Safer childbirth: A rights-based approach

1. Introduction 

The adoption of the Millennium Development Goals (MDGs) by 189 member states in September 2000 is an important commitment by the United Nations General Assembly to women's rights to health [1]. Of the 8 MDGs, although only goal 5 explicitly addresses the health of women, the attainment of all the other goals directly or indirectly influences the women's health. The principles of the MDGs are derived from the fundamental human rights to health in the Universal Declaration of Human Rights of the United Nations General Assembly in 1948 [2].

The important agreement by 179 countries at the International Conference on Population and Development (ICPD) in Cairo in 1994 [3] does try to improve reproductive health, among other things, within a human rights framework. All over the world people are becoming more educated and aware of both their societal and individual rights to access fair, evidence-based, and transparent health care [4]. We would like to show that maternity care in both low- and high-income countries can be improved through advocacy and promotion of sexual and reproductive rights, as well as through the enactment of laws and regulations that can make childbirth safer. This idea is supported by the International Federation of Gynecology and Obstetrics (FIGO) resolution of 2003, “…that advocacy and inclusion of the human rights of women are an integral and priority area in FIGO activities” [5].

2. The global problem 

In October 2007 at the Women Deliver Conference held in London, UK, government representatives, NGOs (national and local), and academic experts set a goal to implement evidence-based cost-effective interventions and to make maternal and newborn health a priority issue on national agendas to reach the MDG targets of a 75% reduction in maternal deaths from 1990 levels by 2015. This was a follow-up to the Safe Motherhood Initiative that was launched by the World Health Organization, World Bank, United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF), International Planned Parenthood Federation (IPPF), and the Population Council in 1987 in Nairobi, Kenya, which aimed to halve maternal deaths by the year 2000.

Worldwide, over half a million women die every year from complications of pregnancy and child birth. For each woman that dies many more women suffer from long-term ill health. Each year over 15 million women experience severe pregnancy-related complications that lead to long-term illness or disability. The tragedy is that the majority of these maternal deaths are avoidable and 99% occur in Sub-Saharan Africa due to poor health and inadequate care [6]. In Sub-Saharan Africa, the lifetime risk of a woman dying during or after pregnancy and childbirth is 1 in 16 compared with a woman in Western Europe whose corresponding risk is about 1 in 2800 [7]. The surviving children of a woman who dies as a result of a pregnancy-related complication are at risk of dying; there is also a wider and far-reaching negative impact on the older siblings, families, and neighbors as well as the wider community. Each year maternal health complications contribute to the deaths of 1.5 million infants in the first week of life and 1.4 million stillborn babies.

The causes of maternal deaths have been identified and vary widely between low- and high-income countries as well as within different regions of a country. Worldwide, obstetric hemorrhage accounts for the overwhelming majority of maternal deaths, followed by complications of infection (15%), unsafe abortion (13%), eclampsia (12%), and obstructed labor (8%). Indirect causes account for approximately 20% of all maternal deaths worldwide [8].

In a high-income country such as the UK, the Seventh Report of the Confidential Enquiries into Maternal and Child Health (CEMACH), entitled “Saving Mother's Lives” [9] showed that the most common cause of direct maternal deaths was thromboembolism, at a rate of about 1.41 per 100000 maternities. The CEMACH report also showed that cardiac disease was the most common cause of indirect deaths at a rate of about 1.01 per 100000 maternities. In contrast, the Third Report on Confidential Enquiries into Maternal Deaths in South Africa, a middle-income country, showed that the most common cause of direct deaths was hypertensive disorders of pregnancy and the most common cause of indirect deaths was nonpregnancy-related infections, mostly HIV/AIDS related [10]. Therefore, strategies and resources to address rights to safer maternity care must differ from country to country.

3. Human rights agenda 

There are two main categories of human rights. First generation or “claim rights” are rights that can be claimed by individuals in law, such as the right to life, liberty and freedom from torture, freedom of religion, and freedom of expression. Second generation rights are economic and social rights or goals that cannot be claimed in law, for example health care, work, social security, food, housing, and education. First generation rights are usually set out in vague general terms and as such are fluid and open to interpretation. An example of first generation rights is the UK Human Rights Act of 1998, which is derived from the European Convention on Human Rights. This is enforced by the European Court of Human Rights [11]. There is a tendency for first generation rights to expand to encompass second generation rights and this is a welcome trend, especially when it improves rights to health that would improve accessibility, availability, and affordability of reproductive health care. A classic example of this is Article 11 of the 1961 European Social Charter [12], which provides the right to protection of health as follows: (1) To remove as far as possible the causes of ill health; (2) To provide advisory and educational facilities for the promotion of health and the encouragement of individual responsibilities in matters of health; (3) To prevent as far as possible epidemic, endemic and other diseases.

