Applying human rights to improve access to reproductive health services

International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j g o Applying human rights to improve access to reproductive health services Dorothy Shaw Rebecca J. Cook a Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canadab Faculty of Law, University of Toronto, Toronto, Ontario, Canada Universal access to reproductive health is a target of Millennium Development Goal (MDG) 5B, and along with MDG 5A to reduce maternal mortality by three-quarters, progress is currently too slow for most countries to achieve these targets by 2015. Critical to success are increased and sustainable numbers of skilled healthcare workers and financing of essential medicines by governments, who have made political commitments in United Nations forums to renew their efforts to reduce maternal mortality. National essential medicine lists are not reflective of medicines available free or at cost in facilities or in the community. The WHO Essential Medicines List indicates medicines required for maternal and newborn health including the full range of contraceptives and emergency contraception, but there is no consistent monitoring of implementation of national lists through procurement and supply even for basic essential drugs. Health advocates are using human rights mechanisms to ensure governments honor their legal commitments to ensure access to services essential for reproductive health. Maternal mortality is recognizedas a human rights violation by the United Nations and constitutional and human rights are being used, andcould be used more effectively, to improve maternity services and to ensure access to drugs essential forreproductive health.
2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
them that governments are obligated to remedy (paragraphs11,14,17,21,23,26-31).
Global recognition now exists that maternal health is critically The UN Human Rights Council has acknowledged that preventable important not only to prevent deaths and disability in women from maternal mortality and morbidity is a human rights violation pregnancy-related causes, but also to prevent associated deaths of and asked the UN High Commissioner for Human Rights to convene newborns, infants, and children and to lay a solid foundation for an expert meeting to prepare guidance on the application of human sustainable economic development of communities and nations.
rights to reduce preventable maternal mortality and morbidity Champions in all sectors have made commitments to address the Through these resolutions, governments made commitments to re- underlying causes of maternal mortality, the vast majority of which double their obligations to guarantee women's rights, including by are preventable. The slow progress of Millennium Development Goal allocating more resources for public health systems. The UN Global (MDG) 5, to reduce maternal mortality by 75% between 1990 and Strategy for Women's and Children's Health, launched in 2010, 2015, led to an addition of MDG 5B, universal access to reproductive echoed these resolutions, by recognizing the human rights and social health, in 2008—past the halfway mark to the target date of 2015.
justice dimensions of improving women's and children's health .
There is growing awareness that lack of progress in achieving As governments make political commitments in UN forums to MDG 5 is a function of discrimination against women. The UN renew their efforts to reduce maternal mortality, health advocates are Committee on the Elimination of Discrimination against Women using human rights mechanisms to ensure governments honor their (the CEDAW Committee), established under the Convention on the legal commitments to ensure access to services essential for repro- Elimination of All Forms of Discrimination against Women to monitor ductive health. The purpose of the present article is to explore how its implementation, never misses an opportunity to explain that constitutional and human rights are being used, and could be used when governments fail to provide health care that only women need, more effectively, to improve maternity services and to ensure access such as maternity care, that failure is a form of discrimination against to drugs essential for reproductive health. The application of humanrights is best done through collaboration with professional medicalassociations, such as affiliates of the International Federation ofGynecology and Obstetrics (FIGO), and technical agencies, such as theWorld Health Organization (WHO), to ensure the use of relevant ⁎ Corresponding author at: 4500 Oak Street, #B242, Vancouver, BC, Canada V6H 3N1.
medical and public health expertise, and to maximize the chances of Tel.: + 1 604 875 3536; fax: + 1 604 875 3456.
0020-7292/$ – see front matter 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi: Electronic copy available at: D. Shaw, R.J. Cook / International Journal of Gynecology and Obstetrics 119 (2012) S55–S59 2. Applying human rights to improve access to maternal her preventable death in childbirth Having been denied her legal entitlements to hospital care for those living below the poverty line,Shanti had to give birth at home without a skilled birth attendant. She Maternal deaths reportedly have declined from 409,100 in 1990 died immediately thereafter leaving a husband and 3 living children.
to an estimated total of 273,500 worldwide in 2011 . This is The direct cause of her death was postpartum hemorrhage due to a encouraging progress but much slower than required to meet MDG 5.
retained placenta. The contributing factors included her socioeco- In addition to mortality, at least 8 million women every year suffer nomic status, which resulted in her being denied needed resources disability as a result of pregnancy complications. Very much related to and services, and her poor health condition resulting from anemia, maternal health, an estimated 3.1 million newborns die annually , tuberculosis, and repeated unsafe pregnancies (paragraphs 28.10 and a further 2.6 million babies are born dead . Direct causes of (i); 35). In recognizing reproductive rights of pregnant women as maternal morbidity and mortality include hemorrhage, infection, inalienable survival rights, the Court ordered compensation to the high blood pressure, unsafe abortion, and obstructed labor, which family for the violation of her rights, receipt of benefits to which they account for 80% of maternal deaths globally . Indirect causes of are entitled under government schemes, and a maternal death audit death, including malaria, anemia, and HIV/AIDS that complicate or are aggravated by pregnancy, contribute the remaining 20% .
