ACCESS TO MATERNAL HEALTH SERVICES FROM A HUMAN RIGHTS PERSPECTIVE

III.       DUTIES OF THE STATES TO ENSURE THAT WOMEN HAVE ACCESS TO MATERNAL HEALTH SERVICES WITHOUT DISCRIMINATION

A.         The principles of equality and non-discrimination

53.                    The Commission has received information indicating that the right to personal integrity of thousands of women in the Americas is affected in terms of their ability to access health services that only they require, generating inequalities between men and women with respect to the enjoyment of this right. These inequalities are manifest in the failure to provide adequate services to meet their specific biological needs related to their reproductive function as well in discriminatory sociocultural patterns that cause situations that present a risk to women’s health (e.g., a pregnant rural women seeking medical attention for some complaint and a health facility that doesn’t want to treat her because they require authorization from her spouse to do so).

54.              The information received also allows for the conjecture that some groups of women, particularly poor women, women living in rural areas, indigenous and/or afro-descendant women and adolescent women, are the groups whose rights to access to such services are most often violated. (e.g., the case of an indigenous woman seeking medical attention who is mistreated at the health facility because she doesn’t speak Spanish). This situation creates inequalities among women themselves in terms of their enjoyment of rights, inequalities that may constitute violations of the principles of equality and non-discrimination that permeate the inter-American system.

55.              Article II of the American Declaration provides that "all people are equal before the law and have the rights and duties established in this Declaration, without distinction as to race, sex, language, creed or any other factor." Article 1 of the American Convention establishes that each of the States Parties undertakes to "respect the rights and freedoms" established therein and to "ensure to all persons subject to their jurisdiction the free and full exercise of those rights and freedoms, without any discrimination for reasons of race, color, sex, language,…national or social origin, economic status…or any other social condition."[77]

56.              The American Convention provides that when a recognized right is not guaranteed by legislative or other provisions, the State Party agrees to adopt the measures necessary to give effect to the right.[78] In Article 24, the American Convention specifically establishes protection for the right to equal protection of the law and before the law.

57.              The Inter-American Court has indicated that “the notion of equality springs directly from the oneness of the human family and is linked to the essential dignity of the individual.”[79] According to the Inter-American Court, the right to equality before the law “prohibits all discriminatory treatment originating in a legal prescription”[80] and in order to achieve that objective, the States have the obligation not to introduce discriminatory regulations in their legal systems with reference to protection of the law.[81] This assertion is supplemented by what the Inter-American Court maintained in the Yean and Bosico case: “States must combat discriminatory practices at all levels, particularly in public bodies and, finally, must adopt the affirmative measures needed to ensure the effective right to equal protection for all individuals.”[82] This includes the duty of the States not only to abstain from producing discriminatory legislation, standards and policies affecting women’s equality, but also that such standards and policies must be eliminated. In addition, this duty includes the active role of the States in guaranteeing that women are able to enjoy their human rights free from all forms of discrimination.[83]

58.              The IACHR has indicated that laws, practices and policies that at first glance seem neutral but that, nevertheless, produce arbitrary or disproportionate distinctions when applied are manifestations of discrimination in that they conceal their prejudicial effect on groups in vulnerable situations.[84]  In this regard, the IACHR has established that an examination of laws and policies based on the principle of effective equality and non-discrimination also includes their potential discriminatory impact, even when their formulation seems neutral, or they apply to everyone, without distinction.[85] In this regard, the ESCR Committee has defined indirect discrimination as “laws, policies, or practices that appear neutral at face value but have a disproportionate impact on the exercise of Covenant rights (referring to the International Covenant on Economic, Social and Cultural Rights) as distinguished by prohibited grounds of discrimination.”

59.              The universal system for the protection of human rights, in Articles 1 and 2 of the Universal Declaration, proclaims that “all human beings are born free and equal in dignity and rights" and thus anyone may invoke all the rights and freedoms established in the Declaration "without distinction," including gender.[86] The Convention on the Elimination of All Forms of Discrimination against Women (hereinafter “the CEDAW”) defined “discrimination against women” as follows[87]:

any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their marital status, on a basis of equality of men and women, of human rights and fundamental freedoms in the political, economic, social, civil or any other field.

60.              This definition covers any difference in treatment based on gender that:[88]

·                     intentionally or unintentionally disadvantages women;

·                     prevents recognition by society as a whole of the rights of women in the public and private spheres; or

·                     prevents women from exercising their rights.

