clearly more work is neededb. Ongoing work to further clarify the implications of health related (and other) extra-territorial obligations will improve specificity but for the purposes of the main issue covered in our study, namely access to EmOC, there is sufficient legal guidance for national and international policy makers to act to fulfil their shared obligations .
The policy stream
In this section we analyse the policy stream around maternal mortality to see how it evolved, maintaining a focus on access to EmOC. As noted in the section on the problem stream this is a complex field with multiple players each with a distinct but overlapping agenda, constituency and approach to achieving their goals; potentially leading to fragmentation.
In Kingdon’s model the policy stream is the second element of the policy process producing the alternative solutions to address the problem. In our case the primary actors are the two main policy communities who work with different technical experts, academics, international agencies, national governments and donors to develop solutions that will help reduce maternal mortality globally. It is at this stage in the policy process that proposals are generated, debated, reworked and eventually accepted or rejected. Kingdon notes that the policy communities involved in this process can be tight knit or fragmented, the consequences of fragmentation being disjointed policy, lack of common orientation and agenda instability . He terms the mix of ideas from which solutions arise the “policy primeval soup”.
In analysing the policy soup we will use universal access to EmOC as a tracer for the right to health approach. We focus on access to EmOC because it a key evidence based intervention vital for reducing maternal mortality in all countries and it is identified as an obligation of comparable priority to a core obligation under the right to health.
On the technical side, health systems policy specialists argue that they know what needs to be done to scale up access to EmOC, while acknowledging that it is highly complex and context specific. A first step in making it a reality is generating both political commitment and funding (domestic and international funding). Before a policy community can advance its claim for funding in the political realm, Kingdon argues, it needs a solution to emerge from the policy soup.
Lack of consensus on a resonating framework in the different reproductive health communities – maternal health and sexual and reproductive health and rights
As Shiffman and Smith noted in their article in 2007 the maternal health community and the sexual and reproductive health and rights community could not articulate a common internal or external problem frame . It seems obvious to state that reducing maternal mortality and morbidity is the key focus of the maternal health community. However it is worth highlighting because the sexual and reproductive health and rights community embraces a more holistic agenda that includes maternal health but not as a main focus. Although as discussed above both communities worked towards a common purpose in having maternal mortality understood and addressed as a human rights issue by the United Nations they have not worked on a common policy to address this issue. Sara Davies characterises the two groups as the right to reproductive health care group and the other as the right to reproductive self-determination group, noting that although they have a different strategy and focus they have both focused on the need for women’s health to be expressed as a right . One respondent also suggested “one point on why it has taken the maternal health people so long to use a human rights approach is that I think they have just been so pre-occupied with trying to establish the standards for improvement, for example for EmOC. First of all to know what the most important health intervention was, a lot of public health epidemiological work went into it” (Interview 8).
Sexual and reproductive health and rights advocacy and solutions to reducing maternal mortality are more comprehensive, political and advocate structural change. This broader focus meant it has not put its full weight behind most maternal mortality reduction advocacy that adopts a less politicised safe motherhood type approach. In addition, it has championed other more political causes more closely tied to advancing the Beijing and Cairo agendas. Marge Berer and Sundari Ravandran observed that “After the 1994 ICPD, the newly agreed reproductive and sexual health agenda, with its equivocal paragraph on unsafe abortion, seemed for a time to have ‘displaced’ the Safe Motherhood agenda, or at least put into question the priority it was to be given ”. In addition, the conservative backlash to Beijing and Cairo led to sexual and reproductive health and rights advocates prioritising different fights .
Shiffman and Smith’s study confirms this analysis noting that the framing of maternal mortality as safe motherhood did not attract the support of the women’s movement . Further, today it is not an issue that energises much of the sexual and reproductive health community. One of our respondents, stated that for their (sexual and reproductive health and rights) organisation focusing on maternal mortality was not a priority noting “I think that a lot of people working in sexual and reproductive health think that maternal mortality should not be an issue anymore. We know we can’t have it happen and that you need to have the hospitals and the quality of care but the whole relationship issue, it is about power” (Interview 1).
