maternal and neonatal health: using a human rights approach maternal and neonatal health: using a...

Maternal and Neonatal Maternal and Neonatal Health: Using a Human Health: Using a Human

Rights ApproachRights Approach

Sofia Gruskin, JD, MIA(2), Adriane Martin Hilber, MPH(1), Sofia Gruskin, JD, MIA(2), Adriane Martin Hilber, MPH(1),

Mindy Jane Roseman, JD, PhD(3), Ornella Lincetto, MD (1), Mindy Jane Roseman, JD, PhD(3), Ornella Lincetto, MD (1),

Eszter Kismodi, JD,LLM (1), Jane Cottingham, MSc (1)Eszter Kismodi, JD,LLM (1), Jane Cottingham, MSc (1)

World Health Organization, Department of Reproductive Health and Research(1); World Health Organization, Department of Reproductive Health and Research(1);

Harvard School of Public Health, Programme on International Health and Human Harvard School of Public Health, Programme on International Health and Human Rights(2), and Harvard Law School, Human Rights Program(3)Rights(2), and Harvard Law School, Human Rights Program(3)

Harvard School of Public HealthPROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

Maternal MortalityMaternal Mortality

• WHO estimates 529, 000 maternal deaths each year (WHO estimates 529, 000 maternal deaths each year ( i.ei.e., ., more than one woman dies per minute from pregnancy-more than one woman dies per minute from pregnancy-related causes)related causes)

• 99% of maternal deaths today occur in Africa, Asia and 99% of maternal deaths today occur in Africa, Asia and Latin AmericaLatin America

• Maternal mortality is the primary cause of death and Maternal mortality is the primary cause of death and disability in women of child-bearing age in developing disability in women of child-bearing age in developing countriescountries

• Lifetime risk: Only 1 in 4,000 women in Western Europe Lifetime risk: Only 1 in 4,000 women in Western Europe v. 1 in 139 women in Latin America / the Caribbean v 1 in v. 1 in 139 women in Latin America / the Caribbean v 1 in 16 in Africa16 in Africa


Neonatal and perinatal mortalityNeonatal and perinatal mortality

• WHO estimates that over 9 million deaths occur WHO estimates that over 9 million deaths occur each year in the perinatal and neonatal periodseach year in the perinatal and neonatal periods

• 98% of these deaths take place in the developing 98% of these deaths take place in the developing worldworld

• Most of these deaths are caused by infectious Most of these deaths are caused by infectious diseases; pregnancy-related complications; or diseases; pregnancy-related complications; or delivery-related complicationsdelivery-related complications

• Neonatal deaths now account for 40 -70% of all Neonatal deaths now account for 40 -70% of all infant mortalityinfant mortality


Maternal and Neonatal Mortality Maternal and Neonatal Mortality under International Human under International Human

Rights LawRights Law


• What are Human Rights?What are Human Rights?

–Formal legal systemFormal legal system

–AdvocacyAdvocacy

–Approach to programmingApproach to programming

DefinitionDefinition


ObligationsObligations

• How are human rights enforced and/or How are human rights enforced and/or realized?realized?

– Through national law and policyThrough national law and policy

– Monitoring mechanismsMonitoring mechanisms

– International technical and financial International technical and financial assistanceassistance

– Civil society movements/activitiesCivil society movements/activities


Applying human rights in the Applying human rights in the context of MNH: timelinecontext of MNH: timeline

• 1960s-70s: MCH programming1960s-70s: MCH programming• 1985: Where is the M in MCH?1985: Where is the M in MCH?• 1987: Safe Motherhood Initiative1987: Safe Motherhood Initiative• 1990s: ICPD/FWCW1990s: ICPD/FWCW• 1997: Safe Motherhood as a Human right1997: Safe Motherhood as a Human right• 1999 to today: 1999 to today:

– Formal/Normative system approaches: concluding Formal/Normative system approaches: concluding comments, etc. comments, etc.

– Advocacy—CRR/ PHR reportsAdvocacy—CRR/ PHR reports– Programs—AMDD Programs—AMDD – Assessment/accountability —WHO/PIHRR Assessment/accountability —WHO/PIHRR


Objectives of the assessment project Objectives of the assessment project (Tool)(Tool)

Assist countries to:Assist countries to:

• Review and address legal and policy barriers Review and address legal and policy barriers to maternal and newborn health, as relevant to to maternal and newborn health, as relevant to health systems data.health systems data.

• Engage health sector and non-health sector Engage health sector and non-health sector actors to eliminate barriers to maternal and actors to eliminate barriers to maternal and newborn healthnewborn health

• Review and document government efforts to Review and document government efforts to respect, protect and fulfil human rights related respect, protect and fulfil human rights related to maternal and newborn health to maternal and newborn health


The ToolThe Tool

The Tool Consist of both a process and an instrument.

•The Tool is designed to help Government's conduct a self-evaluation of their efforts to improve MNH and respect, protect and fulfil human rights of mothers and newborns.

