Maternal and Neonatal Health: Using a Human Rights Approach

1. Maternal and Neonatal Health: Using a Human Rights Approach Sofia Gruskin, JD, MIA(2), Adriane Martin Hilber, MPH(1), Mindy Jane Roseman, JD, PhD(3), Ornella Lincetto, MD (1), Eszter Kismodi, JD,LLM (1), Jane Cottingham, MSc (1) World Health Organization, Department of Reproductive Health and Research(1); Harvard School of Public Health, Programme on International Health and Human Rights(2), and Harvard Law School, Human Rights Program(3) Many of these papers for on individual screening instruments to assess risk factors across populations and target health interventions and strategies. Our project focuses on the structural and system level, rather than a population, and its objective is to assess government efforts in the area of MNH health to improve maternal and newborn outcomes. It also focuses on vulnerable populations for whom governments have to ensure have equal and nondiscriminatory access to necessary, appropriate and quality health services, and who oar often homogenized to the general population when national assessments are done. . The target recommendations often depend on the identified group�these recommendations address, law, policy, as well as healht systems.Many of these papers for on individual screening instruments to assess risk factors across populations and target health interventions and strategies. Our project focuses on the structural and system level, rather than a population, and its objective is to assess government efforts in the area of MNH health to improve maternal and newborn outcomes. It also focuses on vulnerable populations for whom governments have to ensure have equal and nondiscriminatory access to necessary, appropriate and quality health services, and who oar often homogenized to the general population when national assessments are done. . The target recommendations often depend on the identified group�these recommendations address, law, policy, as well as healht systems.

2. Maternal Mortality WHO estimates 529, 000 maternal deaths each year (i.e., more than one woman dies per minute from pregnancy-related causes) 99% of maternal deaths today occur in Africa, Asia and Latin America Maternal mortality is the primary cause of death and disability in women of child-bearing age in developing countries Lifetime risk: Only 1 in 4,000 women in Western Europe v. 1 in 139 women in Latin America / the Caribbean v 1 in 16 in Africa Just some of the macro-epidemiology regarding maternal mortality world wide. Taken from �The world health report 2005 - make every mother and child count� http://www.who.int/whr/2005/en/ Mm: According to the Tenth International Classification of Diseases, a maternal death is defined as �the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes Just some of the macro-epidemiology regarding maternal mortality world wide. Taken from �The world health report 2005 - make every mother and child count� http://www.who.int/whr/2005/en/ Mm: According to the Tenth International Classification of Diseases, a maternal death is defined as �the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes

3. Neonatal and perinatal mortality WHO estimates that over 9 million deaths occur each year in the perinatal and neonatal periods 98% of these deaths take place in the developing world Most of these deaths are caused by infectious diseases; pregnancy-related complications; or delivery-related complications Neonatal deaths now account for 40 -70% of all infant mortality Some global statistics regarding neonatal/perinatal morality Taken from �The world health report 2005 - make every mother and child count� http://www.who.int/whr/2005/en/ Neonatal--the death rate during the first 28 days of life Perinatal--Pertaining to or occurring in the period shortly before or after birth Some global statistics regarding neonatal/perinatal morality Taken from �The world health report 2005 - make every mother and child count� http://www.who.int/whr/2005/en/ Neonatal--the death rate during the first 28 days of life Perinatal--Pertaining to or occurring in the period shortly before or after birth

