The Impact of the Safe Motherhood Initiative from 1987 to 2000

In 1987, the World Health Organization, or WHO, took action to improve the quality of maternal health around the world through the declaration of the Safe Motherhood Initiative, or the SMI, at an international conference concerning maternal mortality in Nairobi, Kenya. Initially, the SMI aimed to reduce the prevalence of maternal mortality around the world, as over 500,000 women died during pregnancy and childbirth annually at the time of its inception, while about 98 percent of those deaths occurred in low-income countries. While WHO led the initiative, many organizations in various countries participated in additional programs in order to implement the goals of the SMI. WHO developed the SMI in order to reduce the prevalence of maternal death, developing one of the first proposals that brought attention to maternal health on a global basis at a time when global maternal mortality was high.

Halfdan Mahler served as the Director-General of WHO during the establishment of the SMI. In 1948, Mahler earned his medical degree from the University of Copenhagen in Copenhagen, Denmark, and joined WHO in 1951. After two decades of work with WHO, Mahler was appointed to be the organization’s Director-General in 1973. He focused on strengthening people’s access to basic healthcare necessities around the world. According to WHO’s biography on Mahler, he was interested in bettering maternal health around the world, especially in low-income, developing countries. For instance, Mahler supported WHO policies encouraging new mothers to breastfeed, which public health officials presented was beneficial for infant development. Mahler served as Director-General for fifteen years until 1988, at which point he continued to support maternal health-related causes such as reproductive rights and family planning. Mahler later served as director of the International Planned Parenthood Federation, which is an organization concerned with improving reproductive healthcare.

Shifts in social movements and policies during the 1970s and 1980s influenced the establishment of the SMI, which occurred in 1987. In response to the rising feminist movement, the United Nations named 1975 as the International Women’s Year. Then, between 1976 and 1985, the United Nations established a movement called Decade for Women, which brought attention to women’s health around the world, aiming for a significant reduction in maternal mortality by the year 2000. Prior to that movement, data concerning women’s health, including maternal mortality rates, were scarcely recorded around the world, and women often did not participate in decision-making processes concerning public health policies. Also, WHO’s Alma-Ata Declaration of 1978, which the organization declared at the International Conference on Primary Health Care in Alma-Ata, Kazakhstan, later called Almaty, identified that healthcare was a right for all people. The Alma-Ata Declaration encouraged researchers to place more focus on how they can use access to healthcare to reduce the prevalence of maternal mortality around the world. However, barriers to implementing the Alma-Ata Declaration in low and middle-income countries specifically, such as lack of trained health workers and poor sanitation, demonstrated that providing access to healthcare for all women would be a difficult task.

The Safe Motherhood Initiative focused its efforts on people living in low and middle-income countries. According to the World Bank, income classification is measured based on gross national income per person, also known as GNI per capita. As of 1 July 2018, low-income countries are those that have a GNI per capita of 995 US dollars or less, while lower-middle income countries are those with a GNI per capita between 996 and 3,895 US dollars.

In 1985, researchers Deborah Maine and Allan Rosenfield called attention to maternal and child health issues in their article, “Maternal Mortality – A Neglected Tragedy. Where is the M in MCH?” in which MCH stood for maternal child health. According to Maine and Rosenfield, over 500,000 women died during pregnancy and childbirth annually, and 99 percent of those deaths occurred in low-income countries. The authors further stated that women died during pregnancy and childbirth due to various reasons such as poor socioeconomic status, high-risk pregnancy, and life-threatening complications. According to a WHO employee, Carla AbouZahr, Maine and Rosenfield effectively provided some of the first statistics that explained there was a disproportionate amount of time and resources being spent on childhood healthcare over maternal healthcare.

