Maternal Rights Research Articles

Caesarean section should be available on request: FOR: Responding professionally to requests for non‐indicated caesarean delivery

Obstetricians should respond professionally to requests for non-indicated cesarean delivery (CD). The professional responsibility model of obstetric ethics provides guidance for doing so (Chervenak et al. Am J Obstet Gynecol 2011;205:315.e1–5). This approach to obstetric ethics avoids the gridlock that results when obstetric ethics based primarily on fetal rights collides with obstetric ethics based primarily on maternal rights. The professional responsibility model is based on the ethical concept of medicine as a profession, introduced into the history of medicine by two British physician-ethicists, John Gregory (1724–1773) of Scotland and Thomas Percival (1740–1804) of England. This concept requires physicians to become and remain scientifically and clinically competent, to use their knowledge and skills primarily for the benefit of the patient, and to keep individual and guild self-interest systematically secondary. The ethical principles of beneficence (undertake clinical management, the outcomes of which are reliably expected to be clinically beneficial) and respect for autonomy (empower the pregnant woman to make informed decisions about the clinical management of her pregnancy) translate this concept into clinical practice. The obstetrician has beneficence-based and autonomy-based obligations to the pregnant woman and beneficence-based obligations to the fetus when it is a patient (McCullough and Chervenak, Ethics in Obstetrics and Gynaecology, New York: OUP; 1994). Because the viable fetus is a patient, the ethics of CD requires balancing of obligations the pregnant and fetal patient (Chervenak and McCullough, Best Pract Res Clin Obstet Gynaecol 2013;27:153–64). In the professional responsibility model of obstetric ethics, the pregnant woman is ethically obligated to take reasonable risks to her life and health for fetal benefit, when there is a reliable evidence base for such benefit. Requests by patients for clinical intervention do not, in themselves, create an ethical obligation to fulfill such requests without careful evaluation of them, to ensure that acting on them is consistent with professional integrity (Brett and McCullough, JAMA 2012;307:149–50). Professional integrity requires that implementing such requests will result in net clinical benefit to the patient. There is no net clinical benefit from non-indicated CD (Minkoff and Chervenak, New Engl J Med 2003;348:946–50). The beneficence-based and integrity-based professional responsibility of the obstetrician is to respond to requests for non-indicated CD with a recommendation against it and for vaginal delivery. Non-directive counselling, i.e., offering both modes of delivery as if both passed muster in beneficence-based clinical judgment, is ruled out by the professional responsibility model. These recommendations should be explained to the pregnant woman and discussed with her in the informed consent process. Obstetricians should take a preventive ethics approach to decision-making, raising it as a possibility and making decisions about it well in advance of the intrapartum period (Chervenak and McCullough, Am J Obstet Gynecol 2013;209:166–7). In rare cases, the pregnant woman will not accept the recommendation of vaginal delivery when CD is not indicated and will reiterate her request for the latter. It is ethically permissible to implement an informed, reflective decision for non-indicated CD. None declared. ■

Bioethics, Human Rights, and Childbirth

The global reproductive justice community has turned its attention to the abuse and disrespect that many women suffer during facility-based childbirth. In 2014, the World Health Organization released a statement on the issue, endorsed by more than 80 civil society and health professional organizations worldwide.The statement acknowledges a growing body of research that shows widespread patterns of women's mistreatment during labor and delivery-physical and verbal abuse, neglect and abandonment, humiliation and punishment, coerced and forced care-in a range of health facilities from basic rural health centers to tertiary care hospitals. Moreover, the statement characterizes this mistreatment as a human rights violation. It affirms: "Every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care throughout pregnancy and childbirth."The WHO statement and the strong endorsement of it mark a critical turn in global maternal rights advocacy. It is a turn from the public health world of systems and resources in preventing mortality to the intimate clinical setting of patient and provider in ensuring respectful care.

