“Playing the Numbers Game”: Evidence-based Advocacy and the Technocratic Narrowing of the Safe Motherhood Initiative

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“Playing the Numbers Game”: Evidence-based Advocacy and the Technocratic Narrowing of the Safe Motherhood Initiative
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Medical Anthropology Quarterly (MAQ).
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Storeng, Katerini T. and Dominique P. Béhague
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Global health
Evidence-based policy
Audit culture
Advocacy coalitions
Maternal health

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Based on an ethnography of the international Safe Motherhood Initiative (SMI), this article charts the rise of evidence-based advocacy (EBA), a term global-level maternal health advocates have used to indicate the use of scientific evidence to bolster the SMI's authority in the global health arena. EBA represents a shift in the SMI's priorities and tactics over the past two decades, from a call to promote poor women's health on the grounds of feminism and social justice (entailing broad-scale action) to the enumeration of much more narrowly defined practices to avert maternal deaths whose outcomes and cost effectiveness can be measured and evaluated. Though linked to the growth of an audit- and business-oriented ethos, we draw from anthropological theory of global forms to argue that EBA—or “playing the numbers game”—profoundly affects nearly every facet of evidence production, bringing about ambivalent reactions and a contested technocratic narrowing of the SMI's policy agenda.
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Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Yasemin Akdas.
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KateriniT.Storeng CenterforDevelopmentandtheEnvironment, UniversityofOslo LondonSchoolofHygieneandTropicalMedicine DominiqueP.B ehague MedicineHealthandSociety, VanderbiltUniversity, DepartmentofSocialScience, HealthandMedicineKing'sCollegeLondon LondonSchoolofHygieneandTropicalMedicine "PlayingtheNumbersGame":Evidence-based AdvocacyandtheTechnocraticNarrowing oftheSafeMotherhoodInitiative BasedonanethnographyoftheinternationalSafeMotherhoodInitiative(SMI), thisarticlechartstheriseofevidence-basedadvocacy(EBA),atermglobal-level maternalhealthadvocateshaveusedtoindicatetheuseofscienticevidenceto bolstertheSMI'sauthorityintheglobalhealtharena.EBArepresentsashiftin theSMI'sprioritiesandtacticsoverthepasttwodecades,fromacalltopromote poorwomen'shealthonthegroundsoffeminismandsocialjustice(entailingbroadscaleaction)totheenumerationofmuchmorenarrowlydenedpracticestoavert maternaldeathswhoseoutcomesandcosteffectivenesscanbemeasuredandevaluated.Thoughlinkedtothegrowthofanaudit-andbusiness-orientedethos,we drawfromanthropologicaltheoryofglobalformstoarguethatEBAor"playing thenumbersgame"profoundlyaffectsnearlyeveryfacetofevidenceproduction, bringingaboutambivalentreactionsandacontestedtechnocraticnarrowingofthe SMI'spolicyagenda. [globalhealth,evidence-basedpolicy,auditculture,advocacy coalitions,maternalhealth] Weneednewarguments.Wehavebeensayingthesamethingfortwenty yearsanditstilldoesn'tresonate. MemberoftheSafeMotherhoodInitiative'sSecretariat(19872005) 260 MEDICALANTHROPOLOGYQUARTERLY ,Vol.28,Issue2,pp.260279,ISSN07455194,onlineISSN1548-1387. C 2014TheAuthors.MedicalAnthropologyQuarterlypublished byWileyPeriodicals,Inc.onbehalfofAmericanAnthropologicalAssociation.Allrightsreserved. DOI:10.1111/maq.12072 ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense, whichpermitsuse,distributionandreproductioninanymedium,providedtheoriginalworkis properlycited.

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Evidence-basedAdvocacy 261 Introduction InOctober2007,nearly2000delegatesfrom115countriesgatheredinLondonat thehigh-proleWomenDeliverConferencetobring"newammunitiontothecase forinvestinginmaternalandnewbornhealth"(WomenDeliver2007).Convened onthe20thanniversaryofthe1987UN-sponsoredconferencethatlaunchedthe internationalSafeMotherhoodInitiative(SMI)inNairobi,Kenya(Starrs1987), WomenDeliversoughttoreinvigorateglobalagencies'anddonors'commitmentto prioritizematernalhealthinlow-incomecountries. Betweenthesetwoconferences,however,amajorshiftoccurredinthetypes ofargumentsusedtodemandinternationalaction.In1987,thecalltoaction invokedasenseofinternationalresponsibility,underpinnedbyastrongfeminist commitmenttoimprovingwomen'sstatus.Theinitiative'sfoundersaccusedthe internationalcommunityofneglectingthehealthofpoorwomeninfavorofa narrowfocusonpopulationcontrolandchildsurvival.Maternalmortalityand morbidityinlow-incomecountries(i.e.,pregnancy-relateddeathandillness)were saidtoremainhighinpartbecauseofgenderandeconomicinequities,orasargued inoneeditorial,becausethoseaffectedbyit"havetheleastpowerandinuence insociety"(Starrs1987:45).Earlysafemotherhoodchampions,includingthe WorldHealthOrganization's(WHO)DirectorGeneralHalfdanMahler,claimed thatreducingmaternalmortalitywoulddemandnottechnicalmagicalbullets,but comprehensive,multi-sectoralapproachestotacklingthesocialdeterminantsof maternalmortality,includingwomen'slowsocialstatus(Mahler1987). Bycontrast,thosespearheadingWomenDeliver20yearslateradvancedtheir claimsthroughwhatconferenceorganizersreferredtoas"evidence-basedadvocacy."Thistermwasusedtohighlighttheimportanceofpersuadingthebroader globalhealthcommunitytoinvestinmaternalhealthnotbymakingexplicitmoral claims,butbyusingquantitativeobjectiveevidence.Inthissense,evidence-based advocacyisrelatedtothebroadershiftinthe1980sand1990stowardevidencebasedmedicineandevidence-basedpublichealth,bothofwhichhavecontributed tothegrowthinmonitoringofhealthtargetsinso-calleddevelopingcountries (Greenhalgh1996;Justice1986)aswellastheimpetustorenderhealthpolicymakingmoreobjective,effective,andeconomicalandlesssubjectiveandideological(Dobrowetal.2004).Indeed,themostvaluabletypeofevidencethatmaternal healthadvocatesnowpointtoisthegoldstandardofcost-effectivenessevidence, usedtocalculateboththehealthandeconomicvalueofproposedinterventionsfor reducingmaternalmortality.Itwasbasedonthistypeofevidencethatorganizers oftheWomenDeliverconferencedevisedastheirslogan:"InvestinWomenIt Pays." However,asaterm,evidence-basedadvocacy(EBA)wasrarelyusedinthe1990s, andaswebeganexploringitsrapidemergenceoverthepastdecade,itbecameclear tousthatEBAisaparticularlyvibrantemicnotioncurrentlyundergoingsignicant ux.Ononelevel,SMIactors'adoptionofEBAsimplyindicatestheirrecognition thatscienceholdsconsiderablesway,particularlyinthecontextofaproliferationof agencies,NGOs,andcoalitionscompetingforfundsandrecognitionontheglobal scene(McCoyetal.2010).Theymaythusbedemonstratingacertainpragmatismin relationtotheriseofwhatStrathern(2000)hasarguedisthebroaderinltrationof

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262 MedicalAnthropologyQuarterly an"auditculture"invarioussectorswiththeriseofneoliberalismandthewaning oftrustintheauthorityofpublicsectorinstitutions. Certainly,manymaternalhealthexpertshavebecomekeenlyawarethatdebates aboutthemeritsofscienticevidenceinpolicy-makingareoftenlessaboutpure epistemicvaluesthantheyareaboutthesignicant,recentexpansionofabusinessorientedethosandaudit-basedorientationtoglobalhealth(Birn2009).Withinthis context,theyhaveembracedEBAtobolstertheSMI'smarketable,credible,and scienticallyauthoritativeidentity,andtodemonstrateits"valueformoney."Yet, whileadvocacyexpertswithintheSMIhavebecomeskilledatusingEBA,they havealsodevelopednewEBAtechniqueswithasenseofironyandconsiderable ambivalence,notingthewayEBAunderminesthepotentialofresearchtoanswer corequestionsrelatingtohealthsystems,equity,anduniversalhealthrights,values towhichtheyremainpoliticallycommitted.Moreover,thetermisincreasinglyused cynicallytohighlightthattheuseofevidenceto"sell"safemotherhoodtoglobal donorssitsindetrimentalcontradistinctiontothemorenecessaryproblem-solving andanalyticalformofevidence-basedpolicy-making. DrawingonanethnographyoftheSMIandanthropologicaltheoryofglobal forms,thisarticleexaminesthecontestedriseofEBA.Aswehavenotedelsewhere (B ehagueandStoreng2008;Storeng2010),somematernalhealthexpertsrespondto theirsenseofambivalenceregardingEBAbyseekingtoseparatetheircontributions toadvocacyfromtheircoreor"realresearch"projects.Inthisarticle,however, wedemonstratethattheshifttowardEBAisnotmerelydiscursivenorindeed easilycontainedintheworldofadvocacy.Instead,EBAor"playingthenumbers game,"asSMIactorsoftenrefertoithascometoprofoundlyaffectnearlyevery facetofevidenceproduction,fromhowresearchbecomesundertakenandevidence conceptualized,tohowitisinterpretedandpresented,bringingaboutagreater degreeofhomogenizationandtechnocraticnarrowingintheSMI'spolicyagenda thanitsproponentshadeverintended.Weendthearticlebyshowingthatitis inresponsetoagrowingsenseofuneasinesswithsuchtechnocraticnarrowing thatsomeexpertsaremakingnewandcreativeusesofevidenceintheireffortsto reintroducejustice,equity,andrightsintomaternalhealthpolicydebates. TheSafeMotherhoodInitiative TheSMIwasinitiallyformedasaninteragencygroupofUNactors(theWHO,the UnitedNation'sChildrenFund[UNICEF],theUnitedNation'sPopulationFund [UNDP],andtheWorldBank)thatcametogethertoraisedonorcommitment tomaternalhealthinlow-incomecountries.Atthetime,thespecicterm"safe motherhood"wascoinedtodrawattentiontohowunsafemotherhoodcouldbe, butalsobecauseitwasdeemedanuncontroversialterm,disassociatedfromongoing debatesinfertilitycontrolandabortion,yetencompassingarangeofactionsto improvewomen'shealththatwouldnotantagonizesociallyconservativedonorsor governments(Storeng2010). ManyoftheSMI'sfoundingmembersbelongtothegenerationofwomenwho participatedintheantiwarandcivilrightsmovementsofthe1960sand1970sand whoworkedinhumanitarianrolesintheirearlytwenties,oftenasPeaceCorps volunteers.Althoughmostwentontotrainasdoctorsandstatisticians,many

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Evidence-basedAdvocacy 263 retainedtheirpoliticizedinterestinwomen'sconditions,givingtheSMI'searlyyears itspoliticallytingeddimension.Overtime,however,theSMIhasdiversiedand expandedtoincludeagrowingnumberofinternationalandregionalNGOsaswell asotherexpertsfrommultilateralandbilateralagencies,academia,andprofessional medicalorganizations.In2005,forexample,theSafeMotherhoodInter-Agency Groupbecameformallyincorporatedintoanew,WHO-hostedPartnershipfor Maternal,NewbornandChildHealth(PMNCH). Althoughadedicatedsafemotherhoodcontingentremains,theoverridingidentitythattypiestheSMIisboundlesstoitspoliticizedoriginsthantothesociopoliticalprocessesentailedinwhatpoliticalscientistsrefertoas"transnational advocacynetworks"(KeckandSikkink1998)or"advocacycoalitions"(Sabatier andJenkins-Smith1993).Akey raisond' etre ofsuchcoalitionsliesincompeting withagrowingand"unrulym elange"ofotherglobalhealthinitiatives(Buseand Walt1997:449).Manyofthesearepublicprivatepartnerships,themostprominent ofwhicharetheGlobalFundtoFightHIV/AIDS,TBandMalariaandtheGAVI Alliance.Thesehaveemergedwithfundingfrombusiness-orientedprivatesector actorsnotleasttheBillandMelindaGatesFoundationandhavechallengedthe positionoftheWHOastheundisputedleaderininternationalhealthgovernance (Brownetal.2006).Indeed,itisinpartbecauseofthegrowingsenseofcompetition withintheglobalhealtharenathat,inthedecadessincetheNairobiconference, safemotherhoodwasstrategicallyredened(reluctantlybysome)torefertothe morenarrowandthuseasier-to-advocate-forgoalofreducingmaternalmortality (women'sdeathduringorwithin42daysofpregnancy)(Storeng2010).Evenso, theSMIhasstruggledtocompetewithmoreprominentglobalhealthinitiatives (Shiffman2007). StudyingtheSafeMotherhoodAdvocacyCoalition Afterseveraldecadesofethnographicresearchonthelocalizedeffectsofglobally derivedhealthpolicies(Berry2010;CastroandSinger2004;Chapman2003;Pigg 1997),anthropologistshavebeguntoshifttheirattentiontotheemergenceofa recognizableandpowerfulglobalhealtheld(Adamsetal.2008;BiehlandPetryna 2013;JanesandCorbett2009;KapilashramiandMcPake2012).JanesandCorbett (2009)cogentlyarguethatanthropologicalstudiesofglobalhealthpolicyshould focusontheformationanddisseminationofexpertknowledgeforms,inadditionto theirlocalconsequences.Hardon(2005),forexample,assertsthathigh-levelglobal policyworkoftenentailsafocuson"magicbullets"thatdenythecomplexityof localrealities. Indissectingthepowersthatenabletheseprescriptions,Nichter(2008:2)describestheroleofglobalhealthelitesandtheiruseofscienticevidencetoperpetuate"masternarratives"thatshapetheverycoreofhowsolutionstoglobal healthproblemsareconceptualized,ofteninoversimplifyingwaysthatassumeuniversalapplicability.Decodingsuchnarrativesnecessarilyentailsattentiontothe socialandpoliticalnegotiationsthatgointotheirmaking,includingtheinterrelationshipsbetweenthevarious"substancesofinternationalhealthpolicy-making [the]knowledge,ideology,politicsofrepresentation,competingvestedinterests,

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264 MedicalAnthropologyQuarterly processesofpersuasionandadvocacy,etc.[that]cometoconstituteit"(Janesand Corbett2009:174). Notwithstandingthestronghomogenizingforcesimbuedwithinsuchmaster narratives,wecontendthat,takingfromOng's(2007:4)workonneoliberalism,advocacycoalitionsarenotsystemsassuch,butareratherconstitutedbya "migratorysetofpractices...thatparticipateinmutatingcongurationsofpossibility."Thus,thoughcoalitionsareentrenchedinbroaderglobal[health]forms, theseglobalformsarenotstructuralbuthave,asCollierandOng(2005:11)assert,a"distinctivecapacityfordecontextualization,abstract-abilityandmovement ...abletoassimilatethemselvestonewenvironments[and]tocodeheterogeneous contextsandobjects."Thoughpowerfullytransportable,suchglobalformsareneverthelesslimitedbyspecictechnicalinfrastructures,administrativeapparatuses,or valueregimes(CollierandOng2005). Itisboththepowerfullyadaptiveandlimitingqualitiesofcoalitionsthatweare interestedinhereengendering"mutations"thatwecontendourinformantsare keenlyawareofandmakeuseofpragmatically,transformingevidenceproduction inparticularintoapowerfultoolforpolitical,moral,andeconomicnegotiations. Theethnographicstudyofsuchdynamicsentailsarangeofchallenges.Notleast oftheseisthereconceptualizationoftheethnographiceldasasocial,political, andepistemicspacethatisdiverseandthatisarticulatednotinspecicinstitutional ornationalsettingsbutthroughgeographicallyloosenetworksofrelationsand power(ShoreandWright1997:14;WedelandFeldman2005).AsMosse(2011)has argued,studyingglobalnetworksethnographicallyrequiresamultifacetedapproach forunderstandingthebroaderinstitutionalcontextsinwhichnetworksoperateand throughwhichspecicperspectives,formsofknowledge,andpracticesareshaped andreproduced. Ourmultifacetedapproachincludedreviewingkeyinternationalpolicydocuments,scienticpapers,andcommentariesinmajorpublichealthjournalsto identifytrendsinkeypolicydebates.Between2004and2009,wealsoconducted participantobservationonsafemotherhoodresearchandpolicynetworkswhile wewereworkingasanthropologistswithinanumberofinterdisciplinaryresearch projectsonmaternalhealth.Inadditiontoday-to-dayparticipationinresearchactivities,weattendedaround20dedicatedfocusingevents.Theseincludedresearch andadvocacymeetings,high-levelpolicymeetingsandinternationalglobalhealth conferences,includingWomenDeliver.Atthesemeetings,weobservedpaneldiscussionsandpresentationsandparticipatedininformaldiscussionswithawide arrayofactors. Wealsoconductedformal,open-endedin-depthinterviewswith72individuals fromthemainorganizationsinvolvedintheSMI.Theseincludedmultilateralagencies,donordevelopmentagencies(U.S.,U.K.,andNorway),prominentresearch institutes,professionalorganizationsforobstetriciansandmidwives,andinternationalNGOsandprivatephilanthropicfoundations. Becausethesafemotherhoodcommunityisamongthesmallestofthemoreinuentialglobalhealthcoalitions,ourethnographyhasbeenparticularlychallengingto writeabout.Toensureourinformants'anonymity,wehaveattimeshadtosacrice ethnographicdetailsideallyneededtoproperlylocateinformantsintime,place,and withinaspecicconstellationofsocialrelationships.

