ACCESS TO MATERNAL HEALTH SERVICES FROM A HUMAN RIGHTS PERSPECTIVE

I.          INTRODUCTION

1.                  High rates of preventable mortality and morbidity are cause for great concern worldwide. This situation is not unknown in the Americas. Maternal mortality continues to be a serious human rights problem with dramatic effects on women throughout the world and in the region, and with repercussions on women’s families and communities. Specifically, it is the women who have historically been marginalized based on reasons of race, ethnicity, economic status, and age who have the least access to the maternal health services they require. This report addresses how the States’ obligation to respect and guarantee human rights without discrimination, particularly the right to personal integrity, may help to overcome inequalities in access to maternal health services – understood as health services for women during pregnancy, childbirth, and the post-partum period – and ensure that all women, particularly those who have been historically marginalized, enjoy effective access to these services.

2.                  The right of every person to physical, mental, and moral integrity without discrimination is enshrined in the American Convention.[1] The right to personal integrity in the area of health is closely tied to the right to health since the provision of adequate and timely maternal health services is one of the principal ways to ensure women’s right to personal integrity. The American Declaration of the Rights and Duties of Man establishes the right to personal integrity, and more specifically, that every person has the right to the preservation of his health through sanitary and social measures (…) and medical care without discrimination, to the extent permitted by public and community resources.[2] The Protocol of San Salvador establishes that everyone has the right to health without discrimination, which is understood as the enjoyment of the highest level of physical, mental, and social well-being.[3]

3.                  Protecting women’s right to personal integrity in the area of maternal health includes the obligation to guarantee that women have equal access to the health services they require according to their particular needs as they relate to pregnancy and the post-partum period and other services and information related to maternity and reproduction throughout their lives.[4] It is important to point out that many complications in pregnancy and childbirth are generally preventable. According to the Pan American Health Organization, illnesses relating to sexual and reproductive health in Latin America and the Caribbean represent 20% of the total health burden in women and 14% in men, pointing clearly to a gender gap.[5]  

4.                  The right to personal integrity is related to the basic principles of human rights such as equality, privacy, autonomy, and dignity. However, the IACHR has found that many women subject to exclusion, understood as a situation that is prejudicial to certain individuals or social groups in terms of access to basic quality health services, are more likely to suffer adverse effects with respect to their right to physical, mental, and moral integrity in terms of their access to maternal health services as a result of some barriers limiting their access to these services.[6]

5.                  These barriers are related to the absence or inadequacy of a gender perspective in public policies addressing women’s health needs, particularly for reducing maternal mortality. They also involve various forms of discrimination historically faced by women at different levels, whether at home or at healthcare facilities, generating health inequalities among women and between women and men in terms of their enjoyment of human rights.

6.                  According to the World Health Organization, maternal mortality is an indicator of the disparity and inequality between men and women and its extent is a marker of women’s place in society and their access to social services, health services, and nutrition as well as economic opportunities.[7] For men, there is no single cause of death and disability of a magnitude comparable to maternal mortality and morbidity.[8]

Maternal mortality and morbidity in numbers

7.                  The Inter-American Commission on Human Rights has received information indicating that approximately 536,000 women die each year throughout the world due to complications from pregnancy and childbirth, despite the fact that these deaths are generally preventable at relatively low cost.[9] The World Bank estimates that if all women had access to care to deal with complications in pregnancy and childbirth, particularly emergency obstetrical care, some 74% of maternal deaths could be prevented.[10]  The United Nations Human Rights Council made reference to an average of 1,500 women and girls who die each day as a result of preventable complications related to pregnancy and childbirth.[11] In addition, for every woman who dies, another 30 women suffer permanent injuries or illnesses that could result in pain throughout their lives, disability, and socioeconomic exclusion.[12]

8.                  Maternal mortality rates in the Americas represent a total of 22,680 deaths each year.[13] The principal causes of maternal death in the region’s countries are preventable and consistent: preeclampsia, hemorrhage, and abortion, with the order varying according to the rate of maternal mortality, coverage levels for prenatal care and childbirth, and the prevalence of contraceptive use.[14]

The impact of inequalities in access to services

9.                  Most of these cases of maternal mortality – defined by the World Health Organization as deaths of women during pregnancy or the 42 days following delivery – and maternal morbidity – defined as complications or illness occurring during gestation, delivery, or the puerperium and affecting the safety and health of women, often permanently,[15] occur in developing countries.[16]

10.              Latin America and the Caribbean are characterized as regions with great diversity in terms of both economic development level and geographic distribution as well as disparities between countries and within countries with respect to access to maternal health services.[17] As a result, 50% of maternal deaths are concentrated in the poorest 20% of the region while only 5% of such deaths are found in the richest 20%.[18] In Haiti, for example, approximately 670 women die for every 100,000 live births, while in Canada approximately 7 women die for every 100,000 live births.[19] In addition, the WHO estimated that in 2006 there were 280,000 perinatal deaths with notable differences across the region, where the risk of perinatal death is three times higher in Latin America and the Caribbean than in Canada and the United States.[20]

11.              While maternal mortality and morbidity affects women in all social and economic strata, the IACHR notes that a disproportionally high number of poor, indigenous, and/or afro-descendent women, most of whom live in rural areas, are the women who most often do not fully enjoy their human rights with respect to maternal health. This is because these groups of women suffer from the conjunction of multiple forms of discrimination limiting their access to these services. Discrimination based on sex, gender, race, ethnicity, poverty, or other factors is in turn considered a social determinant of health.[21]

12.              In fact, at the United Nations Fourth International Conference on Women held in Beijing en 1995, it was determined that the major obstacle preventing women from attaining the highest possible standard of health is inequality between women and men and among women in different geographic areas, social groups, and indigenous and ethnic groups.[22]  This means that the inequalities that women face in society in terms of health, including maternal health, are evident as compared to their male peers, but also among women themselves.