4. Maternal and Neonatal Mortality under International Human Rights Law Why look to human rights? First: Epi slides�When you look at the bald, aggregate numbers, and the disproportionate burden of mortality (and maternal morbidity is estimated to be 15x larger than mm) falls on those populations who are isolated from health services either because of geography (ie. Rural , slums), have no access due to discrimination (poverty, race/ethnicity, gender) etc. Women and newborns who do not have access to necessary health services suffer human rights violations, the consequences of which are ill health and death. Secondly: because this is a WHO driven project, its point of departure is the generation of universally applicable normative standards that direct treatment and care. That is one of the attractions of international human rights. Human rights are global norms for universal application. Finally, human rights is well suited as an approach to programming that can address health disparities, as well as an organizing framework for assessing programmatic response.Why look to human rights? First: Epi slides�When you look at the bald, aggregate numbers, and the disproportionate burden of mortality (and maternal morbidity is estimated to be 15x larger than mm) falls on those populations who are isolated from health services either because of geography (ie. Rural , slums), have no access due to discrimination (poverty, race/ethnicity, gender) etc. Women and newborns who do not have access to necessary health services suffer human rights violations, the consequences of which are ill health and death. Secondly: because this is a WHO driven project, its point of departure is the generation of universally applicable normative standards that direct treatment and care. That is one of the attractions of international human rights. Human rights are global norms for universal application. Finally, human rights is well suited as an approach to programming that can address health disparities, as well as an organizing framework for assessing programmatic response.

5. What are Human Rights? Formal legal system Advocacy Approach to programming Definition "Human Rights are universal legal guarantees protecting individuals and groups against actions which interfere with fundamental freedoms and human dignity. Some of the most important characteristics of human rights are that they are: guaranteed by international standards; legally protected; focus on the dignity of the human being; oblige states and state actors; cannot be waived or taken away; interdependent and interrelated; and universal." Just how are human rights used�generally in 3 ways. First: as a formal system of international law, that states enter into and agree to be bound. There are treaties/contracts, that set out specific obligations and enforcement mechanisms, establish monitoring bodies, and give rise to all sorts of normative interpretations around human rights. There are also �mechanisms� that exist as a result of the UN Charter, and recently are the topic of discussion surrounding UN reform. Human rights, however, are probably much better known to you as a kind of advocacy�groups like Amnesty International and Human Rights Watch and others, take up issues, find facts, produce reports. �Naming and shaming.� Very important and effective but not without its critics.�on issues of torture, for example, or more recently around access to treatment for HIV (TAC; Health Gap coalition.) Finally, and in some ways, the most challenging ways human rights are being used (in health, development, educational and in some other areas) is as a framework for programming and policy. You might have heard or read about �human rights based approaches.� There is much that is still undefined in how to go about this, and I could spend hours on this�Oxfam, Save the Children, various UN agencies, are adopting rights based approaches. "Human Rights are universal legal guarantees protecting individuals and groups against actions which interfere with fundamental freedoms and human dignity. Some of the most important characteristics of human rights are that they are: guaranteed by international standards; legally protected; focus on the dignity of the human being; oblige states and state actors; cannot be waived or taken away; interdependent and interrelated; and universal." Just how are human rights used�generally in 3 ways. First: as a formal system of international law, that states enter into and agree to be bound. There are treaties/contracts, that set out specific obligations and enforcement mechanisms, establish monitoring bodies, and give rise to all sorts of normative interpretations around human rights. There are also �mechanisms� that exist as a result of the UN Charter, and recently are the topic of discussion surrounding UN reform. Human rights, however, are probably much better known to you as a kind of advocacy�groups like Amnesty International and Human Rights Watch and others, take up issues, find facts, produce reports. �Naming and shaming.� Very important and effective but not without its critics.�on issues of torture, for example, or more recently around access to treatment for HIV (TAC; Health Gap coalition.) Finally, and in some ways, the most challenging ways human rights are being used (in health, development, educational and in some other areas) is as a framework for programming and policy. You might have heard or read about �human rights based approaches.� There is much that is still undefined in how to go about this, and I could spend hours on this�Oxfam, Save the Children, various UN agencies, are adopting rights based approaches.