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Evidence-basedAdvocacy 265 TowardEvidence-basedAdvocacy ThedriveforeconomicefciencythatisattherootofEBAprecededtheformation oftheSMI,startingalmostimmediatelyaftertheAlma-AtaConferenceonPrimary Healthcarein1978.Theconferenceembracedthegoalof"HealthforAllbytheYear 2000,"withprimaryhealthcarebeingidentiedasakeymeansforachievinghealth aspartofsocialandeconomicdevelopment(WHOandUNICEF1978).However, withinapoliticalcontextofeconomiccrisisandtheascendancyinmajordonor countriesofaneoliberalideology,acounter-movementpushingfor selective primary healthcarequicklyemerged.Selectiveprimaryhealthcarefocusedontechnicalxes tospecicdiseasesthatweredeemedpragmatic,nanciallyfeasible,measurable,and politicallyunthreateningalternativestotheidealisticcomprehensiveprimaryhealth careagenda(Brownetal.2006:67). Initsearlyyears,theSMIwasformedinpartthroughanexplicitrejectionofthe ethosofselectiveprimaryhealthcare(Storeng2010).Evenso,theinitiativequickly becameboundupinaglobalhealthlogicfocusedontheincreasinglytwinnedissues ofmeasurementandeconomicefciency.Indeed,inalandmarkarticlepublishedin 1992,leadersintheeldarguedthattheneglectofmaternalhealthinresourceallocationontheonehand,andthepoorqualityandscopeofmaternalhealth-related dataontheotherare"self-reinforcingandconstituteameasurementtrap"(Graham andCampbell1992:967).Thismeasurementtrap,theyclaimed,hadconstrained effortstoestablishthelevelsandtrendsofspecicmaternalhealthoutcomes,to identifythecharacteristicsanddeterminantsofhealthoutcomes,andtomonitor andevaluatetheeffectivenessofprograms. Themeasurementtrapproblembecameaccentuatedwiththegrowingpopularityof"burdenofdisease"priority-settingtoolsthroughoutthe1990s.Spearheaded bytheWorldBank,thesetoolscementedtheideathatdiseasesandconditions accountingforahighburdenofmortalityandmorbidityshouldbeprioritized.Althoughmaternalmortalityhadbeenshowntobetheleadingcauseofdeathamong reproductive-agewomeninlow-incomecountries,theburdenofdiseaselogicfosteredthekeyideaamongglobaldonorsthatthenumberofmaternaldeathswastoo smallrelativetodeathsfromotherglobalhealthproblemslikeinfectiousdiseases towarrantprioritizationanideathatmaternalhealthadvocatesclaimpersists today.AsacommunicationspecialistfromtheD.C.-basedPopulationReference Bureauexplained:"Thefactisyoureallyhaveastrugglebecauseifyoucomparethenumberofdeaths,therearehalfamillionmaternaldeathscomparedto 10millioninfantandchilddeathsperyear...peoplesayit'snothingcomparedto someoftheotherissues." TheestablishmentoftheUNMillenniumDevelopmentGoals(MDGs)in2000, oneofwhichistoimprovematernalhealth,reinforcedthisdemandforquantitative healthindicators.Asoneinformantexplained,inthepast"donorsneverwanted indicatorsandthentheywantedresultsandeverybodystartedaskingWhatareyou usingyourmoneyfor?'" Atthesametime,donors'andpolicy-makers'growingemphasisonexperimental randomizedcontrolledtrials(RCTs)andcost-effectivenesscalculations(theratio ofcostsandhealthgain,suchasyearsoflifeordisability-adjustedlifeyearssaved) posedsignicantproblemstomaternalhealthspecialists,whowereunabletoproduceconvincing(experimental)evidencethattheinterventionsrecommendedby

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266 MedicalAnthropologyQuarterly theSMIarecosteffective.Thisisbecauseitisbothexpensiveandimpractical toconductRCTswithmaternalmortalityasanoutcomeduetotheverylarge samplesizethatisneededtobeabletoattributedifferencesinmaternalmortality toagivenintervention(Campbelletal.1995).Aboveandbeyondthis,therecommendedmaternalhealthinterventionssuchasskilledbirthattendance,emergency obstetriccare,andgoodreferralmechanismsarecomplexandspandifferentlevels ofthehealthsystem,andcannoteasilybesubjectedtoexperimentalstudy(Campbell etal.1995).Bythetimewestartedoureldworkin2004,thedearthofRCT-based evidenceoninterventionstoreducematernalmortalityhadsignicantlyreinforced thesortsofanxietiesarticulatedinthe1992measurementtraparticle(B ehagueand Storeng2008).AccordingtooneseniorEuropeanmaternalhealthepidemiologist, lackofexperimentalevidencehadbecomeamainimpedimenttotheSMI'sability tocompetewithotherglobalhealthcoalitionsthat,asheputit,have"abetter recordof[providing]evidence-basedrecommendations." ConsolidatingEvidence-basedAdvocacy Evidence-basedadvocacyismuchmoreeffectivethananyotherkindof advocacythatcanjustbewrittenoffasideological. SeniorinternationalNGOrepresentative Certainly,allglobalhealthcoalitionshaverespondedtothedriveforevidencebasedefciencyandfortheremovalofideologicalandmoralargumentsfromthe policy-makingprocess.However,theSMI'soriginalappealtofeministandsocial justiceargumentshasaddedanadditionalburdenand,accordingtosome,becomea veritableliability(StorengandB ehague2013)."Ithinkeverybody'safraidofgetting thefeministlabelbecauseitturnssomanypeopleoff,"explainedoneresearcher fromaNewYorkbasedwomen'shealthNGO. Infact,someinformantshadcometofeelthatbecausetheoriginalfeminist ideologicalbasisofthemovementhasbeendiscredited,scienticevidencecurrently playsaparticularlyimportantroleincompensatingforthelowpoliticalappealof maternalhealth.Intheearly2000s,keyactorsthusbegantoarguethattheSMI wouldnotachievepolicyleverageandinclusioninhigh-levelpolicyforumsifitdid notlearntotalkmoreauthoritativelythroughuseofscienticevidenceandhealth statistics. ItwasduringthisexplicitrearticulationoftheSMI'sidentityawayfromitsoriginalpoliticalpositioningthatagrowingarrayofEBApractices,tobedescribed below,cametothefore.Themainproponentsofsuchpracticeshavebeenadvocacy andcommunicationspecialistsbasedininternationalNGOs,whicharestrategicallypositionedincitieslikeWashingtonD.C.,NewYork,andLondonto,inthe wordsofonesuchactor,"inuencethehighpolitics'ofglobalhealth."U.S.-based NGOshavebeenespeciallyferventpromotersofEBA,perhapsbecausetheythemselveshavecomeunderintensepressurefromtheirfunders(whichoftenincludes USAIDandsometimesprivatedonorsliketheBillandMelindaGatesFoundation) todemonstratetheirownvalueformoney. AlthoughsomeoftheseNGOshavebeenactivesincetheSMI'sstart,manyare newentitiessustainedbythegrowingemphasison"gettingresearchintopolicy"and

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Evidence-basedAdvocacy 267 inparticular,"knowledgetranslation,"aprocesswherebypeer-reviewedscientic publicationsaresimpliedandmadeintelligibletobusypolicy-makers(Greenhalgh andWieringa2011).Thesenewactorsdistinguishthemselvesfromacademic scientists;althoughtheyoftenconductresearchaspartoftheirworkandrecognize scienticexpertiseaskeytotheirownpoliticalinuence,theydistancethemselves fromthepublishorperishculturetheyseeasconstrainingtheiracademiccounterparts.Nevertheless,NGO-basedadvocacyspecialistsareoftenaidedbycolleagues withinUNagenciesandbyacademicswhohavegradually,ifreluctantly,embraced anadvocacyrole. PerformanceIndicators AlthoughstatisticalevidencewasimportanttotheSMI'sinitialsuccessindrawing internationalattentiontotheissueofmaternalmortalityinlow-incomecountries, thedemandfornumberstosetagendashasincreasedsignicantlywiththeemphasisonevidence-basedpolicy-making.Withtime,advocacyspecialistshavebecome acutelyawareofthepoliticalpowerofnumbers,includingthewayinwhichnumberscanhelpgenerateapoliticalresponsewhererhetoricaloneseemsineffective. Leaguetablesrankingdifferentcountries'maternalmortalityratios(MMRs)have proventobeparticularlyeffectiveadvocacytoolsforgeneratingpoliticalresponses. ABelgianepidemiologistwhocontributedtotheproductionofsuchatableinthe late1990srecalledhowitspublicationsparkedamajorpoliticalresponseinone WestAfricancountrythatwasrankedashavingahigherMMRthanitsneighbor. "Forthepolitician,[theleaguetable]isallabouthowheis[tobe]judged.Becauseunconsciouslypeopleconcentrateonthenumbers,"ourinformantexplained, addingthattheMDGs'emphasisonmeasurableresultshasreinforcedthistendency dramatically.Forhim,theevocativepowertheMMRindicatorhasacquiredreects thatithasbecomeanindicatornotjustofwomen'shealth,butofacountry'soverall development: Maternalmortalityhasbecomesufcientlypartofthecollectiveconscience, somuchsothatishasbecomeoneoftheMillennium[Development]Goals. Itisnowunderstoodbypolicy-makerstobeanimportantindicatorofthe performanceofthehealthsystem,which,inturn,indicatesthesocial performanceofacountry. AhighMMRthuscreatesanincentiveforacountrytoprioritizematernalhealth heexplained,ifonlytoavoidappearinglessdevelopedthanitsneighbors. Thepoliticalpowerofnumbersexistsevenwhenthevalidityofthenumbers iscontested.Infact,controversyoverthevalidityofstatisticscanactuallyhelp galvanizeapoliticalreaction.AnotherepidemiologistataleadingAmericanpublic healthschoolhadwitnessedsuchasituationwhentheUNpublishedamaternalmortalityestimateforMoroccothatwashigherthanthegovernment'sown census-basedgure.Thediscrepancybetweenthenumbersgeneratedintensepoliticaldebateaboutthegovernment'saccountability,trustworthiness,andcommitment towomen'shealth.Assherecalled,"Theoppositiontookthisupandsaid,Thank Godthereareinternationalagencieswhowilltellusthetruthaboutourwomen

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268 MedicalAnthropologyQuarterly whoaredying,thegovernmentisclearlylyingtous.'Andthisissuewasdebated inparliament...itcertainlycausedabig[political]brouhaha."Thisreaction,she explained,occurreddespitethefactthat,atthetechnicallevel,thegureswerenot comparablebecausetheyhadbeenderivedusingdifferentmethods. Advocacygroupsexplicitlycapitalizeonpoliticaleffectssuchasthese.Several U.S.NGOs,forexample,showedusthevisualgraphicsandcolorful"reportcards" thattheyuseintheiryearlyreportstocomparecountries'performanceonmaternal healthindicators.Moreprototypically,even,theCountdownto2015initiative establishedin2005,inwhichanumberofourinformantswereinvolved,hasasits statedaim:"tomonitorandholdcountriesaccountable"fortheirprogresstoward theMDGsthroughcollationandcommunicationofstatisticsonthe"coverage ofhealthinterventionsproventoreducematernal,newbornandchildmortality" (Countdownto20152009).TheexplicitpremiseofCountdownto2015isthat drawingattentiontoperformanceindicatorswillstimulate"betterandstronger effortsatthecountrylevel"bygovernmentsconcernedwiththeirimageandkeen todemonstratetheresultsoftheirdonors'investments(Countdownto20152009). CreativeEpidemiology Advocacyspecialistshavealsobecomeadeptatusingwhatsomepublichealthspecialistsexplicitlyterm"creativeepidemiology"tounderscoretheattention-seeking aspectofresearch(Wallacketal.1993).Displayinganacuteappreciationforhow distinctclassesofstakeholdersinterpretnumbersdifferently,severalofourinformantsexplainedthatthepresentationofstatisticaldataneedstobemodieddependingontheaudience.Forinstance,differentexpressionsofthestatisticalriskof maternaldeathshouldbeusedtoinuenceglobal-levelpolicyelites,national-level decision-makers,andthepublicrespectively. AlthoughtheMMRcanbehighlyeffectiveininuencingnational-levelpolicy debates,preciselybecauseitisthekeyindicatorthathasbeenusedtocompare countriesacrosstheglobe,theMMRwasdeemedtootechnicalforthelaypublic. Rather,statisticalexpressionsthatare"moreimmediate,individual"andamenable, even,tobepersonalizedsuchasthelifetimeriskofmaternalmortalityweresaid tobeeasierforlaypeopletodrawmeaningfromandthusmorehelpfulingaining thepublic'ssupportformaternalhealthinvestment.Asasenioradvisorwiththe NGOwholongservedastheSMI'ssecretariatobserved,"Whenyoutalkwith peopleonetooneandyousaythatoneoutofeverysixwomeninAfghanistandie inpregnancyandchildbirthcomparedtooneinevery30,000inSwedenorNorway, peopleareabsolutelyhorried,shocked." Persuadingglobal-levelpolicyactors,inturn,demandsdifferentstatistics,primarilybecauseoftheviewthatthenumberofmaternaldeathsistoolowtowarrant prioritizationwhencomparedwithotherhealthissues.Asthesenioradvisorcited aboveexplained,whenitcomestoaglobalhealthaudience,"youreallydohaveto frameitinadifferentwaybecausethenumbers[ofmaternaldeaths]alonedon't makethecase."Onestrategyhasbeentofocusnotonlyonmortalitybutalso onproducingnewevidenceofthematernalmorbidities(andevenlong-termdisabilities)thatresultfrompregnancy-relatedproblemsinlow-incomecountries(e.g., WHO2004).Usingthesedata,advocacyspecialistsareeffectivelyabletoarguethat

