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The Lancet, Volume 381, Issue 9873, Pages 1159 - 1160, 6 April 2013

MATERNAL MORTALITY & MORBIDITY: A HUMAN RIGHTS IMPERATIVE

Navanethem Pillay

Ann Johansson/Corbis

Maternal mortality and morbidity continue to be a serious human rights concern—it is estimated that 287 000 women died of maternal causes in 2010.1 There is increased understanding that this is a human rights crisis that stems from discrimination against women, which manifests, for example, in violence against women, underprioritisation and underfunding of services and goods that only women require, and lack of accountability mechanisms to respond to maternal deaths and injuries.2 A human rights-based approach to maternal mortality and morbidity has been advocated by human rights experts for many years,3, 4 and has also gained traction among public health experts and other professionals.5 An important example of this evolution is the 2012 report of the independent Expert Review Group,6 which was mandated to monitor progress on the UN Secretary-General's Global Strategy for Women's and Children's Health and included a specific recommendation on human rights.

Making human rights a reality on the ground is multidisciplinary work, and our common objectives of ensuring better health, improved living standards, and full protection of rights for women will be met only when we strengthen the bridges between sectors. The 2012 Report of the Office of the United Nations High Commissioner for Human Rights entitled 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,7 is a tool that can be used to reinforce these crucial partnerships. This guidance was welcomed by the Human Rights Council in a resolution adopted by consensus,8 which requested that I report back in 2 years on how this new tool is being used by states and other stakeholders. The guidance translates human rights norms and standards into concrete policy action and aims to make human rights more accessible and practical for policy makers.

The guidance begins with general principles that include: recognition of health in a broad sense and not only isolated pathologies; the need for attention to the social determinants of women's health; and special attention to women who are subject to multiple forms of discrimination and have increased rates of maternal mortality and morbidity as a result. The guidance emphasises that women are not passive beneficiaries but active rights holders who are entitled to take part in a meaningful way in matters that relate to their sexual and reproductive health. It also makes clear that human rights principles of non-discrimination/equality, transparency, participation, and accountability should inform the design, organisation, and coordination of WHO's six components of the health system (service delivery; health workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance).9

As a core obligation under human rights law, the adoption of a national plan of action or strategy is an important first step in meeting human rights obligations. The guidance details what issues should be covered in such a plan (eg, access to essential medicines and interventions), with specific steps towards ensuring universal access and addressing disparities in access. It also outlines process requirements to ensure a broadly participatory process with review mechanisms to assess implementation.

In terms of the budget, human rights require states to devote the maximum available resources towards the realisation of economic and social rights, and specific advice is offered to assess whether the maximum of available resources has been allocated to sexual and reproductive health, through a transparent and participatory process.

With regard to implementation, the guidance examines concrete examples of identified problems, using a diagnostic exercise of asking critical questions to reveal human rights concerns and gaps in accountability. Meaningful participation is particularly critical in this exercise of asking questions. By exposing root causes of problems, including system failures, this exercise assists policy makers in designing responses that comply with human rights obligations.

Monitoring and data collection are critical dimensions of accountability and must include examination of quantitative and qualitative indicators.10 The guidance explains several forms of review and oversight, pointing to the various levels of cross-sectoral accountability which are required. The guidance also emphasises the central importance of effective remedies, without which accountability mechanisms will be insufficient; different forms of remedies might include restitution, compensation, satisfaction, or guarantees of non-repetition.11 Ensuring that remedies are effective means that states must raise awareness about rights related to women's sexual and reproductive health not only among women but also among health professionals, lawyers, and the judiciary. Accountability mechanisms must be adequately resourced to fulfil their functions in line with human rights obligations.

The technical guidance concludes with advice on human rights requirements that pertain to international assistance and cooperation, counselling rights-based development policies, policy coherence, and predictable, harmonious, and transparent economic assistance.

This technical guidance on a human rights-based approach to policies and programmes to reduce maternal mortality and morbidity is distinct in its holistic approach; it has implications not only for the ministry of health, but for planning commissions, ministries of finance, education, and infrastructure, as well as parliaments, national human rights institutions, health service providers, and civil society. The positive reception of the guidance by the Human Rights Council gives it added importance in terms of the commitment of states to effectively ensure human rights related to maternal mortality and morbidity. Only through concerted efforts to work in partnership will we realise our mutual goal to eliminate preventable maternal mortality and morbidity, in line with human rights obligations. This technical guidance presents an opportunity to move from rhetoric to reality in implementing policies and programmes on the ground that explicitly work towards the realisation of women's human rights. Everyone has a part to play in making this happen.

The author is the United Nations High Commissioner for Human Rights.

References

1 WHO, UNICEF, UNFPA, the World Bank. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the World Bank estimates. Geneva: World Health Organization, 2012.

2 United Nations. Report of the High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights. A/HRC/14/39. New York: United Nations, 2010.

3 United Nations. Report of the Special Rapporteur on the right to the highest attainable standard of health, Mr Paul Hunt. A/61/338. New York: United Nations, 2006.

4 Ely Yamin A. Towards transformative accountability: applying a rights-based approach to fulfill maternal health obligations. Sur Int J Human Rights 2010; 7: 95-121. PubMed

5 WHO. Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization, 2012.

6 Independent Expert Review Group. Every woman, every child: from commitments to action. Geneva: World Health Organization, 2012.

7 United Nations. Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. Report of the Office of the United Nations High Commissioner for Human Rights. A/HRC/21/22. New York: United Nations, 2012.

8 United Nations. Resolution of the United Nations Human Rights Council on preventable maternal mortality and morbidity and human rights. Oct 9, 2012. A/HRC/RES/21/6. New York: United Nations, 2012.

9 WHO. Everybody's business: strengthening health systems to improve health outcomes. Geneva: World Health Organization, 2007.

10 United Nations Human Rights Office of the High Commissioner. Human rights indicators: a guide to measurement and implementation. New York: United Nations, 2012.

11 Committee on Economic, Social and Cultural Rights. General Comment 14 on the right to the highest attainable standard of health. E/C.12/2000/4, para. 59. New York: United Nations, 2000.