Overview Of The Situation Of Maternal Morbidity And Mortality: Latin .

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Overview of theSituation ofMaternal Morbidityand Mortality:Latin Americaand the CaribbeanDecember 2017

2017, GTRPhotographs: Joey O'Loughlin

Contents2 ACKNOWLEDGMENTS3 ACRONYMS5 EXECUTIVE SUMMARY9 OVERVIEW OF THE SITUATION OF MATERNALMORBIDITY AND MORTALITY: LATIN AMERICAAND THE CARIBBEAN9 Introduction11 The Context of Maternal Morbidityand Mortality in Latin America and theCaribbean14 Lessons Learned in the 2004-2014 Decade22 Conclusions25 ADDITIONAL REFERENCES25 Annex A: Glossary27 Annex B: The International Context forthe Reduction of Maternal Mortality andMorbidity30 Annex C: Regional Trends in MaternalMortality31 Annex D: The SDGs and the New GlobalStrategy for Women's, Children's andAdolescents' Health32 BIBLIOGRAPHIC REFERENCES1

AcknowledgmentsThis publication was made possible thanks to thesupport of all the organizations that comprise theLatin American and Caribbean Regional TaskForce for the Reduction of Maternal Mortality:the United Nations Population Fund, the PanAmerican Health Organization/World HealthOrganization, the United Nations Children’sFund, Jhpiego and the Maternal and ChildSurvival Program, UN Women, ManagementSciences for Health, the Inter-AmericanDevelopment Bank, the World Bank, the InterAmerican Parliamentary Group on Populationand Development, the International Federationof Red Cross and Red Crescent Societies,International Planned Parenthood Federation/Western Hemisphere Region, the InternationalConfederation of Midwives, the Latin AmericanFederation of Obstetrics and Gynecology Societies,and the Organization of American States. Wethank everyone who has offered their invaluablecontributions, observations and suggestions forimproving and enriching this document. Weparticularly wish to thank the representatives ofthe health ministries of Argentina, Belize, Bolivia,Brazil, Colombia, Costa Rica, Ecuador, El Salvador,2Guatemala, Guyana, Honduras, Mexico, Panama,Paraguay, Peru, Dominican Republic, Suriname,Uruguay and Venezuela that participated inthe document’s review and validation meetings(Dominican Republic 2013 and Panama 2015),as well as the Andean Health OrganizationConvention Hipólito Unanue and the Councilof Health Ministers of Central America and theDominican Republic. Our special recognition goesto our colleagues of international cooperationbodies in the different countries and the regionalexperts that participated in the discussions andreview of this consensus document.This document presents an interagency evidencebased framework for addressing the grave problemof maternal morbidity and mortality in LatinAmerica and the Caribbean. The principles andpolicies of each agency are governed by the relevantdecisions of its governing body. Each agencyimplements the interventions described in thisdocument in accordance with its principles andpolicies and within the scope of its mandate.

AcronymsAECIDSpanish Agency for InternationalCooperation for DevelopmentMMEIGUN Maternal Mortality EstimationInter-Agency GroupCARICOMCaribbean CommunityMMRmaternal mortality ratioCLAP/SMRThe Latin-American Center forPerinatology, Woman and ReproductiveHealthMSHManagement Sciences for HealthOHCHROffice of the United Nations HighCommissioner for Human RightsPAHOPan American Health OrganizationPLANEAAndean Plan for the Prevention ofAdolescent PregnancyRELACSISLatin American and Caribbean Networkto Strengthen Health InformationSystemsRMCrespectful maternity careSDGSustainable Development GoalsUNFPAUnited Nations Population FundWHOWorld Health OrganizationCOMISCACommission of Health Ministries ofCentral America and the DominicanRepublicFCIFamily Care InternationalFLASOGLatin American Federation of Obstetricsand Gynecology SocietiesGDPGross Domestic ProductGTRRegional Task Force for the Reductionof Maternal MortalityICPDInternational Conference on Populationand DevelopmentIEBInternational Education Institute ofBrazilMDGMillennium Development Goals3