Pauline Hopkins and the Death of the Tragic Mulatta

Pauline Hopkins and the Death of the Tragic Mulatta JoAnn Pavletich (bio) Pauline Elizabeth Hopkins, turn-of-the-century intellectual, editor of the Colored American Magazine, and author of essays, plays, short stories, and four complex novels written in the short span of five years is deservedly celebrated as a writer whose texts attempt to subvert racist social norms and encourage resistance. As Claudia Tate rightly claims, Hopkins’s first novel, Contending Forces, is a “manifesto on the value of fiction to social activism in black America” (170), and in the introduction to Contending Forces, Hopkins herself claims that “[i]n giving this little romance expression in print, I am not actuated by a desire for notoriety or for profit, but to do all that I can in an humble way to raise the stigma of degradation from my race” (13–14). These activist and didactic intentions are borne out in all four of her novels, which offer readers a parade of righteous and pure men and women who do not deserve the “stigma of degradation” and struggle to rise above it. Hopkins’s politically charged novels transmit their arguments through many genres, but most obviously and predominantly through the conventions of the period’s sentimental and domestic literature, which includes an almost obsessive preoccupation with feminine virtue, submissiveness, and piety. Significantly, each of Hopkins’s full-length novels1 employs these conventions in the context of a mixed-race female protagonist, resulting in a tension between the author’s stated purpose of promoting African American agency and the imperatives that structured sentimentalism. This tension is the focus this essay. The significance of Hopkins’s mixed-race female protagonists has been a central topic in previous scholarship on her work. The figure of the mulatto, or the tragic mulatta,2 a stock figure in nineteenth-century sentimental literature, sprung out of that century’s confluence of abolitionist efforts and gender ideologies, emerging alongside and structured by notions of “true womanhood” in antebellum America. As many scholars have observed, this popular and influential trope functioned as an effective vehicle to explore relations between the races.3 According to Hazel Carby, one of Hopkins’s first and most sensitive critics, “[a]s a mediating device the mulatto had two narrative functions: it enabled an exploration of the social relations between the races … and it enabled an expression of the sexual relations between the races, since the mulatto was a product not only of proscribed consensual relations but of white sexual domination” (xxi–xxii). This literary exploration, however, took place in a specific and limited ideological context where the dominant literary form and the dominant gender ideology were both constituted by notions of “true womanhood.” Thus, while the mulatto functioned as a narrative device, it existed within narratives inextricably tied to the rhetoric of true womanhood. [End Page 647] Separate spheres ideology, later christened the Cult of True Womanhood by Barbara Welter, advanced a regime of purity, piety, submissiveness, and domesticity as the basis for female moral authority. Writers seeking to end slavery or ameliorate racial injustices depicted mixed-race women possessing these characteristics in order to represent Black women as capable of asserting moral authority and participating in civil society. The obvious dilemma presented by this construct, however, is what Shirley Samuels has termed the “double logic of power and powerlessness”: the contradiction between an assertion of female authority and the purity, piety, submissiveness, and domesticity that policed female subjectivity (4). That Hopkins created pure and submissive protagonists and engaged the conventional marriage plot of sentimental literature is not surprising. Given the way in which slavery stripped African American women of maternal and familial rights, Hopkins’s and others’ use of the “seemingly conventional trope of redemptive maternity [and marriage] becomes not so conventional” (McCullough 40).4 Moreover, as Ann duCille notes, for the black female intelligentsia of the post-Reconstruction era, “marriage was the calling card that announced … civility and democratic entitlement” (30). This democratic entitlement came with a price, however, and this article examines Hopkins’s innovative responses to working within the ideological constraints of her era, while simultaneously attempting to “faithfully portray the inmost thoughts and feelings of the...

Our bodies, our choices: Australian law on foetal personhood.

The debate revolving around foetal vs maternal rights has been philosophised for years. It has captured attention internationally with the European Court of Human Rights struggling for over five decades to define personhood, and is still yet to reach a definite formulation. A proposed Law Crimes Amendment Bill (Zoe's Law, 2) is currently fuelling public debate about women's reproductive choices in New South Wales, Australia. The proposed legal bill attempts to redefine a 'person' or 'human being' by placing a marker on when 'personhood begins' namely at 20 weeks or weighing a minimum of 400g. Similar laws recognising personhood at foetal viability have come into force in the United States of America that clearly show the broader consequences of this kind of legislation as American women now face county-by-county, state-by-state anti-choice legislative activism. Midwives work closely with women and their families giving them the authority to formulate opinions on issues of maternal-foetal conflict. If a law such as this is allowed to pass a number of legal and ethical issues will arise for Australian midwives that could potentially have far reaching implications for them and for the women and families that they provide women-centred care for.

