|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|
In the first half of the 20th century, there were approximately 60 nation states, and many of the countries now classified as developing countries, especially the poorest, were colonies or protectorates (Zapata & Godue, 1997). The main international actors in health were the colonizing countries, a few international organizations (e.g. the International Sanitary Conference, or the Pan American Sanitary Bureau), foundations (e.g. the International Health commission of the Rockefeller Foundation) and missions. Most tropical medicine or international health efforts were geared around war and trade (Zapata & Godue, 1997) and oriented around the protection of the colonizing population and it its workforce (Jolly 1997).
During this period, little attention was given to maternal health internationally, except occasionally where colonized populations appeared to be declining, as for example in Fiji (Jolly 1997, Jolly 1997b) and Tanganyika. By the start of the 20th century, however, (Manderson 1997) shows how in Malaya for example, English colonists wives concern with their own maternity flowed over into concerns with the maternity and mothering of other women, and services were developed in response, in this case by the colonial government. In other settings, such services were largely provided by missions5 [see for example in Africa (Chintu & Susu 1994, Beinart 1992, Vaughan 1991) or in Papua New Guinea (Denoon 1989)].
The WHO was founded in 1948 to promote and protect the health of all people. It was built on the premise of building sovereign nation states and intended to function as an inter-governmental institution. In the report of the first 10 years of WHO, maternal and child health is a clearly identified area of action and a chapter is devoted to it (WHO 1958). The major thrust in the 1950s was providing technical support to training sufficient number of personnel (including domiciliary training for midwives in order to raise the standards of home births), creating administrative divisions of maternal and child health within national health systems, and integrating maternal and child health services with general health services.
International co-operation in maternal health started somewhat later, mostly in the mid-1960s, when Western donor countries and international agencies first started to fund maternal and child health (MCH) programmes of national Ministries of Health. However, in the report of WHOs second 10 years (1958-67) overlapping this period, maternal health features much less than previously (WHO 1968).
By the 1970s, the family planning movement influenced those involved in maternal health. WHO clearly adopted and prioritised a family planning strategy (WHO 1974). For other actors too, such as UNICEF or USAID, the focus and funding of MCH was actually geared to child health and family planning (Rosenfield & Maine 1985). WHO remained a key actor in maternal health the late 1970s and early 1980s as a new health-care ideology was promoted for developing countries. This involved switching towards PHC and the proposal of Health For All by the Year 2000 (WHO 1978). WHOs approach to maternal health in the mid-1980s advises training TBAs as one of the most cost-effective strategies to reduce maternal mortality and morbidity (Belsey 1985). TBA training programmes also drew considerable support and funds from UNICEF, UNFPA and USAID, among others, especially since the latter two agencies had a further interest in using TBAs as family planning workers.
During the same period, the international womens health movement, which had emerged in the 1970s in the industrialised West, started leading global campaigns for womens rights and to expand the interest in womens health beyond family planning. Government donor agencies, such as the Swedish Agency for Research Co-operation with Developing Countries (SAREC), foundations and NGOs also supported research and activities in womens health [for example, see the (World Federation of Public Health Associations 1986) or (Bergstrom et al . 1993)]. The Women in Development programme within USAID also supported research-based activities on womens health issues through an NGO, the International Centre for Research on Women (ICRW). Indeed USAID also initiated some funding of maternal health programmes through what were to become the MotherCare projects, despite lacking a congressional mandate, on the strength of advice by their technical staff, many of who were women who identified with the aims of the womens movement. The World Bank also played an important role: in the 1980s, they attempted to counterbalance the child survival work that had been led with strong support by USAID, UNICEF and, to a lesser extent, WHO, and to redress the balance in favour of adult health (Reich 1995).
Finally, in 1985, two academics from Columbia University, (Rosenfield and Maine 1985) wrote a highly influential paper that galvanised interest and put the issue of maternal mortality on the international health policy agenda. They argued that MCH programmes focused almost exclusively on child health, assuming that whatever is good for the child is good for the mother (Rosenfield & Maine 1985 : p 83), and called on obstetricians and the World Bank to take the lead in maternal health policy. The first international conference devoted to maternal mortality (Safe Motherhood Conference, Nairobi, Kenya, 10-13 February 1987) was sponsored by the World Bank, WHO and UNFPA and led to the launch of the Safe Motherhood Initiative (SMI).
International agencies involved in the SMI coalition included five UN agencies (WHO, UNDP, World Bank, UNFPA, and UNICEF) and two NGOs (the Population Council and IPPF). Family Care International, another NGO, also came to be involved in organising the first national conferences on safe motherhood. USAID was not a SMI coalition member but was influential through its MotherCare I demonstration projects and research support. Other, mainly research, activities were also launched in response6. In 1987 the international womens movement also launched a day of action focussed around maternal mortality (te Pas 2000). The success of this event led to a 10-year campaign co-ordinated by the Women's Global Network for Reproductive Rights (WGNRR)7 to reduce maternal mortality that ended in 1996 (te Pas 2000).
International funding of safe motherhood in 1990 showed that of total external assistance a mere 0.2 percent to safe motherhood (although a further 16 percent went to MCH services which would mainly have targeted child health) (Zeitlin et al. 1994) reflecting a low priority by donors. Indeed it was not until the mid-1990s that international actors funded large-scale programmatic activity. Here the main actors were USAID projects with MotherCare II, and more recently the Maternal and Neonatal Health project, and the World Bank. The UKs Department for International Development (originally ODA) also supported large programmes in Nepal and Malawi, and in some countries UNICEF and UNFPA8 also pay considerable attention to maternal health and contributed through national programmes. UNDP appears to have dropped out of the SMI for reasons that are unclear. The International Federation of Gynaecologists and Obstetricians, FIGO, has also started several projects, supported by national societies from industrialized countries. Most recently, in 1999, the Bill and Melissa Gates Foundation has contributed to work in maternal mortality reduction, via Columbia University and Family Care International.