61.              That definition, which incorporates the gender perspective, is very important in the area of health, in which the specific needs of women, particularly on the subject of reproduction, have often not received adequate or specific attention.

62.              The CEDAW also includes the elimination of any form of discrimination against women based on gender. In Article 5(a), the CEDAW establishes the obligation of the States to “modify the social and cultural patterns of men and women, with a view to achieving the elimination of prejudices and customary and all other practices which are based on the idea of the inferiority or superiority of either of the sexes or on stereotyped roles for men and women.”

63.              In addition, Article 2 of the CEDAW requires the States Parties to adopt and implement "by all appropriate means and without delay, a policy of eliminating discrimination against women," which includes the duty to "refrain from engaging in any act or practice of discrimination against women and to ensure that public authorities and institutions shall act in conformity with this obligation,” as well as the duty to adopt appropriate legislative and other measures "to modify or abolish existing laws, regulations, customs and practices which constitute discrimination against women."

64.              Under international instruments providing regional and universal protection for human rights, all women have the right to be treated with the same respect, dignity and responsibility as men, without discrimination. The IACHR has previously maintained that while formal equality does not guarantee the elimination of instances of discrimination in reality, recognizing it makes it possible to encourage transformations in society, thereby enhancing the authority of this right.[89] This means that the commitment to equality must not be limited to achieving legal equality, but must also encompass all social institutions, such as the family, the market, and political institutions.[90] Thus, women’s equality must also be examined in the light of the circumstances in which they live, including the family, the community and the cultural context.

65.              Some international instruments make express reference to discrimination and inequality that women face with respect to maternal health.[91] Article 10 of the International Covenant on Economic, Social and Cultural Rights provides that special protection should be accorded to women during a reasonable period before and after childbirth, without discrimination.[92] In the inter-American system, the Protocol of San Salvador expressly establishes the obligation of the States to provide appropriate protection for women, particularly to provide special care and assistance to mothers during a reasonable period before and after childbirth, without discrimination.[93]

66.              Regarding the discrimination and inequality that women face, the Committee on the Elimination of Discrimination against Women (hereinafter “CEDAW Committee” Committee has maintained that:

The position of women will not improve as long as the underlying causes of discrimination against women and their inequality are not addressed. The lives of men and women must be considered in a contextual way, and measures adopted toward real transformation of opportunities, institutions and systems so that they are no longer grounded in historically pre-determined male paradigms of power and life patterns.[94]

67.              According to the CEDAW Committee, it is not enough to guarantee women the same treatment as men.[95] The biological differences between men and women and the differences that society and culture have created must be taken into account. Under certain circumstances, treatment of men and women will have to be non-identical in order to balance those differences.[96]

68.              For its part, the Inter-American Court has maintained that not all different treatment is discriminatory in itself, because not all differences in treatment can be considered, in and of themselves, as offending human dignity.[97] The Inter-American Court, based on the jurisprudence of the European Court of Human Rights, maintained that a distinction is only discriminatory when it lacks an objective and reasonable justification.[98] The Inter-American Court indicated that there are certain de facto inequalities that may legitimately be reflected in inequalities in legal treatment without such situations being unjust. On the contrary, they may sometimes be necessary in order to achieve justice,[99] as in the case of the application of special measures. In other words, equitable treatment under the law for men and women is expected unless pressing and just, legitimate and reasonable grounds are provided to justify a difference in treatment.”[100] According to the Inter-American Court:

…no discrimination exists if the difference in treatment has a legitimate purpose and if it does not lead to situations which are contrary to justice, to reason or to the nature of things.

69.              The CEDAW Committee states that women must be empowered by an enabling environment to achieve equality of results. Equality of results is the logical corollary of substantive or de facto equality. The results may be quantitative or qualitative, that is, women enjoying their rights in various fields in fairly equal numbers with men.[101]

70.              In this regard, in its report on Access to Justice for Women Victims of Violence in the Americas, the IACHR emphasized that the inter-American system is moving toward a concept of material or structural equality based on the recognition that certain sectors of the population require the adoption of special equalizing measures. This demands different treatment when, due to circumstances affecting a disadvantaged group, equal treatment means limiting or encumbering access to a service, good or the exercise of a right.[102] 

