1. Maternal and Neonatal Health: Using a Human Rights Approach Maternal and Neonatal Health: Using a Human Rights Approach Sofia Gruskin, JD, MIA(2), Adriane Martin Hilber, MPH(1), Mindy Jane Roseman, JD, PhD(3), Ornella Lincetto, MD (1), Eszter Kismodi, JD,LLM (1), Jane Cottingham, MSc (1) World Health Organization, Department of Reproductive Health and Research(1); Harvard School of Public Health, Programme on International Health and Human Rights(2), and Harvard Law School, Human Rights Program(3) Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

2. Maternal Mortality WHO estimates 529, 000 maternal deaths each year (i.e., more than one woman dies per minute from pregnancy-related causes) WHO estimates 529, 000 maternal deaths each year (i.e., more than one woman dies per minute from pregnancy-related causes) 99% of maternal deaths today occur in Africa, Asia and Latin America 99% of maternal deaths today occur in Africa, Asia and Latin America Maternal mortality is the primary cause of death and disability in women of child-bearing age in developing countries Maternal mortality is the primary cause of death and disability in women of child-bearing age in developing countries Lifetime risk: Only 1 in 4,000 women in Western Europe v. 1 in 139 women in Latin America / the Caribbean v 1 in 16 in Africa Lifetime risk: Only 1 in 4,000 women in Western Europe v. 1 in 139 women in Latin America / the Caribbean v 1 in 16 in Africa Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

3. Neonatal and perinatal mortality WHO estimates that over 9 million deaths occur each year in the perinatal and neonatal periods WHO estimates that over 9 million deaths occur each year in the perinatal and neonatal periods 98% of these deaths take place in the developing world 98% of these deaths take place in the developing world Most of these deaths are caused by infectious diseases; pregnancy-related complications; or delivery-related complications Most of these deaths are caused by infectious diseases; pregnancy-related complications; or delivery-related complications Neonatal deaths now account for 40 -70% of all infant mortality Neonatal deaths now account for 40 -70% of all infant mortality Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

4. Maternal and Neonatal Mortality under International Human Rights Law Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

5. What are Human Rights? What are Human Rights? – Formal legal system – Advocacy – Approach to programming Definition Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

6. Obligations How are human rights enforced and/or realized? How are human rights enforced and/or realized? – Through national law and policy – Monitoring mechanisms – International technical and financial assistance – Civil society movements/activities Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

7. Applying human rights in the context of MNH: timeline 1960s-70s: MCH programming 1960s-70s: MCH programming 1985: Where is the M in MCH? 1985: Where is the M in MCH? 1987: Safe Motherhood Initiative 1987: Safe Motherhood Initiative 1990s: ICPD/FWCW 1990s: ICPD/FWCW 1997: Safe Motherhood as a Human right 1997: Safe Motherhood as a Human right 1999 to today: 1999 to today: – Formal/Normative system approaches: concluding comments, etc. – Advocacy—CRR/ PHR reports – Programs—AMDD – Assessment/accountability —WHO/PIHRR Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

8. Objectives of the assessment project (Tool) Assist countries to: Review and address legal and policy barriers to maternal and newborn health, as relevant to health systems data. Review and address legal and policy barriers to maternal and newborn health, as relevant to health systems data. Engage health sector and non-health sector actors to eliminate barriers to maternal and newborn health Engage health sector and non-health sector actors to eliminate barriers to maternal and newborn health Review and document government efforts to respect, protect and fulfil human rights related to maternal and newborn health Review and document government efforts to respect, protect and fulfil human rights related to maternal and newborn health Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

9. The Tool The Tool Consist of both a process and an instrument. The Tool is designed to help Government's conduct a self-evaluation of their efforts to improve MNH and respect, protect and fulfil human rights of mothers and newborns. It is designed to be Government led and, if necessary, externally facilitated (e.g. support provided by the UN or other NGO or institution) Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

10. The Instrument Developed out of a framework provided by Rebecca Cook and WHO -- "Advancing Safe Motherhood through Human Rights" Developed out of a framework provided by Rebecca Cook and WHO -- "Advancing Safe Motherhood through Human Rights" Revised by WHO and HSPH/PIHHR Revised by WHO and HSPH/PIHHR Validated in Switzerland Validated in Switzerland Field-tested in Mozambique, Brazil and Indonesia Field-tested in Mozambique, Brazil and Indonesia Expected publication in early 2007 Expected publication in early 2007 Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

11. International Human Rights Treaties International Development Goals and Targets Government Effort National Laws, Policies & Health Systems Health Indicators Multi Sectoral Action Planning Rights Relating to Information & Education Rights Relating to Non- discrimination Rights Relating to Health and Maternity Rights Relating to Life, Survival & Security HIV prevalence rate in pregnant women Maternal mortality ratioFemale, primary/secondary school enrolment as a percentage of male enrolment Incidence of FGM and/or other harmful traditional practices Number of births attended by skilled attendants Law/policy to reduce maternal mortality Law/policy on compulsory, free primary education Law/policy on elimination of practices harmful to maternal or neonatal health

12. Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

13. Rights Relating to Life, Survival, Security and Identify Law, policy and health system indicators Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

14. Rights Relating to Life, Survival, Security and Identify Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

15. Phase 3 - Prioritizing for action Phase 3 - Prioritizing for action Phase 2 - Adaptation, data compilation and analysis Phase 2 - Adaptation, data compilation and analysis Phase 1 - Establishing commitment & leadership Phase 1 - Establishing commitment & leadership The Tool : the process Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

