Page 1

TABLE OF CONTENTS
Overview Section 1: Executive Summary Key Findings Messaging Implications Messaging Platform Next Steps Section 2: Full Report of Findings Immersion Exploratory Research Workshop and Creative Collective Validation Messaging Platform Conclusions and Opportunities Section 3: Appendix 3 5 5 10 11 14 15 15 19 33 41 58 62 64

Page 2

OVERVIEW
The United Nations Millennial Development Goal (MDG) Five focuses on improving maternal health with an aim to cut maternal mortality by three-quarters by 2015. For maternal health advocates and many in the global health and development community, MDG Five is often considered the heart of the MDGs, because meeting this goal sets the foundation for the success of all of the other MDGs, especially those related to reducing poverty, improving child health and promoting gender equality. Thus, it is particularly concerning that MDG 5 is cited as the goal that is consistently off-track, with progress on maternal health lagging behind most other MDG indicators. Focus and urgent action is needed to advance progress on maternal health to ensure women not only survive, but thrive and help set a course for stronger generations to come. There are a constellation of factors that contribute to improving maternal health, including access to family planning services, care by skilled birth attendants and antenatal care. However, a consistently overlooked, but essential, part of the solution is access to maternal health supplies. Too often, low-cost, effective and simple health supplies -- such as contraceptives, medicines used during child birth and simple equipment -- do not reach the women who need them. As a result, the UN Commission on Life-Saving Commodities was created in the Spring of 2012 to identify strategies for improving the delivery of essential health supplies, including strengthening local production capacities, promoting new technologies and products, strengthening regulatory frameworks, and enhancing innovative financing mechanisms at both the global and local levels. This initiative is an important step forward and it is anticipated the Commission will release a report in September containing recommendations and a work plan for concrete action on 13 commodities, including three maternal health medicines. But it will take the collective efforts of maternal health organizations and advocates to place the need for increased focus and investments in maternal health supplies higher on the political and policy agenda, ultimately supporting the action and sustained momentum needed in order to save millions of women's lives. It is within this landscape that PATH and its partners sought to further define the advocacy case for improved policies and investments in maternal health supplies throughout the developing world with an effort to create a clear, compelling and consistent message platform. Weber Shandwick and KRC Research were commissioned for this project, developing an approach that included: Conducting exploratory research with maternal health stakeholders and policy influencers to gain a deeper understanding of this nascent issue, including current levels of awareness and perceptions of policy challenges and opportunities Seeking input and consensus across multi-sector partners on the strategic framework for messages, including the identification of audiences, challenges, opportunities, and key themes Drafting a message platform, including both the best evidence-based case for maternal health supplies investments and language that resonates emotionally and inspirationally Testing the messages with global policymakers, influencers and their proxies to ensure that they resonate and most importantly, have the desired outcome

This final report contains the results of this effort. The message platform created through this process is designed to provide a unified framework for advocates to support the case for policies and investments that broaden access to life-saving maternal health supplies. This message platform includes themes, messages and evidence-based proof pointsor concrete examples of success-- to be used consistently across multiple communications channels in advocacy efforts, and wherever possible given the

Page 3

emerging nature of the issue. The power of these messages will truly be brought to life through a targeted and fully-integrated advocacy communications effort. Guided by a strategic communications plan, these efforts might include presentations at international fora, advocacy materials featuring the personal perspectives of front-line health care workers delivering life-saving medicines to the women that need them, compelling story-telling through online video vignettes and through many other channels that reach global policymakers and influencers. It is important to note that this platform is not designed as a one-size-fits-all script, but a consistent framework that still allows the flexibility for partner organizations to tailor specific supporting points and illustrative examples in a way that reflect their unique program or policy perspectives. Additionally, given the emerging nature of the issue, the message platform is a living document, to be updated as the Commission shapes its recommendations and as new supporting evidence or refined policy asks emerge from the advocacy community. Most importantly, these messages ultimately support one unified advocacy goal: demonstrating the value of investments in maternal health supplies, inspiring action, saving lives, and, ultimately creating a lasting impact on women, families and communities around the world.

Page 4

Section 1: Executive Summary

Key Findings
Our Task Weber Shandwick and KRC Researchs assignment was to develop and test maternal health supplies advocacy messages that would elevate the awareness and visibility of the importance of maternal health supplies, and persuade global policymakers and influencers to fund these supplies. The target audience was specified as global policymakers, donor partners (e.g. foundations, multi-laterals, and governments) and other influencers. The messaging objective was also specifically defined as building an advocacy case for policies and investments that broaden access to life-saving maternal health supplies, particularly leading up to and following efforts to support the UN Commission on Life-Saving Commodities recommendations. Our approach Developing strong, persuasive messages for advocacy issues are built on three distinct pillars: Framing Principle: The first component is the framing principle, which is a basic assertion of principle that gets heads nodding and our audiences and our spokespeople on common ground. This is often a statement about what is important, or about the ultimate goal. Its about showing the values that guide us and framing the context for communications. Relevant Facts: The second component is generally factual, which are things we want our audiences to know about the situation that will influence their opinions. Its about making our case, proving our point. This component generally emphasizes basic facts that are readily believed and understood. Impact and Inspiration: The third component answers the question so what? What are the consequences? Its about why the issue is relevant to or matters for our audience. Its about whats likely to happen if we do not support or take action to further civility in public discourse.

Combined, these three pillars; framing the issue with widely held values, making the case with believable facts, and making it relevant to the end audience all lead to powerful and persuasive messaging. They are not complete, however, without a clear and compelling ask or request of the audience, whether that be too broadly support/oppose or to take a clear and impactful action. This is an element we will develop with insights from external stakeholders, and provide counsel on how to best make the ask as part of a proposed communications plan. The most successful communications plans are built on a foundation of clear and actionable research. Research is a critical component to building solid messages that resonate with target audiences, allowing us to observe the environment and test ideas, then providing us the opportunity to refine messages to optimize impact. To that end, we employed a four-part process, rooted in research among both those who would be communicating these messages, and those who we ultimately hope to persuade using these messages. The four-part process included: Immersion and exploration, a partner workshop and creative collective, audience validation, and ultimately culminated with a finalized message platform.

Page 5

Phase 1: Immersion The process of building a messaging architecture that the maternal health advocacy community could utilize to persuade global policymakers and influencers to protect and build upon current investments began with a two part immersion phase. The first part of the immersion consisted of a materials review of nine current documents germane to maternal health and supplies. This included Medicines for Maternal Health, the report prepared for the United Nations Commission on Life-Saving Commodities for Women and Children. The materials review showed us that the main themes in maternal health-related messaging include: Complications of pregnancy and childbirth are among the leading cause of death and illness for women in developing nations, especially those who are poor, uneducated, or live in rural areas. Over half a million women die each year, and millions more suffer serious injury. [Figure has since changed] Bleeding, infection, unsafe abortion, preeclampsia, and prolonged/obstructed labor are the major causes of maternal death. Aside from gender inequality, cost of health services including drugs, distance from health facilities, poor infrastructure of and along the supply chain, and other logistics are key factors that contribute to ill health and death. Overall, the immersion phase educated the team on current messaging being used, allowing us to identify strengths, opportunities and gaps for communications purposes. It also informed us of recent public opinion data on maternal health as well as key thought leadership pieces within the community. The second part of the immersion process was an exploratory research exercise. Weber Shandwick and KRC Research conducted telephonic in-depth interviews with 27 individuals identified as representing key stakeholder audiences, in order to further build understanding on existing perspectives, current

Page 6

knowledge and best practices in maternal health as well as quickly identify current stakeholder priorities, opportunities, resources, competing interests and sensitivities. The 27 in-depth interviews with key stakeholder audiences including global policymakers/donor, foundation partners in administrative health and procurement systems, national-level health policy maker/implementers, peers at other NGO organizations and partners in the private sector corporations with leadership roles in maternal health issues. The interview was conducted over the phone, led by a professionally trained moderator, and lasted approximately 30 minutes. Key findings include: Supplies significantly impact maternal health: Target stakeholders were very familiar with maternal health, meaning supporting a womans health before, during and after pregnancy. Supplies are thought to be a small part of many issues surrounding maternal health, however, it is a very critical one because of the significant impact that access to available supplies can have on maternal health. These supplies offer specific improvements to lower maternal mortality, leading to more family and community stability. Medicines are an essential part of supplies: Important supplies included the medicines oxytocin, misoprostol and magnesium sulfate because those medicines can prevent the two major causes of maternal death post-partum hemorrhage and pre-eclampsia/eclampsia. The effectiveness of these medicines actually gives women a reason to go to the medical facility to receive treatment. The demand for these medicines also provides the need for medical staff to be trained and available to dispense the medications appropriately. Obstacles surrounding availability of supplies are numerous. There are many obstacles to having a stocked supply cabinet, beginning with lack of education on the importance of supplies within national governments. Also posing obstacles are supply chain issues for the delivery of supplies, quality control issues as well as transportation and other issues that physically prevent women from getting to the facility. Progress, however, is attainable: Through education and increased government buy-in for the importance of supplies as well as building awareness on the impact that supplies have on maternal health (leading to increased family and community stability), advocates can work toward policy changes that will increase availability of supplies.

Phase 2: Messaging Workshop and Creative Collective Following the immersion, the team (Weber Shandwick and KRC Research) prepared for an interactive messaging workshop with maternal health advocates from several organizations. The message workshop began with an introduction and sharing of objectives for the session which included: Sharing insights from review of an issue and message landscape; Refining communications goals and target audience priorities; Compiling and prioritizing potential messages that convey the key topics, urgency and value of a maternal health supplies advocacy initiative; and An overview of next steps including testing with key external stakeholders.

Page 7

The team paid careful attention to the thoughtful input of workshop attendees so that the first draft of messaging could take into consideration the important themes that emerged from the working group. The key themes and their implications for messaging included: Messages must educate. Audiences must be shown the importance and need for allocating resources to maternal health supplies, including how supplies connect to the broader issue of maternal health. However, challenges are significant. There is concern over lack of data and research that would confirm the impact of maternal health supplies on maternal health overall and that would provide evidence to prove an unmet need. Education is a key short-term goal, as is aligning advocates. In the short term, the maternal health supplies advocacy community feels it is important to include ensure that the target audience is educated on the importance and the issues surrounding maternal health supplies. Education can help secure additional advocates for maternal health supplies that will in-turn help lead the way for tackling the issue, and ensuring accountability for policymakers and global funders to show responsibility and ownership regarding this issue as one of their goals. Opportunities for increasing focus on supplies are numerous. The most visible opportunity is to utilize is the UN Commission to help bring a strong voice and a clear set of policy-focused next steps to the cause. In addition, tools from the reproductive health advocacy community can be adapted and used for models, secondary research such as case studies and pilot programs can help illustrate impact and there are numerous gatherings and meetings within the maternal health advocacy community that can provide a platform to extend the dialogue. Making maternal health supplies available will still face challenges. Past experience shows that it will be difficult to engaged national decision makers into meaningful conversation about making supplies available, and, getting a commitment that truly translates into stocked supply cabinets. Availability of supplies will continue to face systematic challenges within the supply change. Also a challenge is the lack of quantifiable data illustrating the gap in supply and demand. And, these three items can pose significant obstacles to our end goal. Pair the humanistic voice with an economic voice. When it comes to messaging on maternal health supplies, theres room for a humanistic voice, as well as an economic voice. The group would like to enter into the maternal health supplies conversation through the prism of the larger maternal health issue. The humanistic voice addresses what supplies can do for maternal health, how they can truly save a life, and that no woman should die while giving life (especially when a large number of the deaths that occur are from preventable complications). Economic angle is attractive and effective. The economic voice addresses how supplies help bring about a return on investment within other areas of maternal health, although specific proof points may need further development. Women=family=community=nation. Messaging should explore the connection between maternal health and childrens health, the entire family unit and the community as a whole, showing the true impact that women can have. This is a claim that feels logical and believable, but finding data to support could be difficult.

With learnings from the immersion phase and workshop, the team began to draft messages with which they shared with Weber Shandwicks own creative collective group of global communicators who work on issues directly or indirectly related to maternal health. This yielded a level of insight and expertise that aided us in refining words and phrases to increase impact of the statements.

Page 8

The Creative Collective is a group of 12 creative directors and global health and social impact leads from across Weber Shandwicks global network. The Creative Collective includes branding, consumer marketing, digital and advertising experts from the US, Canada, UK, Africa, and Europe. The message brief along with the key messages and proof points were posted in the creative collective to learn what resonated and what did not across this audience. Respondents engaged in a robust online discussion during the response period and built on each others opinions and the conversation.

Phase 3: Validation Following a review and refinement of the messaging architecture, the validation process began. Its here where Weber Shandwick and KRC Research tested the messaging with the target audience, which included individuals who work as global policymakers and donor or foundation partners in administrative health and procurement systems, peers at other NGO organizations and partners in private sector corporations with leadership roles in maternal health issues. In total, nine individuals partook in the validation phase. The interview was conducted over the phone, led by a professionally trained moderator, and lasted approximately 30 minutes. The interview was blinded, meaning the participant did not know the sponsor of the research. During the course of the interview, the participant was asked to provide feedback to the overarching theme guiding advocacy for increased investment in and prioritization of maternal health supplies and test potential messages that convey the value of investment in priority maternal health supplies. During this exploratory exercise, the participant was asked to talk about important themes surrounding maternal health (including maternal health supplies) as well as provide feedback on the various messages and statements that comprised the draft messaging architecture. (The tested messages are included in the Appendix D for reference.) Key findings include: Our audiences of global policymakers and influencers need messages that educate on the importance of supplies illustrate the value of the investment, show commitment and partnerships globally. The short term goal/ask is to elevate the importance of funding supplies. Similarly the long term goal was to secure funding. The overarching theme is accurate, believable, contains powerful word in essential but it needs a more direct or strong statement to engage in what comes next. The supporting statements include emotion as well as facts and information. They also educate on the importance of supplies. The themes convey important points, introduce new arguments for supplies, and provide something for everyone in the audience. They need some refined focus to emphasize the importance of availability of supplies, and a more politically correct way to discuss partnerships.

This knowledge led to implications (described in messaging implications) for messaging that ultimately aided the refining and finalizing of the messaging platform.

