A human rights-based approach to maternal health

Maternal Health

Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period.

A Human Rights-Based Approach

There is no clear definition of a human rights-based approach, but these approaches within the development field generally seek to empower people to claim their human rights, and support duty-bears to deliver particular services anchored by human rights.

Human Rights-Based Approaches to Maternal Health

Human rights-based approaches to maternal health therefore seeks to empower women during pregnancy, childbirth and the postpartum period to enjoy and claim their rights, as well as build the capacity of duty-bearers to deliver maternal health services.

A human rights-based approach to maternal health aims at supporting better maternal health outcomes by analysing and addressing the inequalities, discriminatory practices (de jure and de facto) and unjust power relations which can be at the heart of maternal morbidity and mortality.

The conceptual framework for a human rights-based approach to maternal health rests upon a number of international human rights treaties [1] and general comments, recommendations and concluding observations of several treaty bodies; recognising that maternal mortality implicates a wider range of human rights and recommending that States parties take effective measures to improve maternal health.[2]

Human rights-based approaches to maternal health are informed by two reports produced by the Office of the United Nations High Commissioner for Human Rights (OHCHR). The first OHCHR report identifies seven human rights principles fundamental for understanding maternal mortality and morbidity as a human rights issue: accountability, participation, transparency, empowerment, sustainability, international assistance and non-discrimination.[3] The second OHCHR report outlines categories of good practices to address maternal mortality and improve maternal health in compliance with human rights obligations.[4] 

State parties should do all they can to ensure that maternal health care services are available to everyone in their jurisdiction. This includes facilities, adequate human resources and drugs, supplies and equipment. Maternal health services should also be accessible to everyone without discrimination. This includes safe physical accessibility for all, economic accessibility, including to women living in poverty, and access to information. Maternal health care should be acceptable, respectful of individuals, their culture, sensitive to gender and includes the principle of confidentiality. Finally, maternal health services should be of adequate quality, which requires skilled health workers and respect for evidence-based norms and standards.[5] 

Overall, a human rights-based approach to maternal health can be viewed as a conceptual framework that is normatively based on international human rights standards and norms relevant to maternal health.

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[1] These including the International Covenant on Civil and Political Rights (ICCPR); the International Covenant on Economic, Social and Cultural Rights (ICESCR); and the Convention on the Elimination of All Forms of Discrimination against Women.

[2] See for example: Concluding observations of the Committee on the Elimination of Discrimination against Women: Algeria (A/60/38), para. 131; Czech Republic (A/57/38), para. 85; India (CEDAW/C/IND/CO/3), para. 40; Saint Kitts and Nevis (A/57/38), para. 88; Sri Lanka (A/57/38), para. 217; Turkey (CEDAW/C/TUR/CC/4-5), para. 38; concluding observations of the Human Rights Committee: Bolivia (CCPR/C/79/Add.74), para. 22; Libyan Arab Jamahiriya (CCPR/C/79/Add.101), para. 9; Mongolia (CCPR/C/79/Add.120), para. 8(b); Paraguay (A/51/38),para. 123; Senegal (CCPR/C/79/Add.82), para. 12; concluding observations of the Committee on the Elimination of Racial Discrimination (CERD): Benin (E/C.12/BEN/CO/2), para. 25; Brazil (E/C.12/1/Add.87), para. 27; China (E/C.12/1/Add.107), para. 36; Democratic People’s Republic of Korea (E/C.12/1/Add.95), para. 23; Mexico (E/C.12/MEX/CO/4), para. 25; Morocco (E/C.12/MAR/CO/3), para. 13(f); Paraguay (E/C.12/PRY/CO/3), para. 21; Poland (E/C.12/1/Add.82), para. 29; Senegal (E/C.12/1/Add.62), para. 26; concluding observations of the Committee on the Rights of the Child: Argentina (CRC/C/15/Add.187), para. 46; Azerbaijan (CRC/C/AZE/CO/2), para. 49(b); Benin (CRC/C/BEN/CO/2), para. 51; Botswana (CRC/C/15/Add.242), para. 48; Colombia (CRC/C/COL/CO/3), para. 68(b); Philippines (CRC/C/PHL/CO/3-4), para. 55; Yemen (CRC/C/15/Add.128), para. 55(c).