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Executive SummarySince 1998, the Regional Task Force for theReduction of Maternal Mortality (GTR, for itsSpanish acronym) has promoted interagencycollaboration for the implementation of policiesand programs to reduce maternal mortality inLatin America and the Caribbean. The task forceis comprised of United Nations technical agencies,bilateral and multilateral cooperation organisms,nongovernmental organizations, and professionalassociations. The GTR promotes a joint andcommon vision to combat maternal deaths byoptimizing technical cooperation within countriesand across agencies. In 2003, the GTR spearheadeda broad consultation process that resulted in apolicy declaration, the Interagency Strategic Consensusfor the Reduction of Maternal Morbidity and Mortalityin Latin America and the Caribbean. This document,endorsed by the region’s governments, espousedagreed-upon evidence-based priorities for thereduction of maternal morbidity and mortalityduring the 2004-2014 decade. The StrategicConsensus has served as a frame of reference forthe design and implementation of national plans toreduce maternal mortality, through the harmonizationof technical strategies within countries andbetween the different participating agencies.The current document presents a panorama of thestate of maternal health in the region and reaffirmsthe advances and lessons learned from the previousdecade, in an effort to support countries to identifynew priorities and challenges for the reductionof maternal mortality in the framework of the 2030Agenda. This panorama emerges at a critical time.At the regional level, governments made significantcommitments to reducing maternal mortality duringthe First Regional Conference on Population andDevelopment in Montevideo (2013). Governmentsrenewed this commitment in 2015 with theadoption of the Montevideo Consensus’ OperationalGuide, which outlines a concrete roadmap forreducing maternal mortality in the region. Inaddition, the Santo Domingo Consensus, reachedduring the 2013 Regional Conference on Women,and the Regional Gender Agenda, reachedduring the XIII Conference on Women in 2016,are technical-political documents that aim tomainstream gender in the implementation of theSustainable Development Agenda. At the globallevel, 2015 marked the deadline for attaining theMillennium Development Goals (MDGs). By 2015,no country in the region had achieved the MDG5A target to reduce the maternal mortality ratioby three quarters between 1990 and 2015.In Latin America and the Caribbean, thousandsof women still lose their lives every year frompreventable causes related to pregnancy andchildbirth. Many more suffer complications andexperience long-term health issues that affectthe quality of their lives. Indigenous and Afrodescendant women, as well as women with lowerincomes and fewer years of formal educationoften lack access to family planning services andskilled birth attendance. In many communities,indigenous women are three times more likely todie from causes related to pregnancy and childbirththan are non-indigenous women living in the samecommunities. These inequities in accessing care,and the resulting loss of life, violate women’s rightto health, which includes safe maternal care. Amother’s death has deep emotional, social andeconomic repercussions on the surviving family;following the death of their mother, newbornsare less likely to survive, other children are lesslikely to remain in school, and the family is morelikely to suffer financial consequences from loss ofproductivity and income.5

The GTR reaffirms the evidence-based strategiesfor preventing maternal death outlined in theStrategic Consensus, which include the needto strengthen national health systems at everylevel, ensure adequate financing for public healthservices, and increase high-quality, accessibleand affordable services. The current panoramaseeks to highlight the significant challenges in theregion and to urge countries to respond to them asfollows: reduce inequities by increasing investmentin the health of the most vulnerable communities;6guarantee the rights of adolescents and youthto a healthy life; reinforce maternal mortalitysurveillance and response systems; and focus onpublic policies with a rights-based and genderperspective. The agencies that make up the GTRsupport the underlying principles and strategiesof rights and accountability, social determinantsof health and governance, intercultural care, andintersectoral collaboration.