Tackling the 'Elephant in the Room': Putting Gender Justice at the Core of a Rights-Based Maternal Health Policy Advocacy Agenda

United Nations Population Fund observes that maternal mortality is the single largest health inequity in the world, with 99 percent of deaths occurring in developing countries. Research suggests that violations of women’s right to equality, lack of adequate recognition of women’s rights to life and health and poverty are key determinants of women’s ability to access the requisite obstetric care. The failure of traditional public health approaches to tackle the issue has led many health activists to consider alternative frameworks and re-frame the debate as a human rights issue to secure political priority. However, the growing literature on human rights-based approach (HRBA) to maternal health lacks empirical evidence to confirm this optimistic speculation by health activists and practitioners while development theorists continue to debate the concrete contributions of the human rights paradigm to human development and poverty alleviation efforts. Further, public policy scholars, particularly in the social constructivist tradition, caution us about the complexities (including unintended outcomes) involved in using framing as a strategy for mobilizing resources for progressive policy reform.Hence, this paper evaluates the potential of HRBA to development through examination of the historic and countrywide proclamation of maternal mortality as a human right violation (in a public interest litigation case) in a 2010 High Court verdict in India (claimed to be the first of its kind at a country-level). The research employs a qualitative case study approach including fifty key informant interviews with state and non-state officials.Preliminary findings point to negligible impact of the new framing in provoking institutional change and no alteration in policy design; more importantly, the verdict fails to address the root causes of the issue, i.e. women’s social status. A deeper enquiry reveals: 1) a significant contradiction in the narratives of HRBAs to maternal health advanced by activist groups, which fail to explicitly link maternal health outcomes to its root cause and instead focus on the medicalized and technocratic dimensions of the problem that (regrettably) reverberate the attitude within state machinery and global health agencies; and 2) the inherent contradiction in human rights advocacy that spearheads mobilization around a shared recognition of the problem and solutions, yet its highly abstract, normative and subjective nature renders it more difficult for advocacy groups to outline a shared tactic, to achieve the desired objective(s). Situating these findings against the debates in the “gender justice” literature, the paper draws attention to the ways that gender and other inequalities may inform law and rights agendas of different well intentioned groups, including state-supported projects, that limit themselves to seeking recognition of maternal health rights intended to improve a demand driven public health system but fail to seek active citizenship for women who can pursue state accountability for just governance and can stake women’s claim to new entitlements arising from the needs articulated by those women affected by lack of rights and influences. The findings will be of interest to scholars in political science, human rights and development, women’s studies and practitioners engaged in advocating for better maternal health outcomes.

The emergence of a global right to health norm--the unresolved case of universal access to quality emergency obstetric care.

BackgroundThe global response to HIV suggests the potential of an emergent global right to health norm, embracing shared global responsibility for health, to assist policy communities in framing the obligations of the domestic state and the international community. Our research explores the extent to which this global right to health norm has influenced the global policy process around maternal health rights, with a focus on universal access to emergency obstetric care.MethodsIn examining the extent to which arguments stemming from a global right to health norm have been successful in advancing international policy on universal access to emergency obstetric care, we looked at the period from 1985 to 2013 period. We adopted a qualitative case study approach applying a process-tracing methodology using multiple data sources, including an extensive literature review and limited key informant interviews to analyse the international policy agenda setting process surrounding maternal health rights, focusing on emergency obstetric care. We applied John Kingdon's public policy agenda setting streams model to analyse our data.ResultsKingdon’s model suggests that to succeed as a mobilising norm, the right to health could work if it can help bring the problem, policy and political streams together, as it did with access to AIDS treatment. Our analysis suggests that despite a normative grounding in the right to health, prioritisation of the specific maternal health entitlements remains fragmented.ConclusionsDespite United Nations recognition of maternal mortality as a human rights issue, the relevant policy communities have not yet managed to shift the policy agenda to prioritise the global right to health norm of shared responsibility for realising access to emergency obstetric care. The experience of HIV advocates in pushing for global solutions based on right to health principles, including participation, solidarity and accountability; suggest potential avenues for utilising right to health based arguments to push for policy priority for universal access to emergency obstetric care in the post-2015 global agenda.