The Brazil, Paraguay, and India decisions are historic. They are the Maternal mortality statistics and explanations of causes of ma- first time courts of law have applied constitutional and human rights ternal mortality help to provide context for recent court decisions law to hold governments legally accountable for the preventable ma- on avoidable maternal death. In the first ever maternal death case ternal death of women. The decisions highlight the gaps in the health- to be decided by an international human rights body, the CEDAW care system from the perspective of pregnant women, and establish Committee held Brazil responsible for the preventable maternal death that governments are legally accountable for filling those gaps.
of Alyne da Silva Pimentel Teixeira, a Brazilian national of African Governments are increasingly making delivery care free to all descent, due to postpartum hemorrhage following delivery of a 27- women. India has implemented various strategies, including incen- week-old stillborn fetus in a private health center (paragraph tivizing women to give birth in facilities, but as the case of Shanti 7.4). This decision establishes as a matter of international law Devi's maternal death shows, there are gaps in these strategies.
that governments have human rights obligations to guarantee that Recognizing their obligations, almost half of the 47 African countries all women in their countries, regardless of income level or racial have now introduced free services, albeit with different formulas .
background, have access to timely, nondiscriminatory, and appropri- Other countries, such as Rwanda, have implemented a health insur- ate maternal health services in public and private health facilities.
ance program where members pay an annual premium equivalent to Even when governments outsource health services to private in- US $2, and women who complete 4 prenatal visits deliver at no cost stitutions, the Committee found that they remain responsible for Several countries, like Ethiopia, have included family planning their actions and have a duty to regulate and monitor private health explicitly in their plans to expand access to essential services .
centers. In light of these findings, the Committee ordered the Afghanistan and Haiti committed to remove user fees during the Coordinated efforts to assist low-resource countries in building a • Compensate Alyne's family including her mother and daughter, functional and sustainable public health system focused on maternal who was 5 years old at the time of her mother's death.
and child health are at unprecedented levels, and typically depend on • Ensure women's rights to safe motherhood and affordable access to the government's ability to finance essential drugs and health workers’ salaries . Task sharing (training for specific tasks performed by • Provide adequate professional training for healthcare providers.
different cadres of healthcare workers) is recognized as an important • Ensure that private healthcare facilities comply with national , mechanism for ensuring access to care. Some countries enable task and international standards on reproductive health care sharing by law, such as France, which now allows midwives working at public or private hospitals to perform nonsurgical abortion .
• Ensure that sanctions are imposed on health professionals who In addition to court decisions, strategies to ensure free delivery of violate women's reproductive health rights.
maternity care, and task-sharing approaches to improve reproductivehealth, fact-finding reports expose how health systems have failed In addition to the Alyne decision, the Inter-American Court of pregnant women Some reports show how health centers are Human Rights found Paraguay in violation of the right to life, and so overwhelmed that they fail to deliver care when women arrive in the right to exercise that right without discrimination, of Remigia labor Other reports show how women are harassed in health Ruíz, an indigenous woman who died in childbirth (paragraphs centers in degrading ways , and still others show how health 214,217,232,234,275,301-303,306; at 2,337(2)). The Court held systems are structured in ways that inhibit the delivery of services .
Paraguay responsible for Remigia's maternal death, and explained These reports are exhaustively researched, are based on extensive that the circumstances of her death manifested “many of the signs interviews of people working in various parts of the health system, relevant to maternal deaths, namely: death while giving birth with- and conclude with recommendations of steps to improve maternity out adequate medical care, a situation of exclusion or extreme pov- services. Usually these recommendations are shared with govern- erty, lack of access to adequate health services, and a lack of ments for their suggestions before they are published to ensure documentation on cause of death” (paragraph 232).
cooperation in their implementation. Reports, such as the reports on The ruling concerning Remigia's death was part of an indigenous India , have led to legal strategies of using courts in the lands claim, where the Court ruled that the failure of the government different Indian states to hold governments accountable for improv- to guarantee the Xákmok Kásek indigenous peoples possession of their ancestral property kept this community in a vulnerable stateregarding its health and welfare (paragraphs 214,273). While the 3. Applying human rights to ensure access to essential land is in the process of being returned to the community, the Court ordered provision of appropriate medical care for pregnant womenand their newborns (paragraph 301).
