Safe

Motherhood
A Review

The Safe Motherhood Initiative 19872005

 Safe
Motherhood
A Review

The Safe Motherhood Initiative 19872005

 Table of Contents
Acknowledgments 3

I. Introduction 4

II. A Historical Review of Safe Motherhood: 20 Years and Counting 8

III. International Advocacy and Agreements for Safe Motherhood 13

IV. Media Trends in Safe Motherhood 17

V. Development and Donor Agency Commitment 23

VI. Financial Trends for Safe Motherhood 30

VII. National Programs, Policies, and Budgetary Commitments for Safe Motherhood 35

VIII. Conclusion 83

List of Abbreviations 86

Agencies and Organizations 87

Annexes 88
 Acknowledgments
This report is the result of collaborative efforts and contributions from a range of individuals
and partner agencies.

Family Care International is grateful to the World Bank for its financial support, with special
thanks to Elizabeth Lule for initiating the development of this report.

Ann Starrs, Executive Vice-President, FCI and Rahna Reiko Rizutto, Consultant, kicked off this
project with a wealth of ideas, insights, and inspiration.

Rebecca Casanova, Communications Consultant, carried out in-depth interviews with experts
and the review of international agreements for safe motherhood (section III) and conducted the
media analysis from 20002005 (section IV).

Karuna Chibber, Consultant, developed the country questionnaire guide for the national
reports (section VII) and carried out in-depth interviews with development and donor agency
representatives (section V).

National consultants carried out the research at the country level and drafted the reports:
Alexia Escobar, Alberto De La Galvez Murillo Camberos, and Oscar Viscarra (Bolivia)
Widi Wibisana (Indonesia)
Rebecca Ramos (Lao Peoples Democratic Republic)
Valentino Lema (Malawi)
Mountaga Toure (Mali)
Nikubuka Shimwela (Tanzania)

Researchers at the Netherlands Interdisciplinary Demographic Institute (NIDI) provided

invaluable support and assistance in the analysis of financial data related to safe motherhood
(section VI). Special thanks to UNFPA for permission to use the UNFPA/UNAIDS/NIDI resource
flows database.

FCI staff contributed critical technical feedback, suggestions, and support throughout the
research and writing process: Jill Sheffield, Ann Starrs, Martha Murdock, Cristina Puig, Ellen
Brazier, Ellen Themmen, Fatima Maiga, Rehema Mwateba, and Lauren Goddard. The report
was coordinated by Shafia Rashid and designed by Patricia Quintero. Adrienne Atiles, with
assistance from Luz Barbosa, managed the design and production of the publication.

FCI also wishes to thank the many colleague agencies who contributed their time and
thoughts to this project.


 I Introduction

T he year 2007 will mark 20 years

since the launch of the global Safe
Motherhood Initiative (SMI), an international
Group (IAG)2 was established to realize the
goals of the Initiative. As a group and as
individual organizations, these agencies
effort to raise awareness of the scope and raised international awareness about safe
dimensions of maternal mortality and to motherhood, set goals and programmatic
galvanize commitment among governments, priorities for the Initiative, stimulated
donors, UN agencies, and other relevant research, mobilized resources, and shared
stakeholders to take steps to address this information to make pregnancy and
public health tragedy. The forthcoming childbirth safer.
twentieth anniversary of the SMI provides
a timely opportunity to take stock of how In the 21st century, safe motherhood
safe motherhood has fared within the health has achieved greater prominence on the
and development agenda, and assess the international agenda, with increasing visibility,
Initiatives achievements and shortfalls. resources, and attention being directed
toward it. Many agencies and organizations
now have dedicated programs focusing on
In 1987, when health experts, development maternal health; donors have prioritized
professionals, and policymakers gathered in safe motherhood in their funding programs;
Nairobi to inaugurate the global Initiative, governments have developed national
maternal mortality was not a major national strategies and programs to reduce maternal
or international priority. In fact, it was often mortality; and there is greater knowledge and
the overlooked component of maternal- awareness of the problem and how to address
child health programs, as noted by Maine it. There is broad agreement that good-quality
and Rosenfield in their seminal 1985 article, maternal health services need to include
Where is the M in MCH?1 At the Nairobi skilled care for both routine and complicated
meeting, a group of international agencies cases, including emergency obstetric services
launched a global movement, the Safe for life-threatening complications, and a
Motherhood Initiative, whose aim was to functioning referral system to ensure timely
reduce the burden of maternal death and access to appropriate care.
ill-health in developing countries. Later that
year, the Safe Motherhood Inter-Agency

1
A Rosenfield and D. Maine, Where is the M in MCH? Maternal Mortality: A neglected tragedy. Lancet Jul 13; 2(8446):
83-5, 1985.
2
The founding members of the IAG were the World Bank, World Health Organization, UNFPA, unicef, and UNDP. In October
1987, the group expanded to include the International Planned Parenthood Federation (IPPF) and the Population Council.
In 2000, the International Confederation of Midwives, the International Federation of Obstetrics and Gynecology (FIGO),
the Regional Prevention of Maternal Mortality Network (Africa), and the Safe Motherhood Network of Nepal joined the
IAG. Family Care International served as the secretariat until January 2004, when the Partnership for Safe Motherhood
and Newborn Health was established.


Progress has been achieved on a number Safe Motherhood in Perspective
of key indicators, including the proportion

of pregnant women receiving antenatal
care, and the proportion of births attended ...[M]aternal health rarely gets the priority or
by a skilled birth attendant. Since 1990,
coverage of antenatal care in developing
countries has increased by 20%, and more
than 50% of women receive at least the four

attention that it deserves. Partly thats because
the victims tend to be faceless, illiterate
women who carry little weight in their own
families, let alone on the national or world
recommended antenatal visits.3 Between 1990 agenda.
and 2003, the presence of a skilled attendant
at delivery increased significantly, from 41% Nicholas D. Kristof, New York Times, March 20, 2004
to 57% in the developing world as a whole.4

Despite these achievements, the Safe

Motherhood Initiative has fallen short of the
goal that it set almost 20 years ago: to reduce
E ach year, more than half a million
women die during pregnancy and
childbirthmaking pregnancy-related
maternal mortality by 50% by the year 2000. complications among the greatest killers of
While a few countries have experienced women of reproductive age in developing
sustained reductions in maternal mortality, countries.7 Of all the health data monitored
little or no progress has been achieved in by the World Health Organization, maternal
those countries with the highest levels of mortality demonstrates the greatest disparity
mortality,5 and in some countries, it appears between poor and rich countries: the lifetime
that they have worsened. Maternal mortality risk of a woman dying during pregnancy
remains high even in some countries where or childbirth is much higher in the poorest
utilization of maternal health care (such as countries than in the richest (onein 12for
antenatal and delivery care) has improved; women in east Africa compared with onein
this underscores the importance of improving 4,000in northern Europe). Within countries,
not just the availability of care, but its quality.6 poor, uneducated, and rural women suffer
disproportionately compared to their
Why has the Initiative not achieved its goals? educated, wealthy, and urban counterparts: in
Faltering political commitment, inadequate Kenya, for example, just over 23% of women
funding, and a lack of clear technical priorities in the lowest wealth quintile have access to
have hampered progress. skilled assistance during childbirth, while
almost 78% of women in the highest wealth
quintile are attended by a doctor or a nurse/
midwife.8 Urbanrural differences also affect
3
State of the World Population 2004 Report, The Cairo Consensus at Ten: Population, Reproductive Health, and the Global
Effort to End Poverty. New York: UNFPA, 2004.
4
State of the World Population 2005 Report, The Promise of Equality: Gender Equity, Reproductive Health and the Millennium
Development Goals. New York: UNFPA, 2005. At the regional level, the most marked improvements took place in South-
Eastern Asia (from 34 to 64%) and Northern Africa (from 41% to 76%). In sub-Saharan Africa and Western Asia, the indicator
increased by only 1 percentage point between 1990 and 2003.
5
The Millennium Development Goals Report 2005. New York: United Nations, 2005.
6
Personal communication, Khama Rogo, World Bank.
7
Make Every Mother and Child Count, World Health Report 2005. Geneva: WHO, 2005.
8
Davidson R. Gwatkin, Beyond the Averages, Countdown 2015 Sexual and Reproductive Health & Rights for All.
Washington, DC: IPPF, PCI, FCI, 2004.

 whether a woman receives adequate care spent half as much time in school as other
during pregnancy and childbirth: in Peru, over children. The impact on childrens health and
80% of urban women have a skilled provider survival was not significant when an adult
attend their delivery, whereas less than 20% male died.12
of rural women receive such care.9
In addition to the impact on infants and
In addition to the risk of dying during children, a womans death affects her familys
pregnancy and childbirth, women can well-being and society as a whole. After a
suffer from short- and long-term maternal woman dies, her family is less able to care
disabilities and illnesses. According to for itself, and forfeits any paid/unpaid wages
the 2005 World Health Report, 20 million she contributed to the household. Her death
women each year will experience maternal increases the chances of her family facing
disability, which can range from fever and poverty and malnutrition. Data suggest
depression to severe complications such that the death of an adult woman has a
as obstetric fistula and uterine prolapse.10 significant effect on household consumption
The exact magnitude and scope of maternal in the poorest households for at least a year
morbidity is unclear, due to underreporting, following her death.13
poor recordkeeping systems, and definitional/
classification problems. Investing in maternal health provides
long-term benefits for the entire health
Investing in maternal health saves individual delivery system. Elements that are essential
womens lives and safeguards their well- for effective maternal health care, such
being. It also affects the health and well-being as adequate human resources, effective
of entire societies. Research indicates that communications and referral mechanisms,
the health of newborns is closely linked with and an efficient supply of equipment, drugs,
the health of their mothers. About 3040% and consumable goods such as gloves and
of neonatal and infant deaths result from syringes, also have a positive impact on a
poor maternal health and inadequate care range of non-obstetric services, including
during pregnancy, delivery, and the critical the handling of accidents, trauma, and other
immediate postpartum period. Data also emergencies. In addition, pregnancy and
suggest that a mothers death affects the childbirth are often the first point of contact
overall well-being of her surviving children: for a woman in the health system; antenatal
in Bangladesh, the surviving children of a care can provide an opportunity to address
deceased mother are three to ten times more other reproductive health concerns, such as
likely to die within two years.11 In Tanzania, family planning and STIs, as well as other
children living in homes in which an adult illnesses or conditions including tuberculosis,
woman died during the previous 12 months malaria, and HIV/AIDS.

9
Presentation by Ana Langer, Countdown 2015 Global Roundtable, London, 31 August2 September 2004.
10
Obstetric fistula refers to holes in the birth canal caused by prolonged or obstructed labor. Consequences include: vaginal
incontinence, pelvic and/or urinary infections, pain, infertility, and early death. The social repercussions are often severe,
resulting in abandonment and ostracization. Uterine prolapse is the falling or sliding of the uterus from its normal position in
the pelvic cavity into the vaginal canal.
11
M.A. Strong, The Health of Adults in the Developing World: The View from Bangladesh, Health Transition Review 2(2):
21524, 1992.
12
Ainsworth M. and Over M., AIDS in African Development, Research Observer 9(2): 203240, 1994.
13
Margaret E. Greene and Thomas Merrick, Poverty Reduction: Does Reproductive Health Matter? World Bank HNP
 Discussion Paper, July 2005. World Bank: Washington, DC.
 Introduction

Finally, safe motherhood investments are time, and analyzes how and why maternal
cost effective. According to the 1993 World mortality has been identified as a key
Bank World Development Report, safe priority in international meetings and
motherhood is among the most cost-effective processes. The analysis reviewed relevant
strategies for low-income countries. In 2005, press coverage of safe motherhood to
researchers assessed the costs and benefits identify trends in coverage and regional
of interventions for maternal and newborn or topical trends. In addition, in-depth
health, and determined that strategies at interviews were conducted with key
the community and primary care levels actors from select international meetings
(community-based newborn care, antenatal to ascertain the influence of global safe
care, and skilled care during childbirth) to motherhood events.
lower maternal and newborn deaths are
highly cost-effective.14 Development and donor agency
commitments: To assess shifts in emphasis,
Safe motherhood is fundamentally a matter priority, and commitment within selected
of human rights; all women are entitled to donor and development agencies, a series
good health and high-quality health services. of in-depth interviews were carried out with
Maternal deaths are linked to womens low program representatives (see Annex I for a
status in society, and their lack of decision- listing of agencies included in the analysis).
making ability and economic power. In order
for women to be able to enjoy safe pregnancy Financial trends for safe motherhood:
outcomes, they need to be accorded the Financial trends since 1987 were analyzed
same opportunities to health, education, and using three different data sources: a World
employment as their male counterparts. Bankcommissioned report on funding for
safe motherhood following the launch of
the SMI; the UNFPA/UNAIDS/NIDI financial
What This Report Contains resource flows database of donor funds

T
via bilateral, multilateral, and foundation
his report reviews the impact of the channels; and interviews with selected
global Safe Motherhood Initiative, and donor officials on trends within their
assesses progress in the safe motherhood agencies and in the field as a whole.
field since its launch in 1987. Specifically, the
report examines how the field has evolved in National policies, programs, and budgetary
terms of international advocacy and media commitments: In order to examine
attention; development agency and donor the development of national maternal
commitment to safe motherhood; financial healthpriorities/programs and allocations
trends and allocations; and the development in several countries in Africa, Asia, and
of national policies and programs for Latin America, in-country consultants
safe motherhood. conducted document research and carried
out interviews with government officials,
International advocacy and media relations: donor representatives, and NGOs. Countries
The report reviews how media attention highlighted in this analysis include: Bolivia,
for safe motherhood has changed over Indonesia, Lao Peoples Democratic
Republic, Mali, Malawi, and Tanzania.
14
Adam T., Lim S.S., Mehta S., Bhutta Z.A., Fogstad H., Mathai M., Zupan J., and Darmstadt G.L. Cost effectiveness analysis of
strategies for maternal and neonatal health in developing countries British Medical Journal. Nov. 12, 331(7525), 2005, http://

bmj.bmjjournals.com/cgi/content/full/bmj;331/7525/1107
 II A Historical Review of Safe Motherhood:
20 Years and Counting

T he past 20 years have witnessed

dramatic shifts in how maternal
health is framed and conceptualized at the
The UN Decade for Women
(19761985)

A
international level. Safe motherhood has
evolved from a neglected component in t the first conference on women held
maternal and child health programs to an in Mexico City in 1975, the United
essential and integrated element of womens Nations declared the period 19761985 as
sexual and reproductive health. In the late the United Nations Decade for Women in an
1970s through the mid 1980s, while safe effort to raise international attention on the
motherhood was acknowledged as a key health, rights, and development priorities
priority area for attaining the health and of women. In July 1985, at the third UN
development of women, it was neglected in conference on women, a series of Forward
the development priorities of governments Looking Strategies for the Advancement of
and funding agencies, and maternal and child Women was adopted by delegates to review
health programs tended to focus on the needs and appraise the achievements of the United
of the child and not the mother. In 1987, in Nations Decade for Women.
an effort to redress this situation, a global
movement was launched to bring attention Focusing on the themes of equality,
to the silent tragedy of women dying during development, and peace, the consensus
pregnancy and childbirth. document framed maternal health within the
context of womens health and rights, and
Over the next 15 years, largely a result of supported a reduction of maternal mortality
this landmark worldwide initiative, safe by the year 2000.15 The Strategies also
motherhood became a central component called for:
for the achievement of womens health and equal access to health services.
rights. At the International Conference on adequate health facilities for mothers
Population and Development (ICPD), maternal and children.
mortality was identified as a core component every woman's right to decide on the
of womens sexual and reproductive health, number and spacing of her children, and
and at the Millennium Development Goal access to family planning for every woman.
(MDG) Summit it was situated within the discouragement of childbearing at
broader context of poverty reduction efforts an early age.
and overall development efforts. improvement of sanitary conditions,
including drinking water supply.16
This section traces how maternal health has
figured within the broader development
framework and identifies key events that
shaped its role at the international level.

15
AbouZahr, C. Safe Motherhood: A Brief History of the Global Movement 19472002, British Medical Bulletin 67:
1325, 2003.
16
Paper presented at the Nation Convention on Empowerment of Women: Nairobi (1985) to Beijing (1995) held on
1618 March, 1995, organized by Women for Women, Dhaka, Bangladesh.

The Launch of the Safe For the first time ever, the international
development community focused on the
Motherhood Initiative (1987) plight of women dying during pregnancy

I
and childbirth, and issued a specific goal
n 1987, when the Safe Motherhood for maternal mortality reduction: to reduce
Conference was held in Nairobi, Kenya, maternal mortality by 50% by the year 2000.
the scope and dimensions of maternal health From here on, safe motherhood was coined
were not well known or understood. There as the catch phrase for maternal health.
was little evidence available concerning the
technical and programmatic interventions Following the Nairobi conference, a series
most effective for improving maternal health. of regional and national meetings was
held in Africa, the Arab region, Asia, and
To generate awareness and stimulate Latin America in an effort to generate
commitment among governments and recognition of poor maternal health and
funding agencies to address this public stimulate commitment to address this public
health problem, WHO, the World Bank, health problem among national decision-
and UNFPA brought together a range of makers, health providers, and NGOs. Annex
stakeholders, including government officials, II provides a summary of the meetings
NGO representatives, health providers, and and conferences the Inter-Agency Group17
donor representatives at a conference in organized, and the publications and reports it
Nairobi. The conference underscored the produced since 1987.
relative neglect of maternal mortality in
the development priorities of governments The Childrens Summit
and funding agencies, and urged concerted
action to prevent women from dying during
(1989)

I
pregnancy and childbirth.
n 1989, world leaders, joined by the heads
The conference situated maternal health of UN agencies and senior representatives
within the context of improving womens of the international development community,
status in the economic, social, and political gathered in New York to attend the World
spheres, and outlined specific strategies for Summit for Children. The conference
safer motherhood: reviewed key areas related to the survival,
strengthening community-based health care protection, and development of children and
by improving the skills of community health issued a plan of action for the next ten years.
workers and traditional birth attendants, Maternal mortality was identified as critical
and screening high-risk pregnant women for to the health and survival of children, and
referral for medical care; as one of the major goals of the Summit,
improving referral-level facilities to treat which specifically called for a reduction of
complicated cases and serve as a back-up to maternal mortality by half between 1990 and
community-level care; 2000. Maternal health was framed largely as
developing an alarm and transport system a means to ensure childhood survival, rather
to serve as a link between community and than an end in itself.18
referral care.
17
See note on page 4.
18
AbouZahr, C. Safe Motherhood: A Brief History of the Global Movement 19472002, British Medical Bulletin 67: 1325, 2003.

 The International Conference The ICPD and Beijing commitments also
reinforced the position that maternal deaths
on Population and Development and disability are violations of womens
(1994) human rights, and are strongly tied to

T
womens status in society and economic
he International Conference on dependency.19 At a fundamental level, women
Population and Development (ICPD), have a right to health services that promote
held in Cairo, Egypt, was a watershed event their health and survival during pregnancy
for womens health and rights. Reframing and childbirth.
population and development from a focus on
meeting demographic goals to securing the Tenth Anniversary of the SMI
reproductive health and rights of men and (19971998)
women of all ages, the ICPD put forward a
far-reaching plan for achieving progress in
health and development.

Maternal health was situated within the

T o commemorate the tenth anniversary
of the Initiative, the members of
the Safe Motherhood Inter-Agency Group
executed a wide-ranging program with the
context of the comprehensive approach to
following objectives:
reproductive health. Specifically, the ICPD
invigorate national and international
Programme of Action called for:
commitment and action for safe

motherhood among a range of audiences,
[Maternal health] services, based on the including policymakers, donors, and health
concept of informed choice, [which] should providers; and
include education on safe motherhood, bring together existing knowledge and
prenatal care that is focused and effective, research on the most effective interventions
maternal nutrition programmes, adequate into a set of clear technical messages for
delivery assistance that avoids excessive guiding programs and policies on

recourse to Caesarian sections and
provides for obstetric emergencies; referral
services for pregnancy, childbirth and
abortion complications; post-natal care
the ground.

The Safe Motherhood Tenth Anniversary

program consisted of a comprehensive set of
and family planning activities, including a technical consultation
held in Colombo, Sri Lanka in October 1997
to forge consensus on the most cost-effective
Governments agreed to cut the number of strategies for safe motherhood; a World
maternal deaths by half by the year 2000, Heath Day media event in April 1998 to
and in half again by 2015. In 1995, the Fourth generate high-level attention to the problem
World Conference on Women (FWCW) in of maternal mortality among developing
Beijing gave substantial attention to maternal country policymakers and donors; and a far-
mortality and reiterated the commitments reaching media strategy and communications
made at the ICPD.

19
State of the World Population 2004 Report. The Cairo Consensus at Ten: Population, Reproductive Health, and the Global
Effort to End Poverty. New York: UNFPA, 2004.
10
A Historical Review of Safe Motherhood: 20 Years and Counting

campaign to widely disseminate the findings Millennium Development Goals

and messages to interested parties all over
the world.
(2000)
The Tenth Anniversary program has been
by far the single largest effort to advance
safe motherhood within the international
I n 2000, at the UN Millennium General
Assembly in New York, 189 countries
from around the world adopted specific
and national arenas. Selected products and international development goals with the
outcomes included: aim of reducing poverty and promoting
increased media attention on the human development. Building upon the
dimensions and consequences of agreements and commitments made at the
maternal mortality. series of world conferences held in the 1990s,
a set of ten priority action messages the Millennium Development Goals (MDGs)
reflecting consensus on the key policy and offer a blueprint for reducing poverty and
program strategies for improving maternal hunger, and addressing poor health, gender
health (see Annex III for a summary of the inequality, lack of education, lack of access to
ten action messages for safe motherhood). clean water, and environmental degradation.
a range of communications tools and Millennium Development Goal 5 calls for
resources, including a Web site, fact sheets, an improvement in maternal health and a
public service announcements, a brochure, reduction in maternal mortality by 75% by
and a pocket card. 2015 from 1990 levels.

The ten priority action messages profoundly The identification of maternal health as one
transformed the conception, design, of the eight MDGs firmly situates it as central
and implementation of safe motherhood to poverty reduction and overall development
programs and policies. Two program efforts. Its inclusion has resulted in increased
interventions that the Initiative itself had international attention to maternal mortality,
advocated ten years earlier at the Nairobi and provided a mechanism for monitoring
conference (training of traditional birth progress on maternal health and improving
attendants and risk screening for pregnant access to skilled attendants at deliveries
women to identify those most likely to (the key indicator for measuring progress
develop obstetric complications) were for Goal 5). With the MDGs now widely
deemed to be ineffective for reducing accepted as the framework for assessing
maternal mortality, and not to be promoted progress on overall health and development
as priority strategies. Instead, the ten action at the national and international levels, safe
messages emphasize the need to address the motherhood can figure more prominently
broad social, economic, and political context in country programs and in development
that contributes to womens risks of dying agencies priorities.
during pregnancy and childbirth, and promote
access to essential obstetric care to prevent
or treat serious obstetric complications.20

20
Safe Motherhood at Ten, Final Report on the Program to Mark the Tenth Anniversary of the Safe Motherhood Initiative,
January 1997April 1999. New York: Safe Motherhood Inter-Agency Group, 1999.
11
 For each of the Goals and targets, a task force An Expanded Global
was established to provide governments
and members of civil society with a concrete
Partnership for Maternal Health
plan for achieving progress on health and (2005)

I
development. The Task Force on Child Health
and Maternal Health issued a set of nine n September 2005, a partnership bringing
recommendations for realizing improvements together three existing global health
in maternal health and child mortality (Goal coalitions on maternal, newborn, and child
4 calls for a reduction by two-thirds of the health (the Partnership for Safe Motherhood
under-five child mortality rate). and Newborn Health, which itself evolved
from the Safe Motherhood Inter-Agency
In its report, the Task Force outlined the Group; the Healthy Newborn Partnership;
central challenge for maternal and child and the Partnership for Child Survival) was
health: developing and strengthening launched. The Partnership for Maternal,
functioning health systems through which Newborn, and Child Health (PMNCH) aims to
evidence-based interventions can be strengthen global advocacy and leadership in
delivered and scaled-up to the full population. an effort to raise the profile and visibility of
In particular, the report highlighted the maternal, newborn, and child health; develop
unequal distribution of power and resources, and promote a continuum of care for mothers
and a range of social, economic, cultural, and and children; and coordinate country-level
political inequities, as the main impeding support and action. It builds on the expertise,
factors for achieving progress in maternal and experience, lessons learned, and membership
child health. of the predecessor partnerships, with a major
focus on working effectively at the country
level to achieve improvements in maternal,
newborn, and child health.

