Judith Bueno de MesquitaI,*; Eszter KismödiII
ISchool of Law, University of Essex, Wivenhoe Park, Colchester, C04 3SQ, England
IIDepartment of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
Reducing the world's maternal mortality ratio by three quarters between 1990 and 2015 is one objective of Millennium Development Goal 5. However, progress towards this objective has been slow,1 despite global commitment and the fact that the majority of maternal deaths, 99% of which occur in developing countries,2 can be prevented through well known interventions. So what more is needed to get on track?
The United Nations (UN) Human Rights Council has highlighted maternal mortality as an issue bearing not just on development, but also on human rights.3-5 Human rights can enhance accountability for preventable maternal mortality.6 The UN Secretary-General's Global Strategy on Women's and Children's Health7 and the ensuing Commission on Information and Accountability for Women's and Children's Health have highlighted that strengthening accountability is an essential but neglected strategy for improving women's and children's health and reducing maternal mortality.8 In linking accountability with human rights, the Commission built its accountability framework on the right to health, equity in health and gender equality.
In August 2011, the Committee on the Elimination of Discrimination against Women, charged with overseeing States parties' implementation of their obligations under the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), became the first UN human rights body to issue a decision on maternal mortality. Alyne da Silva Pimentel v. Brazil9 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. The Committee also established that governments outsourcing services to private health-care institutions remain directly responsible for, and must regulate and monitor the actions of, these institutions.
The aforementioned case concerned Alyne da Silva Pimentel, a Brazilian woman of African descent who died from pregnancy-related causes after her local health centre misdiagnosed her symptoms and delayed providing her with emergency obstetric care. Her mother took the case to the CEDAW Committee, arguing that national authorities had made no effort to establish professional responsibility and that she had been unable to obtain justice in Brazil. Alyne's death exemplifies circumstances that are all too common everywhere: preventable maternal deaths seem to be concentrated among marginalized groups of women and they are marked by a lack of accountability.
The Committee found violations of the right to access health care and effective judicial protection in the context of non-discrimination. These rights are guaranteed by the CEDAW in the 187 countries that are party to it and legally bound by its provisions, as well as by most countries' constitutions and laws. Cases of this kind furnish opportunities for international and domestic accountability.
In its authoritative interpretation of States' obligations under the CEDAW, the Committee made several general recommendations intended to reduce preventable maternal deaths. They were: (i) to ensure women's right to safe motherhood and affordable access to emergency obstetric care; (ii) to provide adequate professional training for health workers; (iii) to ensure that private health-care facilities comply with national and international reproductive health-care standards; (iv) to implement Brazil's National Pact for the Reduction of Maternal and Neonatal Mortality, which includes the establishment of more maternal mortality committees to monitor maternal deaths; and (v) to ensure women's access to effective remedies when their reproductive rights have been violated. The Committee also recommended that Brazil provide reparation, including monetary compensation, to Alyne's family.9
The Committee's recommendations with regard to maternal mortality committees and access to effective remedies illustrate how a human rights approach can strengthen accountability for maternal deaths at the national level. International mechanisms can enhance accountability where national mechanisms are inaccessible, ineffective or absent. For example, UN treaty monitoring bodies, which independently oversee the implementation of international human rights treaties, review national reports periodically submitted by States parties and issue recommendations accordingly. Some of them, like the CEDAW Committee, also oversee complaints procedures such as the one described herein.
The case of Alyne da Silva Pimentel has global significance and may have global repercussions. Nationally its impact will be felt in the extent to which Brazil complies with the CEDAW Committee's recommendations. The Committee requested that Brazil submit within six months - i.e. by February 2012 - a written response detailing any action taken in response to its views and recommendations.
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4. Resolution 15/17. Preventable maternal mortality and morbidity and human rights: follow-up to Council resolution 11/8. In: United Nations Human Rights Council, fifteenth session, New York, 7 October 2010. New York: UN Human Rights Council; 2010. Available from: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G10/167/35/PDF/G1016735.pdf?OpenElement [accessed 4 January 2012]
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8. Commission on Information and Accountability for Women's and Children's Health. Keeping promises, measuring results. Geneva: World Health Organization; 2011. Available from: http://www.everywomaneverychild.org/images/content/files/accountability_commission/final_report/Final_EN_Web.pdf [accessed 10 January 2012]
9. Views. Communication No. 17/2008. Committee on the Elimination of Discrimination against Women, forty-ninth session, 11 to 29 July 2011. New York: CEDAW; 2011. Available from: http://www2.ohchr.org/english/law/docs/CEDAW-C-49-D-17-2008.pdf [accessed 10 January 2012] .