6. Obligations How are human rights enforced and/or realized? Through national law and policy Monitoring mechanisms International technical and financial assistance Civil society movements/activities Human rights are realized through national governmental effort. One of the ways in which governments act to uphold their human rights obligations is by taking active steps to put in place institutions and procedures that will enable people to enjoy the rights, such as those that relate to maternal and neonatal health. Adoption of legislative, administrative, budgetary and other measures are indicators of �government effort� to realize rights. Governments that ratify international human rights treaties agree to ensure that their national laws, policies, and practices do not conflict with their obligations under international law. Therefore, national level laws and policies must be consistent with the international human rights laws and policies. Human rights are realized through national governmental effort. One of the ways in which governments act to uphold their human rights obligations is by taking active steps to put in place institutions and procedures that will enable people to enjoy the rights, such as those that relate to maternal and neonatal health. Adoption of legislative, administrative, budgetary and other measures are indicators of �government effort� to realize rights. Governments that ratify international human rights treaties agree to ensure that their national laws, policies, and practices do not conflict with their obligations under international law. Therefore, national level laws and policies must be consistent with the international human rights laws and policies.

7. Applying human rights in the context of MNH: timeline 1960s-70s: MCH programming 1985: Where is the M in MCH? 1987: Safe Motherhood Initiative 1990s: ICPD/FWCW 1997: Safe Motherhood as a Human right 1999 to today: Formal/Normative system approaches: concluding comments, etc. Advocacy�CRR/ PHR reports Programs�AMDD Assessment/accountability �WHO/PIHRR Walk through the slide: the idea that human rights had something to do with health, and women�s health didn�t come out of nowhere. This project is the culmination of many years of thinking and action around women�s and reproductive rights and health. I put up some of major conceptual and policy milestones: 1960s/70s MCH: reduction of child mortality Deborah Maine: Where is the M in MCH: need to focus on women (1985) Safe Motherhood Initiative (1987) By 1994: Cairo articulates reduction of maternal mortality in terms of rights as well as targets. 1997: Safe Motherhood as a Human right C. Rights and Rights Based Approaches: description and analysis Literature review since 1994 Advocacy�CRR/ PHR reports Programs�AMDD Assessment/accountability �MPS Accountability�formal system approaches: concluding comments, etc. However by 1995 and thereafter it is commonplace that maternal mortality rates give rise to some comment. For example, the Human Rights Committee (HRC), which monitors the International Covenant on Civil and Political Rights provided a detailed observation with regard to Mali: ��While noting the considerable efforts made by the State party, the Committee remains concerned at the high maternal and infant mortality rate in Mali, due in particular to the relative inaccessibility of health and family planning services, the poor quality of health care provided, the low educational level and the practice of clandestine abortions (article 6 of the Covenant).� Our work is based on the premise that achieving substantial and sustained reductions in maternal and neonatal mortality is critically dependent on the availability, accessibility and quality of MNH health care services. Therefore, efforts must be focused on the health system (as well as appropriate other systems) at all levels, including primary and first level referrals, and ensuring the linkages between them. Critical to strengthening these systems is the existence of a supportive legal and policy environment that promotes access on the basis of nondiscrimination, among other human rights principals.Walk through the slide: the idea that human rights had something to do with health, and women�s health didn�t come out of nowhere. This project is the culmination of many years of thinking and action around women�s and reproductive rights and health. I put up some of major conceptual and policy milestones: 1960s/70s MCH: reduction of child mortality Deborah Maine: Where is the M in MCH: need to focus on women (1985) Safe Motherhood Initiative (1987) By 1994: Cairo articulates reduction of maternal mortality in terms of rights as well as targets. 1997: Safe Motherhood as a Human right C. Rights and Rights Based Approaches: description and analysis Literature review since 1994 Advocacy�CRR/ PHR reports Programs�AMDD Assessment/accountability �MPS Accountability�formal system approaches: concluding comments, etc. However by 1995 and thereafter it is commonplace that maternal mortality rates give rise to some comment. For example, the Human Rights Committee (HRC), which monitors the International Covenant on Civil and Political Rights provided a detailed observation with regard to Mali: ��While noting the considerable efforts made by the State party, the Committee remains concerned at the high maternal and infant mortality rate in Mali, due in particular to the relative inaccessibility of health and family planning services, the poor quality of health care provided, the low educational level and the practice of clandestine abortions (article 6 of the Covenant).� Our work is based on the premise that achieving substantial and sustained reductions in maternal and neonatal mortality is critically dependent on the availability, accessibility and quality of MNH health care services. Therefore, efforts must be focused on the health system (as well as appropriate other systems) at all levels, including primary and first level referrals, and ensuring the linkages between them. Critical to strengthening these systems is the existence of a supportive legal and policy environment that promotes access on the basis of nondiscrimination, among other human rights principals.