Paul Hunt and Tony Gray (eds), Maternal Mortality, Human Rights and Accountability (London: Routledge, 2013), 256 pp., ISBN: 9780415534581, £135.00, hardback.

Edited by Paul Hunt and Tony Gray, Maternal Mortality, Human Rights and Accountability (2013) is an important contribution to academic knowledge on maternal mortality accountability and agenda setting. I say this for three reasons: it gathers well-known experts and authorities working on maternal health and human rights; it produces the sort of insights and recommendations that are likely to result in international rules and recommendations; and it addresses some important contemporary global health strategies that respond to the widespread issue of maternal mortality from a human rights perspective.

Policy Statement on Planned Home Birth: Upholding the Best Interests of Children and Families

* Abbreviations: AAP — : American Academy of Pediatrics We strongly disagree with Chervenak et al1 that the American Academy of Pediatrics (AAP) policy statement on “Planned Home Birth”2 diverges from its own primary principle, to promote the best interests of the child. First, the statement does not promote home birth. We begin, as the authors note, by agreeing with the statement of the Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists that “hospitals and birthing centers are the safest setting for birth.” In addition, we state that the pediatrician should counsel expectant parents regarding the apparent risks of home birth in the United States. Subsequently, after the infant is born, we specifically promote the best interests of the child who is born at home by setting standards for care that adhere to those delineated in AAP publications.3 The arguments made by Chervenak et al regarding the “best interests of the child” have several notable flaws. First, before delivery, the fetus is not an independent being (child), but a fetus, and the authors inexplicably ignore both the ethical principle of autonomy for the expectant mother and the difficult balance of maternal and fetal benefits and harms. Previous commentary by these authors advocates overriding both maternal and fetal rights, arguing instead for the “professional responsibility model of obstetric ethics, which emphasizes the importance of medical science and compassionate clinical care of both the pregnant and fetal patient. … Address correspondence to Kristi L. Watterberg, MD, Department of Pediatrics, MSC 10 5590, University of New Mexico, Albuquerque, NM 87131-0001. E-mail: kwatterberg{at}salud.unm.edu

Late termination of pregnancy: Maternal counselling and fetal rights

Late termination of pregnancy: Maternal counselling and fetal rights

The Italian Debate on the Lowest Threshold of Viability and Fetalneonatal- maternal Rights: Conflicts Between Law, Case Law, Religious Insights and Clinical Practice

The Italian Debate on the Lowest Threshold of Viability and Fetalneonatal- maternal Rights: Conflicts Between Law, Case Law, Religious Insights and Clinical Practice

The Italian Debate on the Lowest Threshold of Viability and Fetalneonatal- maternal Rights: Conflicts Between Law, Case Law, Religious Insights and Clinical Practice

The Italian Debate on the Lowest Threshold of Viability and Fetalneonatal- maternal Rights: Conflicts Between Law, Case Law, Religious Insights and Clinical Practice

Addressing maternal healthcare through demand side financial incentives: experience of Janani Suraksha Yojana program in India.