Page 9

Messaging Implications
Education brings clarity. While the value of maternal health supplies is logical for many, it is a newer focus in maternal health discussions, and there are curiosities surrounding what constitutes maternal health supplies, what exactly makes them hard to attain, and why they are so critical. Educating on the importance, the need, and the lack thereof builds impact, because the audience then understands more about making maternal health supplies available. Lead with impact. The audience wants (and needs) to feel impact at the onset of the overarching theme. The audience agrees: supplies save lives. This gives them a reason to focus in on the importance and need for supplies. They need to hear that explicitly, and immediately. Even though there is no direct ask, there can still be a call to action and conveyance of impact. Bring everyone along. As we observed in the exploratory research, coalition-building with national governments and international policymakers is essential for truly making maternal health supplies available. Without these groups taking an interest, and making a commitment to the issue, impact wont be long-lasting. To that end, consider wording and phrases that help bring everyone along vs. isolating. Let economics support the moral argument. The audience appreciates messaging that speaks to the moral imperative of caring for women. The economic argument brings a fresh (and welcome) perspective to the issue that can be a vehicle for conveying the moral argument. These supplies save womens lives for small amounts of money, and they provide the tools that health workers/facilities need to make those investments pay off.

Page 10

Messaging Platform
SUMMARY STATEMENT Investing in Essential Supplies Saves Lives and Improves Maternal Health

Becoming a mother is usually a special, joyous event. But for many women in developing countries, childbirth can be life-threatening. Can you imagine a woman in labor arriving at a clinic to deliver her baby only to find that the basic medical equipment, medicines, and health staff arent there? Ensuring access to basic maternal health care will prevent hundreds of thousands of women from dying during pregnancy and childbirth and ensure they and their children live healthier lives. Access to essential maternal health medicines, including items such as medicines, contraceptives, and simple equipment used during childbirth are often a hidden part of the solution. Having a healthy pregnancy, childbirth and the opportunity to see your children grow up healthy should not be a matter of where you live or your economic status. It should be a universal right for every woman, everywhere. The good news: this goal is achievable. Working together, global leaders, national governments and maternal health advocates have the power to elevate the critical role of maternal health supplies in protecting womens lives during pregnancy and childbirth. Policy leadership, matched with additional funding for proven, low-cost maternal health supplies, can improve maternal health and save millions of lives worldwide. Healthy mothers have a powerful ripple effect. To save a mother is to save a family. And to save a family is to lay the foundation for stronger communities and more stable nations. No Woman Should Die Giving Life Essential Supplies Save Lives Leadership and Investments in Saving Mothers Means Stronger and Improve Maternal Maternal Health Supplies Matter Families, Communities and Health Nations
The solution to safe pregnancy and childbirth for women in the developing world begins with access to basic health care, including maternal health supplies. Increasing the availability of supplies is essential to saving lives and improving maternal health, especially during pregnancy and childbirth. Global leaders and national governments have the power and responsibility to protect womens lives during pregnancy and childbirth with greater leadership and additional funding for maternal health supplies. Healthy mothers have a powerful ripple effect. To save a mother is to save a family.

KEY THEMES

SUPPORT

Page 11

PROOF & EVIDENCE

At the heart of good maternal health care is a set of basic, low-cost, but essential supplies that includes items such as medicines, contraceptives, and simple equipment used during childbirth. Each year approximately 287,000 women 99 percent of whom live in developing countries die from pregnancy and childbirthrelated complications. That means one woman dies every two minutes from pregnancyrelated complications Experts estimate that with access to basic health care and proven interventions, the leading causes of maternal deaths are largely preventable. These include: severe bleeding after childbirth; high-blood pressure during pregnancy and infections. Having a healthy pregnancy, childbirth and the opportunity to see your children grow up healthy should not be a matter of where you live or your economic status. It should be a universal right for

The important role of essential maternal health supplies and medicines can be hidden in the face of larger health system challenges in low-resource settings. Maternal health supplies and medicines need to be stocked in health clinics, in the hands of trained health care workers and ultimately delivered appropriately to the women who need them in order to save lives. Three proven, low-cost medicines oxytocin, misoprostol and magnesium sulfate have the potential to save the lives of mothers worldwide, making their accessibility and availability critical during pregnancy and childbirth. Each of these three medicines costs less than US$1.00 Contraceptives are an essential element of maternal health. Essential, lifesaving equipment such as

New global leadership is highlighting the need to improve the availability, quality and impact of proven, low-cost medicines through the UN Commission on LifeSaving Commodities for Women and Children. Coordinated approaches and increased innovative partnerships, as exhibited by the successes of pooled purchase and delivery of vaccines and medicines to prevent HIV, would dramatically improve the impact of low-cost supplies and save more womens lives. Prioritizing funding for maternal health supplies will provide a significant return on the other investments made in maternal health and maximizes the potential impact of health care workers. Reliable availability of maternal health supplies and medicines will strengthen health care systems and make frontline health workers more effective. There is a powerful opportunity to save many more lives and improve maternal health through

From the cradle, to the classroom, to the workplace and community, a healthy mother can mean a world of difference for her child and her family. When women survive and thrive after childbirth, they can increasingly impact change and economic development in their communities and ultimately their nations. There are many complex challenges to improving maternal health, but policy leadership, matched with additional funding for proven, low-cost maternal health supplies, can set off a powerful ripple effect, saving and improving millions of lives worldwide.

Page 12

every woman, everywhere. An essential part of ensuring a woman survives pregnancy and childbirth includes access to maternal health medicines and other supplies.

catheters and urine bags needed for women during childbirth particularly difficult labors cost approximately US$3 The solution is within reach: Delivering a package of services, including essential supplies, is estimated to cost less than US$1.50 per person in the 75 countries where 95% of maternal mortality occurs

policy leadership matched with much-needed investments in supplies.

Page 13

Next Steps
A message platform is most effective when providing a unified framework, with themes and messages to be used consistently across multiple communications channels. Message platforms are always living documents, but given the emerging nature of the maternal health supplies issue, some specific opportunities and next steps include: Continuing to collect and refine additional proof-points that support each message, and bring new evidence or examples to strengthen each element of the messaging architecture, including partner organizations tailoring specific supporting points and illustrative examples in a way that reflect their unique program or policy perspectives. This effort may also involve identifying and prioritizing the need to generate new research or supporting data to strengthen the evidencebased case. Refining and tailoring the messaging for specific events, opportunities, or appeals as the policy and advocacy landscape shifts. Similarly, working with the Maternal Health Supplies Working Group and other members of the advocacy community to clarify both the policy ask and the funding ask, keeping in mind that as milestones such as the release of the UN Commissions recommendations in September 2012 are reached, these asks will be further refined. Bringing the messages to life through a targeted, strategic communications plan, fully integrating them into the work of the maternal health advocacy community.

Additionally, given the more technical nature of maternal health supplies policy issues, as well as the relatively small, but influential, target audience of policymakers and funders who can have the greatest impact on the issue, a stakeholder mapping exercise would be an effective approach toward developing a more comprehensive maternal health supplies advocacy strategy for message delivery. This effort would build on the initial research conducted with policy influencers to inform the message development process, but focus on how best to reach and have an impact on these audiences. Stakeholder mapping includes: Comprehensively identifying the major stakeholders and influencers (either organizations or individuals) in civil society, bilateral and multilateral organizations, donors, policy circles, the philanthropic community and private sector Assessing and prioritizing their relative importance/impact Providing a strategic road-map for advocacy outreach, including best channels of reaching and influencing these stakeholders (e.g. conferences, academic gatherings, influential publications)

Page 14

Section 2: Full Report of Findings

Immersion
The process of building a messaging architecture that the maternal health advocacy community could utilize to persuade global policymakers and influencers to protect and build upon current investments began with an immersion phase. The immersion phase educated the team on current messaging being used, allowing us to identify strengths, opportunities and gaps for communications purposes. It also informed us of recent public opinion data on the topic as well as key thought leadership pieces within the community.

Methodology & Approach

The immersion phase consisted of a top-line review of selected publications and public opinion research on maternal health-related topics in order to build on our existing knowledge of maternal health advocacy issues and sector-specific best practices and avoid reinventing the wheel. This phase allowed us to quickly identify internal priorities, opportunities, resources, competing interests and sensitivities. In preparation for developing messages for use with advocacy partners, PATH shared nine documents to aid immersion into the topic. These maternal health topics include information surrounding leading causes of maternal death due to complications of pregnancy and childbirth including bleeding, infection, unsafe abortion, preeclampsia and prolonged or obstructed labor, information about how the cost and distance from health facilities affects mothers as well as information about the drugs oxytocin, misoprostol and magnesium sulfate. A full list of these materials can be found in Appendix A.

Summary of Learnings
These articles, along with a review of public information on PATHs website and conversations, are indeed useful tools for understanding the dynamics of issues surrounding maternal health, maternal deaths, and maternal health supplies. They have illustrated what is currently known, and what is essential to learn from stakeholder interviews. The four main knowns and need to knows are summarized in the chart below. A larger explanation of the findings follows the chart.

Known: Need to know: Issue of maternal postpartum Is this an issue that warrants broader deaths has grown out of larger attention? What makes it important? global strategies for women and Is this an issue where the maternal health childrens health, and has advocacy community can make a difference? received additional attention Whats considered success or a win? from advocates and global health experts recently Incidence of maternal deaths Designated medicines, virtues and drawbacks of each Are these considered the right drugs for reducing maternal postpartum death?

Page 15

Known: Current access to drugs

Need to know: What can be done to illustrate the virtues of these drugs, and that they are the right drugs so that there is a true cause for increasing access to them? What global mechanisms can be leveraged to increase access to drugs? Are these the right action items for moving down the path? Will these conjure support for funding studies to reduce barriers (below)? What does the outcome of these action items mean for the greater communities within developing nations? To what extent is each of these barriers? How limiting is not having this type of research? What is the community willing to do while these remain unknowns? What elements does messaging need to include to conjure up support for research to fill gaps?

Action items for expanding access to medicines (as described in Medicines for Maternal Health report)

Key barriers to success include lack of research on needs, gaps, systems and financing for medicines Inconsistent medical care/lack of skills also a barrier

Expanded Summary of Learnings

These materials reveal much about the origin of the UN Commission on Life-Saving Commodities for Women and Children, the progress of the Maternal Health Supplies Working Group, arguments for maternal health being part of reproductive health, and, ultimately ways in which critical medicines can be made available to women so as to avoid two major causes of death.

Page 16

The immersion materials provide essential documentation of the facts surrounding maternal death: Complications of pregnancy and childbirth are among the leading cause of death and illness for women in developing nations, especially those who are poor, uneducated, or live in rural areas. Over half a million die each year, and millions more suffer serious injury. [Figure has since changed] Bleeding, infection, unsafe abortion, preeclampsia, prolonged/obstructed labor are the major causes of maternal death. Aside from gender inequality, cost of health services including medicines, distance from health facilities and other logistics are key factors that contribute to ill health and death.

They also provide essential background on the three chosen drugs that PATH is looking to build a stronger advocacy case for in key countries. Oxytocin, a medicine for minimizing postpartum hemorrhaging is extremely effective, but must be stored in specific conditions to preserve its effectiveness. It also requires a health professional trained and authorized to administer the drug. These two elements make it difficult for women in rural areas to receive the drug if in need. Misoprostol, a medicine that can be a substitute for oxytocin for postpartum hemorrhage, does not have the same storage or administering requirements, and therefore is an option for women in rural areas, or when oxytocin is not available. However, it is also associated as an abortion agent which makes some countries reluctant to recommend its use. Magnesium sulfate is a medicine for reducing high blood pressure. High blood pressure can lead to preeclampsia/eclampsia. The WHO recognizes this drug as the safest, most effective and cost-efficient way of treating preeclampsia/eclampsia. Each treatment requires multiple vials of the drug, and is administered via injection.

In looking at case studies from Uganda and Bangladesh, there are country-specific challenges worth noting: In Uganda, availability of supplies truly is limited even though the government is widely viewed as committed to maternal health. Poor financing is only part of the issue. Supply chain issues are a reality. Even though country policies address the need to have more deliveries at health facilities, weak supply chains do not yield the supplies that a facility needs. In Bangladesh, a major challenge related to the supplies issue is the low rate of facility delivery (only 15%) and skilled attendants at birth (18%). While the government is described as supportive of maternal health, many stakeholders feel that this has not translated into additional capacity or funding for maternal health supplies. Additionally, the government only has one procurement cycle per year, leaving many facilities low on supplies at various points during the year. Supplies for maternal health are also not generally funded by development partners.

The immersion process clearly illustrates the proposed action items, the challenges that face action, and background surrounding policy, regulatory, supply chain and manufacturing, and financing issues. All this information is a strong primer for the key elements: Attitudinally, motivationally, emotionally, as well as programmatically, what will bring about change with regard to access to these medicines and other supplies as a way to reduce maternal death?

Page 17

Which global mechanisms are best to leverage as conduits for change in this space? What levers does messaging have to pull to bring about action within the maternal health advocacy and broader global health and development community? How can success best be defined?

The content of the discussion guide was heavily influenced by the findings of this immersion phase. The findings will also help interviewers effectively listen for and probe accordingly on specifics related to maternal deaths, medicines and other supplies, global mechanisms and ways of achieving success while speaking with stakeholders.

Page 18

Exploratory Research
This section summarizes the in-depth interviews conducted among key target audiences in order to explore the important themes and topics in maternal health. These interviews were used to identify current stakeholder priorities, opportunities, resources, competing interests and sensitivities, to help inform the policy and political landscape for the issue and to reveal elements and angles that are important to capture in messaging on the topic.

Research Objectives & Methodology

KRC Research and Weber Shandwick conducted 27 one-on-one in-depth interviews (IDIs) of the key target audience between March 12 and March 28, 2012. Our key target audience was defined as individuals who worked as global policymakers and donor/foundation partners in administrative health and procurement systems, national policymakers, peers at NGO organizations and partners in private sector corporations with leadership roles in maternal health issues.1 A more complete listing can be found in Appendix B and a sample of the pre-notification letter sent to these stakeholders can be found in Appendix C.

Overview of Findings
Overall, we learned that: Maternal health is a topic area with which the targeted stakeholders are very familiar. At its core, maternal health includes supporting a womans health before, during and after pregnancy. However, there are differing opinions regarding the duration of care and type of care encompassed. Maternal health supplies are perceived to be a small part of many, many issues that constitute maternal health; however, they can still have a critical impact. In many ways, supplies address the challenges implicit in issues related to maternal health keeping women alive and healthy during and after pregnancy. Supplies such as oxytocin, misoprostol and magnesium sulfate: o Address two major causes of maternal death, post-partum hemorrhaging and preeclampsia/eclampsia. Give women a reason to seek out medical assistance in labor and delivery, or go to a medical facility. Provide the need for trained health care professionals and/or skilled birth attendants (medicines to administer, reason to seek out trained assistance).