8. Objectives of the assessment project (Tool) Assist countries to: Review and address legal and policy barriers to maternal and newborn health, as relevant to health systems data. Engage health sector and non-health sector actors to eliminate barriers to maternal and newborn health Review and document government efforts to respect, protect and fulfil human rights related to maternal and newborn health So, Human rights based approach helps us look beyond the health system, although obviously the health system is central. Delay in decision to seek care Delay in arriving at care Delay in receiving appropriate care once at facility Raise the spectre of different rights Explain HR as governmental obligations�all parts of the govt. are subject to them. While the obligations are concluded internationally, and monitoring machinery etc exists internationally, it is understood that the POINT of these obligations is that they be fulfilled nationally�through national level laws, policies, programs, budget allocations and so on. Insofar as health is concerned (the right to health�progressive realization), but we know that mm has more contributing causes than just the health sector. So, Human rights based approach helps us look beyond the health system, although obviously the health system is central. Delay in decision to seek care Delay in arriving at care Delay in receiving appropriate care once at facility Raise the spectre of different rights Explain HR as governmental obligations�all parts of the govt. are subject to them. While the obligations are concluded internationally, and monitoring machinery etc exists internationally, it is understood that the POINT of these obligations is that they be fulfilled nationally�through national level laws, policies, programs, budget allocations and so on. Insofar as health is concerned (the right to health�progressive realization), but we know that mm has more contributing causes than just the health sector.

9. The 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) Because of time, this presentation will focus mostly on the instrument rather than the processBecause of time, this presentation will focus mostly on the instrument rather than the process

10. The Instrument Developed out of a framework provided by Rebecca Cook and WHO -- "Advancing Safe Motherhood through Human Rights" Revised by WHO and HSPH/PIHHR Validated in Switzerland Field-tested in Mozambique, Brazil and Indonesia Expected publication in early 2007 I would mention the three field tests at the same time, since they are exactly at the same stage, except Indonesia has a final report, preparing for dissemination, etc. So, the MOz is not finished yet either completely.I would mention the three field tests at the same time, since they are exactly at the same stage, except Indonesia has a final report, preparing for dissemination, etc. So, the MOz is not finished yet either completely.

11. This is the organization and design of the instrument. Under each right: Government effort: laws, policies, regulations, health systems Health data This is the organization and design of the instrument. Under each right: Government effort: laws, policies, regulations, health systems Health data

15. The Tool : the process

16. Results from Field Tests:Key health issues Indonesia - Early pregnancy, early marriage and adolescents� access to sexual and reproductive health information, education and services Mozambique � Access to services; HIV/AIDS; Birth registration; information system; abortion Brazil � Referral system; adolescent utilization of services; marginalized populations access to services; quality of care the median age of marriage has increased from 17 to 19 years (since 1991) marriage of girls 15 years and younger is still practiced in Indonesia, especially in the rural areas, and early childbearing varies considerably from province to province. the percentage of women age 15-19 years old who began childbearing in 2002-03 was still 10.4 percent. unmarried adolescents are unable to access the services they need with regard to their reproductive health. Knowledge of adolescents about reproductive health and sexuality is still low.the median age of marriage has increased from 17 to 19 years (since 1991) marriage of girls 15 years and younger is still practiced in Indonesia, especially in the rural areas, and early childbearing varies considerably from province to province. the percentage of women age 15-19 years old who began childbearing in 2002-03 was still 10.4 percent. unmarried adolescents are unable to access the services they need with regard to their reproductive health. Knowledge of adolescents about reproductive health and sexuality is still low.

