Maternal and Neonatal Health: Using a Human Rights Approach

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Maternal and Neonatal Health Using a Human
Rights Approach
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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)

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Maternal Mortality
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INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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

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Neonatal and perinatal mortality
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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

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Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• Maternal and Neonatal Mortality under
  International Human Rights Law

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Definition
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• What are Human Rights?
• Formal legal system
• Advocacy
• Approach to programming

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Obligations
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• How are human rights enforced and/or realized?
• Through national law and policy
• Monitoring mechanisms
• International technical and financial assistance
• Civil society movements/activities

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Applying human rights in the context of MNH
timeline
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INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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.
• AdvocacyCRR/ PHR reports
• ProgramsAMDD
• Assessment/accountability WHO/PIHRR

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Objectives of the assessment project (Tool)
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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

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The Tool
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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)

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The Instrument
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INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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

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Rights Relating to Health and Maternity
Rights Relating to Information Education
Rights Relating to Non-discrimination
Rights Relating to Life, Survival Security

Multi Sectoral Action Planning
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INTERNATIONAL HEALTH AND HUMAN RIGHTS
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Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS
Rights Relating to Life, Survival, Security and
Identify Law, policy and health system indicators
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Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS
Rights Relating to Life, Survival, Security and
Identify
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The Tool the process
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS
Phase 1 - Establishing commitment leadership
Phase 2 - Adaptation, data compilation and
analysis
Phase 3 - Prioritizing for action
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Results from Field TestsKey health issues
Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS

• 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

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Results from Field TestsGovernment 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.

Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS
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Results from Field TestsIdentified 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

Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS
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Results from Field TestEx Recommendations from
Indonesia

• POLICIES/STRATEGIES and HEALTH SYSTEMS
• Policies and strategies should be developed to
  empower adolescents and young people with sexual
  and reproductive health and rights knowledge,
  understanding and skills.
• Policies regarding the promotion of minimum age
  of marriage for women and men should be
  harmonized.
• Those potentially responsible
• Ministry of Women Empowerment,
• Ministry of Education,
• Ministry of Religious Affairs

• 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

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Lessons learned on Human Rights Impact Assessments

• Target audience matters government led
  processes take longer cant 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

Harvard School of Public Health PROGRAM ON
INTERNATIONAL HEALTH AND HUMAN RIGHTS
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• 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
  womens health
• - Health worker, Rio Grande do Norte, Brazil