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Evidence-basedAdvocacy 269 maternalmortalityisonly"thetipoftheiceberg"oftheneglectofpregnancy-related health. Premisedonthecloseclinicallinksbetweenmothers,children,andnewborns, expressingadvocacymessagesintermsofthecombinedburdenofdiseaseaffecting thesethreegroupshasemergedasacreativestrategyformakingtheproblemofmaternalmortalityappearbiggerand,byextension,moreimportant.Unlikematernal mortalityalone,oneofourinformantsexplained,whencombined,the"MNCH" (maternal,newbornandchildhealth)burdenofdiseasefarexceedsthatattributed toHIV/AIDS,TB,andmalaria,thusinatingthenumberoflivesthatcanbesaved byinvestinginmaternalhealthand"makingamuchstrongeradvocacyargument." Suchanticipatedbenetswereoneofthemainreasonsthatmanysafemotherhood advocatespragmaticallysupportedtheSMI'sinvolvementinthePMNCH,despite widespreadconcernsaboutunderminingtheSMI'slongstandingefforttoensure safemotherhoodnotbeovershadowedbythemorephilanthropicallyappealing issueofchildhealth.AsoneseniorU.K.-basedmaternalhealthresearcherandadvocateexplained,"itmakessensetobungin[include]thebabiesforthenumbers game." CalculatingEconomicImpact DeviatingevenfurtherfromtheoriginalSMI'spoliticalarguments,EBAhasalso entailedproducingandusingeconomicevidencetoappealtothedominantlogic ofcosteffectiveness.AseniorUNFPAadviserwhowasinvolvedinelaborating theWomenDeliveradvocacystrategyinsistedthat"economicrebranding"has becomenecessaryto"sell"safemotherhood.Inhereverydaywork,sheavidly endorsedactivitiesthatwouldbeableto,assheputit,"positionthisproductasan opportunityofdesiresopeoplewillwanttoinvestinit."Afoundingmemberofthe SafeMotherhoodInter-AgencyGroupsharedthisperspective:"Youcanmobilize acertainconstituencygroupjustbytalkingabouttheethicalandinjusticeissues, butforthesehardcoredecision-makerswholookateconomicfactors,thatkindof appealdoesn'tnecessarilycarrytheday." Formanyofourinformants,then,akeywayofensuringthatinvestinginmaternalhealthisseenasagood"globalhealthbuy"(intheway,say,immunizationor antiretroviralHIVmedicationare)isthroughtheproductionofmoreexperimental (RCT-based)evidenceofcosteffectiveness(B ehagueandStoreng2008).Asnoted above,however,thisisalmostimpossibleforcomplexhealthsystemapproaches designedtoreducematernalmortality. Ratherthancontesttheepistemologicallimitationsoftheexperimentalmethod fordemonstratingtheimpactofhealthsystemsstrengtheningandintersectoral innovation,assomeacademicshavebeguntodo(B ehagueandStoreng2013), advocacyspecialistshavepushedforproducingcost-effectivenessevidenceofsimpleandtargetedinterventions,suchasdrug-basedtreatmentsforhemorrhageand infection(amongthemainclinicalcausesofmaternalmortality).Asonesuchinformantputit,"donorswanttoshowthattheysavelives.That'snotwhatyouget byputtingyourmoneyintostrengtheningthehealthsystemortrainingabunchof midwives."Targetedinterventions,anotheradvocacyspecialistimplied,arepseudocommoditiesthatareeasiertosellbecausetheirimpactondeathsavertedcanbe

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270 MedicalAnthropologyQuarterly moreeasilydemonstratedthroughgoldstandardexperimentalresearch.Advocates calledfortheproductiononevidenceofsuchinterventionstoenablethemtoshow thatcosteffectiveinterventionsformaternalhealthexistandthatsavingwomen's livesmakesgoodeconomicsense.Thisisneededtoachievewhatseveralinformants labeled"buy-in"fromdonorswhoarenoteasilyswayedbycallsforbroaderhealth systemsdevelopment. Advocacyspecialistshavealsostartedtoinvokebroadmacro-economicargumentsabouttheimportanceofmaternalhealthforeconomicdevelopment."Women deliversomuchmorethanbabies,"theheadoftheWomenDeliveradvocacyteam repeatedonmorethanoneoccasion,explainingthatthedoublemeaninginthe term"deliver"highlightswomen'scombinedreproductiveandproductive(economic)contributionstohouseholdsandsociety.Inspiredbythemobilizationof similarargumentsintheHIV/AIDSsubeld,theWomenDeliverconferencebecame ashowcaseforneweconomicestimatesofproductivitylossandimpoverishment resultingfrompregnancy-relatedmortalityandmorbidity(e.g.,Gilletal.2007). Moreover,aroundthetimeoftheconference,donorsassessingcosteffectiveness wereurgedtoconsiderthefullbenetofinvestinginmaternalhealth,includingnot onlywomen'ssurvivalandassociatedeconomicoutcomes,butalsothe"knock-on" benetsforchildren'sandnewborns'survivalandtheassociatedlong-termbenets fornationaleconomicproductivityandgrowth(e.g,TheLancet2007). SocentralhavethesekindsofEBApracticesbecomethatmanyadvocacyspecialists'professionalactivitiesarenowfocusedon"capacitybuilding,"orteaching counterpartsinlow-incomecountrieshowtoengageinEBA,whetherbyproducing evidencethemselvesor,morecommonly,learninghowtoimplementknowledge translationprogramsintheirownsettings.Accordingtoonecommunicationspecialist,suchcapacitybuildingcaninvolve"ooding"localpolicychampionswith evidencethroughworkshopsandtrainingsessionstoimprovetheirbargainingpositionvis` a-vistheirowngovernmentsand,especially,foreigndonors:"Isay[to them],thesearethetalkingpointsifyou'regoingtogotoUSAIDorifyou'regoing toasafemotherhoodmeeting...thisiswhy[thisevidenceis]relevanttoyour country.'" AReluctant(andCritical)Evidence-basedAdvocacy Onmanylevels,theEBApracticesdescribedabovehavebeenhighlysuccessfulin respondingtothekeystructuralandideologicalchangesinglobalhealthgovernance,namelyincreasedcompetitionforresourcesandafocusonquick,visible productivityandmeasurableaccountability.ThereisnodoubtthatEBAhascontributedtoarecentsurgeindonorinterestinmaternalhealth,exempliedbythe growthofdonorcommitmenttolargepolicyinitiativessuchastheEveryWoman EveryChildglobalmovementlaunchedbytheUNsecretary-generalin2010and theGlobalStrategyforWomen'sandChildren'sHealth(PMNCH2011). Advocacyexperts'successinengagingwiththiscultureofobjectivity,however, hasbeenmixedinwithagreatdealofconcurrentapprehensionandintensely criticalandself-criticalviewsoftheevidence-basedactivitiesinwhichmanyare partaking.Accordingtoseveralofourinterviewees,theclaimthatsafemotherhood recommendationsarebasedonaparticularlyweakevidentiarybaseisunfounded

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Evidence-basedAdvocacy 271 andrelates,rather,tothefactthatdonors'andhealthpolicy-makers'demandforscienticevidenceisdisproportionatelyhighwhenitcomestomaternalhealth.When askedaboutthereasonsforthis,oneadvocacyspecialistpointedtoawidespread lackofpoliticalcommitmenttowomen'shealthanddisregardforacoalitionthat hastraditionallybeenseenasbeingledbywomenandalignedtothewomen's movement.Assheexplained,HIV,forinstance,capturedattentionnotbecauseit hadgoodqualityevidence,butbecause:"Therst[donorsandleaders]whogot behind[HIV/AIDS]weremalesintheUS!Imean,whatstrongervoices...can therebe?Andthis[safemotherhood]isastoryaboutmothersandchildren.... ifwewomentalkaboutit,we'rewhiningaboutatopicthatis,youknow,not interesting."Andasanotheradvocacyspecialistsimilarlyhighlighted:"Howmany billionsofdollarshavegonetoabstinenceprogramsforHIV/AIDSinthelastsix years?What'stheevidencethere?Youcan'ttakeafractionofthatmoneytosavea woman'slifeunlessyouhavetheevidence." Thoughcriticalviewssuchasthesewerefrequentlylinkedtotheunderlying feministconcernthatwomen'shealthissimplynotapriorityinwhatisstillamaledominatedworld,suchinsightswerenotgratuitous,but,rather,translatedalso intoself-criticalviewsanddeepambivalenceregardingthebenetsofEBA.This ambivalencereectedthewaysitcaneasilydoadisservicetothepoliticalcommitmenttoequityandintrinsichealthrights,whilealsocontributingtoatechnocratic narrowingofthepolicyagenda. TechnocraticNarrowing Ininterviews,advocacyspecialistsreectedcriticallyonthewaytheiractivitieshave contributedtonarrowingthetermsofdebateaboutmaternalhealthbyrestrictingthekindsofargumentsandformsofevidencethat"count"asauthoritative. "It'sallquantitativenow,"acommunicationspecialistworkingforaD.C.-based internationalNGOcommented.Thepresidentofawell-knownadvocacyandresearchNGOclaimedthattheperceivedpressuretouseevidenceinpolicydebates hasbecomesointensethatwhereastwodecadesagokeySMIleaderswereable towritecredibleeditorialscenteredontheimportanceofwomen'sstatusandtheir righttohealth(e.g.,Sai1987),todaytheyarenolongercomfortablemakingpolicy statementsbasedonsuchprincipledidealsifunsupportedbyscienticevidence. Moreover,theideathatburdenofdiseaseandinstrumentaleconomicarguments shouldguidetheallocationofresourcesisinirresolvabletensionwithmanySMI actors'privateconvictionthatintrinsiccommitmenttosocialjustice,rightsandequityshouldbethemainpolicydrivers.Manyworried,forexample,aboutendorsing priority-settingtoolssuchasburdenofdiseaseanalysesthathavebeenshowntosystematicallybiaspriorityawayfromconditionssufferedbypoorwomen,including pregnancy-relatedmortalityandmorbidity(e.g.,Sundby1999). SeveralofthosewhohadparticipatedintheCountdownto2015andsimilar accountabilityprojectsdemonstratedunsettledambivalenceaboutthefactthatthey hadcontributednotjusttoagenda-settingbutalsototheexportationof"target culture"todonor-dependentcountries.Theynoted,forexample,thattheenforcementofaccountabilitydemandscanencouragedonorrecipientstoproducefake numbers.Moreimportantly,respondingtodonors'demandsfornumbersdiverts

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272 MedicalAnthropologyQuarterly attentionfrombuildingsustainableandlocallyrelevanthealthinformationsystems. Onelongstandingsafemotherhoodadvocatenowworkingasaresearcherwitha Gates-fundedNGOevenlamentedthatherinvolvementinaprojecttopromotea drugthatcanpreventmaternaldeathsfrompostpartumhemorrhagehadprobablycontributedtonarrowingthematernalhealthagendafromsocialandpolitical solutionstowardpurelytechnicalones: I'mactuallydoingsomethingthatphilosophicallyIwouldn'thavebelievedI wouldhavedoneafewyearsagobecauseIdobelieveinholisticcareandI dobelieveweneedto...[tackle]thesystem.SowhatamIdoingsitting hereworkingon...Iwouldn'tsayit'sasilverbulletformaternalhealth ...but,youknow,oneofthefewthingsthatcomesasclosetoakindof silverbulletstrategyasyoumightget? Aswehavedescribedingreaterdetailelsewhere(B ehagueandStoreng2008, 2013;Storeng2010),manymaternalhealthspecialistswerealsohighlycriticalof thewaysthedemandsforcost-effectivenessdatareinforcetechnocraticnarrowingbyshiftingresearchprioritiesawayfromtheuseofmultimethodstudieson thedynamicsofmaternalmortalitydeclinesor,indeed,disaggregatedlocal-level statisticsandprocessevaluationsofactualpolicychangetoafocusontargeted interventionsthatcanmoreeasilybesubjectedtoexperimentalstudy. Evidence-basedPolitics Thekindsofcriticalinsightswehavedescribedabovearethusnotsimplyrhetorical, butare,rather,beginningtotranslateintoresearchpracticesofallkinds,including thosebeingdevelopedandsupportedbyanincreasinglyprominentnetworkof academicsworkingalongsidehumanrightslawyers.Thoughnotradicallydifferent, andthoughstillfunctioningwithinthebasicparametersofEBA,thesepracticesare beingactivelyusedtoreintroducejustice,equity,andrightsintopolicy-making,but onmore"legitimate"scienticgrounds. Perhapsthemostnotableofthesepracticesentailsareturntoepidemiology's historicfocusonthesocialdeterminantsofhealth,specically,theuseofdisaggregatedindicatorstoillustrateinequitiesinthesocioeconomic,ethnic,andgeographic distributionsofmaternalmortality,includingdisparitiesinaccesstolife-savingservicesbothbetweenandwithincountries(Freedman2003).Thisapproach,asone lawyerandadvocacyspecialistexplained,allowsonetotalkaboutinequitiesin anobjectivedescriptivemannerand,importantly,avoidsusing"off-puttingrights language."Atthesametime,withinthecontextofaprivateexchange,shedidnot hesitatetointerpretsuchdisparitiesinpoliticalterms: Ifyoulookatacountrywhereyouhaveamiddleclassthat'sabletogive birthsafelybutthenyouseeveryhighratesofmaternalmortalityamong minoritygroups,immigrantgroups,thenitisclearyouhave adiscriminationissueandthat'snotadifcultrightsargumenttomake.

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Evidence-basedAdvocacy 273 Asshefurtherexplained,advocatesusingsuchdataarebeginningtoeffectively engagegovernmentsinadiscussionabouttheiraccountabilitytotheMDGsand, importantly,tointernationalhumanrightstreatiesthat,inprincipleatleast,oblige statestoaddresssystemicdiscriminationandinequitythroughtargetedpolicy action. Thekindofideologicalpragmatismdemonstratedherewasalsoapparentin otheradvocacyspecialists'sophisticatedinvolvementintheprocessofdeningthe targetindicatorstobeusedinglobal-levelmonitoringofcountries'progresstoward theMDGs.SMIleadersandNGOswere,onthewhole,excludedfromhigh-level UN-basedformulationoftheMillenniumDeclarationin2000andthesubsequent articulationoftheeightMDGs.Thoughimprovingmaternalhealthendedupbeing oneofthegoals(MDG5),manyfeltthattheinternationalcommunity,infocusing thegoalexclusivelyonthetargetofmaternalmortalityreduction,hadrenegedon promisestopromotethebroaderconceptofsexualandreproductivehealththathad beenmadeattheUNInternationalConferenceonPopulationandDevelopmentin 1994. Accordingtoourinformants,maternalhealthwaschosenasthefocusofMDG 5becauseitislesscontroversialthanreproductivehealth.However,toargueforan additionalMDGonreproductivehealthoncethegoalshadbeensetwasdeemed politicallyunwise.Instead,keyindividualsbegantodemandNGOrepresentation ontheexpertpaneldrawnuptodenetargetsandindicatorsformeasuringprogress towardsMGD5.Throughthisforum,theysuccessfullyarguedthattheexisting target onmaternalmortalityreductionwastoonarrowtocapturethebroader goal of improvingmaternalhealth.In2006,anadditionaltargetindicatoruniversalaccesstoreproductivehealthwasnallyincludedunderMDG5,theonlynegotiated MDGtargettodate.Thoughclearlyonlyapartialvictory,manywithintheeld consideredthisanimportantachievement,reectingtheirconvictionintheoften repeatedmaxim,"inpublichealth,whatyoumeasureiswhatyoudo." Conclusion EBAhasundoubtedlybeensuccessful.Withinacontextofgrowingemphasison quantitativeevidencetoinformpriority-settingandjustifyinvestments,playingthe numbersgamehasemergedasperhapsthemostviablestrategyforglobalhealth initiativesliketheSMIastheystruggletodenetheiridentityandcompeteeffectively inarapidlychangingglobalhealtheld.Indeed,EBAanditssuccessisexemplaryof thebroader"auditculture"describedbyStrathern(2000)andothers(Power1997). AsShoreandWright(1999)claim,theexpansionofaudittoolsfromnancial accountancyintoothersectorssuchaseducation(and,wewouldargue,health) hasenabledtheexpansionofneoliberalformsofgovernance,whereprofessional relationsarereducedtoquantiableand,aboveall,inspectabletemplates. Indeed,suchgovernmentalizingtendenciesdemonstratethebroaderhistorical growthduringthe20thcenturyofthepowerofscienticauthority,ofapervasive "trustinnumbers"(Porter1995)andcultureofobjectivitythathascometocharacterizemodernsocieties(Daston1992;Nader1996).However,theriseofEBA highlightsthatcost-effectivenessevidencethegoldstandardwithinevidence-based policy-makingis,infact,notremovedfromideology.Rather,itisitselfanother