71.              Moreover, the Inter-American Court has maintained that the duties of the States to adopt measures for prevention and protection “[…] are conditioned upon the knowledge of a genuine, immediate risk to a specific individual or group of individuals and the reasonable possibility of preventing or averting such risk.”[103] This means that the States have an obligation to adopt prevention and protection measures against possible risks to their integrity that women face due to the lack of adequate medical care and services. Following the Constitutional Court of Colombia, the IACHR has established that equality is protected when the law and public policy take into account the particular circumstances and characteristics of those who are in a position of social, political, economic or legal disadvantage.[104]  Thus, the Committee on the Elimination of Discrimination against Women has established that measures to eliminate discrimination against women will not be considered appropriate when a health care system lacks services to prevent, detect and treat illnesses specific to women.[105] 

The link between discrimination and violence

72.              The Inter-American Convention on the Prevention, Punishment and Eradication of Violence against Women (Convention of Belém do Pará) recognizes the crucial linkage between the right to live free of discrimination and the recognition of other fundamental rights, particularly the right to be free of violence based on gender.[106]

73.              The IACHR has indicated that violence against women is a form of discrimination that seriously impairs women’s ability to enjoy rights and freedoms on an equal footing with men.[107]  Article 6 of the Convention of Belém do Pará establishes that a woman’s right to a life free of violence includes, inter alia:

-                      The right of women to be free from all forms of discrimination; and

-                      The right of women to be valued and educated free of stereotyped patterns of behavior and social and cultural practices based on concepts of inferiority or subordination.

74.              Violence has a direct impact on women’s enjoyment of the right to personal integrity. Many women suffer forms of violence during pregnancy that may affect their physical integrity, for example, leading to sterility, and may in some cases lead to a violation of their right to life. On this subject, Article 9 of the Convention of Belém do Pará establishes that the States shall take special account of women’s vulnerability when pregnant.

75.              In the area of access to maternal health services, health care practices such as a refusal to provide medical care to women who need it without the consent of their partners or sterilization performed by health personnel without a woman’s informed consent, as well as the physical and psychological consequences of such a procedure, are examples of forms of violence against women. The IACHR has also underscored the State’s affirmative obligations in the area of access to health services and their relationship with violence, by establishing that the health of victims of sexual violence must be given priority in the legislative initiatives and in the health policies and programs of the Member States,[108] which includes maternal health services. 

76.              The IACHR also believes that the lack of affirmative measures to guarantee both the accessibility of maternal health and its availability, acceptability, and quality may constitute a violation of the obligations arising from the principles of equality and non-discrimination that permeate the inter-American system.

77.              Article 7(e) of the Convention of Belém do Pará requires the States to take all appropriate measures, including legislative measures, to amend or repeal existing laws and regulations or to modify legal or customary practices that sustain the persistence and tolerance of violence against women. Given the obvious relationship between discrimination and violence, this principle should be interpreted in the sense of imposing on the States the duty to revise laws, practices and public policies that are discriminatory or with potentially discriminatory effects on women (for example, laws that prohibit the distribution and sale of all family planning methods used by women). 

B.         Duties of the States to ensure that women have access to maternal health services without discrimination

78.              The IACHR appreciates that the American States have not only recognized maternal mortality as a problem, but have also made efforts to improve the situation. According to the Pan American Health Organization, a study conducted in 2004 based on a survey administered to decision-makers in 16 Latin American and Caribbean countries indicated that strategies to expand coverage and access to primary care constitute one of the most common components of policies to reform health care services in the region.[109] These strategies include increasing the number of primary care centers and directing the delivery of a series of basic services to populations with limitations on access, to vulnerable groups such as children, mothers, or indigenous populations in countries like Brazil, Costa Rica, Ecuador, Honduras, Jamaica, Mexico, Nicaragua, and Panama, among others.[110]

79.              In addition, most countries in the region have been supporting policies or provisions that emphasize the importance of safe motherhood and the goal of reducing maternal mortality by 50% by the year 2015. Some countries such as Bolivia, Ecuador, and Peru have even implemented universal health care coverage for pregnant women.

