Matters of life and death
The neat statistical exercises of agencies such as the World Health Organisation (WHO) and the World Bank are clearly inadequate to capture the predicaments of Shyam Bahadur Tamang, of Rayale VDC (Village Development Committee), Kavre district, Nepal. A mechanic by trade, 48 years of age, he earns NPR 14,000 per month from his Kathmandu workshop. According to the World Bank, a person who earns one US dollar a day is above the poverty line. And according to the WHO, the average household size in rural Nepal is 5.57. Given that he spends six days of the week in Kathmandu and one day in Rayale, it is not really apparent whether Shyam Bahadur is rural or urban. Presuming him to be the former (since his family is in the village), the per capita daily income of his household should work out to USD 1.06 dollars, which, by World Bank standards, should deliver his family above the poverty line.
The only problem is that contrary to the WHO's estimate of the average family size, Shyam Bahadur's household actually numbers 20 and its total monthly cash income is NPR 17,000, which works out to a per capita daily earning of USD 0.36, leaving it well short of clearing the World Bank's poverty line. The WHO's 'complete' rural nuclear family simply does not exist in the case of this single household, which consists of two adjacent houses in which four generations live. At 48, Shyam Bahadur has a family of two parents and a paternal aunt in their mid-60s, a wife, four sons, two of whom, between them, have six children, and three other granddaughters, whose mother is the only missing member of the family.
Four months ago, and 14 years after the global Safe Motherhood Initiative commenced, Shyam Bahadur's daughter, Sheela, gave birth to a fourth daughter at her parents' house. What happened thereafter is not very certain since there are no hospital records to corroborate the household's account. According to the family, she began bleeding profusely after delivery and in due course both mother and infant passed away, within hours of each other. Since there is neither doctor nor hospital in the immediate vicinity, and since in any case the family did not have much money to spare, a 'quack', the customary low-cost community solution of long standing, was called in. He administered some medicines for a nominal fee. She died a little over 24 hours after delivery. The daughter followed a few hours later. Sheela's husband left for India soon after and has since not been heard of.
Across Nepal, women die of complications related to pregnancy. The maternal mortality rate is one of the highest in the world, and no single anecdote will be adequate to explain the extent of the continuing tragedy, which encapsulates within it not only the obvious inadequacies of government but also the failure of development agencies and financial institutions which continue to talk about the problem without bearing any of the burden.
The preventable death of a dispensable village woman in a country with 'too many people' and an average fertility rate of 4.3 does not provoke existential angst on a world scale. However, since the International Safe Motherhood Initiative was launched in 1987, after a conference at Nairobi convened by several multilateral institutions, the aggregation of all such deaths into a sterile statistic has inspired the ceaseless chatter of money-lending dignitaries and their well-heeled factotums in the development enterprise. But it is more than just the slender thread of recurrent bureaucratic platitudes about safe motherhood that connects the humdrum life of Rayale with the glitzy institutions of humanitarian assistance. After all, Rayale is only 23 kilometres from Kathmandu, where the foot soldiers of alpha male development go about on four wheels, tending to their personal comforts and their professional ambitions, implementing, on the side, sustainable projects, only a minute fraction of which has any demonstrable merit
One such project had an immediate bearing on Sheela's demise in Rayale. Recently, a toilet project was initiated in some villages, no doubt after a needs-based assessment was carried out in conformity with donor guidelines. The net result was that, whether or not the felt need for a toilet could be reconciled with financial capacity, without compromising other necessary expenditures and liquidity for emergencies, toilets were constructed for those who could prove the ability to repay a soft loan advanced by the project authorities. Soon toilets began to acquire a certain appeal as a status symbol in surrounding villages, where the majority of the households are hard put to consume two meals of disputable nutritional quality per diem. To compound matters, the architects of the toilet project omitted to supply running water so that household water requirements increased dramatically, necessitating an increase in the number of trips and people required to fetch water from the source.
This ill-conceived scheme became a model for private emulation and many in Rayale succumbed to the pressures of sanitary consumerism, as relieving oneself in the open became a sign of social inferiority. Eight months ago, Shyam Bahadur built two toilets for his household through a private contractor at a cost of NPR 60,000. The repayment and servicing of the debt placed an inordinate strain on the household budget and reduced the intake of food. Sheela, arriving at her parents' home after the toilets were built, began fetching water for the household, making several trips a day to the water source, half a kilometre from the house. The return journey involved two steep uphill climbs. This carried on until very late into her pregnancy. Poor nutrition and the constant ferrying of water took its toll. The toilet evidently contributed to her undoing, but the sanitation project will not figure in the WHO's catalogue of indirect causes of obstetric complications.