12
 III International Advocacy and Agreements
for Safe Motherhood

B eginning in the 1990s, the United

Nations sponsored a series of
international conferences to develop a
The International Conference
on Population and Development
framework for achieving progress on (1994) and the Fourth World
population, health, and development. Safe Conference on Women (1995) 21

T
motherhood, including maternal mortality
reduction, has been consistently identified as he 1994 International Conference
a key development goal at all of these major on Population and Development
global conferences. represented a paradigm shift on approaches
to population, womens rights, and sexual
In order to examine how safe motherhood and reproductive health. Prior to the ICPD,
came to be highlighted as a critical area most leaders in the population community
for action at the international level, and the were concerned primarily with achieving
reasons underlying its inclusion, a set of key demographic targets, rather than meeting
informant interviews were carried out with individuals needs for health services
individuals from multilateral organizations and information.
and NGOs who played a role in negotiating
or otherwise influencing the outcomes The ICPD Programme of Action was a
of international declarations. The major watershed for safe motherhood: for the first
meetings and outcomes included in this time, a UN document defined a time-bound
analysis are: the International Conference and measurable goal for maternal health: to
on Population and Development (1994); the reduce maternal deaths by 75% by the year
Fourth World Conference on Women (1995); 2015.22 The safe motherhood commitment
the Millennium Declaration (2000); and the included in the ICPD Programme of Action
Childrens Summit (2002). What follows is a has been reaffirmed by several major global
summary of the findings. agreements negotiated since the ICPD,
including the Platform for Action of the Fourth
World Conference on Women, the outcome
documents from the UN General Assembly
Special Session on HIV/AIDS, the UN General
Assembly Special Session on Children, and
the Millennium Declaration.

21
NB: The overwhelming majority of content in this section discusses the ICPD. With the exception of one sub-paragraph on
eliminating punitive measures for women who obtained illegal abortions, the FWCW documents safe motherhood language
was basically identical to that of the ICPD. Additionally, the informants noted that the group of countries that opposed
language on family planning and unsafe abortion at the ICPD made the same objections at the FWCW and, as at the ICPD,
eventually joined the consensus, albeit with reservations.
22
While the 1990 World Summit for Children Plan of Action for Implementing the World Declaration on the Survival,
Protection and Development of Children in the 1990s included a goal to reduce maternal mortality by 50% by 2000, it did
so in the larger context of a set of quantitative goals focused primarily on child and infant health and well-being. The ICPD
Programme of Action placed maternal health in the reproductive health framework; in addition, at the ICPD, the international
community pledged financial and other resources to realize this promise.
13
 The informants reported unanimously that motherhood at the Cairo Conference. One
the inclusion of an explicit goal on safe informant noted that, since its first decade,
motherhood was a precedent-setting event UNFPA has been involved in efforts to
that elevated safe motherhood from an improve maternal health and that UNFPA
overlooked public health problem to a central dedicated a significant portion of the time
development goal. This section discusses allocated to the ICPD regional preparatory
the factors that led to the inclusion of safe meetings to discussions of the centrality of
motherhood in the ICPD Programme of safe motherhood to reproductive health and
Action and how this commitment has been development. In addition, Dr. Fred T. Sais
reaffirmed and expanded upon in subsequent strong leadership as ICPD Chair and his long
international agreements. history of involvement in maternal health
played a critical role in securing the safe
Regional conferences organized by the motherhood goal.
Safe Motherhood Initiative in the Arab
region, Southern and Francophone Africa, During the ICPD preparatory process, a large
South Asia, and Latin America in the late coalition of NGOs focused on sexual and
1980s and early 1990s, as well as a range reproductive health, eventually numbering
of national workshops and conferences, more than 1,000 organizations from all
raised the profile of safe motherhood, and regions of the world, concentrated its
helped to pave the way for the inclusion efforts on lobbying for strong commitments
of a holistic approach to safe motherhood to a comprehensive approach to sexual
in the ICPD Programme of Action. Because and reproductive health, of which safe
of these meetings, there was familiarity motherhood was an intrinsic element.
with and support for safe motherhood One informant noted that much of the
when the preparatory ICPD meetings took draft language contained in the coalitions
place. For example, many of the ICPD proposals was incorporated verbatim into
Preparatory Committee and regional the ICPD Programme of Action. The NGO
meeting governmental delegations included coalition, along with European and African
ministry of health staff and parliamentarians governmental delegations, worked with
who had participated in the SMI regional the conference secretariat to highlight the
meetings, and they were strong advocates importance of a strong agreement that took
for safe motherhood. Further, the SMIs a life-cycle approach to reproductive health,
wide dissemination of messages and population, and development.
other outcomes from the regional SMI
meetings helped to raise awareness of safe All informants reported that, given the
motherhood among policymakers, NGOs, awareness of safe motherhood that was
and the media. raised prior to the ICPD, the Programme
of Actions safe motherhood goal enjoyed
The leadership of the ICPD secretariat near-universal support.23 However, achieving
(UNFPA) and key individuals played a consensus on addressing a leading cause
critical role in securing commitment to safe of maternal deathunsafe abortionwas

23
One informant recalled the Holy See being the only delegation that opposed the goal to reduce maternal deaths by 75% by
2015. This was based on the Catholic Churchs long-standing proscription against artificial methods of family planning,
which were recognized as being key to reducing unintended pregnancies and, by extension, maternal deaths.
14
 International Advocacy and Agreements for Safe Motherhood

among the most hotly-contested issues at the built by the SMIs 1997 and 1998 activities
ICPD and FWCW. Several informants recalled that improving maternal health was widely
that a small, vocal minority of delegations viewed as being key to alleviating poverty
from conservative member states made a and ensuring sustainable development. This
sustained effort to prevent consensus on informant noted that, by keeping the focus on
language calling for action on unsafe abortion safe motherhood and articulating clear goals,
and on making reproductive health services the Initiative helped establish the foundation
available on a universal basis. for the MDGs. In addition, an informant noted
that the 1999 WHO/UNFPA/unicef/World
Finally, it was noted that safe motherhood Bank joint statement on safe motherhood24
served an important political purpose for was important for building support of a safe
addressing some of the more controversial motherhood goal.
issues in the Programme of Action. Framing
the reproductive health agenda as critical to Second, the safe motherhood goal was
reducing maternal mortality made it possible seen by some as a substitute for the
to discuss and achieve agreement on issues reproductive health goal. One informant
that were sensitive or controversial, such recalled that the dynamic of the Millennium
as unsafe abortion, and enabled delegates Declaration process was markedly different
to embrace the comprehensive approach to from that of the ICPD and FWCW. Unlike
reproductive health. the conferences of the mid-1990s, NGOs
were provided little access to the Summit,
The Millennium Summit and limiting the possibility of advocacy.
Another difference was the format of the
Millennium Development Goals negotiations: the overwhelming majority of

S
the Declarations text had been negotiated
afe motherhoods inclusion in the through informal diplomatic discussions
Millennium Development Goals was well in advance of the Summit itself, further
both a recognition of its centrality to poverty limiting advocacy efforts. A small minority of
alleviation and a compromise. conservative governments threatened that, if
the reproductive health goal was included as
The UN Secretary Generals document that one of the Millennium Development Goals,
created a framework for the Millennium they would block the consensus. However,
Summit, We the Peoples: the role of the these governments also indicated that a goal
United Nations in the 21st century, did not on maternal health would be an
contain a reference to maternal health. It acceptable substitute.
was noted that the omission of the safe
motherhood goal from We the Peoples was Thus, the inclusion of an explicit Millennium
an oversight rather than intentional neglect of Development Goal on improving maternal
maternal health, which was later inserted into health was driven by the recognition of
the text of the Millennium Declaration. its centrality to development and poverty
alleviation in general, as well as by
One informant noted that there had been political compromise.
so much good will on safe motherhood

24
Reduction of Maternal Mortality: A Joint WHO/UNFPA/unicef/World Bank Statement. Geneva: WHO, 1999.
15
 The UN General Assembly the time of the UNGASS on Children, safe
motherhood was widely accepted as a
Special Session on Children key development goal; governments were

T
focused on identifying and implementing
he UNGASS on Children, held in 2002, maternal health interventions and were
was a ten-year review of the World not interested in revisiting old debates.
Summit for Children. It aimed to assess Additionally, the informant recalled that a
progress on improving childrens lives and to number of delegates referenced materials
identify additional interventions necessary to prepared by the SMI when making statements
achieve the goals of the World Summit. on recommending strong safe motherhood
language in the document.
One informant recalled that commitments
to safe motherhood were included in the
draft outcome document draft prepared
by unicef (the UNGASS secretariat). The
draft document framed safe motherhood as
necessary for improving womens health and
infant and child survival, and included key
actions on priority areas such as increasing
access to skilled care during childbirth. This
was a very effective strategy: although the
most powerful governmental delegationthat
of the United Statesattempted to weaken
the discussion of maternal health by equating
safe motherhood with abortion, all other
delegations reiterated their commitment to
safe motherhood, leading the United States
to retreat. The informant recalled that, by

16
IV Media Trends in Safe Motherhood

T his section assesses how media

attention for safe motherhood has
changed over time, specifically analyzing
Considerable coverage was generated by the
Safe Motherhood Tenth Anniversary events
(the Call to Action on World Health Day in
the impact of the Safe Motherhood Tenth particular) and by the PSAs, which were
Anniversary media campaign. In addition, disseminated to over 350 TV and 200 radio
trends in press coverage between 2000 outlets in more than 80 countries. The PSAs
and 2005 were analyzed to ascertain how were shown frequently by such outlets as
safe motherhood has fared in national and CNN International, CNBC Europe, Star TV, and
international media outlets. MTV (North and South), as well as national
television stations in Malaysia, Bangladesh,
Safe Motherhood at 10 the Czech Republic, Lesotho, Pakistan,
Zimbabwe, and Uganda. In a survey of

A s part of the Safe Motherhood Tenth

Anniversary programme, a media
campaign was carried out to reach influential
country-level participants from the Technical
Consultation, 70% of respondents felt that
local media coverage about safe motherhood
had increased during the campaign, though
media in donor and developing countries.
no formal country-by-country evaluation
Elements of this campaign, which was
was conducted.
launched following the Technical Consultation
in October 1997, included:
The impact of the campaign was assessed
development of story ideas, press releases,
through an analysis of press coverage
and features;
generated around World Health Day 1998
media training for potential safe
events in Washington, DC and around the
motherhood spokespeople in both
world. Press coverage was tracked for the
developed and developing countries;
period covering September 1997 to October
identification of a circle of 100 journalists
1998, which encompassed the Technical
from important print and broadcast outlets;
Consultation on Safe Motherhood in Sri
a media-only Web site for information (also
Lanka and World Health Day, on April 7,
called a virtual press office);
1998.25 One hundred fourteen articles were
event-related press relations;
analyzed across 15 markets: Australia,
a master press kit to help partners in
Canada, China, France, India, Israel, Malaysia,
developing countries extend the media
Russia, Singapore, South Africa, Sri Lanka,
attention on key safe motherhood
Thailand, Turkey, the United Kingdom, and
issues; and
the United States. Key findings are presented
development and distribution of public
on the following page.
service announcements (PSAs).

25
The media analysis was limited to articles featuring the World Health Organization within the context of the IAGs World
Health Day activities, since World Health Day coverage was extensive and beyond the financial means and study of the
communications analysis.
17
 Story Placement: Story Focus and Content:
The greatest number of articles appeared Media attention overwhelmingly cited World
in the United States (55) and the United Health Day (66%). Family planning was
Kingdom (17). India follows with ten articles, the focus of 19 articles (driven by Hillary
Sri Lanka with eight, then Malaysia and Clintons call for family planning to prevent
South Africa with four each. Reasons for unsafe abortion); there were also ten
the heightened interest in these countries mentions of funding (again driven by Mrs.
include: the location of the World Health Day Clintons criticisms of the U.S. Congress).
events and the Technical Consultation, use The most common messages mentioned in
of local speakers and local issues, and the the media coverage were: safe motherhood
attendance of national figures at the events. is a human right (26); safe motherhood is a
A variety of wire services covered safe vital economic investment (13); and greater
motherhood; they were responsible for funding is required (6).
29% of the press. Most prominent were Offering facts and figures in press releases
Associated Press, PressWire, Agence France and other materials helped ensure clear
Presse, and Reuters. and consistent reportage of the extent and
National print was responsible for 43% of the medical causes of maternal mortality.
coverage. The Daily News (Sri Lanka) had Coverage of the socioeconomic and political
the most articles (three) focused on the factors was much more diverse, reflecting
Colombo conference. The UK publications differing political and economic contexts for
the Daily Telegraph and the Financial each media market.
Times also contributed one item each.
Other national print channels included Media Coverage Since 2000
the Jerusalem Post, the New Straits
Times (Malaysia), and the Straits Times
(Singapore).

Story Sources:
T his section analyzes how the media
has covered safe motherhood issues
since 2000, and identifies regional as well
as issue-based trends in press coverage.
Seventy-four of the published articles
Media reporting from January 2000 to June
analyzed were news items, 36 were opinion
2005 was reviewed for coverage of safe
pieces, three were editorials, and one was
motherhood issues. Research was limited
a letter. The source of the coverage was
to English-language press sources included
broken down as follows: interviews or
in the NEXIS academic universe database.
press briefings (62%); third party (i.e., WHO,
To identify coverage addressing safe
unicef) (19%); press releases (11%); and
motherhood issues in developing countries,
spontaneous coverage (3%).
keyword searches were conducted using
Press briefings and interviews with key
the following search terms: maternal health,
spokespeople proved to be very effective;
maternal death, Safe Motherhood Initiative,
they generated good coverage of key
and safe motherhood. In addition, more
messages both in terms of volume and
detailed searches were conducted for articles
favorability. Each market took a keen
that had the terms maternal health and
interest in their own leading figures, and
Millennium Development Goals within 25
also in the keynote figures at World Health
words. The following NEXIS news libraries
Day in Washington.
18
 Media Trends in Safe Motherhood

were examined: Major Papers; World News: From January 1, 2001 until June 1, 2005,
European sources, North and South American maternal health was mentioned in 561 articles
sources, Asia and Pacific Sources, and Africa from Middle Eastern and African sources in
and Middle East Sources. Additionally, a the World News library (see graph below).
compilation of news coverage on the Bush Two hundred thirty-one (41%) of these
Administrations decision to withhold the U.S. articles focused on the MDGs (the remainder
governments contribution to UNFPA was of the articles reported on a range of safe
reviewed for safe motherhood content. motherhood issues such as new maternal
mortality estimates, the impact of unsafe
Observations and Trends abortion on women in the region, and donor
funding for national or regional maternal

I ncrease in Maternal Health Coverage and

the Impact of the MDGs
Perhaps the most striking finding in this
health interventions). In comparison, from
June 30, 1996 until December 31, 2000,
maternal health was mentioned in just 172
articles from Middle Eastern and
analysis was a progressive increase, during
African sources.
the first five years of the new millennium, in
the number of articles referencing maternal
health. This trend, which holds for media
outlets in each region, is strongly correlated
with the adoption of the MDGs in late 2000.
In years 2001 through 2005, MDG reporting
increased references to maternal health by a
significant margin.

Middle East and Africa Maternal Health and MDGs Coverage

250
Maternal Health
Maternal Health
200
Number of Articles

and MDGs

150

100

50

0
2001 2002 2003 2004 Jan-May
2005
Year
19
As the graph below illustrates, similar trends that were maternal health specific either
appear in the Asia and Pacific region. From lauded a countrys success in improving safe
January 1, 2001 until June 1, 2005, maternal motherhood or lamented the likelihood that
health was mentioned in 813 articles; 212 the country would fail to meet the maternal
(26%) of which were focused on the MDGs health goal by 2015. Regional differences in
(the Asia and Pacific region includes Australia; whether the coverage was slanted toward
89 of the non-MDG articles identified in lauding or lamenting maternal health
this search discussed domestic Australian were striking.
maternal health issues). In comparison, from
June 30, 1996 until December 31, 2000 just In Asia, in safe motherhood success story
290 articles from the Asia and Pacific region countries such as Sri Lanka and Malaysia,
mention maternal health. the governments garnered media attention
for their assertion that they had met the

Asia and Pacific Maternal Health and MDGs Coverage

300
Maternal Health

250 Maternal Health

Number of Articles

and MDGs

200

150

100

50

0
2001 2002 2003 2004 Jan-May
2005
Year

While the MDG-related articles were goal of reducing maternal mortality by

numerous, most of them did not dedicate 75%. Interestingly, the Chinese government
significant attention to maternal health. asserted that, while progress had been
Frequently, maternal health appeared merely made, they needed to work harder to meet
in a summary of goals within an article that their MDG on maternal health and noted
examined a countrys effort to achieve one of that expanding access to skilled care during
the other goals, such as reducing poverty or childbirth was key to achieving a 75%
increasing primary school enrolment. reduction in maternal mortality by 2015.
Overwhelmingly, MDG-focused articles
 Media Trends in Safe Motherhood

In Africa, most of the maternal health-specific Afghanistan mentioned either safe birthing
MDG coverage lamented the prospect that kits or the importance of giving birth with a
key countries would not achieve the maternal skilled attendant.
health MDG by the 2015 target. Country-
specific coverage included articles from Mothers Day
Zambia, Kenya, and Ghana. Additionally, The use of Mothers Day as a news hook
several articles from African (Pan-African has helped generate coverage when coupled
News Agency) and other regional press with the release of new information or data.
outlets (such as Deutsche Press-Agentur For example, in the United States in 2000
and Xinhua News) reported that maternal and 2001, just two columns focused on safe
mortality was increasing in countries affected motherhood; once Save the Children began
by civil unrest and/or armed conflict such as to release its Save the Mothers report on
Zimbabwe and Sierra Leone. Mothers Day, Mothers Day press coverage
of safe motherhood issues increased
Overall, while the MDG process appears significantly. In 2003, 2004, and 2005, 20
to have raised the medias awareness of Mothers Day articles featuring the Save
maternal health issues, much of the coverage the Mothers report were identified. This
to date has been superficial. This suggests report focuses on a different aspect of safe
that there is a need for press outreach that motherhood every year and also includes the
emphasizes the centrality of the maternal popular Mothers Index, a compilation of
health goal to the achievement of poverty country-level data on key maternal
alleviation and sustainable development as health indicators.
a whole.
Coverage of Unsafe Abortion
Other Trends During the analysis period for media
coverage (January 1, 2000 through June

R eframing of Maternal Health Issues

Media coverage of maternal health
has generally focused on the numbers or
1, 2005), unsafe abortion was cited more
frequently than any other single cause of
maternal death and disability. Unsafe abortion
was cited in 993 news articles from the
rates of women who die each year from
World News library in NEXIS. Twenty-eight
pregnancy-related causes, with the release
percent of these articles discussed the causal
of maternal mortality estimates by the UN
relationship between unsafe abortion and
agencies approximately every five years
maternal death, many citing the toll of unsafe
garnering significant press attention. In
abortion in a specific country (such as Kenya,
the last 56 years, media coverage has
the Philippines, and Colombia). Additionally,
broadened to discuss effective interventions,
17% of the coverage focused on the impact
in part reflecting efforts by the press offices
of the Bush Administrations policies on
of technical and funding agencies (such as
reproductive health and referenced how such
WHO, unicef and UNFPA) to frame maternal
policies were having a negative effect on
mortality as a problem with known solutions,
efforts to reduce unsafe abortion.
requiring political will and resources. For
example, 14 of 15 articles on UNFPAs
efforts in October and November 2001 to
provide health care to women refugees from
21
 Additionally, the Safe Motherhood Inter- Lessons Learned
Agency Group meeting on unsafe abortion,
held in Kuala Lumpur in September 2003,
generated national attention in Malaysia,
where Bernama (the Malaysian National Press
Agency) published an article that was made
T he prominence of the MDGs in
the media presents an important
opportunity to ensure that MDG-related press
highlights safe motherhood. To this end, it
available via the Financial Timess Global
is important to consider special MDG press
News Wire and reprinted in at least four
outreach focused on maternal health. Such
newspapers around the world.
outreach could include media-friendly case
studies of success and challenge countries.

22
V Development and Donor Agency
Commitment

S ince the launch of the SMI in 1987,

the landscape of agencies working
in the field of maternal and child health
World Bankfunded projects for safe
motherhood increased substantiallyfrom
ten to 150 projects.27 The Bank has also been
has changed significantly. The number a critical partner in the Safe Motherhood
of development agencies with dedicated Inter-Agency Group, through its periodic
safe motherhood programs has grown role as chair and its financial support of
dramatically, and safe motherhood has the secretariat.
received increasing priority. Donor agencies
funding commitments to safe motherhood The World Health Organization: As one
have also risen, in response to international of the co-sponsors of the Nairobi Safe
mandates such as ICPD and the MDGs. Motherhood Conference, the World Health
However, funding remains inadequate to Organization (WHO) has long identified
achieve the Initiatives goals. safe motherhood as a core priority area.
WHO has provided technical leadership in
A review of organizations and agencies the design, implementation, and evaluation
working in health and development just of programs to governments, and has
prior to the launch of the Safe Motherhood worked in collaboration with NGOs and
Initiative in 1987 revealed that few health professional groups, among others,
(approximately six agencies) had specific to strengthen the provision of maternal
programs focusing on maternal health. In health services. The clinical guidelines,
1992, five years after the SMI launch, the policy briefs, training modules, and research
number of agencies with safe motherhood reports and methodologies it has produced
as a priority increased to 26 (including on maternal health have been widely used
multilateral organizations) as part of an and adapted.
analysis conducted in preparation of a
meeting of Partners for Safe Motherhood, UNFPA: Following the ICPD in 1999,
which reviewed progress and prospects for UNFPAs focus on maternal health increased
safe motherhood between 1987 and 1992.26 dramatically. Its current strategy for
preventing maternal mortality includes
The agencies that had identified safe family planning to reduce unintended
motherhood as a priority issue around the pregnancies; skilled care at all births; and
1987 conference included: emergency obstetric care for women who
develop complications. At the country level,
The World Bank: As one of the longest and safe motherhood features prominently
most consistent supporters of the global in UNFPAs programs, and the agencys
Initiative, the Bank has used its financial experience working in safe motherhood in
clout to increase investment in maternal over 140 countries has provided a wealth
health policies and programs. In the ten of programming lessons for the maternal
years following the SMI launch in Nairobi, health community.

