The end of the maternal health moment: an examination of Canada’s evolving global reproductive policy commitments

ABSTRACT

Global maternal, newborn, and child health (MNCH) policy has been in ascendancy over the past ten years. It is an issue that at one time struggled to garner the attention of governments and donors, but then became a “cause célèbre,” evidenced by showpiece policies that committed billions of dollars to improving the health of mothers and infants worldwide. At the same time, the status of the maternal subject, as a social and political figure in the Global North, and as a global health policy subject, has been in decline. In this article, I explain the Canadian government’s evolving commitments to this policy domain and posit that the global maternal health moment might be coming to an end. I argue that while the shift from MNCH to sexual and reproductive health and rights (SRHR) expands the (feminist) focus of previous MNCH commitments, recent Canadian government initiatives are unsuccessful in addressing human rights goals, contradict the partnership model of development that implements policy and fosters relationships with communities, fail to meet the requirements of gender justice at both global and local/contextualized levels, and threaten to further diminish the political authority of the maternal subject.

KEYWORDS:

• Reproductive rights
• global maternal health
• feminist foreign policy
• gender justice
• subjectivity

Introduction

For approximately the past ten years, maternal, newborn, and child health (MNCH) has dominated the global health and development agenda. It has captured the global policy imagination and become a major priority of bilateral government aid and private philanthropic donors. Whereas MNCH once struggled for priority status on the global policy agenda (Shiffman and Smith 2007), in recent years, it has become an ascendant issue, a “cause célèbre” (MacDonald 2019, 269), garnering the attention of rock stars, supermodels, and high-profile billionaires. According to the Guttmacher Institute (2016, 225),

[d]onor development aid for reproductive, maternal, newborn, and child health worldwide more than tripled between 2003 and 2013 … The amount of official development assistance funds plus grants from the Bill and Melinda Gates Foundation … increased by 225% over the period – to nearly $US 14 billion.

In part, this increased attention is a legacy of the Millennium Development Goals (MDGs), which identified improved MNCH as one of the eight global goals for development (MDG 5). It is also the product of other factors, such as the importance of measurability to public health initiatives and donor financial accountability, and the political simplicity of MNCH as a policy field as compared to broader issues of sexual and reproductive health and rights (SRHR).

At the same time as MNCH policy has been gaining in popularity, the status of the maternal subject (the mother) has declined in socio-cultural and political terms. As Stephens (2011, 17) explains,

Two decades ago Sara Ruddick made an observation that to claim a maternal identity was “not to make an empirical generalization but to engage in a political act.” Today, in stark contrast, it has become almost “politically impossible” to make a public claim on the basis of motherhood, according to feminist state theorist Ann Orloff. Political support for women’s caregiving role has diminished in favor of endorsing women’s claims as workers or limiting entitlements to economically active citizens.

Similarly, Bueskens (2018, 168, emphasis in original) argues that

women are now free as individuals and constrained as mothers and that these two apparent polar outcomes are mutually constitutive, generating major paradoxes in women’s civil status in contemporary western societies … Not surprisingly, as the gendered wage gap has narrowed, the gap between mothers and (all) others has increased … Mothers are losing out in the neo-liberal economy because they cannot earn full-time wages in the context of their (largely unshared) caregiving responsibilities.

It is, therefore, necessary to interrogate global MNCH commitments in the context of the declining status of the mother. This declining status is a perverse trend of (donor) countries of the Global North that has serious implications for (aid-receiving) countries of the Global South. MNCH is the focus of countless bilateral and multilateral initiatives that involve governments, private donors, non-governmental organizations (NGOs), communities (epistemic communities, practitioners, networks of families, and others with shared identities and purposes), and individuals. MNCH is an intensely political domain; governments and donors devise programs and policies for multiple purposes, all of which coincide in some way with the cultural meanings of pregnancy and childbirth. In some instances, these meanings are shaped by policies and interventions (projects implemented on the ground); in others, these meanings resist policies and practices enacted at various (global–local) levels. This is summed up nicely by MacDonald (2013), who states that “the task of managing reproduction has always been a biopolitical one.”

In this article, I examine one particular set of relationships within the MNCH policy domain: those arising from Canadian commitments to global MNCH from 2010 to the present. Canada is a country with deep commitments to both international development and human rights and has become a major actor on the global stage in MNCH politics. This began with the Muskoka Initiative (MI) under the Conservative government of Stephen Harper and has recently been transformed by the Liberal government of Justin Trudeau. In this article, I consider what these policy commitments have in common, how they differ, and what they have to offer in terms of (1) development, (2) women’s rights, and (3) the integration of development and women’s rights for the advancement of gender justice.

Moreover, this article is an examination of policy priorities that are established at the national level and then legitimized in global political transactions, mainly through the implementation of development policy. The research presented herein is empirically grounded normative political theory (consistent with the grounded normative theory (GNT) approach, as defined by Ackerly (2018)). I present an argument for the deficiency of Canada’s MNCH and SRHR commitments in the context of MNCH becoming a global imperative and the decline of the status of the maternal figure. As such, my argument contributes to debates concerning global gender justice (Cornwall and Rivas 2015; Htun and Weldon 2018; Jaggar 2014), MNCH policy and politics (Haussman and Mills 2012; Mills 2017; Robinson 2014; Tiessen 2015), and the transition to a policy that focuses on the more thematically inclusive, yet limiting, domain of SRHR (Adewole and Gavira 2018; see also Molyneux 2000; Waylen 1996). I argue that, as students of global public policy and gender politics, we might be witnessing the end of the global maternal health moment. This has complex consequences for health and development initiatives and the women and other reproductive subjects who benefit from and participate in those initiatives.

