A protracted launch: The first two decades of the safe motherhood initiative

The Safe Motherhood Initiative, launched in 1987 to raise awareness of the world's high maternal mortality levels and to find ways to reduce these numbers, is approaching its twentieth anniversary. Many observers express disappointment about its progress to date. This report considers the experience of the initiative with a view to identifying factors that have shaped its development, and challenges it will face over the coming decade. We apply a unique lens to safe motherhood, drawing on social science theory to analyze it in evolutionary perspective as a global health initiative.

We find that the initiative, despite a twenty year history, remains in an early phase of development, incipiency, characterized by weak guiding institutions and leadership, and an unclear identity for the issue itself. Factors connected both to the complexity of the issue, such as measurement difficulties, as well as the decisions of the actors involved, including the way they have conducted debates, explain this slow evolution.

In the coming decade, the initiative faces three primary political challenges:

• Surmounting fragmentation within the advocacy community so that it may speak with a unified, credible and powerful voice to international policy elites • Building effective institutions and finding strong leaders that can guide, unify and institutionalize the initiative • Finding a resonating frame – a public positioning of the issue – that serves to unify the advocacy community and convince political elites that the issue is worthy of attention and resources.

If the advocacy community does not surmount these challenges, the initiative may fall into demise by the end of its third decade. If it transcends these challenges, the initiative may coalesce, ensuring ongoing global attention to the problem of maternal mortality for decades to come.