Reducing Maternal Mortality - Unfpa

Box 1: Human rights treaty protections relevant to reducing maternal mortalityThe Convention on the Elimination of All Forms ofDiscrimination Against Women requires States parties to:“ensure to women appropriate services in connection withpregnancy, confinement and the post-natal period, grantingfree services where necessary, as well as adequate nutritionduring pregnancy and lactation” (article 12.2).The International Covenant on Economic, Social andCultural Rights requires States parties to take steps toprovide for: “the reduction of the stillbirth rate and ofinfant mortality and for the healthy development of thechild.” The UN Committee on Economic, Social and CulturalRights, the body responsible for monitoring this treaty, hasstated that this treaty obligation must be: “understood asrequiring measures to improve child and maternal health,sexual and reproductive health services, including access tofamily planning, pre- and post-natal care, emergencyobstetric services and access to information, as well as toresources necessary to act on that information” (GeneralComment 14, para.14).C. LEGAL PROTECTIONS PROVIDED BY THE RIGHT TO HEALTHIn recent years, there has been a deepening conceptualunderstanding of maternal mortality as a human rightsissue.14 Maternal mortality and morbidity are connectedto a number of human rights, in particular the right tothe highest attainable standard of health.The right to the highest attainable standard of healthis legally protected by international human rightstreaties including the Convention on the Elimination ofAll Forms of Discrimination Against Women (CEDAW),and the International Covenant on Economic, Social andCultural Rights (ICESCR). It is also recognised in regionaltreaties, as well as by the domestic constitutions andlaws of many countries worldwide.International treaties include entitlements andcorresponding obligations on States which are highlyrelevant in the context of reducing maternal mortality(Box 1). If fulfilled, these entitlements and obligationswould entail a reduction of maternal mortality. Thefeatures of the right to health are set out most fullyin General Comments, which are authoritativeinterpretations of treaty provisions adopted by thebodies responsible for monitoring implementationof treaties.15 The following paragraphs draw ontreaties and General Comments to set out keyfeatures of the right to health in the context ofmaternal mortality.D. FREEDOMS AND ENTITLEMENTS ARISING FROMTHE RIGHT TO HEALTHThe right to health takes into account an individual'sbiological and socio-economic preconditions, as well asa State's available resources. It is not a right to behealthy: it is a right to a variety of services, facilities,goods and conditions that promote and protect thehighest attainable standard of health.The right to an effective and integratedhealth systemThe right to health should be broadly understood asan entitlement to an effective and integrated healthsystem, encompassing health care and the underlyingdeterminants of health, which is responsive to nationaland local priorities, and accessible to all.16 An equitable,well-resourced, accessible and integrated health systemis widely accepted as a vital pre-condition for guaranteeing women’s access to the interventions that canprevent or treat the causes of maternal deaths.17Entitlements to specific goods and servicesconnected to reproductive health careThe right to health includes entitlements to a range ofhealth interventions which have an important role toplay in reducing maternal mortality. These include:IEmergency obstetric care (EmOC);18IA skilled birth attendant;19IEducation and information on sexual andreproductive health;20ISafe abortion services where not against the law;21IOther sexual and reproductive health care services,such as family planning services;22Primary health care services.23The State has an obligation to provide these goods andservices in order to prevent maternal mortality. Particularattention must be given to EmOC. As Lynn Freedman hasemphasised: “We know from health research and experience that not all interventions are equal. if the humanright in question is the right not to die an avoidabledeath in pregnancy and childbirth, then the first line ofappropriate measures that will move progressivelytoward the realisation of the right is the implementationof EmOC. In a human rights analysis, EmOC is not justone good idea among many. It is an obligation.” 24IReducing Maternal Mortality The contribution of the right to the highest attainable standard of health 5