Supplies are important because they are specific ways to bring about improvements in maternal health; subsequently reducing maternal mortality means fewer motherless children, more family stability, and greater community stability. There are a number of obstacles facing access to maternal health supplies themselves, starting with getting governments to consider these medicines important. Beyond that, there are also supply chain issues in delivery of the medicines and other supplies, quality control issues, and struggles with an expectant mother being able to physically get to a health care facility. Stakeholders highlighted the multiple actions that need to be taken to minimize these

1 Interviews included: 7 bilaterals/multilaterals, 2 foundations, 6 government donor country influencers, 10 NGO/policy centers and 2 private sector

Page 19

challenges, and most start in the same place getting the right people to fully understand the impact that maternal health supplies has on womens health. When governments know and care about the impact maternal health supplies can have on maternal health, and see the bigger picturewhat maternal health means for the family and community, putting in to place policy to make supplies a reality becomes more obtainable. Along that path, however, maternal health supplies will incur the same challenges that other supplies and medicines incur. In-country supply chains are limited and do not support the needs of the community. There are issues that span from transportation of medicines, supply chain management, to knowing how to monitor the supply cabinet and when to place orders. PATH and members of the Maternal Health Supplies Working Group bring an advantage to this space. Their technical expertise in other areas can greatly benefit its work on maternal health supplies.

Definition of Maternal Health and Key Issues in Space

Issues and challenges surrounding maternal health are numerous. Some are more tactical, related to access and availability of supplies as well as medical professionals. Others pertain more toward current mindset, or more system-wide issues. At its core, maternal health refers to providing care to support a womans health before, during and after pregnancy. Stakeholders also attach additional meanings to the term, in addition to the core understanding. Some stakeholders also include the health of women in their childbearing years, from age 15 to 49. Others shared that maternal health spans from conception through six weeks after birth, or until the mother is no longer carrying primary responsibility for the health of her children. For some, maternal health also includes safe abortion where legal, contraception, reducing or preventing maternal death and morbidity, or even ensuring the newborn survives delivery. Preventing and/or managing preeclampsia and post-partum hemorrhage is frequently referenced with supporting maternal health. Nearly all think of maternal health as specific to giving or providing care. A select few held the perspective that maternal health is a state of being.

Page 20

There are a myriad of issues within the maternal health space, but one clear theme emerged: providing access to quality care is a big challenge. The lack of access to quality care spans many different avenues including having health professionals to provide care, physically being able to access the services, and having supplies necessary, including blood, medicines, and commodities. Stakeholders talk of a shortage of trained workers such as nurses and midwives. They also talk of cultural or physical obstacles that prevent access to care, especially when it is most needed during pregnancy and within the first 24 hours after birth. These barriers include being in a remote location and having to travel far distances with a lack of good, reliable transportation. Some mentioned the need to bring their own supplies to the clinic for labor and delivery. Its here, when discussing access to care, that many include supplies associated with maternal health. Supplies include medicines, equipment, blood, and even consumables such as gloves, gowns, syringes, wound dressings, etc.

Underlying these issues are larger ones. Maternal health has been overlooked until recently. Funding is also a struggle, as is infrastructure (having hospitals, care centers, warehouses for storing supplies) and having a framework and system in place to incorporate pilot programs into a standard medical regime. Stakeholders share that global attention is on HIV/AIDS and malaria, not on maternal, child and newborn health. Also, many countries themselves do not prioritize maternal health. Some share that the attention should be placed more on family planning vs. maternal health. A few stakeholders that worked on pilot programs shared successes of the actual program itself, but said that the country/region was not equipped to take over the program and therefore there was no lasting impact of the program.

Maternal Health Supplies Awareness, Importance, and Major Players

Stakeholders themselves admit to lacking the most current information on maternal health supplies, and many profess to not being experts. This later inhibits stakeholders from offering up more tactical or policy-related solutions, and suggests that stakeholder education is an important component in building support for this issue. Without having as much knowledge as they would like, stakeholders still immediately see the critical importance of maternal health supplies, indicating that little convincing has to be done as to why supplies should be part of the conversation within maternal health. Familiarity with maternal health supplies ranges from vague to more comprehensive. Many, despite familiarity, profess they are not an expert in this area. Those less familiar recognize the reference, and know that supplies are an important part of the larger issue. Those somewhat more familiar offer up commentary about what makes them important, and challenges associated with providing supplies. Those with the most familiarity tend to heavily stress the importance of supplies within maternal health. Without the supplies there cant be a service. Many, across familiarity, feel they are not as up-to-date on whats going on specifically with supplies, yet they understand the importance and need of commodities being at the right place, at the right time. And too, stakeholders were willing to share that they are not experts on this

Page 21

topic, meaning they do not know enough about the nature of the problem or potential solutions. Maternal health supplies are an integral part of maternal health. Supplies are a small piece of a larger issue; however the small piece is a critical component that holds potential to impact the issue in a much larger proportion. More specifically, three medicines, oxytocin, misoprostol, and magnesium sulfate, are critical for addressing two major issues within maternal health, post-partum hemorrhaging and preeclampsia/eclampsia. Stakeholders did not refute or take issue with any of these three medicines being important supplies. Not only do these medicines provide a solution to major medical issues, their availability gives women a reason to seek out medical attention. They also provide a reason for there to be trained health professionals to administer. Remembering that access to care is a top issue for getting women medical attention, some explain that the three areas for improving access are training professionals, providing supplies such as medicines, and getting women to a health facility. There are models in place for training professionals, and therefore the next item on the list is to make supplies more available, which holds the potential to justify a trip to a health facility.

USAID, UNFPA, and the UN Commission on Life-Saving Commodities for Women and Children top the list of key players in the maternal health supply space, according to the survey participants. USAID was listed by a quarter of stakeholders, followed closely by the UN (and more specifically, the UN Commission on Life-Saving Commodities for Women and Children), WHO and UNFPA. JHPIEGO and the Partnership for Maternal, Child and Newborn Health also received multiple mentions.

Challenges Facing Maternal Health Supplies (MHS)

Challenges begin with getting the appropriate people to understand and care about providing maternal health supplies, and drawing the connection between that and a positive impact on community. Then, more tactical challenges can be addressed. It is also important to be mindful of those barriers that are not specific to maternal health. Maternal health supplies will encounter the same system-wide availability complications that other drugs encounter that stem from poor supply chain management. There are two types of challenges facing maternal health supplies; those specific to maternal health supplies and those more system-wide. The system-wide issues appear to be the more challenging, harder to overcome issues.

Page 22

Top on the list of challenges specific to maternal health supplies is making this topic visible and relevant to national governments. Ministers of Health and other leaders need to be educated on the need for these supplies and the impact they can have. The challenge is showing the impact that fostering maternal health can have on the family, the children, and the community. Maternal survival means children grow up with their mother, leading to greater family stability, and greater community stability. Some also share that supplies arent as sexy as other topics. Other challenges include the proper storage and administration of oxytocin, the misuse of misoprostol, and bureaucratic hurdles surrounding the use of misoprostol in countries where it is currently illegal (most African countries). Procurement of medicines and lack of training for administrating medicines is also mentioned, though much less so than other challenges. Maternal health supplies are also subject to system-wide issues which stakeholders describe as hard to overcome. Countries are ill-equipped to manage an effective supply chain and monitoring usage to predict need. And too, transport of medicines from warehouses to medical facilities is also a threat to the supply chain, as distances can be long and roads unsuited for travel in poor weather.

Methods for Addressing Challenges to Providing Maternal Health Supplies (MHS)

Unaided, stakeholders most frequently offer up advocacy as the main method for addressing challenges in providing maternal health supplies. In their minds, making this an issue of importance is the first step to getting these supplies in medical centers or with skilled birth attendants. Stakeholders struggle to offer up specific policy implications or global mechanisms for addressing challenges unaided. They tell us that the first step really is advocacy, or, that they are just unsure as to next steps. Aided, stakeholders find value in the specific policy implications and global mechanisms that we tested. Cost-wise, increasing funds by national governments and donor organizations is highly important, and a reason to advocate for the medicines being placed on the essential medicines list in countries.

Page 23

There are a number of ways that stakeholders felt the issues surrounding maternal health supplies could be addressed, but the foundation of each of these suggestions lie in providing an increased understanding and a hook to ensure support from key groups. The need for collaboration among multilaterals, donor government entities, national government entities and advocacy groups was a strong theme across the interviews. Partnering together can actually make changes and advocacy groups that can help work toward change. In order for national governments to take this charge as seriously as they should, they need an increased understanding of why this is important and how this will impact communities. One stakeholder mentioned that advocacy to maternal health needs to be unpackaged. All the various aspects of maternal health need to be individually understood the need for skilled birth attendants, the need for updated facilities, the need for proper equipment and supplies, everything needs to be thoroughly explained in a way that makes the key groups (government and the like) understand how it will impact their agenda and why it is important for it to be a priority. A few stakeholders cited the need for a commission to take charge and lead the way on the initiatives to help focus on which specific needs need to be tackled first and then provide some accountability on the back end to make sure that those needs are actually addressed. There currently is no ownership of all the various elements that are connected to maternal health supplies. In a similar vein, channels of communication need to be very open between the advocacy groups and the people that are more involved in the day-to-day operations on the ground, including implementing partners, program drivers and provider networks in developing countries to make sure that advocacy groups have a clear picture of what is actually taking place. Other ways to address challenges include, providing training for medical staff on supply chain and inventory management as well as medical training, conducting more research on commodities, investing in health systems and providing funding for medicines. Stakeholders struggle to offer up more specifics, unprompted, surrounding policy implications or global mechanisms for increasing support for supplies. Their current knowledge, coupled with their belief that others need to care more about this topic, seems to limit their assertions as to what else needs to be done.

Page 24

Stakeholders heard up to four of eight potential methods for addressing challenges related to the availability of maternal health supplies (two availability-related, two cost-related).

Availability-Related Challenges Potential Method Providing data on both the unmet need for maternal health supplies as well as available financing for supplies. Relevance Relevant, though very few were aware of a lack of data in this area. Some organizations that have developed a list of essential supplies and equipment that should be available at health facilities depending on the level of care that they provide. One stakeholder recommended that you start with a commitment to creating budgetary line items at the country level, based upon research surrounding unmet need. Others mentioned demographic surveys, gap analysis further down the road. Relevant, but not a first step. This comes after advocacy, perhaps providing data and even after quality assurance. Countries need to ensure the safety of the medicines, ensure they are registered. It is suggested that cues be taken from other efforts when it comes to accelerating adoption and scale up of maternal health supplies, look to malaria or child vaccines in order to prevent reinventing the wheel. Relevant, but not a first step. Challenges/Limitations Figuring out how to get the people and products together at a place that women are coming to is the big issue. Data must capture that. While some stakeholders indicate that not enough data exists, one stakeholder addressed a concern that there comes a time where we need to do the best with the data that we currently have to then spend the money on solving the issue rather than collecting more and more data. Many steps come before this step. Need a model that works and takes into consideration data showing unmet need in supply and financing. Need to generate credibility within country before.

Accelerating adoption and scale up of maternal health supplies.

(note, fewer participants asked/able to address this item) Ensuring quality

Expense National lab and quality

Page 25

Availability-Related Challenges formulations of the medicines are widely available and used. Explore problems not just in manufacturing but along the supply chain and facility storage (especially given what a challenge supply chain poses). FDA is a player. Drug Regulatory Authorities in individual countries are also players. assurance is very expensive. WHOs prequalification process is too slow. Drug regulatory authorities can have problems with funding, being understaffed and under-skilled.

Regulating the quality and usage of medicines across countries for quality assurance purposes at a national level, yet with global accountability.

Relevant, but not a first step. Come up with policies to regulate the import of medicines within individual countries. Then work to monitor the implementation of policies. Global accountability. Association of Physicians or Pharmacists and Ministries of Health, and country presidents can implement policies and monitor the implementation of these policies in the areas of importing, training and dumping. Alliances such as: African Alliance for Malaria also can advocate for the value in regulating the quality and usage of medicines across countries.

Right now very weak as a community. Need to understand needs to come up with policies. Needs to be addressed at the national level, yet at higher political level as well.

Page 26

Cost-Related Challenges Potential Method Increasing funds contributed by national governments for maternal health supplies. Relevance Highly relevant, and enabled by showing the value of investing in MHS. Should document the gap that exists in each country and show the impact that it creates, including the number of women who are dying each year because of it. Need to ring-fence (protect) funding around commodities. Generally, make sure medicines are a part of the essential medicines list because government can distribute more funds to it. Relevant, and can have impact. Increased advocacy by implementers and individual countries. Showcasing what Millennium Development Goals provide. One stakeholder said that maternal health supplies is somewhat of a late-comer so focusing on this now is very positive. Individual countries still need to acknowledge maternal health supplies as an issue; otherwise donor contributions wont have a lasting impact. While its OK to have funding globally, it cant be in place of a government taking responsibility and deeming this an important area. Challenges/Limitations Getting governments to care about maternal health supplies, showing their relevance

Increasing funds contributed by global donors for maternal health supplies.

Page 27

Cost-Related Challenges Ensuring larger purchase volume and more consistent quality. Relevant. Important to have the capacity to distribute and meet need. Need more bilateral and multilateral donors & discussions with manufacturers. One stakeholder reported trying this but that the long-term contracts that came with bulk procurement did not work. Another mentioned that while there is a need to have more discussions with manufacturers, ensuring larger purchase volumes is difficult due to skills in predicting and planning for need. One stakeholder commented that trying to pool and hold until you can negotiate is wrong because there is a disconnect between consumption and demand. There are different mechanisms for financing. Examples already in place include: take another issue, pool other mechanisms, government funding or specific funding for the drugs and supply management at the country level.

Pooledprocurement at global/regional and/or national level.

Feels relevant, but many could not speak to this. Different strategies have already been defined.

Page 28

The WHOs role in Maternal Health

The WHO is seen as an organization that can help amplify the message to national governments (a key element in addressing challenges on this issue) and can provide the necessary accountability for moving forward with policy implementation. Stakeholders sentiments about the WHO largely echoed what they suggested to be done to overcome hurdles and barriers to increasing support for maternal health. The WHO should help provide crucial understanding to national governments and other organizations to ensure that maternal health is a priority by utilizing policies that are in place, such as the essential medicines list and continue their work by monitoring the roadmap to maternal health that has been created, bringing much needed accountability to the space. Stakeholders felt that policies were already in place but that it is important to bring continued understanding to national governments and other organizations such as UNFPA, UNICEF, WHO, and UNAIDS who have influence on policymakers and implementers. One stakeholder mentioned that it would be beneficial if staff from this organization had specific direction and authorization from their headquarters to make the conversations about maternal health and maternal health supplies a high priority. Several stakeholders mentioned WHOs role in putting out the essential medicines list and the importance of this list. While this list exists, one stakeholder mentioned the importance of WHO to clearly articulate what the important medicines are for this. Another also mentions the need for WHO to work closely with drug manufacturers to leave no stone left unturned in search for cheaper, generic drugs. Accountability is another theme that stakeholders mentioned. There is a need to monitor the policies for the governments and other stakeholders to ensure that commitments that have been made are being honored. One stakeholder mentioned that if the existing commitments were monitored and implemented then a large part of the problem would be addressed. One of the barriers to keeping everyone accountable is that prioritizing has to occur and that is very difficult when dealing with competing priorities in health and limited resources. Some also mentioned the need for more integrated medicine policies. Showing support for the issue is also seen as a theme. Some stakeholders believe that this support should be shown at the country and even the community level, through work with organizations of influence, as stated above, while others believe it should be at the UN level. Making sure that everyone is committed should be a priority, through increased budget, and increased training.