BackgroundDemand side financing (DSF) is a widely employed strategy to enhance utilization of healthcare. The impact of DSF on health care seeking in general and that of maternal care in particular is already known. Yet, its effect on financial access to care, out-of-pocket spending (OOPS) and provider motivations is not considerably established. Without such evidence, DSFs may not be recommendable to build up any sustainable healthcare delivery approach. This study explores the above aspects on India’s Janani Suraksha Yojana (JSY) program.MethodsThis study employed design and was conducted in three districts of Orissa, selected through a three-stage stratified sampling. The quantitative method was used to review the Health Management Information System (HMIS). The qualitative methods included focus groups discussions with beneficiaries (n = 19) and community intermediaries (n = 9), and interviews (n = 7) with Ministry of Health officials. HMIS data enabled to review maternal healthcare utilization. Group discussions and interviews explored the perceived impact of JSY on in-facility delivery, OOPS, healthcare costs, quality of care and performance motivation of community health workers.ResultsThe number of institutional deliveries, ante-and post-natal care visits increased after the introduction of JSY with an annual net growth of 18.1%, 3.6% and 5% respectively. The financial incentive provided partial financial risk-protection as it could cover only 25.5% of the maternal healthcare cost of the beneficiaries in rural areas and 14.3% in urban areas. The incentive induced fresh out-of-pocket spending for some mothers and it could not address maternal care requirements comprehensively. An activity-based community worker model was encouraging to augment maternal healthcare consumption. However, the existing level of financial incentives and systemic support were inadequate to motivate the volunteers optimally on their performance.ConclusionDemand side financial incentive could enhance financial access to maternal healthcare. However, it did not adequately protect households from financial risks. An effective integration of JSY with similar social protection or financial risk-protection measures may protect mothers substantially from potential out-of-pocket spending. Further, this integrated approach may help upholding more awareness on maternal health rights and entitlements. It can also address maternal health beyond ‘maternal healthcare’ and ensure sustainability through pooled financial and non-financial resources.

Maternal mortality and human rights: landmark decision by United Nations human rights body

Despite global commitment and prevention through well-known interventions progress has been slow towards Millennium Development Goal 5 of reducing global maternal mortality. The United Nations (UN) Human Rights Council has highlighted maternal mortality as an issue bearing not just on development but also on human rights. In August 2011 the Committee on the Elimination of Discrimination against Women became the first UN human rights body to issue a decision on maternal mortality. The case Alyne da Silva Pimentel v. Brazil established that States have a human rights obligation to guarantee women of all racial and economic backgrounds timely and non-discriminatory access to appropriate maternal health services. After the death of this Brazilian woman who died from pregnancy-related causes after a misdiagnosis and delay in provision of emergency obstetric care the Convention of All Forms of Discrimination against Women (CEDAW) argued that there was no effort to establish professional responsibility and that she was unable to obtain justice in Brazil. The Committee found violations of the right to access health care and effective judicial protection in the context of non-discrimination; cases like this furnish opportunities for international and domestic accountability. The Committee made several general recommendations intended to reduce preventable maternal deaths which include ensuring women’s rights to safe motherhood and emergency obstetric care providing professional training for health workers and implementing Brazil’s national Pact for the Reduction of Maternal and Neonatal Mortality.

Feminist Anthropology Confronts Disengagement

Feminist ethnography was a hot topic at anthropology conferences in the 1980s and 1990s. As students, we remember meeting rooms so packed that people crowded in the doorways, straining to hear energetic debates over the negotiation of power, the embodiment of systemic and structural violence, the possibilities for combining scholarship and political activism, and issues of identity and diff erence – not least the dangers of imposing an ethnocentric feminist agenda on ‘other’ women. By early in the new millennium, that passion had waned; feminist sessions at major conferences were fewer in number, audiences smaller. At the same time, even thinkers foundational to the fi eld began to decry the lost promise of feminist anthropology, arguing that the Y2K version was less political and less eff ective (e.g., Alonso 2000; Moore 2006). For many feminist anthropologists who remain actively commi ed to engagement and advocacy, this is a troubling and puzzling trend. It is not as if the problems are all resolved or the injustices all redressed. This special issue seeks to comment on feminist anthropological engagement during a period of supposed disengagement. The papers represent a selection of the kind of work being done by feminist anthropologists to confront intersecting inequities and to negotiate the persistent ‘awkwardness’ between feminism and anthropology diagnosed by Marilyn Strathern (1987) more than twenty years ago. Drawing on research that spans six countries and diverse topics, these articles embed the concept of engagement within the history and current practices of feminist anthropology to reveal that the fi eld continues to be a site of passion, promise and political activism. Pamela Downe’s article on motherhood in the context of HIV/AIDS ‘talks back’ to the pessimistic chronicling of feminist anthropology by arguing that claims of feminist failure and abandonment are mired – at least in part – in feminism’s intergenerational debates and in ongoing tensions within anthropology and academic feminism over the prospects for reconciling political engagement with theories of deconstruction. As a result, important feminist practices, including those undertaken by the women with whom anthropologists partner in their work, are relegated as secondary to the institutional and disciplinary practices of academic researchers. The potential for feminist anthropological engagement abounds in Downe’s project with HIV-infected and -aff ected women who, against formidable odds and public marginalization, claim maternal rights as mothers of their children whilst simultaneously challenging ethnocentric and class-bound models of ‘good motherhood’. Julia Murphy’s article off ers a similar analysis of the ways in which women’s claims and reactions to feminism do not fi gure as fully as they could or should in the anthropology of development. Despite the arguments of those cited by Downe, Murphy’s work with the Calakmul Model Forest in southeastern Campeche, Mexico, demonstrates that feminist engagement within the anthropology of development