Sheela is fictitious but represents the reality of tens of thousands of women who will die or have died this year in Nepal due to childbearing related complications. Sheela's story is a composite, placed in a real village in a real district of Nepal. In her non-existence, she represents the many women who have already died in the first quarter of 2003 and will die in the three quarters remaining.
Building toilets need not necessarily cause maternal deaths. There are many thousand women with and without toilets who die of obstetric complications. The point is that ill-formulated vertical delivery schemes, which address only a partial component of the total survival needs of poor families and not the general environment, can lead to cross-project anomalies, accentuating existing complications. The current consensus on development, despite all the talk of 'integrated' models, favours such fragmented, often incompatible, vertical delivery mechanisms in scattered locations.
Motherhood in distress
In the age of global solutions to every conceivable issue, proliferating projects and their layers of contracted intermediaries constitute the permanent chain of command between the rural problem and the cosmopolitan trouble-shooter. There are a great many shortsighted suppositions, agendas, institutions, commissioning agents, contractors, consultants and vested interests standing between the expecting mother and safe motherhood. Given this distance between the problem and its solvers, there will be no change at least in the South Asian incidence of mothers dying in and around childbirth so long as the current project-based regime of safe motherhood and reproductive health initiatives remains in force.
The history of this and related initiatives is instructive. The last decade and a half has witnessed an irruption of global summits to end this or that poverty-related malady by some specified year. The global initiative on safe motherhood, with the objective of halving maternal mortality by the year 2000, is now 15 years old. Not only has the objective not been met; worse still, there is no evidence of any progress, particularly in South Asia, a region which has attracted a great many funded projects and expert groups.
In recognition of this comprehensive failure, yet another summit, the Millennium Summit of September 2000, was convened. The target was revised and a new timeframe set. With mechanical resolve the summit pledged to repeat the mistakes of the past. For some unexplained reason, the luminaries who decided the fate of many million women resolved, in the year 2000, to reduce maternal mortality by 75 percent between 1990 and 2015. In 15 years they were going to do almost 50 percent more than what could not be done in 13 years. And this is to be accomplished by persisting with the same slipshod methods responsible for that spectacular failure. Little wonder then that the figures show little sign of improvement since the commitment was renewed two years ago.
Dereliction on a world scale
This premeditated choice of seemingly self-defeating techniques is not necessarily as curious as it might appear to those who are not acquainted with the mala fides of what passes for the philosophy of development. The ideology and the institutions that legitimate and perpetuate these techniques have become autonomous and obdurate facts of the development matrix. That itself is a sufficient incentive for such choices. But in this instance, there is more to it than just a market-friendly international bureaucracy's overriding interest in maintaining itself on other people's debts. There are other sectarian agendas too, masquerading as altruism and gender sensitivity, which intersect in fundamental ways to produce a self-serving narrative of the problem and its solution.
To begin with, issue-based summits cannot produce a realistic assessment of the problems they pretend to address. The consensus that emerges from each summit represents a compromise that sidesteps some of the circumstances precipitating the problem in the first instance. The World Bank, which has presided over some of the most ferocious public policy atrocities in the developing world, is a prominent party to such resolutions and is scarcely likely to concur with any analysis that exposes its culpability. The political economy of health and health care, the most crucial determinant of health profiles in the underdeveloped world, is therefore politely omitted from discussion as a matter of propriety and protocol. Such decisive acts of omission are not the only factors that militate against any concrete outcome.
Accompanying these are the many other interest-driven acts of commission that result in bland summit resolutions. The Safe Motherhood Initiative included among its sponsors more than one organisation of dubious repute, at least one explicitly representing what may be termed patriotic interests, all too often by hawking the welfare of domestic private corporate sector. Among the enthusiastic signatories to the initiative were the Population Council (New York), the United Nations Population Fund (UNFPA), the International Planned Parenthood Association and the United States Agency for International Development, whose stated aim is "to advance US political and economic interests overseas through development assistance". Safe motherhood was obviously in very interested hands.