Following the publication of Maine and Rosenfield’s article, AbouZahr stated that WHO became increasingly concerned with the growing neglect of maternal health around the world and launched the SMI with the intention of decreasing the prevalence of maternal mortality. Then, in 1987, alongside WHO, the United Nations Population Fund and the World Bank sponsored an international conference on maternal health in Nairobi, Kenya, calling it the first international Safe Motherhood Conference. That conference resulted in the formal establishment of the SMI.

Through its increased exposure to issues related to maternal health, the SMI influenced connections at the government level. At a 1997 meeting in Colombo, Sri Lanka, coordinated by the SMI, maternal health specialists sought to place an emphasis on what specific interventions were necessary to improve maternal health around the world. Some of those interventions included employing an adequate number of training health workers, supplying necessary drugs and medical equipment for pregnancy and childbirth, and encouraging new governmental policies to support maternal health.

According to AbouZahr, WHO determined the cost of maternal health-related interventions at the community level in various low-income countries as part of the SMI. WHO began by determining what the current maternal health-related expenditures in various low-income countries were during the time. For example, during the 1980s, in Sri Lanka, maternal health-related expenditures accounted for 12 percent of total health expenditures in the country. Next, WHO determined the cost of implementing new interventions that it thought to better maternal health in low-income countries. Lastly, officials at WHO separated those costs by the type of intervention, such as vaccinations or medications, and service location, such as hospital or health center. At the community-level, according to AbouZahr, many health systems do not allocate their funding efficiently in order to assist maternal health-related issues. AbouZahr indicates that although many maternal health-related interventions are expensive, a simple reallocation of funding may help increase women’s access to such interventions.

Although the initial goals of the SMI were centered around decreasing maternal mortality rates, in the 1990s, maternal health specialists from various organizations worked to expand the goals of the SMI to include treating and preventing human immunodeficiency virus, or HIV, and providing safe abortion care. For example, since 1987, the International Confederation of Midwives held workshops to train other midwives on specific matters of childbirth. In the 1990s, they focused some of those workshops on how to handle HIV-related pregnancy complications. Also, the International Confederation of Midwives additionally held workshops to train midwives how to execute safe abortion practices. Access to safe abortion care was a controversial topic of discussion within societies around the world. According to AbouZahr, although many women’s rights activists argued that access to safe abortion care was fundamental for improving maternal health around the world, many donors of the SMI were hesitant to show support for abortion-related healthcare measures. Also, governments around the world were reluctant to approve policies regarding access to safe abortion care, which according to AbouZahr, impeded the goal of the SMI to better maternal health.

By 2000, the SMI further expanded its focus to include the effects of poverty, gender, education, water, and sanitation on maternal health. In 2000, increasing access to maternal health measures was included as a part of the Millennium Development Goals, which is a set of goals that the United Nations set to help reduce poverty and encourage global development. According to women’s health project coordinator Kayla McGowan, in low and middle-income countries, poverty, gender, education, water, and sanitation largely affect maternal health. For example, in sub-Saharan Africa, WHO found that women have a 1 in 38 probability of dying during pregnancy due to a lack of quality healthcare. Possible improvements included factors such as more well-rounded education of healthcare workers and better access to sterile medical equipment. Although the prevalence of maternal mortality around the world had decreased by 37 percent, by 2015, a majority of maternal-related deaths were caused by preventable causes. As a result, the United Nations included maternal health in its 2016 Sustainable Development Goals, which was a continuation of and expansion upon the Millennium Development Goals.

According to Maine and Rosenfield, the SMI impacted the ways in which specialists approach maternal health-related issues around the world, but the authors critiqued the initiative for not placing a large enough emphasis on community-based solutions. They noted their critiques in their 1999 publication, “The Safe Motherhood Initiative: Why Has It Stalled?” Specifically, Maine and Rosenfield point toward a lack of communication between macro-level policy-making and micro-level community needs. Also, AbouZahr critiqued the initiative for not prioritizing funding for maternal health-related issues. Maine and Rosenfield state that a reallocation of resources and funding is essential to bettering maternal health around the world.