Types of Innovations: Focus for Future R&D

Aside from advocacy, its the supply chain that is most commonly mentioned as an area to address, including innovation. And, supply chain is an issue that plagues not just maternal health supplies. Potentially, there are innovations and/or solutions for providing maternal health supplies that can then apply to other types of medicines and other supplies.

Page 29

Getting stakeholders to set aside advocacy as a focus is difficult, and it even surfaced when asked what types of innovations relative to maternal health supplies development and delivery should be a focus. Many stakeholders struggled to answer questions surrounding innovation, largely due to not having the knowledge to support foresight into what innovations could be worthwhile. Some who found this difficult to answer shared examples from other health sectors that they felt could be relevant here. Ultimately, suggested innovations that would aid in the development and delivery included: o Packaging. A stakeholder cited a little ketchup pouch as a way to deliver medicine to infants with little waste (calling this low-tech technology). Another mentioned micro needle pouches. These examples of packaging from other health sectors felt like relevant ways of thinking for maternal health supplies (even if the actual package recalled was not relevant). Supply chain innovations. Any innovations that can improve the supply chain through reducing travel to hospital, increasing transportation and accessibility, moving regional warehouses closer to a district, management of supply closet, inventory management, supplies management, and qualified staff to manage supply chain tasks. Operations research, and communitybased distribution were also mentioned in tandem with supply chain innovations.

Page 30

Number in parenthesis indicates the total stakeholders interviewed in that sector *Note: one representative from this group only participated in half of an interview

Page 31

Workshop and Creative Collective Summary

This section summarizes the discussion from the PATH Maternal Health Supplies Advocacy Message Workshop held on Wednesday, April 11 at the PAI offices in Washington DC, outlining the goals, target audiences, strengths, opportunities and challenges in messaging related to maternal health supplies advocacy. Attending the session were fellow maternal health advocates from several organizations2.

Overview of Session and Key Outcomes

The message workshop began with an introduction and sharing of objectives for the session which included: Sharing insights from review of an issue and message landscape; Refining communications goals and target audience priorities; Compiling and prioritizing potential messages that convey the key topics, urgency and value of a maternal health supplies advocacy initiative; and An overview of next steps including testing with key external stakeholders.

Six main themes emerged as a result of the workshop, all of which have implications for messaging. Theres synergy between learnings from stakeholder interviews and the dialogue between workshop participants. Stakeholder interviews showed us that maternal health supplies were a critical component for making an impact on maternal health, but the challenges facing them were significant. Much work is to be done to get policymakers to understand the importance of supplies, how these supplies connect to broader maternal health needs and to better understand how key policy issues (e.g., supporting supply chain system improvements) contribute to achieving maternal health goals. Workshop participants echoed these sentiments, and shared their concerns over lack of data and research that would confirm the impact and need for supplies and clarify key policy issues. They also shared that the advocacy community needs to become engaged and recognize its role in emphasizing the importance of supplies. Many of the participants may identify elsewhere in maternal health, but not in supplies. The main overarching goal that brings advocates to the table to talk about maternal health supplies is simple. The goal is to ensure that low cost and high quality maternal health supplies are available for women who need them, when women need them. That goal then supports the groups larger goal, which is to minimize maternal death. No mother should die giving life. There are shorter term goals and objectives of importance. These include ensuring that the target audience is educated on the importance and the issues surrounding maternal health supplies, securing advocates for maternal health supplies that will help lead the way for tackling

Attendees included: Janna Oberdorf- Women Deliver, Rachel Wilson-PATH, Kristy Kade-PATH, Abi Weaver-PATH, Dilly Severin-PAI, Elisha Dunn-Georgiou-PAI, Allie Doody-PAI, Elizabeth Leonard-PAI, Bonnie Keith-RHSC, Shafia Rashid-FCI, Crystal Lander-MSH, Bridget McHenry-White Ribbon Alliance.
2

Page 32

the issue, and ensuring accountability for policymakers and global funders to show responsibility and ownership regarding this issue as one of their goals. Opportunities are numerous. The most visible opportunity to utilize is the UN Commission to help bring a strong voice and a clear set of policy-focused recommendations to the cause. In addition, tools from the reproductive health community can be adapted and used for models. Secondary research such as case studies and pilot programs can help illustrate impact and there are numerous gatherings and meetings within the maternal health community that can provide a platform to extend the dialogue. Challenges are also significant. The most discussed challenge, and the perceived biggest road block by the workshop group, is lack of data and evidence showing the impact of maternal health supplies on maternal health overall, as well as lack of evidence to prove an unmet need. Another significant challenge is the monitoring and accountability in terms of follow-through of policies prioritizing maternal health supplies in countries where they exist. When it comes to messaging on maternal health supplies, theres room for a humanistic voice, as well as an economic voice. The group would like to enter into the MHS conversation through the prism of the larger maternal health issue. The humanistic voice addresses what supplies can do for maternal health, how they can truly save a life, and that no woman should die while giving life (especially when a large number of the deaths that occur are from preventable complications). The economic voice addresses how supplies help bring about a return on investment within other areas of maternal health, although specific proof points may need further development. Lastly, messaging should explore the connection between maternal health and childrens health, the entire family unit and the community as a whole.

Goals, Defining Progress, and Success

Successful communications and advocacy campaigns are rooted in shared goals and indicators of success. Therefore the interactive portion of the messaging workshop began by establishing communications goals, both short term and long term. Short term goals can fall in to three categories: Providing a clear understanding of the issues and policy next steps surrounding maternal health supplies. There is a need to affirm what maternal health supplies are, and why they are important, especially as it relates to access to care and safe childbirth. Lack of awareness and education on the importance of maternal health supplies is an issue, even within the community which works on maternal health and therefore raising awareness and defining maternal health supplies as an issue is critical. Crucial to building awareness is identifying clear next steps with respect to specific policy needs (e.g., quality issues, supply chain, and regulatory needs) and community responsibilities. Connecting maternal health supplies to maternal health, positioning it as a lynchpin for addressing the larger issues surrounding maternal health. Maternal health supplies are absolutely essential to maternal health, and therefore to women. Without supplies, you cannot save lives.

Page 33

Establishing champions for the cause of maternal health supplies. Maternal health supplies needs to have champions that will help coordinate all partners and advocates by way of resources, policies, and donors and would serve as a resource for where medicines and other supplies are available and accessible. Coordination with these champions of sorts could help bridge the gap between the private and public sectors to ensure that everyone is on the same page and working together as well as possible. Ensuring that national governments and global funders are accountable and show responsibility and ownership of providing maternal health supplies. In countries where policies have been established to provide supplies or to fund maternal health, there needs to be monitoring of implementation to ensure that these policies are being enforced. In countries that have not adopted policies that include supplies, work must be done to bring supplies into the fold.

To measure progress toward near term goals, advocates identified the following methods as beneficial in taking the pulse as to where they are: A greater understanding of maternal health and maternal health supplies among the advocacy community and key stakeholders Build the connection between supplies and broader maternal health outcomes Building the case for maternal health supplies, and inspiring policymakers/influencers to action Building partnerships and engaging advocates Monitor message pick up in the media Oversight to make sure that policies exist and are being implemented Engaging national governments so that they care about the issue

Long term goals center around deepening some of the short term goals, such as educating and engaging additional audiences, creating more partnerships spurring accountability and measurement. The long term goals included: Building an infrastructure to support the necessary supply chain for quality maternal health supplies A reduction in maternal death and an improvement of maternal health through access to essential supplies that are where they are needed when they are needed made possible through donors and the maternal health community striking an important partnership

For the long term, success will be defined mostly by a reduction in maternal death, and existence of an infrastructure to support the supply chain and other delivery issues. However, measuring the reduction in maternal death is challenging given the lack of data quantifying death due to inability to access supplies.

Page 34

Targeted Audience
The ultimate audience is global policymakers, national governments and influencers. However, there are audiences surrounding that group that can be conduits for influencing and reaching that group. The group discussed how maternal health advocates in the room held the ability to influence the working group and community of maternal health advocates as well as the UN Commission Thereby both parties could influence donors. And, all three then play a role in influencing governments, as well as global policymakers and influencers.

Strengths and Weaknesses

Strengths, assets and opportunities Perhaps the most visible and immediate strength, opportunity and asset is the UN Commission. This is seen as a group that can bring a voice to the issue, clarify key policy issues and can use its influence to build accountability and drive change. Additionally, the following elements were mentioned as beneficial for maternal health supplies: Tools from the reproductive health community can be adapted and used as models for supplies when building systems to track usage and build accountability. This may also help quantify need and unmet need; There are case studies and pilot programs in providing supplies that can be useful for illustrating impact; Solutions are known, and low cost; There are various convening and meetings within the maternal health community that could support extended dialogue on supplies; The request is not just monetarily based; and Supplies can be linked to ROI on other investments. A skilled health worker is not effective if there are no medicines available. Healthcare clinics and community health workers arent nearly as useful if they dont have medicines to dispense as needed. Supplies can be positioned as the element that makes the rest of these areas have the most impact.

Challenges, weaknesses and liabilities Strengths outnumbered the challenges identified by the group, however some challenges are considered significant. The group largely focused on the lack of data and evidence to show the impact of maternal health supplies and the unmet need. With that, there is also a lack of collected data surrounding usage and outcomes.

Page 35

While it is commonly understood that the presence of supplies enables healthcare workers to treat a woman who is hemorrhaging or has pre-eclampsia/eclampsia, and ultimately saves her life, there is a lack of hard proof for quantifying usage and unmet need. That makes it hard to show the severity of the situation, the opportunity of impact and to then show progress toward a goal. It should be noted that this is an issue that was perceived to be a much greater challenge among workshop attendees than it was among target stakeholders interviewed during the landscape assessment. This could in part be due to the intuitive nature of the need and some stakeholders belief that research and data already exist. Other challenges cited by the group included: The lack of a clear ask or monetary commitment. Part of this ties back to lack of research and evidence in quantifying an unmet need The politics surrounding misoprostol and its use as an abortion agent It is challenging to make a case for global production when medicines are already low-cost Getting on meeting agendas To date, most spokespersons on maternal health supplies are technical experts not advocates, and therefore messaging to date has been very technical vs. advocacy-oriented. While the technical expertise is critical, sometimes it is the emotional or personal angle that gets targeted audiences to connect and feel committed to the issue Affirming what maternal health supplies are, and why they are important, especially as it relates to access to care and safe childbirth. As stated previously, there is a lack of awareness and education on the importance of MHS as an issue, even within the community who work on maternal health

Top Strengths
UN Commission Tools from RHSC

Top Challenges
Lack of data to quantify unmet need and impact

Case studies and pilot programs Politics surrounding misoprostol showing success Justifying need for global production Convenings Known , low-cost supplies Spokespersons need to be less technical

Page 36

Message Platform Development

Each workshop participant was asked to complete their own messaging platform, listing the objectives, principles, facts, impact and inspiration from which the messages should be built. The target audience for this exercise was global policymakers and influencers. The sections and the grid below summarize themes shared by the group, and also provides representative examples of responses from the worksheets. It should be noted here that the group did not come to consensus on how to go about obtaining the research that they felt was lacking for effectively bringing policymakers and influencers along on seeing the importance of maternal health supplies. Principles Advocates were asked what some of the basic beliefs or values that they and the audience (global policymakers and influencers) could take on faith are true. There was one main theme that emerged from this discussion. Every woman has the right to survive - there are no good reasons why deaths should NOT be prevented. Many advocates mentioned that safe motherhood should be universal, that every woman deserves to live, especially when the price of saving her life amounts to a solution that already exists, and is cost-effective.

A couple advocates mention the importance and feasibility of a flourishing supply chain. A well-stocked, well -run supply chain is essential to building a strong health system. Managing this supply chain is something that should be achievable.

Supporting Themes Advocates were asked what facts or supporting ideas would most likely be relevant and persuasive in making the case for increased support for and investment in maternal health supplies. Most found facts that centered around the following themes to be most important to convey in messaging. Facts illustrating known solutions to problems plaguing maternal health in general, and supplies. Right now, the solution is at hand, not something that needs to be thoroughly researched to determine how to keep women from dying during and after childbirth. The facts about the true problems that are plaguing women in developing countries, that pregnancy-related deaths cause so many women to die, is something that needs to be exposed to ensure that everyone is on the same page about how huge of an issue this is.

Facts showing that the solution is low cost and effective. Advocates believe that the facts need to be displayed in black and white. Numbers need to be put down that show just how many lives are saved when a certain amount of money is spent on this cause. The economic impact that women have is also something that needs to be explored, as when a womans life is cut short, all other investments in her life were in vain and her future contributions are lost forever.

Page 37

Outcomes-oriented facts, showing the full value of a mother to both her family and the larger community. Tying the health of the mother to the health of the child is very important. Showing facts that bring to light the number of children that live to the age of 5 after the mother has died during/after childbirth would help to show how essential that mothers life is to that child.

Supplies are essential for administering care. Just like you cant drive a car without gas, you cannot provide care to pregnant women or women who just gave birth without the essential supplies. Without supplies, healthcare workers, hospitals and care facilities are handicapped in what they can do.

Impact & Inspiration Advocates were also asked why the world or audience would be better off if the goals were achieved. Feedback included: Humanistic/mother focused: Imagine a world where more mothers would be able to come to expect to survive the birth of their children and also have a healthy child. With mothers in this world, their children, their family and their communities are better off. The impact that mothers have on their children, family and communities is something not to be discounted.

Financial/ROI focused: Financial goals would be realized for donors who would receive the return on investment that they expected or higher than they expected. Other goals would be met, like the Millennium Development Goals (MDGs).

Health-system and health worker focused: Health systems and facilities would be operating more to their potential, leading health workers to be more at their potential.

The chart below reflects the notes that workshop participants made in drafting their own platform. These will serve as a reference and source material as our team constructs the draft message platform.

Page 38

Participant Notes

Audience

Objective MHS are the lynchpin for problems plaguing maternal health; increase in support for funding, policies and access to essential supplies.