[3] UN Human Rights Council, 'Report of the Office of the United Nations High Commissioner for Human Rights on Preventable Maternal Mortality and Morbidity and Human Rights.' (2010)  A/HRC/14/39

[4] UN Human Rights Council, 'Practices in Adopting a Human Rights-Based Approach to Eliminate Preventable Maternal Mortality and Human Rights,' (2011) A/HRC/18/27

[5] UN Human Rights Council, "Preventable Maternal Mortality and Morbidity and Human Rights." (2012) A/HRC/RES/21/6

G7 Letter

The G7 Summit in Germany in early June is a key moment to request support from G7 member-states on issues of great importance to us. This includes the ambitious but achievable goal of ending of preventable maternal, newborn and child deaths by 2030 in the post-2015 negotiations; improving access to quality health services for women, children and adolescents everywhere, including those in fragile and conflict settings, and making sure these and other issues are linked to the updated Global Strategy for Women’s, Children’s and Adolescents’ Health to be launched by UN Secretary-General Ban Ki-moon in September 2015.

 

If you would like to have the name of your organisation included on this letter, please send an email to Kel Currah (kel@whatworldstrategies.com)

Letter:

Putting women’s, children’s and adolescents health at the centre of the G7 agenda

The G7’s efforts to improve global health rank among its greatest development achievements. G7 leaders have played an important role in shaping and supporting global initiatives that have made a significant impact including the Global Fund for HIV/AIDS, TB and Malaria and the Muskoka Initiative. Launched at the G8 Summit in 2010, the Muskoka Initiativehas contributed to substantial progress in improving the healthof women, newborns and children, including through galvanizing international support and commitments for the UN Secretary General’s Global Strategy for Women’s and Children’s Health (the Global Strategy). The recently published report on the Global Strategy named it as the fastest growing public health partnership in history, with 2.4 million women’s and children’s lives saved since 2010

The forthcoming Schloss Elmau G7 Summit will address issues that are fundamental to improving the health and rightsof women, newborn, children and adolescents, particularly women’s empowerment and resilience in health systems. Through the G7’s leadership, the international community can empower women and support increased resilience by strengthening health care systems, fighting infectious diseases, improving sexual, reproductive, maternal, newborn, child & adolescent health and ensuring that the unfinished business of the health-related Millennium Development Goals is not lost in the transition to the Sustainable Development Goals. 

Therefore, we urge G7 leaders to include commitments in the Summit Communique to:

• Renew commitments made under Muskoka and the Global Strategy for Women’s and Children’s Health such as A Promise Renewed, Every Newborn Action Plan and Family Planning 2020 and ensure they are met;

• Welcome and support the renewed Global Strategy for Women’s, Children’s and Adolescent’s Health, to be launched in September 2015;

• Support the ambitious but achievable goal of ending of preventable maternal, newborn and child deathsby 2030 in the post-2015 negotiations and agree to tackle inequality by focusing on those groups that are furthest behind;

• Provide financial and non-financial resources to deliver the post-2015 framework and support countries to raise and spend greater domestic resources on universal public services, including viathe newly established Global Financing Facility in support of Every Woman Every Child to be launched at the Financing for Development Conference in Addis Ababa in July 2015. 

• Deliver an ambitious commitment on aid expenditure in support of increased domestic resource mobilisation and align ODA for the health and rightsof women, children and adolescents, includingthrough the Global Financing Facility;

• Ensure that every woman, every child, every adolescent everywhere, including fragile and conflict affected contexts, has access to quality RMNCAH health services and adequate nutrition.

Addressing the rights and needs of women and children is key to creating sustainable change and development. The last five years of the Global Strategy for Women’s and Children’s Health have shown that well-planned, coordinated interventions can achieve results and save lives. 2015 is the time to build on this achievement, renew commitments and support strong strategies that will end preventable maternal, newborn and child deaths by 2030and improve overall health. In this crucial year, we call on for G7 leadership to make this a reality. 

