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This Briefing Paper uses new research by the Africa Power and Politics Programme to explore the factors that shape maternal health outcomes in Malawi, Niger, Rwanda and Uganda. It examines the institutional causes of bottlenecks in the provision of maternal health services and considers the policy implications for country actors and donors.

Maternal health outcomes will not improve quickly in low-income Africa as long as the known bottlenecks in public provision are not addressed. Improving the flow of resources will help, but not enough and not on its own. The similarities and differences between Malawi, Niger, Rwanda and Uganda point to the importance of three types of institutional factor in shaping outcomes. This indicates clearly what governments and development partners need to be doing if they are serious about improving maternal health:

• The whole set of policies bearing on maternal health outcomes needs to be reviewed regularly to ensure it is internally coherent.
• Provider performance standards need to be enforced, with appropriate upward accountability and monitoring.
• Where local solutions to major bottlenecks are found, they should be supported, not discouraged.