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274 MedicalAnthropologyQuarterly ideologythatisbeingintroducedand,aswehavedocumentedinthisarticle,adopted andadaptedwithvariousdegreesofambivalence.Safemotherhoodadvocacyspecialistsrecognize,asHaraway(1988)haspointedout,thatclaimsforactiongain moreauthorityandlegitimacyiftheyaredissociatedfromsubjectiveideologiesand linkedtohigh-statussocialagents,suchasscienticevidence.Onecouldevenargue thatadvocacyspecialistsrelyexplicitlyonthewayinwhichhealthstatisticsacquire anauthoritativesociallifeoftheirown,despitethefactthattheyarealsoawareof thewaysnumberscansoeasilybefraughtwithtechnical,andindeedideological, difculties(Hacking2007;NichterandKendall1991). Ouranalysessupportkeyndingsfromtheanthropologicalstudyofglobalforms ofexpertise(Adams2010;Lakoff2010;PfeifferandNichter2008).Wehave,for example,underscoredthewayinwhichglobalhealthpolicy,andespeciallyits emphasisonquantitativeevidence,reinforcesanoversimplied"master-narrative" circumscribedbytechnicalsolutionstohealthproblems(Nichter2008).Asaresult, moralandsocialjusticeargumentshavebecomepartiallyeclipsedbythemore competitiveusestowhichevidence-basedpolicy-makingactivitieshavebeenput. Importantly,however,wehavealsohighlightedthesociopoliticalstrugglesand riftsthatgointothemakingofthesenarratives,specicallythewayssafemotherhoodexpertsnotonlydisseminateauthoritativeknowledgeandcreatemasternarratives,butalsoresistandmodifythem,showingbothreexivityanddecidedly ambivalentattitudestotheirowncontributionstoEBA(B ehagueandStoreng2013). Insomeinstances,SMIexpertscogentlyechothekindsofcriticismsthatanthropologistsoftenmakeregardingthegrowingmarginalizationofpluralformsofevidence (Adams2005;BiehlandPetryna2013;Lambert2006,2013). Thealternativeevidence-basedactivitiessomeexpertsareengagingin(e.g.,to keepabroadconceptualizationofthesocialdeterminantsofmaternalhealthand rightsontheagenda)givelietotheideathatideologyhasbeenfullybanishedfrom theevidence-baseddecision-makingdomain.WhatappearstobeoccurringsimultaneoustomorestandardformsofEBAisarearticulation,orperhapsevencouching, ofideologicalconvictionsintheauthoritativelanguageofscienticevidencefor thesakeofpoliticalexpediency.Thoughmanyofourinformantshavebegunto skepticallypointtoEBA'sreductionisttendencies,theyarealsondingwaysto continueusingthepowerofscienceandobjectivitytofullltheirenduringcommitmenttoethicalandmoralprinciples.Ideologicaldebatesandsubjectivevaluesare thusnotbeingeliminatedbutratherobfuscatedasscienticandhenceobjective, andarereintroducedinwaysthataremorereadilyfungiblewithanevidence-based framework. Suchmulti-layeredappealstoobjectivitydemonstratetheextenttowhichSMI experts'criticalawarenessandresistantactivitiesareindeedconstrainedbythe "technicalinfrastructures,administrativeapparatuses[and]valueregimes"ofglobal forms(CollierandOng2005:11).Fosteringsuchaheavyrelianceonpurportedly objectiveclaims,ratherthanchallengingthebasisonwhichglobal-leveldecisionmakingtakesplacethroughexplicitlyvalue-basedpoliticalarguments,mayhave negativeconsequences,asmanyofthosecontributingtothesetrendsacknowledge. ThoughtheadoptionofEBAaimsto"save"theSMIaswellasthewomenon whosebehalfitadvocates,ithascontributedtomakingitmoredifculttoadvance principledargumentsabouttheimportanceofmaternalhealth,unlesstheseare

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Evidence-basedAdvocacy 275 articulatedintermsofinstrumentalscientic,technical,oreconomicrationales. Thetechnocraticpriority-settingtoolsthatarenowdominatingsustainanarrow cost-effectivenessfocusnoteasilyappliedtothekindsofbroaderhealthsystem developmentsmaternalhealthspecialistssaytheyareconvincedareessentialfor reducingmaternalmortality.ByparticipatinginEBA,maternalhealthadvocates arealsocontributingtotheunwelcomefragmentationofglobalhealthgovernance andnationalhealthsystemsthatresultsfromdifferentprofessionalcommunity advocatingfortheuptakeoftheirownsetofissuesandinterventions.Asaresult ofsuchcompetition,littleattentionisdirectedtocross-cuttingissuescentralto thefunctioningoftheoverallhealthsystemorsocialandeconomicdeterminants ofhealth(McCoy2009).Andevenlessattentionisgiventothepoliticalchanges neededtoaddressthehealthinequitiesthatmaternalmortalityillustratessoclearly (JanesandChuluundorj2004;Spangler2011). Maternalhealthadvocates'experienceshighlightthatthepressuretoparticipate inthenumbersgame,aswellastheambivalencewithwhichplayersapproachthis game,emergeoutofthemessyandcontradictoryeverydaylifeofglobalhealth politics.However,bypanderingtothepoliticsofglobalhealth,safemotherhood advocatesmaybeextendingthedominanceofatechnocraticapproachthatisat oddswiththeunderlyingpoliticalagendatheyhavebeensokeentosupportsince theSMI'sinception. Note Acknowledgments. Wethankallourinformantsforbeingsuchforthrightand helpfulparticipantsinthisresearch.ThanksalsotocolleaguesattheLondonSchool ofHygieneandTropicalMedicine(LSHTM)andattheUniversityofOslo,to DavidMcCoyandHilaryStanding,andtoparticipantsonthesession"TheEpistemologicalEthicsofResearchinGlobalHealth"atthe2009SocietyforMedical Anthropologymeeting(YaleUniversity),especiallydiscussantsMargaretLockand IanHarperforcommentsonanearlierdraftofthisarticle.Wewouldalsoliketo thanktheeditorsandthetwoanonymousreviewersforveryhelpfulcomments. Thisarticleisbasedonacollaborativeresearchproject(B ehagueandStoreng) fundedbytheEconomicandSocialResearchCouncil(RES-000221039)and Storeng'sPh.D.research(fundedbytheResearchCouncilofNorwayandthe LSHTM).ApostdoctoralfellowshipfromTheWellcomeTrust(GR077175MA) supportedB ehaguefrom2005to2010.Thefunderswerenotinvolvedindeterminingthestudydesign,thecollection,analysis,andinterpretationofdata,orin writingthisarticle.TheLSHTMethicsboardapprovedthestudy. ReferencesCited Adams,V. 2005SavingTibet?AnInquiryintoModernity,Lies,Truths,andBeliefs.Medical Anthropology24:71110. 2010AgainstGlobalHealth?ArbitratingScience,Non-scienceandNonsensethrough Health. In AgainstHealth:HowHealthBecameaNewMorality.J.MetzlandA. Kirkland,eds.Pp.4060.NewYork:NYUPress. Adams,V.,T.E.Novotny,andH.Leslie 2008GlobalHealthDiplomacy.MedicalAnthropology27:315323.

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276 MedicalAnthropologyQuarterly B ehague,D.P.,andK.T.Storeng 2008CollapsingtheVertical-HorizontalDivide:AnEthnographicStudyofEvidencebasedPolicymakinginMaternalHealth.AmericanJournalofPublicHealth98:644 649. 2013PragmaticPoliticsandEpistemologicalDiversity:TheContestedandAuthoritative UsesofHistoricalEvidenceintheSafeMotherhoodInitiative.Evidence&Policy 9:6585. Berry,N.S. 2010UnsafeMotherhood:MayanMaternalMortalityandSubjectivityinPost-war Guatemala.NewYork:BerghahnBooks. Biehl,J.,andA.Petryna,eds. 2013WhenPeopleComeFirst:CriticalStudiesinGlobalHealth.Princeton:Princeton UniversityPress. Birn,A.-E. 2009TheStagesofInternational(Global)Health:HistoriesofSuccessorSuccessesof History?GlobalPublicHealth4:5068. Brown,T.M.,M.Cueto,andE.Fee 2006TheWorldHealthOrganizationandtheTransitionfrom"International"to "Global"PublicHealth.AmericanJournalofPublicHealth96:6272. Buse,K.,andG.Walt 1997AnUnrulyM elange?CoordinatingExternalResourcestotheHealthSector:A Review.SocialScience&Medicine45:449463. Campbell,O.,M.Koblinsky,andP.Taylor 1995OfftoaRapidStart:AppraisingMaternalMortalityandServices.International JournalofGynaecology&Obstetrics48:S33S52. Castro,A.,andM.Singer,eds. 2004UnhealthyHealthPolicy:ACriticalAnthropologicalExamination.NewYork: AltaMira. Chapman,R.R. 2003EndangeringSafeMotherhoodinMozambique:PrenatalCareasPregnancyRisk. SocialScience&Medicine57:355374. Collier,S.J.,andA.Ong 2005GlobalAssemblages,AnthropologicalProblems. In GlobalAssemblages:Technology,Politics,andEthicsasAnthropologicalProblems.A.OngandS.J.Collier, eds.Pp.321.Oxford:BlackwellPublishing. Countdownto2015 2009TrackingProgressinMaternal,NewbornandChildHealth.http://www. countdown2015mnch.org(accessedOctober4,2011). Daston,L. 1992ObjectivityandtheEscapefromPerspective.SocialStudiesofScience22:597618. Dobrow,M.J.,V.Goel,andR.E.G.Upshur 2004Evidence-basedHealthPolicy:ContextandUtilisation.SocialScience&Medicine 58:207217. Freedman,L.P. 2003StrategicAdvocacyandMaternalMortality:MovingTargetsandtheMillennium DevelopmentGoals.GenderandDevelopment11:97108. Gill,K.,R.Pande,andA.Malhotra 2007WomenDeliverforDevelopment.TheLancet370:13471357. Graham,W.J.,andO.M.Campbell 1992MaternalHealthandtheMeasurementTrap.SocialScience&Medicine35:967 977.

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Evidence-basedAdvocacy 277 Greenhalgh,S. 1996TheSocialConstructionofPopulationScience:AnIntellectual,Institutional,and PoliticalHistoryofTwentieth-CenturyDemography.ComparativeStudiesinSociety andHistory38:2666. Greenhalgh,T.,andS.Wieringa 2011IsItTimetoDropthe"KnowledgeTranslation"Metaphor?ACriticalLiterature Review.JournaloftheRoyalSocietyofMedicine104:501509. Hacking,I. 2007BritishAcademyLecture2006:KindsofPeople,MovingTargets.Proceedingsof theBritishAcademy151:285318. Haraway,D. 1988SituatedKnowledges:TheScienceQuestioninFeminismandthePrivilegeof PartialPerspective.FeministStudies14:575599. Hardon,A. 2005ConfrontingtheHIV/AIDSEpidemicinSub-SaharanAfrica:PolicyversusPractice. InternationalSocialScienceJournal57:601608. Janes,C.R.,andO.Chuluundorj 2004FreeMarketsandDeadMothers:TheSocialEcologyofMaternalMortalityinPost-SocialistMongolia.MedicalAnthropologyQuarterly18:230 257. Janes,C.R.,andK.K.Corbett 2009AnthropologyandGlobalHealth.AnnualReviewofAnthropology38:167 183. Justice,J. 1986Policies,Plans,andPeople:ForeignAidandHealthDevelopment.Volume17. Berkely:UniversityofCaliforniaPress. Kapilashrami,A.,andB.McPake 2012TransformingGovernanceorReinforcingHierarchiesandCompetition:ExaminingthePublicandHiddenTranscriptsoftheGlobalFundandHIVinIndia.Health Policy&Planning28:626635. Keck,M.E.,andK.Sikkink 1998ActivistsbeyondBorders:AdvocacyNetworksinInternationalPolitics.Ithaca: CornellUniversityPress. Lakoff,A. 2010TwoRegimesofGlobalHealth.Humanity:AnInternationalJournalofHuman Rights,HumanitarianismandDevelopment1:5979. Lambert,H. 2006AccountingforEBM:NotionsofEvidenceinMedicine.SocialScience&Medicine 62:26332645. 2013PluralFormsofEvidenceinPublicHealth:ToleratingEpistemologicaland MethodologicalDiversity.Evidence&Policy:AJournalofResearch,Debateand Practice9(1):4348. Lancet,The 2007WomenDeliverPressConferenceandPressRelease.TheLancet,London,October 12. Mahler,H. 1987TheSafeMotherhoodInitiative:ACalltoAction.TheLancet1:668670. McCoy,D. 2009GlobalHealthInitiativesandCountryHealthSystems.TheLancet374:1237 1237.

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278 MedicalAnthropologyQuarterly McCoy,D.,K.T.Storeng,V.Filippi,C.Ronsmans,D.Osrin,M.Borchert,O.M.Campbell, A.Roques,R.Wolfe,A.Prost,andZ.Hill. 2010Maternal,NeonatalandChildHealthInterventionsandServices:Movingfrom KnowledgeofWhatWorkstoSystemsthatDeliver.JournalofInternationalHealth 2:9798. Mosse,D.,ed. 2011AdventuresinAidland:TheAnthropologyofProfessionalsinInternationalDevelopment.NewYork:BerghahnBooks. Nader,L.,ed. 1996NakedScience:AnthropologicalInquiryintoBoundaries,PowerandKnowledge. London:Routledge. Nichter,M. 2008GlobalHealth:WhyCulturalPerceptions,SocialRepresentations,andBiopolitics Matter.Tuscon:UniversityofArizonaPress. Nichter,M.,andC.Kendall 1991BeyondChildSurvival:AnthropologyandInternationalHealthinthe1990s. MedicalAnthropologyQuarterly5:195203. Ong,A. 2007NeoliberalismasaMobileTechnology.TransactionsoftheInstituteofBritish Geographers32:38. Pfeiffer,J.,andM.Nichter 2008WhatCanCriticalMedicalAnthropologyContributetoGlobalHealth?AHealth SystemsPerspective.MedicalAnthropologyQuarterly22:410415. Pigg,S.L. 1997AuthorityinTranslation:Finding,Knowing,NamingandTraining"Traditional BirthAttendants"inNepal. In ChildbirthandAuthoritativeKnowledge:CrossculturalPerspectives.R.Davis-FloydandC.Sargent,eds.Pp.233263.Berkeley: UniversityofCaliforniaPress. PMNCH 2011AnalysingCommitmenttoAdvancetheGlobalStrategyforWomen'sandChildren'sHealth.ThePMNCH2011Report.Geneva:ThePartnershipforMaternal, NewbornandChildHealth. Porter,T.M 1995TrustinNumbers:ThePursuitofObjectivityinScienceandPublicLife.Princeton, NJ:PrincetonUniversityPress. Power,M. 1997TheAuditSociety:RitualsofVerication.Oxford:OxfordUniversityPress. Sabatier,P.A.,andH.C.Jenkins-Smith 1993PolicyChangeandLearning:AnAdvocacyCoalitionApproach.Boulder,CO: Westview. Sai,F.T. 1987TheSafeMotherhoodInitiative:ACallforAction.IPPFMedicalBulletin21:12. Shiffman,J. 2007HasDonorPrioritizationofHIV/AIDSDisplacedAidforOtherHealthIssues? HealthPolicyandPlanning23:95100. Shore,C.,andS.Wright 1997Policy:ANewFieldofAnthropology. In AnthropologyofPolicy:CriticalPerspectivesonGovernanceandPower.C.ShoreandS.Wright,eds.Pp.334.London: Routledge. 1999AuditCultureandAnthropology:Neo-liberalisminBritishHigherEducation.The JournaloftheRoyalAnthropologicalInstitute5:557575.

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Evidence-basedAdvocacy 279 Spangler,S.A. 2011"ToOpenOneselfIsaPoorWoman'sTrouble":EmbodiedInequalityandChildbirthinSouth-CentralTanzania.MedicalAnthropologyQuarterly25:479498. Starrs,A. 1987PreventingtheTragedyofMaternalDeaths:ReportoftheSafeMotherhood ConferenceheldinNairobi,Kenya,February.NewYork:FamilyCareInternational. Storeng,K.T. 2010SafeMotherhood:TheMakingofaGlobalHealthInitiative.Ph.D.Thesis,London:UniversityofLondon. Storeng,K.T.,andD.P.B ehague 2013Evidence-BasedAdvocacyandtheRecongurationofRightsLanguageinSafe MotherhoodDiscourse. In HealthRightsinGlobalContext:GeneaologiesandAnthropologies.A.MoldandD.Reubi,eds.Pp.149168.LondonandNewYork: Routledge. Strathern,M.,ed. 2000AuditCultures:AnthropologicalStudiesinAccountability,Ethics,andthe Academy.NewYork:Routledge. Sundby,J. 1999AreWomenDisfavouredintheEstimationofDisabilityAdjustedLifeYearsand theGlobalBurdenofDisease?ScandinavianJournalofPublicHealth27:279285. Wallack,L.,L.Dorfman,D.Jernigan,andM.Themba-Nixon 1993MediaAdvocacyandPublicHealth:PowerforPrevention.NewburyPark,CA: SagePublications. Wedel,J.R.,andG.Feldman 2005WhyAnAnthropologyofPublicPolicy?AnthropologyToday21:12. WHO 2004BeyondtheNumbers:ReviewingMaternalDeathsandComplicationstoMake PregnancySafer.Geneva:WorldHealthOrganization. WHOandUNICEF 1978DeclarationofAlma-Ata.InternationalConferenceonPrimaryHealthCare, Alma-Ata,USSR,612September1978.Geneva:WorldHealthOrganization. WomenDeliver 20072007Conference.http://www.womendeliver.org/conferences/2007-conference/ (accessedJanuary10,2011).