Promoting Fetal Personhood: The Rhetorical and Legislative Strategies of the Pro-Life Movement after Planned Parenthood v. Casey

The article examines the pro-life movement's efforts to advance the legal, moral, and political arguments for fetal personhood in the period following the Supreme Court's case Planned Parenthood v. Casey . It begins with an overview of the efforts to define the fetus as a legal person prior to Casey , and proceeds to describe the opportunity created for pro-life forces by the court's ambiguous holding on the issue of personhood.Examining rhetorical and legislative strategies, the article argues that pro-life forces have transformed their framing of the abortion issue, from one that pits fetal rights against maternal rights, to one that emphasizes the unique and intimate bond between the woman and the "child." This rhetorical shift coincides with legislative agendas that indirectly attack the central claim of mainstream pro-choice activists: That the fetus is not a person. The article examines the imagery used by pro-life activists and the substantive statutory reforms they advocate. By casting the relationship between woman and fetus as nonadversarial and pursuing legislation expanding the rights of the fetus, such activists have been effective in establishing indices of fetal personhood. The article contends that these strategies are effective and serve to undermine the rhetorical and legal foundations of the abortion right.

Spotlight on health and human rights

The community of medical ethics and law educators are commendable for their consistent endeavours to communicate with students regarding their views on subjects addressed, assessments and teaching methods. There is still, however, some division between how and what students want to learn and the reality in practice. The ‘Spotlight on: Health and Human Rights’ conference, held at the Royal Society of Medicine on 31 October 2009, provided medical students and junior doctors with the opportunity to discuss the implications of human rights on health, patient rights, medical ethics and law, and their future role in health care. The conference was supported by the World Health Organization, the Royal Society of Tropical Medicine & Hygiene and the Institute of Medical Ethics, and over 100 delegates shared their views during an intensive one-day programme. Speakers from a variety of backgrounds in medicine, public policy, law and academia commended the young delegates for their commitment and attending on a Saturday. Dr Peter Hall, Chair of Doctors for Human Rights in the UK, opened the conference with an introduction to health and human rights and a poignant account of his experiences in Rwanda. Subsequent sessions covered specific topics, both theoretical and practical. Dr Christoffer Van Tulleken, University College London (UCL) Centre for International Development and Health, shed light onto a human rights-based approach in humanitarian crises, building on his experience in Burma with Cyclone Nargis. Lawyer Susan Wright, Director of Medecins du Monde UK, and her inspiring lecture on undocumented migrants and access to essential health care left a resounding impression on the delegates. Dr David McCoy, also from the UCL Centre for International Development and Health, lectured on health systems and the right to health – speaking memorably of the shift observed in the NHS, where individuals are treated as consumers rather than simply as patients. Support from the Institute of Medical Ethics allowed Gunilla Backman, of the Swedish International Development and Cooperation Agency, to contribute an insightful lecture on the value added by a human rights-based approach to health, drawing on both experience at a local level, such as in Guatemala, and with large international health organizations, such as the GAVI Alliance in Geneva. For the afternoon session, workshops discussing case studies on maternal health, patient rights and access to essential medicines shifted the focus from keynote speakers to the delegates and culminated in a closing panel debate. Led by two speakers from Amnesty International, Naomi McAuliffe and Dr Jim Welsh, discussion focused primarily on what health-care workers can actively do, with Ms McAuliffe reiterating that ‘health professionals are human rights defenders’. Evaluation feedback stressed the need to incorporate human rights into the medical student curriculum and inspired delegates to gain a better understanding of the subject. The day was considered by many delegates to be ‘inspirational’, ‘fascinating’ and with ‘a lot to absorb’. The right to health is a notion that strikes a chord with medical students and appeals to their compassionate, considerate and ethically minded side. As children growing up during the UN Decade for Human Rights Education (1995–2004), human rights principles and language in a world characterized by migration and globalization may provide a missing link for students in today’s medical ethics and law curriculum. Medical ethics and law education in the United Kingdom is undergoing continuous transformation. We anticipate the event to be the first of many focusing on medical ethics, law and human rights. The ‘Spotlight on: Medical Ethics & Law’ conference, supported by the Institute of Medical Ethics, is currently in preparation and will be held at the Royal Society of Medicine. If you are interested in contributing, or would like further information, please contact Joseph.fitchett@doctors.org.uk.