WHO estimates that over 10 million deaths per year could be At the national level in India, the High Court of Delhi found the avoided by 2015 by scaling up certain health interventions, the government in violation of Shanti Devi's right to life and health for majority of which depend on essential medicines At least 30% of Electronic copy available at: D. Shaw, R.J. Cook / International Journal of Gynecology and Obstetrics 119 (2012) S55–S59 the world's population lacks access to essential medicines . The professionals, and dispensing of medicines, without hindering access.
UN Prequalification Program for Priority Essential Medicines aims to Despite WHO technical guidance and assistance, overall, 38.7% (75 of increase global access to priority medicines that meet unified stan- 194) of member states have no website indicating their regulatory dards of acceptable quality, safety, and efficacy . MDG 8 on global authority, with 65.2% of African countries affected .
partnerships targets cooperation with pharmaceutical companies toincrease access to affordable essential medicines in low-resourcecountries, including essential reproductive health medicines.
3.1. Misoprostol to reduce postpartum hemorrhage The Essential Medicines List (EML) is devised by a WHO expert panel and revised every 2 years to reflect current global health con- Globally, postpartum hemorrhage is the most common cause of cerns. Medicines are identified through an evidence-based process maternal mortality. Much attention has been given to the use of and quality, safety, efficacy, and cost-effectiveness are key selection evidence-based interventions for prevention and treatment. The ideal criteria. The WHO EML includes oral hormonal contraceptives, inject- is for skilled birth attendants to provide active management of the able hormonal contraceptives, intrauterine devices, barrier methods, third stage of labor, but this is not the reality for about 37% of the implantable contraceptives, and emergency contraception.
world's women (about 50% in Africa) who give birth at home WHO, through its “packages of essential interventions” for safe Barriers to prevention of hemorrhage-related death and disability motherhood, deems the following medicines essential at the primary also include cost to the woman, supply chain issues, and the ability of care level: uterotonics (oxytocin and misoprostol), magnesium sul- health workers to administer uterotonics without a physician's order.
fate, antibiotics, and calcium gluconate, and the ability to administer Oxytocin is the uterotonic drug of choice, but it is an injectable that these drugs parenterally (intravenously or intramuscularly) requires refrigeration in tropical climates, whereas misoprostol is heat WHO also established a list in 2011 of priority medicines for mothers stable and in tablet form. FIGO, the International Confederation of and children based on the WHO EML . Even though these drugs Midwives (ICM), and others have been calling upon national regulatory are relatively inexpensive, to ensure wide access, laws and policies agencies and policy makers to approve misoprostol for postpartum may be required to facilitate task sharing, for example, to allow mid- hemorrhage prevention and treatment . Some countries, such as Mozambique and Tanzania, have studied the provision of misoprostol National EMLs are based on WHO's EML and vary from country to directly to pregnant women to prevent postpartum hemorrhage, and country. A report on access to essential medicines indicated that 19% of low-resource countries needed to establish or update a published In 2011, the WHO Essential Medicines Expert Committee approved national EML . Interestingly, there seems to be little correlation misoprostol for prevention of postpartum hemorrhage including use between identified population need for reproductive health, and the by health workers in the community. Its use for treatment of post- mirroring of national lists with that of WHO. Even when a medicine is partum hemorrhage was not approved noting: “Countries need to listed nationally as essential it does not guarantee access even in work to make oxytocin available for treatment of women who are countries that have shown leadership in making maternal and bleeding after delivery and misoprostol should only be used if there is newborn services freely available at point of service. It is also no other option” In many cases there is currently no other option.
challenging to locate any collated information on national EMLswhereby systematic comparisons can be made.
National EMLs are the cornerstone in providing access to prevent the common causes of reproductive mortality and morbidity. Theavailability of essential medicines requires a system that includes a The unmet need for family planning is acknowledged as a serious functioning supply and distribution system, adequate facilities and gap affecting up to 215 million couples globally, including married staff, affordable prices, and sustainable financing. However, a survey adolescents . Family planning has the potential to reduce 32% of in Uganda showed that among 28 nationally listed essential medi- all maternal deaths, 10% of newborn, infant, and child deaths, and cines, only 55% could be found in free health facilities . "Out-of- to decrease 71% of unwanted pregnancies—thus eliminating 53 mil- pocket” prices were 13.6 times higher for branded products and 2.6 lion unintended pregnancies, 22 million fewer unplanned births, times higher for generics than the international pricing reference 25 million fewer induced abortions, and 7 million fewer spontaneous A WHO study in China of 41 surveyed medicines, 19 of which abortions . FIGO has issued important Consensus Statements with were essential, showed that only 10% were available in private phar- ICM and the International Council of Nurses on the importance of macies as branded products and 15% as generics .