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Overview of the Situation ofMaternal Morbidity and Mortality:Latin America and the Caribbean1. IntroductionThe human right to health, articulated innumerous international conventions, protocols, anddeclarations signed by countries in the LAC region,is reflected in national constitutions, which affirmtheir obligations to respect, protect, and fulfillthis right for their citizens. The right to health†includes the right to maternal health. An indicatorof women’s unequal status in society and weakhealth care systems, maternal mortality, togetherwith child mortality, is a proxy for social inequality.In 2009, the United Nations Human Rights Councilissued a resolution stating that preventablematernal death constitutes a grave human rightsviolation and is a social, rather than an individual,problem.¹ (See Annex A for terminology, as used inthis document.)The Latin America and Caribbean region is amongthe most unequal regions in the world in terms ofincome inequality. While countries in the regionhave experienced significant economic development,the richest 10% of people in the region own 71% ofthe region’s wealth.² Such wide income inequalitycontinues to limit access to quality health servicesfor vulnerable or socially marginalized groups, suchas indigenous communities and those of Africandescent, people with fewer years of education,those in the lower income quintiles, and peopleliving in rural areas and in the periphery of largecities. Most countries in the region are classifiedas middle income, and do not qualify for significantforeign aid because, in theory, they have enoughdomestic financing to cover their national health†needs. Consequently, governments face thechallenge of setting their priorities in health,broadening their commitments, and improvingthe efficiency of their health services and systemsthrough the adoption of evidence-based practices.Since 1998, the Regional Task Force for theReduction of Maternal Mortality (Grupo de TrabajoRegional para la Reducción de la Mortalidad Materna,GTR, for its Spanish acronym) has promotedinteragency collaboration for the implementation ofpolicies and programs to reduce maternal mortalityin Latin America and the Caribbean. The GTR iscomprised of United Nations technical agencies,bilateral and multilateral cooperation organisms,non-governmental organizations, and professionalassociations.In 2003, the GTR spearheaded a broad consultationprocess that resulted in a policy declaration, theInteragency Strategic Consensus for the Reduction ofMaternal Morbidity and Mortality in Latin Americaand the Caribbean. This document, endorsed by theregion’s governments, promoted a set of agreedpriorities and strategies, based on the best availableevidence, for the reduction of maternal morbidityand mortality for the next decade (2004-2014).The Strategic Consensus has served as a frame ofreference for the design and implementation ofnational maternal mortality reduction plans, andthe harmonization of technical strategies amongdifferent agencies. Between 2004 and 2014, theStrategic Consensus aimed to:The key elements in the right to health are availability, accessibility, acceptability, and quality of services.9

Foster interagency dialogue and the developmentof a common strategic framework for thereduction of maternal morbidity and mortality; Achieve greater coherence of national policiesand interventions based on the best availablescientific information; Focus on the support and provision of qualityservices, prioritizing skilled birth attendanceand promoting evidence-based interventions; Strengthen maternal mortality surveillance andresponse systems; and Encourage intersectoral collaboration and theexchange of lessons learned within and betweencountries.The panorama presented in this document reaffirmsthe advances and lessons learned through programimplementation in the previous decade to helpcountries identify priorities for the reductionof maternal mortality in the framework of theSustainable Development Goals (SDGs). In addition,it offers guidelines for governments and differentinstitutional actors to harmonize their efforts toreduce maternal mortality in the period 2018-2025.The GTR presents this panorama at a criticaltime in which global development has undergonea paradigm shift. When the global MillenniumDevelopment Goals (MDGs) ended in 2015, nocountry in the region had achieved the MDG 5Atarget to reduce the maternal mortality ratio bythree quarters between 1990 and 2015. The regionmade progress on some MDG indicators,³ includingfamily planning and contraception, prenatal care,and skilled birth attendance. However, in 2016,the region as a whole had a maternal mortality ratio(MMR) of 60.8 maternal deaths for every 100,000live births,⁴ which signifies a 56.6% reduction from1990 levels (140 maternal deaths for every 100,000live births), well below the target of 75%.†In September 2015, United Nations member statesadopted the Sustainable Development Goals(SDGs), which prioritize the reduction of maternalmortality. The Global Strategy for Women’s,†10Children’s and Adolescents’ Health (2016-2030) offersa framework to make this priority operational.At the regional level, the First Regional Conferenceon Population and Development in Montevideo(2013) resulted in joint commitments to reducematernal mortality. In 2015, governments renewedtheir commitments to reduce maternal morbidityand mortality with the adoption of the OperationalGuide. In addition, the Santo Domingo Consensus,signed during the 2013 Regional Conference onWomen, and the Regional Gender Agenda, approvedat the XIII Conference on Women in 2016, arepolicy documents that aim to mainstream gender inthe implementation of the Sustainable DevelopmentAgenda (see Annex B on “The international contextfor the reduction of maternal mortality andmorbidity: Conceptual frameworks and global andregional strategies”).The maternal mortality panorama presented hereinseeks to: contribute to the achievement of thedescribed global and regional initiatives; highlightnew challenges and conceptual developments; andbuild the scientific evidence base. This panoramahighlights the issues of rights and accountability,social determinants of health, governance, intercultural health and the importance of intersectoralcollaboration. This document is aligned with theStrategy for Universal Healthcare Access and Coverage,the Montevideo Consensus and the Global Strategyfor Women’s, Children’s and Adolescents’ Health,adopted in September 2015.⁵, ⁶, ⁷Latin America and the Caribbean must overcomeseveral persistent challenges to improve women’ssexual and reproductive health and end maternalmorbidity and mortality. Such challenges includeconsistently high maternal mortality ratios andadolescent pregnancy rates; low quality anddisrespectful care during pregnancy, childbirthand the postnatal period; and limited access tofamily planning services and contraception. Withintheir borders, countries still grapple with extremeinequalities in access to health care amongpopulation groups, with marginalized groups facingthe most barriers to health care. This documentEach country reports its MMR to PAHO. The United Nations Maternal Mortality Estimation Inter-Agency Group, based on defined internationalstandards to guarantee comparability between countries, estimates the MMR of LAC to be 68 maternal deaths for every 100,000 live births.