In recent years various members of the sexual and reproductive health and rights community, representing diverse groups from around the world, have argued for the need to re-politicise the sexual and reproductive health and rights agenda. For many, the limited MDG agenda reaffirmed a specific concern that since the gains of the Cairo and Beijing in the 1990s, reproductive health has been narrowed to safe motherhood or simply surviving pregnancy . The 2010 World Bank reproductive health action plan 2010–2015 noted that “maternal health has not emerged as a political priority for a number of reasons and that the rise of competing priorities and the loss of focus on family planning within the broader ICPD agenda have contributed to declining attention and funding ”.
Since the mid-1990s the sexual and reproductive health and rights community’s prime focus is on advancing the holistic Cairo and Beijing principles and commitments, which is not aligned with the main focus narrower focus of the maternal health community . The disparate focus of these groups means that EmOC never really makes it onto their common agenda. The maternal health community continues to focus on the three pillar solution advanced by the United Nations Population Fund (UNFPA); family planning, skilled attendance at birth and access to EmOC . These important goals are less politically charged, and do not advocate the structural changes in power and gender dynamics underpinning Cairo and Beijing. As such, we suggest, it was easier for them to partner with other policy communities, including newborn and child health, and seize the opportunity of the open policy window in 2010, discussed below.
The maternal health community -multiple solutions and policy community fragmentation
Within the maternal health community disagreement over which medical intervention(s) to prioritise was problematic from the outset and initially hampered progress on advocating for a focused policy. In the late 1980s to 90s one school pushed for low-cost interventions for reducing maternal mortality that focused on predicting and preventing obstetric complications, clean birthing practices and training traditional birth attendants. This contrasted with those persuaded by the arguments in Maine and Rosenfeld’s 1985 article which argued forcefully for the need to scale up access to EmOC, stressing that it was not possible to adopt preventive strategies to address maternal mortality stemming from unpredictable obstetric causes . The spectre of demanding what was perceived as a high cost intervention continues to cast a shadow over discussions [58, 59]. It was gradually accepted that all pregnant women are at risk of life-threatening obstetric complications with each pregnancy and that screening does not work. This did not prevent further fragmentation as some advocates moved from advocating the training of skilled birth attendants and antenatal risk screening to the “skilled attendance approach [60, 61]”.
As noted above both the Committee on Economic, Social and Cultural Rights (in General Comment 14) and the CEDAW Committee have recognized EmOC as a priority intervention [30, 47]. The 1997 process indicators related to EmOC could be used as both public health and human rights indicators to drive policy and assess progress on implementation [23, 62]. Despite being endorsed by key United Nations agencies including the UNFPA, WHO and UNICEF, vital funding commitments and implementation activities did not follow. The frustration of those advocating for EmOC to be prioritised comes through in a 2000 article by Maine in which she laments that the then newly issued WHO Safe Motherhood Needs Assessment.
“contains suggestions for evaluating (in this order): ‘ . . .policy on antenatal care services .. . policy on clean and safe delivery…policy on postpartum care for mother and newborn....policy on essential obstetric care . . . ’ The last item in this list includes the treatment of major complications. Why is ‘essential’ obstetric care (EOC) listed fourth? Why are the interventions which have been proven to save women’s lives listed after those whose value is questionable? ”.
Eventually the skilled attendance and EmOC approaches would be reconciled and included as complementary vital element in the three pillars of maternal mortality reduction as advanced by the UNFPA and supported by other global health actors requiring that:
All women have access to contraception to avoid unintended pregnancies.
All pregnant women have access to skilled care at the time of birth.
All those with complications have timely access to quality emergency obstetric care .
Of the three pillars of maternal mortality reduction EmOC has proved the hardest to gain traction. After a lengthy period of neglect mid 2012 saw family planning return to the top of the global agenda at the London Family Planning Summit co-sponsored by the UNFPA and the Bill and Melinda Gates Foundation . The 2010 Lancet Commission Review of progress on the MDGs notes that “Except for financing initiatives initiated in very recent years, there is very little evidence of wide-scale interventions to increase the quantity or quality of, or the access to [skilled birth attendance]. Nor have credible efforts been made to improve access to Emergency Obstetric Care (EmOC) for women with complications. Rather, actions in support of MDG 5 often attempt to bypass a facility-based health system by seeking community-based solutions, such as educating women on warning signs of complications or training traditional birth attendants or community volunteers ”.
