Rights to safe motherhood and newborn health: Ethical issues

1. Introduction 

Goal 5 of the United Nations Millennium Development Goals (MDGs) is to reduce the maternal mortality ratio (MMR) by 75% by 2015 [1]. Fifteen years after the first International Conference on Population and Development (ICPD) in Cairo in 1994, approximately 600000 pregnant women are dying each year, one every minute, with 98% living in resource-poor countries: 60% in Asia, 30% in Africa, 7% in South America, and 1% in Oceania [2], [3]. The MMR ranges between 2 and 8 per 100000 live births in Europe compared with between 1.6 and 2 per 100 live births in Sierra Leone, Afghanistan, Malawi, Angola, and Niger. In India, the MMR per week is greater than the MMR in Europe per year.

The main cause of maternal death is hemorrhage. Why do so many pregnant women die during delivery, and as a result of postpartum hemorrhage in particular? The answer to this question is that they deliver alone, unattended by skilled birth professionals. In resource-poor countries only 34% of deliveries are attended by a birth professional: 6% in Ethiopia, 14% in Chad, and 16% in Niger [4]. In these circumstances, the “3 delays” often account for maternal death: the delay in recognizing an obstructed labor; the delay in transfer to an appropriate birth center; and the delay in gaining access to proper care within the birth center because of a lack of financial resources. The training of traditional birth attendants (TBAs) has proven inefficient as a single measure to reduce maternal mortality [5]. Management of life-threatening complications in pregnancy and childbirth needs services that cannot be provided solely by TBAs. The rate of maternal lifesaving cesarean delivery is estimated to be at least 5%. The cesarean delivery rate is around 1.7% in low-resource countries: 1.5% in Ivory Cost, 1.6% in Mali, 0.7% in Mauritania, and 0.8% in the Kaolack province of Senegal [6].

The HIV epidemic is an additional threat for pregnant women. Worldwide, 26 million women are infected with HIV, most of them aged between 15 and 45 years; an example of this burden is the 40% prevalence of HIV positive women in Swaziland. The coverage of antiretroviral therapy is less than 30% in Ethiopia, Malawi, China, Burundi, Kenya, and South Africa [4]. The MMR is 22 times higher among HIV-positive pregnant women in Zimbabwe and Malawi. In addition, among the 75 million unplanned pregnancies occurring worldwide every year, 40 million end in voluntary abortion, with 20 million conducted using unsafe procedures [7]; this accounts for 70000 maternal deaths each year.

2. Women's rights to safe motherhood 

The 1948 Universal Declaration of Human's Rights [8] states that “Everyone has the right to a standard of living adequate for the health and well-being of him/herself, and his/her family, including food, clothing, medical care and necessary social services.” These principles of responsibility and solidarity have been reinforced by the UNESCO 2006 Universal Declaration on Bioethics and Human Rights, articles 13 and 14 [9]: “Solidarity among human beings and international cooperation towards that end are to be encouraged” and,

“(1) The promotion of health and social development for their people is a central purpose for governments that all sectors of society share; (2) Taking into account that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition, progress in science and technology should advance: (a) access to quality health care and essential medicines, especially for the health of women and children, because health is essential to life itself and must be considered to be a social and human good…”

Professional obstetric societies should publicize the tragedy of maternal mortality as a violation of women's rights and not just as a health problem. Health professionals should collaborate with advocates of human rights [10].

Prenatal and intrapartum care should be organized so that every woman at risk for a life-threatening obstetric complication is transferred without delay to a medical center providing the human and technical resources essential for emergency obstetric care, including cesarean delivery and blood transfusion [10].

In counties where abortion is legal, every woman should have the right, after appropriate counseling, to access medical or surgical abortion [10].

Reduction of maternal mortality also depends on nonmedical policies such as development of roads and transportation, and financial support for underprivileged women, particularly in rural communities and remote areas. Obstetricians should lead the way in demonstrating how emergency obstetric care can be provided in a cost-effective way in low-resource settings. For example, Mauritania implemented Obstetric Risk Insurance to allow risk-sharing among all pregnant women on a voluntary basis, giving an efficient guarantee of access to obstetric care to all women at an affordable cost [11].

How can women's rights to safe motherhood, an ontological dignity of human beings, be secured in low-resource countries where more than 1 billion individuals live on less than US $2 per day? An ethical approach may be enlightening [12], [13].

The first principle of moral philosophy supporting women's rights is philanthropy [14], such as humanitarian support. Where affordable and safe obstetric care is not available, it must be supported by state subsidized programs or by private foundations. International agencies such as the WHO, UNFPA, the World Bank, the International Monetary Fund, and the International Federation of Gynecology and Obstetrics (FIGO) provide such funds for women's health. Private donations also fund public health programs, such as the Bill and Melinda Gates Foundation, the Buffet Foundation or the Ford Foundation, among others. Unfortunately, in low-resource countries, health authorities, either governmental or nongovernmental, are overwhelmed with pressing demands. The HIV epidemic, malaria, tuberculosis, breast and cervical cancer, and gynecological fistulas are an increasing burden and compete for limited budgets. In at least 37 low-resource countries, food riots have erupted for wheat, rice, and millet. It is likely, regrettably, that in that context, as long as women's reproductive rights—too often despised and neglected—are not fully respected, maternal mortality will be set as a low priority for resource allocation.

The second principle of moral philosophy supporting women's rights to safe motherhood is equity [15]. Equity is not equality, nor even distribution of means. Equity consists of shaping the means according to the needs. It follows Aristotle's principle of proportional equality: if B is the needs of A, and D the needs of C, A/B=C/D. Pregnant women are in great need of safe motherhood [16] and therefore have the right to the proportionate means to secure pregnancy and delivery, which is a “win-win” deal in any case.

Indeed, the third principle of moral philosophy in favor of safe motherhood is utilitarianism [13]. Securing women's rights to safe motherhood must be understood as a shared interest. The death of a pregnant woman is a tragedy, not only for herself and her family, but also for society at large. Her orphans, if any, will be at greater risk of illness and even of death; they will require a foster mother; and there will be an economic impact, even on domestic work, brought about by the demise of any young individual. Disability due to unsafe delivery, such as obstetric fistula, carries even greater moral and material detrimental consequences for society at large. Therefore, rights to safe motherhood should be regarded as a profitable investment.

The fourth ethical principle to support safe motherhood is pragmatism. In reality, few believe that resource-poor countries will soon achieve the same standard of care as high-income regions. That is why the 2015 MDG does not aim for the “best proven” level of care for pregnant women as in high-income countries, but rather, as argued in Bloom's advocacy, toward the "highest attainable" levels of care achievable in each particular setting.

These four principles of moral philosophy belong to ethics and not to law, but since they are perceived as being just, they pertain to the laws: "What is just does not come from the laws, but laws come from what our conscience perceives as being just" (Julius Paulus, 3rd century).

Ethics may force any society to move the lines, to move the laws, to move toward women's rights to safe motherhood.