Voluntary Family Planning and its provision by their members, Selection for procurement is important in rationalizing the scarce recognizing the urgent need for improved access .
resources for essential medicines that must be available at all levels The US Department of Health and Human Services announced that it of health care. However, procurement outside the EML is common will include coverage of contraceptive counseling and provision of all because of local needs and lack of availability of listed products, Food and Drug Administration approved methods to patients in new as illustrated in Tanzania in 2007 where only about 52% of surveyed private health plans written on or after August 1, 2012 Making facilities procured medicines within the EML . Additionally, contraceptive counseling, services, and supplies, including long-acting, vertical disease programs in many African countries forecast disease reversible methods, with high up-front costs more affordable, acknowl- specific medicines, separate from the Ministry of Health forecasts for edges and addresses the cost barrier to effective contraceptive use.
other essential medicines . This has often resulted in fragmenta- In contrast to the USA, is Slovakia, where a fact-finding report tion and weakening of the system for medicines procurement.
exposed the country's stagnant stance on sex education and failure Health insurance systems in low-income countries might logically be to subsidize contraceptives The government has now legally seen as a solution to poverty from high out-of-pocket expenses on prohibited the public health insurance system from covering con- medicines, but the evidence is lacking, especially for essential medicines.
traceptives which means that millions of women, especially In addition to EMLs, national governments are responsible for those on low incomes, adolescents, and women in abusive relation- establishing strong national medicines regulatory authorities consis- ships have difficulty accessing affordable contraception. Worse still, tent with internationally developed norms, standards, and guidelines, the CEDAW Committee is investigating the prohibition of distribution and with accountability and transparency. Regulatory authorities of hormonal contraceptives in public health centers in Manila City, are charged with promoting and protecting public health and safety Philippines, pursuant to a fact-finding report showing the harms to in the manufacturing, storage, distribution, rational use by health women and their families of this ban .
D. Shaw, R.J. Cook / International Journal of Gynecology and Obstetrics 119 (2012) S55–S59 provides opportunities for a health system to learn about gapsthrough failing a given individual, as the Brazil, India, and Paraguay WHO includes emergency contraception (EC) on its Essential cases show. The application of human rights is critical to the success Medicines List. Moreover, EC is an important means to provide of the larger strategies to improve maternal and newborn health “secondary prevention of sexual violence,” that is measures that can because human rights shift understanding of maternal deaths as mere be taken after violence has occurred to reduce its health-related misfortunes to injustices that states are obligated to remedy.
harms and other consequences . EC has been the subject of many Human rights provide tools to hold governments legally account- legal contests regarding its registration and distribution, particularly able for their failure to address the preventable causes and to dis- tribute medicines essential for reproductive health. Accountability Some countries, such as Honduras, have banned EC, others, such as mechanisms are needed to track national EMLs, access by the end Costa Rica, have refused to register it . In response to such devel- user, and transparency in the listing of medicines essential for re- opments, the Federation of Latin American Associations of Obstetrics productive health. Where health ministries fail to establish such and Gynecology in 2010 explained that “to deny or erect obstacles to the mechanisms, health advocacy groups will move to apply constitu- utilization of emergency contraceptives constitutes a human rights tional and human rights law to hold governments accountable for violation, principally, to the right to decide to have children and when to not ensuring availability, including through subsidization, of medi- have them, the right to be free from discrimination for reasons of gender cines that are essential for reproductive health. As UN monitoring and/or age, and the right to have access to medication and the benefits committees, such as the CEDAW Committee, apply human rights to of scientific advances . In the wake of the 2010 earthquake in Haiti, ensure that women can survive pregnancy and childbirth and have the Inter-American Commission on Human Rights granted precaution- access to medicines essential for their reproductive health, they are ary measures to ensure that victims of sexual violence living in camps acknowledging women as human beings who have rights that entitle for internally displaced people have access to HIV prophylaxis and National courts have upheld or prohibited the distribution of EC.
For example, the Supreme Court of Mexico upheld an order callingfor the provision of EC to female victims of sexual violence and the The authors have no conflicts of interest to declare.
Colombian State Council endorsed the registration of EC Theconstitutional courts of Argentina, Chile, Ecuador, and Peru haveprohibited the distribution of EC . The Constitutional Court of Peru prohibited the Ministry of Health from distributing EC in the public [1] United Nations. Report of the Committee on the Elimination of Discrimination sector, ignoring the amicus curiae (“friend of the court”) brief—a brief against Women. General Recommendation 24 (twentieth session). A/54/38/Rev.1 presented by nonparties to a law suit—filed by the Association of Peruvian Obstetricians and Gynecologists . The brief estimated [2] United Nations. Human Rights Council. Preventable maternal mortality and morbidity and human rights. General Assembly. Eleventh session. June 16, 2009.
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