It is essential for us to bear in mind that societal rights are greater than individual rights, and that individual rights are seen as privileges in most circumstances. The “double-edged sword” effect of the law, in that the law can act as a barrier as well as facilitating access to women's health services, needs to be recognized so that as we pursue legal and nonlegal rights to maternity care our efforts are not counter productive. An example is the legal system concerning malpractice insurance in the United States, which is negatively impacting access to health care in many parts of the country [13].

4. A rights-based approach 

Most countries are signatories to several international human rights treaties, such as the Declaration of Human Rights and the Convention on the Elimination of All Forms of Discrimination Against Women (the Women's Convention). These treaties do specify a country's legal obligations relating to the prevention of maternal mortality and provision of appropriate services for pregnant women.

The renewed commitments to the Safe Motherhood Initiative by 70 cabinet ministers and parliamentarians at the Women Deliver Conference to re-enforce political will to implement interventions and treaties were made to achieve the MDGs by 2015. The targets set by the MDGs are achievable, but governments may need to introduce changes to laws and policies that improve reproductive health rights to do so. The current global economic difficulties affecting countries like the UK, the USA, and many other countries around the globe will undoubtedly put a strain on the ability of many governments to allocate sufficient financial and human resources to ensure that maternity care is safe, available, accessible, and affordable to its population. Low-income countries will be harder hit in the current economic turmoil, but at the same time, these countries have to do more because they carry the largest burden of the global maternal mortality. Global partnerships between low- and high-income countries to address reproductive health issues are critical. It is also critical that we continue to engage the governments and policy makers of all nations to ensure that reproductive rights remain a priority. The Maternal Mortality Campaign is one such example where European Union and G8 leaders are encouraged to commit to costed and timetabled actions that improve women's access to health care and reduce maternal mortality in under-resourced countries.

Postpartum hemorrhage (PPH) is the leading medical cause of maternal mortality worldwide. Eclampsia is another important cause. There is sufficient evidence available on successful interventions such as treatment of severe pre-eclampsia/eclampsia with magnesium sulfate as well as the use of ergot and oxytocics for PPH secondary to uterine atony [14]. All these evidence-based interventions that can reduce maternal mortality and morbidity can only be performed when issues such as adequate and appropriate facilities, adequate staffing levels of knowledgeable skilled attendants, and availability of essential drugs are addressed. The provision of such a functioning health system by the government must be seen as a fundamental right of every community. Similarly, use of the partogram for early identification and prevention of obstructed labor, one of the major causes of maternal deaths worldwide, is encouraged for all laboring women. All evidence-based practices that reduce maternal, newborn, and infant mortality and morbidity must be made available to women in labor as a basic right.

Female genital mutilation (FGM) is associated with increased risk of urinary tract infections in pregnancy, anemia, preterm labor, and preterm delivery. Over 13 African countries as well as most high-income countries have laws prohibiting female genital mutilation/cutting (FGM/C) as a means to eradicate a harmful cultural and traditional practice. As expected, changing attitudes to harmful traditions and cultures can be met with resistance, as shown by the high prevalence (90%) of FGM/C in countries such as Eritrea, Guinea, Mali, and Egypt [15]. A prolonged and concerted effort through education and engagement of community leaders and government officials is needed in such communities to bring change.

Globally, unsafe abortions are responsible for over 67000 maternal deaths annually, accounting for 13% of total maternal mortality [16]. Ninety-seven percent of unsafe abortions occur in under-resourced countries. In Western Europe the incidence rate of unsafe abortion is negligible compared with a rate of 31 per 1000 women in East Africa and 34 per 1000 in South America. There is a clear relationship between high maternal mortality from unsafe abortions in countries with restrictive abortion laws. The maternal mortality rate from unsafe abortion is 34 per 100000 live births in a country with restrictive abortion laws compared with 1 or less in those with liberal laws. The Confidential Enquiries into Maternal Deaths in South Africa [17], [18] have shown that maternal deaths as a result of septic abortion have been declining since the introduction of the Choice on Termination of Pregnancy Act in 1996 [19]. Similarly, significant reductions in maternal deaths were seen in Romania when less restrictive abortion laws were introduced in 1989 [20]. These laws ensured access to safe legal abortions in Romania. Termination of pregnancy is a sensitive issue in many parts of the world because of religious, cultural, social, and traditional beliefs. We would like to challenge and encourage societies and countries with restrictive abortion laws to look at the evidence available in favor of liberal abortions laws and debate the possibility of making the choice of termination of pregnancy a legal right for women. In the same breath, it is important to stress that wherever there is a liberal law on termination of pregnancy, the provision of safe and comprehensive abortion care is paramount to a successful reduction in maternal morbidity and mortality as a result of the complications of abortion.

