Historically, attempts to alter the conditions and cultures of maternity and motherhood have been part of the civilizing projects of colonialism and the modernizing agendas of international development. The goals have varied over time and space — from the prevention of maternal and infant deaths amidst fears of a depleted labour pool, to the prevention of “excessive fertility” amidst fears of overpopulation. But the task of managing reproduction has always been a biopolitical one.
In this article I will reflect on the biopolitics of global campaigns to reduce maternal mortality in low resource settings since the 1980s and describe a shift I have observed in the “humanitarian reason” (Fassin 2011) of such efforts. For more than a decade I have been conducting anthropological research on international development policy with regard to maternal mortality. In May 2013 I attended a conference called Women Deliver in Kuala Lumpur, Malaysia. Women Deliver is one of the most influential women’s health advocacy organisations in the world. The 2013 conference brought together representatives of UN agencies, national Ministries of Health, non-governmental organisations, private philanthropic foundations, professional associations, and corporate sponsors to discuss the latest clinical research, medical technologies, policy proposals and program implementation strategies to reduce maternal mortality in low resource settings around the world. Meetings like Women Deliver are ethnographic sites for me — places to observe and participate in an international network of advocates, policy makers, and practitioners. For my research, I also conduct formal interviews, gather data on-line, join webinars as a participant observer, and follow twitter feeds and blogs.
Once dubbed the neglected tragedy of international health, maternal mortality has recently become somewhat of a cause célèbre, capturing public attention in new ways: during the G8 and G20 meetings in Toronto in June 2010 the Canadian government was lauded in the national and international press for putting maternal health high on the agenda and then harshly criticized for not including access to safe abortion in its proposal; that same month the second Women Deliver conference convened in Washington DC with appearances by UN Secretary-General Ban Ki Moon, U.S. Secretary of State Hilary Clinton, and philanthropist Melinda Gates, as well as a number of celebrated journalists and film-makers; former supermodel Christy Turlington premiered her documentary film about maternal mortality at the conference and launched her own NGO, “Every Mother Counts,” seeking to reach “new audiences” through new media, including a fund-raising compilation CD that featured Sting and U2 that one can purchase at Starbucks.
Women Deliver’s third triennial conference in Kuala Lumpur — with a similar roster of world leaders, famous speakers, and media attention – demonstrates the success of this organisation in raising public interest and amassing political will around the issue of maternal health. It has done so in part by harnessing the power associated with celebrity, but more so, I suggest, by engaging in novel modes and conventions of representing the problem of maternal mortality. Two particular aspects of the conference illustrate this point. First, the mandate of the conference was more expansive this year, addressing not only maternal mortality but also the “sexual and reproductive health and rights” of girls and women. Second, the role of video, film and photographic images has been significantly scaled up to meet the requirements of a new era of high profile humanitarianism. These two themes greeted delegates in the foyer of the conference venue.
The Problem of Maternal Mortality
Maternal mortality first appeared on the international agenda in 1987 with the launch of the Safe Motherhood Initiative (SMI) — a joint initiative of WHO, the World Bank, and UNFPA. (Maternal mortality is defined as the death of a woman from pregnancy related causes and up to 42 days post partum). At that time, it was estimated that 500,000 women died each year in pregnancy, childbirth, and the post partum period – with the vast majority of deaths occurring in the developing world. The SMI ambitiously challenged all nations to reduce maternal deaths by half by the year 2000. This goal was to be accomplished primarily through family planning efforts, upgrading peri-natal services to approximate western biomedical standards, and making improvements in the scope and quality of education for midwives and traditional birth attendants. Clinical research and project reporting in the first decade of the SMI, identified a set of “direct” obstetrical causes of maternal mortality: hemorrhage, sepsis, obstructed labour, unsafe abortion, and convulsive disorders of pregnancy. Barriers to accessing preventions and treatments for these conditions and events — including poverty, remote locations, gender discrimination, harmful cultural beliefs and practices, lack of transport, and poor health and nutritional status – were also documented as “indirect causes.”