Sincerely,

 

The undersigned organisations:

 

Citizens' Hearings

A series of Citizens’ Hearings have been taking place around the world, providing an opportunity for citizens to feed in their priorities for the next development agenda and to outline their role in improved accountability for delivery of reproductive, maternal, newborn, and child health.   

More information on the hearings can be found here: http://www.citizens-post.org/

Anthropology of Childbirth

Anthropology plays an important role in defining problems within the field of childbirth, because ethnographic methods can be used to collect data about women’s specific health problems, in order to ensure better policy and practice, as well as evaluate future health interventions. During the first decades of the twentieth century, anthropologists paid very little attention to childbirth within different cultural contexts, perhaps due to the dearth of female anthropologists, and therefore a lack of interest, and access to an exclusively female domain. However, with the influx of female anthropologists, their ethnographies and comparative studies have shown the different ways in which pregnancy, childbirth and the postpartum period have been managed physically, but also socially constructed in unique ways within different cultural contexts (von Hollen, 2003). Inhorn (2007) states that, by listening to the women themselves through ethnographic research, anthropologists are able to determine women’s own health and childbirth priorities, as the setting of priorities in women’s health still tends to come “from the top down” (2007, p.4). With regard to the anthropology of childbirth, childbirth story interviews with mothers are often a research method in the anthropology of childbirth (Davis-Floyd, 1992; Callister and Vega, 1998; von Hollen, 2003), as it is understood to produce vital insights into the experiences of birthing women ( Savage, 2001; Carolan, 2006). Leamon highlights that, within each mother’s childbirth story, lies a ‘complex combination’ of factors involving the storyteller, her sense of self, the childbirth, and her reflections about the experience (2009, p.171). 

Farley and Widmann describe how childbirth stories are “symbolic representations of birth through word” and argue that articulating the birth experience into a story gives it structure, as well as “an onset, a climax, and a resolution” (2001, p.22). Livo and Ruitz (1986) maintain that, in the ‘narrative exchange’ that takes place when a childbirth story is told, the ‘learner’ reconstructs knowledge amassed from the story. The shared story therefore becomes a ‘vicariously learned experience’ (Savage, 2001).

International Human Rights in the Context of Childbirth

The Universal Declaration of Human Rights (UDHR) was adopted by the UN General

Assembly in 1948, legislating that “All human beings are born free and equal in dignity and rights.” (Art. 1). However, since the UDHR is not legally binding, the process of drafting a legally binding instrument enshrining the rights of the UDHR started immediately afterwards. Initially, it was envisioned that there would be a single covenant, encompassing all the human rights, however, the ideological battle between the West and the Soviet Union bloc meant that the General Assembly eventually requested that two separate covenants be formulated. The International Covenant on Civil and Political Rights (ICCPR) outlined rights such as the right to participate in government and the prohibition of torture, whereas the International Covenant on Economic, Social and Cultural Rights (ICESCR) outlined social, economic, and cultural rights, such as the right to healthcare. Together with the Universal Declaration, the Covenants are referred to as the International Bill of Human Rights. A series of international human rights treaties have since been adopted, which have all expanded the body of international human rights law. These include the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CTI), and the Convention on the Rights of Persons with Disabilities (CRPD), Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (ICMRW), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), among others (Smith, 2010). CEDAW protects a wide range of gender-based rights, including rights related to non-discrimination, gender-based stereotyping, prostitution, participation in public life, nationality, employment, education, health, economic and social benefits, special rights for rural women, equality before the law,

and equality in marriage and family life.

Maternal mortality was not recognised as a global health concern, let alone a human rights issue, until the 21st century. Historically, the majority of health professionals, policy makers, and politicians paid insufficient attention to the high number of maternal deaths in low-income countries, as maternal and child health programmes were mostly driven by concerns about infant mortality and morbidity (Rosenfield and Maine, 1985). In 1985, the World Health Organisation (WHO) finally hosted an Interregional Meeting on the Prevention of Maternal Mortality, which highlighted the problem of maternal mortality in low- and middle-income countries. Subsequently, the WHO, the United Nations Population Fund (UNFPA) and the World Bank sponsored the first International Safe Motherhood Conference in 1987. The conference officially launched the Safe Motherhood’s Initiatives (SMI) to increase women’s access to family planning, promote the value of prenatal care, and increase the access to emergency treatment. The SMI was successful in bringing international attention to maternal mortality in low-income countries, and even more importantly, cemented the fact that maternal mortality was not ‘natural,’ but instead represented avoidable loss of life. As Stroeng states, “it was a preventable tragedy that governments and the international community had an ethical obligation to address” (2010, p. 80). 

