|19. What Are Maternal Health Policies in Developing Countries and Who Drives Them? A Review of the Last Half-century|
|International Maternal Health Actors and Policies|
The early international maternal health policies adopted are best summarised by the report of the 1950 WHO Expert Committee on Maternity Care that stated In the implementation of a programme of maternity care, expenditure for adequate training of personnel should take precedence over other expenditures if, in fact, a choice has to be made (WHO 1958). WHO assigned teaching staff to medical and midwifery schools, and in-service training was organised. Efforts were made to include domiciliary training of midwives to raise the standards of home births and many fellowships were awarded for academic study ad study tours (WHO 1958). UNICEF assisted by providing equipment and in developing training courses for traditional birth attendants. A 1954 WHO Expert Committee on Midwifery Training described the different types of personnel required, their characteristic functions and their training requirements (WHO 1958).
These policies were translated into activities in various countries. For example, in Kabul Afghanistan, WHO assisted in establishing a maternity hospital, a domiciliary midwifery service and antenatal care, staffed by the first trained midwives to give service in the history of the country (WHO 1958). MCH services were seen as creating appreciation among the national populations for curative and preventive health services and hopes were expressed that such services, particularly the rather limited MCH services in rural areas, would become the nucleus for more comprehensive health services. By the mid 1950s, WHO was also proclaiming the desirability of integrating MCH activities into general public health and medical services where these existed (WHO 1958).
By the 1960s, WHO seems to have lost its focus on maternal health and its policies were less clearly articulated. For example, its summary of the second 10 years (WHO 1968) has no specific chapter heading on maternal and child health, but seems instead to concentrate instead on an expanding range of issues. At national level though, training activities appeared to continue as in the first 10 years. For example, Zambia opened community and professional midwifery schools in 1967 and 1969 respectively with support from WHO (Chintu & Susu 1994). A lack of data may have exacerbated the neglect of maternal health (Graham & Campbell 1992): maternal mortality in the industrialised countries was plummeting, while data from very poor countries was virtually non-existent.
The 1970s saw more reliable maternal mortality estimates for developing countries that made the very high rates in developing countries evident (Vaughan 1987) and the production of one of the first WHO documents to focus exclusively on maternal health (WHO 1974). WHOs document (1974) clearly describes a maternal health strategy that prioritises family planning as a way of improving maternal health. It argues that maternal morbidity and mortality and foetal perinatal and infant mortality increase with repeated pregnancies and calls for integration of family planning into already existing MCH and family health programmes. This shows the influence of the strong international family planning agenda (see annex 1). At the same time, the 1974 WHO document also makes the statement that the training of traditional birth attendants for home deliveries is recommended rather than trying to persuade rural women to go to hospitals or trying to train enough professional midwives. This policy shift may have been a pragmatic response to the growing observations that professional midwives and obstetricians were reaching very few women and that hospitals gobbled up huge portions of national health budgets but it was also clearly thought that training TBAs could improve equity in access to health care, one of the key features of the PHC ideology that was emerging at this time (see annex 1).
By the late 1970s and early 1980s, implementing PHC for maternal health in a cost constrained environment translated into a limited set of activities, none of which were particularly effective. The promotion of minimally-trained multipurpose workers at the community level, including traditional and volunteer health cadres that did not need government salaries, was a development very much in harmony with the thrusts of both primary health care and cost-containment. As part of this trend, support for the training of traditional birth attendants (TBAs) increased, whereas training of specialist cadres, those most necessary for preventing maternal deaths, decreased. For example, in the mid 1970s, the Bangladesh government discontinued training women who were in effect specialist community midwives and replaced them with family welfare visitors who were eventually to prioritise the delivery of contraceptives at the community level (Sherrat 1999). Similarly, in Egypt, midwifery schools were closed in the 1970s, and the current shortage of trained personnel with midwifery skills is a consequence that many other countries share today (Kwast 1992).