Argument, theory, and method

The main argument identifies a paradox in the policy rhetoric and action of the Global North – namely, the ascendancy of MNCH policy commitments and the decline of the maternal subject. It does so because this paradox has consequences for the intended beneficiaries of this policy: countries, communities, and individuals in the Global South. The main focus of this examination, therefore, is the implications of the paradox for policy action and international development. Also of concern are the ways in which the declining maternal subject has the potential to amplify gender injustices. The maternal subject as a political actor is in decline in the Global North; in some parts of the Global South, such as Latin America, the maternal subject continues to hold political currency even in the context of truncated political, legal, and social rights for women (such as in the political mobilizations of the Madres de la Plaza de Mayo in Argentina or the Sepur Zarco Grandmothers in Guatemala). In global policy terms, however, the maternal subject is in uniform decline as it is transformed into an SRHR subject.

The declining status of the maternal subject has implications for gender justice because it affects the status of women and other reproductive subjects in society. In this article, I use definitions of gender justice that are drawn from public policy discussions rather than philosophical accounts as such (see Jaggar (2014) for those formulations). Htun and Weldon (2018, 3) explain:

All policies promoting gender justice seek changes to the social and political institutions that construct – often in binary ways – the categories of sex and gender, imbue them with social meaning, and embed them in our material surroundings (buildings, clothes, wages). Gender justice policies challenge prevailing patterns of cultural value and require changes to societal norms at the macro level as well as at the micro level of social practices, in the interstices of daily life.

MNCH and SRHR policies affect change on multiple levels, from the level of global policy to the level of individual daily practice. Changes that devalue status, narrow choices, or close programs are incompatible with the goals of gender justice, despite policy promises or normative aspirations to the contrary.

In this article, I am also concerned with identifying and exploring a number of other paradoxes and contradictions concerning MNCH. For example, there is an apparent simplicity to MNCH as a policy field and political problem to be solved, in that the goal of policy or political action – the reduction or elimination of needless death and suffering of women during pregnancy and childbirth – is clear and measurable. However, this clarity obscures a number of complex causes, not to mention potentially dubious political motives. In addition, the maternal subject, as the intended beneficiary of policy interventions, gains from development initiatives and is also burdened by them. MNCH policy delivers practical benefits to mothers, yet the policy domain is heavily criticized by feminists who complain that it undermines women’s strategic gender interests. The maternal subject is highly visible and easy to identify, yet also biologically determined and vulnerable to essentialist limitations. Furthermore, while the development model that facilitates the policy shift from MNCH to SRHR is one that is based on community-level, NGO-led partnerships, the shift itself is a top-down discursive approach to change that does not consider the effects of local contexts and practices.

GNT is a composite theoretical and methodological approach that is committed to both empirical and normative analysis. For Ackerly (2018), normative claims (such as those undertaken in an inquiry into some form of global injustice, for instance) are generated from and tested by the empirical data and personal experiences of the researcher. GNT is inspired by a dialectical process of considering oppositional viewpoints and differing experiences: “Inspired by this dialectic [as imagined by Audre Lorde], a feminist grounded normative theory invites us to develop a political theory under conditions of moral and ethical disagreement and competing social epistemologies within and across experiences” (Ackerly 2018, 137). Moreover, Ackerly (2018, 145, emphasis in original) emphasizes that

[g]rounded normative theory is a methodology in which the theorist does not depend on her own reflections about how she would respond responsibly or on her imagination about how others would or should respond responsibly to injustice in order to understand the ethics of responsibility at play in our hearts and minds. Instead, grounded normative theorizing is a dynamic and multidimensional process of theorizing through engagement with struggle.

The argument that I am constructing in this article proceeds from the inductive, grounded point of the empirical-normative dialectical process. It builds on empirical work that I conducted in Guatemala and Mexico over the past five years in communities that are in the process of negotiating the policy shift from MNCH to SRHR policy.¹ My arguments about MNCH policies, their ascendancy and conversion, and the status of the maternal subject in various contexts are based on empirical research and observation and built from socio-cultural and political facts as revealed by women/mothers/actors/participants/friends/allies/critics in the communities that are included in my analysis. I have developed my normative argument concerning gender justice, global public policy commitments, and the complexities of subjectivities from grounded research and from trying to understand and interpret reproductive injustice itself. The reproductive justice framework situates reproductive rights issues in wider discussions of social justice; it broadens the realm of reproductive issues beyond individual choice and rights to consider context, relationships, and inequality (Chrisler 2012). Ackerly (2018, 73) explains that “injustice itself is constituted by the power dynamics of both the material practices and the meaning-making practices of human social life.” Taken together, the “conversion” and “layering” of maternal and SRHR policies and subjectivities have both tangible and symbolic consequences for gender justice (Hacker 2004). I return to this below.