Maternal Mortality and Human Rights

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Maternal health and human rights

In Malawi the maternal mortality ratio is extremely high. Since almost all maternal deaths are avoidable, maternal mortality is also an issue of human rights. This paper examines the root causes of high maternal mortality in Malawi and applies a human rights-based approach to the reduction of maternal mortality. It recommends roles for the various duty-bearers. It describes indicators to monitor and evaluate the strategy and suggests how transparency and accountability should be ensured. In conclusion, full and effective implementation of the strategy is indispensable for achieving the fifth Millennium Development Goal that calls for the reduction of maternal mortality.

Accessing Maternal Health Services in Eastern Burma

Burma is a country that has endured decades of war and civil conflict. The State Peace and Development Council, the current military regime that has governed the country for decades, has had ongoing conflicts with ethnic minority groups. Specific policies of the State Peace and Development Council have resulted in forced labor, forced relocation, torture, killings, and deliberate destruction of food supplies [1–3], largely targeted at ethnic minorities within the country [4]. Over one million Burmese are estimated to have been displaced since 1996 [5], and about half have been unable to resettle or return to their homes. The eastern border of the country bears the largest burden of internally displaced persons in the country [5]. Accurate measures of health are critical to address the high morbidity and mortality in this vulnerable population. However, there is a wide variation in reported estimates of health indicators. For example, the World Health Organization reports a maternal mortality ratio of 360 per 100,000 live births [6]; in 2006 UNICEF reported an under-five mortality rate of 104 per 1,000 live births and an infant mortality rate of 74 per 1,000 live births [7]. In contrast, surveys conducted by the Back Pack Health Worker Team—a community-based organization providing health care to internally displaced persons in active conflict zones (“black zones”)—give very different results. The team's surveys estimate maternal mortality as 1,000–1,200 per 100,000 live births [4] and infant mortality and under-five mortality as 91 per 1,000 live births and 221 per 1,000 live births, respectively [4]. Linked Research Article This Perspective discusses the following new study published in PLoS Medicine: Mullany LC, Lee CI, Yone L, Paw P, Oo EKS, et al. (2008) Access to essential maternal health interventions and human rights violations among vulnerable communities in eastern Burma. PLoS Med 5(12): e242. doi:10.1371/journal.pmed.0050242 Luke Mullany and colleagues examine access to essential maternal health interventions and human rights violations within vulnerable communities in eastern Burma.

Access To Essential Maternal Health Interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma

BackgroundHealth indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.Methods and FindingsSelected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15–45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or ≥ 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates ≤ 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95–2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21–25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23–15.8) times higher among those forcibly displaced.ConclusionsCoverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.