MATERNAL MORTALITY AND THE RIGHT TO HEALTH: THE CONCEPTUAL LINKSD. FREEDOMS AND ENTITLEMENTSCONTINUEDAn entitlement to health goods, servicesand facilities which are available in adequatenumbers, accessible, acceptable and goodmedical qualityEntitlements to the underlying determinantsof healthHealth care services, goods and facilities connected topreventing maternal mortality must be available, accessible, acceptable and good quality. Each of these criteriahas particular importance for maternal mortality (seeBoxes 2 and 3):The right to health is not only a right to health care. Italso encompasses a right to underlying determinants ofhealth. Many of these determinants play a key role inensuring women are able to access the necessary services and facilities to prevent maternal mortality. Here wemention just two important determinants of maternalhealth: gender equality, and water and sanitation.Box 2: Availability, accessibility, acceptability and quality of health facilities, goods and servicesand their relevance to maternal mortalityCriteriaRight to health requirementRelevance to maternal mortalityAvailableAn adequate number of goods,services and facilities necessary formaternal health, as well as sufficientnumbers of qualified personnel tostaff the services.Increasing care, and improving humanresource strategies – including increasingthe number and quality of healthprofessionals and improving terms andconditions – will be key for reducingmaternal mortality in many countries.25Physically andeconomicallyaccessibleMaternal health and sexual and reproductive health services which are bothphysically and financially accessible.Physical access to, and the cost of, healthservices often influence whether women areable to seek care.26Accessible onthe basis ofnon-discriminationHealth services must be accessible onthe basis of non-discrimination.Ensuring women’s access to maternal healthand other sexual and reproductive healthservices may require addressing discriminatory laws, policies, practices and genderinequalities in health care and in societythat prevent women and adolescents fromaccessing good quality services.AccessibleinformationThe right to seek, receive and impartinformation and ideas concerninghealth issues, including information thatcan help prevent maternal mortality.Laws or policies that restrict women’s accessto information on sexual and reproductivehealth have a direct impact on maternalmortality.27AcceptableAll health facilities, goods and servicesmust be respectful of the culture ofindividuals, minorities, peoples andcommunities and sensitive to genderand life-cycle requirements.Preventing maternal mortality and enhancing access to maternal and other sexualand reproductive health care is not simplyabout scaling up technical interventions ormaking the interventions affordable. Alsoimportant are strategies to ensure that theservices are sensitive to the rights, culturesand needs of pregnant women, includingthose from indigenous peoples and otherminority groups (see Box 3).28Good qualityMaternal health care services mustbe medically appropriate andgood quality.The quality of care often influences theoutcome of interventions and it alsoinfluences a woman’s decision of whetheror not to seek care.6 Reducing Maternal Mortality The contribution of the right to the highest attainable standard of health