encourages concerted action among countries inLatin America and the Caribbean to develop,adapt, and implement the SDGs, and to complywith regional and global commitments to reachuniversal health coverage and access to reproductivehealth care.2. The Context of Maternal Morbidity and Mortality in LatinAmerica and the CaribbeanIn 2015, the UN Maternal Mortality EstimationInter-Agency Group (MMEIG) estimated theabsolute number of maternal deaths in LAC at7,300. Yet, progress towards improving maternalhealth has been uneven between and withincountries. Of the 13 countries in LAC, the Bahamas,Bolivia, the Dominican Republic, Guatemala,Guyana, Haiti, Honduras, Jamaica, Nicaragua,Panama, Paraguay, Suriname and Venezuela havean MMR above the regional average—between89 and 359 for every 100,000 live births.⁸ Thesecountries also have high fertility rates, high povertylevels, and insufficient coverage and quality of care.Although no country achieved by 2015 the desired75% reduction in this indicator, 12 countriesreduced maternal mortality by more than half.⁸Most of these maternal deaths are preventable.Access to quality maternal health care wouldprevent 54% of these deaths and universal accessto family planning could prevent an additional 29%of maternal deaths.⁹ The most frequent causes ofmaternal mortality in the region are hemorrhage(23.1%), pregnancy-induced hypertension (22.1%),indirect causes (18.5%), other direct causes (14.8%),complications associated with unsafe abortion(9.9%), and sepsis (8.3%).¹⁰ Among the estimated3.6 million adolescent pregnancies in the region in2016, 1.4 million (39%) resulted in abortion, mostof them clandestine and unsafe.¹¹ The indirectcauses of maternal mortality have increaseddisproportionately in some countries, partly due toinsufficient coverage and quality of prenatal care,and lack of access to modern contraceptives forwomen who do not wish, or are not able because ofhealth reasons, to have more children. For example,36% of adolescents in Latin America and theCaribbean have an unmet need for contraception.¹¹†In El Salvador, women in the lowest incomequintile have 3.9 times greater unmet need forcontraception than those in the highest quintile;similarly, women in the lowest income quintile inGuatemala have 3.8 times greater unmet need forcontraception. In Bolivia and Panama the unmetneed for contraception is 3.6 times greater in thelowest income quintile. In Costa Rica, El Salvador,Guatemala, Panama, Peru and Suriname, womenwithout a formal education have more than twicethe unmet need for contraception than women whohave completed at least high school.¹²In the region, for every woman who dies fromcomplications during pregnancy, childbirth, or thepostpartum period, approximately another 20(around 1.2 million women) every year suffer severecomplications with long-term health impacts thatmay eventually result in death.⁵ The number ofwomen with serious morbidity related to pregnancyand childbirth varies according to the health facility,from 3 to 38 cases for every maternal death. Insome hospitals, the morbidity rate is almost doublethe global average of 20 cases of serious morbidityfor every maternal death. Although there havebeen some efforts to document serious maternalmorbidity,† an essential strategy for preventingmaternal deaths, few countries have implementeda standard to regularly record and analyze thisindicator. Annex C shows the differences betweenthe number of recorded maternal deaths in 1990and estimated maternal deaths in 2015.Inequity in access to high quality, respectfulmaternal health care within countries remains achallenge with human rights implications. TheLatin America and the Caribbean region is oneof the most unequal in the world, with 10 of 15The Latin American Center for Perinatology, Woman and Reproductive Health designed a registration system—based on variables definedby the World Health Organization—that provides healthcare professionals with guidelines for the care of pregnant women, with the aim ofanticipating and preventing these cases and documenting them.11