HIV and AIDS are common causes of complications of pregnancy and delivery. In many Sub-Saharan African countries, as much as 40% of the pregnant women attending prenatal clinics are HIV positive. Decreased immunity due to HIV infection does lead to increased risks such as anemia and delayed wound healing after cesarean delivery. Without antiretroviral therapy, up to 40% of newborns from HIV-positive mothers will be infected. Therefore, in our attempts to make pregnancy and delivery safer, we need to ensure universal access to antiretroviral therapy for all HIV-positive pregnant women. The provision of antiretroviral therapy through the application of legal principles to force a government, even in low-income countries, to provide treatment for pregnant women in public health facilities is possible and can be effective [21].

In 1999, women's groups in Colombia convinced the government to include family planning as a right protected by the Constitution. They were successful because Columbia is signatory to the Women's Convention. The Women's Convention specifies a state's obligations such as prevention of maternal mortality and provision of appropriate services for pregnant women. The Human Rights Committee (HRC) of the United Nations Assembly has set 6 guidelines for monitoring the availability and use of obstetric services, which can assist treaty-monitoring bodies [22]. The HRC monitors the implementation of the Universal Declaration of Human rights and hold all signatory states to account.

There are many initiatives worldwide that seek to promote partnerships among countries, as well as international organizations, to improve reproductive health by: (1) improving access; (2) promoting evidence-based care; (3) capacity building; and (4) putting a focus on a human rights agenda.

The Global Elimination of Congenital Syphilis is a new initiative and a joint commitment by WHO, UNFPA, and other organizations. They have called for universal access to syphilis screening and adequate treatment of all pregnant women and their partners, thereby improving maternal and child health and hence achieve MDGs 4, 5, and 6.

There are also several ongoing initiatives in different regions of the world, such as the national road maps that help African governments reduce maternal and newborn mortality rates. In September 2006, western pacific countries committed themselves to making pregnancy safer through projects to strengthen health information systems and services and medical research capabilities in the region.

An important document put together by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, and the Royal College of Paediatrics and Child Health collectively sets out minimum standards for the organization and delivery of care in labor in the UK [23]. This report provides healthcare planners, unit managers, and clinical directors with guidelines on which to base realistic costing of the maternity service. This document discusses the minimum standards required to achieve safer childbirth through the principles of risk management, staffing roles and staffing levels, education, training and continued professional development, as well as facilities and equipment. This document shows commitment by professional bodies to achieve safer childbirth.

The Advances in Labour and Risk Management (ALARM) International Program (AIP) [24] is also one of the many important collaborative initiatives aiming to reduce maternal and neonatal mortality and morbidity. Countries such as Guatemala, Haiti, and Uganda have been in partnership with the Society of Obstetricians and Gynaecologists of Canada (SOGC) since 1999, under an initiative funded by the Canadian International Development Agency (CIDA). The partnership aims to strengthen the capacity of professional associations to assume leadership roles in the promotion of women's reproductive health and rights. These are but a few examples of global partnerships and initiatives that aim to improve reproductive health and rights that will lead to safer childbirth.

5. Conclusion 

The MDGs set for 2015 can be achieved as long as accessibility, affordability, and availability of reproductive health are seen as an integral part of basic human rights. There are already many treaties, regulations, and national and international laws that can ensure safer childbirth for women in most parts of the world, but more has to be done by increasing advocacy for the rights to safer childbirth in all parts of the world. More can be achieved through education, as well as introducing new laws and regulations that will improve empowerment of women in society in addition to improving the reproductive health of women in general. Through global and regional partnerships and by actively engaging politicians all over the world on reproductive health rights, safer childbirth will be a reality in all parts of the world. The rights-based approach is everyone's business.