These organisations seemed to be less anxious about promoting safe motherhood and more concerned with finding new avenues for advancing pet theorems about the ostensible link between underdevelopment and high population growth. As a result, population control objectives gradually inserted themselves into the safe motherhood agenda. Many maternal health projects directly funded by these agencies were more specifically directed towards family planning advocacy and contraceptive awareness activities than in saving women at risk from pregnancy-related death. This descent into fertility management, to the detriment of maternity risk reduction, was not surprising. The disaggregated regime of vertically delivered health service, promoted by the World Bank and other lending and aid agencies, effectively precludes comprehensive health care, but that does not prevent it from adopting "holistic" and "integrated" methods, baptised in unnamed "synergies" of various kinds.
The initiative took the form of "inter-sectoral participation", involving supposedly 'proximate' agencies like UNFPA, whose "core competence" is not the safety of pregnant women but the promotion of birth control programmes. Recourse to the eccentric theory of avoided pregnancy as a technique of making motherhood safe is conspicuous in the project literature on maternal mortality. The logical absurdity of a safe motherhood in which safety is achieved only at the expense of motherhood seems to have escaped the project-keepers' notice. Fertility regulation has thus come to acquire a prominent place in safe motherhood through the efforts of partner agencies preoccupied with the potential implications of relative demographics on the balance of power between various categories of people.
Unite and rule
This family planning tendency inside the motherhood initiative assumed a much more insidious institutional form with the convening of the 1994 United Nations International Conference on Population and Development in Cairo. This conference officially reaffirmed the importance of population policy and politics for multilateral institutions. The controversial Programme of Action (POA) emerging from this summit laid out the guidelines for population and development programmes over the next 20 years.
The 16-chapter document that came out of the Cairo summit spelt out in detail its analysis of population and development and its recommendations for critical interventions in the areas of girls' education, maternal and child health, economic development and poverty alleviation. This, on the face of it, is what should be expected from a population conference, and indeed there seem to be remarkable similarities in the broad objectives between the agendas of safe motherhood and population and development. To all outward appearances, there are only a few modulated differences of emphasis on some of the aspects common to both goals. For the rest, all the references to women's empowerment seem to be no more than the routine gender-sensitive curlicues that decorate late capitalist development literature.
These appearances, however, are deceptive. The POA, which the institutions of contraception now call the Cairo Consensus, lays out the fundamentals of a "sound" population policy, and stresses the importance of the "right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, and to have the information and means to do so". It also argues that good schooling and health care provides girls and young women with the knowledge and the means to delay pregnancy and time their childbearing as they wish. It dwells on the theme of women's "empowerment" through expanded access to primary and reproductive health care and its positive impact on the family. And then it declares that provision of reproductive health services should be the focus of population initiatives. A chapter in the POA devoted to reproductive health, defines it as including prenatal care, delivery services, family planning and treatment of reproductive tract infections and sexually transmitted diseases.
The transition is so surreptitious as to go practically unnoticed. Until Cairo, family planning, dressed up as avoided, delayed and spaced pregnancy, was conceptually just one component of safe motherhood. By the time the Cairo Consensus was forged, safe motherhood became a mere subset of population initiatives, whose focus by definition is reproductive health which "includes prenatal care and delivery services". Given the experience with avoided pregnancy, it is not entirely far-fetched to assume that prenatal care and delivery services could be namesakes for contraceptive propagation and abortion facilities respectively.
The old bogey of population control has evidently reinvented itself in a compassionate guise and now there are two parallel international initiatives to "empower" women to deal with "childbirth": in addition to the Safe Motherhood Initiative, there was a surge in reproductive health initiatives. Since each is a component of the other and a common set of institutions is active in both, the distinction between the two has become increasingly blurred. Further, there is not much evidence that the numerous projects coming out of each of these two initiatives are working in any coordinated fashion. Consequently, the impression that there are a great many programmes working specifically to reduce maternal deaths may actually be misleading.
It is not surprising that while nobody is able to indicate the level of progress in reducing maternal mortality, the Population Council could in 1991 report that an estimated 412 million births had been averted in the developing world through organised family planning programmes. Since the physical verification of an averted birth is impossible (for reasons of propriety), these figures need to be treated with caution and perhaps even scepticism. Nonetheless, it seems that 'reproductive health' interventions are better-organised and more generalised than safe motherhood programmes. It is also useful to remember, in the context of women's empowerment, that the Population Council is the chief patron of Norplant, the contraceptive that frees women from male decision-making but promptly places them under the control of physicians, for both implant and removal. Norplant is being promoted in several reproductive rights programmes, particularly in Bangladesh, despite the fact that a class action suit had been filed in the US for side effects.