13.              Thus, in Peru, 74% of women in rural areas give birth at home without qualified professional care, compared to 90% of women in indigenous communities, even though one of the factors recognized internationally as associated with reducing maternal morbidity and mortality is childbirth attended by qualified personnel.[23] In Bolivia, a country with the highest maternal mortality rate in the Andean region (290),[24] the rate of maternal mortality varies significantly depending on geographic region (high plateau, valleys, or  tablelands) and depending on place of residence (urban or rural),[25] with obstetrical complications, hemorrhage, and infections being the principal causes of maternal mortality.[26]

14.              With regard to the maternal health situation of indigenous women, according to the Pan American Health Organization, in Guatemala, where 42% of the population is indigenous, maternal mortality is three times higher among indigenous women ( (211 for every 100,000 live births) than among non-indigenous women (70 for every 100,000 live births).[27]  In addition, according to United Nations Economic Commission for Latin America and the Caribbean (herein after “ECLAC”), while 68% of non-indigenous women get professional prenatal care, only 45.6% of indigenous women get such care.[28]

15.              In addition, the IACHR notes with alarm the maternal health situation among the region’s adolescents. Each year, records indicate about two million mothers between the ages of 15 and 19 and approximately 54,000 births to mothers under the age of 15.[29] Statistics show that high pregnancy rates among adolescents have not declined significantly since 1990, despite a decline in the region’s total fertility.[30] High adolescent pregnancy rates (among those under age 18) are a serious problem because pregnant adolescents face risks of maternal death that are two to five times higher than among women aged 20 or older.[31] In addition, their children are more likely to die during infancy.[32]

International commitments and the duties of States

16.              The IACHR recognizes that there is consensus among the States that improving access to maternal health is a matter of priority. An example of this is that improving maternal health is established as one of the eight Millennium Development Goals.[33] In addition, the United Nations Human Rights Council recently issued a resolution expressing its concern over maternal mortality and asked the States to renew their commitment to eliminating preventable maternal morbidity and mortality at the local, regional, and international level.[34]

17.              At the regional level, the countries in the Americas have undertaken various efforts to address the challenge through changes in legislation, policies, programs, and services.[35] Nonetheless, trends indicate that despite these efforts, they are well below the 5.5% improvement needed to achieve the target established in the Millennium Development Goals.[36] To illustrate, although the maternal mortality rate in Latin America and the Caribbean fell from 180 to 130 deaths for every 100,000 live births between 1990 and 2005, that figure is still very high and reflects this serious and persistent situation affecting the region’s women.

18.              Thanks to support from the Government of Spain, the IACHR has been implementing a project to produce, through its Rapporteurship on the Rights of Women, a series of publications, including a brief analysis and recommendations to the States, regarding subjects linked to access to health in the area of women’s reproduction at the regional and subregional level, the aim being to ensure greater protection for the human rights of women in this area.

19.              For this reason, the IACHR has developed this report, with the purpose of analyzing the duties of the States in guaranteeing women’s human rights without discrimination in terms of access by women to maternal health services, and to formulate general recommendations to the States on the subject. The recommendations in the report primarily cover the duties of the American States with respect to their legislation and public policies, services, and judicial branch, so as to guarantee the right to personal integrity for all women with respect to their access without discrimination to maternal health services.

20.              Thus, while the OAS Member States are working toward full implementation of the applicable obligations in the area of maternal health, the IACHR believes there are certain fundamental obligations that require immediate priority measures:

·                     Identification and allocation of human and material resources to work toward eliminating barriers in access to services.

·                     Implementation of measures to reduce preventable deaths due to pregnancy or childbirth, particularly to ensure that women have effective access to emergency obstetrical services and to care before and after delivery.

·                      Incorporation of the gender perspective and elimination of de facto and de jure forms of discrimination that impede women’s access to maternal health services.

·                     Prioritization of efforts and resources in order to guarantee access to maternal health services for women who may be at greater risk because they have been subject to various forms of discrimination such as indigenous, afro-descendant, and adolescent women, women living in poverty, and women living in rural areas.

·                     Education for users regarding health services, as well as services to provide information on their rights as patients and on their health, including family planning.

·                     Design and implementation of maternal health policies, plans, and programs on a participatory basis.

·                     Timely access to effective judicial remedies to ensure that women who allege that the State has not met its obligations in this area have access to effective judicial remedies.

21.              With this first report, the Commission hopes to contribute, along with the States’ efforts, to the protection and promotion of women’s human rights in terms of their access to maternal health services without discrimination.

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