Principles Every woman has the right to survive; no good reasons why deaths are NOT be prevented; having a well-stocked, well run supply chain is doable and essential to building strong health system.
Every woman deserves access to skilled health provider and the necessary medicines to save her life during delivery. A healthy happy mom is better able to raise healthy kids and is a force for positive change in her community. Imagine life without a mother. Why wouldn't you do everything to prevent any child from going through that? Access to quality MHS are important for saving women's lives.

Facts Proven solutions are cost effective, available and they exist TODAY; how many deaths could be prevented spending x number of dollars on medical supplies; womens impact on family and communities.
Proven, effective medicines exist that could prevent the majority of maternal deaths.

Impact and Inspiration Impact women have on children, family and communities; goals being reached (MDGs); financial goals are met and have better ROI, improvements to health system.
Saving women's lives has a ripple effect - her children are healthier, her communities are stronger, and economies can benefit for her inputs.

Themes of responses

Global policymakers and influencers

Mothers and women are essential for the economy of a country & you can't support child survival w/o maternal health. Maternal health supplies are the lynchpin to solving this maternal mortality challenge that they (the global policymakers & influencers) have committed to fix. Example of responses Global policymakers and influencers Increase support for and funding to both increasing maternal health supplies and improving access.

Lifesaving technologies and supplies EXIST TODAY.

More mothers will live and more children will have mothers.

MH supplies are essential to the global health and development agenda.

Maternal health leads to family/community stability.

MHS gives women a reason to go to facilities for labor/delivery. MHS gives governments/donors a reason to build and expand trained health worker base. MHS are a cost-effective investment. X # of maternal deaths could be prevented through X investment in X # of oxytocin, magnesium sulfate, misoprostol. MHS are low cost. MHS are proven to improve maternal health, save women's lives, and help achieve MDG 5.

With access to medicines and skilled health care providers, most women across the world can expect a successful delivery and a healthy newborn.

Women healthier. Women not dying.

Understanding that commodity security for MHS is integral to quality provision of maternal health care.

Death from preventable causes/lack of supplies to treat conditions is unacceptable. Managing a supply chain is possible.

Healthy moms lead to healthy families and communities.

Page 39

Validation
This section of the report will outline the results of the validation research message testing among key external stakeholders.

Research Objectives and Methodology

KRC Research conducted nine 30-40 minute, one-on-one in-depth interviews (IDIs) with the key target audience between May 24 and June 12, 2012. Our target audience was comprised of individuals who work as global policymakers and donor or foundation partners in administrative health and procurement systems, peers at other NGO organizations and partners in private sector corporations with leadership roles in maternal health issues. Participants were recruited to partake in the interview by a recruiting team, and the sponsor of the research was not disclosed during the recruit process, or at any time during the interview. The objective of this research was to explore thoughts, opinions and reactions to the overarching theme guiding advocacy for increased investment in and prioritization of maternal health supplies and test potential messages that convey the value of investment in priority maternal health supplies. To that end, the conversation followed a custom-designed discussion guide that addressed the three purposes of the research.

Overview of Findings
Our audience of global policymakers and influencers needs messages that educate on the importance of supplies, illustrate the value of the investment, show commitment and partnerships globally. The short-term goal/ ask is to elevate the importance of funding supplies. Similarly the longterm goal was to secure funding. The overarching theme is accurate, believable, contains powerful word in essential but it needs a more direct or strong statement to engage in what comes next. The supporting statements include emotion as well as facts and information. They also educate on the importance of supplies. The themes convey important points, introduce new arguments for supplies and provide something for everyone in the audience. They need some refined focus to emphasize importance of availability of supplies, and a more politically correct way to discuss partnerships.

Messaging Needs of the Audience

The audience is global policymakers and influencers. They therefore need messages that: Educate on the importance and need for supplies Can be applied and used across the broad community Show partnerships, working together to improve maternal health

Page 40

Show the economics of the issue, the investment, the ROI of investing in supplies In their own words: One thing I think commodities have going for them in the broader discussions is that you can actually count them and talk about them as defined things.

This initiative is asking both donors and stakeholders for increased funding for services and resources and increased political attention but that policy is a secondary "ask" to funding ( not a lot of points specifically focusing on policy).

Global heath leaders and organizations such as: UN Commission, UNFPA, Reproductive Health Supplies Coalition, Bill and Melinda Gates Foundation, CARE, Save the Children, Every Mother Counts, PATH and Family Care International would be the voices behind this message, according to the survey participants.

We need to move a little bit further away from these general statements of no woman should die giving birth, to this is what your money buys - this is what your policies will achieve.

In order to increase support among this audience it is recommended the messages connect to specific evidence, using a ROI model. Also, partnering with other advocates in reproductive health, abortion, family planning etc., to ensure everyone is on same page and increase support for messaging will ultimately increase support for needed policy changes and funding.

Overarching Theme: Health Supplies: Essential to Protecting Mothers Before, During and After Childbirth, Improving Maternal Health
The statement is found to be accurate according to those in the target audience, yet it lacks an exciting call to action needed to emphasize the importance of supplies and the life-saving potential they carry. As a statement, it is accurate and believable and it includes an important reference to stages associated with maternal health. The word essential was found to be very important and influential, but the statement overall lacks excitement or a call to action. In their own words: If the mother doesnt survive, it obviously has very negative impacts on the wellbeing of children but its a little detached from the wider ramifications of maternal survival.

As a theme, it should more specifically connect essential with womens health so that it carries more interest and it should emphasize the life-saving potential of supplies.

Its generic. It doesnt sound like people have strong information and its not powerful enough. Its right, but its what you can read in any paper on maternal health.

Page 41

The audience expects to hear a clear ask a statement of the impact it will have on womens lives as a result of the funding and clear data-based evidence that supports the follow-up statements in terms of the impact it has. In order to improve, more closely associate essential with improving womens lives. Supplies: Essential for improving womens lives throughout stages. brings impact while preserving the message. Essential for improving lives gives people a reason to listen.

Respondents felt the use of imagery was very compelling. The overall message is a familiar topic of discussion in the area of maternal health, allowing it to correspond well with the current maternal health initiative.
Supporting Statement Can you imagine a woman in labor arriving at a clinic to deliver her baby only to find that the basic medical equipment, medicines, and health staff arent there? But for many women in developing countries, childbirth can be life-threatening. Why it works The imagery of a woman coming to an ill-equipped center was very compelling, memorable and well liked. Vagueness piques curiosity a bit: What are these medical centers lacking in exactly? But the knowledge gap means that messaging must answer that question. The fact that childbirth is still life threatening for women is unacceptable. The audience can tolerate this element being so direct without being bothered by the content. Begs the question: how many actually are at risk or do die during childbirth? Very appropriate for the maternal health movement and its current goals. Women need to and should be able to reach these supplies with easebut it is as much if not more about availability vs. just access. Reference to basic maternal health care feels inclusive. Reference to healthy lives and children help establish the value of a woman, as well as her connection to a child.

Ensuring access to basic maternal health care will prevent hundreds of thousands of women from dying during pregnancy and childbirth and ensure that they and their children live healthier lives.

While respondents felt positively about the imagery in statements, they disliked statements that did not clearly define the roles and actions of government and other influential figures, or why there is a lack of supplies.

Page 42

Supporting Statement
Policy leadership matched with much-needed investments

Why it needs strengthening

The specificity on how the entities involved are going to solve the problem is compelling, but the statement could be strengthened with exactly what investments can be made by these global leaders, national governments and maternal health advocates. It was also mentioned that these entities need to make commitments, not investments, to maternal health improvement. Economic argument is important, and a welcomed addition to the typical moral arguments in maternal health. Lacks call to action without more data about need or impact. Begs the question- if low cost, why isnt there more access? The idea of working together resonates well, and the merger of the entities that have the ability to resolve the situation is powerful. Starts people thinking about the role of each entity, and how they actually do work together. Sensitivities surrounding the use of power as it feels like a strong, almost threatening word. Its more about opportunity, ability, and authority to make a change.

will provide women with access to proven, low-cost maternal health supplies needed to save millions of lives worldwide.

Working together, global leaders, national governments and maternal health advocates have the power to elevate the critical role of maternal health supplies

Page 43

Themes
After the statement, a series of themes was read to participants. Again, respondents felt positively about the use of imagery and economic ROI reasoning. Respondents did, however, express a desire for more specificity and details in each statement.
Theme Text Theme 1: No woman should die giving life The solution to safe pregnancy and childbirth for women in the developing world starts with access to basic health care, including maternal health supplies. Theme 2: Access to overlooked supplies saves lives and improves maternal health Supplies are an essential solution to improving maternal health, especially during pregnancy and childbirth. Maternal health supplies need to be available at the health clinics and in the hands of trained health care workers to save womens lives. Theme 3: Leadership and investments in maternal health supplies matter Global leaders and national governments have the power and responsibility to protect womens lives during pregnancy and childbirth with greater investments in maternal health medicines and other supplies. Theme 4: Saving mothers means stronger families, communities and nations Healthy mothers have a powerful ripple effect. To save a mother is to save a family. And to save a family is to lay the foundation for stronger communities and more stable nations.

On the whole, the impact of all four themes can increase by using more examples, evidence, and specifics to back up the statements:

Theme
No woman should die giving life

What does it Communicate

Moral argument that basic care and supplies are the solution to maternal health.

How to Increase its Impact

Allow for customization that includes specific supplies. Because the focus is on supplies being part of the solution, naming them becomes more important Consider reference to economic impact along with moral argument Reduce length and complexity Re-focus on availability of supplies. Having available supplies means health care workers have something to administer, women have a

Access to overlooked supplies saves lives and improves maternal

Access to supplies, saving lives, improving maternal health, and the connection to health care workers.

Page 44

Theme
health

What does it Communicate

How to Increase its Impact

reason to go to the facility, and the medicines for saving lives are literally within arms reach. Focus on the authority and ability that governments have to make a difference, in place of power and responsibility which feels obligatory and forceful. The value in this message is that governments are partners, and forceful words counteract that. Give examples of investments that have been done in the past (perhaps as proof points). Build evidence reference into theme, so that this is less philosophical. In countries where in communities where Use available data to build the proof step-by-step, even if proof of the direct connection doesnt exist.

Leadership and investments in maternal health supplies matter

Brings national governments and global leaders along as partners in improving maternal health.

Saving mothers Importance of mothers health to means stronger her family and community. families

Page 45

Theme 1: No woman should die giving life

No woman should die giving life The solution to safe pregnancy and childbirth for women in the developing world starts with access to basic health care, including maternal health supplies. Overall Observations: Even though No woman should die giving life is a common phrase most see it as a positive, compelling statement. Adding examples of supplies will avoid the question what supplies, even if it is a broad range. Some suggest this statement needs to be strengthened, referencing the value of the investment in maternal health. The expectation is that data on maternal deaths and cost of supplies will be used to support the statement. Some note that family planning is missing. Positive Elements Those portions of the theme that were well received included:
Phrase No woman should die giving life The solution to safe pregnancy and childbirth for women Its impactful because Phrase is powerful and repeatable Showing stages of pregnancy and childbirth is a positive

Areas for Improvement: Those portions of the theme that could benefit from improvement included:
Phrase Including maternal health supplies Improve because Desire to see illustrative examples of supplies because the message is so focused on supplies being the solution

Recommendations for this theme: In order to be more impactful for the target audience, the theme needs to allow flexibility in naming the specific supplies needed. Also, while the moral argument is very impactful, this theme could do more to reference the equally impactful economic argument for increasing maternal health supplies.
In their own words:

I think that the no women should die giving life is a very powerful phrase that we use often in this field. Its short, its compelling, no woman should die from things that are preventable and especially when giving birth. I liked it, it does point out or highlight the fact that these are preventable deaths and theres something that can be done, and that something starts with essential supplies.

Page 46

Theme 2: Access to overlooked supplies saves lives and improves maternal health Access to overlooked supplies saves lives and improves maternal health Supplies are an essential solution to improving maternal health, especially during pregnancy and childbirth. Maternal health supplies need to be available at the health clinics and in the hands of trained health care workers to save womens lives.

Overall Observations: The link to health care workers makes this a valuable and powerful message. However, it feels confusing and complex, referencing access, supplies, workers, when this really feels like availability. Additional statements provide much needed clarity around theme. Some say this has a less emotional pull than others tested, focus on availability could amplify. Leverage proof points that show outages, supply, deaths and costs to work in an economic angle. Positive Elements Those portions of the theme that were well received included:
Phrase Maternal health supplies need to be available at the health clinics and in the hands of trained health care workers to save womens lives. Its impactful because Brings availability of supplies into the conversation (not just access) Good duality of end-user need and health care worker need

Areas for Improvement: Those portions of the theme that could benefit from improvement included:
Phrase Access to overlooked supplies save lives and improves maternal health Improve because Feels less about access more about availability.

Recommendations for this theme: This theme needs to focus more on the availability of supplies, rather than access, using language that stresses the importance of having these supplies continuously and readily available to health care workers. Also, reducing the length and complexity of the message would make its goal clearer for the intended audience, and, therefore, more likely to incite action.

Page 47

In their own words: Its good because it brings in the skilled workers aspect, because without skilled workers the supplies cant be delivered effectively that linkage is critical in this message.

You want short statements that convey as much in the statement without being too wordy, so its access to essential maternal health supplies. This message was pretty clear. It addresses the issues of supplies as well as a trained provider, thats important and I think taken together this is a more powerful message. I think its important to be more specific on supplies as we possibly can be. But when this is such a high-level advocacy statement, it might be a bit difficult to be more specific. I think the contexts are pretty different, depending on the region or the country.

Additional Statements: Additional statements were similarly presented to participants, which were found to have a positive impact on the original theme.
Theme At the heart of good maternal health care is a set of basic, low-cost, but essential supplies which include contraceptives, medicines, and simple equipment (e.g. manual vacuum aspiration), among others. Women everywhere depend on a stocked supply cabinet. In their own words: What does it Communicate Addresses curiosities in theme & strengthens argument. How to Increase its Impact Fear over MVA being offputting

Good imagery, speaks to availability.

Feared that reference is more for Westerners.

It basically shows you are not just asking for pregnancy and childbirth you are asking for the whole reproductive span of a womens life from planning a pregnancy to having a pregnancy and childbirth to choosing not to have or terminating a pregnancy. That is a much wider scope of a womens reproductive span than just the childbirth which is what normally I think of when I think of maternal health supplies. Yeah, I mean again I think it depends on who the audience is. I think for a U.S.

Page 48

government type of audience it could be somewhat off-putting if people know what that is, but if its outside the maternal healthcare family planning, they might not.

If you need to mention MVA, you might wish to mention it as part of a longer list, rather than singling it out. Because I think youre just looking for trouble. A stocked supply cabinet is something we can visualize. Its effective if its high income audience and if its in an environment where there are very many stock outages but that having a healthy stocked cabinet is something but that it may be foreign to most people.

