Shiffman, J. (2007).American Journal of Public Health, 97, 796-803.

Tn 1990 there were approximately 585,000 maternal deaths in the world; there has been little decline in maternal mortality since then. This study examined the political factors necessary to connect medical and technical interventions with resources to reduce maternal mortality. Five countries were chosen: Honduras (one of the few countries to have experienced a decline in maternal mortality); Guatemala (with higher maternal mortality rate despite greater wealth and resources in contrast to Honduras); Indonesia (because of its unique initiative to place a midwife in each of 60,000 villages); and India and Nigeria (because they rank first and second in numbers of maternal deaths annually). Documents and interviews (124) were used in a process-tracing methodology. Two basic questions were addressed: (1) To what extent is maternal mortality reduction a part of the national policy agenda? (2) What factors contribute or interfere with giving political priority to maternal mortality reduction?

Not surprisingly, the foundation for all reduction efforts was establishing a global norm about the unacceptability of maternal mortality, for example, the appearance of maternal health on the Millennium Development Goals (MDGs). In providing financial and technical resources, international agencies such as the International Monetary Fund also can influence certain policies/priorities as a prerequisite for loans. Even if countries recognize norms, have resources, and are aware of MDGs, however, they still may not make maternal mortality a priority or take action. Another key was cohesive working networks within the country. For example, in Honduras a working group from the Ministry of Health, the Pan American Health Organization, USAID, the UN Fund for Population Activities, and UNICEF became the core for safe motherhood efforts. Other factors for effective maternal mortality reduction were individual political entrepreneurs within the country to promote the cause, a data system to yield clear indicators to highlight the problem and monitor progress, clear proposals to convince policy makers that problems such as maternal mortality are resolvable, and attention-centering events to create national visibility for the issue. (Think of all the walks/runs in our country that have done this.) Using these criteria, results indicated that political priority for maternal mortality reduction was very high in Honduras, high in Indonesia, moderate in India (a recent rise), and low in Guatemala and Nigeria.

So what does this mean to nurses in the United States, where maternal mortality is rare? The study provides a template of how necessary political priorities are for generating solutions not only for maternal mortality but also for other health problems such as malaria, HIV/AIDS, and tuberculosis in developing and developed countries. It reminds us that not only evidence-based interventions and resources determine outcomes but also getting the attention of politicians and leaders who make policies. This requires data and careful strategies that nurses are in a unique position to provide.

Linda Beth Tiedje