26
Otsea K. Progress and Prospects: The Safe Motherhood Initiative 19871992. Washington, DC: The World Bank, 1992.
27
Safe Motherhood and the World Bank: Lessons from 10 Years of Experience. Washington, DC: The World Bank, 1999.
23
 Family Care International: Family Care The Safe Motherhood Inter-Agency Group:
International (FCI) was one of the earliest Founded in 1987 following the Nairobi
NGOs to situate maternal health as central conference, the Safe Motherhood Inter-
to its organizational mission. At the safe Agency Group was launched in an effort
motherhood conference in Nairobi, FCI to redress the gross neglect of maternal
played a critical role in setting the agenda, mortality and morbidity in the priorities of
coordinating the meeting logistics, and development agencies, within the national
documenting and disseminating the plans of developing country governments,
conference findings. In its role as secretariat and in the mindsets of the general public.
to the Safe Motherhood Inter-Agency Bringing together UN agencies and
Group (IAG, 19872004), FCI helped shape civil society partners, the IAG was an
the global landscape for safe motherhood; unprecedented partnership of organizations
the materials produced with and on behalf united by a common goal: to halve the
of the IAG, as well as the conferences it maternal mortality ratio. While its impact
organized, influenced the policy agenda at on the global SMI is difficult to determine in
the global and national levels, set technical quantitative terms, it is clear from informal
priorities, and raised awareness around this feedback and a general assessment of
public health tragedy. trends that the IAG has made substantial
inroads for maternal health on the policy,
MotherCare (a USAID-funded project advocacy, and technical fronts.
implemented by John Snow International):
From 1990 to 2000, MotherCare was Columbia University, Prevention of
USAIDs flagship project on maternal Maternal Mortality Program: From 1988 to
health (subsequently superseded by the 1996 researchers at Columbia University,
Maternal & Neonatal (MNH) Program and New York, collaborated with a network of
ACCESS). With the aim of improving the eleven multi-disciplinary teams in West
health, nutrition, and survival of women Africa (based in Ghana, Nigeria, and Sierra
and newborns through a continuum of care, Leone), called the Prevention of Maternal
it provided evidence-based programmatic Mortality (PMM) Network. These teams
approaches through needs assessments, carried out operations-research projects
monitoring and evaluation, and policy on maternal mortality, collected a body of
dialogue. The lessons and experiences information on the design and evaluation
gleaned from MotherCares work in over 25 of such programs, and produced analytical
countries had a significant influence on the work that significantly influenced program
design, planning, and implementation of design (such as the three delays model,
safe motherhood programs in the decades which analyzed the factors that prevent
to come. women from receiving essential care, and
their focus on the importance of emergency
care for life-threatening complications).
Their experiences have provided the safe
motherhood community with solid evidence
on the types of interventions that have the
greatest impact on reducing maternal death
and disability.
24
 Development and Donor Agency Commitment

Beginning in the 1990s and continuing into FCIs Skilled Care Initiative is an innovative
the new millennium, a number of large, five-year project being implemented in three
visible, and relatively well-funded projects rural, underserved districts in Burkina Faso,
and programs aiming to reduce maternal Kenya, and Tanzania to improve womens
mortality were launched. These included access to skilled care during pregnancy
the Averting Maternal Death and Disability and childbirth. The project examines the
(AMDD) program, implemented by Columbia feasibility, cost, and impact of implementing
University and partner agencies; the a comprehensive approach to skilled care
Initiative for Maternal Mortality Programme during childbirth in low-resource settings.
Assessment (IMMPACT) project which
is coordinated through the University of ACCESS is USAIDs flagship program on
Aberdeen; FCIs Skilled Care Initiative; and the maternal health. Building on the work of
USAID-sponsored MNH Program and ACCESS the MotherCare and MNH projects, ACCESS
housed at JHPIEGO. These projects/programs aims to improve the availability, access,
are a testament to the increasing visibility and and use of maternal health and newborn
import accorded to safe motherhood as an services in select countries around the
issue area over the last decade. world. ACCESS works at the clinical and
community levels (from the facility to the
AMDD was launched in 2000 as a large- household) in an effort to bring care as close
scale demonstration project focusing on as possible to women and their families.
implementing emergency obstetric care
interventions in low resource developing Agency Trends in Policy and
countries through a human rightsbased
approach. Implemented in over 50 countries,
Funding for Safe Motherhood

I
the program has achieved high impact,
high visibility, and is well-regarded by n order to assess how safe motherhood
governments, international development has fared at the policy, program, and
agencies, and civil societies. budgetary levels within development and
donor agencies, interviews were held with
IMMPACT is a global research initiative that selected representatives between May and
aims to provide rigorous evidence of the July 2005. The objectives of the research
effectiveness and cost-effectiveness of safe were to:
motherhood interventions, specifically in Assess agency trends in policy commitment
terms of equity and sustainability. Funded to safe motherhood over the last ten years.
by a range of development aid agencies, Track agency trends in funding for safe
IMMPACT plans to develop a series of tools motherhood/maternal health over the past
and methodologies, among other activities, ten years.
by the end of 2007. Identify the main factors that have shaped
developmentagencies commitment to and
investment in safe motherhood.
Evaluate general trends and events that
have influenced funding for and progress
toward achieving safe motherhood goals.

25
 Development Agency Trends The majority of agencies felt that maternal
health would continue to be a priority in

S ixteen representatives from major

international development agencies28
based in the U.S. and Europe were
the future in some capacity or the other: 13
of the 16 respondents explicitly identified
maternal health as a future priority area
for their agency. The clear trend was
interviewed for this report. Responding to
integrating safe motherhood with other areas:
a pre-set questionnaire, representatives
specifically, agencies planned to develop
shared information regarding their agencies
linkages between safe motherhood and
commitment, funding, and technical priorities
HIV/AIDS, given the increasing importance
related to safe motherhood.
of preventing mother-to-child transmission.
Another proposed area of integration is
The majority of development agency
maternal health and newborn health.

representatives (13 out of 16) participating
in the survey reported that over the past
ten years safe motherhood has remained a Safe motherhood will become a bigger
consistent priority within their agency. Safe part of our work in the next few years.
motherhood was often classified as one
of the priorities within the larger gamut of
sexual and reproductive health or broader
development issues such as gender and

One reason for this change is the new
approach to working with mothers and
newborn care.With new money from
foundations, there is a lot of energy
violence, and many representatives identified around newborn health.
specific aspects of safe motherhood (skilled
care during childbirth, postabortion care, and
One representative noted that newborn
malaria in pregnancy) as key priority areas
health programs typically have different
over the past ten years.
strategies and priorities than those focusing
on maternal health. For example, they place
The factors that contributed to the inclusion
considerable emphasis on community-
of safe motherhood as an agency priority
based care, including hygienic delivery, cord
were varied. For some agencies, it was
care, breastfeeding, kangaroo care, etc.;
driven entirely by internal push factors
emergency obstetric care, abortion-related
individuals interested in promoting safe
care, and addressing obstetric fistula are not
motherhoodwhile others were influenced
typically part of newborn care programs.
by external factors such as research,
With more and more donor funding focusing
evidence from the field, and global
on integrating newborn and maternal health,
conferences on maternal health.
it may become challenging to marry the
varying priorities.

28
Participating agencies included: Academy for Educational Development; Alan Guttmacher Institute; American College of
Nurse Midwives; Care International (USA); EngenderHealth; Family Health International; Global Health Council; International
Planned Parenthood Federation; Ipas; International Rescue Committee; IntraHealth International; Pathfinder International;
Population Reference Bureau; Program for Appropriate Technologies in Health; Save the Children; Womens Commission for
Refugee Women and Children.
26
 Development and Donor Agency Commitment

The trend toward integrating safe health consequences of unsafe abortion. One
motherhood with other development issues respondent noted that advocacy efforts need
stems from addressing the entire continuum to be supported by clear, evidence-based
of womens health issues. In addition, several interventions with demonstrated impact.
representatives noted that safe motherhood Increasing emphasis on the rights
is gaining greater prominence with other framework which situates safe
relevant development issues: motherhood as an essential human right,

and includes the right to receive basic
health care services.
The role of safe motherhood is evolving Emphasizing skilled assistance at childbirth
within HIV/AIDS; for example, looking at and emergency treatment for complications.
the safety of contraception and prevention Representatives noted that there has been
of unwanted pregnancy for HIV-positive
women is increasingly being encompassed
in HIV/AIDS work. So aspects of safe
motherhood are expanding to cover new
growing consensus that skilled care at the
time of childbirth, along with emergency
obstetric care to handle complicated
cases, is a critical intervention for reducing
areas. maternal mortality.

Representatives were asked to reflect on These changes in programmatic and technical

shifts in programmatic and technical areas emphasis were attributed to two broad areas:
within their agencies over the past ten years. The impact of international conferences and
Commonly recurring themes include discussions, global partnerships, and global
the following: advocacy initiatives for maternal health:

A shift from primarily emphasizing facility-
level work to building capacity at the
International dialogue tells us what
community level.
is important. We are constantly informed
Focusing on the entire health system,
which involves strengthening capacity at
all levels of the health care infrastructure,
from primary to referral levels, and

by what is happening internationally. For
example, recently WHO has emphasized
safe motherhood and newborn care to
be looked at collectively, and this has
engaging community members in service
influenced our thinking.
provision. Specific programmatic areas
of focus include: improving referral and
transfer to higher-level facilities; improving Lessons learned from the field:


communication systems; strengthening
skills in emergency obstetric care at
We are influenced by programming in
all levels.
the field. The lessons learned are adapted
Increased advocacy for all sexual and
into our programs.
reproductive health issues, including
increasing womens access to safe abortion
services (where not against the law) and the

27
 Representatives emphasized the importance Among those who reported expenditure
of operations and field research in providing information, the majority (7 out of 12
evidence for the design and development representatives) reported that their agencies
of program interventions. For example, the maternal health budget as a proportion of
recent focus on neonatal mortality reduction the total annual health budget had increased.
rose in large part from evidence illustrating They attributed this increase to a recent
that simple, home-based interventions can heightened emphasis on safe motherhood
reduce neonatal deaths. Research in particular and other reproductive health issues, as well
can identify what the gaps are and what can as the rise in funding for specific aspects
be done to address them. of safe motherhood such as postpartum
care, skilled assistance, etc. Further, with the
Some representatives also discussed the integration of safe motherhood and newborn
influence of donors and specifically noted healthan area of growing importance
that agencies programming priorities were more funding was becoming available for
shaped by what donors wanted and were safe motherhood activities.
willing to fund.
Donor Agency Trends
Data on annual health expenditure was
available from 12 of the 16 representatives
interviewed for this survey. Among the 12,
only five agencies specifically earmarked
funds for maternal health, and their maternal
A ll donor agency representatives
participating in the survey29 reported
that over the past ten years, safe motherhood
had consistently been a priority area for their
health budgets ranged from 1060% of their
agency. Reasons cited for its inclusion as a
total annual health budget; seven agencies do
priority area included: the influence of the
not earmark funds by topical area, or they no
1987 Safe Motherhood conference and the
longer allocated specific parts of their health
ICPD conference in 1994; the identification of
budget to maternal health activities. Of the
maternal health as a goal in the MDGs; and
latter, some agency representatives explained
the beliefs of individual members within
that they did not receive funds specifically
the agency.

for safe motherhood (or other areas), but
rather funding was country-specific and
for a specific project or program. Another
agency representative said that until 2000
they received funding specifically for safe

Reaching the MDGs and poverty
reduction is our first goal, yet maternal
health has become increasingly important
since it has become a milestone in the
motherhood; this is no longer the case, and
now they receive lump sum funds for a range MDGs.
of reproductive health issues, with maternal
health programs included in this package.

29
Donor agencies participating in this review included: The Bill & Melinda Gates Foundation; Department for International
Development (DFID), UK; Department for Development Aid Cooperation, Finland; MacArthur Foundation; Swedish
International Development Cooperation Agency (Sida); United Nations Population Fund (UNFPA); United States Agency for
International Development (USAID); The World Bank; and World Health Organization.
28
 Development and Donor Agency Commitment

All but one representative felt that safe With the identification of maternal health as
motherhood would continue to be a priority one of the MDGs, donors feel their energy
area in the future, and the majority (five out is invested less on funding service delivery
of nine respondents) felt that its importance programs or projects, but on scaling-up
would increase. With the MDG goals of operations in an effort toward achieving
improving maternal health and reducing broad development goals.
childhood mortality, many representatives
felt that safe motherhood was now back on There is increased emphasis on financing
the map and gradually regaining importance. mechanisms. Donors now consider it
Some respondents also pointed out that important to have a public health system
their agencies were integrating maternal with detailed data on costs for each health
and newborn health, and hence in terms of service. This level of detail is considered
priority and budgets safe motherhood would critical for efficient fund allocation, and
become increasingly important in the future. in order to measure success. Sector-wide
approaches (SWAps) are increasingly being
Many of the representatives interviewed pushed and endorsed by more donors, and
identified a dramatic shift in funding they are aiming to advocate for increased
strategies and priorities in the health field in maternal health allocation in SWAp budgets.
general, and safe motherhood specifically.
Most agencies are now shifting from a A discussion of financial trends for safe
piecemeal approach to a health systems motherhood is provided in section VI.
approach. This encompasses all aspects
of the health system such as upgrading
communications systems, strengthening the
capacity of health workers, setting up referral
systems, etc. Since maternal health depends
upon a working health system, many donors
identify safe motherhood as a barometer of
the overall health system.

We, unlike other agencies, which may

say they work on emergency obstetric
care, are working at improving national-
level health systems. We are also trying
to influence technical reform and
decentralization of health care delivery.

29
VI Financial Trends for Safe Motherhood

T o provide an assessment of financial

flows for safe motherhood since 1987,
several data sources were used:
A series of interviews with key safe
motherhood bilateral and multilateral
donors to assess changes in funding
priorities for reproductive health generally
A World Banksponsored report, Supporting and safe motherhood specifically, and to
Safe Motherhood: A Review of Financial identify future funding directions for
Trends, assessed funding levels related safe motherhood.
to official development assistance (ODA)
for three years (19861988). The review While these sources provide a snapshot of
employed data sets from this time period, how funding for safe motherhood has fared
supplemented with interviews with donor over time, they do not yield a complete
representatives and official annual reports analysis of financial trends since the launch
from bilateral and multilateral agencies. of the Initiative. Since the data sets are not
comparable, information from one source
The study included the following project/ cannot be used in conjunction with the other,
program categories: those specifically resulting in data and time gaps. Efforts to
labeled safe motherhood activities; collect data from individual donor agencies
projects categorized as maternal health regarding safe motherhood expenditures
programs; family planning and population were problematic, primarily for two reasons:
programs; general health system projects lack of electronic information systems (and
with components that contribute to improving dedicated staff) that have kept track of
maternal health; nutrition programs; IEC funding data since the mid-1980s;
programs; women in development projects; tendency to aggregate safe motherhood
and intersectoral programs that benefit into broader reproductive health and/or
women of reproductive age through population programs, thereby making it
improvements in education, employment, difficult to isolate how much is actually
rural development, or agriculture. spent on safe motherhood projects
and programs.
The UNFPA/NIDI resource flows database,
covering a time span of 19962002,
was developed following ICPD to track
Funding for Safe Motherhood
resources for the costed package, a set Following the SMI

I
of reproductive health interventions and
services (including family planning, basic n May 1990, the World Bank commissioned
reproductive health, STD and HIV/AIDS a report to assess how financial flows for
prevention, and research policy analysis). maternal health changed since the launch
Maternal health care is included under of the global Safe Motherhood Initiative.
the basic reproductive health category. Focusing specifically on ODA (and not other
The database assesses financial flows for funding sources, such as foundations or
population via bilateral, multilateral, and NGOs), the analysis estimated trends in
private-sector channels, as well as from external financing for safe motherhood in
development banks. developing countries.
30
According to the report, for the 17 bilateral Funding for Safe Motherhood
sources, assistance for safe motherhood
increased from US$691.5 million in 1986 to
following the ICPD

A
US$818.8 million in 1988 (in current dollars);
for the six multilateral agencies, spending s noted above, the ICPD provided cost
increased as well, from US$396.7 million estimates for the implementation of a
(1986) to US$477.7 million (1988).30 set of services needed to achieve universal
access to reproductive health by 2015 (the
Interviews with the major bilateral and ICPD costed package), and initiated a
multilateral agencies were held to assess mechanism for tracking donor expenditures
individual agencies commitment to safe toward this goal. Initially, the majority of
motherhood and respective funding expenditures (70%) were on family planning
expenditures to developing countries. and reproductive health services, with the
Covering the period from 1985 to 1988, all latter including information and routine
17 bilateral donor representatives and six services for prenatal, delivery, and postnatal
multilateral agencies included in the survey care; abortion and postabortion care; and
reported a gradual increase in current complications of pregnancy and delivery.
dollars for safe motherhood and indicated Trends in the ICPD categories over time, as
plans to increase financial support for safe outlined in the graph below, point to a sharp
motherhood in the future. increase in expenditures toward STIs and
HIV/AIDS in response to the escalating AIDS
crisis. Expenditures for basic reproductive
services, which include maternal health,
appear to have remained fairly constant
between 19962004, with small spikes and
declines from one year to the next.
Donor Expenditures on ICPD Costed-Population Package Categories
(in US$), 19962004 (Figures for 2003 and 2004 are estimates)
2500

2000
(In hundred of thousands)

1500
US Dollars

1000

500

0
1996 1997 1998 1999 2000 2001 2002 2003 2004

Family Planning STD/HIV/AIDS Reproductive Health Basic Health

Accessed: http://www.resourceflows.org/index.php/articles/c78/ 10 August, 2005.

30
Since bilateral data can include government contributions to multilateral and United Nations agencies, expenditures from
31
both categories cannot be summed to yield an annual total. The financial data represent donor allocations for a specific year.
 In addition to examining trends in broad Number of Safe Motherhood projects
categories of the ICPD costed package, a word found per year
search of safe motherhoodrelated terms was 600

conducted to obtain expenditures specific 500

to maternal health between 19962002. The

Number of projects
400
analysis revealed that the total amount of
funds spent on safe motherhood projects 300

increased steadily from US$74.75 million 200

in 1996 to US$182.63 million in 1999; from
100
1999 to 2002, however, there was a gradual
decline in the amount of funds, to US$177.93 0
1996 1997 1998 1999 2000 2001 2002
million. It is interesting to note that the
amount of funding peaked in 1999, the period Geographic distribution of funds for safe
corresponding with the tenth anniversary of motherhood between 1996 and 2002 provides
the Safe Motherhood Initiative. insight into how donor priorities have shifted
over time: in 1996, the region receiving the
largest number of funds was Asia and the
Total US$ amount spent per year on Pacific, followed by Global/Inter-regional,
Safe Motherhood projects with Western Asia and North Africa rounding
200,000,000 out the top three. In 2002, regional priorities
180,000,000
related to safe motherhood shifted, such that
160,000,000
140,000,000
Global/Inter-regional received the largest
share of donor funds, Asia and Pacific the
US Dollars

120,000,000
100,000,000 second largest share, and sub-Saharan Africa
80,000,000 the third largest. With data unavailable for
60,000,000
2003 and 2004 at the time of publication, it
40,000,000
20,000,000
is unknown how these regional allocations
0 have changed; however, there are indications
1996 1997 1998 1999 2000 2001 2002
that more funds are being directed toward
sub-Saharan Africa, in large part a result
As the next graph outlines, the number of of stagnating, and even rising, maternal
safe motherhood projects and programs mortality levels.
illustrates a rising trend, with an increase
from 366 programs in 1996 to 468 in 2002. Donor Funding Trends for
Safe Motherhood

I nterviews were carried out with nine

key safe motherhood donor agencies,
representing bilaterals, multilaterals, and
foundations31 (see Annex I for full list of
agencies), in an effort to assess past and
31
Donor agencies participating in this review included: The Bill & Melinda Gates Foundation; Department for International
Development (DFID), UK; Department for Development Aid Cooperation, Finland; MacArthur Foundation; Swedish
International Development Cooperation Agency (Sida); United Nations Population Fund (UNFPA); United States Agency for
International Development (USAID); The World Bank; and World Health Organization.
32
 Financial Trends for Safe Motherhood

future funding trends for safe motherhood. Donor agency views on whether global
Data on annual health investments (from 2004 concern about HIV/AIDS has resulted in funds
or the last fiscal year for which data were being shifted from safe motherhood varied,
available) were made available by all donor reflecting at least in part different internal
representatives interviewed for this survey: mechanisms and funding flows. Four donor
most indicated that funds for maternal health representatives stated that in their view the
had increased in their agencies in the past impact has been negative, since in their
ten years. agencies funds for maternal health and HIV/
AIDS were drawn form the same pool.

With regard to overall trends in maternal
health funding, donors had mixed views as to
whether funding has increased or decreased.
Half the respondents felt that the total funds

donors need to fund the
Global Fund initiative, and this is normally
quoted as the reason why funding in other
available for maternal health had increased
areas is not going.
in the recent past with additional funds
coming in from new donors such as the
Gates Foundation and DFID. Representatives In cases where HIV/AIDS funds do not
noted that, as a result of the identification necessarily come from the same pool, donor
of maternal health as one of the MDGs, representatives indicated that it would
donor commitment and collaboration had be incorrect to say that HIV/AIDS is taking
increased. They hoped that this would money away from maternal health. One
translate into more money for maternal representative noted that, The whole pie has
health in the near future. increased, so not sure it is an issue of sucking

funds away from one area to the other.
We can say that with the MDGs,
A handful of donor representatives also felt

maternal health is now on the map and
it has now become an issue of knowing
what to do and how to scale it up. It is
less about getting peoples attention, but of
that despite the fluctuations in the past, things
were beginning to change, and that money
would be coming back to maternal health.


actually setting things in place.
The fund committed to HIV/AIDS has
already been allocated, and now new money
Others felt that there had been no change in
is available to maternal health.
funding for maternal health, and if anything,
funds had slightly decreased. Although
overall donor commitment to reproductive Donor representatives were asked to
health seems to have increased, it was comment on whether the current-level
difficult to tease out the impact on maternal funds were adequate for meeting the ICPD
health. Measuring funding levels for maternal and MDG goals for maternal health, and
health is likely to become even more difficult to suggest how to augment funding levels.
in the future, with donors and foundations While all representatives agreed that funds
moving toward a more integrated or basket were inadequate to meet stated maternal
approach to funding using channels such health goals, they proposed a wide range of
as SWAps and Poverty Reduction Strategy solutions, including the following:
Papers (PRSPs).
33

Central to increasing funds is doubling
advocacy efforts around maternal health, Part of the problem is us. We are too
and developing stronger linkages between
maternal health and other public
health priorities.

focused on the money but not on how
it is being used. Money will always be
inadequate, but we need to focus on how
best to use what is available and countries

need to start investing themselves.
Part of the problem is our inability

to connect things. Internationally we
discuss SM and HIV separately, but
the issues in both areas are common
and should be discussed on the same
Finally, some representatives felt that funds
would always remain short of what is
needed. It may be more important to focus
playing field. on using funds efficiently, and not on how
much money is available.

Several donors called for broadening focus

from an issue-specific approach (focusing on
single areas such as maternal health or HIV/
AIDS) to one on health systems; this would
build technical capacity and infrastructure,
and have a much wider impact on several
public health priorities.

Also cited was the need to increase political

will and donor commitment to maternal
health. A few representatives felt that the
donor community had not fulfilled its own
commitments, and that governments and
donors both must increase the total amount
of funds available.

34
VII National Programs, Policies, and
Budgetary Commitments for
Safe Motherhood

P olitical commitment and action in

support of safe motherhood have been
mixed at the country level: in some countries
The profiles provide a brief overview of the
key policy, programmatic, and budgetary
efforts related to safe motherhood in
(e.g., Malaysia, Sri Lanka, Egypt, Honduras) these countries, and as such are not a
concerted efforts on the policy, program, and comprehensive analysis of what has occurred
budgetary fronts resulted in improved access at the national level. They examine how
and availability of maternal health services and why maternal health was identified as
and a reduction in maternal mortality levels; a national priority, what main programmatic
in other countries, maternal mortality ratios strategies were put forward, and what have
have stagnated, and in some settings, appear been the associated budgetary allocations.
to have increased.32 For those countriesoperatingunder SWAps, it
assesses to the extent possible how maternal
What needs to be in place at the national healthhas fared within this resource-allocation
level in order for pregnancy and childbirth mechanism. Through interviews and
to be safe for all women? Several published document research, in-country consultants
reports33 have examined the strategies and traced the development of each governments
interventions that have been conducive for commitment to safe motherhood; identified
improving maternal health. Building upon the main programmatic priorities; and, to
this body of work, this report seeks to analyze the extent possible, analyzed the budgetary
the development of national (government) allocations for safe motherhood. What follows
policies, programs, and budgetary allocations are the main findings from each of the
for safe motherhood in select countries in country reviews.
Latin America, sub-Saharan Africa, and Asia,
in particular focusing on the time period from
1987 to the present. In consultation with a
range of partners, the following countries
were identified: Bolivia, Indonesia, Lao
Peoples Democratic Republic, Malawi, Mali,
and Tanzania.