80.              Despite the efforts of the States, there are still great challenges in the region with respect to health services, including maternal health services. Access to health care is not universal and is practically non-existent in many cases for the social groups most in need of it.[111] The supply of services does not always reflect the expectations, social values, and cultural preferences of the region’s populations.[112] In many cases, the delivery of services is ineffective and of low technical quality.[113] Similarly, available resources are not always used appropriately, which in turn generates inefficiencies in services and contributes to increased health costs. In some cases, the financing of services is insufficient and unsustainable.[114]

81.              In the inter-American system, the American Declaration and the Protocol of San Salvador expressly establish the States’ obligation to provide adequate protection to women, and particularly to grant special care and attention to mothers during a reasonable period before and after childbirth.[115] The Protocol of San Salvador specifically establishes the States’ obligation to adopt the following measures to guarantee the right to health as applicable to maternal health, consistent with their available resources and taking into account their level of development, in order to gradually make the right to health fully effective: primary health care, understood as essential health care put within the reach of all individuals and families in the community; the extension of the benefits of health services to all individuals subject to the jurisdiction of the State; full immunization against the principal infectious diseases; prevention and treatment of endemic, professional, and other diseases; education of the population on prevention and treatment of health problems; and meeting the health needs of the groups most at risk and most vulnerable due to their poverty.

82.              The Protocol of San Salvador refers to satisfying the right to health in a context of developing a health system that, as basic as it might be, must guarantee access to primary health care (PHC) and gradual development of a system providing coverage to the country’s entire population. In turn, it gives special attention to vulnerable groups or groups in situations of poverty.[116]

83.              The IACHR wishes to emphasize, as the States themselves recognized when agreeing to the Millennium Development Goals and/or the Cairo Programme of Action, that to a great extent the high rates of maternal mortality reflect historical discrimination against women and the inadequacy of the measures applied to remedy it. Since prohibiting discrimination is a guiding principle in the regional system, the States should redouble their efforts to adopt measures and assign the resources necessary to eliminate the various forms of discrimination against women that still impact the preventable risks and injuries women face in the field of maternal health.

84.              Following international standards on the protection of maternal health and the inter-American system’s own jurisprudence, the IACHR notes that the duty of the States to guarantee women’s right to physical, mental and moral integrity in terms of access to maternal health services under equal conditions implies giving priority to resources to serve women’s specific needs with respect to pregnancy, childbirth, and the post-partum period, particularly by implementing key interventions that contribute to guaranteeing maternal health, as well as emergency obstetrical care.[117] At a minimum, the States must guarantee maternal health services that include the basic factors that are determinants of health. Thus, the CEDAW specifies in Article 12(2) the States’ obligation to ensure equal conditions for women to obtain health services required by women only according to their specific health needs.[118] The CEDAW Committee even recommended that the States Parties ensure “that women are not forced to seek unsafe medical procedures such as illegal abortion because of a lack of appropriate services in regard to fertility control.”[119]

85.              International standards establish that the States must provide health services under appropriate and safe conditions and that such services should be free when necessary, and must ensure adequate nutrition during pregnancy and while mothers are nursing.[120] With respect to nutrition, it is important to emphasize that it is estimated that approximately half of the pregnant women in the world suffer from some form of anemia. The situation of pregnant adolescents is even more serious because they are more likely to suffer from anemia than older women and because they have fewer opportunities to receive treatment for this condition.[121]

86.              For its part, the CEDAW Committee specifically established the States’ obligation to guarantee women’s right to free maternity services by allocating the highest amount of resources available to such services:[122]

Many women are at risk of death or disability from pregnancy-related causes because they lack the funds to obtain or access the necessary services, which include antenatal, maternity, and post-natal services. The Committee notes that it is the duty of States Parties to ensure women’s right to safe motherhood and emergency obstetrical services, that they should allocate to these services the maximum extent of available resources.[123]

87.              In addition, the duty to protect women’s integrity under conditions of equality includes the States’ need to prioritize their resources and efforts to address the particular needs of the groups of women identified in this report who are most at risk of suffering injury to their integrity in terms of access to maternal health services, i.e., poor women, women in rural areas, including indigenous and/or afro-descendant women, due to the multiple forms of discrimination they face. According to the United Nations Special Rapporteur on the right of everyone to enjoy the highest attainable standard of health, the principles of equality and non-discrimination mean that neighborhood and other programs should be implemented to ensure that disadvantaged individuals and communities such as women who are excluded actually have the same access as other more favored groups.[124]

88.              Specifically with respect to indigenous women, the Inter-American Court has held that the States must pay particular attention and care to the protection of this group and must adopt special measures to ensure that mothers have access to adequate health care services, particularly during pregnancy, childbirth, and lactation.[125]

89.              Consequently, the States must eliminate obstacles limiting the access that women, particularly women in these groups, have to maternal health services, such as fees, distance from health centers, and the lack of adequate and accessible public transportation.[126] One way to reduce the effects of distance from health services may be to establish homes for pregnant women.