Page 49

Theme 3: Leadership and investments in maternal health supplies matter Leadership and investments in maternal health supplies matter Global leaders and national governments have the power and responsibility to protect womens lives during pregnancy and childbirth with greater investments in maternal health medicines and other supplies. Overall Observations: The economic angle in this message is important, and new to the issue. Sensitivity exists regarding wording choice. While some like the call out to leadership/governments , others do not like the word responsibility. This is about persuading leaders to leverage their authority and ability to bring about change. They have the opportunity to make a difference. Examples of investments will help add clarity surrounding what leaders can/should do Positive Elements Those portions of the theme that were well received included:
Phrase Leadership and investments in maternal health supplies matter Its impactful because Including leadership as a partner in making maternal health supplies available is necessary and important.

Economic angle is a new, and welcome argument alongside the moral position. Areas for Improvement: Those portions of the theme that could benefit from improvement included:
Phrase Global leaders and national governments have the power and responsibility with greater investments in maternal health medicines Improve because The words power and responsibility can feel uncomfortable and cause resistance in using for some.

Desire for specificity on the type of investments

Recommendations for this theme: While it was seen as beneficial to call out specific entities who play a role in improving maternal health, the forceful language used such as power and responsibility didnt fit with the overarching theme of a need for shared and voluntary efforts among government powers. Continuing the specificity with examples of what has been done in the past would also help to make this theme more impactful.

Page 50

In their own words: I think its good to call on governments to say that you have both the opportunity and the responsibility to impact maternal mortality. I think if you could follow it up with a strong concrete ask with how much you are looking for people to invest or what kinds of programs you are looking for them to invest in supplies, etc.

The word power seems strange. We have the power to, I dont know what. Is that money or something else? Influence? What is it?

Theme 4: Saving mothers means stronger families, communities and nations Saving mothers means stronger families, communities and nation. Healthy mothers have a powerful ripple effect. To save a mother is to save a family. And to save a family is to lay the foundation for stronger communities and more stable nations.

Overall Observations: This theme was well received by most. It resonates with many because of the link to the bigger picture. It clearly shows the link between a mother and nations, which logically makes sense. In order to strengthen the statement, consider alluding to where this is evident. Utilize the proof points to build the case off of incremental data that currently exists. Positive Elements Those portions of the theme that were well received included:
Phrase Saving mothers means stronger families, communities and nations Its impactful because Ripple effect resonates with many.

Areas for Improvement: Those portions of the theme that could benefit from improvement included:
Phrase Healthy mothers have a powerful ripple effect Improve because Desire to allude to where this is evident, so it is less philosophical and more actual.

Page 51

Recommendations for this theme: As in other themes, this could be improved with more specificity and detail. Having examples or statistics of how mothers impact their community could support the statement, and in turn make it more impactful among those in the target audience.
In their own words:

I think it is the evolution of the statement is quite good, stronger woman, stronger health that makes stronger family and I think its a good point. I always think that is a good message but it would have to come after youve explained with that problem is, why do you need to save mothers, I mean not why do you need to save mothers but whats the problem, that women are dying in childbirth. That one is very believable because its set in a wider context about why does this matter, I mean ultimately this is about peace and security, apart from the happiness of an individual and individual family unit. Its a big jump between women, between saving womens lives and laying the foundations for stronger countries or nations.

Additional Statement:
Phrase Tell me more about what type of proof we need here to show longlasting impact through funding maternal health supplies. Its impactful because Show countries where this is effective. Show data that builds the case (in stages helps mothers helps families, etc.)

In their own words: There is a lot of follow up facts that even exist today that you could add to that, the ripple effect so that sort of effect it has on children, the effect it has on families and communities, the effect it has on economies Additionally it would be great if, again, we could have a cost on the other side of how much it would cost to save these womens lives.

I always like those kinds of things, you know, those more general things followed up by some facts. Like, the risk of a newborn dying is twice as high, or 10 times as high, if their mother dies. Or, things like that, that support the statement that, in fact, saving a mothers life saves, improves their childrens life chances, supports their familys economic wellbeing and helps build the community.

Page 52

Priorities for Proof Points

One of the key ways that the messages will become more effective is by adding specificity and reliability through proof-points. The most important ones include: The overarching theme is the scope of the issue how many women is this affecting? How many women are dying in childbirth? What percent of women are denied this access of care? Where do these women live? What supplies are lacking? How much do those supplies cost? No woman should die giving life Provide illustrative examples of what supplies are and the number of maternal deaths in developing world. Access to overlooked supplies Provide illustrative examples of what supplies are and the number of maternal deaths in developing world. Leadership and investments in maternal health supplies matter Needs an explanation as to if it is so easy, why isnt it happening? What are the barriers getting in the way? Show concrete examples of how responsibility and partnership between entities have made a difference. Saving mothers means stronger families Show reduced mortality in countries where maternal health improved. Statistics on how saving mothers helps children( what percent will live to fifth birthday, relationship between living mother and education/nutrition of child, etc.)

Page 53

In Summary: Maximizing Impact

Theme: No woman should die giving life This theme is about: To increase impact:

Moral argument that basic care and supplies are the solution to maternal health Access to supplies, saving lives, improving maternal health, and the connection to health care workers.

Allow for customization that includes specific supplies. Because the focus is on supplies being part of the solution, naming them becomes more important. Consider reference economic impact along with moral argument. Reduce length and complexity. Re-focus on availability of supplies. Having available supplies means health care workers have something to administer, women have a reason to go to the facility, and the medicines for saving lives are literally within arms reach.

Access to overlooked supplies saves lives and improves maternal health Leadership and investments in maternal health supplies matter Saving mothers means stronger families

Brings national governments and global leaders along as partners in improving maternal health. Importance of mothers health to her family and community

Focus on the authority and ability that governments have to make a difference, in place of power and responsibility which feels obligatory and forceful. The value in this message is that governments are partners, and forceful words counteract that. Give examples of investments that have been done in the past (perhaps as proof points). Build evidence reference into theme, so that this is less philosophical. In countries where in communities where Use available data to build the proof step-by-step, even if proof of the direct connection doesnt exist.

Page 54

Implications
The core goal of this process was to create a jointly emotional and economically motivated theme that encompasses the reasons why maternal health specifically is so important and how access to health supplies is the key to improvement. The theme needs to be not only concise but also specific, providing evidence and examples in order to better educate the audience and call them to action. To that end, there are four implications for themes when it comes to obtaining funding for maternal health supplies. Education brings clarity. While the value of maternal health supplies is logical for many, it is a newer focus in maternal health discussions, and there are curiosities surrounding what constitutes maternal health supplies, what exactly makes them hard to attain, and why they are so critical. Educating on the importance, the need, and the lack thereof builds impact, because the audience then understands more about making maternal health supplies available. Lead with impact. The audience wants (and needs) to feel impact at the onset of the overarching theme. And, they agree, supplies save lives. This gives them a reason to focus in on the importance and need for supplies. They need to hear that explicitly, and immediately. Even though there is no direct ask, there can still be a call to action and conveyance of impact. Bring everyone along. As we observed in the exploratory research, coalition-building with national governments and international policymakers is essential for truly making maternal health supplies available. Without these groups taking an interest, and making a commitment to the issue, impact wont be long-lasting. To that end, consider wording and phrases that help bring everyone along rather than isolating any group. Let economics support the moral argument. The audience appreciates messaging that speaks to the moral imperative of caring for women. The economic argument brings a fresh (and welcome) perspective to the issue that can be a vehicle for conveying the moral argument. These supplies save womens lives for small amounts of money, and they provide the tools that health workers/facilities need to make those investments pay off.

Page 55

Final Messaging Platform SUMMARY - Investing in Essential Supplies Saves Lives and Improves Maternal Health
Becoming a mother is usually a special, joyous event. But for many women in developing countries, childbirth can be life-threatening. Can you imagine a woman in labor arriving at a clinic to deliver her baby only to find that the basic medical equipment, medicines, and health staff arent there? Ensuring access to basic maternal health care will prevent hundreds of thousands of women from dying during pregnancy and childbirth and ensure they and their children live healthier lives. Access to essential maternal health medicines, including items such as contraceptives, medicines, and simple equipment used during childbirth are often a hidden part of the solution. Having a healthy pregnancy, childbirth and the opportunity to see your children grow up healthy should not be a matter of where you live or your economic status. It should be an universal right for every woman, everywhere. The good news: this goal is achievable. Working together, global leaders, national governments and maternal health advocates have the power to elevate the critical role of maternal health supplies in protecting womens lives during pregnancy and childbirth. Policy leadership, matched with additional funding for proven, low-cost maternal health supplies, can improve maternal health and save millions of lives worldwide. Healthy mothers have a powerful ripple effect. To save a mother is to save a family. And to save a family is to lay the foundation for stronger communities and more stable nations. Themes:

No Woman Should Die Giving Life

Essential Supplies Save Lives and Improve Maternal Health

Leadership and Investments in Maternal Health Supplies Matter

Saving Mothers Means Stronger Families, Communities and Nations

Page 56

THEME 1: No Woman Should Die Giving Life

MESSAGE The solution to safe pregnancy and childbirth for women in the developing world begins with access to basic health care, including maternal health supplies.

PROOF

At the heart of good maternal health care is a set of basic, low-cost, but essential supplies that includes items such as medicines, contraceptives, and simple equipment used during childbirth. Each year approximately 287,000 women 99 percent of whom live in developing countries die from pregnancy and childbirth-related complications. That means one woman dies every two minutes from pregnancy-related complications.i Experts estimate that with access to basic health care and proven interventions, the leading causes of maternal deaths are largely preventable. These include: severe bleeding after childbirth, high-blood pressure during pregnancy and infections. o Proven, low-cost medicines such as oxytocin and misoprostol prevent and treat severe bleeding, and magnesium sulfate can prevent seizures caused be high-blood pressure during pregnancy. o Examples of low-cost, but essential health equipment include blades, plastic sheets, clean thread, needles and clamps for the umbilical cord. Having a healthy pregnancy, childbirth and the opportunity to see your children grow up healthy should not be a matter of where you live or your economic status. It should be a universal right for every woman, everywhere. o In the United States where education, family planning, and health care services and supplies are widely available to all, one out of 4,800 women dies from complications of pregnancy and childbirth. The rate is even lower in the United Kingdom, where one out of every 8,200 women dies. Contrast that to Niger, where poverty and a shattered health care system mean pregnancy-related causes will kill one out of every seven women. ii An essential part of ensuring a woman survives pregnancy and childbirth includes access to maternal health medicines and other supplies.

THEME 2: Essential Supplies Save Lives and Improve Maternal Health MESSAGE Increasing the availability of supplies is essential to saving lives and improving maternal health, especially during pregnancy and childbirth.

Page 57

The important role of essential maternal health supplies and medicines can be hidden in the face of larger health system challenges in low-resource settings. o Access to these essential supplies in developing countries is limited due to supply chain management challenges, regulatory hurdles, and funding gaps. Maternal health supplies and medicines need to be stocked in health clinics, in the hands of trained health care workers and ultimately appropriately delivered to the women who need them in order to save lives. o A supply shortage in hospitals can become a patients responsibility; those seeking care are often required to pay for all their medications, blood and even surgery when supplies are scarce. This can add up to $200 to $300, which is several months' wages for many.iii Three proven, low-cost medicines oxytocin, misoprostol and magnesium sulfate have the potential to save the lives of mothers worldwide, making their accessibility and availability critical during pregnancy and childbirth. Each of these three medicines costs less than US$1.00. o Oxytocin, used to prevent and treat severe bleeding after childbirth, costs roughly between US$0.18 and US$.72 per dose and is given by injections [difference based on doses for prevention (10 IU) and treatment (40 IU)]. o Misoprostol, also used to prevent severe bleeding after childbirth especially in settings where oxytocin is not available costs between approximately US$0.15 and US$.60 per dose [difference based on doses for prevention (3 tablets) and treatment (4 tablets)]. In a ten year period, it is estimated that 41 million cases of severe bleeding would be prevented and 1.4 million lives would be saved if oxytocin and misoprostol were available to all women giving birthiv Up to 50 percent of all maternal deaths take place during the first 48 hours after delivery, a time when every minute counts. The presence of oxytocin and misoprostol can mean the difference between life or death.v o Magnesium sulfate, is recognized by the WHO as the safest, most effective and economical medication for preventing and treating deadly seizures caused by high blood pressure during pregnancy, at a cost of approximately US$1.00 per dose.vi Contraceptives are an essential element of maternal health. o More than 215 million women worldwide lack access to modern contraceptives. Experts estimate that by providing women wider access to modern contraceptives and family planning services, maternal deaths would reduce by a third. This is a highly cost-effective public health strategy.vii Essential, lifesaving equipment such as catheters and urine bags needed for women during childbirth particularly difficult labors cost approximately US$3.viii The solution is within reach: Delivering a package of services, including essential supplies, is estimated to cost less than US$1.50 per person in the 75 countries where 95 percent of maternal mortality occurs. ix o A package includes costs for medicines, other supplies, and lab tests; the service of health care workers; and investments in the health

Page 58

system such as training, transport, infrastructure updates and community program costs.x By prioritizing the availability and delivery of maternal health supplies, many more womens lives will be saved and women will be healthier.

Page 59

THEME 3: Leadership and Investments in Maternal Health Supplies Matter MESSAGE Global leaders and national governments have the power and responsibility to protect womens lives during pregnancy and childbirth with greater leadership and additional funding for maternal health supplies.
New global leadership is highlighting the need to improve the availability, quality and impact of proven, low-cost medicines through the UN Commission on LifeSaving Commodities for Women and Children. o The UN Commission will identify strategies to improve the delivery of a range of essential health supplies by recommending ways to streamline the regulatory environment, explore supply chain improvements, examine innovations and best practices and identify market shaping opportunities, all with the aim to improve women and childrens health. o An example of national leadership includes the government of Tanzania prioritizing access to maternal health. Over the past 15 years, Tanzania has made steady progress toward ensuring that family planning and maternal health supplies are available throughout health systems, effectively putting them closer to accomplishing the Millennium Development Goal 5 target of reducing maternal mortality by three-quarters.xi Coordinated approaches and increased innovative partnerships, as exhibited by the successes of pooled purchase and delivery of vaccines and medicines to prevent HIV, would dramatically improve the impact of maternal health supplies, and save more womens lives. Prioritizing funding for maternal health supplies will provide a significant return on the other investments made in maternal health and maximizes the potential impact of health care workers. o All the skilled health care workers in the world cant deliver the care women need if a clinics supply cabinet is bare and the next round of supplies is weeks away. o Nepal a county of the worlds poorest, with a GDP per capita income of $438.00 has well-established cadre of 50,000 frontline health volunteers, mainly women, who provide a wide range of maternal and child health services throughout the country. These health workers have been a bridge between the formal health system and the communities they serve. These health workers: Carry out home visits before and after birth and have been trained in essential newborn care. They counsel women about contraception and link them to needed supplies. Augment a system of care that has developed since 1990, cutting Nepals maternal mortality rate nearly in half. And, its under-5 mortality rate fell 64 percent between 1990 and 2008. Reliable availability of maternal health supplies and medicines will strengthen health care systems and make frontline health workers more effective. There is a powerful opportunity to save many more lives and improve maternal health through policy leadership matched with much-needed investments in supplies.