32
Make Every Mother and Child Count. Geneva: WHO, 2005.
33
Pathmanathan I., Liljestrand J., Martins J.M., Rajapaksa L.C., Lissner C., de Silva A., Selvaraju S., and Singh P.J. Investing in
Maternal Health: Learning from Malaysia and Sri Lanka. Washington DC: The World Bank, 2003.
Koblinsky M.A.. Reducing Maternal Mortality: Learning from Bolivia, China, Egypt, Honduras, Indonesia, Jamaica, and
Zimbabwe. Washington, DC: The World Bank. 2003.
Skilled Care During Childbirth: Country Profiles. New York: Family Care International, 2002.
35
 Bolivia

Bolivia Safe motherhood is a national priority,

evidenced by the level of public discourse

I n Bolivia, maternal mortality stands at

229 deaths for every 100,000 live births.
In the last ten years, between 1991 and 2001,
and in the creation of progressive national
policies and programs. Since 1985 there have
been more than five incumbent government
administrations in Bolivia, the most recent
Bolivia was able to reduce maternal mortality
elected by a clear majority in December 2005.
by 40%, from 390 to its current level. In spite
While the health sector has undergone a
of this decline, maternal mortality remains
series of structural changes, the commitment
a health problem, particularly for women in
to guaranteeing Bolivian women the right
lower social strata and income levels. Wide
to safe motherhood has been paramount in
disparities in the countrys socioeconomic
almost every government administration.
indicators pose an obstacle for effectively
The political commitment, however, has not
guaranteeing all Bolivian women a safe
always been translated into, or supported by,
pregnancy and childbirth.
concrete actions.
Bolivia is located in the heart of South
America. It is bordered by Brazil at the north Policies for Safe Motherhood

N
and east, Argentina in the south, Peru in the
west, Paraguay at the southeast, and Chile ational policies for safe motherhood
at the southwest. The country is divided can be categorized according to the
into three significant geographical areas: following time periods:
the Andean zone which covers 28% of the
territory, the sub Andean zone (13%), and the 19851989. During this period, there was no
Plains, at 59%. explicit policy document on safe motherhood.
While infant health was identified as a
The 2001 census indicates a population national priority, national health plans did not
of just over 8 million inhabitants.34 The include concrete maternal health strategies,
population structure by age suggests Bolivia or set specific goals for reducing maternal
is a young country: 38% of the population mortality or increasing coverage of maternal
is under the age of 14 years, and 56% health services.
between 15 to 64 years. Bolivia is among the
three poorest countries in Latin America, as 19891993. During this period, maternal
evidenced by the high levels of inequality: mortality was a key component of the
49% of Bolivias municipalities have a very National Child Survival Plan (which focused
low Human Development Index,35 35% are at on service delivery), and of the ten-year
the low level, and the remaining 16% are at Action Plan for Children and Women, which
the medium level. The average income of the highlighted the governments obligation
richest 10% of the population is 15 times the to reduce maternal mortality by 50% by
average income of the poorest 10%. the year 2000. In 1993, the Andean Safe

34
The National Statistics Institute projection for 2005 is 9,427,219 inhabitants.
35
The Human Development Index (HDI) is a composite index to measure a countrys progress in human development, as
measured by life expectancy at birth, adult literacy and educational enrollment, and GDP per capita.
36
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Motherhood Conference36 brought together In 1996, a National Safe Motherhood

key policymakers, program planners, and Committee37 was legally established as
researchers from the Andean Region who an intersectoral body responsible for
worked together to analyze the problem of coordinating and monitoring national action
maternal death, develop priorities for action, to reduce maternal mortality and morbidity.
and outline guidelines for inter-country and The national committee was created under
national action on safe motherhood. the authority of the Office of the First Lady,
which helped strengthen the committees
19931997. Bolivia experienced profound potential to conduct outreach and advocacy
structural changes that transformed the at the national and international levels.
organization and operation of the national Since 1996, the First Ladies of Bolivia have
health care system. With the implementation assumed a paramount role in promoting safe
of the Law of Popular Participation, the motherhood in national and international fora,
administrative and management functions of including the 1997 World Health Day activities
the public health system were decentralized in Washington.
from the national to the municipal levels.
The National Treasury transferred funds to 19972002. During this period, the
municipalities for health-related infrastructure new National Program for Sexual and
improvement, while the normative Reproductive Health (19982002) was
functions of the Ministry of Health consolidated, and a new health insurance
remained centralized. program (Seguro Bsico de Salud) was
implemented as part of the National Plan
During this period, the National Plan for of Maternal and Neonatal Health. These
Reducing Maternal and Neonatal Mortality programs and policies set the goal of
(19941997) and the Life Plan for the reducing maternal mortality by 35%, and
Accelerated Reduction of Maternal and infant mortality by 15%, by 2002 (from 1991
Neonatal Mortality and for Child Survival base line figures).
were implemented, as were several
other strategic plans for improving safe With safe motherhood positioned as a key
motherhood at the national, departmental, issue in the national dialogue on sexual
and municipal levels. The National Insurance and reproductive health, the problem of
for Maternity and the Child was launched, maternal death in Bolivia gained greater
which mandated that municipal governments international visibility and attention. National
provide a basic package of services at no fee action on safe motherhood led to improved
to all women during pregnancy, delivery, and coordination between and among a range
the postpartum period, and to children under of health programs. In the opinion of many
the age of five. health officials, this integrated approach was
the factor that most contributed to reducing
maternal mortality in Bolivia over the last
ten years.
36
Delegations from Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela participated as members of the Andean subregion,
as well as Argentina, Mexico, Nicaragua, and Uruguay; other participants included agencies like FCI, the Population Council,
IPPF, and Ipas. The meeting issued a declaration and a report.
37
Members of the council include FCI, UNFPA, PAHO/OPS, USAID, Save the Children, PROCOSI, and the Ministry of Health and
Sports, and several non-health organizations. In 2002, the Committee was renamed the Inter-Institutional Council. Since
2004, the Council has not been in operation.
37
 Bolivia

20022007. During this period, the Universal introduction of Depo Provera has been a key
Maternal/Child Health Insurance Law (Seguro factor in increasing contraceptive coverage.
Materno Infantil or SUMI) was implemented, According to the 2003 ENDSA survey, in
as well as a range of processes within the the last five years modern contraceptive
broader context of decentralization, including: method use among women in union has
strengthening the decisionmaking power of increased from 25.2 to 34.9%. For the first
primary health care networks; time, the increase in rural areas (from 11.3
building bridges between health care to 25.0%) was higher than the increase in
providers and social networks; urban areas, due in large part to an increase
improving the clinical and communication in use of Depo Provera. The Ministry of
skills of providers at the health Health considers that the higher contraceptive
care level; and prevalence rates, resulting from the increase
promoting community mobilization in availability of services and of modern
strategies and individual, family, and methods, have helped result in a decrease in
community empowerment schemes. maternal deaths in Bolivia.

During this period, policies focused on the

need to address obstetric emergencies Programmatic Priorities

T
and incorporate evidence-based clinical
protocolsby improving the referral system, echnical shifts in programmatic
strengthening transport and communication approaches and priorities reflect the
networks, and developing strategies to changes occurring at the international and
promote community mobilization and regional levels: a shift from the risk approach
advocacy in response to gaps in service. Also, to evidence-based practice; from training
the National Government adopted a set of traditional birth attendants to promoting
goals including: reducing maternal mortality the use of skilled attendants and of the
by 40% by 2008 and 75% by 2015 (based care they provide; from an emphasis on
on 1990 levels); reducing infant mortality the mother and child to a more integrated
by 10% by 2008 in relation to the ENDSA approach that focuses on sexual and
2003 (National Survey on Demographics and reproductive health more broadly. For
Health); and increasing the number of births example, since 1983, the risk approach was
assisted by skilled attendants by 24%. developed and implemented as a long-
term strategy, staunchly supported by the
Family planning has been an implicit and Ministry of Health. From 1983 until 1994,
explicit component of national policies, other program strategies were put forward
especially in the 19982003 National Program to complement the risk approach, including
for Sexual and Reproductive Health, and in the promotion of prenatal and delivery care,
the current 20042008 program,which adopts and care during the postpartum period.
a strong rightsbased approach. Ministry of Although the risk approach has not been
Health efforts have focused on strengthening completely abandoned, it became outdated
the availability of contraceptives; the with the enactment of Resolution 0496,

38
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Number of Health Facilities by Type and Year

Bolivia, 1996, 1999, and 2003

Type of Facility 1996 1999 2003

Basic Health Center 891 1112 1332

Health Care Clinic 818 947 1129

Basic Hospital 111 127 155

General Hospital 23 26 26

Specialized Institute 20 22 26

TOTAL 1863 2234 2668

Source: Ministry of Health, National Statistics Institute

which introduced a set of 18 evidence-based prenatal care were introduced after 2000, and
practices to prevent the over-medicalization of are considered relatively new priority areas.
delivery care, and promote the humanization The skilled care approach was introduced
of maternal and neonatal services.38 However, on a national scale during the Regional
as this resolution has not been widely Technical Consultation on Skilled Care during
publicized, efforts are needed to continue to Childbirth, convened in Santa Cruz, Bolivia
promote it. in July 2003, by the Regional Task Force
on Maternal Mortality Reduction in Latin
Between 1993 and 1997, the national program America and the Caribbean.40 In 2003, an
for training traditional birth attendants in extensive survey was conducted to assess the
clean birthing techniques gradually declined conditions under which emergency obstetric
and disappeared. Although there have been services were provided at key health care
renewed interest and efforts to build bridges facilities. Findings from the survey pointed
with traditional providers in the broader to the urgency of improving emergency
context of promoting inter-cultural dialogue obstetric care services at the district and
and tolerance,39 this should not be interpreted tertiary care levels (see Monitoring and
as a return to former program strategies. Evaluation section).
Skilled care during childbirth and focused

38
The resolution was adopted by the Ministry of Health in October 2001.
39
It is well known, for example, that some NGOs have been training and even recruiting lay/traditional midwives, since the
decentralization process has allowed them to avoid the central and departmental health sector ministries and their policies.
40
The Regional Task Force is composed of the following members: UNFPA, IDB, the World Bank, FCI, the Population Council,
unicef, and PAHO.
39
 Bolivia

National Insurance Fund The data in the chart below highlight the
In 1996, the National Maternal and Child progress made in improving coverage of
Insurance41 was launched to help reduce the maternal health services, following the
economic barriers that prevent women and implementation of the National Maternal
children under age five from accessing public and Child Insurance. While coverage has
health services. The strategy focused on improved, coverage rates in rural areas
providing health centers with medicine and remain low. In urban areas, three out of
supplies for pregnant women before and after every four births (75.5%) take place at a
childbirth, and for children under age five. health facility, whereas in rural areas, only
The health centers receive financial support one of every three births (32.7%) takes
from the municipal fund, which in turn place in a facility. In certain regions of the
receives support from the National Treasury. country where indigenous populations are
The strategy has made it possible to increase concentrated, the proportion of deliveries in
the number of services that can be provided health facilities has actually decreased.
for pregnant women, including clinical,
surgery, and trauma services.

Coverage of Prenatal Care and Labor by Health Care Services

for Women Who Gave Birth in the Five Years Before the Survey
(Percentage). Bolivia, 19892003

90
80
70
Percentage (%)

60
50
40
30
20
10
0
1989 1994 1998 2003

Prenatal Labor

Source: INE/National Survey on Demographics and Health

41
In 1998, its name was modified to Basic Health Insurance, and in 2005 to the Universal Maternal/Child Health Insurance
(SUMI is the Spanish acronym).

40
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Critics of the free voluntary health coverage circumstances. The figure below illustrates
strategycreated for all but aimed in favor of how institutional births are distributed by
the poorestclaim that it has in fact benefited income quintile, from the poorest to
groups living under better economic the richest.

Percentage of Births in Health Service Facilities in the Five Years

Before the Survey, by Level of Income. Bolivia, 2003

120

97.9
100
85.5
Percentage (%)

80
65.5
60
45.1

40
21.6
20

0
Q1 Q2 Q3 Q4 Q5
Q1 = Poorest Quintile Q5 = Richest Quintile
Source: National Survey on Demographics and Health 2003

41
 Bolivia

Monitoring and Evaluation In 2003, the Ministry of Health conducted an

evaluation of the availability, access, and use

N ational Surveys on Demographics and

Health (ENDSA) carried out in 1994 and
2003 and the Post-Census Survey on Maternal
of emergency obstetric health care services
for 85 key healthcare facilities in the health
system, with financial support from UNFPA.
The survey estimated the percentage of
Mortality (EPMM)42 conducted in 2000 provide
obstetric emergencies treated, and found
a snapshot of national maternal mortality
that the average percentage of obstetric
levels in Bolivia (see below).
emergencies handled at health care facilities
Average Maternal Mortality Rate in the Three Available
Surveys. Bolivia, 19942003

X 1000,000 Births
Maternal mortality per 100,000 live births

450
390
400
350
300
229 235
250
200
150
100
50
0
ENDSA (19891994) ENDSA (19992003) EPMM (2000)
Sources: ENDSA/INE 1994, 2003 and EPMM 2000

varies between 2228%. Factors related to

Another indicator is the percentage of
these trends include: the distance women
pregnant women able to access health care
experiencing complications have to travel
facilities for obstetric complications. But this
to reach facilities; the availability of public
information is not registered consistently by
transportation; the condition of transportation
the National System for Health Information
networks; and the level of trust the
(SNIS, for its Spanish Acronym) or the
community has toward health care providers.
Universal Maternal/Child Insurance system
(SUMI, for its Spanish acronym).

42
This was generated by a different procedure from the ENDSA, but is still consistent with the results of these surveys.

42
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Expenditures for Integrated Project of Healthcare Services, or

PROISS), and the Institutional Development
Maternal Health Project financed by the Inter-American

F
Development Bank. These projects provided
unds for government expenditures on a total of US$16 million of support for basic
health come from different sources: infrastructure and equipment. In 1998, public
the nations General Treasury; fees for investment was near US$98 million.
services not covered under the insurance
program; municipal allotments through the Currently, the Safe Motherhood Initiative
tax co-participation scheme; international in Bolivia faces a financial challenge.
cooperation funds and extraordinary Although SUMI and international cooperation
allotments, like those linked to the external provide resources specifically to support
debt relief program. One very specific source safe motherhood, coverage is still lagging
of funds, the National Lottery for Poverty and funding is insufficient to meet the
Assistance and Health, has encountered populations needs. Not only is there a need
problems due to corruption. for additional resources for safe motherhood,
but funds allotted must also be expended
As a percentage of GDP, health expenditure in an effective, efficient, and transparent
has varied considerably. After reaching 4.52% manner, and reach the populations most
in 1989, it dropped to 2.5% in 1992; it has in need.
since recovered without reaching an optimum
level. In 1997 it rose to 3.98%, and again in Over the last ten years, international
1998 to 4.9%; both years this increase came cooperation agencies including USAID,
as a result of allotments made for the National UNFPA, and unicef have radically changed the
Insurance for Maternal and Child Health. modality of funding and fund disbursements.
They have gone from direct disbursements
Public investment in maternal health includes to the national government to creating
both external aid and funds from the Treasury. agency projects with separate structures and
External aid is channeled through the personnel. In addition, two of the three UN
government (bilateral and multilateral aid) agencies (UNFPA and unicef) have cut back
and through nongovernmental organizations, on funds allotted to national initiatives in
in the form of cash donations or credit. Bolivia. USAID has reduced funds for health;
The Treasury, which is usually the national from the US$20 million dollars disbursed
counterpart when these funds are invested, in 2000, the amount has dropped to US$16
is in charge of monitoring expenditures in million for 2005. Sexual and reproductive
capital investment projects. Between 1993 health receives one third of these funds. It
and 1997, public investment related to health remains to be seen how the recent political
grew 269%, from US$22.8 to US$61.3 million. transition in Bolivia will affect bilateral
This was due in large part to two large-scale contributions from USAID.
projects, one financed by the World Bank (the

43
 Bolivia

Conclusion While international cooperation has supported

safe motherhood projects in Bolivia, funding

M aternal mortality decreased by

40% between 1991 and 2000 in
Bolivia.Safe motherhood policies and
has been adversely affected by broader
global economic processes, which eventually
resulted in a change in priorities and a
refocusing of programs. National allotments
programs evolved from a simple and
for safe motherhood, on the other hand,
relatively isolated vision to integrated plans
increased on account of the national maternal
developed in the broad context of sexual
and child insurance strategies and the
and reproductive health. Safe motherhood
involvement of municipal governments.
was first identified as a priority in the early
1980s with a general understanding of the
In spite of a national insurance fund for
problem, but not based on the available
safe motherhood focusing on the poor,
evidence. In the 1990s, the landscape for safe
marginalized women, especially those living
motherhood changed as a consequence of
in the rural highland regions, and those
the Andean Safe Motherhood Conference
with limited income and educational levels,
(1993); the results of the National Survey on
continue to lack adequate coverage.
Demographics and Health (1994); and the
National Insurance for Maternal and Child
Health (1996). Subsequently, safe motherhood
policies have increasingly been based on
epidemiological data and have promoted
evidence-based protocols addressing the
obstetric causes of maternal mortality.

44
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Indonesia National Policies for

W
Safe Motherhood

T
ith 215.3 million people in 2003,
Indonesia is the fourth most here have been several milestones
populous country in the world. A vast in the government policies for safe
tropical archipelago of 17,000 islands across motherhood in Indonesia. Since the 1970s, as
the equator between Asia and Australia, it part of government policy to expand primary
occupies a total area of 9.8 million sq km care, MCH became an integral component
covering 7.9 million sq km of ocean and 1.9 of six basic services provided at the health
million sq km of land. The country is home center level (serving 30,000 people).
to more than 300 ethnic groups spread
over 6,000 inhabited islands with five big Beginning in 1989, as a result of the high
land masses (Sumatra, Java, Kalimantan, maternal mortality of 450 per 100,000 live
Sulawesi, and Papua). births found in the Indonesian Household
Survey (IHHS, 1985), in 1989 the Minister of
On a number of health and social indicators, Health issued a new policy to accelerate the
Indonesia has experienced significant gains: reduction of MMR; and to train and deploy
life expectancy has increased (from 59.8 to a large number of community midwives to
65.4 years), infant mortality has decreased provide village-based MCH services. The
(from 71 to 47 per 1,000), and maternal objective was to improve womens access
mortality was reduced from 450 to 373 deaths to skilled attendants through the training
per 100,000 live births in the period 1986 and deployment of over 54,000 community
1996.43 The population growth rate in 1999 midwives (nursing school graduates plus
2000 was 1.48%. one-year midwifery education) between 1990
to 1996.

Estimated Maternal Mortality Ratio by Source,

Indonesia 19852002
500
Maternal Mortality per 100,000 live-births

450
450 425
390
400 373
334
350 307

300
250
200
150
100
50
0
IHHS 1985 IHHS 1992 IDHS 1994 IHHS 1995 IDHS 1997 IDHS 200203

Source: MOH,
Source2004

43
Ministry of Health and World Health Organization. Country Profile of Womens Health and Development in Indonesia.
Jakarta, 1999.
45
 Indonesia

In 1994, the government reaffirmed its Following the economic crisis that devastated
commitment to accelerate the reduction of Indonesia and the rest of Asia in late 1997,
maternal mortality through management the government took steps to protect the
of the complications of pregnancy and increasing proportion of the poor (which rose
delivery and improving the proportion of from 11% in 1996 to 40% in 1998) with social
births attended by health personnel. The safety net (SSN) programs, including one on
strategy aimed to increase the coordination of health services. Initially supported with a loan
different health care providers and facilities to from the Asian Development Bank in 1998,
function as a comprehensive referral network: the government continued the program with
the community midwife as first-level provider funding derived from oil price compensation.
for obstetric and neonatal emergency; the Through this safety program, the poor receive
health center as the source for 24-hour basic free services ranging from basic outpatient
emergency obstetric and neonatal care, care including MCH to hospital inpatient care.
and the district hospital providing 24-hour
comprehensive emergency obstetric and In the year 2000, following the Millennium
neonatal care referral services.44 Development Goals, the President launched
the Making Pregnancy Safer (MPS) Strategic
The ICPD (1994) and the Beijing Fourth Plan 20002010, with support from WHO,
World Conference on Women (1995) brought with the goal of reducing maternal mortality
about a more integrated approach vis--vis to 125 per 100,000 live births by 2010. The
safe motherhood and reproductive health, four strategies put forward in the MPS
and promoted linkages with womens program were:
socioeconomic status and reduction of 1. to improve access and quality of obstetric
maternal mortality. and neonatal services;
2. to develop effective partnership among
In 1996, the President launched the Mother sectors, programs, and different parties for
Friendly Movement aimed at mobilizing optimum mobilization of resources;
communities and providers to address 3. to enhance the empowerment of women
the three delays in obstetric and neonatal and families in healthy behavior and
emergencies (delay in household decision utilization of maternal and neonatal
making, delay in making referral, delay in services; and
case management at health facilities). The 4. to facilitate community involvement in
movement enhanced efforts to increase ensuring availability and utilization of
the demand for safe motherhood among maternal and neonatal services.
families and communities, improve access
of pregnant/delivering/postpartum women to The MPS strategy was developed in
quality maternal care, and support the referral conjunction with the Strategy to Achieve
of obstetric and neonatal emergencies with Healthy Indonesia by 2010, which identifies
district resources.45 safe motherhood and reproductive health
as one out of ten priority areas. In 2000,

44
Ministry of Health, Republic of Indonesia. Strategies to Accelerate the Reduction of MMR. Jakarta: MOH, 1997.
45
Cholil et al., 1997.
46
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

a decentralization policy shifted the includes height and weight measurement,

responsibility for providing MCH services blood pleasure examination, iron tablet,
from central to province/district levels, with tetanus toxoid immunization, abdominal
the aim of improving access and quality (height of top-uterine) examination and
of services. health/nutrition education.46 In Indonesia, the
SM program has set at least four visits for
Despite the high-level commitment to antenatal care: one in the first trimester, one
improving maternal health in Indonesia, a in the second trimester and two in the
number of factors have hindered adequate third trimester.
decline in maternal mortality levels. The
process of decentralization, after a 32- Beginning in 1990, the government,
year period of strong commanded central supported by a World Bank loan, began
rule, has been problematic due to the implementing an expansive program
lack of preparedness of different levels of (Bidan Di Desa or BDD) to ensure improved
government bureaucracy to changing roles coverage by a skilled birth attendant during
related to technical capacity and funding delivery. The BDD program posted a
management. Further, the 1997 monetary community midwife (nursing graduate with
crisis brought prolonged social conflicts and one additional year of midwifery training) at
unrest that impaired the development of the the village level. By 1996, almost all 65,000
safe motherhood program. villages had been staffed with a community
midwife. Subsequently, the training of
the midwife was upgraded (12-year basic
Programmatic Priorities for education plus three-year nursing and
Safe Motherhood midwifery training) in a move toward the

S
provision of improved skilled care.
ince the early 1990s, the national
program no longer promotes the The Making Pregnancy Safer and Healthy
training of TBAs due to its inconsequential Indonesia 2010 policies have put forward
role in improving maternal health. three program interventions:
Evidence-based knowledge on screening 1. improving access to skilled
for high-risk pregnant women resulted in health providers;
its discontinuation, to be replaced with 2. increasing access to referral services; and
the philosophy that every pregnancy faces 3. prevention of unwanted pregnancy and
risk since the late-1990s. Greater emphasis care of postabortion complications. At
has been placed on the education and the operational level, the implementation
mobilization of communities through multi- of this program during 20002004 has
channel IEC activities and social mobilization been hindered by lack of resources,
principles. Antenatal care and counseling has administrative capacity, and
improved with a standardized content that funding support.

46
Departemen Kesehatan Republik Indonesia. Rencana Strategis Nasional Making Pregnancy Safer [MPS] di Indonesia,
20012010. Jakarta: 2001, p. 8.
47
 Indonesia

While the national safe motherhood program demographic analyses such as the IHHS and
gained strength and momentum during the Indonesian Demographic Health Survey;
1980s and 1990s as a result of high-level national censuses; periodic socioeconomic
policy commitment, less progress has been surveys; survey on the profile of womens
observed in the last 56 years. The end of status; maternal and neonatal studies; and
the 32-year centrally dominated government behavioral studies and studies on specific
in 1998, replaced by a more democratic sentinel/pilot project areas supported by
and decentralized system, has resulted international donors. The long, periodic
in diminished concern, enthusiasm, and nature of data collection and analysis often
response for top-down government initiatives. fails to resonate with policymakers. Policy
decisions are often made without proper use
Monitoring and Evaluation of evidence.