countries having the highest levels of incomeinequality.¹³ Maternal morbidity and mortality areexacerbated by inequity in income (income percapita), low educational attainment, malnutrition,lack of safe drinking water, low or uneven publichealth spending, geographical area of residence,membership in indigenous or Afro-descendantgroups, and disability status, among other factors.Eleven out of 23 countries reported maternalmortality ratios equal to or greater than 125maternal deaths per 100,000 live births insub-national districts, and 7 countries reportedeven greater mortality in ethnic populations.¹⁴Weak health information systems and lack ofdisaggregated data complicate efforts to measureand take actions to remedy these inequalities.Women living in poverty and from indigenous andAfro-descendant communities often experienceinadequate and discriminatory care. They alsoface geographical, economic, cultural and socialbarriers to accessing quality services, and theirsocial status is associated with higher mortalityand morbidity.¹⁵ Women seeking health servicesoften find that health providers do not recognizeor respect their culture and do not communicate intheir language. After experiencing discriminatoryand offensive treatment, women may find healthservices unacceptable and stop going to thehealth facility altogether. Countries with largerpopulations of indigenous peoples or Afrodescendants in Latin America (Bolivia, Brazil,Guatemala, Ecuador, Haiti, Mexico, Peru, andDominican Republic) have the highest levels ofMMR in the region or in the absolute number ofdeaths, as in the case of Brazil and Mexico. Evenwithin countries, the MMR of indigenous andAfro-descendant women is significantly higherthan for the rest of the population. For example,in Bolivia, the 2011 national study of maternalmortality showed that 68% of maternal deathsoccurred in indigenous populations,¹⁶ andGuatemala reported an MMR three times higheramong indigenous than non-indigenous women.¹⁶†12Similarly, studies in Brazil have found that in thestate of Parana, women of African descent werethree times more likely to die from maternityrelated causes than other women.The majority of countries still have not achieveduniversal access to essential reproductive healthservices. The region maintains the highest rate ofunwanted pregnancy, 56%,¹⁷ in the world and stillhas an unmet need for contraception between 19%for women in the highest income quintile to 31% forwomen in the lowest income quintile, indicatinglimited access to and use of contraception. About32% of pregnancies in the region end in abortion.¹⁸As of 2017, the Zika epidemic had affected 48countries and territories in the Americas throughlocal, mosquito-borne transmission of the virus.†In addition, five countries (Argentina, Canada,Chile, United States of America, and Peru) hadreported sexually transmitted Zika cases. Between2015-2017, 26 countries and territories reported3,125 cases of the congenital syndrome associatedwith the Zika virus infection; the large majority ofthese cases were reported in Brazil (2,653).¹⁹Zika response has focused on vector control toreduce the spread of disease among the generalpopulation and pregnant women, more specifically,to prevent potential harm to fetuses and newborns.However, governments should prioritize accessto sexual and reproductive health and familyplanning services, especially for women who wantto postpone pregnancy. Similarly, governmentsshould strengthen efforts to provide comprehensivecare, including mental health care, to mothers andcaregivers of children with congenital syndrome.The financial repercussions of Zika on mothersand families with children affected by congenitalsyndrome remain unknown.The total fertility rate in Latin America and theCaribbean is 2.15 children per woman, a notabledecrease from 3.02 during the 1990-1995 period²⁰and less than the global average of 2.53 children perAnguilla, Antigua and Barbuda, Argentina, Aruba, Barbados, Belize, Bolivia, Bonaire, Brazil, Colombia, Costa Rica, Cuba, Curacao, Dominica,Dominican Republic, Ecuador, El Salvador, French Guiana, Granada, Guadalupe, Guatemala, Guyana, Haiti, Honduras, Jamaica, Martinique,Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saint Bart’s, Saint Martin, Saint Vincent and the Grenadines, Saint Lucia, St Kitts andNevis, Saint Maarten, Saint Eustatius and Saba, Suriname, Trinidad and Tobago, Turks and Caicos Islands, United States, US Virgin Islands andVenezuela.