The annexation of motherhood issues by the population control establishment has many adverse consequences. This is not just a random instance of distorted priorities. There is a systematic connection between averted birth and averted health care through the concentration of resources on the former at the cost of the latter. The Cairo Consensus, which is engrossed with third world population to the exclusion of development and resource redistribution, will eventually fail, despite the expenditure of several billion dollars that could have been diverted into reducing mortality among pregnant women. In fact, the World Bank never tires of repeating that a low-cost strategy designed to prevent maternal and infant deaths and disability in low-income countries due to complications of pregnancy and childbirth, costs no more than USD 3 a year per capita.
This diversion of resources into extravagant hobbies is consistent with the historical trends in developing countries. The population control ideology, with an arresting history of paranoia about group encirclement and extinction, arising from the differential fertility as between the global North and South, has had an array of powerful backers and interesting partners. As a result, it managed to find a market for its doomsday prediction in poor countries across the world, notably India where the Family Planning and Welfare programme developed into the single largest 'health' institution in the country, consuming more than half the plan resources for the health sector. Since birth-related risks in poor countries often arise out of factors that precede pregnancy, continuity in access to and use of general health care facilities has a principal role in averting maternal deaths.
Yet, as experience from across the developing world suggests, to the extent that there were functioning health systems they became disproportionately oriented towards providing family planning services, leaving them inadequately equipped to deal with other problems. In the circumstances, the UNFPA's advice on ensuring safe motherhood does not inspire much confidence. According to the Report on UNFPA Support for Maternal Mortality Prevention, "Programmes to reduce maternal morbidity and mortality should include information and reproductive health services, including family-planning services. In order to reduce high-risk pregnancies, maternal health, and safe motherhood programmes should include counselling and family planning information". We are back where we began, from maternal mortality to fertility management.
Data, definition, delivery
The entry of incidental agendas into the effort to save dying mothers is not the sole problem with the global maternal mortality campaign. The identified solutions to the problem of maternal mortality clearly legitimised and even encouraged such incursions. This is itself symptomatic of larger institutional failures. The World Health Organisation, as the only 'technical' multilateral partner in the collaboration, was clearly not up to the task of restraining the role of special interests by formulating policies that did not easily lend themselves to being hijacked for other ends.
In an age overwhelmingly geared to the welfare of large capital and financial interests, the WHO, increasingly the instrument of the medical industry and various cash-rich development oligarchies, endorsed a plan of action that sidestepped many fundamental issues by reducing the problem to a set of static factors suited for permanent international interventions. In effect, the philosophy of the solution, for various disagreeable reasons, seems to be intentionally geared to yield the most marginal improvement in the problem. This suited many intermediaries who stood to gain from such an approach. Unquestionably, the monster bureaucracies of development, proficient in the art of paradox management, had taken over. By the rules of this perpetual-motion machine, to evade redundancy a campaign should not succeed and to avoid closure it must not fail. The outcome is achieved by implementing projects that succeed individually but fail collectively, without making any dent on the problem in the aggregate. Consistent with this approach, the global initiative to reduce maternal mortality includes some features integral to a comprehensive solution which have only a partial impact in selective strategies, as well as elements which are altogether superfluous, simply because the agencies dealing with them cannot ab initio rectify the situation.
This is evident from three interrelated dimensions of the intervention, involving data, definition and delivery. According to routinely quoted statistics, one woman in the world dies every minute of pregnancy-related complications. This adds up to over half a million deaths annually. Half of these are in South Asia, where, barring Sri Lanka, only 20 percent of the births are attended by qualified personnel and even fewer take place in hospitals. Given the low use of medical institutions, indirect methods are employed to estimate the rate of mortality. This accounts for the huge discrepancy between government figures and the data furnished by international bodies. Even in Sri Lanka, where the use of institutional facilities for child delivery is high, the WHO figure for the ratio of deaths per 100,000 live births is six times the government's reckoning.
Given the low use of medical institutions, indirect methods are employed to estimate the rate of mortality. The lack of data obstructs the precise verification of both the total annual mortality figures and the proportion of deaths attributable to different causes. According to some studies indirect methods of estimation can overstate the problem by as much as 30 to 40 percent. At the same time, many quantitative studies have argued that the number of deaths is persistently understated. The result is that there is no accurate depiction of the problem.