In the SMI policy literature and program materials the direct and indirect causes of maternal mortality were crystallized in the story of “Why did Mrs. X die?” in which a pregnant woman in an un-named developing nation with her burden of poverty, poor heath, illiteracy, gender oppression, many pregnancies, and lack of access to life-saving biomedical services sets out on the road to death simply by becoming pregnant. Meant to be a model for understanding the problem and a means to identify interventions along the way, the story of Mrs. X effectively homogenized thousands of nameless individuals, separated from their particularities, into one grand narrative with one obvious solution: the adoption of western ideas and practice (Allen 2004; Berry 2010; MacDonald 2004). Implicit in this policy narrative was the assumption that western cultural logic and biomedicine must be delivered and made to triumph over aspects of traditional society and culture that appeared as “barriers” to progress: women must shift their trust from traditional birth attendants to trained nurse-midwives in facilities; traditional patriarchal thinking must give way to gender equality so that scarce family resources can be redirected to prenatal care and delivery at local clinics.
The SMI did not deliver the hoped for results and by the late 1990s, there was a new diagnosis for the syndrome of maternal mortality: lack of political will. (The impact of HIV/AIDS was significant, but not noted at the time). The creation of the Millennium Development Goals in 2000 was a turning point. Reducing by three quarters the maternal mortality ratio by the year 2015 became MDG 5. Achieving universal access to contraceptives by the year 2015 became MDG 5B. Since 2000 there has been a significant reduction in maternal mortality worldwide, but the statistics remain sobering. In 2010 an estimated 287,000 maternal deaths occurred worldwide, most of them still in the developing world.
Women Deliver 2013
The 2013 Women Deliver conference set itself a broader mandate than in the past billing itself as: “An international conference calling for investments in girls and women.” In contrast to previous iterations of the conference, there were very few panels on the topic of safe maternity itself. Instead, a very particular constellation of topics dominated the conference program: girls’ education, access to sex education, access to contraceptives, access to safe and legal abortion. The two most repeated phrases during the conference were “girls’ education and empowerment ” and “sexual and reproductive health and rights” — the latter being a direct reference to the notion of reproductive rights introduced at the International Conference on Population and Development (ICPD) held in Cairo in 1994. The sessions at Women Deliver 2013 described the technical goals and challenges of the above, while the plenaries crystalised the main message: the goal of sexual and reproductive rights is to be achieved through girls’ education and empowerment. This is the new road not only to safe motherhood, but to development itself, that is, ‘to vibrant, healthy societies and economies’ as Melinda Gates put it in her closing plenary speech.
Family planning and safe abortion are extremely important issues. 220 000 women in the world are said to have an ‘unmet need’ for contraception. Death from unsafe abortion accounts for over 10% of maternal mortalities world wide each year. Yet the conference left me wondering whether maternal mortality can only garner sustained attention and commitment when bundled with other issues that have greater social and political cache. Family planning and safe abortion must be argued in terms of human rights and empowerment, rather than maternal health.
The image world of maternal mortality
A special feature of Women Deliver in Kuala Lumpur was the Cinema Corner – a curated showing of music videos, PSAs, short films, and feature length documentaries to do with girls and women. In the opening slot on the opening day of the conference a documentary called Half the Sky was screened. Based on the best selling book of the same name by journalists Nick Kristof and Sheryl WuDunn, the film makers take Hollywood actresses along to investigate challenges facing girls and women in the non western world, including maternal mortality. The film has received a lot of attention, some of it quite dramatic in its praise. In Sept 2012 for example, during a side event at the UN General Assembly in New York, the communications director of a US university-based global health NGO told me that Kristof deserved a Nobel Prize for drawing attention to the effects of gender inequality around the world. In the opening scene of Half the Sky, George Clooney reflects on the importance of celebrity in telling stories:
“There are so many things going on in the world right now. There are so many things that we all pay attention to. But there are stories that need to get out there. [The] interesting thing about tragedy is that we have to be able to relate to it…The celebrity involvement may be able to amplify the story.”