The ascendancy of maternal health and Canadian government initiatives

The literature shows that there were at least two trends that coincided to produce MNCH as a global priority. The first is the failure of the population control policies of the 1960s and 1970s, and the second is the advancement of and preference for evidence-based medicine. The decline of population control policies in the Global South and the emergence of SRHR was driven by both ideological and scientific imperatives. Grimes (1998, 376) has described population control policies aimed at fertility reduction as “the diffusion of Western ideological views on the desirability of small families and a powerful state bureaucracy … for whom controlling Third World expansion had become a major aspect of its foreign policy.” As a consequence,

at the international level there is [and has been since the 1990s] strong opposition to intervention by outside forces in the politically sensitive issue of fertility reduction, which is generally regarded as a matter of national sovereignty. Scholars from the South are also critical of their marginalisation by the foreign population establishment in researching population dynamics within their own countries. (Grimes 1998, 376)

In the ensuing decades, population control policies were rescinded and replaced on the global agenda by reproductive rights policies. At first glance, this shift is a positive one, in that it is a less coercive policy direction. However, commitments to reproductive rights contain the not-so-veiled assumption that these rights include access to abortion and contraception, ostensibly in order to increase individual women’s choices rather than reduce fertility. This assumption is the problematic foundation for MNCH policy, which is simultaneously a critical MNCH rights commitment and its nemesis. The shift from population control to reproductive rights was consolidated in 1994 with the Cairo Declaration, yet the matter remained contentious, especially regarding the authority with which actors of the Global North attempted to establish universal reproductive rights. Whaley Eager (2004, 146) reminds us that “global population policy prior to the Cairo Conference on Population and Development (1994) sanctioned demographic goals, quantitative quotas and acceptors, and the utilisation of incentives and disincentives to affect reproductive behavior.” The Cairo conference was not able to reach consensus, yet “proclaimed that women have the right to control their reproductive capabilities free of coercion, violence, and discrimination by governments and non-state actors” (Whaley Eager 2004, 146).

The emergence of a global reproductive rights agenda is therefore attributable, in large part, to the decline of fertility control and other coercive measures of international development. Furthermore, in the 1990s, there were increased demands for inclusion (and receptivity to these demands) by voices from marginalized and coerced and controlled communities that had hitherto been excluded (Mohanty 1984, 2003, 2013; Roberts 1997; Schoen 2005). However, global commitments to reproductive rights were converted into commitments to MNCH for a variety of practical and ideological reasons.

First, the need to measure and account for advancement toward policy goals is more expediently addressed through MNCH initiatives. In the population control agenda of the past, reductions in birth rates (the ultimate goal) were easy to measure. Key indicators such as fertility rates, access to and use of contraception, and infant mortality rates, among others, were vital components in narratives about development and progress. Countries with declining fertility rates were successfully responding to development imperatives, and countries and populations with indicators that remained fixed and resistant to change were in need of more assistance. With the shift to a reproductive rights framework, it was not clear exactly what would be measured and what indicators would serve as clear evidence of progress or decline. Furthermore, it remained to be determined how outcomes of policy intervention could be evaluated. While the policy focus shifted from fertility control to reproductive rights, the need for measurement and evaluation remained and became more acute with the coincident calls for greater accountability in financial and moral terms.

Second, the emphasis on measurement was reinforced by the trend toward evidence-based medicine. According to McDougall (2016, 3), “evidence-based framing in public health has risen significantly in the past decade as part of a wider thrust towards evidence-based medicine and clinical practice.” This trend toward “evidence-based framing in public health,” when coupled with the morally compelling “mother–child dyad” (McDougall 2016, 5), generated increased political support and became a priority of the donor agenda. Moreover, “evidence-based framing has been adopted by the MNCH community² in a bid to ‘professionalize’ its advocacy through biomedical and economic framing, thus reducing reliance on moral arguments in swaying the attention of political leaders” (McDougall 2016, 3).

This is also apparent in the rise of evidence-based advocacy and political and social policy responses to the problems that create vulnerability to maternal death increasingly being reduced to technical quick fixes (Storeng and Béhague 2014). The consequence of this fusing of scientific, moral, and actuarial frames is that MNCH and maternal survival became an irresistible development issue for governments bent on demonstrating their commitments to international development and global justice. While many global MNCH policies were able to fulfill development objectives by addressing the proximate causes of maternal mortality and morbidity,³ and dedicated resources to improving access to critical health services, they often fell short of addressing the distal causes⁴ and therefore did not fulfill commitments to gender justice.

The Harper government’s MI was one such policy. The government invested significant political capital in generating global consensus on measures to reduce maternal death in the developing world. The MI was introduced by the Canadian government in 2010 and committed Can$2.85 billion over five years (Can$1.75 billion in baseline funding and Can$1.1 billion in new funding) and encouraged other G8 countries to do the same (the total G8 commitment for five years was US$5 billion) (Christie 2010; GAC 2016). The MI was a global demonstration of Canada’s aid commitments and multilateral capabilities, and it seemed to garner the Harper government a significant amount of praise.