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KateriniT.Storeng CenterforDevelopmentandtheEnvironment, UniversityofOslo LondonSchoolofHygieneandTropicalMedicine DominiqueP.B ehague MedicineHealthandSociety, VanderbiltUniversity, DepartmentofSocialScience, HealthandMedicineKing'sCollegeLondon LondonSchoolofHygieneandTropicalMedicine "PlayingtheNumbersGame":Evidence-based AdvocacyandtheTechnocraticNarrowing oftheSafeMotherhoodInitiative BasedonanethnographyoftheinternationalSafeMotherhoodInitiative(SMI), thisarticlechartstheriseofevidence-basedadvocacy(EBA),atermglobal-level maternalhealthadvocateshaveusedtoindicatetheuseofscienticevidenceto bolstertheSMI'sauthorityintheglobalhealtharena.EBArepresentsashiftin theSMI'sprioritiesandtacticsoverthepasttwodecades,fromacalltopromote poorwomen'shealthonthegroundsoffeminismandsocialjustice(entailingbroadscaleaction)totheenumerationofmuchmorenarrowlydenedpracticestoavert maternaldeathswhoseoutcomesandcosteffectivenesscanbemeasuredandevaluated.Thoughlinkedtothegrowthofanaudit-andbusiness-orientedethos,we drawfromanthropologicaltheoryofglobalformstoarguethatEBAor"playing thenumbersgame"profoundlyaffectsnearlyeveryfacetofevidenceproduction, bringingaboutambivalentreactionsandacontestedtechnocraticnarrowingofthe SMI'spolicyagenda. [globalhealth,evidence-basedpolicy,auditculture,advocacy coalitions,maternalhealth] Weneednewarguments.Wehavebeensayingthesamethingfortwenty yearsanditstilldoesn'tresonate. MemberoftheSafeMotherhoodInitiative'sSecretariat(19872005) 260 MEDICALANTHROPOLOGYQUARTERLY ,Vol.28,Issue2,pp.260279,ISSN07455194,onlineISSN1548-1387. C 2014TheAuthors.MedicalAnthropologyQuarterlypublished byWileyPeriodicals,Inc.onbehalfofAmericanAnthropologicalAssociation.Allrightsreserved. DOI:10.1111/maq.12072 ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense, whichpermitsuse,distributionandreproductioninanymedium,providedtheoriginalworkis properlycited.

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Evidence-basedAdvocacy 261 Introduction InOctober2007,nearly2000delegatesfrom115countriesgatheredinLondonat thehigh-proleWomenDeliverConferencetobring"newammunitiontothecase forinvestinginmaternalandnewbornhealth"(WomenDeliver2007).Convened onthe20thanniversaryofthe1987UN-sponsoredconferencethatlaunchedthe internationalSafeMotherhoodInitiative(SMI)inNairobi,Kenya(Starrs1987), WomenDeliversoughttoreinvigorateglobalagencies'anddonors'commitmentto prioritizematernalhealthinlow-incomecountries. Betweenthesetwoconferences,however,amajorshiftoccurredinthetypes ofargumentsusedtodemandinternationalaction.In1987,thecalltoaction invokedasenseofinternationalresponsibility,underpinnedbyastrongfeminist commitmenttoimprovingwomen'sstatus.Theinitiative'sfoundersaccusedthe internationalcommunityofneglectingthehealthofpoorwomeninfavorofa narrowfocusonpopulationcontrolandchildsurvival.Maternalmortalityand morbidityinlow-incomecountries(i.e.,pregnancy-relateddeathandillness)were saidtoremainhighinpartbecauseofgenderandeconomicinequities,orasargued inoneeditorial,becausethoseaffectedbyit"havetheleastpowerandinuence insociety"(Starrs1987:45).Earlysafemotherhoodchampions,includingthe WorldHealthOrganization's(WHO)DirectorGeneralHalfdanMahler,claimed thatreducingmaternalmortalitywoulddemandnottechnicalmagicalbullets,but comprehensive,multi-sectoralapproachestotacklingthesocialdeterminantsof maternalmortality,includingwomen'slowsocialstatus(Mahler1987). Bycontrast,thosespearheadingWomenDeliver20yearslateradvancedtheir claimsthroughwhatconferenceorganizersreferredtoas"evidence-basedadvocacy."Thistermwasusedtohighlighttheimportanceofpersuadingthebroader globalhealthcommunitytoinvestinmaternalhealthnotbymakingexplicitmoral claims,butbyusingquantitativeobjectiveevidence.Inthissense,evidence-based advocacyisrelatedtothebroadershiftinthe1980sand1990stowardevidencebasedmedicineandevidence-basedpublichealth,bothofwhichhavecontributed tothegrowthinmonitoringofhealthtargetsinso-calleddevelopingcountries (Greenhalgh1996;Justice1986)aswellastheimpetustorenderhealthpolicymakingmoreobjective,effective,andeconomicalandlesssubjectiveandideological(Dobrowetal.2004).Indeed,themostvaluabletypeofevidencethatmaternal healthadvocatesnowpointtoisthegoldstandardofcost-effectivenessevidence, usedtocalculateboththehealthandeconomicvalueofproposedinterventionsfor reducingmaternalmortality.Itwasbasedonthistypeofevidencethatorganizers oftheWomenDeliverconferencedevisedastheirslogan:"InvestinWomenIt Pays." However,asaterm,evidence-basedadvocacy(EBA)wasrarelyusedinthe1990s, andaswebeganexploringitsrapidemergenceoverthepastdecade,itbecameclear tousthatEBAisaparticularlyvibrantemicnotioncurrentlyundergoingsignicant ux.Ononelevel,SMIactors'adoptionofEBAsimplyindicatestheirrecognition thatscienceholdsconsiderablesway,particularlyinthecontextofaproliferationof agencies,NGOs,andcoalitionscompetingforfundsandrecognitionontheglobal scene(McCoyetal.2010).Theymaythusbedemonstratingacertainpragmatismin relationtotheriseofwhatStrathern(2000)hasarguedisthebroaderinltrationof

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262 MedicalAnthropologyQuarterly an"auditculture"invarioussectorswiththeriseofneoliberalismandthewaning oftrustintheauthorityofpublicsectorinstitutions. Certainly,manymaternalhealthexpertshavebecomekeenlyawarethatdebates aboutthemeritsofscienticevidenceinpolicy-makingareoftenlessaboutpure epistemicvaluesthantheyareaboutthesignicant,recentexpansionofabusinessorientedethosandaudit-basedorientationtoglobalhealth(Birn2009).Withinthis context,theyhaveembracedEBAtobolstertheSMI'smarketable,credible,and scienticallyauthoritativeidentity,andtodemonstrateits"valueformoney."Yet, whileadvocacyexpertswithintheSMIhavebecomeskilledatusingEBA,they havealsodevelopednewEBAtechniqueswithasenseofironyandconsiderable ambivalence,notingthewayEBAunderminesthepotentialofresearchtoanswer corequestionsrelatingtohealthsystems,equity,anduniversalhealthrights,values towhichtheyremainpoliticallycommitted.Moreover,thetermisincreasinglyused cynicallytohighlightthattheuseofevidenceto"sell"safemotherhoodtoglobal donorssitsindetrimentalcontradistinctiontothemorenecessaryproblem-solving andanalyticalformofevidence-basedpolicy-making. DrawingonanethnographyoftheSMIandanthropologicaltheoryofglobal forms,thisarticleexaminesthecontestedriseofEBA.Aswehavenotedelsewhere (B ehagueandStoreng2008;Storeng2010),somematernalhealthexpertsrespondto theirsenseofambivalenceregardingEBAbyseekingtoseparatetheircontributions toadvocacyfromtheircoreor"realresearch"projects.Inthisarticle,however, wedemonstratethattheshifttowardEBAisnotmerelydiscursivenorindeed easilycontainedintheworldofadvocacy.Instead,EBAor"playingthenumbers game,"asSMIactorsoftenrefertoithascometoprofoundlyaffectnearlyevery facetofevidenceproduction,fromhowresearchbecomesundertakenandevidence conceptualized,tohowitisinterpretedandpresented,bringingaboutagreater degreeofhomogenizationandtechnocraticnarrowingintheSMI'spolicyagenda thanitsproponentshadeverintended.Weendthearticlebyshowingthatitis inresponsetoagrowingsenseofuneasinesswithsuchtechnocraticnarrowing thatsomeexpertsaremakingnewandcreativeusesofevidenceintheireffortsto reintroducejustice,equity,andrightsintomaternalhealthpolicydebates. TheSafeMotherhoodInitiative TheSMIwasinitiallyformedasaninteragencygroupofUNactors(theWHO,the UnitedNation'sChildrenFund[UNICEF],theUnitedNation'sPopulationFund [UNDP],andtheWorldBank)thatcametogethertoraisedonorcommitment tomaternalhealthinlow-incomecountries.Atthetime,thespecicterm"safe motherhood"wascoinedtodrawattentiontohowunsafemotherhoodcouldbe, butalsobecauseitwasdeemedanuncontroversialterm,disassociatedfromongoing debatesinfertilitycontrolandabortion,yetencompassingarangeofactionsto improvewomen'shealththatwouldnotantagonizesociallyconservativedonorsor governments(Storeng2010). ManyoftheSMI'sfoundingmembersbelongtothegenerationofwomenwho participatedintheantiwarandcivilrightsmovementsofthe1960sand1970sand whoworkedinhumanitarianrolesintheirearlytwenties,oftenasPeaceCorps volunteers.Althoughmostwentontotrainasdoctorsandstatisticians,many

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Evidence-basedAdvocacy 263 retainedtheirpoliticizedinterestinwomen'sconditions,givingtheSMI'searlyyears itspoliticallytingeddimension.Overtime,however,theSMIhasdiversiedand expandedtoincludeagrowingnumberofinternationalandregionalNGOsaswell asotherexpertsfrommultilateralandbilateralagencies,academia,andprofessional medicalorganizations.In2005,forexample,theSafeMotherhoodInter-Agency Groupbecameformallyincorporatedintoanew,WHO-hostedPartnershipfor Maternal,NewbornandChildHealth(PMNCH). Althoughadedicatedsafemotherhoodcontingentremains,theoverridingidentitythattypiestheSMIisboundlesstoitspoliticizedoriginsthantothesociopoliticalprocessesentailedinwhatpoliticalscientistsrefertoas"transnational advocacynetworks"(KeckandSikkink1998)or"advocacycoalitions"(Sabatier andJenkins-Smith1993).Akey raisond' etre ofsuchcoalitionsliesincompeting withagrowingand"unrulym elange"ofotherglobalhealthinitiatives(Buseand Walt1997:449).Manyofthesearepublicprivatepartnerships,themostprominent ofwhicharetheGlobalFundtoFightHIV/AIDS,TBandMalariaandtheGAVI Alliance.Thesehaveemergedwithfundingfrombusiness-orientedprivatesector actorsnotleasttheBillandMelindaGatesFoundationandhavechallengedthe positionoftheWHOastheundisputedleaderininternationalhealthgovernance (Brownetal.2006).Indeed,itisinpartbecauseofthegrowingsenseofcompetition withintheglobalhealtharenathat,inthedecadessincetheNairobiconference, safemotherhoodwasstrategicallyredened(reluctantlybysome)torefertothe morenarrowandthuseasier-to-advocate-forgoalofreducingmaternalmortality (women'sdeathduringorwithin42daysofpregnancy)(Storeng2010).Evenso, theSMIhasstruggledtocompetewithmoreprominentglobalhealthinitiatives (Shiffman2007). StudyingtheSafeMotherhoodAdvocacyCoalition Afterseveraldecadesofethnographicresearchonthelocalizedeffectsofglobally derivedhealthpolicies(Berry2010;CastroandSinger2004;Chapman2003;Pigg 1997),anthropologistshavebeguntoshifttheirattentiontotheemergenceofa recognizableandpowerfulglobalhealtheld(Adamsetal.2008;BiehlandPetryna 2013;JanesandCorbett2009;KapilashramiandMcPake2012).JanesandCorbett (2009)cogentlyarguethatanthropologicalstudiesofglobalhealthpolicyshould focusontheformationanddisseminationofexpertknowledgeforms,inadditionto theirlocalconsequences.Hardon(2005),forexample,assertsthathigh-levelglobal policyworkoftenentailsafocuson"magicbullets"thatdenythecomplexityof localrealities. Indissectingthepowersthatenabletheseprescriptions,Nichter(2008:2)describestheroleofglobalhealthelitesandtheiruseofscienticevidencetoperpetuate"masternarratives"thatshapetheverycoreofhowsolutionstoglobal healthproblemsareconceptualized,ofteninoversimplifyingwaysthatassumeuniversalapplicability.Decodingsuchnarrativesnecessarilyentailsattentiontothe socialandpoliticalnegotiationsthatgointotheirmaking,includingtheinterrelationshipsbetweenthevarious"substancesofinternationalhealthpolicy-making [the]knowledge,ideology,politicsofrepresentation,competingvestedinterests,

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264 MedicalAnthropologyQuarterly processesofpersuasionandadvocacy,etc.[that]cometoconstituteit"(Janesand Corbett2009:174). Notwithstandingthestronghomogenizingforcesimbuedwithinsuchmaster narratives,wecontendthat,takingfromOng's(2007:4)workonneoliberalism,advocacycoalitionsarenotsystemsassuch,butareratherconstitutedbya "migratorysetofpractices...thatparticipateinmutatingcongurationsofpossibility."Thus,thoughcoalitionsareentrenchedinbroaderglobal[health]forms, theseglobalformsarenotstructuralbuthave,asCollierandOng(2005:11)assert,a"distinctivecapacityfordecontextualization,abstract-abilityandmovement ...abletoassimilatethemselvestonewenvironments[and]tocodeheterogeneous contextsandobjects."Thoughpowerfullytransportable,suchglobalformsareneverthelesslimitedbyspecictechnicalinfrastructures,administrativeapparatuses,or valueregimes(CollierandOng2005). Itisboththepowerfullyadaptiveandlimitingqualitiesofcoalitionsthatweare interestedinhereengendering"mutations"thatwecontendourinformantsare keenlyawareofandmakeuseofpragmatically,transformingevidenceproduction inparticularintoapowerfultoolforpolitical,moral,andeconomicnegotiations. Theethnographicstudyofsuchdynamicsentailsarangeofchallenges.Notleast oftheseisthereconceptualizationoftheethnographiceldasasocial,political, andepistemicspacethatisdiverseandthatisarticulatednotinspecicinstitutional ornationalsettingsbutthroughgeographicallyloosenetworksofrelationsand power(ShoreandWright1997:14;WedelandFeldman2005).AsMosse(2011)has argued,studyingglobalnetworksethnographicallyrequiresamultifacetedapproach forunderstandingthebroaderinstitutionalcontextsinwhichnetworksoperateand throughwhichspecicperspectives,formsofknowledge,andpracticesareshaped andreproduced. Ourmultifacetedapproachincludedreviewingkeyinternationalpolicydocuments,scienticpapers,andcommentariesinmajorpublichealthjournalsto identifytrendsinkeypolicydebates.Between2004and2009,wealsoconducted participantobservationonsafemotherhoodresearchandpolicynetworkswhile wewereworkingasanthropologistswithinanumberofinterdisciplinaryresearch projectsonmaternalhealth.Inadditiontoday-to-dayparticipationinresearchactivities,weattendedaround20dedicatedfocusingevents.Theseincludedresearch andadvocacymeetings,high-levelpolicymeetingsandinternationalglobalhealth conferences,includingWomenDeliver.Atthesemeetings,weobservedpaneldiscussionsandpresentationsandparticipatedininformaldiscussionswithawide arrayofactors. Wealsoconductedformal,open-endedin-depthinterviewswith72individuals fromthemainorganizationsinvolvedintheSMI.Theseincludedmultilateralagencies,donordevelopmentagencies(U.S.,U.K.,andNorway),prominentresearch institutes,professionalorganizationsforobstetriciansandmidwives,andinternationalNGOsandprivatephilanthropicfoundations. Becausethesafemotherhoodcommunityisamongthesmallestofthemoreinuentialglobalhealthcoalitions,ourethnographyhasbeenparticularlychallengingto writeabout.Toensureourinformants'anonymity,wehaveattimeshadtosacrice ethnographicdetailsideallyneededtoproperlylocateinformantsintime,place,and withinaspecicconstellationofsocialrelationships.