While the absence of precise data does not reduce the urgency of dealing with a problem, it has serious consequences for vertical programmes with specified targets, since the efficacy of intervention is entirely dependent on a reliable representation of the magnitude of the problem and the intra-country variations in incidence. In the absence of such information there can be no scientific basis for arriving at decisions on where to locate programmes and how to identify the requirements for remedial action. Nor will it be possible to verify the adequacy of the given global definition of the problem for local requirements. Finally, and perhaps most conveniently, there is no way of evaluating the success or failure of the intervention.
There was obviously good reason why, after 10 years of 'effort', all that the Safe Motherhood Initiative could say in its 'Report on the Safe Motherhood Technical Consultation' (produced after a 1997 meeting in Sri Lanka), was that the programme "has accomplished a great deal in its first decade — though much remains to be done", a sentiment that is echoed in every report on maternal mortality in the last five years. A report that sets out the priorities for the next 10 years had no figures to give either about the progress that had been made or the data that had been collected by the various projects.
Given this situation, it obviously makes more sense to move away from such intensive campaigns that perforce have to pick their way through the muddle. The large amount of international aid being pumped into project-based solutions could more usefully have been invested in setting up at least a few well-equipped permanent health care centres with trained personnel to provide comprehensive care. This would not only have the advantage of offering care on a continuous basis, but also monitoring epidemiological trends in their respective command areas, thereby routinising primary data collecting. But that would have benefited too many people in an age and a process that believes in profiting as few as possible. Besides, it would have entailed a departure from the entrenched philosophy of identifying solution-oriented problems.
Since the remedy is the same for all maladies, the problem of maternal mortality had to be defined to suit the solution. Following the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems, a maternal death is defined as "the death of a woman while pregnant or within 42 days of termination of the pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes". While problems have been encountered in the application of this definition, the issue at hand is quite different. In the absence of reliable data, the identification of "causes related to or aggravated by pregnancy and its management" is a serious obstacle. More specifically, calculating the rates of prevalence of these different causes is almost impossible for different local contexts. In this sense, the only criterion that distinguishes a maternal death from any other kind of mortality, especially also reproductive-age mortality, is the fact of pregnancy and not the exact reason for the death.
Despite these constraints, the global Safe Motherhood Initiative, which functions like an emergency campaign, relies on a simplified catalogue of causes. Consequently, by this definition, there are direct and indirect obstetric causes of which the former is responsible for 80 percent of all maternal deaths. Of the direct obstetric causes, haemorrhage accounts for 25 percent of mortality, sepsis 15 percent, unsafe abortion 13 percent, hypertensive disorders of pregnancy and eclampsia 12 percent and obstructed labour 8 percent, while other direct causes like ectopic pregnancy, embolism, and anaesthetic-complications are responsible for 8 percent of the deaths. Indirect causes arising from aggravation by diseases such as malaria, anaemia, jaundice, tuberculosis or heart problems during the course of a pregnancy or delivery are said to account for 20 percent of the deaths.
These figures are based on disaggregated studies in many parts of the world and tend to vary over time and across documents. It is also argued that these obstetric complications are not predictable or preventable but treatable. Since, the purpose of the argument is to advocate increased availability and use of Emergency Obstetric Services (EmOC), this objective could have been stated plainly – such services are absolutely essential, irrespective of the numbers involved or the probability of complication. But doing that would also mean acknowledging that some fundamental factors antecedent to and accompanying pregnancy that conduce such obstetric complications are being ignored completely.
An instance of this is anaemia, which, officially, is responsible only for a portion of the 20 percent deaths that occur due to indirect causes. Literature on projects delivering nutritional supplements invariably highlight the fact that as much as 80 percent of pregnant women are anaemic, and that this anaemia, far from being episodic, is a life-long condition, and therefore has cumulative effects. But in safe motherhood literature where so much of the enthusiasm is reserved for EmOC, there are only passing references to it, typically tucked away in some obscure corner. So, nutritional anaemia becomes just one of the many factors connected with 20 percent of all maternal deaths arising from obstetric causes. For the rest, it makes an appearance in annexure and footnotes that are reserved for all the 'soft agendas', where there usually are lengthy paragraphs on the need for advocacy and awareness campaigns to end nutritional discrimination and poverty. This advocacy includes lobbying with client governments of the World Bank to ensure that poor people get more food to eat. The lack of awareness is very serious indeed.
