A protracted launch: the first two decades of the safe motherhood initiative

1. A protracted launch: the first two decades of the safe motherhood initiative Jeremy Shiffman, Ph.D. Associate Professor of Public Administration The Maxwell School of Syracuse University Visiting Fellow, Center for Global Development Stephanie Smith Ph.D. Candidate The Maxwell School of Syracuse University Presentation at UNFPA April 3rd, 2007 Funding from the MacArthur Foundation

2. Aims of the safe motherhood initiative • Launched at international conference in Nairobi in 1987 • To raise awareness and spark action on a neglected problem: • Half a million maternal deaths in childbirth annually • Leading cause of death for adult women of reproductive age • Initiative aimed to reduce levels by 50 percent by 2000 • As year passed, not even close to reaching target

3. A quote “Nairobi succeeded and the movement failed….It is one of the greatest disappointments of my career that the movement didn’t bear greater fruit in terms of having impact.” -- Statement from one of the individuals centrally involved in the launch of the safe motherhood initiative

4. Indicators of performance • Difficulty in evaluating performance • Might consider initiative as large pre-post quasi-experiment • Indicators: • Maternal mortality decline: • since initiative launch not great • Government commitment: • high on government policy agendas only in a few countries • Maternal health service use: • has increased • Organizations involved: • a number of new initiatives have been launched since 1987 • But difficulty in attributing causality to initiative itself • Most observers express disappointment on initiative performance

5. The study • Research collaborator: Stephanie Smith of Syracuse University • Examination of history of the initiative to assess factors shaping its effectiveness • Focus on international, not national efforts • Methodology: process-tracing • Data sources: • Archival research • Interviews with key actors • Examination of published research on safe motherhood

6. Perspective: safe motherhood as a transnational social initiative • An effort that transcends borders to push governments to act on a particular issue • Safe motherhood in stage of incipiency; it is still being launched despite entering its twentieth year • Slow progression due to factors connected to: • Nature of issue • Decisions of actors

7. Theory on social initiatives: core constructs • Social initiatives in evolutionary perspective • Factors shaping social initiative development: • Mobilizing structures • Framing processes • Political opportunity structures • Issue characteristics

8. Mauss: social movement stages • Applied by Blanc and Tsui to international family planning movement • Stages: • Incipiency: growing concern for problem but weak organization and leadership • Coalescence: strong leaders and organizations have emerged • Institutionalization: movement at pinnacle; strong commitment • Fragmentation: goals may be achieved; remaining actors unsure of direction • Demise: movement is obsolete

9. Mobilizing structures • What they are: • Collective vehicles through which people mobilize to act • Such as UN agencies; secretariats of transnational initiatives; grassroots structures • How they matter: • Need to build enduring structures for movements to be sustained • Need to have strong leadership to build these structures and sustain initiatives

10. Framing processes • What they are: • Way in which actors understand and publicly position the issue • Subjective component of mobilization • Example: HIV/AIDS has been framed as a human rights issue, a public health concern, a threat to development, a security concern, etc. • How they matter: • A key to initiative effectiveness is development of a resonating frame – one that inspires action

11. Sabatier’s policy core beliefs • Related to framing: concerns the subjective component of mobilization • These are basic normative commitments of actors: • What is the nature of the problem? • What is causality behind the problem? • How serious is the problem? • What should be done about it? • These bind advocacy coalitions – horizontal networks of private and public actors with shared concern. • If advocacy coalitions diverge on policy core beliefs, they are likely to have problems advancing their priorities.

12. Political opportunity structures • What they are: • Political changes that shape initiative possibilities • For instance, democratic transitions • How they matter: • Their opening create windows of opportunity

13. Issue characteristics • What they are: • Features of issue itself that make the cause easier or harder to promote • How they matter - issue easier to promote if: • Seen as serious • Clear indicators available to show severity and monitor progress • Cost-effective interventions have been developed • Victim seen as blameless

14. Summary: what factors facilitate initiative effectiveness? • Mobilizing structures: • Enduring • Strong leadership • Frames: • Resonating • Political opportunity structures: • Open policy window • Issue characteristics: • Severe • Clear indicator • Cost-effective intervention • Blameless victim

15. History of the initiative • Launch: 1985-1989 • Stall: 1990-1999 • Partial resurgence: 2000-2007

16. Launch – initiating factors • End of UN Decade for Women • Search for issues to sustain agenda • WHO studies • First time evidence on extent of problem • Lancet article • Where is the M in MCH? • Highlights absence of the ‘M’

17. Launch – initial activities • The search for a name • The Nairobi conference • Formation of Inter-Agency Group (IAG) • Launch of regional conferences • As of 1989: much optimism

18. Stall through 1990s: three debates • Intervention • Measurement • Venue

19. Stall: intervention debates • What element of problem to tackle? • TBAs, antenatal care and risk-screening • Skilled attendants – key message of Colombo conference in 1997 • Emergency obstetric care • Where is the ‘E’ in MCH? • Different actors associated with different preferred interventions: link between technical position and identity in safe motherhood field

20. Stall: intervention debates “[People became] extremely defensive about their ideas...If you didn’t agree with the idea you were bad and wrong…It was kind of like President Bush. If you are against this idea then you are a traitor.” -- Statement from informant

21. Stall: measurement debates • Difficulty in measuring maternal mortality • Process versus outcome indicators

22. Stall: measurement debates “We hang out our dirty washing. Other people are more discrete. We are quite self-critical and very demoralized.” “I would go with my ideas [to a donor] and [X] would go with hers and who was to say who was correct.” -- Statements from respondents

23. Stall: venue debates • Who will be in the Inter-agency Group? • USAID and others excluded – and upset about this • Who will lead the initiative? • “Safe motherhood doesn’t have a Jim Grant. Where’s the ambassador?” – Statement from respondent • Which UN agency will take the lead? • UNFPA, UNICEF, WHO – no clear UN venue

24. Stall: venue debates “The problem with the safe motherhood movement is that no UN agency embraced it very clearly. UNICEF was involved but children are its bread and butter…UNFPA was neither here nor there…It had advocacy and policy but not programs. The WHO balances between norms and standards and implementation – back and forth – it deals with many things. So safe motherhood doesn’t have a home in the United Nations and that’s a big problem.” -- Statement from respondent

25. Partial resurgence: 2000-2007 • Millennium Development Goals • Maternal health is MDG number five; maternal mortality as key indicator • Nation-states respond • Lancet series • Intervention consensus? • Twentieth anniversary of initiative sparks renewed attention • Global Business Plan for MDGs 4 and 5 • New partnership • Maternal, newborn, child • Ongoing tensions

26. Partial resurgence “There are three siblings. Child survival is older, richer, more resourceful. The newborn is weak, small, but got a new grant from Gates for $60 million. It is the small child in the family that everyone looks to. Safe motherhood is the middle child; it doesn’t know exactly where to be. We need a good parent to take care of the three equally – or unequally: safe motherhood needs more vigorous opportunities.” -- Statement from informant

27. Factors hindering initiative • No enduring mobilizing structure • No strong leader • Absence of resonating frame • Lack of intervention consensus • Complexity of interventions • Difficulty in measurement

28. Safe motherhood v. child survival

29. But positive developments • Increased consensus on intervention • Emerging cohesion in advocacy community • Political opportunities from: • MDGs • 20th anniversary of initiative

30. Challenges • Key challenges: • Building advocacy community cohesion • Creating enduring mobilizing structures • Finding a resonating frame • Necessary for safe motherhood to move from incipiency to coalescence • Alternative future: in ten years initiative is in demise, never having moved beyond launch phase