As Shiffman and Smith documented in their 2007 Lancet article the absence of agreement on which strategy to adopt was a key reason for the fragmentation of the safe motherhood (including much of the maternal health) policy community and its failure to generate sufficient international political priority from 1987–2006 .
Despite the widely accepted 1997 EmOC process indicators that allow for countries to track progress, the requisite political priority to fund EmOC scale up did not follow. A consequence is that ongoing measurement issues related to EmOC data quality or even absence in the countries most impacted by maternal mortality has proved an insurmountable obstacle in the competition for funding and priority that is even more target driven since the MDGs. As Yamin notes despite countries asking for improved access to EmOC with respect to commitments in the Global Strategy on Women and Children “the 2011 WHO Information and Accountability Commission report did not include EMOC among the eleven indicators (six related to maternal health) that it selected, precisely because they are not available in enough countries ”. A recent study on available facilities in six low coverage countries, Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India concluded that availability of EmOC was well below minimum UN target coverage levels . These UN targets are not included in the WHO Information and Accountability’ Commission’s (IAC) eleven indicators. In discussing the absence of EmOC indicators, like those found in the UN targets, one respondent stated, “This policy stuff does not happen at local level. I think the responsibility is really at the international level and the importance of indicators is crucial. What you measure is what you report on” (Interview 5).
The legacy of competition for donor attention and funding – the emergence of an integrated approach
The fact that newborn and child survival are intricately linked to maternal survival meant that newborn, child and the maternal health/safe motherhood communities have long competed for attention and funding [24, 69]. In 2006 the global SMI joined with the Partnership for Maternal, Newborn and Child Health (PMNCH) which helped to bring these communities togetherc. Despite the uneasy nature of this union it has proved successful in helping attract political attention and funding for a new integrated, comprehensive policy.
The different members of the PMNCH have embraced the reproductive, maternal, newborn and child health continuum of care (RMNCH). The objective of this approach flows from the World Health Report 2005 and aims to offer a constellation of services and interventions for mothers and children from pre-pregnancy/adolescence, through pregnancy, childbirth and the postnatal/postpartum period, until children reach the age of five years . One respondent remarking on the success of this approach noted that “This was going to the solution to bring health systems approaches to the MDGs and accelerate progress to reduce the gaps etc.” (Interview 2).
As we shall discuss later the PMNCH managed to push its approach through the political window that opened in mid-2009. A recent informal assessment of the RMNCH continuum of care by key thought and policy makers identified both positive and negative results. Starrs argues that “maternal health has not been marginalized within the continuum from a broad policy, program and funding perspective” citing evidence that of the 275 commitments to the Global Strategy 53% had maternal health content . She noted that others, including Horton and Graham, welcomed the unifying impact of the RMNCH continuum but expressed concern that it may contribute to the compartmentalization of women and girls viewing them primarily as mothers or future mothers . A respondent echoed this concern noting “Now I think one important thing we now know is that the RNMCH continuum of care does not go far enough; we have talked about the impact of maternal mortality on family and society and what the RNMCH continuum does is an improvement but it does not go far enough” (Interview 3).
The political stream
The third stream in Kingdon’s policy process is the political stream. As his study focused on the policy process in a single country we have extrapolated from his wide-ranging analysis, extending from the importance of the national mood to the impact of the bureaucratic turf wars, to the international stage. As such we have been guided by studies on similar topics, including that of Shiffman and Smith, in which they suggested the need to examine international political developments and publicly visible actors like UN agency heads and the leaders of large advocacy organizations. In this section we focus on the MDGs and the recently established WHO IAC, key milestones and actors in maternal health.
Pressure to measure and show results
Since 2001 the MDGs have emerged as the dominant development assistance framework and in the area of health they have guided both national and international policy towards meeting health related targets. Although not legally binding, the target driven model has proved appealing to politicians and funders and consequently has pushed large international advocacy agencies to ensure they engage in actions that allow for reporting of tangible results. One respondent noted that their organisation, which focuses on sexual and reproductive health and rights, had previously eschewed targets due to the inherent difficulties of measuring key issues like empowerment. Since the MDGs they, and other partner organisations, have felt the need to embrace some of the more measurable outcomes to show donors the impact of their work, noting the following change, “With maternal health you can focus on the numbers. You can easily say we need to decrease maternal mortality by X. That is what is attractive to donors. But that is very much a curative approach as opposed to a preventive approach.” And continuing “It is not that you focus on reproductive health and family planning that you should forget the rest. It is a selling point it is a way to get the interest and the funding of the donors. So that is a lesson learned” (Interview 1).