woman. Yet, this decrease has not been even acrossage groups. For example, the adolescent birth ratehas remained relatively stable over the last twodecades. Almost 2 million children, 13% of births,are born to adolescent mothers.²¹ The adolescentbirth rate in Latin America and the Caribbean is73.2 live births per 1,000 women 15 to 19 years old,much greater than the global average of 48.9 per1,000 and the average for developing countries of52.7 per 1,000. The region’s adolescent birth rateis almost double the levels for other regions, andis only surpassed by Sub-Saharan Africa, whereit reaches 103 live births per 1,000 women ages15 to 19. High adolescent birth rates are closelyrelated to abuse and sexual violence, and, therefore,constitute a double social debt for adolescents.²¹Adolescent pregnancies present a risk for thebiopsychosocial health of young women and theirchildren, especially for younger teenagers. In fact,pregnancy and childbirth are among the main causesof death for adolescent women ages 15 to 19 yearsin Latin America and the Caribbean.²² The risk ofmaternal mortality for women 15 years and youngercan be double or triple than that of women aged15-to-19, the three main causes are: (1) hypertensivedisorders, (2) late maternal deaths due to pregnancyor childbirth complications, and (3) unsafe abortions.²³Due to the effects of the demographic dividend,the size of the adolescent population will increaseduring the coming decades, and the availabilityof education and sexual and reproductive healthservices will impact achievement of the developmentgoals.²⁴ In the region, adolescents still face barriersto accessing sexual and reproductive healthservices, and less than 10% of adolescents regularlyuse effective contraceptive methods. Althoughmany countries in the region have establishedpolicies, guidelines and programs to support thesexual and reproductive health services and rightsof adolescents, studies show that these are notgenerally supported by dedicated budget lines orby evidence-based strategies to improve theprovision and universal access of adequate andtimely quality services. Also, legal barriers persistin some countries and there is a need to strengthenintersectoral approaches and alliances, and toencourage enabling environments for adolescentsexual and reproductive rights.The quality of care in reproductive health stillrequires considerable improvement; in particular,technologies and medical interventions continueto be overused. For example, health facilities havedisproportionately increased the use of Cesareansection, which while it is considered a keyobstetric intervention that saves lives, it can alsounnecessarily put women and their babies at risk.In Latin America, almost four out of ten deliveriesend in a Cesarean section (38.9%), well above thelevel recommended by WHO (between 10% and15%).²⁵ In Brazil, for example, 54% of deliveriesare through Cesarean section. The proportion ofCesarean section deliveries is increasing even incountries with a historical prevalence of normaldeliveries, such as Bolivia, where Cesarean sectiondeliveries rose from 14.6% in 2008 to 19% in 2012,or Peru, where they increased from 15.8% to 25%in the same period. On the other hand, Haiti, thecountry with the highest maternal mortality in theregion, has a Cesarean section delivery rate of 5.5%,below the recommended levels, which indicates theinequity in access to essential obstetric care.Abortion continues to pose a serious public healthproblem in the region. Annually it is estimated that6.5 million abortions are performed in unsafe, highrisk conditions.²⁶ The rate of abortions performedunder high-risk conditions is 31 abortions per 1,000women between 15 and 44 years of age, versus 22in the rest of the world; and the MMR due toabortions in high-risk situations is three timeshigher in Latin America and the Caribbean thanin developed regions (10 and 3 maternal deathsper 100,000 live births, respectively).²⁷ The safetylevel of the procedure is directly related to thesocioeconomic status of the woman, the capacity ofthe service provider, and the conditions in whichthe abortion is performed, thus, access to abortionis also affected by health care inequity. Accordingto an analysis by the Guttmacher Institute,²⁸ theCaribbean is the region with the highest abortionrate, 6.5 for every 1,000 women between 15 and44 years of age. Even though the abortion ratehas substantially decreased from 46 during 19901994 to 27 per 1,000 women during 2000-2014 indeveloped countries, the reduction in developingcountries (39 to 37 per 1,000 women in the sameperiod) has been insignificant.²⁷13

3. Lessons Learned in the 2004-2014 Decade3.1 Policies and Approaches thatContributed to the Reduction ofMaternal Morbidity and MortalityTHE RIGHT TO HEALTHPregnant women’s lack of access to acceptable,affordable, equitable and high-quality healthservices is a violation of their right to life, health,equity and non-discrimination. Maternal death anddisabilities are generally preventable and the directresult of discriminatory laws and practices, thefailure to establish and maintain operational healthsystems and services, and the lack of accountability.In the past ten years, countries in the LAC regionhave incorporated rights-based principles andstandards in their constitutions and laws; 18countries refer specifically to the right to healthand another five include social protection in healthas a basic principle of the healthcare system.Countries that have p

9 OVERVIEW OF THE SITUATION OF MATERNAL . MORBIDITY AND MORTALITY: LATIN AMERICA AND THE CARIBBEAN 9ntroduction I 11he Context of Maternal Morbidity T . 22onclusions C 25 ADDITIONAL REFERENCES 25nnex A: Glossary A 27nnex B: The International Context for A the Reduction of Maternal Mortality and . Morbidity 30nnex C: Regional Trends in .

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