Source: APO – Report:
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“As a midwife, I’ve held a torch in one hand while I prayed on one side that a mother didn’t die in childbirth,” said Angela Nguku, founder of the White Ribbon Alliance Kenya.
A midwife by vocation, Nguku said her 16-year journey as a talent advocate for pregnant women and newborns began in the delivery room, where she stood beside women giving life in dark birthing facilities with no electricity or medical supplies and without dignity.
Preventable maternal mortality and morbidity is no longer considered solely as a public health concern; it is also increasingly recognized as a human rights issue. With one woman dying every two minutes from preventable causes related to pregnancy and childbirth today, according to 2023 estimates by WHO, this phenomenon continues to be the deadliest manifestation of gender-based discrimination.
In 2012, UN Human Rights presented a technical guidance to the Human Rights Council that offered a human rights-based approach to tackling the issue which primarily affects women and girls in low- and middle-income countries, as well as the most marginalized populations in high-income nations. An update to this technical guidance was presented recently at the Human Rights Council in Geneva.
In the update, UN Human Rights reminded States that maternal deaths are not inevitable but only reflect their failure to uphold women’s human rights, especially the sexual and reproductive health and rights of those most marginalized. Women are not dying from untreatable diseases, they are dying because there is no political will to genuinely address the roots causes of maternal deaths, Nguku said.
“The reason I centre the voices of mothers is because I have walked with them. I have held their hands in labour wards. I have listened to their truths. Maternal mortality is not just a health statistic. It is a justice issue. It is women who are dying, yet most of the decisions about them are still made without them,” she added. “The world is still negotiating the worth of women’s lives. And when a woman dies giving life, justice is denied.”
Kenya’s maternal mortality ratio stands at 379 deaths per 100,000 live births as of 2023.While this represents a decline from earlier figures, it remains far above global targets.
Nguku also described the “poly-crisis” she said contributes to preventable maternal deaths, including economic, dignity, community, generational, cultural, social, and justice crises. “These overlapping crises primarily affect the underserved, including adolescents, Indigenous and pastoralist women, the rural and urban poor, migrants and refugees, and those living with disabilities. Yet most programmes still treat women as a single, homogeneous group, forgetting that their needs are shaped by specific contexts and lived realities,” she said.
Crucially, pregnancy and childbirth complications are among the leading causes of deaths of adolescent girls globally. According to WHO estimates, each year, adolescent girls have 21 million pregnancies in low- and middle-income countries, half of which are forced or unintended.
“Our mothers have to decide whether to use the money they have for the bus fare to get to the facility or use it to buy the supplies the hospital cannot provide for their stay or send their children to school or feed their families,” Nguku said. “Some women are disrespected at our healthcare facilities, they are not given any information or even called by their names. So, they prefer delivering their babies at home and risk death. But the minute a mother dies, the whole family collapses. This is what women told us through our unprecedented What Women Want campaigns. It shows the power of asking and listening.”
Nguku stressed that such a complex, multi-faceted issue as preventable maternal mortality and morbidity requires a holistic, integrated approach to resolve, which would include various stakeholders such as the women and girls themselves, the health practitioners, those in charge of the programmes and the policymakers in various sectors.
She also pointed out the need to take a multi-sectoral and intersectional tactic that would go beyond the health sector and focus on better education, including sexual and reproductive health education, water and sanitation, improved civil infrastructure and public financing, and the participation of the private manufacturers of the products that women and girls need.
“Until we stop looking at maternal deaths from the lens of development only and look at it from a comprehensive human rights perspective, we won’t be able to realise that we are talking about justice and we will keep failing women,” Nguku said.
At the 60th session of the Human Rights Council in Geneva, Switzerland, a resolution was adopted that reaffirms the importance of adopting a human rights-based approach, including the fulfilment of sexual and reproductive health and rights, in eliminating preventable maternal mortality.
Compounded injustices and systemic failures as a cause
In Colombia, Dr. Jezid Miranda, an obstetrician and maternal foetal medicine specialist, and professor at the University of Cartagena has, for the past 15 years, focused his research on improving pregnancy outcomes, particularly for conditions such as preeclampsia, and understanding how social inequalities influence these outcomes. He also serves as Chair of the Health System Strengthening Committee at the International Federation of Gynaecology and Obstetrics (FIGO), where he contributes to global discussions on the importance of robust health systems for improving maternal health worldwide.
“Although this happens around the world, what was shocking to me was seeing many women in my country face discrimination or neglect during pregnancy and childbirth, especially those from marginalized communities,” Miranda said. “Protecting women’s health is inseparable from protecting all their human rights, and research and advocacy are ways to make those rights visible and, in some way, actionable.”
Facts about maternal mortality and morbidity
- A woman dies approximately every two minutes from preventable causes related to pregnancy and childbirth.
- Women and girls in sub-Saharan Africa are up to 400 times more likely to die from these causes than women in high-income countries.
- Women and adolescent girls in low- and middle-income countries and from marginalized communities in high-income countries are most affected.
- Sixty-one percent of maternal deaths occur in crisis settings.
- Unsafe abortion remains a leading cause of preventable maternal mortality and morbidity in certain countries.
- Under international human rights law, governments have legal obligations to maintain the highest possible standard of health, including sexual and reproductive healthcare.