The problems inherent in using the globally established MDGs as national planning targets or for measuring progress have been the subject of considerable scholarship [72, 73]. It is beyond the scope of this paper to assess how such target driven reporting impacts on policy and program planning beyond the obvious observation that they include measurement of a specific target, which focuses the attention of policy makers at global and national level. With respect to maternal mortality access to EmOC was neither an indicator nor a target.
From a right to health perspective it is clear that universal access to EmOC is an obligation that should be prioritised by both national and international actors, but the MDGs did not advance this. Further, as noted above the absence of EmOC among the eleven indicators included in the recent 2011 WHO IAC report is problematic for accountability and funding reasons, and more importantly, for the message it sends to countries with high maternal mortality rates as to which interventions to prioritise in addressing this issue.
Pressure to advance MDGs 4 and 5
Following the 2006 launch of the PNMCH the maternal health community hoped to be able to report positive news. A 2007 global estimate of maternal mortality showed that little progress had been made in decades.  This contrasted with progress on MDG 6. A 2010 study showed that the rise of vertical disease focused Global Health Initiatives, like the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) and the GAVI Alliance was accompanied by huge increases in funding to global health . However from 1999–2008 the distribution of this funding was uneven, with a ten-fold increase in funding for communicable diseases like AIDS and tuberculosis and only a doubling of funds for maternal, newborn and child health.
In the lead up to the 2010 MDG summit it became clear that MDGs 4 (maternal mortality) and 5 (child mortality) were most off track and particularly in much of sub-Saharan Africa . The maternal health community knew that a policy window would open at the MDG Summit in 2010.
The joining of the streams
Kingdon’s model asserts that an issue emerges on a policy agenda when the problems, policies and politics stream couple. The continuum of care concept advanced by the PNMCH community offered a solution to reducing maternal mortality (MDG 5) and child mortality (MDG 4), two popular global political commitments. Political leaders welcomed the emergence of the PMNCH and its integrated agendas and the maternal, newborn and child health communities were able to harness political momentum building around this approach.
The MDG summit in 2010 was a perfect policy window for the PNMCH community to push its policy through and generate the necessary funding. It was here that United Nations’ Secretary-General Ban Ki-moon launched a ‘Global Strategy for Women’s and Children’s Health’ (Global Strategy) . The Global Strategy embraced the continuum of care concept advanced by the PNMCH. One respondent commented, “I would say, and I am not alone in this, Richard Horton said it too, the continuum of care reached its apotheosis in the Global Strategy” (Interview 2).
The international community responded with the Canadians jumping on the bandwagon at the Toronto G8 summit and launching the Muskoka Initiative on Maternal Newborn and Under-Five Child Health, which included funding and accountability commitments . International and national pledges to realize the Global Strategy were estimated at $40 billion between 2011 and 2015, or $8 billion per year . Efforts to create an accountability structure led to the IAC . The IAC recommended the establishment of both national level accountability mechanisms and a global independent Expert Review Group (iERG) mandated to review progress on IAC recommendations until 2015. As Yamin notes “this immense flurry of activities and commitments surpassed, by any measure, those made after the International Conference for Population and Development (Cairo) from funding to political commitments” (page 368) .
Where does support for policy to prioritize the scaling up EmOC stand after all of this? As noted above, it is not one of the key indicators used by the PNMCH or the iERG. One respondent noted “Is there universal agreement that EmOC is a key pillar intervention for reducing maternal mortality and morbidity? Absolutely. Are there all kinds of problems in practice because it requires health systems interventions and not vertical interventions one off magic bullet solutions like this ridiculous shock suit? Or giving every trained birth attendant in the country misoprostol? Are there all kinds of problems with health work force and budgeting making sure that supply chains are working and there is a referral network. Yes. But I think there is absolute agreement at international and at national level that you need EmOC” (Interview 2).
Some would argue that the failure of the maternal health community to persuade policy makers of the need to prioritize EmOC as an intervention is reflected in the recent Countdown to 2015 findings that “much remains to be done in the most crucial area – childbirth ”.