PROOF

Page 60

THEME 4: Saving Mothers Means Stronger Families, Communities and Nations MESSAGE Healthy mothers have a powerful ripple effect. To save a mother is to save a family. And to save a family is to lay the foundation for stronger communities and more stable nations. From the cradle, to the classroom, to the workplace and community, a healthy mother can mean a world of difference for her child and her family. o Babies who lose their mothers are five times more likely to die in infancy than those who do not.xii o Motherless children face consequences of family impoverishment (diminished resources for the children in particular), malnutrition, and decreased educational opportunities as older children leave school to earn money or care for their homes and younger siblings.xiii When women survive and thrive after childbirth, they can increasingly impact change and economic development in their communities and ultimately their nations. o The death or illness of a mother also leads to a reduction in income given the important economic role of women, such as in agricultural production and trade. xiv o The U.S. Agency for International Development (USAID) estimated the global economic impact of maternal and newborn mortality at US$15 billion in lost productivity every year.xv o When women and girls earn income, they reinvest 90 percent of it into their families.xvi There are many complex challenges to improving maternal health, but policy leadership, matched with additional funding for proven, low-cost maternal health supplies, can set off a powerful ripple effect, saving and improving millions of lives worldwide.

PROOF

THE ASK Support polices and investments that broaden access to life-saving maternal health supplies.

Page 61

Conclusions and Opportunities

While supplies and medicines may be an essential, but currently comparatively hidden part of the solution to improving maternal health and meeting MDG 5, the path ahead is filled with great promise to make a lasting impact on this issue. The research insights in this report provide a clearer picture of the policy and stakeholder landscape on this emerging issue. This includes the pressing need to further educate target audiences about the role of supplies. Most importantly, it demonstrates how supplies may be a relatively small element in the broader context of maternal health, but they hold the potential to make a much larger impact on womens health. The research also reaffirms the importance of advocacy efforts that lead with the moral imperative of saving womens lives and success stories, while providing a compelling new way to view the issue by way of emerging economic arguments, hence the connection is made to the ripple effect on families and communities. The message platform created as a result provides a unified framework for advocates to support the case for policies and investments that broaden access to life-saving maternal health supplies. This message platform includes themes, messages, evidence-based proof points and concrete examples of success to be used consistently across multiple communications channels in advocacy effort. Message platforms are always living documents, but given the emerging nature of the maternal health supplies issue, some opportunities ahead include: Continuing to collect and refine additional proof-points that support each message, and bringing new evidence or examples to strengthen each element of the messaging architecture, including partner organizations tailoring specific supporting points and illustrative examples in a way that reflect their unique program or policy perspectives. This effort may also involve identifying and prioritizing the need to generate new research or supporting data to strengthen the evidence-based case. Refining and tailoring the messaging for specific events, opportunities, or appeals as the policy and advocacy landscape shifts. Similarly, working with the Maternal Health Supplies Working Group and other members of the advocacy community to clarify both the policy ask and the funding ask, keeping in mind that as milestones, such as the release of the UN Commission recommendations in September are reached, these asks will be further refined. Given the more technical nature of maternal health supplies policy issues, as well as the relatively small but influential target audience of policymakers and funders who can have the greatest impact on the issue, a stakeholder mapping exercise would be an effective approach toward developing a more comprehensive maternal health supplies advocacy strategy for message delivery. This effort would build on the initial research conducted with policy influencers to inform the message development process, but focus on how best to reach and have an impact on these especially targeted audiences.

Ultimately, the power of these messages will truly be brought to life through a targeted and fully-integrated advocacy communications effort. Guided by a strategic communications plan,

Page 62

these efforts might include presentations at international fora, advocacy materials featuring the personal perspectives of front-line health care workers delivering life-saving medicines to the women that need them, compelling story-telling through online video vignettes and through many other channels that reach global policymakers and influencers. Most importantly, these messages ultimately support one unified advocacy goal: demonstrating the value of investments in maternal health supplies, inspiring action, saving lives, and, ultimately creating a lasting impact on women, families and communities around the world.

Page 63

Section 3: Appendix
Appendix A: Immersion Materials
Delivering on the Promise Maternal Health Working Meeting notes; April 2011, September 2011, January 2012 Family Health: Communication and Message Research Draft Call to Action for Access for All: Supplying a new decade for reproductive health Postpartum Hemorrhage: A Challenge for Safe Motherhood Misoprostol for Postpartum Hemorrhage Maternal Health Supplies in Uganda Maternal Health Supplies in Bangladesh Medicines for Maternal Health

Page 64

Appendix B: Exploratory Interviews List

Message testing with key external stakeholders consisted of 27, 30-40 minute one-on-one indepth interviews (IDIs) that included:
Interviewee Luc de Bernis Julia Babinard Aron Betru Dr. Yves Bergevin Shannon Marsh Joar Svanemyr Renee Vander Weerdt Judith Helzner and Erin Sines France Donnay Organization UNFPA World Bank UN Foundation UNFPA USAID Zambia NORAD Norway UNICEF MacArthur Foundation Gates JHPIEGO JSI Sector Bilaterals/Multilaterals Bilaterals/Multilaterals Bilaterals/Multilaterals Bilaterals/Multilaterals Bilaterals/Multilaterals Bilaterals/Multilaterals Bilaterals/Multilaterals Foundations Foundations Government, Donor country influences Government, Donor country influences Government, Donor country influences Government, Donor country influences Government, Donor country influences Government, Donor country influences NGO/Policy Centers NGO/Policy Centers NGO/Policy Centers NGO/Policy Centers

Michelle Wallon Walter Proper

Zambia Ministry of Health

Dr. Bonface Fundafunda

MOH Zambia

Abraham Chingalika
USAID/Kenya

Lynn Adrian
JHPIEGO

Dr. Kwame Asiedu Andrienne Germain

John Townsend Ann Starrs Pape Gaye

Elisha Dunn-Georgiou Frances Ganges Karl Hofman Meg Greene John Skibiak Barbara Crane Scott Ratzan Maria Schneider

International Women's Health Coalition Population Council Family Care International IntraHealth Population Action International White Ribbon Alliance PSI Woodrow Wilson Center GHI RHSC IPAS Johnson & Johnson Merck for Mothers

NGO/Policy Centers NGO/Policy Centers NGO/Policy Centers NGO/Policy Centers NGO/Policy Centers NGO/Policy Centers Private sector Private sector

Page 65

Appendix C: Exploratory Stakeholder Audience Pre-notification Letter

Dear {Sample field: Fname}{Sample field: Lname}, PATH is currently working to better understand approaches for improving access to maternal health supplies in low-resource setting. To that end, we are reaching out to our peers, including institutional donors, national and international policy influencers, international development NGOs, and some private sector organizations with whom we interact with or collaborate on this topic. We are writing to you because we feel we would benefit from your perspective, and would like for you to take part in a research interview. We have engaged KRC Research, an independent, third party research firm, to conduct in-depth interviews. The interview would take approximately 30-45 minutes. The results of the interviews will be analyzed and reported in a policy landscape assessment that PATH is planning to publish. If you choose to partake in an interview, you will be listed as a participant in the landscape assessment, however no quotes, ideas or positions will be attributed to you. You may also request an advanced copy of the report to review prior to it being published. Your participation in an in-depth telephone interview would be greatly appreciated, as your unique perspective will provide invaluable insight that will help guide us in the future. In consideration of your time, we will make a contribution to a charity of your choice. A representative from KRC Research, Kim deBelle, will contact you in the next two weeks to follow-up on this letter. In the meantime, if you have any questions please feel free to contact me or Colleen Learch, KRC Research (clearch@krcresearch.com). Thank you for your consideration. Sincerely, PATH Signature Colleen Learch KRC Research clearch@krcresearch.com

Page 66

Appendix D: PATH Maternal Health Supplies Stakeholder Exploratory Interview Discussion Guide My name is _____ and I am calling from KRC Research, an independent research firm. As (recruiter) mentioned, we have been engaged by PATH to conduct a research study among select individuals who work on topics within the larger issue of maternal health in low resources settings. We know how busy your day is, and we appreciate you taking the time to participate in this research. Your opinions are very important to us, and to PATH. There are a few things Id like to tell you before we get started with the interview. I am an independent researcher, and as such, I am not vested in any particular viewpoint or policy. I am looking to learn from you and your experiences. Your candidness in responses is very useful to me in learning about the topics in this interview. The results of the interviews will be analyzed and reported in a policy landscape assessment that PATH is planning to publish. You will be listed as a participant in the landscape assessment, however no quotes, ideas or positions will be attributed to you. Responses will be summarized in aggregate only. At the end of the interview, you may also request an advanced copy of the report to review prior to it being published if you so choose. The interview will take 30-40 minutes of your time. With your permission, Id like to record the interview so that I dont need to slow down to take notes.

For my own background, could you tell me a little bit about yourself and your role at (organization)?

Context- Maternal Health Topics 5 minutes I. (Purpose: Warm-up section before delving into the heavier, more detailed aspects of the topic. This section will be short, but will also help us understand what is top of mind for these individuals when it comes to maternal health. Our interview team is prepared to curtail conversation in this section so that it is productive, but does not dominate the interview).

Page 67

As I mentioned, I am an independent researcher, not an expert on maternal health specifically. How do you, personally, define maternal health? Are there variations in how this is defined within the community? How so? How would you describe the political landscape in relation to maternal health right now? What are the two or three most important topics within the larger maternal health space today? How do you see this changing over the next 5 to 10 years? - Who are the biggest players in this space? Who can really make a difference in this area? - Does the issue have opponents or people or organizations that are obstacles? Are there elements that make issues related to maternal health different from other global health issues with which you are familiar? - Does this pose a greater challenge? - Is this difference advantageous at all? - How much attention does Maternal Health get vs. the others? What are some of the reasons these topics get more/less? How much of an issue is the amount of attention paid to maternal health? If not already discussed: Tell me more about the political landscape regarding this issue at the national level? What about internationally? If not already discussed: What about improving access to maternal health supplies in low-resource setting? Whats the political landscape like when it comes to maternal health supplies? Are you familiar with it at all? What have you heard?

II. Maternal Health Supplies Challenges and Opportunities 15 minutes (Purpose: Probe deeper into the topics that fall under maternal health, including availability of supplies, knowledge of work being done to date, what makes it important, who can make a difference and how).
For the rest of our time together today, were going to be talking about maternal health supplies. Specifically, the issue of making available specific medicines that can help minimize maternal death following labor and delivery. How large a factor in maternal health do you think this issue is? Who currently works on that topic? What makes it important? Who or what is driving the discussion on maternal health? Or, who or what is driving progress on maternal health? Are supplies currently a robust part of the conversation within maternal health? How come? Is this an area where a difference can be made?

Page 68

Medicines that are part of maternal health supplies include Oxytocin, Misoprostol, and Magnesium Sulfate available. How does that match up with your understanding of issues in Maternal Health? What do you think about the inclusion of those three medicines? What are the challenges for making supplies more readily available? - Moderator listen for and probe accordingly on: - Making this issue a priority - Quality of the drugs - Cost for user - Cost for government - Access - Ability to administer the drugs - Packaging - No research/proof that this works/lack of data Based upon your knowledge and experience, how do we best address these challenges? (listen first before probing on questions below) - What policies or actions are necessary for: (NOTE: EACH RESPONDENT WILL BE ASKED AT LEAST FOUR OF THE ACTIONS/POLICIES BELOW, TIME PERMITTING) Availability-related Providing data on both the unmet need for maternal health supplies as well as available financing for supplies. Accelerating adoption and scale up of administration of maternal health supplies? Ensuring quality formulations of the drug are widely available and used? Regulating the quality and usage of medicines across countries for quality assurance purposes? FOR EACH OF THESE ABOVE ASK: - How important is this? - Who is best positioned to lead this type of action? - How could this action occur? - Are there specific road blocks for this action? How can they be overcome? Cost-related Increasing funds contributed by national governments for maternal health supplies Increasing funds contributed by global donors for maternal health supplies Ensuring larger purchase volume and more consistent quality Pooled-procurement at global/regional and/or national level?

Page 69

FOR EACH OF THESE ABOVE ASK: - How important is this? - Who is best positioned to lead this type of action? - How could this action occur? What strategies or mechanisms could help this? - Are there specific road blocks for this action? How can they be overcome? - Pooled-procurement: What form would this take?

In your opinion, what WHO and/or other global policies or actions are needed to propel national agendas and actions related to increasing access and availability of

maternal health supplies?

What are the roadblocks to creating these policies? How can they be overcome? [Probe on Misoprostol specifically and data, information, and logistics management information systems and health management information systems need]

What types of innovations relative to maternal health supplies development and delivery should be a focus for future research and development? - What makes this important? - How does one build interest and investment in this area? IF NOT ALREADY COVERED: What else has to happen so that these challenges to maternal health supplies do not stand in the way of the work? - Listen for and probe accordingly on: Politically/Advocacy-related-? Policy-related? Regulatory-related? Programmatic-related Supply chain-related?

III. Importance of Maternal Health Supplies and Outcomes 12 minutes (Purpose: Exploration of what makes this important, and the desired and/or potential outcome of working on the issue).
In your opinion, who knows what Maternal Health Supplies are? Who doesnt know what Maternal Health Supplies are? Who needs to know, and doesnt currently? - What specifically do those parties need to know? I understand all that youve told me so far, but I really want to understand what makes the overall maternal health supplies so critical.

Page 70

Lets start with your organization. What makes it important for your organization? What about your peers, peer organizations? What makes it important for them? Who else is this work important for? (PROBE ON: WOMEN, MOTHERS, CHILDREN, COMMUNITIES, ETC). How does this impact those? What is it that makes it important? Does advocacy for maternal health supplies alter the maternal health policy landscape at all?