For Miranda, these preventable deaths and injuries occur against a backdrop of growing misinformation, distrust in science and global pushbacks against gender equality. Women continue to face abuses, disrespect and systemic barriers linked to poverty, ethnicity, language and legal status. Healthcare systems are also under pressure, he said, because of underfunding, the privatization of healthcare, and fragile health systems — especially in contexts compounded by crises such as migration, violence and armed conflict.
“Women’s health should not be covered by private interests, it should be a human right, but this is not the reality of our world today,” he said. “Women must pay to give birth in dignity. Some economies argue that this is how they keep their health systems on track, but it is a question of priority. With a better health system, comes healthier populations and healthy populations drive stronger economies.”
As stated in the UN Human Rights update to the technical guidance, the root causes of maternal mortality and morbidity lie in engrained gender inequalities, compounded by socio-economic injustices and systemic failures. These intersecting factors perpetuate disadvantages and risk, restricting women’s access to sexual and reproductive healthcare.
These injustices and failures, the report states, can manifest in lack of access to contraception to ensure adequate birth spacing, or denial of autonomy over pregnancy decisions or essential antenatal care; delays in reaching an appropriate health facility; underfunded and ill-equipped health systems, lacking the necessary interventions, medications or capacity to prevent and treat life-threatening complications; and discriminatory laws and lack of access to essential sexual and reproductive health services and information, or even their criminalization in some countries.
“When I look at maternal health, I see more than biology; I see rights, dignity and justice.“ – Dr. Jezid Miranda, obstetrician and professor at the University of Cartagena, Colombia
Miranda provided examples of how countries like Colombia have been able to reduce maternal mortality rates from 95 deaths per 100,000 live births in 2000 to 42 in 100,000 today. This comprised focusing on community-based solutions and training, including in Indigenous territories, and political commitment, rather than solely relying on expensive medical equipment.
He also highlighted the critical role of global organizations like UN Human Rights in supporting the implementation of relevant standards and pushing countries to respect women’s sexual and reproductive health and rights.
The importance of disaggregated data
In India too, the health system has improved pregnancy outcomes with increasing institutional births, although the quality of care in these institutions still needs much improvement, according to Dr. Subhasri Balakrishnan. An obstetrician by training, she has been working for more than 20 years in civil society organizations, including now at Common Health India that has adopted a human rights-based approach to maternal and reproductive health.
Balakrishnan’s organization has used ‘social autopsies’ to acquire data on maternal deaths in different states in India that analyse the social determinants of maternal mortality and morbidity through a human rights lens. Women in India are increasingly choosing to give birth in health facilities and maternal mortality has improved tremendously over the past two decades, she said. However, this improvement does not translate in the quality of care provided to women by medical institutions.
“There is a huge gap in terms of availability of human resources and supplies, in a diverse country like India, especially in states where health systems have historically been under-resourced and under-funded,” she said. “There has also been a lot of disinvestment in health systems over the years, in terms of privatisation, both overtly and covertly, which has resulted in increased contractualization of the workforce.”
Balakrishnan further pointed out that the women still dying from preventable maternal causes belong to historically marginalized and disadvantaged communities, such as Indigenous women and those living in remote areas, who still face discrimination in accessing healthcare. She stressed that maternal deaths are deeply tied to social determinants such as poverty, nutrition, caste, and gender and that these broader factors need to be adequately addressed.
For UN Human Rights, eliminating preventable maternal mortality and morbidity requires bold, systemic changes and solidarity. This would include establishing comprehensive data-collection systems. Balakrishnan confirmed that India has a sample registration system that counts maternal deaths from representative samples across the country, which, she said, is probably the most credible data that can be retrieved from the country’s large data sets. However, although that system provides some geographical disaggregation, it hasn’t proven useful in specifically identifying which communities are mainly affected.
“Caste is a huge determinant of access to health or discrimination in health in India and smaller studies or data sets would show that the most marginalised castes are disproportionately more represented in maternal deaths than the rest of the population,” Balakrishnan said. “Nor do we have cause of death data. The Sample Registration System doesn’t provide any cause of death data or disaggregated data by community. And unless we know those kinds of details, how are we actually going to address these issues?”
Balakrishnan stressed that it was essential to invest in strengthening the whole healthcare system to adequately start preventing maternal mortality and morbidity. This includes providing better working and contractual conditions for healthcare workers, supporting continuous training, and promoting their human rights.
In India, maternal mortality and morbidity have significantly decreased from 200 per 100,000 live births to half that amount in two decades. Balakrishnan credited political will, international frameworks such as the Sustainable Development Goals, and civil society accountability initiatives for these results. She also included the country’s maternal death surveillance and response system and emergency transport systems as examples of good practices.
“Civil society organizations have been able to document maternal deaths and brought attention to them, to a smaller scale. But there are no real accountability spaces,” Balakrishnan said. “The update [to the technical guidance] is useful in the sense that it gives us a document to support our accountability efforts and keep the attention on the issue.”
According to the update to the technical guidance, eliminating preventable maternal mortality and morbidity is a moral and human rights imperative involving clear State obligations. Because it is a matter of justice, only a human rights-based overhaul will ensure that no more women and girls die from preventable causes.
Tackling gender inequalities and the underlying social determinants of health, including sexual and reproductive health; addressing intersecting forms of discrimination; and addressing harmful dominant economic systems that prioritize profit over human rights were among recommendations made to States in the report.
– on behalf of United Nations: Office of the High Commissioner for Human Rights (OHCHR).
