Maternal Mortality Conference

SIHRG members Olivia Streater and Simon John were sponsored by SIHRG to attend an important conference on this subject in Geneva in September 2010.

Here is a summary report and their full report is attached below.

If you wish to join the new Working Group being established to pursue the issue CLICK HERE to read the remit and follow the link to sign up.

INTERNATIONAL ROUNDTABLE: MATERNAL MORTALITY, HUMAN RIGHTS & ACCOUNTABILITY

BACKGROUND AND SUMMARY

Maternal mortality is the leading cause of death among women and girls of reproductive age. More than 1,500 women and girls die every day as a result of preventable complications occurring in pregnancy, labour or shortly after childbirth.

The reasons women die are well-known and have been for several decades. Globally, the most common causes of death are haemorrhage, infection, unsafe abortion, eclampsia/pre-eclampsia, prolonged or obstructed labour and ectopic pregnancy.

Equally well and long known are the solutions. These deaths are preventable: through prenatal, birthing and basic health care and access to emergency obstetric care.

World leaders are about to gather in New York to discuss global progress in meeting the Millenium Development Goals. Millenium Development Goal Number 5 aims to reduce the maternal mortality ratio (or “MMR”) by three quarters between 1990 and 2015.

The high (75%) reduction target was predicated upon the degree of preventability. And yet the world is not anything like on track to meet MDG 5. The ratio of maternal mortality (or “MMR”) is not decreasing. It is the goal from which we are currently the farthest in terms of achievement.

Maternal mortality has recently become a “hot potato” campaigning issue for human rights groups, litigators and the international community. Underlying this energy is the fact that, as Mary Robinson emphasised in her conference address, straightforward practical solutions to MM exist. What is lacking is implementation and the strong political and social leadership required to achieve it.

Secondly, the right to health in particular, and social, economic and cultural rights in general, are receiving more focus than in the past. The former UN Special Rapporteur on Health (and conference convener), Paul Hunt, stated that the right to health can be understood as the “the right to an effective and integrated health system encompassing health care and the underlying determinants of health, which is responsive to national and local priorities, and accessible to all. Underpinned by the right to health, an effective health system is a core social institution, no less than a court system or a political system.” The scope of this right is thus not confined to healthcare but includes other variables such as sanitation, housing and nutrition and both health care and other essential conditions for health must be afforded without discrimination.

Thirdly, both human rights advocates and the UN are increasingly framing MM as an issue of basic human rights and developing a common understanding of what it means to apply a “human rights based approach” to health. Even the UN Secretary General has stated that human rights must be central to development and “mainstreamed” into development programmes. The UN High Commissioner on Human Rights recently published a report

very clearly delineating the human rights dimensions of preventable maternal mortality and current initiatives within the UN human rights system to address it. http://www2.ohchr.org/english/bodies/hrcouncil/docs/14session/A.HRC.14.39_AEV-2.pdf

The following is a brief extract from that report:

“International human rights law specifies that all human beings must be able to enjoy and exercise their human rights on a basis of equality between women and men, and free from discrimination on the basis of sex, race, colour, language, religion, political or other opinion, national or social origin, property, birth or other status. Among other things, these fundamental legal requirements oblige States to refrain from discriminatory actions, to take positive proactive steps to guarantee equality (not just in law, but in policy and practice), to ensure that seemingly neutral measures and approaches do not have a discriminatory effect in real terms, and in certain contexts to actively recognize and take account of difference.”

The report goes on to describe in great detail (at paras 22-31) the applicable rights to life, health, education and information under international human rights law.

Paragraph 32 is particularly worth noting:

“C. Human rights-based approach to maternal mortality and morbidity

The practical implications of the human rights values of dignity and non-discrimination result in a set of working principles that form the basis of a human rights approach. The treaty bodies and United Nations experts have clarified the importance of seven such principles: accountability, participation, transparency, empowerment, sustainability, international cooperation and non-discrimination. These principles have particular application when examining a human rights-based approach to addressing maternal mortality and morbidity as discussed in this section.”

Behind the staggering death toll lies a litany of discrimination and the failure to promote and protect effectively the human rights of women and girls. For MM to be successfully reduced, women's human rights must be prioritised. Lack of reproductive rights, sexual violence, inability to own property and lack of access for reasons of distance, cost and lack of cultural sensitivity have all been linked to slow progress on achieving MG5. The WHO states that maternal deaths are “not mere misfortunes and unavoidable natural disadvantages of pregnancy but rather injustices that societies are able and obligated to remedy” and has stated that the failure to do so “represents one of the greatest social injustices of our time.”