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Evidence-basedAdvocacy 265 TowardEvidence-basedAdvocacy ThedriveforeconomicefciencythatisattherootofEBAprecededtheformation oftheSMI,startingalmostimmediatelyaftertheAlma-AtaConferenceonPrimary Healthcarein1978.Theconferenceembracedthegoalof"HealthforAllbytheYear 2000,"withprimaryhealthcarebeingidentiedasakeymeansforachievinghealth aspartofsocialandeconomicdevelopment(WHOandUNICEF1978).However, withinapoliticalcontextofeconomiccrisisandtheascendancyinmajordonor countriesofaneoliberalideology,acounter-movementpushingfor selective primary healthcarequicklyemerged.Selectiveprimaryhealthcarefocusedontechnicalxes tospecicdiseasesthatweredeemedpragmatic,nanciallyfeasible,measurable,and politicallyunthreateningalternativestotheidealisticcomprehensiveprimaryhealth careagenda(Brownetal.2006:67). Initsearlyyears,theSMIwasformedinpartthroughanexplicitrejectionofthe ethosofselectiveprimaryhealthcare(Storeng2010).Evenso,theinitiativequickly becameboundupinaglobalhealthlogicfocusedontheincreasinglytwinnedissues ofmeasurementandeconomicefciency.Indeed,inalandmarkarticlepublishedin 1992,leadersintheeldarguedthattheneglectofmaternalhealthinresourceallocationontheonehand,andthepoorqualityandscopeofmaternalhealth-related dataontheotherare"self-reinforcingandconstituteameasurementtrap"(Graham andCampbell1992:967).Thismeasurementtrap,theyclaimed,hadconstrained effortstoestablishthelevelsandtrendsofspecicmaternalhealthoutcomes,to identifythecharacteristicsanddeterminantsofhealthoutcomes,andtomonitor andevaluatetheeffectivenessofprograms. Themeasurementtrapproblembecameaccentuatedwiththegrowingpopularityof"burdenofdisease"priority-settingtoolsthroughoutthe1990s.Spearheaded bytheWorldBank,thesetoolscementedtheideathatdiseasesandconditions accountingforahighburdenofmortalityandmorbidityshouldbeprioritized.Althoughmaternalmortalityhadbeenshowntobetheleadingcauseofdeathamong reproductive-agewomeninlow-incomecountries,theburdenofdiseaselogicfosteredthekeyideaamongglobaldonorsthatthenumberofmaternaldeathswastoo smallrelativetodeathsfromotherglobalhealthproblemslikeinfectiousdiseases towarrantprioritizationanideathatmaternalhealthadvocatesclaimpersists today.AsacommunicationspecialistfromtheD.C.-basedPopulationReference Bureauexplained:"Thefactisyoureallyhaveastrugglebecauseifyoucomparethenumberofdeaths,therearehalfamillionmaternaldeathscomparedto 10millioninfantandchilddeathsperyear...peoplesayit'snothingcomparedto someoftheotherissues." TheestablishmentoftheUNMillenniumDevelopmentGoals(MDGs)in2000, oneofwhichistoimprovematernalhealth,reinforcedthisdemandforquantitative healthindicators.Asoneinformantexplained,inthepast"donorsneverwanted indicatorsandthentheywantedresultsandeverybodystartedaskingWhatareyou usingyourmoneyfor?'" Atthesametime,donors'andpolicy-makers'growingemphasisonexperimental randomizedcontrolledtrials(RCTs)andcost-effectivenesscalculations(theratio ofcostsandhealthgain,suchasyearsoflifeordisability-adjustedlifeyearssaved) posedsignicantproblemstomaternalhealthspecialists,whowereunabletoproduceconvincing(experimental)evidencethattheinterventionsrecommendedby

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266 MedicalAnthropologyQuarterly theSMIarecosteffective.Thisisbecauseitisbothexpensiveandimpractical toconductRCTswithmaternalmortalityasanoutcomeduetotheverylarge samplesizethatisneededtobeabletoattributedifferencesinmaternalmortality toagivenintervention(Campbelletal.1995).Aboveandbeyondthis,therecommendedmaternalhealthinterventionssuchasskilledbirthattendance,emergency obstetriccare,andgoodreferralmechanismsarecomplexandspandifferentlevels ofthehealthsystem,andcannoteasilybesubjectedtoexperimentalstudy(Campbell etal.1995).Bythetimewestartedoureldworkin2004,thedearthofRCT-based evidenceoninterventionstoreducematernalmortalityhadsignicantlyreinforced thesortsofanxietiesarticulatedinthe1992measurementtraparticle(B ehagueand Storeng2008).AccordingtooneseniorEuropeanmaternalhealthepidemiologist, lackofexperimentalevidencehadbecomeamainimpedimenttotheSMI'sability tocompetewithotherglobalhealthcoalitionsthat,asheputit,have"abetter recordof[providing]evidence-basedrecommendations." ConsolidatingEvidence-basedAdvocacy Evidence-basedadvocacyismuchmoreeffectivethananyotherkindof advocacythatcanjustbewrittenoffasideological. SeniorinternationalNGOrepresentative Certainly,allglobalhealthcoalitionshaverespondedtothedriveforevidencebasedefciencyandfortheremovalofideologicalandmoralargumentsfromthe policy-makingprocess.However,theSMI'soriginalappealtofeministandsocial justiceargumentshasaddedanadditionalburdenand,accordingtosome,becomea veritableliability(StorengandB ehague2013)."Ithinkeverybody'safraidofgetting thefeministlabelbecauseitturnssomanypeopleoff,"explainedoneresearcher fromaNewYorkbasedwomen'shealthNGO. Infact,someinformantshadcometofeelthatbecausetheoriginalfeminist ideologicalbasisofthemovementhasbeendiscredited,scienticevidencecurrently playsaparticularlyimportantroleincompensatingforthelowpoliticalappealof maternalhealth.Intheearly2000s,keyactorsthusbegantoarguethattheSMI wouldnotachievepolicyleverageandinclusioninhigh-levelpolicyforumsifitdid notlearntotalkmoreauthoritativelythroughuseofscienticevidenceandhealth statistics. ItwasduringthisexplicitrearticulationoftheSMI'sidentityawayfromitsoriginalpoliticalpositioningthatagrowingarrayofEBApractices,tobedescribed below,cametothefore.Themainproponentsofsuchpracticeshavebeenadvocacy andcommunicationspecialistsbasedininternationalNGOs,whicharestrategicallypositionedincitieslikeWashingtonD.C.,NewYork,andLondonto,inthe wordsofonesuchactor,"inuencethehighpolitics'ofglobalhealth."U.S.-based NGOshavebeenespeciallyferventpromotersofEBA,perhapsbecausetheythemselveshavecomeunderintensepressurefromtheirfunders(whichoftenincludes USAIDandsometimesprivatedonorsliketheBillandMelindaGatesFoundation) todemonstratetheirownvalueformoney. AlthoughsomeoftheseNGOshavebeenactivesincetheSMI'sstart,manyare newentitiessustainedbythegrowingemphasison"gettingresearchintopolicy"and

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Evidence-basedAdvocacy 267 inparticular,"knowledgetranslation,"aprocesswherebypeer-reviewedscientic publicationsaresimpliedandmadeintelligibletobusypolicy-makers(Greenhalgh andWieringa2011).Thesenewactorsdistinguishthemselvesfromacademic scientists;althoughtheyoftenconductresearchaspartoftheirworkandrecognize scienticexpertiseaskeytotheirownpoliticalinuence,theydistancethemselves fromthepublishorperishculturetheyseeasconstrainingtheiracademiccounterparts.Nevertheless,NGO-basedadvocacyspecialistsareoftenaidedbycolleagues withinUNagenciesandbyacademicswhohavegradually,ifreluctantly,embraced anadvocacyrole. PerformanceIndicators AlthoughstatisticalevidencewasimportanttotheSMI'sinitialsuccessindrawing internationalattentiontotheissueofmaternalmortalityinlow-incomecountries, thedemandfornumberstosetagendashasincreasedsignicantlywiththeemphasisonevidence-basedpolicy-making.Withtime,advocacyspecialistshavebecome acutelyawareofthepoliticalpowerofnumbers,includingthewayinwhichnumberscanhelpgenerateapoliticalresponsewhererhetoricaloneseemsineffective. Leaguetablesrankingdifferentcountries'maternalmortalityratios(MMRs)have proventobeparticularlyeffectiveadvocacytoolsforgeneratingpoliticalresponses. ABelgianepidemiologistwhocontributedtotheproductionofsuchatableinthe late1990srecalledhowitspublicationsparkedamajorpoliticalresponseinone WestAfricancountrythatwasrankedashavingahigherMMRthanitsneighbor. "Forthepolitician,[theleaguetable]isallabouthowheis[tobe]judged.Becauseunconsciouslypeopleconcentrateonthenumbers,"ourinformantexplained, addingthattheMDGs'emphasisonmeasurableresultshasreinforcedthistendency dramatically.Forhim,theevocativepowertheMMRindicatorhasacquiredreects thatithasbecomeanindicatornotjustofwomen'shealth,butofacountry'soverall development: Maternalmortalityhasbecomesufcientlypartofthecollectiveconscience, somuchsothatishasbecomeoneoftheMillennium[Development]Goals. Itisnowunderstoodbypolicy-makerstobeanimportantindicatorofthe performanceofthehealthsystem,which,inturn,indicatesthesocial performanceofacountry. AhighMMRthuscreatesanincentiveforacountrytoprioritizematernalhealth heexplained,ifonlytoavoidappearinglessdevelopedthanitsneighbors. Thepoliticalpowerofnumbersexistsevenwhenthevalidityofthenumbers iscontested.Infact,controversyoverthevalidityofstatisticscanactuallyhelp galvanizeapoliticalreaction.AnotherepidemiologistataleadingAmericanpublic healthschoolhadwitnessedsuchasituationwhentheUNpublishedamaternalmortalityestimateforMoroccothatwashigherthanthegovernment'sown census-basedgure.Thediscrepancybetweenthenumbersgeneratedintensepoliticaldebateaboutthegovernment'saccountability,trustworthiness,andcommitment towomen'shealth.Assherecalled,"Theoppositiontookthisupandsaid,Thank Godthereareinternationalagencieswhowilltellusthetruthaboutourwomen

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268 MedicalAnthropologyQuarterly whoaredying,thegovernmentisclearlylyingtous.'Andthisissuewasdebated inparliament...itcertainlycausedabig[political]brouhaha."Thisreaction,she explained,occurreddespitethefactthat,atthetechnicallevel,thegureswerenot comparablebecausetheyhadbeenderivedusingdifferentmethods. Advocacygroupsexplicitlycapitalizeonpoliticaleffectssuchasthese.Several U.S.NGOs,forexample,showedusthevisualgraphicsandcolorful"reportcards" thattheyuseintheiryearlyreportstocomparecountries'performanceonmaternal healthindicators.Moreprototypically,even,theCountdownto2015initiative establishedin2005,inwhichanumberofourinformantswereinvolved,hasasits statedaim:"tomonitorandholdcountriesaccountable"fortheirprogresstoward theMDGsthroughcollationandcommunicationofstatisticsonthe"coverage ofhealthinterventionsproventoreducematernal,newbornandchildmortality" (Countdownto20152009).TheexplicitpremiseofCountdownto2015isthat drawingattentiontoperformanceindicatorswillstimulate"betterandstronger effortsatthecountrylevel"bygovernmentsconcernedwiththeirimageandkeen todemonstratetheresultsoftheirdonors'investments(Countdownto20152009). CreativeEpidemiology Advocacyspecialistshavealsobecomeadeptatusingwhatsomepublichealthspecialistsexplicitlyterm"creativeepidemiology"tounderscoretheattention-seeking aspectofresearch(Wallacketal.1993).Displayinganacuteappreciationforhow distinctclassesofstakeholdersinterpretnumbersdifferently,severalofourinformantsexplainedthatthepresentationofstatisticaldataneedstobemodieddependingontheaudience.Forinstance,differentexpressionsofthestatisticalriskof maternaldeathshouldbeusedtoinuenceglobal-levelpolicyelites,national-level decision-makers,andthepublicrespectively. AlthoughtheMMRcanbehighlyeffectiveininuencingnational-levelpolicy debates,preciselybecauseitisthekeyindicatorthathasbeenusedtocompare countriesacrosstheglobe,theMMRwasdeemedtootechnicalforthelaypublic. Rather,statisticalexpressionsthatare"moreimmediate,individual"andamenable, even,tobepersonalizedsuchasthelifetimeriskofmaternalmortalityweresaid tobeeasierforlaypeopletodrawmeaningfromandthusmorehelpfulingaining thepublic'ssupportformaternalhealthinvestment.Asasenioradvisorwiththe NGOwholongservedastheSMI'ssecretariatobserved,"Whenyoutalkwith peopleonetooneandyousaythatoneoutofeverysixwomeninAfghanistandie inpregnancyandchildbirthcomparedtooneinevery30,000inSwedenorNorway, peopleareabsolutelyhorried,shocked." Persuadingglobal-levelpolicyactors,inturn,demandsdifferentstatistics,primarilybecauseoftheviewthatthenumberofmaternaldeathsistoolowtowarrant prioritizationwhencomparedwithotherhealthissues.Asthesenioradvisorcited aboveexplained,whenitcomestoaglobalhealthaudience,"youreallydohaveto frameitinadifferentwaybecausethenumbers[ofmaternaldeaths]alonedon't makethecase."Onestrategyhasbeentofocusnotonlyonmortalitybutalso onproducingnewevidenceofthematernalmorbidities(andevenlong-termdisabilities)thatresultfrompregnancy-relatedproblemsinlow-incomecountries(e.g., WHO2004).Usingthesedata,advocacyspecialistsareeffectivelyabletoarguethat

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Evidence-basedAdvocacy 269 maternalmortalityisonly"thetipoftheiceberg"oftheneglectofpregnancy-related health. Premisedonthecloseclinicallinksbetweenmothers,children,andnewborns, expressingadvocacymessagesintermsofthecombinedburdenofdiseaseaffecting thesethreegroupshasemergedasacreativestrategyformakingtheproblemofmaternalmortalityappearbiggerand,byextension,moreimportant.Unlikematernal mortalityalone,oneofourinformantsexplained,whencombined,the"MNCH" (maternal,newbornandchildhealth)burdenofdiseasefarexceedsthatattributed toHIV/AIDS,TB,andmalaria,thusinatingthenumberoflivesthatcanbesaved byinvestinginmaternalhealthand"makingamuchstrongeradvocacyargument." Suchanticipatedbenetswereoneofthemainreasonsthatmanysafemotherhood advocatespragmaticallysupportedtheSMI'sinvolvementinthePMNCH,despite widespreadconcernsaboutunderminingtheSMI'slongstandingefforttoensure safemotherhoodnotbeovershadowedbythemorephilanthropicallyappealing issueofchildhealth.AsoneseniorU.K.-basedmaternalhealthresearcherandadvocateexplained,"itmakessensetobungin[include]thebabiesforthenumbers game." CalculatingEconomicImpact DeviatingevenfurtherfromtheoriginalSMI'spoliticalarguments,EBAhasalso entailedproducingandusingeconomicevidencetoappealtothedominantlogic ofcosteffectiveness.AseniorUNFPAadviserwhowasinvolvedinelaborating theWomenDeliveradvocacystrategyinsistedthat"economicrebranding"has becomenecessaryto"sell"safemotherhood.Inhereverydaywork,sheavidly endorsedactivitiesthatwouldbeableto,assheputit,"positionthisproductasan opportunityofdesiresopeoplewillwanttoinvestinit."Afoundingmemberofthe SafeMotherhoodInter-AgencyGroupsharedthisperspective:"Youcanmobilize acertainconstituencygroupjustbytalkingabouttheethicalandinjusticeissues, butforthesehardcoredecision-makerswholookateconomicfactors,thatkindof appealdoesn'tnecessarilycarrytheday." Formanyofourinformants,then,akeywayofensuringthatinvestinginmaternalhealthisseenasagood"globalhealthbuy"(intheway,say,immunizationor antiretroviralHIVmedicationare)isthroughtheproductionofmoreexperimental (RCT-based)evidenceofcosteffectiveness(B ehagueandStoreng2008).Asnoted above,however,thisisalmostimpossibleforcomplexhealthsystemapproaches designedtoreducematernalmortality. Ratherthancontesttheepistemologicallimitationsoftheexperimentalmethod fordemonstratingtheimpactofhealthsystemsstrengtheningandintersectoral innovation,assomeacademicshavebeguntodo(B ehagueandStoreng2013), advocacyspecialistshavepushedforproducingcost-effectivenessevidenceofsimpleandtargetedinterventions,suchasdrug-basedtreatmentsforhemorrhageand infection(amongthemainclinicalcausesofmaternalmortality).Asonesuchinformantputit,"donorswanttoshowthattheysavelives.That'snotwhatyouget byputtingyourmoneyintostrengtheningthehealthsystemortrainingabunchof midwives."Targetedinterventions,anotheradvocacyspecialistimplied,arepseudocommoditiesthatareeasiertosellbecausetheirimpactondeathsavertedcanbe