Missing
What is excluded from the effective operational scope of the safe motherhood campaign is indicative of the limitations of such interventions. In the case of fly-by-night biomedical projects, there is a long list of critical causes which are unfailingly acknowledged, and then programmatically ignored. These include the lifelong health status of girls and women, ie anaemia, malaria, violence, micronutrient deficiencies, insufficient food, excess work, lack of education, poverty, and, in many cases, inadequate contraceptive and reproductive choice. Thus, according to one WHO South East Asia Region Health Forum document, authored by an Indian physician, "…of all the variables which influence maternal health, poverty of a nation or a family is the most important and the most difficult to tackle". Having recognised this indisputable fact, he goes on to argue that in India, the "… time has come when every maternal death should be legally investigated like a dowry death and provision should be made for punishing those who either neglect or prevent a pregnant woman from getting adequate and timely medical help". Technocrats, fixated on tidy solutions, are prone to forget the fundamentals.
How can the social bases of maternal mortality to be tackled by the kind of approach that has been adopted? According to one estimate, over 15 percent of maternal deaths in some areas are caused by violence, the estimate for Maharashtra (India) being 16 percent. It is not clear how any preventive action, which can only be long-term and state-dependent, against domestic violence can be undertaken by fragmented and circumscribed 'medical' initiatives. And what funder-sponsored action can be taken against organised violence? The death of pregnant women in Afghanistan due to complications caused by wounds from daisy-cutters cannot be pre-empted by allocating a budget for educating the Pentagon in gender-mainstreamed precision bombing. Nor can the allocation of funds for an awareness campaign neutralise systematic family violence against women, inflicted physically, physiologically, educationally and financially. It is clear that in a great many of the safe motherhood programmes designed to show quick, short-term results to donors, allusion to the social and cultural causes of death is not just the poignant poetry of resignation; it is as much an anticipatory confession of inevitable failure.
This inevitability is an outcome of the inherent limitations of the delivery mechanism adopted to reach specified targets. As a result of these shortcomings, within programmes to ensure safe motherhood the distribution of prevalent causes was designed to make the problem amenable to a purely medical solution. The infirmity of the vertical delivery programme is that it is forced invariably to adopt a biomedical perspective on health problems that are inextricably connected to the political economy and to the principles on which social life organises itself under conditions of a relentless and unequally distributed scarcity. The description of the general institutional, economic and social environment of maternal mortality and morbidity in South Asia is adequate proof that any attempt to deal with just the medical face of the problem will fail to rectify the condition.
Moreover, this failure will incur very high costs in terms of wasted direct expenditure because even the medicalised solution that is being implemented is too narrow in its scope to take into account a range of other equally medical variables. Thus, while a global pattern of prevalence of causes has been widely circulated, by the WHO's own admission there could in "some aspects" be significant deviations from the statistical template. Citing studies from Nepal and India, it concedes that given the high levels of prevalence of communicable diseases such as malaria in South Asia, and the greater susceptibility of pregnant women to infections, infectious and parasitic diseases may contribute more to maternal mortality in the region than is the case globally.
WHO estimates also suggest that infectious and parasitic diseases as well as chronic or degenerative conditions feature as prominently in the region's morbidity patterns as they do in the distributed mortality figures. In countries such as India, disease control programmes, such as the anti-malaria programme, which too operated on the vertical delivery principle, have been in limbo since the early 1990s following the cutbacks in public expenditure enforced under the regime of structural adjustment and fiscal prudence on the orders of the World Bank. In such circumstances, given the likelihood of some of these diseases continuing into pregnancy, genuine safe motherhood programmes require to have at least a therapeutic component for women in the reproductive age category, rather than deal with just EmOC cases of obstetric emergencies due to malarial and other aggravations in the advanced stage of pregnancy. And to compound matters, the pattern of morbidity in urban areas of South Asia differs from the pattern in rural areas.
Even from a strictly medical point of view, a single-issue safe motherhood campaign cannot undertake to provide the comprehensive facilities that are required by the commitment to maternal care. If it did, it would have to reinvent itself as both a primary health centre and a multi-speciality hospital. Hence, it has to ensure that its intervention in maternal care stops at the prevention of mortality and steers clear of maternal morbidity.