90.              Information and education enable women to make decisions at all levels in all areas of their lives, particularly regarding health, sexuality, and reproduction.[127] Access to information in the area of maternal health also includes recognizing the warning signs of obstetrical emergencies, as well as access to information on personal medical history and institutional and systemic information on maternal health expenses and statistics.[128]

91.              In this respect, the Inter-American Commission has indicated that the concepts of independence and empowerment should be a part of the agenda for reducing gender inequalities.[129] Women with more education generally have tools for adopting appropriate prevention and health promotion behaviors, including maternal health and the health of their families, such as having their children vaccinated.[130] The gap between women with greater resources and poor women and between men and women in this area requires that States provide educational and employment opportunities for women in order to remedy the inequality. This includes the need for the State to dedicate resources to ensure that women have knowledge regarding their rights as users of the health system and health services.

92.              As a result, protecting women’s right to personal integrity under conditions of equality is achieved in the area of maternal health through the provision of information and education on the subject so that women will adopt free, well-founded, and responsible decisions regarding reproduction, including family planning.[131]  On this subject, the Constitutional Court of Colombia stated that “the right to health has a sphere in which it is closely linked to personal autonomy and the free development of one’s personality, in terms of the power to make decisions regarding one’s own health.”[132] According to those principles, the States must pay particular attention to the specific information needs of women belonging to vulnerable groups such as poor women, women living in rural areas, including indigenous and afro-descendant women and adolescent women.[133]

93.              According to the United Nations Rapporteur on the right of everyone to enjoy the highest attainable standard of health, in order to prevent maternal mortality and improve access to maternal health, it is not enough to gradually increase technical procedures or make them more accessible.[134] According to the Rapporteur, it is also essential to address social, cultural, political, and legal factors that influence a woman’s decision to seek maternal health or reproductive health services.[135] This requires the States to eliminate discriminatory laws, policies, and practices and gender inequalities that prevent women and adolescents from seeking good quality services.[136] Among discriminatory practices, the States must redouble their efforts to eliminate gender stereotypes such as restrictions on women’s access to health care services because they do not have authorization from their spouse, or companion, or parents, or health authorities, based on their marital status, or because they are women.[137]

94.              The IACHR emphasizes the need to involve the principal beneficiaries in the design and implementation of policies, plans, and programs that affect them. The United Nations Committee on Economic, Social, and Cultural Rights has maintained that an important aspect of the right to health involves the population’s participation in the entire decision-making process with respect to health issues at the community, national, and international level.[138]

95.              The IACHR underscores the States’ duty to guarantee that maternal health services are provided through respectful attention to women. In the case of indigenous and afro-descendant women, the States must adapt preventive services as well as health care and treatment services, with respect for their cultures, for example, through informed selection of the type of childbirth. According to the Committee on Economic, Social, and Cultural Rights, “health facilities, goods, and services must be accessible, in fact and under the law, to the most vulnerable and marginalized sectors of the population, without any discrimination based on any prohibited grounds.”[139] In this respect, goods, services, and facilities “must adjust to existing needs in the area of gender and to the rights and cultures of minorities and indigenous populations.”[140]

96.              In this regard, it is important to point out that the Inter-American Court has held that anyone who is in a vulnerable situation has the right to special protection, based on the special duties with which the State must comply in order to satisfy its general obligations to respect and guarantee human rights.[141] In addition, the Court has reiterated that it is not enough for the States to refrain from violating rights, but it is essential that they adopt affirmative measures, to be determined based on the specific needs for protection of the subject of law, whether due to his or her personal circumstances or the specific situation in which he or she is found.[142]  In this respect, the States must consider that groups of persons living in adverse circumstances and with fewer resources, such as women living in poverty, indigenous women, afro-descendant women, and adolescents, are those who are most at risk of having their right to personal integrity affected in terms of access to maternal health services.

97.              Consistent with the position taken by the Inter-American Court, the States Parties have the obligation to establish and adopt in their domestic legal systems all the measures necessary to comply with and implement the provisions of the Convention, and to ensure that such legislation does not become a mere formality, unrelated to reality.[143] This obligation includes setting up accountability systems and providing women with effective and timely access to justice when their heath-related rights are violated, through criminal, civil, or administrative proceedings. On this subject, the IACHR emphasizes the importance of the active participation of women in determining the priorities in maternal health policies.