•It is designed to be Government led and, if necessary, externally facilitated (e.g. support provided by the UN or other NGO or institution)


The InstrumentThe Instrument

• Developed out of a framework provided Developed out of a framework provided by Rebecca Cook and WHO -- by Rebecca Cook and WHO -- "Advancing Safe Motherhood through "Advancing Safe Motherhood through Human Rights"Human Rights"

• Revised by WHO and HSPH/PIHHRRevised by WHO and HSPH/PIHHR

• Validated in SwitzerlandValidated in Switzerland

• Field-tested in Mozambique, Brazil and Field-tested in Mozambique, Brazil and IndonesiaIndonesia

• Expected publication in early 2007Expected publication in early 2007


International Human Rights TreatiesInternational Development Goals and Targets

Government EffortNational Laws, Policies & Health Systems

Health Indicators

Multi Sectoral Action Planning

Rights Relating to Information & Education

Rights Relating to Non-discrimination

Rights Relating to Health and Maternity

Rights Relating to Life, Survival & Security

HIV prevalence rate in pregnant women

Maternal mortality ratio Female, primary/secondary

school enrolment as a percentage of male

enrolment

Incidence of FGM and/or other harmful traditional

practices

Number of births attended by skilled

attendants

Law/policy to reduce maternal mortality

Law/policy on compulsory, free

primary education

Law/policy on elimination of practices harmful to maternal or

neonatal health

Has country ratified the following treaties? If yes, any reservations?

1a. International Covenant on Civil andPolitical Rights (ICCPR)

Yes No Please note relevant reservations

1b. International Covenant on Economic,Social and Cultural Rights (ICESCR)

? ?

Has the government ever reported to any of the appropriate treaty bodies on any of the following issues?

2a. Maternal and neonatal survival

Yes No ? ?

Summarise key points raised

2d. Abortion ? ?

2g. Early marriage ? ?

Has the Treaty Body (or Bodies) issued any concluding comments, observations orrecommendations addressing the following issues?

3a. Maternal and neonatal survival

Yes No ? ?

Summarise key points raised

3d. Abortion ? ?

3g. Early marriage ? ?

? ?


Reducing maternal mortality

Is there: Yes NoIf yes, key provisions

(Specify any restrictions)

8a. Law ? ?8b. Policy ? ?8c. Strategy ? ?8d. Plan ? ?

8e. Status of implementation

Referral system for maternal and neonatal emergencies

Is there a: Yes No

If yes, key provisions (Specify any restrictions)

10a Law □ □

10b Policy □ □

10c Strategy □ □

10d Plan □ □

10e. Status of implementation

Rights Relating to Life, Survival, Security and Identify

Law, policy and health system indicators


Health indicators

IndicatorsCurrentdata

%change Source Comments

1. Life Expectancy

2. Maternal mortality ratio

3. Infant mortality rate (up to 1 year)

4. Perinatal mortality rate

5. Neonatal mortality rate

6. Proportion of women estimated tohave complications who are treated inComprehensive EOC facilities

7. Ceasarian sections as percentage ofall births

8. Case fatality rate women

9. Case fatality rate newborns

Rights Relating to Life, Survival, Rights Relating to Life, Survival,

Security and IdentifySecurity and Identify


Phase 3 - Prioritizing for action

Phase 3 - Prioritizing for action

Phase 2 - Adaptation,

data compilation and analysis

Phase 2 - Adaptation,

data compilation and analysis

Phase 1 - Establishing

commitment &leadership

Phase 1 - Establishing

commitment &leadership

The Tool : the processThe Tool : the process


Results from Field Tests:Results from Field Tests:Key health issuesKey health issues

• IndonesiaIndonesia - Early pregnancy, early marriage and - Early pregnancy, early marriage and adolescents’ access to sexual and reproductive adolescents’ access to sexual and reproductive health information, education and serviceshealth information, education and services

• Mozambique Mozambique – Access to services; HIV/AIDS; Birth – Access to services; HIV/AIDS; Birth registration; information system; abortionregistration; information system; abortion

• Brazil Brazil – Referral system; adolescent utilization of – Referral system; adolescent utilization of services; marginalized populations access to services; marginalized populations access to services; quality of careservices; quality of care


Results from Field Tests:Results from Field Tests:Government EffortsGovernment Efforts

• IndonesiaIndonesia - Government launched an adolescents - Government launched an adolescents reproductive heath (ARH) programme. information, education, reproductive heath (ARH) programme. information, education, counselling) and included ARH in the national RH policy and counselling) and included ARH in the national RH policy and strategy which covers communication and counselling and strategy which covers communication and counselling and provision of servicesprovision of services

• MozambiqueMozambique – Government has scaled up Em OC; updated – Government has scaled up Em OC; updated referral hospital equipment, put in radio equipment etc and as referral hospital equipment, put in radio equipment etc and as a result reduced the MMR by two thirds over the past ten a result reduced the MMR by two thirds over the past ten years.years.