In 2000, the UN General Assembly announced the Millennium Development Goals (MDGs), a set of eight goals to combat poverty, hunger, disease, illiteracy, environmental degradation, and improve healthcare. Each MDG had targets set for 2015 and indicators to monitor progress. MDG 5 aimed at improving maternal health by reducing the maternal mortality ratio by 75 percent by 2015 (United Nations, 2015). A key ‘success’ indicator was the proportion of births attended by a skilled birth attendant, with the aim to increase the number of births assisted by skilled attendants to 80 percent by 2005 and 90 percent by 2015 (Rasch, 2007).1 Even though the MDGs succeeded in propelling the issue of maternal mortality to the top of the international agenda, the MDGs soon came under criticism for the slow progress in terms of maternal mortality in sub-Saharan Africa, as well as the predominant focus on (economic) poverty reduction whilst ignoring other dimensions of development, such as empowerment and human 1 The MDGs were subsequently replaced in 2015 by the Sustainable Development Goals (SDGs), which are 17 goals focused on peace and prosperity. Target 3.1 is focused on the reduction of the global MMR to less than 70 per 100,000 by 2030. 

Human Rights in Childbirth

A number of the international human rights treaties are relevant to protecting mothers' human rights in childbirth, including the ICCPR, ICESCR, ICERD, CEDAW, ICMRW, CTI and CRPD. The Maternity Charter draws upon the above human rights treaties, as well as regional human rights treaties including the African Charter on Human and People’s Rights (African Charter), the African Charter on the Rights and Welfare of the Child (ACRWC), the American Convention on Human Rights (ACHR), and the European Convention for the Protection of Human Rights and Fundamental Freedoms (ECHR), to establish the rights of women before, during and after childbirth. Finally, there are a number of relevant, specialised human rights treaties, including the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights, the Convention of Belem do Para, and the European Convention on Human Rights and Biomedicine. Thus, human rights in childbirth are anchored in international, as well as regional, human rights law.

Human Rights Violations in Childbirth

In 2010, the ground-breaking report by Bowser and Hill revealed the various human rights violations, as well as disrespect and abuse (D&A), that numerous mothers experienced during childbirth in healthcare facilities. The primary purpose of the report was to review the evidence in published literature with regard to the definition, scope, contributors, and impact of disrespect and abuse in childbirth, to review promising intervention approaches, and to identify gaps in the evidence. In their systematic review of the topic, Bowser and Hill drew upon examples from various human rights organisations, shining the spotlight on the violations and disrespect that mothers had experienced in childbirth. From this, seven D&A categories were established, which include:

 

i) physical abuse, 

ii) non-consented clinical care, 

iii) non-

confidential care, 

iv) non-dignified care, 

v) discrimination, 

vi) abandonment, 

and vii) detention in health facilities. 

They stated that “the recognition, ratification, as well as enforcement of human rights treaties is one important strategy for reducing disrespect and abuse in childbirth” (2010, p.17).

In 2010, the Human Rights Council held a panel discussion on maternal mortality as a human rights issue, and the Office of the United Nations High Commissioner for Human Rights (OHCHR) subsequently publishing a report on the topic. The report highlights that States are obligated under international human rights law to respect, protect and fulfil human rights in relation to pregnancy and childbirth. It states that preventable maternal death is a violation of the right to the highest attainable standard of physical and mental health, including sexual and reproductive health, the rights to equality and to non-discrimination and the rights to information, to education and the benefits of scientific progress. Additionally, the report identifies seven human rights principles fundamental for understanding maternal mortality and morbidity as a human rights issue, including accountability, participation, transparency, empowerment, sustainability, international assistance, and non discrimination (Human Rights Council, 2010).