There is clear evidence that the MI has been effective in improving health networks and outcomes (Kirton, Kulik, and Bracht 2014; Scott, McCarney, and Shaw 2012). Furthermore, Christie (2010) called the Canadian government’s MI commitments a “high water mark for Canadian multilateralism.” This is primarily because it galvanized global (G8/G20) support for maternal and child health, and also because it “helped to build momentum toward the September 2010 review conference on the United Nations Millennium Development Goals” (Christie 2010, 147). In other words, the global political and foreign policy dimensions of the MI were significant and laudable, even if the underlying gender dynamics (which made women vulnerable to maternal death and morbidity) were not challenged.

However, the MI also drew heavy criticism, primarily for its reliance on the politically suspect language of maternity⁵ not as a conduit for reproductive rights, but as its substitute. The gender-related and broader reproductive rights concerns are addressed by Tiessen (2015), Robinson (2014), and Haussman and Mills (2012). For these scholars, it is impossible to separate the global political dimensions of the issue – MNCH prioritization – without questioning its micro-political, gendered dimensions. For Tiessen (2015) and Robinson (2014), emphasis on the maternal is essentialist and paternalistic and elides more complex political dynamics. For Haussman and Mills (2012), the main oversight is the lack of discussion concerning abortion and the Canadian government’s refusal to provide funding for safe abortion.

Beyond being controversial and anti-feminist, the MI’s exclusion of abortion services also seems to violate Canada’s human rights commitments. Women’s human rights are enumerated in the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and the Beijing Declaration (among other places). These human rights documents clearly indicate that women have the right to family planning (UN 1979, Art. 12.1), to health services during pregnancy and childbirth (UN 1979, Art. 12.2), to equality (UN 1979, Art. 16.1), to be free from discrimination (UN 1979, Art. 12.1, Art. 16.1), and to “the same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education, and means to enable them to exercise these rights” (UN 1979, Art. 16.1.e). The Beijing Declaration and Platform for Action (UN 1995) provides the most fulsome articulation of MNCH and SRHR for women. It recognizes that “complications related to pregnancy and childbirth are among the leading causes of mortality and morbidity of women of reproductive age in many parts of the developing world,” and that “[u]nsafe abortions threaten the lives of a large number of women, representing a grave public health problem as it is primarily the poorest and youngest who take the highest risk.” However, recommendations for health services and family planning are limited to those “which are not against the law” (UN 1995, C. 97).

Of course, one of the main premises of human rights is that they are indivisible, which means that reproductive and MNCH rights are interconnected with all other human rights, in particular those that specifically address gender equality, individual autonomy, and dignity. Notwithstanding this indivisibility, it is useful to highlight specific international commitments to MNCH rights for the following reasons. First, it becomes clear that Harper’s initiative addresses almost none of these rights. Arguably, the MI fulfills the commitment of CEDAW Article 12 Section 2 (access to health services during pregnancy and childbirth), although it does so in isolation of the other commitments, such as family planning and autonomy in reproductive decision making. The Beijing Declaration is more emphatic in the scope and consequences of reproductive health rights. The MI did not adequately include measures to improve access to contraception and prohibited funding for abortion services. This prohibition constitutes a human rights violation in countries where abortion is legal, as indicated in the text of the Beijing Declaration. If one reads into the spirit of the Declaration and its wider intentions and implications, the policy’s prohibition also arguably constitutes a human rights violation more broadly in all countries regardless of the legality of abortion.

Second, the MNCH provisions are helpful in measuring the merits of past, present, and future policy initiatives. If the MI did improve MNCH indicators but did not uphold the commitments to women’s rights made in international covenants (to which Canada is a signatory), then this suggests a failure on political and ethical grounds and also that progress toward the goal of MNCH would have been much greater if the full spectrum of rights and obligations had been included in the policies. It also serves as a warning that policy progress in the medium to long term might be undermined by the enduring structural factors that make pregnant and parturient women vulnerable to mortality in the first place.

In these ways, MNCH is a global policy domain riddled with paradoxes. As described in the Introduction, the maternal subject is in decline, a devalued political actor in the Global North even as MNCH policy has been gaining traction; MNCH has become a global priority that featured prominently in both the MDGs (in MDG 5) and their successor, the Sustainable Development Goals (in SDG 3), as well as on the agenda of numerous governments and donors. In addition, MNCH is a policy area that delivers important benefits to women and improves their lives in real terms, yet is also subject to heavy criticism that it is too narrowly defined and fails to address strategic gender interests (Molyneux 2000; Waylen 1996) and structural violence (Farmer et al. 2013). Governments, donors, and NGOs that hope to improve the lives of pregnant and parturient women have to navigate these paradoxes amid the complexities of cultures, institutions, and webs of global rights and responsibilities while attending to the specific identities, practices, and needs of women as mothers.

The former Executive Director of the United Nations Population Fund (UNFPA), the late Babatunde Osotimehin, concludes that the MI “made a difference, but I think what we are trying to make out here is that we should not treat women just as bodies that deliver babies but actually as human beings with rights and dignity” (Dib 2016). In other words, the MI was a policy that prioritized the problem of maternal death, providing resources for the most significant means of reducing maternal mortality and morbidity: access to skilled attendants at the time of delivery and access to emergency medical services (WHO 2006; Yamin and Maine 2005). Yet, it did not provide funding or support for contraception and did not address the distal causes of maternal death – namely, the low social status of women and the underlying causes of structural inequality. It also failed to provide funding and support for one of the main proximate causes of maternal death: lack of access to legal and safe abortion.⁶ This is, of course, an old feminist trope (access to abortion), but for good reason. Hemorrhage caused by illegal abortion accounts for a significant proportion of all maternal deaths; 27 percent of all maternal deaths are due to hemorrhage (which likely includes death from abortion coded as hemorrhage rather than abortion), while 7–9 percent are due to abortion (Say et al. 2014). It is disingenuous for a government or other actor to develop a global policy to improve MNCH and reduce maternal mortality rates without attending to the issue of abortion (and the need for safe access for all women).