The lopsided concentration on immediate causes to the exclusion of their primary and underlying determinants is just one of the many problems with such theme specific programmes. The long history of such interventions in India has attracted strong censure, primarily because of their tendency to slice up the epidemiological environment into proprietary turfs. In addition, they are susceptible to greater control by their financiers, which accounts for the ease with which they can be shut down at short notice if the situation demands it. But most of all they have a tendency to colonise existing facilities, infrastructure and personnel for their own ends, instead of expanding physical capacity at the project level. In the case, of internationally inspired projects, implementation can take various forms, though there is a tendency towards operational integration with existing single-issue institutions run either by multilateral institutions or by international NGOs.
To cite one example, there are reports from across the developing world that point to the fate that befell primary health centres, of being overloaded with family planning commitments. Besides diverting the energies of nurses and other personnel into a non-medical 'facility', they have been used for implementing forced sterilisation policies (famously in India's state emergency of 1975-77), which undermined popular faith in public health facilities. This misuse of general health facilities for directly or indirectly repressive activities has had long-term consequences. Reportedly, in India certain groups of people thus victimised 25 years ago have been reluctant to permit personnel of the polio immunisation campaign, which is yet another issue- and target-specific mechanism, access to their children.
'Powerpoint'
The dominant impression of a series of institutions working at cross-purposes, hindering each other even as they fail to achieve their own targets while maintaining a pretence of action is confirmed by a 1998 "effectiveness evaluation report" of UNFPA-supported projects to reduce maternal mortality, which were all clearly part of its reproductive health initiative. The main points of the report bear out all the conceptual problems with the data, definition and delivery aspects of the maternal safety campaign that have been consistently raised by critics. Its hesitant and equivocal tone might lead sceptics to the interpretation that none of the projects achieved anything of note, like identifying a more accurate figure of mortality ratios in the areas of their operation, the local causes of mortality, the reasons for non-treatment, and how much of a difference each of these projects made to the safety of pregnant women.
According to the report, "The evaluation found that all projects reviewed responded to national concerns about high levels of maternal mortality". Considering that "national concerns" dealt fleetingly with maternal deaths, if at all, until international funds entered the picture, project enthusiasm cannot have been very high. The report confirmed the critical importance of project-based collection of data to identify the extent of deviation from rough national figures and the need to modify remedies and targets in line with the revised figures. Accordingly, it said, "Even though all projects responded to a national priority and were relevant in a broad context, they were based on national-level data rather than on assessments of needs at the local level". In other words, the projects were mechanically implemented and the implementing agency did not have a clue about the areas in which the projects were located and, for all practical purposes, made little difference to the people they were trying to rescue for the clutches of mortality.
The UNFPA evaluation is candid, in a subtle sort of way, about the definitional problem, and the need to extricate the real locally prevalent causes of maternal death from the general and convenient 'powerpoint' format into which the global causes had been arranged to make it consistent with the multilaterally (or is it unilaterally?) identified solution. The projects failed to make this departure, which the report records in a mildly reproving tone. Thus, "…the projects did not address clearly defined local problems. Thus, even though most of the projects focused on specific regions or districts, the strategies did not address the particular causes of maternal deaths in those selected areas". And lest the projects still did not get the point, it offered them some useful advise, even if it was somewhat late in the day. It recommended that "formal needs assessments, based on the causes of maternal deaths at the local level be an integral component of the project formulation". It is not certain whether the report was referring to the ongoing projects or future projects. Either way, it was rather phlegmatic about the wastage incurred so far.
The next part of the report seems to make a subdued hint about grave consequences if the projects persisted in violating donor conditionalities and preferences. They had made the cardinal mistake of deviating from the consensus, by choosing not only to give antenatal care but all put their faith in traditional birth attendants (TBA). With quiet firmness it quells the upstarts in the ranks and warns, "The strategies chosen to reduce maternal mortality, the evaluation found, were not necessarily the most effective ones. For example, all of the projects promoted antenatal care as part of their safe motherhood strategies, even though evidence shows that antenatal care to detect pregnancy-related complications, in and of itself, cannot bring about significant reductions in maternal mortality, since every pregnancy involves risk. Also, four of the seven projects had training programmes for traditional birth attendants. It is now recognised that TBAs alone cannot substantially reduce maternal mortality". It is a wonder the project was awarded to people who did not know all this.