At Women Deliver and in the wider context of global maternal health campaigns — the role of film and photographic images has indeed been amplified to meet the expectations of a new era of high profile humanitarianism and attract new levels of public attention and donor support. High quality photographs and moving images are deployed at conference presentations and receptions, on NGO websites, and circulated through traditional and social media. As an anthropologist I am interested not only in the celebrity involvement, but in the aesthetic and narrative conventions of this scaled-up “image world” (Sontag 1973). What kind of images captivate public attention and compel viewers to thinking and action? What information, affects, and moral judgments about maternal mortality and its otherness lie within these images? How does the image world of maternal mortality ‘frame’ (Tagg 2009) the problem and point to its solutions?
It has been said that humanitarianism needs a suffering body — ideally an apolitical one (Fassin 2011; Malkki 1996: 348; cf Laqueur 1989). Many scholars have argued that visual images of suffering have the power to bind the spectator to a shared sense of humanity with another. Sliwinsky, for example, writes that “[t]he ideal of a human subject naturally endowed with dignity and rights migrate[s] through the public imagination, in part, by virtue of spectators’ passionate engagement with pictures” (2011: 9). In what Ahmed might call an “affective economy” (2004:120) shared sentiments are linked to a set of moral arguments about humanity. The moment of connection is the catalyst to the idea that something can be done (Azoulay 2008; Campbell 2012; Sliwinsky 2011; Sontag 1973). Equally importantly, photos and film function as critical evidence in juridical processes that seek to address suffering and injustice. This view of the power and responsibility of images is held by photo-journalists and development and humanitarian photographers as well (Azoulay 2008).
The contemporary image world of maternal mortality seems to contain a new “humanitarian reason” (Fassin 2011) — one that resonates with Clooney’s second point: we have to be able to relate to tragedy in order to care or be moved to action. The wager that maternal health advocates are making today is that our shared sense of humanity and impulse to act is fomented not solely through images of suffering, but through an affective economy of hope and aspiration. Certain kinds of photos now dominate — photos that depict social injustice overcome or medical disaster averted: the teenage girl in the photo is still in school; a nurse talks to a pregnant woman in a health facility while her husband looks on supportively; a smiling new mother holds her healthy baby. Images of maternal suffering tend to be structured by this new narrative as well: an exhausted woman on a blood stained hospital bed with her newborn swaddled neatly beside her shares the frame with the basic biomedical equipment and packages of brand name drugs that we are to assume just saved her life.
My interview data bears out this new logic. On the topic of how images are chosen for the website and publications of his organization, the Communications Director of a US global health NGO remarked:
My view is that it’s just as simple as images make connections for people on different part of the planet….We don’t take the approach through the images of trying to shock people. We tend to try to select more positive images. It really just comes down to this very simple factor of, Is there something in this that will connect for people? We tend to focus on positive rather than negative images… We tend to just pick young women who are engaged with the camera. Or mothers and babies. Or a young couple and a baby…And then it just comes down to, Are we trying to send a message of despair or hope?
Humanitarianism and development are widely acknowledged as powerful forces that are re-shaping how we see the world and governing how people live. My goal in this research is to document and understand what new ways of being are being scripted for people on both sides of the humanitarian divide. The scaled up image world of maternal mortality, I suggest, is doing some of this biopolitical work. Women Deliver’s new mandate of investing in girls and women by delivering sexual and reproductive rights to them reframes the problem of maternal mortality. The technical solutions may be familiar – biomedicine, culture change, and political will — but the human rights discourse redirects the affective and aesthetic narrative. Images of hope and aspiration rather than suffering and despair show us the dividends of doing so.
Margaret E MacDonald is Associate Professor of Anthropology at York University in Toronto. She conducts research on reproduction, gender, and health, including long-term research on midwifery in Canada. The research described in this post on the image world of maternal mortality is part of a larger project that looks at the key issues and changes in global health policy with regard to maternal mortality over time.
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Allen, Denise Roth. 2004. Managing Motherhood Managing Risk. Fertility and Danger in West Central Tanzania. Ann Arbor, MI: University of Michigan Press.
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Tagg, John. 2009. The Disciplinary Frame: Photographic Truths and the Capture of Meaning. Minneapolis: The University of Minnesota Press.