Why, then, would a conservative government choose MNCH as its foreign policy legacy if it is not invested in the issue in its entirety? The saving of women and girls is a source of political capital, as it enables the targeting of a “deserving” population (Schneider and Ingram 1993) while disciplining that population and establishing a moral threshold for female behavior. In simple terms, this policy played to Harper’s socially conservative base, as it was both heroic and pronatalist. This element of his base, however, is too small (in terms of potential votes) for a domestic policy focus. Harper expressly avoided the abortion issue on his domestic agenda, as it would have been politically disadvantageous to magnify the socially conservative dimensions of a broadly appealing brokerage party. Therefore, the government sacrificed moral neutrality (concerning the abortion issue) in global gender politics and delivered a socially conservative, and potentially deadly, message abroad – one that would align with other socially conservative policy initiatives (such as those of the United States (US) government under Republican administrations since Ronald Reagan’s presidency in the 1980s, and those of the Bill & Melinda Gates Foundation, a significant actor and donor in the field of global health). This politically expedient move garnered Harper a positive image on the world stage and generated some positive results, which are acknowledged even by his critics. Unfortunately, Harper’s approach to development in the area of MNCH also undermined gender justice, which is a precondition for improved MNCH, and both violated and failed to promote human rights.

In the next section, I demonstrate that despite the progressive rhetoric of Canada’s Trudeau government (2015–present) and the fact that its feminist approach to development corrects many of the shortcomings of the MI, the policy remains seriously flawed because it is not oriented toward rights. It does fulfill human rights commitments to female autonomy in reproductive decision making, and access to contraception and abortion services as a means to empowerment. However, the goal of empowerment is not rights consciousness and gender justice, nor does it serve as a means to recognize human rights and then convert them into legal rights that are respected and enforced by the state. Rather, the goal of women’s empowerment is economic productivity and the improvement of national economic indicators.

Feminist international assistance policy

According to Marie-Claude Bibeau, Canada’s former Minister of International Development and La Francophonie (2015–2019),

Canada is adopting a Feminist International Assistance (FIA) Policy that seeks to eradicate poverty and build a more peaceful, more inclusive and more prosperous world. Canada firmly believes that promoting gender equality and empowering women and girls is the most effective approach to achieving this goal. (GAC 2017a)

Bibeau states that this is “Canada’s vision for international assistance,” which reveals the tendency toward a focus on the economic ends of women’s empowerment. The full policy articulation of the Feminist International Assistance Policy (FIAP) provided by Global Affairs Canada (GAC 2017a) is even more revealing, with the first plank described as follows:

As powerful agents of change, women and girls have the ability to transform their households, their societies and their economies. Increasing gender equality can: … deliver strong economic growth … Women already generate nearly 40 percent of the world’s gross domestic product (GDP) and the potential for further growth led by women is relatively untapped. According to a 2015 global study, achieving gender equality around the world could increase global gross domestic product by $12 trillion in a single decade.

The policy also articulates core human rights commitments, such as ensuring human dignity, fighting discrimination, and reducing conflict. However, it is clear that the economic justifications for the FIAP are primary and that increased participation of women in the workforce is the ultimate goal of the policy intervention; this will both generate economic growth and lift women and their families out of poverty. Such a policy focus is not without its merits, and it is certainly progressive in its distinctly feminist orientation. However, this economic orientation is also problematic: (1) it is an ostensibly progressive means to a conventional end – namely, development through economic growth; (2) it remains caught in the same paradox identified by Bueskens (2018) above, wherein women are liberated as workers but further constrained as mothers; and (3) it does not focus sufficient attention on human rights or gender justice.

However, while the FIAP does not, in its foundational commitments, include direct references to women’s reproductive rights as maternal rights, the Trudeau government has made additional commitments to SRHR and MNCH through other initiatives. On March 8, 2017, a press release from GAC (2017b) declared:

As part of its strong commitment to gender equality and a feminist lens, Canada is taking a leadership role by championing the sexual and reproductive health and rights of women and girls globally … Canada’s support will focus specifically on providing comprehensive sexuality education, strengthening reproductive health services, and investing in family planning and contraceptives. Programs aided by this announcement will help prevent and respond to sexual and gender-based violence, including child, early, and forced marriage and female genital mutilation and cutting, and support the right to choose safe and legal abortion, as well as access to post-abortion care.