Gender equality: Behind maternal mortality is afailure to guarantee women’s human rights. This isoften manifested in, among others, low status ofwomen and girls, poor access to information and care,early age of marriage and restricted mobility.29 Genderequality has an important role to play in preventingmaternal mortality. Gender equality and empowermentlead to greater demand by women for family planningservices, antenatal care and safe delivery. The Conventionon the Elimination of Discrimination Against Womenprovides that States Parties “agree to pursue by all appropriate means and without delay a policy of eliminatingdiscrimination against women” and that they “shalltake all appropriate measures to eliminate discriminationagainst women in the field of health care in order toensure, on a basis of equality of men and women,access to health care services, including those relatedto family planning.” 30Water and sanitation: Water and sanitation mustbe ensured for the provision of prenatal care and emergency obstetric care. Water and sanitation are essentialelements of the right to health.THE RIGHT TO HEALTHENCOMPASSES AN ENTITLEMENTTO UNDERLYING DETERMINANTSOF HEALTHFreedomsIn addition to the numerous entitlements associated withthe right to health, this human right includes a number offreedoms. In the context of maternal mortality, relevantfreedoms include freedom from discrimination; harmfultraditional practices, such as early marriage; and violence.Photograph P. Delargy,courtesy of UNFPA. StopGender DiscriminationAgainst Women, Liberia.Box 3: Culturally acceptable maternal health services in PeruIn the village of San José de Secce and the communitiesof Oqopeqa, Punkumarqiri, Sañuq and Laupay in Ayacuchodistrict, Peru, an assessment by non-governmental organisations showed that there were various barriers to using healthservices in these communities, which had very high maternalmortality rates. In addition to the distance that had tobe travelled to the establishment, the inability to pay fortransport or care and the lack of health personnel andequipment, the main barrier was reluctance on the part ofthe population to use health facilities offered by the state.This situation was reflected in the high percentage of women(94 per cent) giving birth at home, compared with 6 per centwho gave birth in health centres.The state health services did not take account of localcultural conceptions of health and sickness. The populationhad no trust in the ability of the personnel or the servicesand viewed attending a health facility as inconvenient orrisky and therefore resisted using the facilities.Between 1999 and 2001, in consultation with the communities in question, a culturally-adapted project to providesexual and reproductive health services was put into effect.The project promoted communication between healthprofessionals and the community, user participation, and acloser relationship between traditional midwives and healthpersonnel. In health centres, the environment of the deliveryroom and care given during prenatal checkups, delivery andthe postnatal period were adapted to make them culturallysensitive. These measures included creating a private environment, with curtains to keep out draughts and anyone notassociated with the birth, as well as the provision of a bedand a sturdy rope, so that women could give birth in anupright position, or squatting and gripping the rope, as theywished. The protocol for care also stipulated, among others,that the person attending the birth should speak Quechuaand preferably be female. In addition, in accordance with thebeliefs of the communities, the protocol included the requirement to deliver the placenta to the family member presentso that it could be buried, and the opportunity for the userto remain in the health facility for up to eight days. Accordingto an assessment, after the project was implemented, therewas a great increase in deliveries at health centres.Source: adapted from Amnesty International, Peru: Poor andexcluded women – denial of right to maternal and child health,2006.Reducing Maternal Mortality The contribution of the right to the highest attainable standard of health 7

MATERNAL MORTALITY AND THE RIGHT TO HEALTH: THE CONCEPTUAL LINKSE. THE THREE DELAYS MODEL AND ITS RELATIONSHIPTO THE RIGHT TO HEALTHIt is often said that maternal mortality is overwhelmingly due to a number of interrelated delays whichultimately prevent a pregnant women accessing thehealth care she needs.31 Each delay is closely related toservices, goods, facilities and conditions which areimportant elements of the right to health (see Box 4).Box 4: Three delays and the right to healthThree delaysCorresponding right to health entitlementsand freedomsin seeking appropriate medical help for1.Delayan obstetric emergency for reasons of cost,IAccess to health information and educationIAccess to affordable and physically accessiblehealth careIEnjoyment of the right to health on the basis ofnon-discrimination and equalityISafe physical access to health careIAn adequate number of health professionalsIAvailability of essential medicinesISafe drinking water, sanitation and otherunderlying determinants of healthlack of recognition of an emergency, pooreducation, lack of access to information andgender inequality.in reaching an appropriate facility2.Delayfor reasons of distance, infrastructureand transport.in receiving adequate care when a3.Delayfacility is reached because there areshortages in staff, or because electricity, wateror medical supplies are not available.OTHER HUMANRIGHTS THAT HAVEA BEARING ONMATERNALMORTALITYINCLUDE THE RIGHTTO EDUCATIONPhotograph 2002 TeunVoeten, Sierra Leone,courtesy of UNFPA.Schoolsgirls walking pastbill board promotingeducation.F. OTHER HUMAN RIGHTSAs well as its relationship to the right to health,maternal mortality has a close relationship to otherhuman rights. Preventable maternal mortality oftenrepresents a violation of the right to life. Other humanrights that have a bearing on maternal mortalityinclude the right to decide freely on the number andspacing of one’s children and the right to education.These human rights can also be integrated intostrategies to reduce maternal mortality (see ChaptersII and III).8 Reducing Maternal Mortality The contribution of the right to the highest attainable standard of health