The report goes on to say, "Monitoring at the central level occurred regularly for almost all the projects reviewed. Monitoring at lower levels, however, was often neglected. This hampered the ability of the project management team to conduct in-depth technical analyses". In other words, there was no way of confirming beyond all reasonable doubt whether the project was any good or not. It added, "Overall, the evaluation found that project personnel focused most of their time and effort on ensuring that the activities were carried out rather than on assessing whether the activities implemented were actually improving maternal health care". Presumably, this means that though the projects were doing things all wrong, they were at least doing something.
The report comes back to make the crucial and clinching point that ensures, as it must, that all is well for the projects precisely because of their own failures, but also gives them a bit of advice for the future. "Since most projects did not identify indicators to determine the effectiveness of the selected strategy, there was insufficient information to show whether activities had achieved the intended results [emphasis added]. The evaluation did show that in most cases there had been an increase in the provision of different maternal health services. However, it was not possible, with the exception of the Bangladesh project, to determine whether the increase was a result of the UNFPA-supported activities. The evaluation recommended that project managers identify indicators that can provide information on the progress made in implementing the selected strategy and regularly collect data at the levels where activities are conducted. Such information should be used at local and central levels to resolve problems, assess progress in preventing maternal deaths and determine policies related to maternity care. In addition, the evaluation underscored the importance of process indicators. The indicators selected should be practical, operationally significant, and based on available and reliable data". This simply means these are the things that were supposed to be done but were not done last year. It is hoped that matters will be rectified next year.
The report ends with usual caveat that anticipates eventual macro-level failure because of the magnitude of the problem and the lack of coordination among all the numerous agencies replicating or thwarting each other's work in different locations. "The evaluation found that although the Safe Motherhood Initiative is conceptually a concerted effort involving a variety of agencies, the projects studied were either conducted in isolation or were not coordinated with other projects. Moreover, none of the projects provided for a review of the status of maternal mortality in partnership with other agencies. The evaluation underscored the crucial importance of partnerships among agencies, donors and national governments to the success of safe motherhood programmes, since no one organisation can by itself bring about a decrease in maternal mortality".
There is a final flourish about how maternal mortality had been domesticated within the confines of population control. It concluded on a triumphant note, deciding that, "…advisory notes on how to integrate safe motherhood interventions into reproductive health programmes would be prepared on the basis of the lessons learned from the evaluation".
Macroeconomy of health
There cannot be more conclusive evidence of the irrationalities of the global prototype that has been adopted to save pregnant women's lives. Yet, barring some occasional admission of problems at the project level, total programme inadequacies are ignored and at the macro-level there is no sign that any change will be introduced. In fact, if WHO activities are anything to go by, it appears that this approach, despite all the evidence of its limitations, is going to be a permanent part of life in the third world. In 1978, at Alma Ata, the WHO had endorsed the idea of universal health through a horizontal network of primary health centres backed by a secondary tier of referral hospitals. By the 1990s, the WHO had moved far from this sensibility and seemed to be taking its orders from other institutions. By 2000, it had begun officially endorsing measures that have shown themselves to have failed consistently over many decades merely because it suited the development oligarchy.
This was the year, 2000, that it constituted the Commission on Macroeconomics and Health, which reaffirmed the value of the vertical or categorical approach to health. The reasons that the agency advanced in support of this view of why failed mechanisms linger on in the world of development policy are revealing. Essentially, the commission believed that the vertical delivery mechanism simply had to be retained because donors liked it. And the reason why donors liked it was because it could be subjected to centralised technical and financial control and because of its "tendency to be assessed more easily". Primary health care does not possess such attractive attributes because where it is allowed to function properly it must respond more to the needs of the user than the sentiments of the financier. Vertical programmes, however, can devise their own understanding of problems and their own explanations of failure.
Thus, a report on the Gates Foundation-funded Averting Maternal Death and Disability Programme of the Columbia University's Joseph L Mailman School of Public Health, describing its third year of activities in 2002, could count among its achievements the expansion of partnerships, the development of the "UN Process Indicators" to measure progress on the basis of proper EmOC availability and use, and a couple of anecdotes about caesarean-section deliveries in Ethiopia and Nepal. Apart from that, it could only say that maternal mortality ratio, which is the basis on which the problem is identified, cannot be the criterion for measuring progress. Intriguingly, and perhaps much to the delight of many, the reprot went on to add, "Another problem with measures of maternal mortality ("impact" indicators) is that they do not show what is working well in programs and where additional efforts are required".
That is to say, pregnant women of the poorer classes need not expect any relief from the global campaign to prevent their death any time soon.