• Brazil Brazil – Government launched a Policy package to reduce – Government launched a Policy package to reduce MMR. It implements this policy through training, establishment MMR. It implements this policy through training, establishment of MMR committees in each of the over 1700 municipalities of MMR committees in each of the over 1700 municipalities across 27 States, through monitoring and supervision.across 27 States, through monitoring and supervision.


Results from Field Tests:Results from Field Tests:Identified Barriers and GapsIdentified Barriers and Gaps

Indonesia - Indonesia - Unequal provision on age of marriage, inadequate Unequal provision on age of marriage, inadequate protection of girls/women from early marriage in the Law on protection of girls/women from early marriage in the Law on Marriage; Inadequate legal protection for unmarried Marriage; Inadequate legal protection for unmarried adolescents in relation to reproductive health services in the adolescents in relation to reproductive health services in the Population LawPopulation Law

Mozambique Mozambique – despite regulatory efforts, abortion remains illegal – despite regulatory efforts, abortion remains illegal for most of the population; under the table fees inhibit access to for most of the population; under the table fees inhibit access to care; lack of accountability measures in place to enforce care; lack of accountability measures in place to enforce attendance of basic service provisionattendance of basic service provision

BrazilBrazil - Despite universal coverage, many marginalized - Despite universal coverage, many marginalized population receive inadequate care due to distribution and population receive inadequate care due to distribution and monitoring mechanism failures; political challenges by monitoring mechanism failures; political challenges by professional association limit mid level providers authority to professional association limit mid level providers authority to perform some life saving interventions and emphasis perform some life saving interventions and emphasis medicalisation of caremedicalisation of care


Results from Field Test:Results from Field Test:Ex: Recommendations from Indonesia Ex: Recommendations from Indonesia

LAW and REGULATIONSLAW and REGULATIONS• The existing marriage law should be The existing marriage law should be

revised in order to eliminate early revised in order to eliminate early marriage and early pregnancy by marriage and early pregnancy by increasing the minimum legal age of increasing the minimum legal age of marriage.marriage.

• Both the Law on Population and the Both the Law on Population and the Law on Health should be Law on Health should be amended/revised to make amended/revised to make comprehensive reproductive health comprehensive reproductive health services including contraceptive services including contraceptive services available, accessible, and services available, accessible, and affordable for unmarried and affordable for unmarried and adolescents as well.adolescents as well.

Those potentially responsible: Those potentially responsible: • Ministry of JusticeMinistry of Justice• Ministry of Women Empowerment, Ministry of Women Empowerment, • Ministry of Education andMinistry of Education and• Ministry of Religious AffairsMinistry of Religious Affairs• ParliamentariansParliamentarians


• POLICIES/STRATEGIES and HEALTH POLICIES/STRATEGIES and HEALTH SYSTEMSSYSTEMS

• Policies and strategies should be Policies and strategies should be developed to empower adolescents and developed to empower adolescents and young people with sexual and young people with sexual and reproductive health and rights reproductive health and rights knowledge, understanding and skills. knowledge, understanding and skills.

• Policies regarding the promotion of Policies regarding the promotion of minimum age of marriage for women and minimum age of marriage for women and men should be harmonized. men should be harmonized.

Those potentially responsible: Those potentially responsible:

• Ministry of Women Empowerment, Ministry of Women Empowerment,

• Ministry of Education, Ministry of Education,

• Ministry of Religious Affairs Ministry of Religious Affairs

Lessons learned on Human Rights Impact Lessons learned on Human Rights Impact AssessmentsAssessments

• Target audience matters – government led processes Target audience matters – government led processes take longer; can‘t be controled; but if done well and take longer; can‘t be controled; but if done well and owned, can lead to significant advancesowned, can lead to significant advances

• Linking HRs and Health can be both technically and Linking HRs and Health can be both technically and intellectually difficultintellectually difficult

• Involving other sectors necessary but meaningful Involving other sectors necessary but meaningful participation is a challengeparticipation is a challenge

• Data is often unavailable or of low quality – but -validity Data is often unavailable or of low quality – but -validity of the data provides legitmacyof the data provides legitmacy

• Indicators and Frame alone do not make it a RBA; need Indicators and Frame alone do not make it a RBA; need an analysis framework that uses a rights lens to evaluate an analysis framework that uses a rights lens to evaluate the findings the findings

• Implications of results – advocacy, programming for Implications of results – advocacy, programming for change, involvement of other sectors – who follows change, involvement of other sectors – who follows implementation outside of the health sectorimplementation outside of the health sector


““Knowing the need for intersectoral action, political Knowing the need for intersectoral action, political commitment and implemenattion with a broader, more commitment and implemenattion with a broader, more

humane perspective of the questions and the answers is humane perspective of the questions and the answers is the biggest challenge facing women’s health”the biggest challenge facing women’s health”

- Health worker, Rio Grande do Norte, Brazil- Health worker, Rio Grande do Norte, Brazil

maternal and neonatal health: using a human rights approach maternal and neonatal health: using a...

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