Youve just shared the impact that work on maternal health supplies can have, but whats the outcome of working on this issue? What results from organizations or people caring about maternal health? Who benefits? What can we expect/what is the result of the work? Whats the outcome of access to supplies? What results from that? What does success in maternal health supplies look like? What drivers do you see in evolving the discussion or issue to achieve this success (if needed, give timeframe: over the next decade, beyond the next 10 years) Are there barriers that you see in evolving this discussion or issue? (if needed, give timeframe: over the next decade, beyond the next 10 years) If not already covered: Lets take a step back for a moment, and I want to understand more about how Maternal Health Supplies ties in to the overall topic of Maternal Health. Can you explain that to me? What is the role that Maternal Health Supplies plays within Maternal Health? How much of a factor in Maternal Health is it? Do you feel that you have a role in increasing access to maternal health? How so? What about in making supplies available? What do you need to see, or have, before you/your organization can act?

Page 71

PATHs Role in Maternal Health 5 minutes IV. (Purpose: Gauge knowledge and reactions of PATHs work in this area, the anticipated or potential outcomes/impact, as well as identification of opportunities and challenges)
As you may know/as you described, PATH is working alongside other advocates to improve access to maternal health supplies in a low-resource setting, focusing on three medicines; Oxytocin, Misoprostol, and Magnesium Sulfate How does that sound to you? Listen for references to past work by PATH, UN report, other reports issued Does making medicines such as those named available for purposes of saving lives align with your thinking about what youd expect from advocates for maternal health? Are you familiar at all with this type of work? Does that align with your thinking about what youd expect from PATH within the maternal health community? What does PATH have to offer in working to improve access to maternal health supplies? What should PATH be considering as they work on this topic? What are their biggest strengths in working on this topic? What are their biggest challenges? Are there any big roadblocks or obstacles that they should foresee? What should their role be in improving access to maternal health supplies? Listen for and probe accordingly: Advocacy Implementation Research OTHER In thinking about all the advocates working on this issue, including PATH, how do those advocates best capture attention for this issue? Are there things that PATH specifically can do to or offer, or prove to prompt attention? - What story should they tell? - Who should it matter most too? - What audiences do they most directly target? Indirectly target? Whats the desired outcome/win for advocates? What do advocates need to do to gain your support and involvement?

V.

Wrap Up

2 minutes

Last question before we wrap up: What does PATH need to most keep in mind as they work on this issue?

Page 72

Thank you very much for your time and feedback. Would you be willing to be contacted further by PATH in relation to the report of findings that will be generated from these interviews? You are not obligated in any way to say yes. Would you like to receive an advance copy of the policy landscape report? Any final thoughts or questions for me?

Page 73

Appendix E: Workshop Agenda

I. Welcome & Introductions (continental breakfast served) ......................................1:00

II.

Overview of PATHs maternal health supplies advocacy message development goals

Objectives for Session .................................................................................. 1:15 Share key insights from policy landscape interviews Determine communications goals and target audience priorities Compile and prioritize potential messages that convey the urgency and value of a maternal health supplies initiative Overview next steps including creative process and testing

III. IV.

Key Findings from Policy Landscape Interviews ......................................... 1:30 Defining Communications Success .............................................................. 2:15 What does success or the win look like for messaging outreach? What is the long-term goal? What are the short-term milestones?

V.

Target Audiences ......................................................................................... 2:45 Given our goals, who or what audiences must we reach and persuade? What is the desired outcome of the communication to this audience(s)?

VI.

Situational Assessment ................................................................................ 3:15 What are our strengths, assets and opportunities in the maternal health supplies arena? What are the challenges, weaknesses and liabilities we face?

VII.

Message Platform Development ................................................................ 3:45 What are the most important principles or values that we want our target audiences to share and believe? What are we for? What are the themes or facts that are most likely to be relevant and persuasive? Ultimately, what the consequences to our target audience? Why should they care about maternal health supplies?

Page 74

VIII.

Final Comments & Adjourn .......................................................................... 4:45

Page 75

Appendix F: PATH Maternal Health Supplies Stakeholder Validation Interview Discussion Guide My name is _____ and I am calling from KRC Research, an independent research firm. As (recruiter) mentioned, we have been engaged by a community of maternal health advocates to conduct a research study to better understand approaches for addressing maternal health challenges overseas. We know how busy your day is, and we appreciate you taking the time to participate in this research. Your opinions are very important to us, and to the maternal health advocates.

o MODERATOR TO ACKNOWLEDGE THAT THIS IS PART TWO FOR THOSE INDIVIDUALS WHO PARTICIPATED IN THE FIRST PHASE. There are a few things Id like to tell you before we get started with the interview. I am an independent researcher, and as such, I am not vested in any particular viewpoint or policy. I am looking to learn from you and your experiences. Your candidness in responses is very useful to me in learning about the topics in this interview. Your participation in this interview is anonymous and your feedback will remain confidential. The interview will take 30-40 minutes of your time. With your permission, Id like to record the interview so that I dont need to slow down to take notes.

For my own background, could you tell me a little bit about yourself and your role at (organization) and your current or past work on maternal health issues in low resource settings?

I. Context Maternal Health Supplies 5 minutes (Purpose: Warm-up section before delving into the messages that we want to test about the topic. This section will be short, but will also help us understand what is top of mind

Page 76

for these individuals when it comes to maternal health issues. Our interview team is prepared to curtail conversation in this section so that it is productive, but does not dominate the interview.) As I mentioned, I am an independent researcher, and I only know what I learn from these types of interviews. There are no wrong answers, Im just looking for your experiences and perspectives. We are going to be focusing on maternal health supplies today. What are the two or three most talked-about topics when it comes to making available maternal health supplies in low resource settings?

What are some of the reasons that it is important to support policies and increased investments in maternal health supplies? In your experience, are there any particularly good ways to illustrate the importance or impact of increased investments in maternal health supplies? Who or what entities do you think could be the most effective champions or advocates in increasing support and investments in maternal health supplies? Overarching Theme 8 minutes

II.

Im going to read you a statement that could be used to help increase support for and investment in maternal health supplies among global policymakers and influencers. Id like to know what you think of when you hear it.

The statement is: Health Supplies: Essential to Protecting Mothers Before, During and After Childbirth, Improving Maternal Health o What do you think of when you hear this? o Who do you feel would say this? What type of group? o What questions or curiosities do you have about this statement? o Does this at all feel relevant to increasing support and investments in maternal health supplies in developing countries? o Does this feel like something that would get the attention of global policymakers and influencers?

Page 77

NOTE: IF PARTICIPANT ASKS FOR CLARIFICATION ON GLOBAL POLICY MAKERS, FIRST ASK WHO THEY PERCEIVE TO BE GLOBAL POLICY MAKERS. Ive got a few sentences to read to you now that might be used with this overall theme. Id like to get your reaction on each. The first/next is: o Becoming a mother is usually a special, joyous event. But for many women in developing countries, childbirth can be life-threatening. Can you imagine a woman in labor arriving at a clinic to deliver her baby only to find that the basic medical equipment, medicines, and health staff arent there? Ensuring access to basic maternal health care will prevent hundreds of thousands of women from dying during pregnancy and childbirth and ensure they and their children live healthier lives. However, access to essential maternal health medicines and other supplies are an often overlooked part of the solution.

o Working together, global leaders, national governments and maternal health advocates have the power to elevate the critical role of maternal health supplies in protecting womens lives during pregnancy and childbirth. Policy leadership matched with much-needed investments will provide women with access to the proven, low-cost maternal health supplies needed to save millions of lives worldwide. After each, ask: What are your initial reactions? Do you find this particular phrase accurate and believable? Do you find this particular phrase to be compelling? Something that you would want to take action on? If you were to hear this, what type of evidence or follow-up statements would you expect to also hear to make it more believable?

MODERATOR TO LISTEN FOR AND PROBE ACCORDINGLY ON: o Economic ROI o Scope of the problem o Impact data

Page 78

o o o o o

Examples of solutions Costs of solutions Firsthand experience or accounts Anecdotal stories from mothers Attitudinal data

AFTER ALL: What words or phrases do you feel really resonate with you from what I read to you? o Is there anything with which you disagree? Or that you would change?

AFTER ALL: Are there any elements in here that you feel particularly speak to an increased investment in maternal health supplies? Does this feel like something that would get the attention of global policymakers and influencers?

III.

Messages

10 minutes

Im going to read you some additional themes or ideas that might be used to support policies and increased investments in maternal health supplies, and Id like to get your reaction on each. The first/next is:

o No woman should die giving life: The solution to safe pregnancy and childbirth for women in the developing world starts with access to basic health care, including maternal health supplies. o Access to Overlooked Supplies Saves Lives and Improves Maternal Health: Supplies are an essential solution to improving maternal health, especially during pregnancy and childbirth. Maternal health supplies need to be available at the health clinics and in the hands of trained health care workers to save womens lives. o Leadership and investments in maternal health supplies matter: Global leaders and national governments have the power and responsibility to protect womens lives during pregnancy and childbirth with greater investments in maternal health medicines and other supplies.

Page 79

o Saving mothers means stronger families, communities and nations: Healthy mothers have a powerful ripple effect. To save a mother is to save a family. And to save a family is to lay the foundation for stronger communities and more stable nations. FOR EACH, READ TEXT FIRST, THEN ASK: In the context of increasing support for and investments in maternal health supplies, what does that statement say to you? Do you find it believable? Do you find it compelling? Would it get your attention? IF STATEMENT IS NOT WELL-RECEIVED, ASK: Is there a part of this statement that is just not working for you? Lets break it down. If you were to hear this, what type of evidence or follow-up statements would you expect to also hear to make it more believable?

MODERATOR TO LISTEN FOR AND PROBE ACCORDINGLY ON: o Economic ROI o Scope of the problem o Impact data o Examples of solutions o Costs of solutions Probe: Does knowing that each of the three medicines costs less than $1 USD lend support for the message? o Cost per person Probe: does knowing that delivering a package of services, including supplies necessary for improving maternal health is estimated to cost less than $1.50 USD? o Firsthand experience or accounts o Anecdotal stories from mothers or fathers o Attitudinal data Should these be focused on specific supplies? Which ones?

Page 80

Does this feel like something that would get the attention of global policymakers and influencers? For Theme 2: Im going to read you a few more sentences and Id like your thoughts on them: o At the heart of good maternal health care is a set of basic, low-cost, but essential supplies that includes contraceptives, medicines, and simple equipment ( e.g. manual vacuum aspiration), among others. o Women everywhere depend on a stocked supply cabinet

After each, ask: o Do you find it compelling? o Would it get your attention? For Theme 4: Tell me more about what type of proof we need here to show long-lasting impact through funding maternal health supplies o IF NEEDED: What proof points or evidence does the community have to offer, or need to find, to support this? AFTER ALL MESSAGES: Of those that Ive read, are there one or two messages that you think speaks to the need for increasing supportive policies and increased investments in maternal health supplies particularly well? AFTER ALL: Are there one or two that are less compelling to you?

IV.

The Ask and Messengers

5 minutes

In thinking about these messages, in your own words, how would you describe what the community of maternal health advocates is asking for?

Would the messages that you heard today support the community of maternal health advocates asking for increase support for polices that broaden access to life-saving maternal health supplies?

Page 81

o What about increased investments that broaden access to life-saving maternal health supplies? Who would you expect to be asking for this? o Are there other voices that you could see asking for increased support: Moms, nurses, a celebrity, corporate CEO, a scientist or a non-profit organization that works on this issue? o Are there organizations that you find are well-suited to ask for this? How so? o Are there organizations that you think would be better received among your peers?

V.

Wrap Up

2 minutes

To wrap up, what have you heard during our conversation that you feel is the most compelling reason to increase the investment in maternal health supplies in developing countries? o What is the single best example of why it is important to increase the investment? o If you had to choose between moral and economic reasons for increasing the investment, which argument would you be drawn toward most?

Do you have any advice for the community of maternal health advocates on how to make a targeted investment for maternal health supplies a reality?

Thank you very much for your time and feedback. Any final thoughts or questions for me?

Page 82

Appendix E: Messaging Key Phrases, Words, and Jargon

KEY PHRASES and WORDS (working list) Essential maternal medicines and supplies save lives. Healthier moms, healthier babies, healthier communities. Proven, cost effective medicines prevent a majority of maternal deaths. Healthy women and mothers are good for everyone. Maternal supplies must be in-stock. Mothers should be able to count on maternal medicines and supplies. JARGON TO CONSIDER RETIRING (FOR MESSAGE PURPOSES ) (working list): Commodities Supplies (without an example or context) Maternal mortality and morbidity-MMR

USAID, Saving the Lives of Women and Children, retrieved from: http://www.usaid.gov/our_work/global_health/mch/mh/index.html ii Every Mother Counts, Country Statistics, retrieved from: http://everymothercounts.org/issue iii Washington Post, A Mother's Final Look at Life (2008), retrieved from: http://www.washingtonpost.com/wpdyn/content/article/2008/10/11/AR2008101102165.html?sid=ST2008101201887&s_pos iv United Nations Commission on Life-Saving Commodities for Women and Children (Prepared for), Medicines for Maternal Health, retrieved from: http://bit.ly/IryoJY v The World Health Report (2005), Make Every Mother and Child Count, retrieved from: http://www.who.int/whr/2005/whr2005_en.pdf vi United Nations Commission on Life-Saving Commodities for Women and Children (Prepared for), Medicines for Maternal Health, retrieved from: http://bit.ly/IryoJY vii John Hopkins Study find link viii UNFPA ix Women Deliver, Focus on 5: Womens Health & the MDGs, retrieved from: http://www.womendeliver.org/assets/Focus-on-5.pdf x The World Health Report (2005), Make Every Mother and Child Count, retrieved from: (http://www.who.int/whr/2005/whr2005_en.pdf xi Maternal Health Task Force, U.N. Commission on Life Saving Commodities for Women and Children: Country Case Studies(2012), retrieved from: http://maternalhealthtaskforce.org/components/com_wpmu/wpcontent/uploads/blogs.dir/1/files/2012/06/UN-Commission-for-Lifesaving-Commodities_CountryCase-Studies_June-2012-clean.pdf xii Brown. UNICEF. Working Together for Maternal and Newborn Health, retrieved from :http://www.unicef.org/sowc09/docs/SOWC09-Panel-5.1-EN.pdf
i

Page 83

xiii USAID, Two Decades of Progress: USAIDS Child Survival and Maternal Health Program, retrieved from: http://pdf.usaid.gov/pdf_docs/PDACN044.pdf xiv The World Health Organization, Maternal Health: Investing in the Lifeline of Healthy Societies & Economies, retrieved from: http://www.who.int/pmnch/topics/maternal/app_maternal_health_english.pdf xv Women Deliver, Focus on 5: Womens Health & the MDGs, retrieved from: http://www.womendeliver.org/assets/Focus-on-5.pdf xvi ONE, Africas Future is Female, retrieved from: http://one.org/c/international/hottopic/3806/

Page 84