Finally, maternal and child rights are closely inter-related. At the most basic level, every mother’s death leaves a child or children at increased risk of death, illness or discrimination. (As the psychiatrist Winnicott once remarked, there is no such thing as a baby, only a mother and a baby). Action on MM should reflect this while emphasising that MM matters not simply because of women’s identities as mothers. Women’s rights are of value in themselves.

Against this background, this roundtable brought together an interdisciplinary group to move beyond a general examination of maternal mortality and human rights and explore the concept of accountability – understood as lying at the heart of the human rights approach - as it applies to the issue of MM. It sought to provide illustrative examples of three inter-related aspects of accountability: monitoring, oversight and redress.

Examples of monitoring in relation to MM included citizenship surveillance, the role of indicators, especially Emergency Obstetric Care (EmOC) Indicators, and budget analysis. Peru has seen efforts to make very practical the premise that those who wield power of others should be answerable to them for their actions, in the form of rural health facility monitoring by local women. Dr Francisco Arroyo from CARE Peru explained that findings were discussed with local and regional officials to improve responsiveness. This was a powerful form of advocacy particularly since those involved typically came from marginalised and historically “voiceless” communities. Helena Hofbauer from the International Budget Project stressed that both UN agencies (such as UNIFEM) and civil society organisations (such as Sonora Ciudadana in Mexico) have increasingly used budgets to analyse state accountability with key human rights instruments.

The issue of MM may not be one which immediately strikes lawyers as one for which their skills may come in handy. However it was seen that law is vital to prevent MM, albeit as part of a broader advocacy strategy of social mobilization. “Constructive accountability” – the opposite of naming, shaming and punishing individuals – was explained as one of the most important but contested notions in combating MM. Delegates heard how oversight mechanisms, particularly from the Global South, have assessed whether human rights law has been respected with regard to MM and attempted to address systemic failings. These included parliamentary committees in Bangladesh, courts in India and South Africa, national human rights organisations in Kenya, civil society organisations in Brazil and UN treaty bodies.

Ximena Andion from the Center for Reproductive Rights emphasised that courts are part of the solution to address MM with potential to affect far-reaching social change and to develop creative remedies. At the national level cases include Sandesh Bansal v Union of India (W.P. No. 9061/08), in which interim orders for a blood bank and electricity were made. At the international level a decision is pending on the Alyne da Silva Pimentel v. Brazil, the first MM case to be brought before the UNCEDAW Committee.

At the quasi-legal level Commissioner Winfred Lichuma detailed the Kenyan National Human Rights Institution’s plans to initiate a national public inquiry on MM in the next few months. Drawing from the experiences of other commissions (namely the TRC in South Africa), it would seek not only to identify root causes of inadequate health care and underlying causes of MM but to provide a healing forum for grieving relatives to be “heard” – a form of therapeutic justice rather than fault-finding with emotion at its heart. It remains to be seen how the inquiry will manage to balance this exciting ideal with its intention to identify “victims” (those affected by MM) and “perpetrators”.

Sandeep Prasad from Action Canada for Population and Development argued that existing UN mechanisms need to provide far more detailed guidance on what a human rights based approach to eliminating MM requires and suggested the creation of a new UN special procedure to offer state-specific and general advice.

Rachel Ward (AI USA) finished the day with a presentation of a new Amnesty International report (Deadly Delivery: The Maternal Health Care Crisis in the USA), which urged action to tackle a crisis which sees up to 3 women die a day during pregnancy and childbirth amid widespread obstacles to care, including lack of insurance and autonomy in decision-making on care. It might have been reasonable to assume that the richest country on earth that spends more than any other country on health care (86 billion annually) could tackle its upward trend in MM. Yet in the USA, one in three African American and Native American women receive inadequate prenatal care, 13 million women of reproductive age (half of whom come from minorities) lack health insurance and 64 million live in shortage areas for maternal care.

Rachel Ward (AI USA)’s presentation may be seen as a metaphor for several of the most important aspects of the world wide problem of MM:

· its distribution largely in groups of marginalised people within affluent societies,

· its known preventable causes

· its presence despite adequate funds,

· the lack of accountability, political will and leadership.

Overall, the key message emerging for the SIHRG from the roundtable is that lawyers can be part of the solution to MM in thoughtful collaboration with health workers and other professionals. There is a real opportunity here for lawyers to make a difference. There are many potential ideas for action. With the forthcoming high level summit of the UN General Assembly to assess progress to achieving the Millenium Development Goals, and an upcoming meeting of the UN Human Rights Council to decide its next steps on MM, the time is ripe.

SIHRG members

Simon John

And

Olivia Streater