T he national monitoring and evaluation

system includes a set of indicators
that includes MMR and causes of maternal
Survey data show that the BDD program
of training and deploying community
midwives at the village level has improved
maternal care. Between 1991 and 2002, the
deaths; coverage of antenatal care; births
percentage of women receiving four or more
attended by skilled providers; access to
antenatal visits increased (from 56% to 81%),
comprehensive emergency care at district
with higher numbers of pregnant women
hospitals and basic emergency care at health
visiting a midwife (from 65% to 81%). Those
centers; proportion of obstetric complications
completing four antenatal visits are more
managed by the district health system
likely urban women (72%) than rural women
including its case fatality rate; and percentage
(57%). The percentage of births attended by
of C-section deliveries.47
TBAs is declining (from 64% to 32%) while
those attended by trained health providers is
The quality of service statistics is poor,
increasing (from 32% to 57% by doctor and
particularly a result of the decentralization
midwife). The use of modern contraception
process which fostered a noncompliant
has also gone up (from 47% to 57%) in the
attitude toward the national monitoring
same period. However, despite the declining
system. Health staff show a lack of
percentage of deliveries attended at home
appreciation for data recording and collection,
(from 79% to 59%), home deliveries remained
and underreporting is also common.
at 60% in 2002 (Series of IDHS 1991, 1994,
1997, and 2002).
Lacking accurate data from service units,
monitoring and evaluation is based on
the following mechanisms: local area
monitoring (LAM)48 revitalized after 2000,
the periodical survey reports from national

47
Ministry of Health, Republic of Indonesia. Strategies to Accelerate the Reduction of MMR. Jakarta: MOH, 1997, pp. 1315.
48
Local Area Monitoring (LAM) is a management tool for monitoring MCH program coverage in a specific area. Through
tracking coverage indicators (e.g., antenatal care visits, births attended by skilled professionals, postpartum care, neonatal
care) on a monthly basis, LAM aims to facilitate prompt and quick action for achieving MCH program objectives.
48
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Estimated MMR, Antenatal Care Coverage, Birth Attendance, and

Contraceptive Prevalence, Indonesia, 19912002
Indicator 1991 1994 1997 2002
Estimated MMR per 100,000 live births 425* 390 334 307
Antenatal care coverage (%)
- no visit 20 13 11 4
- 1 visit 5 4 3 3
- 4 or more visits 56 64 69 81
Source of antenatal care (%)
- by doctor n/a 10.6 10.6 11.0
- by midwife n/a 65.3 71.4 80.5
- by TBA n/a 4.2 3.2 3.9
- by no one n/a 12.7 7.4 4.4

Birth attendant (%)

- no one 0.3 0.4 0.3 0.3
- TBA 63.7 59.5 54 32
- midwife 29.3 33.8 40 52.5
- doctor 2.4 2.7 3 4.7
Place of delivery (%)
- home delivery 79 77 73 59
- government facilities 7 8 9 9
- private facilities 12 10 11 31**

Contraceptive prevalence (% married women)

- any method 49.7 54.7 57.4 60.3
- any modern method 47.1 52.1 54.7 56.7

Source: IDHS 1991, 1994, 1997, 2002. * IHHS 1992. ** including maternity homes by community midwife.

Financial Expenditures for Health development has been consistently

underfunded. Government health expenditure
Safe Motherhood has been around 0.70.8% of Gross Domestic

T
Product (GDP), contributing roughly 30%
he main sources of government health of total expenditure. In 19841985 and
funding are central and regional 19941995, the per capita expenditure on
government budgets. At the national level, health was $11.40 and $17.10 respectively.49
the main source is the State Income and A marked increase in the health budget
Expenditure Budget (APBN or Anggaran was noted in 1997 and 1998 following the
Pendapatan dan Belanja Negara) which economic crisis, as the government instituted
includes International Loans and Grants. SSNs for health (including increased funding
At the regional level, funding comes from for maternal health) from an ADB Loan.
provincial and district budgets. However, the increase is not real due to the
devaluated rupiah (Rp.) currency as a result of
the crisis.
49
Ministry of Health and World Health Organization. Country Profile of Womens Health and Development in Indonesia. Jakarta:
1999, p. A-21, para A8.2 Health Expenditure.

49
 Indonesia

Percentage of National Budget (APBN) for Health,

1990/911999/2000
4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Source: GOI-unicef, 2000 in MOH-WHO, 2003
Source: GOI-UNICEF, 2000 in MOH-WHO, 2003

Accurate data are not available regarding of Family Health, it is estimated that central-
the level of health expenditures for safe level safe motherhood activities have
motherhood, as the budgetary system is received a very small portion from the overall
based on integrated funding by institution central health development budget, ranging
or services unit (hospital, health center, etc.) from 0.14% to 1.13% annually in the period of
down to the operational level. Using the 19992000 to 200450 as shown in the following
allocation for programs under the Directorate table and figure.

Safe Motherhood/Family Health Budget as Percentage of Total

Health Development Expenditure, 20002004 (in Million Rupiah)
Budget Items 1999/00 2000 2001 2002 2003 2004
Total Development 83,648,300 41,605,700 465,461,400 52,299,100 55,770,000 70,871,200
Budget in APBN*
Total Development 4,428,800 2,910,900 3,927,000 3,505,500 3,790,100 5,442,000
Budget for Health*
% Development Budget 5.08 7.0 8.6 6.7 6.85 7.7
for Health*
Central Development 3,139,517 1,532,618 3,011,994 3,370,322 5,138,546 4,784,191
Budget for Health**
% of Foreign Assistance 44.1 52.5 45.8 32.2 20.9 21.1

Central Development 35,426 16,034 17,032 10,065 12,169 6,472

Budget for Family
Health***

% Central Health Dev 1.13 1.05 0.57 0.30 0.24 0.14

Budget for SM/RH***

* National Development Planning Board 2005 (1 USD=Rp. 9000)

** Bureau of Planning and Budgeting, MOH, 2005
*** Directorate of Family Health, MOH, 2005

50 Bappenas, Health Development Budget. Personal Communication, 2005.

50
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Percentage of Central Health Development Budget for Safe Motherhood/

Reproductive Health as Compared to the Percentage of Central Development
Budget for Health, by Year, 19992004
10
0.57
9
1.05 0.14
8
0.3 0.24
7 1.13
Percentage

6
5
4
3
5.08 7 8.6 6.7 6.85 7.7
2
1
0
% Dev. Budget for Health % Dev. Budget for SM/RH

For 20052010, the government is expected not yet affected funding for maternal health.
to elevate safe motherhood to priority status, Indonesia has finalized its PRSP document in
with a corresponding increased budget 2005, and has only recognized SWAps as a
allocation. The greater funding allocation potential mechanism without follow-up
for safe motherhood fits within an overall for implementation.
increase in health (development and routine)
budget of Rp. 11 trillion in 2006, a 22% International Financing
increase from the 2005 level of Rp. 9 trillion.

It will be a challenge to safeguard the 2006

increased allocation for safe motherhood,
especially with the decentralized budget that
T he figure below illustrates that health
sector grants have been increasing
from US$52 million in 2000 to US$95 million
in 2003, with a slight decrease to US$83
places priority on physical infrastructure/
million in 2004. In the future, grants are
equipment rather than health and social
expected to increase with The Global Fund to
development programs. SWAps and other
Fight AIDS, Tuberculosis and Malaria as one
finance mechanisms such as PRSPs have
of the major contributors.51
Aggregated Grants for Health 200004 (in US$ Thousand)
120,000

100,000 95,288
85,854
US Dollar

80,000 70,304

58,053
60,000 52,406

40,000

20,000

0
2000 2001 2002 2003 2004
51
Fleischer, C. Donor Activity in the Indonesian Health Sector between 20002004. WHO country office Indonesia, May 2005. 51
 Indonesia

Aggregated Grants for SM/RH, 20002004 (in US$ Thousand)

36,000
34,841
35,000 34,732

34,000
33,000
US Dollar

31,690
32,000 31,158
31,000 30,259
30,000
29,000
28,000
27,000
2000 2001 2002 2003 2004

Conclusion The slow decline in maternal mortality

in the last 1520 years is an indication

I ndonesia has been addressing its high

maternal mortality level with increasing
policy action since the 1987 Nairobi
of poor quality of care and problems at
the supply and demand levels. Policies
formulated at the national level have not
always been supported by proper and
Conference. The commitment shown by the
effective implementation. With greater
President and other high level officials to
emphasis on decentralization and regional
accelerate the reduction of maternal mortality
autonomy, district governments have gained
has fostered the development of a range of
responsibility for a wider spectrum of
technical guidance and manuals for lower-
tasks that include health, education, public
level implementation. At the operational level,
works, industry, trade, and communication,
the national program of posting community
often without adequate management skills
midwives at the village level has increased
needed for implementation. Finally, a
the coverage of antenatal care and births
review of national budgets indicates that
attended by skilled providers.
safe motherhood has not been prioritized
adequately, although politically it has attained
a certain level of commitment.

52
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Lao Peoples Despite considerable improvement in the

quality of life over the past two decades
Democratic Republic the general health status of the Lao PDR

T
population remains low. The health situation
he Lao Peoples Democratic Republic is characterized by a low life expectancy of
is a landlocked nation in southeast 59 years, an infant mortality of 82 per 1,000
Asia whose western border is defined by the live births, under-five mortality of 106 per
Mekong River. It is approximately 1,700 km 1,000 live births, and a maternal mortality
long from north to south and 400 km wide. ratio of 530 per 100,000 live births. Only one
It shares lengthy borders with Vietnam to half of the entire population has access to
the east, Thailand to the west, Cambodia to safe drinking water and less than half to safe
the south, and China and Myanmar to the sanitation facilities.
northwest. The Mekong River serves as a
source of transport and food. Two thirds of Approximately one third of the population
the terrain is mountainous, with consequent is considered ethnic minorities who live in
challenges regarding communication and geographically isolated mountain areas.
provision of social services. Over 65% of the Health and socioeconomic indicators lag
population lives along the Mekong and for these minorities as compared to the
the lowlands. whole nation. The ethnic minority areas in
the highlands have higher rates of poverty,
The Lao PDR is one of the worlds least worse health indicators and fewer services for
developed countries52 and one of the poorest many reasons among which are remoteness,
in Asia with an average annual per capita lower levels of educational achievement,
income of US$350. More than three-quarters and increasing land pressure that limits their
of the people live on less than US$2 a day, ability to achieve food self-sufficiency. Many
and the countrys social indicators are of the ethnic minorities do not speak Lao.
among the worst in the region.53 While the
economic situation has improved since the Public health services in the Lao Peoples
introduction of the New Economic Mechanism Democratic Republic are provided through a
in 1986, which shifted the economy from a network of about 700 facilities at the central,
centrally planned system to a largely free provincial, district, and sub-district levels.
market model, it is estimated that 46% of the About 67% of the population has access to at
countrys total population of 5.5 million54 live least some basic health services. Although
below the poverty line. The population is 79% of villages were within four hours of a
young, with 43.6% below 15 years old, and district hospital in the dry season as of 1999,
has a total fertility rate of 4.9. utilization of the public health care system
was very low. About 33% of the villagers seek
care from the informal private sector when ill;
these include drug sellers, birth attendants,
traditional healers, and herbalists.

52
United Nations Development Assistance Framework for Lao PDR 20022006.
53
Lao Country Brief, World Bank, 2004.
54
Millennium Development Goals Progress Report, Lao PDR, Final Draft, Jan. 2004.
53
 Lao Peoples Democratic Republic

There has been a trend toward falling Safe motherhood interventions remained
maternal, infant, and child mortality as largely uncoordinated and donor-driven.
measured by national health surveys from As was true for other health sector
1995 through 2000; however, these rates are programs, much of the conceptualizing
still among the highest in the region. During and designing of programs were done by
this period, MMR fell from 656 to 530 per outside agencies, limiting opportunities to
100,000. There is no vital registration system build local capacity and leadership.
and the health information system is not able Health personnel generally lacked clinical
to provide estimates for other indicators. and management skills and most had not
received in-service training in recent years
The Reproductive Health Survey 2000 showed The consistency and quality of routine MCH
that only 23% of women received antenatal services varied considerably.
care from a midwife, nurse, or doctor while Monitoring was difficult as recordkeeping
76% did not receive any antenatal care at all. was poor due to:
Traditional birth attendants (TBAs) provided - Lack of uniform guidelines for proper
antenatal care to less than 1% of pregnant recording of information
women. Relatives or friends assisted in 55% - Short supply of blank records to document
of deliveries while skilled health workers relevant patient information
assisted in 17%, TBAs in 13%, and 8% of - Lack of staff training
deliveries were unattended. Severe urban - Insufficient supervision and feedback
rural disparities exist in receiving care by
health professionals (63% for urban and 12% These findings were validated by the
for rural areas).55 Strategic Assessment of Reproductive
Health conducted in 1999 (MOH/WHO).
In view of the limited availability of In addition, the assessment noted that
information regarding maternal health community members did not recognize
services in Lao PDR especially prior to 1995, the complications of pregnancy and
an assessment of maternal health needs childbirth requiring immediate referral; a
was conducted by a team of experts in three large number of the district hospitals had
provinces in 1998 (unicef/Lao MOH/FCI). very limited resources and were providing
Among the key findings were the following: substandard care; and there was lack of
Centralized, vertical structure of health and strong professional leadership in obstetric
family planning and gynecological care. The assessment
Limited resource allocations for health recommended the strengthening of the safe
The lack of an action plan. Safe motherhood motherhood program and the development of
was a vague concept for most policymakers a comprehensive reproductive health policy
who lacked information on what constituted in order to integrate reproductive health
the basic elements of a safe motherhood services with safe motherhood.
program.
Insufficient NGO capacity for service
delivery and research

55
State Planning Committee, Report of the Lao Reproductive Health Survey. National Statistical Center, 2000.
54
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Policies for Safe Motherhood for improved quality of care through the
development of clinical protocols and the

I
promotion of good maternal health practices
n 1995, the National Birth Spacing Policy such as antenatal and postnatal care, and
was formulated to ensure that the number skilled attendance at delivery. The aim of the
of children born to a woman would not policy was to reduce the MMR by 25% by
impair her health and well-being. Family the year 2000 (from a MMR of 653 in 1993).
planning services were to be made available It mandated the provision of antenatal care
as a means of child spacing for health (at least once), and called for the prompt
reasons and for the overall reduction of recognition and treatment of the five most
maternal and infant morbidity and mortality. common obstetric emergencies. At the
The major goals were: community level, TBAs, health volunteers,
Reduce maternal mortality and infant and family members were to be provided
mortality by 25% in the year 2000. training on the recognition of high-risk
Increase access and availability of birth conditions during pregnancy, childbirth, and
spacing methods and services as well as after delivery to be able to assist in early
accurate information needed by women and referrals to hospitals. For health promotion
couples who wish to plan and space the purposes, they are also required to be trained
births of their children. on early breastfeeding, maternal and child
nutrition, and immunization.
The birth spacing program was to be
implemented in a phased manner and In 2002, the safe motherhood policy was
integrated with safe motherhood activities. amended with the following revisions:
It covered a variety of issues like program Acknowledgment of the rights of women
management, contraceptive methods, service regardless of age and class to reproductive
delivery, IEC, clinic management, fertility, and health information and services and as well
the import of contraceptives. as the newborns rights to health care.
Need for a continuum of care from
In 1997, the Safe Motherhood Policy was childhood to menopause.
promulgated as an addition to the existing Reiteration of the four pillars of maternal
Birth Spacing Policy. This policy document health care services (antenatal care, delivery,
was prepared after the first safe motherhood postnatal care, and family planning) and
conference was held in Vientiane in March the relevant activities to be conducted at
1996. Ninety-seven delegates from the central the central, provincial, and district hospitals
and provincial health departments, institutes, as well as the health center and in the
and hospitals worked together to come up community. The role of the community in
with a draft document that was approved these four areas of safe motherhood
in 1998. Only in 2000 was the action plan was emphasized.
developed. The 1997 policy defined the roles
of each health facility level; emphasized Furthermore, the document called attention
the need to upgrade these facilities and the to the need to upgrade the midwifery skills of
competencies of health staff; and called health care providers at the different levels of

55
 Lao Peoples Democratic Republic

care, and develop a new training curriculum In response to recommendations to broaden

to include emergency obstetric care, the scope of family planning into an
counseling, management of complications of integrated approach to reproductive health,
abortion, management and treatment of STIs, a National Reproductive Health Policy was
and prevention of HIV/AIDS. It also reiterated developed in January 2005. The policy
the need for training TBAs, especially in mandates that a core package of integrated
remote areas and where ethnic groups have reproductive health services consisting of safe
expressed a preference for them. motherhood and nutrition, family planning,
and prevention and control of RTIs (including
In 1999, the Birth Spacing Policy was STIs and HIV/AIDS) will be made available
amended by the National Population and in all primary health care facilities. A two-
Development Policy (NPDP) of Lao PDR. way referral system will ensure vertical and
One of the goals of the amended policy horizontal continuity of care from different
was to motivate and assist the population health and information providers and service
in improving the quality of their lives by delivery points.
ensuring safe motherhood, reducing maternal
and child morbidity and mortality, and
enabling couples to responsibly decide the
number and spacing of their children.

Specific targets are included in the

table below.
Targets of the National Population and Development Policy

Indicators Baseline data 2000 2010 2020

Maternal mortality ratio
(per 100,000 live births) 656 in 1993 490 250 130

Total fertility rate 5.6 children 4.5 3.5 3

in 1995
Contraceptive 3% in 1994 2530% 5055% 6065%
prevalence rate
Infant mortality rate 104 in 1995 85 40 20
(per 1,000 live births)
Under 5 mortality 170 in 1995 127 60 30
(per 1,000 live births)
Literacy rate of women 48% in 1995 60% 75% 85%
Girls enrollment rate 68% in 1995 75% 89% 95%
in primary school
Girls enrollment rate 28% in 1995 35% 55% 74%
in secondary schools

56
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

The policys specific objectives to reduce Beginning in 1995, a government-led

maternal, infant, and perinatal mortality and community health project to integrate
morbidity include: maternal and child health services was
achieve a significant and sustainable instituted at the community and district levels,
reduction in maternal, perinatal, and infant with the aim of building the capacity of the
mortality and morbidity health system to improve the coverage and
ensure adequate child growth, nutrition, and quality of maternal health care. Maternal and
development among children child health services serve as an entry point
protect the mothers and children from to link other primary health care interventions
preventable infectious diseases and facilitate the delivery of services to the
integrate safe motherhood and child growth community. The project has expanded to six
and monitoring with reproductive health provinces and is still ongoing.
program activities
Donor-financed projects include the
The policy calls for the upgrading of facilities Survival, Growth and Development program
and skills of health care providers at the implemented by unicef which targets
district/sub-district levels for improved women and children through an integrated
detection and early referral of emergency project of maternal and child health
obstetrical conditions as well as provision management and promotion, child survival
of transport and systematic referral. It also interventions, growth development, and safe
mandates the dissemination of clinical motherhood.56 The latter component included
practice guidelines in all health centers and the development of an integrated package
hospitals. The government has formulated of safe motherhood outreach services
other policy papers, poverty reduction in remote villages of six provinces; the
strategies, and master plans up to the year development of training curricula/guidelines
2020 which included maternal and child on emergency obstetric care; and training
health as one of the priority concerns, physicians and nurses in collaboration with
especially among poor and marginalized WHO and UNFPA. A UNFPA project supports
minority groups. It has also targeted mobile clinics and provides equipment
the improvement of the health sector and supplies to health facilities in three
and education of girls to correct gender southeastern provinces. The mobile clinics
imbalances. provide a range of reproductive health
services and informationincluding family
Programmatic Priorities planning, prenatal care, treatment of sexually
transmitted infections, and education on

M ost activities have been carried out

on a project basis and are funded by
different international agencies. As outlined in
HIV/AIDS prevention.

the 1995 maternal needs assessment, projects

have generally been implemented as vertical
programs in specific areas of the country, and
not on a national scale.

56
unicef Country Program (20022006), Survival, Growth and Development Program, Mid-Term Review, 2004.
57
 Lao Peoples Democratic Republic

Monitoring and Evaluation In 2005, a high-level committee was

established to monitor progress in

T he system for monitoring and

evaluating progress toward safe
motherhood goals and assessing health
implementation. The committee is headed
by the Minister of Health with two deputy
ministers, department directors, and the
division chief of safe motherhood. The
system performance remains inadequate. country has been divided into three areas
With no uniform health information north, central, and southto facilitate
system, recordkeeping remains poor and monitoring, with the intention to fast track the
nonstandardized. As a result, data needed to activities on safe motherhood to reach the
assess national progress toward improving Millennium Development Goals.
maternal health are not systematically
collected. The necessary forms and records
exist but are often not available. National Expenditures on
Safe Motherhood
Surveys and studies have identified general
trends in a number of indicators: the MMR,
IMR, under-5 mortality rate (see graph
below), and total fertility rate have declined;
whereas the contraceptive prevalence rate,
H ealth expenditure constitutes as little
as 2% of Laos PDRs Gross Domestic
Product. In the mid-1990s the government
allocated 5% of its budget to the health sector
the proportion of deliveries attended by
but it currently stands at 2%. Health spending
skilled personnel, and the proportion of
is about $12 per capita with 11.5% from
pregnant women receiving antenatal care
government sources. Households contribute
have increased.
approximately 55% of health expenditure and

foreign assistance accounts for 35%.57

Trends in MMR, IMR, U5MR

800

700

600

500

400

300

200

100

0
1990 1995 2000

MMR IMR U5MR

Sources: National Population and Development Policy (NPDP); Lao PDR Reproductive Health
Survey 2000; Country Health Information Profiles, 2004 Revision, WHO WPRO (CHIPS).

57
Country Health Information Profiles, 2004 Revision, WHO WPRO (CHIPS).
58
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

According to the MOH during a round table Donor spending represents an important
meeting in 2000, government funding for proportion of health expenditure. Usually
health has been increasing in nominal terms, it falls into one of four categories: technical
though inflation in recent years has decreased assistance, general construction and vehicles,
the value of this funding. Government medical equipment and pharmaceuticals, and
recurrent and investment spending by central study fellowships and tours. Overall donor
MOH contributes 3.2% of total expenditures, assistance represents 24.3% of total
1.1% by other ministries, and provincial health expenditure.58
health offices contribute more than twice this
level at 7.2%. In the national Department of The main donors to the safe motherhood
Hygiene and Prevention, safe motherhood program are unicef, WHO, and UNFPA. It is
constitutes about 2% of the budget. This difficult to determine the level of funding for
does not include the costs of conducting safe motherhood because of its integration
deliveries, managing complications, and with other programs. According to the
the funds channeled through other units in main donors, their funding contributions
funding safe motherhood-related areas such have been consistent as far as their regular
as reproductive health, primary health care, budgets are concerned.
health sector reform, and others. As a result,
it is difficult to quantify the expenditure and
financial contributions related to
safe motherhood.

External Resources for Health 19982002, Lao PDR

External resources as percentage

100
of total expenditure on health

90
80
70
60
50
40
30 20.4 21.1
19.5 19.7
20
9.6
10
0
1998 1999 2000 2001 2002

Year

58
Lao Health Master Planning Study 2001.
59
 Lao Peoples Democratic Republic

Conclusion The government is making efforts to

coordinate the multiple agencies to fast-

I n Lao PDR, the maternal mortality ratio

is among the highest in Asia at 656
per 100,000 live births in 1995. The high
track implementation, avoid duplication
of programs, promote better working
relationships, and identify unmet program
needs. Substantial efforts are still needed
MMR is attributed to a range of factors,
to improve monitoring and evaluation
including very low utilization of health
systems, establish registration and referral
facilities, poor coverage of skilled attendance
systems, develop more effective partnerships
during childbirth, very low antenatal care,
with NGOs, and provide an assessment of
almost no postpartum care, inadequate
program implementation. A reassessment of
essential obstetrics care, lack of functioning
maternal health needs is needed to determine
referral system, absence of birth and death
the quality of maternal and neonatal care
registration systems, and a poor functioning
available, the level of service utilization, and
health system. Compounding these are
the sustainability of interventions in an effort
a high total fertility rate at 5.6, and a low
to build on the gains that have been achieved
contraceptive prevalence of 3%.
thus far.
While maternal mortality has declined,
progress has been slow. A long history of
neglect of the health system, punctuated
by inadequate human resources and poor
infrastructure, has featured as a main
obstacle to continued improvements in
safe motherhood.

Most safe motherhood interventions have

been funded by international donors, with
the government contributing recurrent
expenditures including staff salaries, facilities
maintenance, etc. While financial support
in general has been inadequate, the lack
of coordination among donors, the vertical
programming structure, and the lack of
efficient monitoring and data systems have
further contributed to funding inefficiencies.

60
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Malawi globally. Preliminary results of the 2005

Malawi DHS indicate that the MMR may have

M alawi is a landlocked country in

Central Africa, with a total surface
area of just over 118,000 sq km, of which 80%
risen even higher.