This commitment included a Can$650 million funding package, aimed at providing a counterweight to global anti-abortion laws, which are mainly the product of increased restrictions on abortion and health care funding imposed by the Trump administration in early 2017.⁷ This policy initiative also stands

in sharp contrast to the policy of the previous Conservative government. While the Conservatives created a multibillion-dollar foreign-aid program for maternal and child health, less than 2 per cent of its budget was allocated for contraception services and it refused to pay for any abortion-related services. (York and Zilio 2017)

When asked about the source of funding for the new commitments,

a spokesman for Ms. Bibeau said that the $650 million will be financed from “unallocated funds” in the government’s existing aid budget for foreign aid. He said it won’t reduce the $3.5 billion allocated for maternal and child health by the previous Conservative government, which has three years remaining in its five-year budget. (York and Zilio 2017)

When the MNCH commitments expire in 2020,⁸ it is unclear whether maternal and child health will remain on the Liberal government’s agenda. If absorbed completely into the FIAP and corresponding SRHR commitments, the specific focus on the maternal subject might be lost, which will have a range of complex consequences. On the one hand, this might correct the pronatalist, conservative bent of MNCH policy commitments. An expanded focus on SRHR under FIAP commitments might allay feminist concerns that the MNCH commitments are essentialist and directed only at women who are pregnant, ready to give birth, or who have just given birth. According to this critique, MNCH excludes the needs of other women and reinforces the patriarchal message that women are only worthy of public benefits and social concern if they are performing maternal roles. The removal of MNCH as a distinct policy focus would prevent governments from capitalizing on the politically virtuous terrain of “womenandchildren” (Enloe 2014, 25).

On the other hand, discontinuation of policy commitments to MNCH might reproduce some of the population control tendencies of the past, in that commitment to SRHR, while in reality a commitment to a broader category of rights and services, often translates to access to contraception and abortion. In the same way that MNCH policy might fail to address underlying causes of morbidity and mortality (such as structural violence and inequality), wider distribution of contraception and access to abortion do not necessarily demand attention to the structural dimensions of gender injustice. In addition, a shift away from a focus on MNCH might further mask the problem identified by O’Reilly (2016) – namely, that women are marginalized in particular ways as mothers, and therefore maternal subjects need consideration for the particular ways in which they are vulnerable in globalized, (neo)liberal societies. O’Reilly (2016, 2) contends that

mothers need a matricentric mode of feminism organized from and for their particular identity and work as mothers. Indeed, a mother-centered feminism is needed because mothers – arguably more so than women in general – remain disempowered despite forty years of feminism.

By the same logic, it might make sense to continue to advocate for distinctly MNCH policies, with commitments to the full range of sexual and reproductive health rights that are inevitably integrated into the determinants of MNCH and maternal survival.

Development partnerships and policy conversions

With the conversion of MNCH into SRHR, community-level partnerships⁹ must facilitate national-level political shifts in policy language and goals. In Guatemala,¹⁰ the Canadian government funds four MNCH programs through its Partnerships for Strengthening Maternal, Newborn, and Child Health (PSMNCH) program. This initiative, announced in May 2014, required applications that demonstrated pre-existing partnerships between Canadian and Guatemalan NGOs. The successful Canadian NGO applicants had deep roots in Guatemalan communities and extensive development experience. These NGOs are Action Against Hunger, CAUSE Canada, Tula Foundation, and Horizons of Friendship. The first two, Action Against Hunger and CAUSE, focus on nutrition, whereas the others focus on mobile technology and access to health information and services (Tula) and community development and midwife training (Horizons). Three of the projects are based on partnerships with communities (Action Against Hunger, CAUSE, and Tula), whereas Horizons has an independent local NGO partner (Pies De Occidente).

In each case, the Canadian NGOs and Guatemalan communities or NGOs have built a partnership based on a shared understanding of MNCH conditions and needs. For example, Pies de Occidente is a Guatemalan NGO that is committed to health promotion, research, and education in the Western Highlands. With a shift to SRHR (some programs were expanded or converted in 2018 and a formal call for proposals was announced in 2019), the basis of the partnership is dislocated. It might be revised or changed completely, but the centrality of the maternal subject is lost with the reconstruction of MNCH as SRHR. If, for example, in the new configuration and call for proposals by the Canadian government, Pies de Occidente does not reconstitute its purposes or organizational focus to align with a broader SRHR set of commitments, then it might not be a suitable partner for Canadian NGO applicants. MNCH might be viable in some contexts (such as Guatemala), although it is contested in others (such as Canada).

In the same way, Canadian NGOs that do not reconfigure their mandates to address the new SRHR focus will not be good candidates for donor funding and program support. The partnership model is maintained with the shift in commitments, but the bases for many partnerships might be lost. Furthermore, the substitution of an abstract, more theoretically inclusive domain (SRHR) for a more concrete, narrow, and easily identifiable subject (MNCH) needs to be questioned. It has the potential to both disrupt stable, community-based partnerships and render invisible maternal subjects (who will continue to suffer from high rates of maternal morbidity and mortality, and various forms of obstetric violence in the Global South).