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270 MedicalAnthropologyQuarterly moreeasilydemonstratedthroughgoldstandardexperimentalresearch.Advocates calledfortheproductiononevidenceofsuchinterventionstoenablethemtoshow thatcosteffectiveinterventionsformaternalhealthexistandthatsavingwomen's livesmakesgoodeconomicsense.Thisisneededtoachievewhatseveralinformants labeled"buy-in"fromdonorswhoarenoteasilyswayedbycallsforbroaderhealth systemsdevelopment. Advocacyspecialistshavealsostartedtoinvokebroadmacro-economicargumentsabouttheimportanceofmaternalhealthforeconomicdevelopment."Women deliversomuchmorethanbabies,"theheadoftheWomenDeliveradvocacyteam repeatedonmorethanoneoccasion,explainingthatthedoublemeaninginthe term"deliver"highlightswomen'scombinedreproductiveandproductive(economic)contributionstohouseholdsandsociety.Inspiredbythemobilizationof similarargumentsintheHIV/AIDSsubeld,theWomenDeliverconferencebecame ashowcaseforneweconomicestimatesofproductivitylossandimpoverishment resultingfrompregnancy-relatedmortalityandmorbidity(e.g.,Gilletal.2007). Moreover,aroundthetimeoftheconference,donorsassessingcosteffectiveness wereurgedtoconsiderthefullbenetofinvestinginmaternalhealth,includingnot onlywomen'ssurvivalandassociatedeconomicoutcomes,butalsothe"knock-on" benetsforchildren'sandnewborns'survivalandtheassociatedlong-termbenets fornationaleconomicproductivityandgrowth(e.g,TheLancet2007). SocentralhavethesekindsofEBApracticesbecomethatmanyadvocacyspecialists'professionalactivitiesarenowfocusedon"capacitybuilding,"orteaching counterpartsinlow-incomecountrieshowtoengageinEBA,whetherbyproducing evidencethemselvesor,morecommonly,learninghowtoimplementknowledge translationprogramsintheirownsettings.Accordingtoonecommunicationspecialist,suchcapacitybuildingcaninvolve"ooding"localpolicychampionswith evidencethroughworkshopsandtrainingsessionstoimprovetheirbargainingpositionvis` a-vistheirowngovernmentsand,especially,foreigndonors:"Isay[to them],thesearethetalkingpointsifyou'regoingtogotoUSAIDorifyou'regoing toasafemotherhoodmeeting...thisiswhy[thisevidenceis]relevanttoyour country.'" AReluctant(andCritical)Evidence-basedAdvocacy Onmanylevels,theEBApracticesdescribedabovehavebeenhighlysuccessfulin respondingtothekeystructuralandideologicalchangesinglobalhealthgovernance,namelyincreasedcompetitionforresourcesandafocusonquick,visible productivityandmeasurableaccountability.ThereisnodoubtthatEBAhascontributedtoarecentsurgeindonorinterestinmaternalhealth,exempliedbythe growthofdonorcommitmenttolargepolicyinitiativessuchastheEveryWoman EveryChildglobalmovementlaunchedbytheUNsecretary-generalin2010and theGlobalStrategyforWomen'sandChildren'sHealth(PMNCH2011). Advocacyexperts'successinengagingwiththiscultureofobjectivity,however, hasbeenmixedinwithagreatdealofconcurrentapprehensionandintensely criticalandself-criticalviewsoftheevidence-basedactivitiesinwhichmanyare partaking.Accordingtoseveralofourinterviewees,theclaimthatsafemotherhood recommendationsarebasedonaparticularlyweakevidentiarybaseisunfounded

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Evidence-basedAdvocacy 271 andrelates,rather,tothefactthatdonors'andhealthpolicy-makers'demandforscienticevidenceisdisproportionatelyhighwhenitcomestomaternalhealth.When askedaboutthereasonsforthis,oneadvocacyspecialistpointedtoawidespread lackofpoliticalcommitmenttowomen'shealthanddisregardforacoalitionthat hastraditionallybeenseenasbeingledbywomenandalignedtothewomen's movement.Assheexplained,HIV,forinstance,capturedattentionnotbecauseit hadgoodqualityevidence,butbecause:"Therst[donorsandleaders]whogot behind[HIV/AIDS]weremalesintheUS!Imean,whatstrongervoices...can therebe?Andthis[safemotherhood]isastoryaboutmothersandchildren.... ifwewomentalkaboutit,we'rewhiningaboutatopicthatis,youknow,not interesting."Andasanotheradvocacyspecialistsimilarlyhighlighted:"Howmany billionsofdollarshavegonetoabstinenceprogramsforHIV/AIDSinthelastsix years?What'stheevidencethere?Youcan'ttakeafractionofthatmoneytosavea woman'slifeunlessyouhavetheevidence." Thoughcriticalviewssuchasthesewerefrequentlylinkedtotheunderlying feministconcernthatwomen'shealthissimplynotapriorityinwhatisstillamaledominatedworld,suchinsightswerenotgratuitous,but,rather,translatedalso intoself-criticalviewsanddeepambivalenceregardingthebenetsofEBA.This ambivalencereectedthewaysitcaneasilydoadisservicetothepoliticalcommitmenttoequityandintrinsichealthrights,whilealsocontributingtoatechnocratic narrowingofthepolicyagenda. TechnocraticNarrowing Ininterviews,advocacyspecialistsreectedcriticallyonthewaytheiractivitieshave contributedtonarrowingthetermsofdebateaboutmaternalhealthbyrestrictingthekindsofargumentsandformsofevidencethat"count"asauthoritative. "It'sallquantitativenow,"acommunicationspecialistworkingforaD.C.-based internationalNGOcommented.Thepresidentofawell-knownadvocacyandresearchNGOclaimedthattheperceivedpressuretouseevidenceinpolicydebates hasbecomesointensethatwhereastwodecadesagokeySMIleaderswereable towritecredibleeditorialscenteredontheimportanceofwomen'sstatusandtheir righttohealth(e.g.,Sai1987),todaytheyarenolongercomfortablemakingpolicy statementsbasedonsuchprincipledidealsifunsupportedbyscienticevidence. Moreover,theideathatburdenofdiseaseandinstrumentaleconomicarguments shouldguidetheallocationofresourcesisinirresolvabletensionwithmanySMI actors'privateconvictionthatintrinsiccommitmenttosocialjustice,rightsandequityshouldbethemainpolicydrivers.Manyworried,forexample,aboutendorsing priority-settingtoolssuchasburdenofdiseaseanalysesthathavebeenshowntosystematicallybiaspriorityawayfromconditionssufferedbypoorwomen,including pregnancy-relatedmortalityandmorbidity(e.g.,Sundby1999). SeveralofthosewhohadparticipatedintheCountdownto2015andsimilar accountabilityprojectsdemonstratedunsettledambivalenceaboutthefactthatthey hadcontributednotjusttoagenda-settingbutalsototheexportationof"target culture"todonor-dependentcountries.Theynoted,forexample,thattheenforcementofaccountabilitydemandscanencouragedonorrecipientstoproducefake numbers.Moreimportantly,respondingtodonors'demandsfornumbersdiverts

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272 MedicalAnthropologyQuarterly attentionfrombuildingsustainableandlocallyrelevanthealthinformationsystems. Onelongstandingsafemotherhoodadvocatenowworkingasaresearcherwitha Gates-fundedNGOevenlamentedthatherinvolvementinaprojecttopromotea drugthatcanpreventmaternaldeathsfrompostpartumhemorrhagehadprobablycontributedtonarrowingthematernalhealthagendafromsocialandpolitical solutionstowardpurelytechnicalones: I'mactuallydoingsomethingthatphilosophicallyIwouldn'thavebelievedI wouldhavedoneafewyearsagobecauseIdobelieveinholisticcareandI dobelieveweneedto...[tackle]thesystem.SowhatamIdoingsitting hereworkingon...Iwouldn'tsayit'sasilverbulletformaternalhealth ...but,youknow,oneofthefewthingsthatcomesasclosetoakindof silverbulletstrategyasyoumightget? Aswehavedescribedingreaterdetailelsewhere(B ehagueandStoreng2008, 2013;Storeng2010),manymaternalhealthspecialistswerealsohighlycriticalof thewaysthedemandsforcost-effectivenessdatareinforcetechnocraticnarrowingbyshiftingresearchprioritiesawayfromtheuseofmultimethodstudieson thedynamicsofmaternalmortalitydeclinesor,indeed,disaggregatedlocal-level statisticsandprocessevaluationsofactualpolicychangetoafocusontargeted interventionsthatcanmoreeasilybesubjectedtoexperimentalstudy. Evidence-basedPolitics Thekindsofcriticalinsightswehavedescribedabovearethusnotsimplyrhetorical, butare,rather,beginningtotranslateintoresearchpracticesofallkinds,including thosebeingdevelopedandsupportedbyanincreasinglyprominentnetworkof academicsworkingalongsidehumanrightslawyers.Thoughnotradicallydifferent, andthoughstillfunctioningwithinthebasicparametersofEBA,thesepracticesare beingactivelyusedtoreintroducejustice,equity,andrightsintopolicy-making,but onmore"legitimate"scienticgrounds. Perhapsthemostnotableofthesepracticesentailsareturntoepidemiology's historicfocusonthesocialdeterminantsofhealth,specically,theuseofdisaggregatedindicatorstoillustrateinequitiesinthesocioeconomic,ethnic,andgeographic distributionsofmaternalmortality,includingdisparitiesinaccesstolife-savingservicesbothbetweenandwithincountries(Freedman2003).Thisapproach,asone lawyerandadvocacyspecialistexplained,allowsonetotalkaboutinequitiesin anobjectivedescriptivemannerand,importantly,avoidsusing"off-puttingrights language."Atthesametime,withinthecontextofaprivateexchange,shedidnot hesitatetointerpretsuchdisparitiesinpoliticalterms: Ifyoulookatacountrywhereyouhaveamiddleclassthat'sabletogive birthsafelybutthenyouseeveryhighratesofmaternalmortalityamong minoritygroups,immigrantgroups,thenitisclearyouhave adiscriminationissueandthat'snotadifcultrightsargumenttomake.

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Evidence-basedAdvocacy 273 Asshefurtherexplained,advocatesusingsuchdataarebeginningtoeffectively engagegovernmentsinadiscussionabouttheiraccountabilitytotheMDGsand, importantly,tointernationalhumanrightstreatiesthat,inprincipleatleast,oblige statestoaddresssystemicdiscriminationandinequitythroughtargetedpolicy action. Thekindofideologicalpragmatismdemonstratedherewasalsoapparentin otheradvocacyspecialists'sophisticatedinvolvementintheprocessofdeningthe targetindicatorstobeusedinglobal-levelmonitoringofcountries'progresstoward theMDGs.SMIleadersandNGOswere,onthewhole,excludedfromhigh-level UN-basedformulationoftheMillenniumDeclarationin2000andthesubsequent articulationoftheeightMDGs.Thoughimprovingmaternalhealthendedupbeing oneofthegoals(MDG5),manyfeltthattheinternationalcommunity,infocusing thegoalexclusivelyonthetargetofmaternalmortalityreduction,hadrenegedon promisestopromotethebroaderconceptofsexualandreproductivehealththathad beenmadeattheUNInternationalConferenceonPopulationandDevelopmentin 1994. Accordingtoourinformants,maternalhealthwaschosenasthefocusofMDG 5becauseitislesscontroversialthanreproductivehealth.However,toargueforan additionalMDGonreproductivehealthoncethegoalshadbeensetwasdeemed politicallyunwise.Instead,keyindividualsbegantodemandNGOrepresentation ontheexpertpaneldrawnuptodenetargetsandindicatorsformeasuringprogress towardsMGD5.Throughthisforum,theysuccessfullyarguedthattheexisting target onmaternalmortalityreductionwastoonarrowtocapturethebroader goal of improvingmaternalhealth.In2006,anadditionaltargetindicatoruniversalaccesstoreproductivehealthwasnallyincludedunderMDG5,theonlynegotiated MDGtargettodate.Thoughclearlyonlyapartialvictory,manywithintheeld consideredthisanimportantachievement,reectingtheirconvictionintheoften repeatedmaxim,"inpublichealth,whatyoumeasureiswhatyoudo." Conclusion EBAhasundoubtedlybeensuccessful.Withinacontextofgrowingemphasison quantitativeevidencetoinformpriority-settingandjustifyinvestments,playingthe numbersgamehasemergedasperhapsthemostviablestrategyforglobalhealth initiativesliketheSMIastheystruggletodenetheiridentityandcompeteeffectively inarapidlychangingglobalhealtheld.Indeed,EBAanditssuccessisexemplaryof thebroader"auditculture"describedbyStrathern(2000)andothers(Power1997). AsShoreandWright(1999)claim,theexpansionofaudittoolsfromnancial accountancyintoothersectorssuchaseducation(and,wewouldargue,health) hasenabledtheexpansionofneoliberalformsofgovernance,whereprofessional relationsarereducedtoquantiableand,aboveall,inspectabletemplates. Indeed,suchgovernmentalizingtendenciesdemonstratethebroaderhistorical growthduringthe20thcenturyofthepowerofscienticauthority,ofapervasive "trustinnumbers"(Porter1995)andcultureofobjectivitythathascometocharacterizemodernsocieties(Daston1992;Nader1996).However,theriseofEBA highlightsthatcost-effectivenessevidencethegoldstandardwithinevidence-based policy-makingis,infact,notremovedfromideology.Rather,itisitselfanother