The national increase in MMR has been

mirrored by an increase in institutional MMR;
is land.59 The total population is currently
for example, at the Central Teaching Hospital
estimated at 12 million people, with a
in Blantyre, the MMR increased from 476 in
population density of 105 persons per square
19941996 to 1,125 per 100,000 live births
kilometer. This is not evenly distributed: the
in 19992000. A 2005 national assessment
more fertile plains in the Southern Region of
of emergency obstetric care showed a case
the country are more densely populated than
fatality rate of 3.4%, which is higher than the
the drier, rocky, and hilly areas.
recommended level of 1% by UN process
indicators. The impression of many health
The annual population growth rate is 2.0%,
care providers in the country is that the
and life expectancy is 40 years for males and
current MMR may actually be much higher
44 years for females.60 Life expectancy has
than what is seen in health facilities.
deteriorated over the past 10 years mainly due
to the HIV/AIDS epidemic, which is considered
Several factors have been cited as
the number one cause of death among
contributing to the high MMR in Malawi.
adults.61 The total fertility rate has dropped
There has been a significant decline in the
from 7.6 in 1977 to 6.3 in 2000, with urban
quality of health care delivery nationally. This
areas having a lower level than rural areas,
has been documented in studies, surveys, and
(4.5 vs. 6.7 respectively). These are higher
assessments conducted nationally or within
than the desired fertility, 5.2 nationally and 3.5
health institutions. Over the past ten years,
for urban and 5.5 for rural residents, possibly
the country has witnessed an unprecedented
indicating the degree of unmet need for family
depletion of the workforce within the health
planning and extent of unplanned pregnancy.
sector, through death from the HIV/AIDS
epidemic or resignations due to the low pay.
In the early 1990s the estimated national
Hundreds of nurses have left the country
MMR in Malawi was 620 per 100,000 live
for overseas posts or public service for local
births. Between 1992 and 2000, the MMR
NGOs. Physicians training overseas have not
increased from 620 to 1,120 per 100,000 live
returned home for economic reasons. Many
births based on local surveys; WHO/unicef/
health facilities have no qualified staff and
UNFPA (2000), however, estimates that the
therefore essential services such as deliveries
MMR stands at 1,800 per 100,000 live births,
are conducted by unqualified auxiliary staff.
making Malawi the country with the second
highest MMR in Africa, and the third highest

59
National Statistical Office (2000). Malawi Demographic and Health Survey, 2000. Zomba, Malawi.
60
National Statistical Office (1998). National Housing and Population Census, 1997. Zomba, Malawi.
61
National Statistical Office (2000, 1998, 1977). National Housing and Population Census. Zomba, Malawi.
61
 Malawi

There is a shortage of essential drugs, economic reasons, especially for the poor
supplies, and equipment for life-saving rural majority. Decisions to seek care are
procedures and treatment. Although the often made by family members rather than
country has established a national blood the woman herself. Studies have indicated
transfusion service (MBTS) supported wholly delays in receiving care after reaching a
by the European Union, there is a critical facility due to lack of skilled personnel,
shortage of viable blood donors, due to the equipment and supplies, or poor staff
HIV/AIDS epidemic. Many health facilities do attitudes. It is not unusual for a woman to
not have functional blood banks, yet obstetric wait for 24 hours or more from the time a
hemorrhage is the second largest cause of decision is made to perform an emergency
maternal deaths in the country. In the 2005 caesarean section to the time it is actually
national assessment on emergency obstetric carried out. Studies have also shown that
care, not one of the health centers could be the national public health facility caesarean
classified as a basic emergency obstetric care section rate is 2.8%, which is about half of the
(EmOC) facility as they did not provide the minimum recommended level of 5.0% by UN
requisite six signal functions.62 process indicators.

Good quality of care is also influenced by Unsafe abortion, resulting from an unplanned
the availability and accessibility of essential or unwanted pregnancy is a major contributor
services, which is another problematic gap to the high maternal mortality rate in Malawi,
in Malawis health care delivery system. A accounting for about 25% of the maternal
number of health centers, which function deaths, with the majority taking place
as the entry points for the health system, among adolescents and youths (< 25 years).
are not open and functional 24 hours a day, Adolescents contribute between 2025% of
seven days a week due to staff shortages maternal deaths in Malawi.
and security concerns. In some areas, staff
have no official houses near health facilities. Policies for Safe Motherhood
They must walk long distances, even at
night after their shift ends. Women who go
into labor at night or on weekends/public
holidays may resort to a TBA, travel to
distant health facilities, or wait till the next
S ince independence in 1964, the
government of Malawi has endeavored
to provide free health care services including
maternity care. As with other developing
day. Referral systems and mechanisms are
countries, national health policies and
also not always functional for a number
programs have to a large extent been dictated
of reasons, such as staff attitudes, lack of
or influenced by international declarations
recognition of emergencies, and unavailable
or events. Notable among such international
or poorly maintained vehicles and radio
declarations or events are the International
communication facilities.
Safe Motherhood Conference in Nairobi 1987;
the International Conference on Population
There is significant delay in deciding to seek
and Development (ICPD) in Cairo 1994; The
maternal health care for social, cultural, or

62
Signal functions refer to a set of important emergency obstetric activities that must be available at an EmOC facility. The six
signal functions that are performed at the health center level include: administer parenteral antibiotics; administer parenteral
anticonvulsants; administer parenteral oxytocic drugs; perform manual removal of placenta; perform removal of retained
products; and perform assisted vaginal delivery.
62
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Fourth World Conference on Women (FWCW) to reduce delays by expectant mothers to

in Beijing 1995; and the United Nations reach emergency obstetric care; and
Millennium Summit in New York 2000. to improve the quality of reproductive health
Regional events have also had an influence, care and to reduce the total number of high-
such as the Abuja Declaration on malaria risk pregnancies.
(April 2000), etc. These have contributed to
the development of national policies and/or Between 1996 and 1998 the national safe
programs to address maternal health issues motherhood program supported by WHO
in Malawi. undertook a range of programmatic activities
(see next section). However, with the launch
National Safe of a DFID-supported project in the Southern
Region, the pace of activities increased. In
Motherhood Policy 20042005, when the DFID project ended,

F
there was diminished activity at the national
ollowing the Global Safe Motherhood level, mainly due to a dependence on external
Conference (1987), which brought funds for its operation and implementation.
to the worlds attention the high maternal
mortality in the developing world, the While a national safe motherhood program
government of Malawi responded favorably. was established in 1996, it has not had the
Malawi was represented at the conference desired impact on improving maternal health.
by a government delegation, which upon Although studies and surveys have shown
returning home briefed the government. In increasing maternal deaths and deteriorating
acknowledgement of the high MMR and the quality of health care services, there has been
need to reduce it, the government of Malawi little, if any, government or political response
undertook a series of steps which included and commitment to address them. The
the establishment of a national SM Task objectives and goal of the national program
Force (1993) to guide program development have not changed since 1996, although the
and its implementation; a National Needs target year for reducing maternal mortality
Assessment (1994); and a National Strategic (2000) has passed. According to Ministry of
Plan in 1995. Health officials, safe motherhood is regarded
as a low-to-medium priority health issue
In 1996, a national safe motherhood program nationally. It is reportedly not on the top of
was launched with the goal of reducing MMR the national development agenda.
by 50% over a period of four years (1996
to 2000). It also included a goal to reduce
neonatal mortality by 50% within the
National Reproductive
same period. Health Policy
The program had four key strategies:
to increase public awareness on maternal
mortality issues;
I n 2002, a comprehensive reproductive
health policy was promulgated; the policy
outlined reproductive health as a major
to generate political, government, and donor component of the poverty reduction plan
commitment for resource allocation; (PRSP). Six priority areas were identified:

63
 Malawi

Safe motherhood National Road Map

Adolescent reproductive health


Family planning
Prevention, early detection, and
management of cervical, prostate, and
breast cancers
I n 2004, the MOH developed a national
Road Map for Maternal Mortality
Reduction. This policy document outlines
nine strategies for safe motherhood,
Prevention and management of STIs and
including policy review and development,
HIV/AIDS
program implementation, and monitoring and
Elimination of harmful practices and
evaluation. The Road Map will serve to guide
reduction of domestic violence and infertility.
policymakers; government, international, and
donor representatives; training institutions;
With regard to safe motherhood, the policy
civil society; and the community on safe
states that:
motherhood and maternal health care
Provision of safe motherhood services will
issues. The Road Map has clear targets and
be offered by skilled health workers at all
indicators for monitoring and evaluation,
health facilities.
which are based on the MDGs.
Safe motherhood services will be made
male-friendly.
At the community level, safe motherhood Program Priorities

T
services shall be provided by trained and
supervised TBAs. he following activities have been
Comprehensive essential obstetric care carried out through the national safe
services shall be provided to all motherhood program:
pregnant women. Advocacy for political, government, and
Health facilities providing safe motherhood donor commitment for resource allocation
services shall put in place appropriate and IEC campaigns for the public through
functional transport and communication dramas (on national mothers days, world
systems. health days, etc); jingles; radio messages;
Public, NGO, and private health facilities and posters
shall offer voluntary counseling and testing Training of health care providers
(VCT) to all pregnant women according to Pre-servicepostgraduate nursing for BSc
National AIDS Commissions (NAC) policy. and MSc
HIV-positive mothers shall be counseled In-service for nurses working in maternity
on breastfeeding. areas in health centers and hospitals
Postabortion care services shall be provided including NGO and private facilities on life-
at all approved health facilities. saving skills
All pregnant women shall be screened for Improvement of physical infrastructure
syphilis and treated with involvement of Building new health facilities such as health
their partners.63 centers or maternity wings in existing
hospitals and health centers
Refurbishment of existing maternity units in
existing health facilities
Improvement of the referral system

63
Ministry of Health. Reproductive Health Policy. Lilongwe, Malawi, 2002.
64
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Procurement of motorized ambulances course, which includes emergency obstetric

Procurement and installation of radio anesthesia and resuscitation of the newborn.
communication equipment in health Influencing policies of professional
facilities and ambulances regulating bodies such as the Medical
Telephone networks, including mobile Council and Nurses and Midwives Council.
phones for central hospitals, and land line Nurse Midwives were not previously
phones for district hospitals and some allowed to perform manual removal of
health centers placenta, or give intravenous oxytocics
Development of emergency obstetric case or intravenous anticonvulsants. State
management protocols, for health centers Registered Nurse Midwives are now trained
and for district hospitals, and orientation of and allowed to perform manual vacuum
health care providers on its use aspiration (MVA) for incomplete abortion
National Conference on Safe Motherhood and provide postabortion care.
(2001) Increased public awareness on maternal
Introduction of PMTCT in 31 health facilities health issues, through posters, jingles,
by 2004 dramas, public speeches, etc.
Research on various aspects of maternal Increased availability, and to some extent
health, including use of bicycle ambulances; accessibility and quality, of services
barriers to utilization of maternity services; provided in some health facilities,
perceptions, utilization, and quality of care through building of new health facilities;
in maternity waiting huts; feasibility and refurbishment and renovation of some
acceptability of revolving health funds for dilapidated structures.
emergency medical and obstetric referral Development of other national policies,
Assessments on various issues related to guidelines, etc. to facilitate implementation
maternal health of the SM policy and program, e.g.,
PMTCT, Human Resource Development and
Monitoring and Evaluation Management Policy.

W hile the national safe motherhood

program has not lowered overall
maternal mortality levels in Malawi, it has
With regard to the quality of obstetric care
services, all assessments and research
reports have shown that it remains very
poor. Many facilities lack basic equipment for
achieved some measurable improvements in
quality obstetric care services such as blood
the following key programmatic areas:
transfusion, and there is a critical shortage
Upgrading the training of health care
of health care providers, especially nurse
providers, particularly at the health center
midwives.64 The national EmOC assessment
level. Medical assistants have been trained
(2005) showed that none of the health centers
in maternity care and clinical officers as
could be regarded as a basic EmOC facility as
anesthetists through an upgraded diploma
they did not provide the six signal functions.65

64
Ministry of Health. Report on the National Assessment of EmOC. Lilongwe, Malawi, 2005.; Sangala W.O.O. Human
Resources for Health in MalawiOvercoming the Crisis. Unpublished report. Ministry of Health, Lilongwe, Malawi, 2005;
Ministry of Health. Report on a Quality of Care Assessment. Lilongwe, Malawi, 2004. Maclean G.D. Obstetric Life Saving
Skills in Malawi: An Evaluation. Lilongwe, Malawi: DFID, 2000.
65
Ministry of Health. Report on the National Asessment of EmOC. Lilongwe, Malawi, 2005.
65
 Malawi

Numerous studies have shown that lack of World Bank, and USAID. According to the
appropriate knowledge and skills and poor MOH there has not been an increase in
staff attitudes are some of the contributing donor presence since 1996 when the safe
factors to poor quality of care.66 motherhood program was launched.67

Financial Expenditures for The general consensus is that current

levels of funding for safe motherhood are
Safe Motherhood inadequate, though it is unclear how much

F
more is needed.
ollowing external pressure, the
government of Malawi adopted the Conclusion
SWAp approach in October 2004. While not all
relevant systems and mechanisms necessary
for its operation are complete, it is expected
to be functional by the end of 2005. Donors
will pool their resources in the SWAp basket;
T he national safe motherhood program,
launched in 1996, was a response to
a call by the international community at the
some donors may continue to manage their 1987 global SMI conference held in Nairobi,
funds directly. Both donor and government Kenya, to reduce maternal mortality by half
representatives assert that it is too early to tell by the year 2000. A range of strategies was
what impact SWAp will have on health care proposed and interventions carried out, with
delivery and safe motherhood specifically. It financial support by international agencies
is interesting to note that safe motherhood and donors. In spite of this investment,
does not feature specifically in either the MOH maternal mortality has continued to increase
budget or SWAp. It is therefore impossible and the quality of maternal health care
to identify how much will be used for safe services has deteriorated considerably. These
motherhood activities in Malawi. are partly due to inadequate government
support and commitment, with safe
According to the finance department of the motherhood largely influenced and financed
Ministry of Health, the budget for the health by international agencies and donors.
sector under the SWAp is US$89.9 million
over a period of six years (20042010). The Safe motherhood is not a high-priority
government will contribute 37.0% of the health concern in Malawi, and is not
earmarked budget, while the remainder will visible in the MOH budget or national
be donor funds. The British Government development agenda. Unless there are
appears to be the main contributor to the adequate and appropriate domestic influence,
SWAp, with contributions of 100 million over determination, and development of locally
this period. appropriate programs, supported by
adequate financial resource allocation, safe
The principal external donors include: motherhood will continue to elude most
UNFPA, unicef, WHO, DFID, the EU, the women in Malawi.

66
Ministry of Health. Report on the National Assessment of EmOC. Lilongwe, Malawi, 2005.; Sangala W.O.O. Human
Resources for Health in MalawiOvercoming the Crisis. Unpublished report. Ministry of Health, Lilongwe, Malawi, 2005;
Ministry of Health. Report on a Quality of Care Assessment. Lilongwe, Malawi, 2004. Maclean G.D. Obstetric Life Saving
Skills in Malawi: An Evaluation. Lilongwe, Malawi: DFID, 2000.
67
Namasasu J. Personal Communication. Ministry of HealthReproductive Health Unit. Lilongwe, Malawi. 2005.
66
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Mali A critical shortage of human resources,

particularly of medical practitioners

M ali is a landlocked Sahelian country

located in the heart of West Africa,
with a surface area of 1,241,238 sq km, a
capable of performing cesarean deliveries.
Specialized training is not available
at the local level and fellowships for
training abroad have become increasingly
population of 11.6 million (2005), and an
difficult to obtain. Huge overcrowding of
average population density of 9 inhabitants
educational establishments (e.g., 15,000
per square kilometer. In terms of basic and
students enrolled at a school built initially
economic indicators, Mali ranks near the very
to accommodate 200), coupled with the
bottom among countries worldwide. Mali is
shortage of teachers (instructor/student
the fourth poorest county in the world (after
ratio of 1:80) and the lack of a continuing
Niger, Burkina Faso, and Ethiopia), with 64%
education system, make it impossible to
of the population living in poverty. Food
ensure quality training for students. Medical
absorbs close to 60% of household budgets.68
students today, unlike their predecessors,
no longer learn to perform cesareans, which
Nevertheless, in the past decade the economy
underscores the urgent need to ensure
has improved and notable progress has
proper training.
been achieved, a result of controls on
Poor distribution of human resources,
public spending, sound management of
especially midwives, of whom more than
the devaluation of the CFA franc, and the
60% are concentrated in urban areas. While
implementation of an ambitious policy for
they are plentiful in the nations capital, they
economic and social development. Major
are critically lacking in underserved areas,
programs have been introduced, particularly
such as the northern regions.
in the areas of health, education, rural
Poor quality of services, a result of
development, and agriculture. These sectoral
inadequately trained personnel; high
programs are linked together under the
turnover rates; uncaring provider attitudes;
Strategic Framework for Poverty Reduction
services that are unaffordable for most
(SFPR), adopted in 2002.
Malians; stock shortages of drugs;
irregularity of supervision; unsatisfactory
Maternal mortality levels in Mali have
health facilities at all levels of the health
remained stagnant over the last 15 years: the
system; and deficiencies in health
number of maternal deaths per 100,000 live
recordkeeping.
births was 700 in 1987, 577 in 1996, and 582
in 2001.69 Factors contributing to this slow
progress include:

68
DNSI, 1993.
69
Demographic and Health Survey for Mali I, III, and III.

67
 Mali

Safe Motherhood Policy The Safe Motherhood Conference held

in Nairobi in 1987, which set the goal of

M ali has demonstrated growing

political commitment to reducing
maternal mortality, as evidenced by
reducing maternal mortality, and which
was subsequently reaffirmed at other
international meetings.
The International Conference on Population
its accession to various international
and Development (1994) in Cairo and the
declarations and conventions, including:
Safe Motherhood Technical Consultation
the Bamako Declaration by the First Ladies
(1997) in Colombo, which incorporated a
of West and Central Africa (Vision 2010),
gender and rights lens for addressing
issued in 2001, which calls for a 50%
safe motherhood.
reduction in maternal and neonatal mortality
by the year 2010. In recognition of the
The highest level government authorities
fact that any woman can face risk during
have demonstrated a commitment to safe
pregnancy and childbirth, the Vision 2010
motherhoodin particular the First Lady,
Forum mobilized First Ladies, ministers
who is a trained midwifethrough a number
of health, reproductive health experts,
of advocacy initiatives. These include the
womens associations and groups, NGOs,
designation of a national Safe Motherhood
development partners, and the media to:
Day (June 8); the celebration of National
- ensure political commitment and political
Midwives Day; and the awarding of the
support for the implementation of regional
Tara Bor prize for outstanding efforts to
operational strategies for the reduction of
reduce maternal and neonatal mortality. In
maternal and neonatal mortality.
addition, a number of national entities such
- advocate for pro-womens health policies,
as the Ministry of Health; the Ministry for
particularly the allocation of resources for
the Promotion of Women, Children and the
maternal and newborn health care.
Family; the Ministry of Social Development,
- raise awareness of the magnitude of
Solidarity and Aging; and civil society
maternal and neonatal mortality in West
groups such as the Malian Association for
and Central Africa.
the Protection and Promotion of the Family
- share experiences concerning the
(AMPPF) and Groupe Pivot/Sant Population,
reduction of maternal and neonatal
have also demonstrated strong commitment
mortality in
to maternal health.
the region.
the Millennium Development Goals, which
Malis national health policy is grounded in
aim to reduce current maternal and child
the principles of primary health care, the
mortality rates by 75% by 2015.
Bamako Declaration, and the African Strategy
The Alma-Ata conference in 1978 which
for Health Development.70 The overarching
highlighted the importance of maternal and
goal of the national health policy is the
child health.
achievement of health for all. To attain this
overall objective, the following intermediate
goals have been identified:

70
The African Strategy for Development (1998 2007) aims to help member-states develop comprehensive reproductive
health programs, especially at the district level, in an effort to foster a more coherent approach to program conception and
development
68
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Improve the health status of the Malian 19902002: During this period, a five-year
people to enable them to participate plan (19982002) on reproductive health
more actively in the social and economic was promulgated. The plan included
development of the country. four components, including one on safe
Extend health care coverage and make motherhood, and aimed to improve
health services accessible to the population. health care coverage. With regards to safe
Improve the effectiveness and performance motherhood, the plan sought to expand the
of the health system. referral and evacuation system, with the
Improve general management and perinatal period as the port of entry, and
strengthen institutions. improve the health systems capacity for
Prevent and control diseases and promote managing obstetric emergencies.
reproductive health.
Strengthen and maintain infrastructure For 20052009, the Program for Health and
and equipment. Social Development identifies the following
Strengthen training and research. aims for safe motherhood, with greater
emphasis on addressing poverty:
Malian health policy can be characterized by The reduction of maternal, neonatal, and
three distinct time periods: infant/child mortality through attention to
the problems of acute respiratory infections,
19601979: The health policy during this diarrheal diseases, malaria, malnutrition,
period was guided by the political ideology and communicable diseases such as HIV
of the socialist era, the aim of which was to infection and tuberculosis.
equip the country with a core set of health The reduction of maternal morbidity
institutions. It advocated access to modern and mortality through better maternal,
health care services for all, free of charge. antenatal, and obstetric care, and
The governments policy in maternal and attention to nutritional deficiencies and
child health focused on expanding coverage communicable diseases.
of health services through the development
of rural childbirth centers and the training Programmatic Priorities for
of TBAs.
Safe Motherhood

T
19801990: In the second ten-year health
development plan for the period 19811990, he governments current priorities for
the primary health care strategy focused maternal mortality include:
on the development of rural health care Organization of a referral/evacuation system,
services and deploying village health workers, and establishment of a solidarity fund
particularly public health/first-aid workers and financed by contributions from individual
trained traditional birth attendants. and village members in all district health
facilities and hospitals
Development and implementation of an
emergency obstetric care (EmOC) program
that includes postabortion care

69
 Mali

Follow-through on the recommendations of the system. Over the past 20 years,

and conclusions of the Regional Forum there have been significant shifts in the
on Reduction of Maternal and Neonatal governments programmatic emphasis.
Mortality (Vision 2010) Specific thematic shifts included:
Implementation of a policy providing free The training of TBAs: While in the years
services for women requiring cesarean following 1987 the emphasis was chiefly
delivery in all district and referral health on providing training to TBAs, the current
facilities and all public hospitals emphasis is on the professionalization of
Repositioning of family planning and skilled birth attendants. TBAs serve as a
coverage of unmet family planning needs as link to the formal health system and their
a means of reducing maternal, infant, and role is oriented toward clean delivery,
child mortality recognition of danger signs, and referral
Development of alternative health care of pregnant women with complications to
financing mechanisms (health mutual funds health facilities.
and health insurance schemes) A shift from risk screening to refocused
Development of the human resource system antenatal care as an approach for managing
obstetric complications and birth planning.
The deficiency in the number and quality The latter approach recognizes that
of health and social services personnel has frequent visits do not necessarily improve
been identified as a serious concern for the pregnancy outcomes, and that many women
government. This situation has prompted identified as high-risk do not develop any
the country to formulate a policy aimed complications, whereas those considered
at improving the availability, quality, and low-risk can potentially experience them.
motivation of health personnel through
the planning and management of human Monitoring and Evaluation
resources, formulation of new professional
training programs, revision of the training
curricula, and strengthening the capacity
of schools to train sufficient health care
personnel. Accordingly, schools for the
T he mechanisms for monitoring
and evaluating the national safe
motherhood program include:
Integrated supervision
training of health personnel have been
Quarterly reports from the health
opened in almost every region in Mali, and
information system on maternal and
an Institute for Training in the Health Sciences
neonatal morbidity and mortality data
has also been created. A national continuing
Annual report of the Health and Social
education policy, with norms and standards,
Development Program, which contains
has been disseminated nationwide.
specific reproductive health indicators
Report of the monitoring committee for
As outlined above, current government
Vision 2010
priorities emphasize extending coverage and
The health information system monitoring
enhancing quality of services, developing
software (DESAM)
alternative health care financing systems,
Evaluation of EmOC facilities and the
and training human resources able to help
referral and evacuation system
improve the effectiveness and performance

70
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Audits of maternal deaths and serious cases In 1992, the physician/population ratio
of maternal and neonatal illness and safe was 1:23,154, which is far below the
motherhood assessments recommended standard of one physician
Twice-yearly monitoring meetings at per 10,000 population. For the same period,
community health centers to: the ratio of registered or graduate nurses
- measure progress to population was 1:12,120, which was
- identify operational problems and also less than the recommended standard
their causes of 1 per 5,000. In 2001, the ratios had
- recommend corrective action that can be improved somewhat, particularly in the
carried out with available local resources physician category, approaching the level
recommended by WHO.