17. Results from Field Tests:Government Efforts Indonesia - Government launched an adolescents reproductive heath (ARH) programme. information, education, counselling) and included ARH in the national RH policy and strategy which covers communication and counselling and provision of services Mozambique � Government has scaled up Em OC; updated referral hospital equipment, put in radio equipment etc and as a result reduced the MMR by two thirds over the past ten years. Brazil � Government launched a Policy package to reduce MMR. It implements this policy through training, establishment of MMR committees in each of the over 1700 municipalities across 27 States, through monitoring and supervision. Governments, including the Indonesian Government, through international treaties and consensus documents agreed to protect and promote the rights of adolescents to reproductive health education, information and care. In its latest concluding observations the CRC Committee recommended to: develop comprehensive policies and plans on adolescent health, ensure access to reproductive health counseling and information and services for all adolescents; ensure that no discrimination based on sex remains, and that the age of marriage for girls is the same age as that for boys (16 -19), take all other necessary measures to prevent early marriage. Governments, including the Indonesian Government, through international treaties and consensus documents agreed to protect and promote the rights of adolescents to reproductive health education, information and care. In its latest concluding observations the CRC Committee recommended to: develop comprehensive policies and plans on adolescent health, ensure access to reproductive health counseling and information and services for all adolescents; ensure that no discrimination based on sex remains, and that the age of marriage for girls is the same age as that for boys (16 -19), take all other necessary measures to prevent early marriage.

18. Results from Field Tests:Identified Barriers and Gaps Indonesia - Unequal provision on age of marriage, inadequate protection of girls/women from early marriage in the Law on Marriage; Inadequate legal protection for unmarried adolescents in relation to reproductive health services in the Population Law Mozambique � despite regulatory efforts, abortion remains illegal for most of the population; under the table fees inhibit access to care; lack of accountability measures in place to enforce attendance of basic service provision Brazil - Despite universal coverage, many marginalized population receive inadequate care due to distribution and monitoring mechanism failures; political challenges by professional association limit mid level providers authority to perform some life saving interventions and emphasis medicalisation of care The Commission on Reproductive Health which was established in Indonesia in 1996 is not functioning well. The establishment of adolescent friendly services in Indonesia is still in a pilot phase and does not constitute a programme disseminated all over the country. For adolescent sexual and reproductive health information and services, national and provincial level implementation plans appear to be either lacking or inadequate The primary focus on information and counselling for adolescent on reproductive health mainly on morale and abstinence issues. The Commission on Reproductive Health which was established in Indonesia in 1996 is not functioning well. The establishment of adolescent friendly services in Indonesia is still in a pilot phase and does not constitute a programme disseminated all over the country. For adolescent sexual and reproductive health information and services, national and provincial level implementation plans appear to be either lacking or inadequate The primary focus on information and counselling for adolescent on reproductive health mainly on morale and abstinence issues.

19. Results from Field Test:Ex: Recommendations from Indonesia LAW and REGULATIONS The existing marriage law should be revised in order to eliminate early marriage and early pregnancy by increasing the minimum legal age of marriage. Both the Law on Population and the Law on Health should be amended/revised to make comprehensive reproductive health services including contraceptive services available, accessible, and affordable for unmarried and adolescents as well. Those potentially responsible: Ministry of Justice Ministry of Women Empowerment, Ministry of Education and Ministry of Religious Affairs Parliamentarians

20. Lessons learned on Human Rights Impact Assessments Target audience matters � government led processes take longer; can�t be controled; but if done well and owned, can lead to significant advances Linking HRs and Health can be both technically and intellectually difficult Involving other sectors necessary but meaningful participation is a challenge Data is often unavailable or of low quality � but -validity of the data provides legitmacy Indicators and Frame alone do not make it a RBA; need an analysis framework that uses a rights lens to evaluate the findings Implications of results � advocacy, programming for change, involvement of other sectors � who follows implementation outside of the health sector

22. �Knowing the need for intersectoral action, political commitment and implemenattion with a broader, more humane perspective of the questions and the answers is the biggest challenge facing women�s health� - Health worker, Rio Grande do Norte, Brazil