This study began with an interesting empirical puzzle concerning a pressing public health issue in the developing world. More than half a million women die related to pregnancy and childbirth each year. One in four maternal deaths worldwide occur in India. This study asks, given two Indian states with comparable socio-cultural contexts and economic indicators, what explains differing progress for maternal mortality reduction? Comparative analysis of the policy processes in each state provides insights to the research question and suggests the need for more holistic frameworks for analyzing policy processes than currently exist.

Comparative case studies draw on more than 140 interviews with health policy experts, managers and service delivery personnel in the two Indian states, as well as with representatives of domestic and international NGOs and donor agencies over three months in 2007; numerous national and state government reports; policy and program documents; and reports and documents from international donor and nongovernmental organizations to triangulate data relevant to answering the research question.

The findings suggest that differing social historical influences in each state; worldviews, priorities and degrees of power among major political parties; strength and ideas of key policy actors; and capacity and norms in the concerned public health bureaucracies shaped variation in availability and access to publicly provided safe motherhood services in the two states, especially for more vulnerable groups (e.g. women with lower economic, educational and social status).

The results suggest a need for more holistic frameworks for analyzing policy processes—frameworks that highlight the influence of such social historical influences as major social movements and other feats of social organization (e.g. colonialism) as they shape conditions of the political environment, the power of policy actors and ideas, and organizational structures that shape subsequent policy processes. In doing so, the study identifies a neglected set of variables in historical social organization, refines our understanding of how the political environment matters, and presents political-bureaucratic actors and ideas as a category of factors that bridges policy and management to better reflect the overall set of causal relationships that influence policy outcomes.