Type of Health Care Ratio 1992 Ratio 2001 WHO Recommended

Practitioner Ratio

Physician 23,154 13,478 10,000

Graduate/registered nurse 12,120 10,022 5,000

Registered midwife 24,524 21,329 5,000

Practical/technical nurse 9,020 9,276 1,000

Between 19982004, the antenatal care

rate rose from 48% to 69%, while the rate Funding for Safe Motherhood

T
of skilled attendance during childbirth
increased modestly, from 37% to 40%. A he health budget for the 2005 financial
study conducted in Mali in 1998 indicated year is CFAF 55.7 billion, which is
an unmet obstetric need of 52% (75% in 6.7% of the total national budget. While the
rural areas versus 3% in urban areas). A amount of the national budget allocated to
subsequent analysis carried out in June 2005 health is known, it is difficult to determine
demonstrated that the overall unmet obstetric how much of the health budget is allocated
need remains high (44%), with levels varying for safe motherhood, given the catch-all
from one region to another. nature of the account.

71
 Mali

About 80% of the health budget is devoted The portion of expenditures committed at
to the most vulnerable population groups the central level, out of total expenditures,
women, children, and young people. For has remained relatively stable (52% in 1999
2005, the budget for safe motherhood at the and 49% in 2001), whereas the proportion of
central level is estimated at around CFAF 98.5 expenditures committed at the regional level
million; the budget figures for the regional has declined steadily (21% in 1999 and 15% in
and local levels, which account for a larger 2001). This situation shows that the process
share, remain to be compiled. of decentralization is not being accompanied
by a decentralization in funding.
As the table below outlines, financing for
the health sector has been erratic between With regard to the government budget for
the ten-year period 19952005. While there health, two persistent difficulties exist:
was an increase in the health budget as a The government budget remains insufficient
proportion of the total budget from 19992003 to cover the operating expenses of national
(from 5.3% to 6.8%), the percentage of funds institutions; as a result, they are unable to
allocated to health has declined. function without outside funding.
The proportion allocated to health
within the overall budget in 2005 is only
6.68%, well below the target percentage
established under the Abuja Declaration,
in which the member states of the African
Union agreed to devote 15% of their total
budgets to health.

Health Budget as a Proportion of the National Budget

(in Thousands of CFA Francs)

Year Health Budget Total Budget %

1995 25,683,090 353,960,000 7.26
1996 31,352,837 380,325,000 8.24
1997 28,777,080 400,323,000 7.19
1998 27,065,754 433,712,000 6.24
1999 23,967,365 476,113,000 5.03
2000 34,580,607 522,537,000 6.62
2001 36,943,517 556,881,000 6.63
2002 39,577,529 607,952,155 6.51
2003 51,322,941 754,385,000 6.80
2004 51,834,459 767,110,164 6.76
2005 55,749,686 834,576,138 6.68

72
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

The guidance issued with regard to the In spite of this policy commitment, Mali faces
2006 budget calls for greater emphasis on a number of challenges in reducing maternal
reproductive health and, especially, safe mortality levels; these include the scarcity
motherhood. Accordingly, CFAF 1.64 billion of trained specialists; lack of incentives and
have been mobilized for safe motherhood career plans for health workers; shortages
activities, of which CFAF 840 million are and poor distribution of health personnel,
to cover the cost of providing cesarean particularly midwives; high rates of unmet
deliveries free of charge and CFAF 800 obstetric needs and low rates of skilled
million are for the purchase of medicines, attendance during childbirth; and the threat
notably contraceptives. of HIV/AIDS. In addition to human resource
issues, other factors that have limited
Notable shifts have occurred in donor policies progress on safe motherhood include poor
over the last several years; for example, there quality of services, inadequate budget
is greater emphasis on a program approach levels, and the low level of education of the
involving all donors, rather than on individual population, which contributes to poor use
projects, and increased country ownership of services.
and greater emphasis on national five-year
plans. Some donors, such as the Netherlands The current level of financing for health in
Development Organization, have opted for Mali (in 2005) is well below the Abuja target
sector-wide budgetary support in 2006. Other of 15%. Despite strong political commitment,
partners plan on adopting SWAp in 2007. the level of financing is plagued with poor
management and limited decentralization
of funds.
Conclusion
To achieve its objectives with regard to safe

T he current policy of the Malian

government on reproductive health
and safe motherhood is fully in line with
motherhood, Mali needs to focus on:
Extending health care coverage, with the
creation or strengthening of community
health centers offering the basic package
the Millennium Development Goals and the
of services.
Vision 2010 targets, both of which identify
Increasing the financial resources allocated
maternal and child health as a priority.
to the sector.
Combating the persistence of certain
To translate this priority into action, a number
customs and traditions that are harmful
of initiatives have been undertaken, including
to health.
the designation of 8 June as National
Raising the level of literacy, education, and
Maternal and Neonatal Mortality Reduction
information among the population.
Day, the introduction of a policy providing
Involving communities at the grassroots in
for cesarean delivery free of charge in public
health activities.
health care facilities, and the awarding of
Improving health human resources in both
the Tara Bor prize for outstanding efforts to
number and quality.
reduce maternal and neonatal mortality.

73
 Tanzania at roughly this level since 1992.72 In 2005,

S
only 46% of deliveries were attended by a
ituated on the east coast of Africa, the health professional at a health facility; this
United Republic of Tanzania is bordered is a decline from 53% in 1992. Less than 2%
by Kenya and Uganda on the north; Rwanda, of deliveries were conducted by cesarean
Burundi, and the Democratic Republic of the section in 20042005 as compared to 3% and
Congo on the west; and Zambia, Malawi, 2% in 1999 and 1996 respectively.73
and Mozambique in the south. To the east
lies the Indian Ocean. Population distribution In terms of data on maternal mortality
in Tanzania is extremely uneven. Density and morbidity, the Tanzanian government
varies from 1 person per sq km (3/mi) in estimates that for the period 19952004
arid regions to 51 per sq km (133/mi) in the the maternal mortality ratio was 578; in the
mainlands well-watered highlands. More than preceding ten years, the MMR was recorded
80% of the population is rural, with much of at 529 deaths per 100,000 births.74 Because
the livelihood dependent on agriculture.71 The of the statistically insignificant difference
population is ethnically diverse, consisting of between these figures, it is difficult to
over 120 ethnic groups. conclude whether national maternal mortality
levels have improved or deteriorated in the
Tanzanias population is estimated at 36.1 last 20 years. While there is little data on
million (2004) of whom 51% are female and maternal morbidity in Tanzania, it is estimated
47% are under 15 years of age. With the that between 150,000 to 450,000 women
economy growing in real terms by 6.7% in and girls suffer from pregnancy-related
2004, Tanzania has one of the highest per morbidities annually.75
capita income growth rates in Africa.
Despite the high rates of maternal mortality,
Ministry of Health (MOH) statistics and it is believed that there is significant
national surveys offer some indication of underreporting, with many deaths occurring
the magnitude of womens health problems outside of health facilities. Many of these
in Tanzania. According to DHS (2004) data, unreported deaths are due to unsafe abortion,
25% of all women in Tanzania are currently which are not disclosed for fear of stigma
using a contraceptive method and 17% are and/or prosecution. Reflecting a recent rise
using modern methods. The National AIDS in mortality from anemia, malaria, and HIV/
Control Program estimates the 2003 national AIDS in Tanzania, an increased proportion of
HIV prevalence at 8.8%. Antenatal care maternal deaths (approximately 4050%) are
attendance is high at 94% and has remained due to indirect causes.

71
United Republic of Tanzania/Ministry of Health. National Policy Guidelines for Reproductive and Child Health Services. May
2003.
72
United Republic of Tanzania/ National Bureau of Statistics. Tanzania Demographic and Health Survey, 2004.
(Summary)/1999/1996.
73
United Republic of Tanzania/ National Bureau of Statistics. Tanzania Demographic and Health Survey, 2004. 2004/1999/1996.
As a proportion of all births in a population, C-sections should account for not less than 5% nor more than 15%.
74
Op. cit.
75
Maternal and Neonatal Program Effort Index (MNPI) Tanzania. POLICY Project. Washington DC: 2002.
74
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Factors contributing to the persistently high The First and Second

levels of maternal mortality and
morbidity include:
Five-Year Plans
poor quality and availability of basic and
essential obstetric care, at primary and first
referral level;
insufficient numbers and outdated skills of
T he First Five-Year Plan (19641969)
focused on the achievement of two
major objectives:
self-sufficiency in health personnel
health personnel, due to inadequate basic
requirements and
education, and lack of continuing education
raising life expectancy from 3540 to
and supervision, with particular neglect of
50 years.76
midwifery cadres;
In 1967, the Arusha Declaration for Socialism
poor-quality antenatal care;
and Self Reliance put forward an egalitarian,
cost of health care, as a result of official and
people-centered development philosophy
unofficial charges, and fees for transport
that aimed to rapidly extend primary
and delivery-related supplies; and
health care to all rural areas. Following the
weak referral systems.
promulgation of the Arusha Declaration, the
Second Five-Year Plan (19691974) sought
Indirect factors include the HIV/AIDS epidemic
to expand services with particular emphasis
and the increasing incidence of malaria;
on controlling the spread of contagious
distance to health facilities; the low status of
diseases.77 Emphasis was placed on the
women and lack of decision making power;
provision of preventive services and on the
and the widespread poverty and inequity in
construction of rural health units.
access to health care.

Government Policy for The Third Five-Year Plan

Safe Motherhood

B eginning in the 1960s, the government

pursued people-centered egalitarian
L argely informed by the egalitarian
philosophy of socialism and rural
development, the Third Five-Year Plan
policies which aimed to ensure and expand (19761981), identified the following priority
health services to the majority of the areas for health: environmental sanitation;
population. With regard to safe motherhood, good nutrition; expansion and consolidation
there was no explicit policy prior to 1990; of preventive services; enrollment of all
the governments health and development school-age children in primary school;
objectives were laid out in the countrys five- and construction of rural health centers
year plans, as outlined below. and dispensaries.78 This period marked the
beginning of a multi-sectoral approach in

76
Government of Tanganyika. Tanganyika Five-Year Plan for Economic and Social Development, 1 July 1964 30 June 1969.
Dar es Salaam: Government Printer, 1964.
77
United Republic of Tanzania. Tanzania Second Five-Year Plan for Economic and Social Development, 1 July 1969 30 June
1974. Dar es Salaam: Government Printer, 1969.
78
United Republic of Tanzania. Tanzania Third Five-Year Plan for Economic and Social Development, 1 July 1974 30 June
1979. Dar es Salaam: Government Printer, 1974.

75
 Tanzania

the delivery of primary health care, which recruited and retrained to take up teaching
brings together other areas and actors, positions at the MCH Aide training schools.
including water, education, community Over 3,000 basic MCH kits were in use in all
development, political parties, and civil the clinics in the country. By 1980, on average
society organizations, in an effort to make 93% of the population were living within
use of all available resources. 10 km of a health facility.80

In 1974, the first national maternal health

program was launched. A coordinating team The 1990 National Health Policy
consisting of MOH, UMATI (National Family
Planning Association), and UWT (National
Womens Organization) was appointed to
formulate a maternal and child health policy
and a unit was established in the Ministry
I n 1988, the Ministry of Health appointed
an internal team of experts to prepare
proposals for a comprehensive national
health policy. The team prepared
of Health to plan, organize, coordinate, and
and circulated initial suggestions and
administer its implementation nationwide.
recommendations to other ministries and key
The overall goal of the program was to
players in the health sector for comment. The
reduce the morbidity and mortality of
final proposals were submitted to the Minister
mothers and infant children.
in 1989 and formed the basis of the first
Health Policy81 published in 1990.
The overarching policy objective was to
provide integrated health care services to at
The overall objective of Tanzanias first health
least 90% of the population by 1980 through a
policy was to improve the health and well-
chain of rural dispensaries and health centers.
being of all Tanzanians, with a focus on those
Services at the lowest level were to be
most at risk, and to encourage the health
provided by trained MCH Aidesa new cadre
system to be more to responsive to the needs
of medical personnel79under the direct
of the people.
supervision of medical assistants and rural
medical aides. The MCH Aides would replace
The government states as its first specific
traditional village midwives.
policy objective: to reduce maternal and
infant morbidity and mortality and increase
The program aimed to train 2,500 MCH Aides
life expectancy through the provision of
at the rate of 600 per year. By 1980, MCH Aide
adequate and equitable maternal and child
training schools had been built in each of
health services, promotion of adequate
the countrys 17 regions. Approximately 600
nutrition, control of communicable diseases,
aides had graduated from themfar short of
and treatment of common conditions.
the 2,500 target. About 100 trainers had been

79
MCH Aide training lasted 18 months, and included six months of practice at a recognized health center under the close
supervision of the district MCH coordinator. Beginning in 2000, basic training for the MCH Aide cadre was discontinued, and
the government embarked on upgrading all MCH Aides to Public Health Nurses-B and Clinical Officers through a two-year
in-service training program.
80
United Republic of Tanzania/ Ministry of Health. National Health Policy, February 1990 Dar es Salaam: Government Printer,
1990.
81
Ibid.

76
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Referring specifically to maternal and child While finalized in 1991, the strategy
health, the government directed that such was not published until a year later. Its
services must be provided in all health implementation, however, was inconsistent
facilities throughout the countryas an and uneven, and little or no action was taken
integrated curative and preventive in key areas. Programs were implemented
service which: in a vertical fashion, and there was little
Reduces deaths, diseases, and disabilities coordination among relevant stakeholders.
among women and children and women of For example, no steps were taken to establish
child-bearing age; a multi-sectoral safe motherhood coordinating
Provides comprehensive health education committee, as was called for in the strategy
to mothers; document. As a result, a WHO/UNDP/NORAD
Promotes proper health care to families mission recommended undertaking a rapid
through home visits and health assessment of maternity care in select
education; and districts. The evaluation, which was conducted
Sensitizes mothers, communities, and using the Rapid Evaluation Method developed
leaders at all levels about the importance of by WHO, assessed the quality and availability
childhood immunization and solicits their of maternal health services. The assessment
active support. revealed that quality of care was poor, and
identified gaps in human resources, providers
The National Safe Motherhood knowledge and skills, and equipment and
supplies. In addition, the findings indicated
Policy Document, 1992 and that there was little community involvement
19951999 in maternal health care.83

T anzania was one of the first countries

in sub-Saharan Africa to endorse
and adopt a safe motherhood strategy.
Based on these findings, the strategy was
significantly revised in 1993 to adopt a more
integrated approach to maternal health,
and was reflected in the National Safe
A multisectoral Safe Motherhood Task
Force, consisting of representatives from Motherhood Project Document of 19951999,
government ministries, NGOs, and UN which called for improving maternal health
agencies, was established in 1989 to services and emergency obstetric care, and
undertake a situation analysis and plan for expanding family planning services. The
the launch of the national safe motherhood Safe Motherhood Strategy was consequently
program. Following its establishment, a superseded by a comprehensive strategy on
national workshop was held in 1990, followed reproductive health (see next section).
by a meeting of parliamentarians and other
lawmakers in 1991, in an effort to raise
awareness of and mobilize support for safe
motherhood. These activities helped to raise
the profile of safe motherhood at the national
level and resulted in increased discussion and
public attention to these issues.82
82
Report on Status of the Safe Motherhood Strategy in Tanzania, prepared by Ann Starrs, Family Care International, 1992.
83
United Republic of Tanzania, Ministry of Health, 1994. The Safe Motherhood Project Document 1995-97, Dar es Salaam.
77
 Tanzania

Strategy for Reproductive Health experiences and lessons learned from the
implementation of the previous versions. The
and Child Survival (19972001) vision of the Strategy is to foster a healthy

F
and well-informed Tanzanian population
ollowing the International Conference with access to quality reproductive and child
on Population and Development in health services that are accessible, affordable,
Cairo in 1994, the government developed sustainable, and which are provided through
a comprehensive strategy for reproductive an efficient and effective support system.
and child health. This broader strategy, Maternal health is identified as a key priority,
titled The Strategy for Reproductive Health and includes the following areas of action:
and Child Survival 19972001, aimed to focused antenatal care, skilled care during
improve the health of women, children, and childbirth, care for obstetric emergencies,
adolescents. With regard to maternal health postpartum care, postabortion care, family
care, the Strategy aimed to reduce maternal planning, and prevention of harmful practices
mortality by 50% by the year 2001 through (e.g., female genital mutilation).84
the following strategies:
improving the nutritional and socioeconomic The Strategy also puts forward a framework
status of women; for research and monitoring and evaluation
strengthening postabortion and in an effort to better assess service
antenatal care; utilization patterns and monitor progress on
reviving postnatal care; implementation of interventions.
increase human resource capacity for
managing maternal care; Health Sector Reform
strengthening management of obstetrical and Decentralization
problems in health facilities; and
enhancing efficiency of the referral system.

The Strategy was developed in the context

of health sector reform (see next section),
I n 1996, the government instituted a
process of health sector reform which
included the decentralization of health care,
and provided a framework for district level cost-sharing, and other modifications in the
planning. While no formal evaluation of the delivery of health services. The planning,
Strategy has been undertaken, anecdotal monitoring, and management of health
evidence indicates that little progress has services is devolved to district health
been made toward stated indicators. management teams, as part of a strategy
to provide greater autonomy in identifying
and prioritizing the health needs of the
Reproductive and Child Health districts. The government continues to guide
Strategy (20052010) policy formulation and regulation, while

A
the private sector plays a more prominent
follow-up strategy document, role in the provision of health services. As
Reproductive and Child Health Strategy part of this effort, cost-sharing of health
20052010, was developed based on the services are decentralized to health centers
and dispensaries, and communities assume

84
United Republic of Tanzania, Ministry of Health. Reproductive and Child Health Strategy 20052010 (Draft), 2005.
78
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

responsibility for the financing of health chaired by the Ministry of Health, Presidents
services through a range of mechanisms, Office, Regional Administration and Local
such as community health funds. Government, and the Ministry of Finance,
approves funding for each council on the
As part of the health sector reform process, basis of a consolidated Council Health Plan
in June 1998 the government of Tanzania and recommendations made by MOH, and
and the donor community agreed to pursue a releases funds quarterly, in line with existing
SWAp to improve and increase government government procedures and based on
ownership of the health care delivery system, performance reports and recommendations
and to improve aid coordination. Donors from both the Ministries of Health and
have shifted from project-based development Finance. The District Council therefore is
assistance to basket or pooled funding of the accounting office for all local and donor
a specific sector. Eight donors (the Danish resources going into primary health care,
International Development Agency (DANIDA), including safe motherhood.
DFID, GTZ/KfW, Irish Aid, Netherlands,
Norwegian Agency for Development Both government and donor representatives
Cooperation (NORAD), Swedish International interviewed for this report concurred that
Development Cooperation, and the World basket funding has succeeded in minimizing
Bank) established a Health Sector Basket off-budget financing and improved
Fund (HSBF) through which they would coordination of the flow of donor resources
deposit funds into a US$ holding account at into safe motherhood and other primary
the Bank of Tanzania. In 2005, while many health care services.87 A recent increase
donors continue sector-based support, some in earmarked funding for specific health
have shifted to general-budget support.85 areas (e.g., HIV/AIDS, malaria, and TB) has,
however, weakened joint planning processes,
The decentralization of health care delivery as these tend to operate in parallel
has altered the delivery system for safe project mode.
motherhood and maternal and child health
care.86 Each of the 113 district councils is Funding for Health
required to prepare an annual health plan
for recurrent and development expenditure.
Since 2004, this process is part of an overall
Council Development Plan and council-
specific Medium-Term Expenditure
T he Tanzanian budgetary allocation
system consists of five broad sector
categories: Administration, Defense, Social
Sectors, Productive Sectors, and Economic
Framework. A Basket Fund Committee,
Infrastructure. Health falls under the Social

85
General-budget support is an approach in which allocation of donor finances to different sectors is left to the government
to determine according to nationally defined priorities. Sector-budget support, on the other hand, is an arrangement under
which a donor prefers to support a specific sector, regardless of sector priorities as defined in the national development plan.
86
Semali, Innocent A.J., Understanding Stakeholders Roles in Health Sector Reform Process in Tanzania: The Case of
Decentralizing the Immunization Program, PhD Thesis. University of Basel, Switzerland, 2003.
87
Off-budget financing of development projects is discouraged because it is influenced by donor preferences and introduces
distortions in the national development investment plan and in reporting on external development financing. The preferred
option is general-budget support under which all donor resources are channeled through the Treasury, which then allocates
them centrally to different projects according to nationally defined priorities.

79
 Tanzania

Sectors category, along with education and budget supported by a health insurance
water. Approximately 10% of the recurrent scheme and two cost-sharing funds
budget is allocated to health (see table below). established between 20022003.

Percentage Share of Health Budget in Recurrent and

Development Expenditures, 20032004 to 20062007

Ceiling Projection Projection Projection

2003/04 2004/05 2005/06 2006/07
Administration 27.3 34.9 35.2 35.0
Defense 18.1 15.9 15.8 15.8
Social Sectors
Education 22.3 20.5 20.6 20.6
Health 10.8 9.7 9.6 9.6
Water 1.5 1.5 1.5 1.5
Other Social 0.6 0.6 0.6 0.6
Subtotal Social Sectors 35.2 32.3 32.3 32.3
Economic Infrastructure
Roads 7.7 6.7 6.7 6.8
Others 3.7 3.1 3.1 3.1
Subtotal Economic Infra 11.4 9.8 9.8 9.9
Productive 7.5 6.8 6.6 6.6
Grand Total 100 100 100 100
Source: United Republic of Tanzania/Task Team Ministry of Health: Health Sector Public Expenditure
Source: United
Review (per) Republic of Year
Update Fiscal Tanzania/Task Team May
2004: Final Report, Ministry
2004 of Health: Health Sector Public Expenditure Review
(PER) Update Fiscal Year 2004: Final Report, May 2004.

The four sources of funds for government As stated previously, the HSBF was
expenditure on health include: established in 1998 as part of the Health
domestic revenue; Sector Reform process, and is managed by a
foreign loans and grants; National Basket Financing Committee hosted
private cost sharing through the Health by the Ministry of Health, the Ministry of
Service Fund and Community Health Service Finance, and the Presidents Office, Regional
Fund; and Administration and Local Government. While
The National Health Insurance Fund (NHIF). basket funds initially supported the recurrent
budget, they have begun in 20012002 to
Beginning in 19992000, more than 50% of support the development budget as well.88
the health budget is financed by donor funds, Basket funding has increased steadily from
largely through the HSBF, described above. 1.0% of total health funds in 19992000 to just
Central government tax revenues finance over 15% in 20042005 as shown on
between 4346%, with the remainder of the the next page.

88
The recurrent budget finances salaries and operational costs (such as drugs, fuel, etc.); the development budget funds
capital works and purchases of a capital nature, such as new construction and repairs and the purchase of motor vehicles,
machines, and equipment.
80
 National Programs, Policies,
and Budgetary Commitments for Safe Motherhood

Sources of Health Expenditure by Percentage

1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005

(Estimated)

Government Funds 50.9 45.7 44.4 43.0 46.5 48.4 41.1

NHIF 0.0 0.0 0.0 2.5 2.7 3.4 2.2

Cost Sharing 0.9 1.1 1.0 0.6 0.7 2.4 1.7

Total Local Funds 51.8 46.9 45.5 46.0 50.0 54.2 45.0

Donor Basket Funds 0.0 1.0 5.9 11.8 15.1 8.0 15.2

Donor non-Basket* 13.7 7.0 7.0 6.4 10.1 11.1 10.3

Donor Others** 34.5 45.2 41.6 35.8 24.8 26.7 29.5

Total Foreign Funds 48.2 53.1 54.5 54.0 50.0 45.8 55.0

Total Health Funds 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Source: United Republic of Tanzania/Task Team Ministry of Health: Health Sector Public Expenditure
Source: United
Review Republic
(per) Update of Tanzania/Task
Fiscal Year 2004: Final Report,Team Ministry
May 2004 of Health.
and for Fiscal Health
year 2005, OctoberSector
2005. Public Expenditure Review (PER)
Update Fiscal Year 2004: Final Report, May 2004 and for Fiscal year 2005, October, 2005.

