Ambivalent Allies

The frequent name changing that has characterised the recent history of safe motherhood has been symptomatic of another problem, that of weak alliances. The linkages between women’s health and rights and safe motherhood would appear to be natural and unquestioned. But in practice, things are not so simple. Some perceive that attention to maternal health derives more from concern about the impact on children than from the risk to women themselves. In this paradigm, women are seen simply as the vehicles for making children, their own health and rights subsumed to that of their infants. In part, this perception is due to fact that safe motherhood was born in the shadow of child survival. Indeed, during the 1990 Children’s Summit, the issue of maternal mortality was an item for discussion, but almost entirely within the context of ensuring the survival and health of children. As James Grant himself noted, “...the emphasis on goals for maternal mortality is largely a by-product of child survival efforts” (Grant 1990).

At the start of the Initiative, women’s health activists had the issue of maternal mortality high on their agenda and were working to promote solidarity among women around the world. The Women’s Global Network for Reproductive Rights and the Latin American & Caribbean Women’s Health Network/ISIS International, issued at Call to Action on 28 May 1990, declared International Day of Action for Women’s Health (Women’s Global Network for Reproductive Rights and the Latin American & Caribbean Women’s Health Network/ISIS International 1990). This campaign was instrumental in drawing attention to the issue of maternal mortality, particularly in Latin America. The campaign focused particular attention on unsafe abortion and on the poor quality of care meted out to women (particularly poor or indigenous women) by the formal health care system. Maternal mortality was presented as a political challenge with responsibility firmly attributed to high level decision-makers: “To cure the health problems of women is to acknowledge that oppression - and health problems - are not determined by biology but by a social system based on the power of sex and class” (Araujo and Diniz 1990).

At the same time, NGOs around the world were working in the area of reproductive health and safe motherhood, often at a very local level, engaging in community-based research, participating in awareness-raising or public education campaigns, promoting workshops, meetings or media events, and even delivering care (WHO 1992). The breadth and extent of the types of activities is such that it is impossible to evaluate their impact, particularly at the international level. While they undoubtedly make a contribution, its extent is likely to be limited by the availability of resources - human and material - to sustain a long-term effort.

More recently, the energies of many NGOs have been absorbed by the broadening of the women’s health agenda to address previously neglected problems such as female genital mutilation, violence and trafficking. And among some activists, ambivalence about safe motherhood has strengthened. Even the title is suspect because it draws attention to the outcome of the pregnancy rather than to the choice to become pregnant in the first place.

The women’s movement recognised early on that the abortion issue would be the most contentious aspect of efforts to reduce maternal mortality. Almost universally, they identified societal reluctance to endorse the right of women to decide whether and when to have children and to provide both contraceptive and abortion services to enable them to do so safely. The “abortion issue” complicated efforts to draw attention to safe motherhood. Among anti-abortionists, safe motherhood was seen as the trojan horse for the introduction of legal abortion. Funders interested in supporting safe motherhood programmes became wary and to this day certain donors cannot be approached for support to projects or programmes that include an abortion-related component.

Problems such as these have added to the ambivalence and hesitation of policy-makers. In some countries, for example, although national plans for the reduction of maternal mortality exist, government officials have an ambivalent attitude towards reproductive health which has hampered implementation (UNFPA 1999).

The complexities of this debate may account for the difficulties that safe motherhood has faced in bringing new partners into the effort, notably the private sector. During the preparations for Safe Motherhood at 10, the IAG created a pilot project to attract the support of global business (Safe Motherhood Inter-Agency Group 1999). The project’s goals were modest and did not include fund-raising, focusing instead on raising awareness about the Safe Motherhood Initiative and the issues among an elite group and encouraging businesses to support safer motherhood among their employees and within the communities in which they work.

As a result of the project, 12 businesses publicly endorsed a corporate “charter” and became founding members of the Corporate Council for Safe Motherhood. However, since the 1998 World Health Day event, follow-up activities have been sporadic and there remains much to be done in terms of identifying feasible and appropriate activities for the private sector. Despite its potential benefits, the potential pitfalls of working with the private sector and the strict criteria for corporate involvement imposed by the UN organizations in particular, have put a brake on any major attempt to involve corporations more fully in safe motherhood.