The influence of PHC and cost containment on the policy focus in maternal health can also be seen in the emphasis on antenatal care (as a preventive rather than costly curative service that could be delivered by relatively untrained health workers), and risk approach (as a way to rationally triage resources in poor environments by paying attention to those in greatest need) (Backett et al. 1984). These factors combined, meant that TBA training and antenatal care came to be thought of as the most cost-effective solutions to the problem of maternal mortality and morbidity until the mid to late 1980s (WHO 1974, Belsey 1985), though they came to be discredited by the 1990s. Global indicators for Health for All by the Year 2000 included measures of the proportion of the pregnant population receiving antenatal care, and the proportion delivered by trained attendants (including trained traditional attendants), that reflected these policies. In the poorest countries, coverage of professional delivery care services remained severely restricted; levels of maternal mortality remained very high.
In the early and mid 1980s, the womens movement activities to draw attention to womens health status brought the issue of maternal health successfully to the attention of major international institutions like the WHO and the World Bank. They made a public outcry about the high levels of maternal mortality in the developing world at the Mexico City Population Conference of 1984, and the World Conference to Review and Appraise the Achievements of the United Nations Decade for Women in Nairobi in 1985. The womens movement was also an important influence leading to the 1987 Safe Motherhood Conference in Nairobi. The latter highlighted the persisting tragedy of maternal death in developing countries and set itself a target to halve maternal deaths by the year 2000 (Mahler 1987). The international womens movements own campaign to prevent maternal mortality and morbidity also had similar goals (te Pas 2000).
Unfortunately, although the womens movement advocated for maternal health, it was never as specific in its demands for delivery services as it was in its demands for abortion services. For example, (Correa's 1994) book on feminist perspectives on reproductive health makes only mentions abortion as a cause of maternal mortality. Womens groups may have been fearful of focussing too much on womens traditional value as mothers (Jolly 1997). In her analysis of the contribution of the international womens movement to safe motherhood, (te Pas 2000) suggests that factors responsible for this included the diverse nature of the movement membership, their reluctance to being co-opted by engaging too closely with governments an international players like the World Bank. She also points out that the SMI had also failed to pay much attention to the question of how services could be best organised. For their part, some SMI advocates distanced themselves from the feminist agenda and attempted to focus on the technical aspects of Safe Motherhood, rather than diluting it by addressing womens status and living conditions more broadly: SMI is not the womens initiative. It is not intended to meet all of womens medical and social needs (Law et al . 1991). In 1996, the WGNRR decided to end its campaign on maternal mortality, replacing it with two campaigns: one on abortion and the other opposing cuts in health budgets and the World Bank (te Pas 2000).
Womens groups also promoted maternal health within the context of the 1994 ICPD. The 1993 Womens Declaration on Population Policies published prior to the ICPD incorporated previously separate areas of health, including maternal, into the definition of reproductive health. This was despite relatively little involvement of the international maternal health policy community in defining the reproductive health agenda (those involved were mainly concerned with ensuring that maternal health was part of this agenda for advocacy purposes and in the hope of attracting greater financial resources). At ICPD, womens groups saw maternity services as a core element of a comprehensive reproductive health care package. However a conflict remained over how the new ICPD agenda was to be funded (Murphy & Merrick 1996).
Policies within the international Safe Motherhood Initiative evolved slowly over time. Until the early 1990s, the SMI struggled to clarify the paradigms for providing maternal health services. Strong arguments were also made against exclusive reliance on the high risk screening approach and the value of TBA training. Maine 1991 cogently articulated the case for services at the referral hospital level. In an UNDP document with Law and colleagues (Law et al. 1991) also argued for a strong focus on maternal mortality and away from maternal health. In 1994, WHO articulated its policies in the form of the Mother -Baby package (WHO 1994), which included four pillars: antenatal care, clean safe delivery, EOC and family planning. The international SMI was not much influenced by the debates within ICPD. Perhaps the most significant shift in policy has occurred with respect to the call that all women have access to a skilled attendant. At the 1997 technical meeting of the SMI in Sri Lanka, Koblinsky and colleagues presented case studies of developing countries that had successfully reduced maternal mortality. In most of these countries skilled attendants were involved. The 1997 Technical conference document (Starrs 1998) presents a broad spectrum of policies9, including one reflecting a growing consensus on the need for skilled attendant for all births. The 1999 World Assembly adopted this goal. The maternal mortality target was also shifted to reducing the maternal mortality ratio by 75% by 2015 (DFID 1999).