*Donor non-Basket are members of the Health Sector Basket Fund who finance activities/projects without passing
through the basket.
**Donor Others are donors who are not members of the Health Sector Basket Fund.

The Budget for Safe Motherhood Under the circumstances, budgetary

allocation for reproductive and child health

T he government budget allocation for

safe motherhood is not easily isolated
as government records categorize it together
serves as the best proxy for government
expenditure to safe motherhood. As the table
below outlines, while there was an increase
by 40% in the MOH budget between 2001
with the other components of reproductive
2002 and 20022003, there was a drop in the
and child health. Further complicating matters
percentage of funds allocated to RCH/SM
is that funding for safe motherhood cannot
(from 5.9% to 3.7%). The subsequent year
be isolated from broad budget categories,
saw an absolute reduction in funds for RCH/
such as human resources, equipment, drugs,
SM, from Shs. 3.2 billion to Shs. 2.2 billion,
transport, and communication. In addition,
although the total MOH budget remained
with primary health care devolved to local
steady. In 20042005, there was a large
authorities, funding is also decentralized
increase in the MOH budget for health, with
and consequently more difficult to isolate. A
a proportionate rise in the amount of funds
review of Public Expenditure Review reports
allocated to RCH/SM.
produced every year provided important
general budgetary information relating to the
health sector but no specific data on the safe
motherhood component.

81
 Tanzania

Ministry of Health Budgetary Allocations to RCHS/SM (TShs. million)

Year 19992000 20002001 20012002 20022003 20032004 20042005

MOH 39,200 49,390 61,600 86,380 86,380 104,081

Budget

RCHS/SM 3,655.8 3,199.8 2,170.0 8,081.3

Percentage 0 0 5.9% 3.7% 2.5% 7.7%

of MOH
Budget
Allocated to
RCHS/SM

Source: Planning
Source: Planning and Privatizations
and and and
Privatizations Ministry of Finance.
Ministry Guidelines
of Finance. for the Preparation
Guidelines of Medium of
for the Preparation Term
Medium Term
Plan and
Plan andBudget
Budget Framework
Framework for for
2004/05-2006/07
2004/052006/07

Conclusion Tanzanias funding base depends in large

part on external donor support and in the last

S ince the 1960s, Tanzania has

demonstrated strong and consistent
policy commitment to ensuring health
five years, dependency on donor funds to
finance health has increased. Most bilateral
and some multilateral donors have shifted
their assistance from project-specific funding
services for its citizens, particularly in rural
to a central basket that is used by the MOH
and other underserved areas. As part of
for central and district-level health activities.
this commitment, Tanzania was the first
While government budget allocations to
African country in the 1990s to issue a safe
health increased by 9% over the period
motherhood strategy as part of its national
19992002, they remain below the target of
health policy. Following the ICPD in 1994,
15%. The shift to basket funding has resulted
Tanzania developed a comprehensive
in an overall improved coordination of funds;
reproductive health strategy that included
however, more needs to be done to ensure
safe motherhood as a key priority area. While
that funding for NGOs is maintained and that
there has been strong policy support for safe
the government can respond to emergency
motherhood, program implementation has
needs in the health sector. It remains to
been weak and inconsistent. Policies have
be determined whether basket funding
not been been adequately funded to produce
ultimately increases available resources for
measurable impact or reach all districts. This
safe motherhood.
has hampered a sustained decline in maternal
mortality levels.

82
VIII Conclusion

S ince the launch of the global Safe

Motherhood Initiative in 1987, the
landscape for safe motherhood has changed
functioning referral system to ensure timely
access to appropriate care. The challenge
remains to develop and evaluate effective
dramatically. The last two decades have strategies through which this approach can
witnessed improvements in maternal health be implemented in low-resource settings.
indicators, e.g., the proportion of births
attended by a skilled birth attendant, and At the national level, as illustrated by the
several middle-income developing countries case studies presented in this report, there
(e.g., Honduras, Bolivia, Egypt) have has been increasing political commitment for
dramatically reduced their maternal mortality safe motherhood through the promulgation
levels. As one of the essential components of national policies; these however, have
of a comprehensive reproductive health not always been supported by adequate
framework, safe motherhood is central in the programs and financing. The case study
fight to reduce poverty and advance on Lao PDR, for example, highlights how a
human development. range of specific policies and objectives to
promote safe motherhood were developed
Since 1987, safe motherhood has achieved at the national level, but did not receive
widespread attention and prominence adequate support for full-scale, nationwide
in international agreements. The call for implementation. In many of the case
a reduction in maternal mortality has studies, the level of funding allocated to safe
reverberated in all the major international motherhood is impossible to discern, thus
conferences in the 1990s; most recently in making it difficult to assess whether funding
the Millennium Development Goals, it was is sufficient to meet stated policy goals. Not
defined as essential for poverty reduction only is safe motherhood absorbed within
and development. Yet it is also recognized broader categories such as reproductive
that maternal health has not achieved its due health and population, making it difficult to
place in the global health agenda. isolate, but recent trends in selected countries
toward decentralization and basket funding
Over the past 18 years, the knowledge have further complicated the challenge of
base for safe motherhood is more clearly identifying the amount of funding dedicated
articulated and understood. The technical for maternal health. Finally, many general
interventions for preventing and/or treating budget categories, such as commodities and
the vast majority of obstetric complications personnel, include expenditures relevant to
are known, and have been identified as maternal health.
simple and cost-effective. There is broad
agreement that good-quality maternal Over the last few years, a notable shift has
health services need to include skilled care reframed maternal health from a disease-
for both routine and complicated cases, specific approach focusing on quick fix
including emergency obstetric services interventions to improving the broader
for life-threatening complications, and a health system through which maternity

83
 care is provided. The 2005 report of the UN mortality being as high as one in eight in
Millennium Project Task Force on Child Health some places. With the increasing focus
and Maternal Health calls for strengthening on the MDGs, there is an extraordinary
the health system, particularly at the district opportunity for accelerating progress and
level, in an effort to achieve dramatic and expanding efforts to improve maternal health
sustainable progress in maternal health. A worldwide. Governments are being called on
well-functioning health system can ensure to clarify their policies, develop practical and
the equitable and efficient delivery of safe achievable plans, and identify the resources
motherhood information and services to needed to achieve these goals. Civil society
the entire population, reaching them at organizations can make a critical contribution
home, in the community, and within health to this process, in part by monitoring and
facilities at both primary and referral levels. evaluating the implementation of government
Programmatically, this implies implementing programs (recommendations 2 and 3 of the
multiple, mutually supportive strategies UN Millennium Project, UNDP 2005).
that affect systems (e.g., human resources,
education and training, supplies and logistics, The goal of improving maternal health by
transportation, and communication, etc.) with 2015 will not be met unless dramatic action is
the aim of improving the use and availability taken. In discussions with a range of national
of high-quality maternal health services. Both decision makers and colleague agencies, the
the supply side (e.g., availability of drugs, following recommendations were
supplies, and equipment; adequately trained put forward:
personnel) and the demand side (community
behaviors and practices regarding care- The most critical requirement for realizing
seeking during pregnancy and childbirth) of MDG and ICPD goals in maternal health is
the equation need to be addressed. for donors and governments to increase
their financial commitment to maternal
As the findings highlighted in this report health specifically, and to the health sector
illustrate, financial trends have improved more generally. Several representatives also
overall for safe motherhood since the launch reiterated the importance of ensuring that
of the global Initiative. But it appears that these funds are used efficiently:

they are not adequate to meet international
goals for improving maternal health.
We need to make sure funds are being
Responding to the Challenge used in the best manner, and we are using

D espite the strides made in maternal

health, women in the developing

opportunities as they arise. How come we
do not see PEPFAR89 as an opportunity for
womens health? We need to change our
attitude to funding, and the environment
world are still at extremely high risk of dying
of doing business.
or being injured from pregnancy-related
causes, with the lifetime risk of maternal

89
PEPFAR is President George W. Bushs Emergency Plan for AIDS Relief, a U.S. five-year $15 billion global initiative enacted in
2003 to combat the HIV/AIDS epidemic.
84
 Conclusion

Increased funds need to be invested in Finally, health and gender equity need to
strengthening the existing health system. be addressed within overall development
Donors need to broaden their funding strategies and those specifically for maternal
scope, and move from a disease-based health. Long-neglected issues within safe
approach to one focused on making motherhood, such as unsafe abortion and
systemic improvements in the delivery of the needs of pregnant adolescents (married
services. For maternal health in particular, as well as unmarried), should be dealt with
the continuum of care at the health system in a scientific and nonbiased manner.
needs to be addressed, from the community
level to referral care available at the facility.

In maternal health we cannot get
away with a health facility that is not

functioning optimally, as may be the case
for other diseases. For maternal health
everything has to be connected and well
tied together, or else it will result in higher
mortality and higher morbidity

Greater advocacy is needed for safe

motherhood at the global and national
levels. What has been missing from
previous advocacy campaigns is a single,
unified message supported by the safe
motherhood community globally. Safe
motherhood advocates have tended to
lobby for individual or separate components
(e.g., emergency obstetric care, skilled care
during childbirth), rather than for maternal
health as a whole.

There needs to be better understanding

of the various financing mechanisms in
development. National funding strategies
either have already adopted or are in the
process of adopting a basket approach,
in the form of SWAps, PRSPs, or other
financing mechanisms. Only through
engagement with finance and economics
experts will safe motherhood be ensured a
piece of the funding pie.

85
 List of Abbreviations
AIDS Acquired Immunodeficiency Syndrome
BDD Bidan di Desa (Program in Indonesia)
CHIPs Country Health Information Profiles
EmOC Emergency Obstetric Care
ENDESA National Survey on Demographics and Health
EPMM Post-Census Survey on Maternal Mortality (Bolivia)
FWCW Fourth World Conference on Women
GDP Gross Domestic Product
HDI Human Development Index
HIV Human Immunodeficiency Virus
HSBF Health Sector Basket Fund
ICPD International Conference on Population and Development
IEC Information/Education/Communication
IHHS Indonesian Household Survey
IMR Infant Mortality Rate
LAM Local Area Monitoring
MCH Maternal and Child Health
MDG Millennium Development Goal
MMR Maternal Mortality Ratio
MOH Ministry of Health
MVA Manual Vacuum Aspiration
NGO Nongovernmental Organization
NPDP National Population and Development Policy
ODA Official Development Assistance
PER Public Expenditure Review
PMTCT Prevention of Mother-To-Child Transmission
PRSP Poverty Reduction Strategy Paper
PSA Public Service Announcement
RTI Reproductive Tract Infection
SFPR Strategic Framework for Poverty Reduction
SSN Social Safety Net
STI Sexually Transmitted Infection
SWAp Sector-Wide Approach
TBA Traditional Birth Attendant
VCT Voluntary Counseling and Testing

86
Agencies and Organizations
ACCESS Access to clinical and community maternal, neonatal, and womens health
services (USAIDs global program to improve maternal and newborn health)
ACNM American College of Nurse-Midwives
AMDD Averting Maternal Death and Disability
AMPPF Malian Association for the Protection and Promotion of the Family
DANIDA Danish International Development Agency
DFID Department for International Development
FCI Family Care International
FHI Family Health International
FIGO International Federation of Obstetrics and Gynecology
IAG Safe Motherhood Inter-Agency Group
IDB Inter-American Development Bank
IMMPACT Initiative for Maternal Mortality Programme Assessment
IPPF International Planned Parenthood Federation
MPS Making Pregnancy Safer
NAC National AIDS Commission
NHIF National Health Insurance Fund
NIDI Netherlands Interdisciplinary Demographic Institute
NORAD Norwegian Agency for Development Cooperation
PAHO Pan American Health Organizatoin
PCI Population Communications International
PMM Prevention of Maternal Mortality Network
PMNCH Partnership for Maternal, Newborn, and Child Health
PROCOSI Collaborative Program for Integrated Health
PROISS Integrated Project of Healthcare Services funded by IDB
SIDA Swedish International Development Cooperation Agency
SMI Safe Motherhood Initiative
UMATI National Family Planning Association, Tanzania
USAID United States Agency for International Development
UNAIDS Joint UN Programme on HIV/AIDS
UNDP United Nations Development Programme
UNGASS UN General Assembly Special Session on Children
unicef United Nations Childrens Fund
WHO World Health Organization

87
 Annex I: Development and donor agencies participating in in-depth interviews
Academy for Educational Development
Alan Guttmacher Institute
American College of Nurse Midwives
The Bill & Melinda Gates Foundation
Care International (USA)
Department for International Development (DFID), UK
Department for Development Aid Cooperation, Finland
EngenderHealth
Family Health International
Global Health Council
International Planned Parenthood Federation
Ipas
International Rescue Committee
IntraHealth International
MacArthur Foundation
Pathfinder International
Population Reference Bureau
Program for Appropriate Technologies in Health
Save the Children Federation
Swedish International Development Cooperation Agency (Sida)
United Nations Population Fund (UNFPA)
United States Agency for International Development (USAID)
Womens Commission for Refugee Women and Children
World Bank
World Health Organization

88
 Annexes

Annex II: History of The Safe Motherhood Initiative

I. Launch of the SMI (19871996)

Major Activities/Publications Area of Emphasis/Action

International SM Conference (Nairobi, Gathered 130 participants to draw attention

1987); conference report to maternal mortality and to mobilize action
at the international and national levels

Regional Workshops (19891994): To mobilize and inform government and

- Andean region, 1993 (Bolivia, Colombia, NGO leaders around the issue of maternal
Ecuador, Peru; held in Bolivia) death and disability
- Central America, 1992 (Belize, Costa Rica,
Cuba, Dominican Republic, El Salvador,
Guatemala, Honduras, Nicaragua,
Panama; held in Guatemala)
- Francophone Africa, 1989 (22 sub-
Saharan francophone countries;
held in Niger)
- Arab states, 1988 (13 Arab states;
held in Jordan)
- South Asia, 1990 (Bangladesh, Bhutan,
India, Maldives, Myanmar, Nepal,
Pakistan, Sri Lanka; held in Pakistan)
- Southern Africa, 1990 (Angola, Botswana,
Lesotho, Malawi, Mozambique, Namibia,
Swaziland, Tanzania, Zambia, Zimbabwe;
held in Zimbabwe)

National Workshops (19891993): Brazil, To mobilize and inform government and

Cameroon, Ethiopia, Egypt, Indonesia, NGO leaders around the issue of maternal
Mexico, Morocco, Namibia, Niger, Nigeria, death and disability
Philippines, Sudan, Tanzania, Uganda

NGO Bellagio Conference (1989) Brought together worlds largest

international NGOs involved in health/family
planning to mobilize commitment to SM

89
 Major Activities/Publications Area of Emphasis/Action

Information Tools & Resources: To provide information resources on safe

- SM: the NGO Challenge (1989) motherhood
- Challenge for the Nineties: Safe
Motherhood in South Asia (1990, full and
summary versions)
- The Challenge of Survival: Safe
Motherhood in the SADCC Region (1991)
- SM brochure (1992, 1994) in English,
Spanish, French, Arabic
- Global Fact Sheet (1992)
- Regional Fact Sheets (1990, 1994
South Asia, West Africa, Southern and
Lusophone Africa, Mexico and
Andean region)
- Mexico & Andean SM conference
declaration and report (1994)
- Report of the Central America SM
conference (1994, Spanish)
- Safe Motherhood Action Kit (1994) in
English, Arabic
- Safe Motherhood in Latin America and
Caribbean (1994) monograph
- Videos of the SM Regional Workshops:
SADCC (1991) and South Asia (1990)
- Vital Allies: Making Motherhood Safe for
the Worlds Women video (1992, long and
summary versions)

Meeting of Partners for SM Review progress of the SMI at the local,

(Washington DC, 1992); background national, and international levels; discuss
document; conference report (full and priorities; and generate support for field-level
summary versions) programs. Shift from advocacy to design and
implementation of community-level programs

Program Guidelines Workshop Gathered international experts to work

(Washington DC, 1992); toward development of SM program
conference report guidelines for World Bank staff and others

Issues in Essential Obstetric Care Technical Held to clarify the definition of EmOC, bridge
Meeting (New York, 1995); the gap between research and program
conference report planning, and stimulate field-level activity

90
 Annexes

II. The Tenth Anniversary (19971998)

Major Activities/Publications Area of Emphasis/Action

SM Technical Consultation (Colombo, 1997) Brought together over 200 specialists,

program planners, and decision makers
to share experiences, review needs and
priorities, and identify cost-effective
strategies for SM; development of ten SM
Action Messages

World Health Day (Washington DC and Issued a Call to Action to urge developing
countries all over the world, 1998) country policymakers to make SM a policy
and programmatic priority and to ensure that
SM receives continued, sustained
financial support

Corporate Council Aimed to raise awareness about the

SMI among global corporations, and to
encourage their support of SM

Information Tools and Resources A set of materials designed to be useful,

- SM brochure enduring, and targeted to different audiences
- Fact sheets
- Pocket card
- The SM Action Agenda: Priorities for the
Next Decade
- National press kits
- SM Presentation Package
- Public Service Announcements
- Technical Consultation video
- SM Experiences video
- SM Web site
- International Commitments to Safe
Motherhood

Media campaign:
- media training for potential SM
spokespeople; SM speakers bureau
- creation of journalist circle
- journalist press kit

91
 III. Information Clearinghouse (19872004)

Major Activities/Publications Area of Emphasis/Action

Development of new resources: Annotated bibliography of SM publications

SM Resource Guide (July 2000) and other resources, structured along the ten
Action Messages

Dissemination of SM information and Respond to individual requests for

materials information and materials; distribute
materials at relevant conferences
and meetings

SM Partners listserve (launched 2000) Improve communication and collaboration

among a range of organizations

IV. Skilled Care During Childbirth (19992000)

Major Activities/Publications Area of Emphasis/Action

Preparation of a review of the evidence A review of the evidence on the impact of

paper skilled care during childbirth in reducing
maternal mortality

Technical Consultation (Geneva, April 2000) Gathered leading experts to assess the
evidence on skilled care, and to develop key
strategies for implementing the intervention
in a range of developing country settings

International Conference (Tunisia, Facilitated the development of national-

November 2000) level action plans on skilled care in selected
countries in sub-Saharan Africa and
South Asia
A set of materials on skilled care: Resources for program planners and
- policy booklet managers interested in developing or
- briefing cards modifying programs/projects on skilled care
- country case studies
- Tunisia conference report

92
 Annexes

V. Address Unsafe Abortion (20032005)

Major Activities/Publications Area of Emphasis/Action

Regional conference (Kuala Lumpur, Brought together delegations from 11

Malaysia, SeptemberOctober 2003) countries and internationally recognized
experts to highlight unsafe abortion as a major
Conference report contributor of maternal deaths and to situate it
within the safe motherhood framework

93
 Annex III: Ten Action Messages for SM
During the tenth anniversary of the Safe 6. Ensure Skilled Attendance at Delivery
Motherhood Initiative, a series of action 7. Improve Access to Quality Reproductive
messages were articulated that summarized Health Services
key programmatic priorities from the 8. Prevent Unwanted Pregnancy and Address
Initiatives first decade. The messages Unsafe Abortion
highlight the most critical interventions for 9. Measure Progress
reducing maternal mortality and morbidity, 10.The Power of Partnership
and the range of barriers (economic, legal,
social, and cultural) that women face in
accessing high-quality maternal health care.
These messages have been widely adopted
by national and international partners,
and are echoed in a range of publications
produced by the Inter-Agency Group
members and other partner agencies.

Each of the action messages is solidly

grounded in research and country-level
experiencesthe first three messages
are directed at changing the political
environment to support womens health and
empowerment; the remaining seven action
messages relate to health services
and education.

The action messages are described in detail

in the following two pages:
1. Advance Safe Motherhood Through
Human Rights
2. Empower Women, Ensure Choices
3. Safe Motherhood Is a Vital Economic and
Social Investment
4. Delay Marriage and First Birth
5. Every Pregnancy Faces Risks

94
 Annexes

1. Advance Safe Motherhood Through 4. Delay Marriage and First Birth

Human Rights Pregnancy and childbearing during
Preventing maternal death and illness is adolescence can carry considerable risks.
an issue of social justice and womens To delay first births, reproductive health
human rights. Making motherhood safer information and services for married
requires womens human rights to be and unmarried adolescents need to be
guaranteed and respected. These include legally available, widely accessible, and
their rights to good-quality services and based on a true understanding of young
information during and after pregnancy peoples lives. Community education must
and childbirth; their right to make their encourage families and individuals to delay
own decisions about their health freely, marriage and first births until women are
without coercion or violence, and with full physically, emotionally, and economically
information; and the removal of barriers prepared to become mothers.
legal, political, and healththat contribute
to maternal mortality. 5. Every Pregnancy Faces Risks
During pregnancy, any woman can develop
2. Empower Women, Ensure Choices serious, life-threatening complications that
Maternal deaths are rooted in womens require medical care. Because there is no
powerlessness and their unequal access reliable way to predict which women will
to employment, finances, education, basic develop these complications, it is essential
health care, and other resources. These that all pregnant women have access to
realities set the stage for poor maternal high-quality obstetric care throughout their
health even before a woman becomes pregnancies, but especially during and
pregnant, and can worsen her health immediately after childbirth when most
when pregnancy and childbearing begin. emergency complications arise. Antenatal
Legal reform and community mobilization care programs should not spend scarce
are essential for empowering women to resources on screening mechanisms
understand and articulate their health that attempt to predict a womans risk of
needs, and seek services with confidence developing complications.
and without delay.
6. Ensure Skilled Attendance at Delivery
3. Safe Motherhood Is a Vital Economic and The single most critical intervention for
Social Investment safe motherhood is to ensure that a health
All national development plans and policies worker with midwifery skills is present at
should include safe motherhood programs, every birth, and transportation to a health
in recognition of the enormous cost of a facility is available in case of an emergency.
womans death and disability to health A sufficient number of health workers must
systems, the labor force, communities and be trained and provided with essential
families. Additional resources should be supplies and equipment, especially in poor
allocated for safe motherhood, and should and rural communities.
be invested in the most cost-effective
interventions (in developing countries,
basic maternal and newborn care can cost
as little as US$3 per person, per year).
95
 Annexes

7. Improve Access to Quality Reproductive 9. Measure Progress

Health Services Governments around the world have
A large number of women in developing pledged to reduce maternal mortality
countries do not have access to maternal by 50%. However, maternal mortality is
health services. Many of them cannot difficult to measure, due to problems with
get to, or afford, high-quality care. identification, classification, and reporting.
Cultural customs and beliefs can also Therefore, safe motherhood partners have
prevent women from understanding developed alternative means for measuring
the importance of health services, and the impact and effectiveness of programs;
from seeking them. In addition to legal for example, by recording the proportion of
reform and efforts to build support within births attended by a skilled health provider.
communities, health systems must work to These indicators can identify weaknesses
address a range of clinical, interpersonal, and suggest programmatic priorities
and logistical problems that affect the so that maternal deaths can be better
quality, sensitivity, and accessibility of the prevented in the future.
services they provide.
10. The Power of Partnership
8. Prevent Unwanted Pregnancy and Address Reducing maternal mortality requires
Unsafe Abortion sustained, long-term commitment
Each year, an estimated 75 million and the inputs of a range of partners.
unwanted pregnancies occur around the Governments, nongovernmental
world. Many women without access to organizations (including womens
safe services for termination of pregnancy groups and family planning agencies),
resort to unsafe abortionwhich often international assistance agencies, donors,
results in death or disability. Unsafe and others should share their diverse
abortion is the most neglectedand most strengths and work together to promote
easily preventable cause of maternal safe motherhood within countries
death. These deaths can be significantly and communities and across national
reduced by ensuring that safe motherhood borders. Programs should be developed,
programs include client-centered family evaluated, and improved with the
planning services to prevent unwanted involvement of clients, health providers,
pregnancy, contraceptive counseling and community leaders. National plans
for women who have had an induced and policies should put maternal health
abortion, the use of appropriate into its broad social and economic
technologies for women who experience context, and incorporate all groups and
abortion complications, and, where sectors that can support
not against the law, safe services for safe motherhood.
pregnancy termination.

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