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274 MedicalAnthropologyQuarterly ideologythatisbeingintroducedand,aswehavedocumentedinthisarticle,adopted andadaptedwithvariousdegreesofambivalence.Safemotherhoodadvocacyspecialistsrecognize,asHaraway(1988)haspointedout,thatclaimsforactiongain moreauthorityandlegitimacyiftheyaredissociatedfromsubjectiveideologiesand linkedtohigh-statussocialagents,suchasscienticevidence.Onecouldevenargue thatadvocacyspecialistsrelyexplicitlyonthewayinwhichhealthstatisticsacquire anauthoritativesociallifeoftheirown,despitethefactthattheyarealsoawareof thewaysnumberscansoeasilybefraughtwithtechnical,andindeedideological, difculties(Hacking2007;NichterandKendall1991). Ouranalysessupportkeyndingsfromtheanthropologicalstudyofglobalforms ofexpertise(Adams2010;Lakoff2010;PfeifferandNichter2008).Wehave,for example,underscoredthewayinwhichglobalhealthpolicy,andespeciallyits emphasisonquantitativeevidence,reinforcesanoversimplied"master-narrative" circumscribedbytechnicalsolutionstohealthproblems(Nichter2008).Asaresult, moralandsocialjusticeargumentshavebecomepartiallyeclipsedbythemore competitiveusestowhichevidence-basedpolicy-makingactivitieshavebeenput. Importantly,however,wehavealsohighlightedthesociopoliticalstrugglesand riftsthatgointothemakingofthesenarratives,specicallythewayssafemotherhoodexpertsnotonlydisseminateauthoritativeknowledgeandcreatemasternarratives,butalsoresistandmodifythem,showingbothreexivityanddecidedly ambivalentattitudestotheirowncontributionstoEBA(B ehagueandStoreng2013). Insomeinstances,SMIexpertscogentlyechothekindsofcriticismsthatanthropologistsoftenmakeregardingthegrowingmarginalizationofpluralformsofevidence (Adams2005;BiehlandPetryna2013;Lambert2006,2013). Thealternativeevidence-basedactivitiessomeexpertsareengagingin(e.g.,to keepabroadconceptualizationofthesocialdeterminantsofmaternalhealthand rightsontheagenda)givelietotheideathatideologyhasbeenfullybanishedfrom theevidence-baseddecision-makingdomain.WhatappearstobeoccurringsimultaneoustomorestandardformsofEBAisarearticulation,orperhapsevencouching, ofideologicalconvictionsintheauthoritativelanguageofscienticevidencefor thesakeofpoliticalexpediency.Thoughmanyofourinformantshavebegunto skepticallypointtoEBA'sreductionisttendencies,theyarealsondingwaysto continueusingthepowerofscienceandobjectivitytofullltheirenduringcommitmenttoethicalandmoralprinciples.Ideologicaldebatesandsubjectivevaluesare thusnotbeingeliminatedbutratherobfuscatedasscienticandhenceobjective, andarereintroducedinwaysthataremorereadilyfungiblewithanevidence-based framework. Suchmulti-layeredappealstoobjectivitydemonstratetheextenttowhichSMI experts'criticalawarenessandresistantactivitiesareindeedconstrainedbythe "technicalinfrastructures,administrativeapparatuses[and]valueregimes"ofglobal forms(CollierandOng2005:11).Fosteringsuchaheavyrelianceonpurportedly objectiveclaims,ratherthanchallengingthebasisonwhichglobal-leveldecisionmakingtakesplacethroughexplicitlyvalue-basedpoliticalarguments,mayhave negativeconsequences,asmanyofthosecontributingtothesetrendsacknowledge. ThoughtheadoptionofEBAaimsto"save"theSMIaswellasthewomenon whosebehalfitadvocates,ithascontributedtomakingitmoredifculttoadvance principledargumentsabouttheimportanceofmaternalhealth,unlesstheseare

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Evidence-basedAdvocacy 275 articulatedintermsofinstrumentalscientic,technical,oreconomicrationales. Thetechnocraticpriority-settingtoolsthatarenowdominatingsustainanarrow cost-effectivenessfocusnoteasilyappliedtothekindsofbroaderhealthsystem developmentsmaternalhealthspecialistssaytheyareconvincedareessentialfor reducingmaternalmortality.ByparticipatinginEBA,maternalhealthadvocates arealsocontributingtotheunwelcomefragmentationofglobalhealthgovernance andnationalhealthsystemsthatresultsfromdifferentprofessionalcommunity advocatingfortheuptakeoftheirownsetofissuesandinterventions.Asaresult ofsuchcompetition,littleattentionisdirectedtocross-cuttingissuescentralto thefunctioningoftheoverallhealthsystemorsocialandeconomicdeterminants ofhealth(McCoy2009).Andevenlessattentionisgiventothepoliticalchanges neededtoaddressthehealthinequitiesthatmaternalmortalityillustratessoclearly (JanesandChuluundorj2004;Spangler2011). Maternalhealthadvocates'experienceshighlightthatthepressuretoparticipate inthenumbersgame,aswellastheambivalencewithwhichplayersapproachthis game,emergeoutofthemessyandcontradictoryeverydaylifeofglobalhealth politics.However,bypanderingtothepoliticsofglobalhealth,safemotherhood advocatesmaybeextendingthedominanceofatechnocraticapproachthatisat oddswiththeunderlyingpoliticalagendatheyhavebeensokeentosupportsince theSMI'sinception. Note Acknowledgments. Wethankallourinformantsforbeingsuchforthrightand helpfulparticipantsinthisresearch.ThanksalsotocolleaguesattheLondonSchool ofHygieneandTropicalMedicine(LSHTM)andattheUniversityofOslo,to DavidMcCoyandHilaryStanding,andtoparticipantsonthesession"TheEpistemologicalEthicsofResearchinGlobalHealth"atthe2009SocietyforMedical Anthropologymeeting(YaleUniversity),especiallydiscussantsMargaretLockand IanHarperforcommentsonanearlierdraftofthisarticle.Wewouldalsoliketo thanktheeditorsandthetwoanonymousreviewersforveryhelpfulcomments. Thisarticleisbasedonacollaborativeresearchproject(B ehagueandStoreng) fundedbytheEconomicandSocialResearchCouncil(RES-000221039)and Storeng'sPh.D.research(fundedbytheResearchCouncilofNorwayandthe LSHTM).ApostdoctoralfellowshipfromTheWellcomeTrust(GR077175MA) supportedB ehaguefrom2005to2010.Thefunderswerenotinvolvedindeterminingthestudydesign,thecollection,analysis,andinterpretationofdata,orin writingthisarticle.TheLSHTMethicsboardapprovedthestudy. ReferencesCited Adams,V. 2005SavingTibet?AnInquiryintoModernity,Lies,Truths,andBeliefs.Medical Anthropology24:71110. 2010AgainstGlobalHealth?ArbitratingScience,Non-scienceandNonsensethrough Health. In AgainstHealth:HowHealthBecameaNewMorality.J.MetzlandA. Kirkland,eds.Pp.4060.NewYork:NYUPress. Adams,V.,T.E.Novotny,andH.Leslie 2008GlobalHealthDiplomacy.MedicalAnthropology27:315323.

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276 MedicalAnthropologyQuarterly B ehague,D.P.,andK.T.Storeng 2008CollapsingtheVertical-HorizontalDivide:AnEthnographicStudyofEvidencebasedPolicymakinginMaternalHealth.AmericanJournalofPublicHealth98:644 649. 2013PragmaticPoliticsandEpistemologicalDiversity:TheContestedandAuthoritative UsesofHistoricalEvidenceintheSafeMotherhoodInitiative.Evidence&Policy 9:6585. Berry,N.S. 2010UnsafeMotherhood:MayanMaternalMortalityandSubjectivityinPost-war Guatemala.NewYork:BerghahnBooks. Biehl,J.,andA.Petryna,eds. 2013WhenPeopleComeFirst:CriticalStudiesinGlobalHealth.Princeton:Princeton UniversityPress. Birn,A.-E. 2009TheStagesofInternational(Global)Health:HistoriesofSuccessorSuccessesof History?GlobalPublicHealth4:5068. Brown,T.M.,M.Cueto,andE.Fee 2006TheWorldHealthOrganizationandtheTransitionfrom"International"to "Global"PublicHealth.AmericanJournalofPublicHealth96:6272. Buse,K.,andG.Walt 1997AnUnrulyM elange?CoordinatingExternalResourcestotheHealthSector:A Review.SocialScience&Medicine45:449463. Campbell,O.,M.Koblinsky,andP.Taylor 1995OfftoaRapidStart:AppraisingMaternalMortalityandServices.International JournalofGynaecology&Obstetrics48:S33S52. Castro,A.,andM.Singer,eds. 2004UnhealthyHealthPolicy:ACriticalAnthropologicalExamination.NewYork: AltaMira. Chapman,R.R. 2003EndangeringSafeMotherhoodinMozambique:PrenatalCareasPregnancyRisk. SocialScience&Medicine57:355374. Collier,S.J.,andA.Ong 2005GlobalAssemblages,AnthropologicalProblems. In GlobalAssemblages:Technology,Politics,andEthicsasAnthropologicalProblems.A.OngandS.J.Collier, eds.Pp.321.Oxford:BlackwellPublishing. Countdownto2015 2009TrackingProgressinMaternal,NewbornandChildHealth.http://www. countdown2015mnch.org(accessedOctober4,2011). Daston,L. 1992ObjectivityandtheEscapefromPerspective.SocialStudiesofScience22:597618. Dobrow,M.J.,V.Goel,andR.E.G.Upshur 2004Evidence-basedHealthPolicy:ContextandUtilisation.SocialScience&Medicine 58:207217. Freedman,L.P. 2003StrategicAdvocacyandMaternalMortality:MovingTargetsandtheMillennium DevelopmentGoals.GenderandDevelopment11:97108. Gill,K.,R.Pande,andA.Malhotra 2007WomenDeliverforDevelopment.TheLancet370:13471357. Graham,W.J.,andO.M.Campbell 1992MaternalHealthandtheMeasurementTrap.SocialScience&Medicine35:967 977.

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Evidence-basedAdvocacy 277 Greenhalgh,S. 1996TheSocialConstructionofPopulationScience:AnIntellectual,Institutional,and PoliticalHistoryofTwentieth-CenturyDemography.ComparativeStudiesinSociety andHistory38:2666. Greenhalgh,T.,andS.Wieringa 2011IsItTimetoDropthe"KnowledgeTranslation"Metaphor?ACriticalLiterature Review.JournaloftheRoyalSocietyofMedicine104:501509. Hacking,I. 2007BritishAcademyLecture2006:KindsofPeople,MovingTargets.Proceedingsof theBritishAcademy151:285318. Haraway,D. 1988SituatedKnowledges:TheScienceQuestioninFeminismandthePrivilegeof PartialPerspective.FeministStudies14:575599. Hardon,A. 2005ConfrontingtheHIV/AIDSEpidemicinSub-SaharanAfrica:PolicyversusPractice. InternationalSocialScienceJournal57:601608. Janes,C.R.,andO.Chuluundorj 2004FreeMarketsandDeadMothers:TheSocialEcologyofMaternalMortalityinPost-SocialistMongolia.MedicalAnthropologyQuarterly18:230 257. Janes,C.R.,andK.K.Corbett 2009AnthropologyandGlobalHealth.AnnualReviewofAnthropology38:167 183. Justice,J. 1986Policies,Plans,andPeople:ForeignAidandHealthDevelopment.Volume17. Berkely:UniversityofCaliforniaPress. Kapilashrami,A.,andB.McPake 2012TransformingGovernanceorReinforcingHierarchiesandCompetition:ExaminingthePublicandHiddenTranscriptsoftheGlobalFundandHIVinIndia.Health Policy&Planning28:626635. Keck,M.E.,andK.Sikkink 1998ActivistsbeyondBorders:AdvocacyNetworksinInternationalPolitics.Ithaca: CornellUniversityPress. Lakoff,A. 2010TwoRegimesofGlobalHealth.Humanity:AnInternationalJournalofHuman Rights,HumanitarianismandDevelopment1:5979. Lambert,H. 2006AccountingforEBM:NotionsofEvidenceinMedicine.SocialScience&Medicine 62:26332645. 2013PluralFormsofEvidenceinPublicHealth:ToleratingEpistemologicaland MethodologicalDiversity.Evidence&Policy:AJournalofResearch,Debateand Practice9(1):4348. Lancet,The 2007WomenDeliverPressConferenceandPressRelease.TheLancet,London,October 12. Mahler,H. 1987TheSafeMotherhoodInitiative:ACalltoAction.TheLancet1:668670. McCoy,D. 2009GlobalHealthInitiativesandCountryHealthSystems.TheLancet374:1237 1237.

PAGE 19

278 MedicalAnthropologyQuarterly McCoy,D.,K.T.Storeng,V.Filippi,C.Ronsmans,D.Osrin,M.Borchert,O.M.Campbell, A.Roques,R.Wolfe,A.Prost,andZ.Hill. 2010Maternal,NeonatalandChildHealthInterventionsandServices:Movingfrom KnowledgeofWhatWorkstoSystemsthatDeliver.JournalofInternationalHealth 2:9798. Mosse,D.,ed. 2011AdventuresinAidland:TheAnthropologyofProfessionalsinInternationalDevelopment.NewYork:BerghahnBooks. Nader,L.,ed. 1996NakedScience:AnthropologicalInquiryintoBoundaries,PowerandKnowledge. London:Routledge. Nichter,M. 2008GlobalHealth:WhyCulturalPerceptions,SocialRepresentations,andBiopolitics Matter.Tuscon:UniversityofArizonaPress. Nichter,M.,andC.Kendall 1991BeyondChildSurvival:AnthropologyandInternationalHealthinthe1990s. MedicalAnthropologyQuarterly5:195203. Ong,A. 2007NeoliberalismasaMobileTechnology.TransactionsoftheInstituteofBritish Geographers32:38. Pfeiffer,J.,andM.Nichter 2008WhatCanCriticalMedicalAnthropologyContributetoGlobalHealth?AHealth SystemsPerspective.MedicalAnthropologyQuarterly22:410415. Pigg,S.L. 1997AuthorityinTranslation:Finding,Knowing,NamingandTraining"Traditional BirthAttendants"inNepal. In ChildbirthandAuthoritativeKnowledge:CrossculturalPerspectives.R.Davis-FloydandC.Sargent,eds.Pp.233263.Berkeley: UniversityofCaliforniaPress. PMNCH 2011AnalysingCommitmenttoAdvancetheGlobalStrategyforWomen'sandChildren'sHealth.ThePMNCH2011Report.Geneva:ThePartnershipforMaternal, NewbornandChildHealth. Porter,T.M 1995TrustinNumbers:ThePursuitofObjectivityinScienceandPublicLife.Princeton, NJ:PrincetonUniversityPress. Power,M. 1997TheAuditSociety:RitualsofVerication.Oxford:OxfordUniversityPress. Sabatier,P.A.,andH.C.Jenkins-Smith 1993PolicyChangeandLearning:AnAdvocacyCoalitionApproach.Boulder,CO: Westview. Sai,F.T. 1987TheSafeMotherhoodInitiative:ACallforAction.IPPFMedicalBulletin21:12. Shiffman,J. 2007HasDonorPrioritizationofHIV/AIDSDisplacedAidforOtherHealthIssues? HealthPolicyandPlanning23:95100. Shore,C.,andS.Wright 1997Policy:ANewFieldofAnthropology. In AnthropologyofPolicy:CriticalPerspectivesonGovernanceandPower.C.ShoreandS.Wright,eds.Pp.334.London: Routledge. 1999AuditCultureandAnthropology:Neo-liberalisminBritishHigherEducation.The JournaloftheRoyalAnthropologicalInstitute5:557575.

PAGE 20

Evidence-basedAdvocacy 279 Spangler,S.A. 2011"ToOpenOneselfIsaPoorWoman'sTrouble":EmbodiedInequalityandChildbirthinSouth-CentralTanzania.MedicalAnthropologyQuarterly25:479498. Starrs,A. 1987PreventingtheTragedyofMaternalDeaths:ReportoftheSafeMotherhood ConferenceheldinNairobi,Kenya,February.NewYork:FamilyCareInternational. Storeng,K.T. 2010SafeMotherhood:TheMakingofaGlobalHealthInitiative.Ph.D.Thesis,London:UniversityofLondon. Storeng,K.T.,andD.P.B ehague 2013Evidence-BasedAdvocacyandtheRecongurationofRightsLanguageinSafe MotherhoodDiscourse. In HealthRightsinGlobalContext:GeneaologiesandAnthropologies.A.MoldandD.Reubi,eds.Pp.149168.LondonandNewYork: Routledge. Strathern,M.,ed. 2000AuditCultures:AnthropologicalStudiesinAccountability,Ethics,andthe Academy.NewYork:Routledge. Sundby,J. 1999AreWomenDisfavouredintheEstimationofDisabilityAdjustedLifeYearsand theGlobalBurdenofDisease?ScandinavianJournalofPublicHealth27:279285. Wallack,L.,L.Dorfman,D.Jernigan,andM.Themba-Nixon 1993MediaAdvocacyandPublicHealth:PowerforPrevention.NewburyPark,CA: SagePublications. Wedel,J.R.,andG.Feldman 2005WhyAnAnthropologyofPublicPolicy?AnthropologyToday21:12. WHO 2004BeyondtheNumbers:ReviewingMaternalDeathsandComplicationstoMake PregnancySafer.Geneva:WorldHealthOrganization. WHOandUNICEF 1978DeclarationofAlma-Ata.InternationalConferenceonPrimaryHealthCare, Alma-Ata,USSR,612September1978.Geneva:WorldHealthOrganization. WomenDeliver 20072007Conference.http://www.womendeliver.org/conferences/2007-conference/ (accessedJanuary10,2011).