G. WHAT ARE STATES’ RIGHT TO HEALTH OBLIGATIONSTO REDUCE MATERNAL MORTALITY?The responsibilities created by international humanrights law provide a basis for ensuring accountabilityand determining which actors are responsible forreducing maternal mortality.States that have ratified ICESCR, CEDAW and otherinternational treaties, or that have national constitutionsguaranteeing the right to health, have a legal obligationto realise the right to health. Other relevant stakeholders– including international organisations, private providersof health care, families and communities – also haveresponsibilities.32States have three primary obligations towards theright to health:IRespect: States must not interfere with the rightto health, for example by adopting discriminatorypolicies or laws;IProtect: States must ensure that third parties(e.g. non-state actors) do not infringe the enjoymentof the right to health;IFulfil: States must take positive steps to realise theright to health, such as policy, legislative, budgetaryand administrative measures.These obligations mean that States must take steps toensure women can access maternal health care andother relevant sexual and reproductive health services.This may require actions including increasing resourcesto the relevant services within the health sector, developing a policy and plan of action, developing more services and improving staffing ratios, improving transportto existing services, and addressing social, cultural andeconomic reasons why women do not access services.The obligation to progressively realise the rightto healthInternational law does not expect States to instantaneously provide all goods, services and facilities relevantto the right to health. Instead, States are expected totake concrete and deliberate steps to progressivelyrealise the right to health. These steps may include legal,policy and administrative measures. What is expected ofa State depends on the resources available to it – inother words, the same is not expected of a rich andof a poor State. Where resources are limited, Statesare expected to prioritise certain key interventions,including those that will help guarantee maternalhealth,33 and in particular EmOC.Although subject to progressive realisation andresource constraints, the right to health imposes variousobligations of immediate effect. These immediateobligations include ensuring the realisation of the rightto health on a non-discriminatory basis; the provision ofprimary healthcare, safe water and adequate sanitation;and equitable distribution of all health facilities, goodsand services.International assistance and cooperationThe right to health requires high-income States toassist low-income States in their efforts to reducematernal mortality.34 This responsibility is also reflectedin international development commitments such asMillennium Development Goal 8, which is a commitment to develop a global partnership for development.High-income States should, for example, ensure thatreducing maternal mortality is adequately reflected intheir development assistance contributions and policies.They should also undertake other measures such asrefraining from the proactive recruitment of healthprofessionals from developing countries where thiswould result in staffing shortages that hamper thereduction of maternal mortality.35The duty of high-income States to assist lowincome States does not deprive the latter of theirown obligations to progressively realise the right tohealth. Low-income States must still undertake measures within their domestic resources, and supplementdomestic with international resources where necessaryand possible.THE RIGHT TO HEALTH REQUIRES HIGH-INCOME STATESTO ASSISTLOW-INCOME STATES IN THEIR EFFORTS TO REDUCEMATERNAL MORTALITYReducing Maternal Mortality The contribution of the right to the highest attainable standard of health 9

THE RIGHT TO HEALTH: A FRAMEWORK FOR EFFECTIVE POLICIES TO REDUCE MATERNAL MORTALITYII. THE RIGHT TO THE HIGHESTATTAINABLE STANDARD OF HEALTH:A FRAMEWORK FOR EFFECTIVE POLICIESTO REDUCE MATERNAL MORTALITYHuman rights violations are both a cause and consequence of poverty and ill-health. Respect for humanrights can enhance poverty reduction and improvehealth outcomes.A human rights-based approach explicitly integrateshuman rights norms, standards and principles intoprogrammes, plans and policies to reduce maternalmortality. While there is no set formula for a humanrights-based approach, key characteristics include:IMaking the realisat

for maternal mortality. In short, the promotion and protection of the right to health demands actions that lead to a significant and sustained reduction in maternal mortality. This briefing introduces the contribution of the right to the highest attainable standard of health to reducing maternal mortality. This contribution is twofold. The