No abstract

Ethiopia is among the top six countries contributing to the highest numbers of maternal deaths globally. The Ethiopian total fertility rate was estimated at 4.8 in 2011, and the use of contraceptives by married women was 29%. Lack of knowledge, cultural stigma surrounding abortion, and barriers to access of services contribute to persistently high rates of unsafe abortion and abortion-related mortality. This study seeks to assess the generation and institutionalization of political priority for reproductive health within the political systems of Ethiopia. Interviews with key policy makers, government ministers, academics, and leaders of prominent non-governmental organizations in Ethiopia between July 2010 and January 2011 were conducted, using Shiffman and Smith's Framework, to analyse the key actors and ideas behind the shift towards prioritization of reproductive health in Ethiopia, as well as the political context and primary characteristics of the issues that propelled progressive action in reproductive health in that country. Some of the key lessons point to the readiness of the Ethiopian government to reform and to improve the socioeconomic status of the population. The role of civil society organizations working alongside the government was crucial to creating a window of opportunity in a changing political climate to achieve gains in reproductive health. To our knowledge, this is the first time Shiffman and Smith's Framework has been used for reproductive health policies. We conclude that Ethiopian experience fits well within this framework for understanding prioritization of global health issues and may serve as a model for other sub-Saharan African countries.

Guatemala's 1996 Peace Accord ending the 36‐year civil war included the goal to lower its maternal mortality ratio (MMR). Yet, Guatemala still has one of Latin America's highest MMRs, especially among Mayan women. To improve maternal health, the professional midwife is being reintroduced in Guatemala. Meier's Linear Model of the Public Policy Process states that policymakers respond to international and society‐centered forces when making policy decisions. How have such forces influenced the creation of birth attendance policies in Guatemala from 1996 to today? Using a process tracing approach, we analyzed 132 policy documents, peer‐reviewed journal articles, and gray literature noting international and national maternal health recommendations and all birth attendance legislation passed in Guatemala from 1996 to present. International forces advocated for skilled birth attendance (SBA) to address maternal mortality. Society‐centered forces promoted intercultural care with traditional birth attendants (TBAs). Both—sometimes conflicting—forces have influenced policymakers in the creation of maternal health policies in post‐war Guatemala. Policymakers must constantly reconcile tensions between society‐centered realities and international agendas when making policies. The reintroduction of professional midwifery in Guatemala presents a means of addressing both agendas: Increasing SBA and improving intercultural care.

Guatemala plans to open its first government‐sponsored professional midwifery school since 1960. During the new program's design stages, it is imperative to consider possible impediments to the program's sustainability. Schell's Sustainability Framework assesses internal and external domains to consider a program's capacity for sustainability. We conducted in‐depth interviews with Guatemalan key decision makers and professional midwives (n = 7) and matched pertinent open codes from these interviews with Schell's Sustainability Framework's a priori domains. We analyzed the content of the coded segments, triangulating the findings with policy documents, peer‐reviewed journal articles, and gray literature to identify facilitators and impediments to midwifery's sustainability. Recommendations follow. Our study revealed the following internal facilitators for sustainability: strategic planning, program adaptation, organizational capacity, and funding stability. External facilitators such as political support and funding sustainability were also present. The program's poor internal communications and weak external partnerships pose significant impediments to the program's sustainability. Program evaluation and public health impact were not discussed in the interviews, which merits further consideration. At the launch of this important midwifery program, program designers must heed recommendations informed by identified facilitators and impediments to increase midwifery's likelihood of success in Guatemala.