Many SRHR policies in the Global South seem to focus on the problem of adolescent pregnancy, a narrower issue than either what is fully imagined by the policy domain of SRHR or what was previously included in MNCH policies. This shift is significant, yet it is also important to recognize that the pregnant adolescent represents another type of maternal subject. However, she is quite different from the maternal subject of MNCH policy. First, the pregnant adolescent is not a high-status, socially valued figure; rather, she is a “problem” to be solved by SRHR policy. The pregnant adolescent is the focus of policy interventions in a number of areas and is herself considered to increase the risk of maternal mortality. The maternal subject and the sexual/reproductive subject are distinct and are addressed in policies that are also distinct. These policies, I am suggesting, are converted (from MNCH to SRHR) for political purposes at relatively high levels with consequences for communities (with little or no communication with those communities), or layered (for example, the World Health Organization (WHO) and the UNFPA refer to both MNCH and SRHR policies) in order to accommodate multiple constituencies and policy networks. These processes of conversion and layering (Hacker 2004) have consequences that go beyond policy framing and language and have the potential to affect the lived experiences of women and other reproductive subjects.

However, according to NGO partners in both Canada and Guatemala,¹¹ the shift from MNCH to SRHR does not represent a significant practical shift and might or might not require major changes in plans for existing activities. One NGO program director describes the shift as a “re-branding” that produces uncertain expectations. For example, some partnerships have narrowed their MNCH focus to the SRHR “problem” of adolescent pregnancy, a trend that has increased in recent years and has serious negative consequences for MNCH. However, the same program director explains that in one key MNCH project,

where [the community has] been using smart phones that we’ve deployed, we have Ministry of Health opinions [and guidelines] around promotion, high risk pregnancies, emergency planning situations, adolescent health, all translated into … 13 different Mayan languages. People can [access] those in their own communities in their own language. I won’t say it has solved every problem, but it seems to be hitting a nerve and it seems to be working [to improve MNCH]. We are not quite sure what we can do quite honestly around the issue of sexual reproductive health and rights and especially for dealing with … increasing prevalence in adolescents.¹²

Therefore, in some cases, it seems that MNCH projects are seamlessly converted into SRHR projects, especially in communities where the conversion is a narrowing of focus from MNCH in general to a specific focus on adolescent pregnancy. Yet in others, where the interventions were already narrow and focused, as described above, the conversion from MNCH to SRHR requires different initiatives, areas of expertise, and community capacity.

MacDonald (2019) describes the shift in imagery and political framing of MNCH and maternal mortality from a focus on death and suffering to a focus on hope and aspiration. The subject of the latter is the adolescent girl because she is future facing, uncomplicated, and easy to diagnose and treat with education and public health information campaigns. MacDonald (2019, 276) explains that

the poster child for reducing maternal mortality is literally a child – not a newborn, not a young mother, but an adolescent girl, who, if we succeed in our aspirations for her, will stay in school, get access to information about her reproductive and sexual health, not marry while in her teens, have access to and use contraceptives in her marriage, plan her pregnancies, access a skilled birth attendant in a health facility, and generally experience a level of economic and social equality that we are to imagine her mother’s generation never had.

Moreover, the adolescent girl is a good investment, which reflects the broader “economization of life” prevalent in global health initiatives and elsewhere (Murphy 2017). This neoliberal approach to MNCH and SRHR effectively captures the essence of the FIAP, as described above, although the problems for NGOs working with communities go beyond the conversion of the maternal subject into a wise capital investment (Murphy 2017, 113–132). These problems include the narrowing of policies and programs to focus on adolescents (rather than all maternal subjects), and the expectation that these programs will also address a broad range of sexual and reproductive health services in contexts where these topics (related to lesbian, gay, bisexual, transgender, and queer (LGBTQ) health and rights, for example) are taboo, without providing resources for capacity building. SRHR as a policy field also includes commitments to addressing gender-based violence, a broad structural problem that is related to SRHR and also creates vulnerability to maternal death.

Needless to say, the overarching problem, and the point that I am making in this article, is that the replacement of MNCH policies with SRHR policies, and the replacement of the maternal subject with the sexual subject (in this case, the pregnant adolescent), presents the danger that the real benefits that were delivered through MNCH policies and programs will be replaced by promises that will be difficult to deliver. There were problems with MNCH policies – they were essentialist, pronatalist, and incomplete – and there was a real need to add to them a full range of SRHR. However, the Canadian government seems to have eliminated the domain of global MNCH altogether and replaced it with an SRHR policy that is guided by an FIAP that is committed to a human capital model of empowerment.

Conclusion

While global MNCH policy has been in ascendancy over the past decade, the maternal subject has been in decline. In the Global North, this decline has included the economic and political status of virtually all maternal identities (Bueskens 2018; Stephens 2011), whereas, in global terms, it might signal the end of the maternal health moment and its replacement with SRHR commitments. While global health agencies such as the WHO and the UNFPA maintain commitments to both MNCH and SRHR, the Canadian government, a leader in this policy area, has ended its contributions to MNCH policy. Furthermore, a recent article in the Lancet finds that funding for reproductive, maternal, newborn, and child health reached “the highest amount ever reported,” at $15.9 billion in 2017; child health received the largest share of this amount, then reproductive health, followed by MNCH, which saw a decrease in its total share of aid (Dingle et al. 2020). The maternal health moment, as a single galvanizing global focal point, if not ending, is certainly being eclipsed by other policy concerns. Of course, the shift from MNCH to SRHR brings with it many benefits and addresses many (feminist) criticisms of former and enduring MNCH policies – namely, that they were essentialist and pronatalist, and limited access to other realms of reproductive health care such as to contraception, abortion, and LGBTQ health services.