In 2011, the White Ribbon Alliance launched the Respectful Maternity Care Charter (Maternity Charter), which anchors the rights of individual mothers in childbirth to international human rights law. The Maternity Charter states that childbirth care needs to encompass basic human rights, including the rights to respect, dignity, confidentiality, information and informed consent, the right to the highest attainable standard of health, as well as freedom from discrimination and from all forms of ill-treatment. The Maternity Charter highlights that the sole focus on preventing maternal and newborn morbidity and mortality is not enough, as the wellbeing of the mother and her infant during childbirth should not be compromised. The table below contains the Respectful Maternity Care Charter.

Although the Maternity Charter established human rights for mothers in childbirth in theory, human rights scholars were aware that they needed to find ways to ensure that these rights were implemented in practice. Freedman highlights that “human rights norms could be readily used to characterize and categorize the chilling scenes of humiliation, neglect and abuse” (2003, p.111), but to actively change the situation - so that the public health systems respected, protected, and fulfilled human rights in practice - the impetus provided by human rights law would have to move beyond the legal realm into healthcare practice.

The Human Rights-Based Approach to Maternal Morality

In 2011, the UN Human Rights Council received the OHCHR report on effective practices when adopting a human rights-based approach to preventing maternal mortality and morbidity, which included (a) an identification of how such initiatives embodied a human rights-based approach; (b) the elements of these initiatives that succeeded in achieving a reduction in maternal mortality and morbidity through a human rights-based approach; and (c) ways in which similar initiatives could give effect more fully to a human rights-based approach. The report makes clear that States should make efforts to build functioning healthcare systems with adequate supplies, equipment, and infrastructure, as well as an efficient and effective syste of communication, referral, and transport. Furthermore, it highlighted that the strengthening of healthcare systems, however costly, is beneficial to all citizens, not just women, thereby illustrating the interlinkages among international development, human rights and public health.

Finally, the report concludes that “accountability is at the core of the enjoyment of all human rights and has two main components: (a) addressing past grievances; and (b) correcting systematic failure to prevent future violations” (para. 31).

In 2012, the United Nations General Assembly (UNGA) was presented with the ‘Technical Guidance on the Application of a Human Rights-Based Approach to the Implementation of Policies and Programmes to Reduce Preventable Maternal Mortality and Morbidity’ (OHCHR, 2012). The human rights-based approach “identifies rights-holders and their entitlements and corresponding duty-bearers and their obligations and promotes strengthening the capacities of both rights-holders to make their claims and duty-bearers to meet their obligations” (para. 10). The UN Technical Guidance highlights that a human rights-based approach to maternal mortality “is premised upon empowering women to claim their rights, and not merely avoiding maternal death or morbidity” (para. 12). 

Finally, the UN Technical Guidance states that mechanisms should be established to promote accountability, transparency, participation, empowerment, non discrimination, universality, and equity, so that healthcare policies meet their citizen’s needs meanwhile respecting their human dignity. Overall, the UN Technical Guidance provides a blueprint for states on how to integrate human rights-based approach to maternal mortality into government policy and practice.

Global Maternal Newborn Health Conference 18-21 October 2015

As countries around the world prepare for a new set of ambitious targets to end preventable deaths, the maternal and newborn health communities have an ideal opportunity to consider successes and challenges, share lessons learned and technical updates, and set priorities for the way forward.

The technical conference will focus on discussing programs, policies, research, and advocacy to support achieving effective and sustainable coverage of maternal and newborn interventions at scale in countries and regions of highest need, and will continue to galvanize momentum and commitment to mothers and newborns on the global agenda. Mexico will provide a wonderful venue, as many lessons can be learned from its recognized leadership in maternal and newborn health in Latin America and worldwide, particularly in addressing issues of equity within and across population groups.

Visit the official conference website for additional information. The conference is sponsored by the Maternal Health Task Force (MHTF) at the Harvard School of Public Health, USAID’s flagship Maternal Child Survival Program (MCSP), and Save the Children’s Saving Newborn Lives program (SNL), in coordination and collaboration with a number of global and regional partners.