16. Results from Field Tests: Key health issues Indonesia - Early pregnancy, early marriage and adolescents’ access to sexual and reproductive health information, education and services Indonesia - Early pregnancy, early marriage and adolescents’ access to sexual and reproductive health information, education and services Mozambique – Access to services; HIV/AIDS; Birth registration; information system; abortion Mozambique – Access to services; HIV/AIDS; Birth registration; information system; abortion Brazil – Referral system; adolescent utilization of services; marginalized populations access to services; quality of care Brazil – Referral system; adolescent utilization of services; marginalized populations access to services; quality of care Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

17. Results from Field Tests: Government Efforts Indonesia - Government launched an adolescents reproductive heath (ARH) programme. information, education, counselling) and included ARH in the national RH policy and strategy which covers communication and counselling and provision of services Indonesia - Government launched an adolescents reproductive heath (ARH) programme. information, education, counselling) and included ARH in the national RH policy and strategy which covers communication and counselling and provision of services Mozambique – Government has scaled up Em OC; updated referral hospital equipment, put in radio equipment etc and as a result reduced the MMR by two thirds over the past ten years. Mozambique – Government has scaled up Em OC; updated referral hospital equipment, put in radio equipment etc and as a result reduced the MMR by two thirds over the past ten years. Brazil – Government launched a Policy package to reduce MMR. It implements this policy through training, establishment of MMR committees in each of the over 1700 municipalities across 27 States, through monitoring and supervision. Brazil – Government launched a Policy package to reduce MMR. It implements this policy through training, establishment of MMR committees in each of the over 1700 municipalities across 27 States, through monitoring and supervision. Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

18. Results from Field Tests: Identified Barriers and Gaps Indonesia - Unequal provision on age of marriage, inadequate protection of girls/women from early marriage in the Law on Marriage; Inadequate legal protection for unmarried adolescents in relation to reproductive health services in the Population Law Mozambique – despite regulatory efforts, abortion remains illegal for most of the population; under the table fees inhibit access to care; lack of accountability measures in place to enforce attendance of basic service provision Brazil - Despite universal coverage, many marginalized population receive inadequate care due to distribution and monitoring mechanism failures; political challenges by professional association limit mid level providers authority to perform some life saving interventions and emphasis medicalisation of care Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

19. Results from Field Test: Ex: Recommendations from Indonesia LAW and REGULATIONS The existing marriage law should be revised in order to eliminate early marriage and early pregnancy by increasing the minimum legal age of marriage. The existing marriage law should be revised in order to eliminate early marriage and early pregnancy by increasing the minimum legal age of marriage. Both the Law on Population and the Law on Health should be amended/revised to make comprehensive reproductive health services including contraceptive services available, accessible, and affordable for unmarried and adolescents as well. Both the Law on Population and the Law on Health should be amended/revised to make comprehensive reproductive health services including contraceptive services available, accessible, and affordable for unmarried and adolescents as well. Those potentially responsible: Ministry of Justice Ministry of Justice Ministry of Women Empowerment, Ministry of Women Empowerment, Ministry of Education and Ministry of Education and Ministry of Religious Affairs Ministry of Religious Affairs Parliamentarians Parliamentarians Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS POLICIES/STRATEGIES and HEALTH SYSTEMS POLICIES/STRATEGIES and HEALTH SYSTEMS Policies and strategies should be developed to empower adolescents and young people with sexual and reproductive health and rights knowledge, understanding and skills. Policies and strategies should be developed to empower adolescents and young people with sexual and reproductive health and rights knowledge, understanding and skills. Policies regarding the promotion of minimum age of marriage for women and men should be harmonized. Policies regarding the promotion of minimum age of marriage for women and men should be harmonized. Those potentially responsible: Ministry of Women Empowerment, Ministry of Women Empowerment, Ministry of Education, Ministry of Education, Ministry of Religious Affairs Ministry of Religious Affairs

20. Lessons learned on Human Rights Impact Assessments Target audience matters – government led processes take longer; can‘t be controled; but if done well and owned, can lead to significant advances Target audience matters – government led processes take longer; can‘t be controled; but if done well and owned, can lead to significant advances Linking HRs and Health can be both technically and intellectually difficult Linking HRs and Health can be both technically and intellectually difficult Involving other sectors necessary but meaningful participation is a challenge Involving other sectors necessary but meaningful participation is a challenge Data is often unavailable or of low quality – but -validity of the data provides legitmacy Data is often unavailable or of low quality – but -validity of the data provides legitmacy Indicators and Frame alone do not make it a RBA; need an analysis framework that uses a rights lens to evaluate the findings Indicators and Frame alone do not make it a RBA; need an analysis framework that uses a rights lens to evaluate the findings Implications of results – advocacy, programming for change, involvement of other sectors – who follows implementation outside of the health sector Implications of results – advocacy, programming for change, involvement of other sectors – who follows implementation outside of the health sector Harvard School of Public Health PROGRAM ON INTERNATIONAL HEALTH AND HUMAN RIGHTS

22. “Knowing the need for intersectoral action, political commitment and implemenattion with a broader, more humane perspective of the questions and the answers is the biggest challenge facing women’s health” - Health worker, Rio Grande do Norte, Brazil - Health worker, Rio Grande do Norte, Brazil