However, as argued, the shift from a focus on MNCH to a focus on SRHR is also problematic. MNCH is clearly linked, for better or worse, to the maternal subject. The subject of SRHR, by way of contrast, is more ambiguous, as are its goals and purposes. The broader rhetorical promise of SRHR is potentially transformative, but unless it can be harnessed into clear policy objectives and interventions, it threatens to undermine progress toward gender justice. This is particularly true where policy is converted from one set of commitments to another, in the context of economically driven, purportedly feminist foreign policy initiatives (such as Canada’s FIAP), and without consultation with those who have a stake in programs and policy at the local level (such as NGOs and their community partners). In a global policy context where the maternal subject is in decline and SRHR priorities are diffuse (in that they are multiple, not well defined, and politically fraught), prospects for reproductive health in particular, and gender justice in general, might be more elusive than ever.

Acknowledgments

A preliminary version of this paper was presented at the Annual Meeting of the American Political Science Association in Boston, MA, in 2018. The author would like to thank Marc Trussler and the anonymous reviewers for this journal for their comments on this article, and the research participants in Canada, Guatemala, and Mexico who shared their time and expertise.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Funding

This work was supported by Social Sciences and Humanities Research Council of Canada (SSHRC) [grant number: 435-2017-0164].

Notes on contributors

Candace Johnson

Candace Johnson is a Professor in the Department of Political Science at the University of Guelph, Canada. She has conducted research with communities in Mexico, Guatemala, Honduras, Cuba, the US, and Canada, and has published widely on topics related to gender and politics, reproductive rights, maternal health, human rights, and Latin American politics. She is co-editor (with Stephen Henighan) of Human and Environmental Justice in Guatemala, and author of Maternal Transition: A North–South Politics of Pregnancy and Childbirth and Health Care, Entitlement, and Citizenship, and has published numerous journal articles. Her current research examines the transnational politics of maternal health and SRHR, which is funded through a SSHRC Insight Grant.

Notes

1 In Guatemala, I conducted interviews with government officials and NGO directors who were participants in the PSMNCH program of the Canadian government (interviews conducted in 2019). In Mexico, I developed a research partnership with a group of scholar-activists who are working on MNCH and SRHR with adolescents in their communities (interviews conducted in 2019, research ongoing). Details from this empirical research are presented elsewhere. The focus in this article is on the policy context and the consequences of policy shifts for practitioners and community members.

2 The MNCH community is an “epistemic community” (Haas 1992), or “transnational advocacy network” (Storeng and Béhague 2014), which is a constellation of global policy actors, advocates, and researchers who work within the shared thematic space of MNCH policy.

3 The proximate causes of maternal mortality are the immediate causes of death, such as hemorrhage, infection, obstructed labor, high blood pressure, unsafe abortion, and other complications from delivery (WHO 2019).

4 The distal causes include everything from lack of access to skilled birth attendants and emergency obstetrical services to the low status of women in society and generalized gender inequality (Yamin 2013; see also Farmer et al. 2006).

5 Feminists are often suspicious that political commitments to maternal identities in any form are socially conservative, essentialist, and ultimately confining manipulations.

6 Of course, it is important to address both the proximate and distal causes of maternal death. Effective policies must address the technical elements of risk (such as hemorrhage and complications during delivery) and access to health services and providers. However, it is also important for policies and policymakers to understand why some women are at higher risk for complications than others and why some women will not be able to access services even when they are available (due to gender inequality, lack of resources, and low household status and authority).

7 One of Donald Trump’s first actions as President of the US was to reinstate the Global Gag Rule, which restricts funding for US agencies or their affiliates abroad (Center for Reproductive Rights 2017).

8 In 2014, the Canadian government under Harper renewed Canada’s MNCH commitments, this time under the PSMNCH program, the MI’s successor. Partnerships were confirmed in 2015 and have received funding under the Trudeau government. These partnerships are funded for five years under the PSMNCH guidelines (GAC 2014).

9 Canada has adopted a partnership approach to development assistance, which entails federal funding for transnational NGO partnerships. NGOs in Canada that have established partnerships with NGOs in countries in the Global South can apply for various funding initiatives (including Harper’s MI and its successor, PSMNCH, and Trudeau’s new initiatives on SRHR). The benefits of the partnership model include the following: funds are not distributed directly to governments in the Global South, many of which are hampered by endemic corruption and have weak or no relationships with their own populations; donor governments do not have to institutionalize expertise within their own public services, which tends to isolate policy agents from realities “on the ground”; the model facilitates (and often requires) a community-driven set of priorities, as specific priorities are not set at the level of the donor government; and the focus is on determining appropriate interventions within particular and complex community and cultural contexts.

10 The theoretical and normative research presented in this article is part of a much larger project that focuses on the politics of global MNCH initiatives. The empirical component of this research, which is beyond the scope of this article, examines Canadian government commitments to MNCH and SRHR in Guatemala. Guatemala is one of the few countries in the Americas that receive funding and support from GAC (Guatemala is the country with the second-largest number of Canadian government-funded projects in the region, after Haiti).

11 From May 2019 to December 2019, I conducted six in-depth interviews with participants from NGOs and government agencies who work on Canada–Guatemala partnerships.

12 Confidential interview with NGO program director, May 10, 2019.