98.              With respect to protecting adolescents’ right to integrity, the IACHR has previously stated that early pregnancy poses various risks that, in addition to health problems, include higher risk of abortions under unsafe conditions and interrupted education.[144] In this regard, the Human Rights Committee has established the duty of the States to provide adolescents with access to information on the harm early pregnancy can cause. In addition, the Committee has established that pregnant girls and adolescents must be given health services appropriate to their rights and specific needs.[145]  For its, part, the Committee on the Rights of the Child has urged the States Parties to adopt measures to reduce maternal morbidity and mortality among adolescent girls, particularly that produced by pregnancy and unsafe abortion practices, and to provide support to the parents of adolescents.[146]  As a result, the Commission believes that the States must design policies and programs for this specific group based on their specific maternal health needs, while respecting their rights to privacy and confidentiality.

99.              Improving maternal health is established as one of the eight Millennium Development Goals.[147] The goal set is to reduce maternal mortality by three-fourths, with the following indicators to measure progress: the rate of maternal mortality and the percentage of childbirths attended by specialized health personnel and the rate of contraceptive use.[148] In addition, the second goal is to achieve universal access to reproductive health by 2015, with indicators to measure progress: the fertility rate among adolescents, prenatal care coverage, and unmet needs in the area of family planning.

100.          It should be noted that the Inter-American Commission on Human Rights developed a series of guidelines for assessing and monitoring economic, social, and cultural rights provided in the Protocol of San Salvador. The document specifically develops a series of structural, process and outcome indicators relating to pregnancy and maternity. The outcome indicators for measuring progress in the right to health include the percentage of individuals who have access to basic sanitation, the number of professionally attended deliveries, and the percentage of women of reproductive age with anemia. The outcome indicators for measuring progress in the right to health with respect to equality are specified as: the rate of maternal and perinatal mortality; the distribution of maternal mortality by cause, broken down by age group; the perinatal mortality rate;, the percentage of newborns weighing less than 2.5 kg; the rate of assistance due to domestic violence; and estimated cases of illegal abortion by age, place of residence (urban and rural), and socioeconomic circumstances of the pregnant woman or other available data.[149]

101.          At the International Conference on Population and Development held in Cairo in 1994, more than 171 States agreed to the following objectives related to women’s health and maternity:[150]

(a) To promote women’s health and safe motherhood to achieve a rapid and substantial reduction in maternal morbidity and mortality and to reduce the difference between and within developed and developing countries. On the basis of a commitment to improving women’s health and well-being, to reduce greatly the number of deaths and morbidity from unsafe abortion;

(b) To improve the health and nutritional status of women, particularly pregnant and nursing women.

102.          The measures agreed upon included increasing the delivery of maternity services within the framework of primary health care. Said services, based on the concept of choice based on correct information, should include education on safe motherhood; coordinated and effective prenatal care; maternal nutrition programs; appropriate care for deliveries; avoiding excessive use of caesarean sections and providing emergency obstetrical care; referral of cases when there are complications during pregnancy, childbirth, and abortion; prenatal care; and family planning. All births should be attended by trained personnel, preferably nurses and midwives, but at least by trained birth attendants.[151]

103.          It was also established that the underlying causes of maternal morbidity and mortality should be determined and attention should be paid to developing strategies to eliminate them and to developing mechanisms for adequate evaluation and supervision, in order to evaluate progress made in reducing maternal mortality and morbidity and increasing the effectiveness of ongoing programs. The importance of obtaining the support of men for activities intended to secure the health of mothers and safe motherhood was also identified.

104.          Finally, the IACHR wishes to emphasize that in order to achieve the full effect of the right to personal integrity “the States have the legal obligation to adopt deliberate, concrete measures intended to realize the right to health for all.”[152] This means adopting effective policies to address maternal health with particular attention given to the specific needs of the groups of women indicated in this report. In addition, although Article 26 of the American Convention establishes that the States Parties undertake to gradually achieve the full effectiveness of economic, social and cultural rights to the extent of the available resources, the IACHR reiterates that non-discrimination is an obligation that must be complied with immediately. As the United Nations Rapporteur on the right of everyone to enjoy the highest attainable standard of health has indicated, equal treatment between women and men is not subject to gradual achievement nor to the availability of resources,[153] and like equality among women, is a fundamental obligation to be implemented immediately.