Human Rights Accountability for Advancement of Gender Equality and Reproductive Justice in the Sustainable Development Agenda
Since Cairo’s International Conference on Population and Development in 1994, several countries have developed innovative strategies and programs to advance the sexual and reproductive health and rights (SRHR) agenda leading to real and substantial accomplishments (ICPD Program of Action 1994). In the last decades, SRHR was recognized by states through the adoption of international consensus document. SRHR embrace human rights that are already recognized in international human rights treaties and conventions, and they have been incorporated in Constitutions, health policies, programs, and domestic legislation. SRHR imply that individuals should have control over their bodies and, in turn, live their lives, be healthy, and have sexual and reproductive autonomy and that they can enjoy their right to be free from injuries and preventable maternal deaths. SRHR also requires entitlements to health facilities, goods, and services as well as a broad range of social determinants; it also requires changes in laws and policies as well as in social, cultural, and institutional practices to be fully protected and realized (Yamin and El Falb 2012).
In 1995, the Beijing Declaration and Platform for Action represented a significant step forward in stipulating that women’s human rights include “their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence” (United Nations 2005). Ten years later, at the 2005 Millennium Development Goals’ Summit in New York, world leaders acknowledged that “universal access to reproductive health services by 2015” is necessary to improve maternal health (UN Millennium Development Goals Report 2015). At that time, governments believed that MDG 5 could only be met if the majority of women had access to key interventions, including prenatal care, skilled birth attendants, safe and legal abortion services, and postpartum services (UN Millennium Project Task Force on Child Health and Maternal Health 2005).
Despite to that, since then, abuses of human rights have been occurring in many countries in the delivery of sexual and reproductive health services. Women and adolescents living in poverty in rural and other isolated areas, without having the information, means, and ability to make autonomous decisions about their sexuality and life plans, or belonging to disenfranchised groups, suffer far more adverse health outcomes as compared to advantaged groups such as preventable maternal death causes or injuries. However, the growth of conservative nationalism agenda against SRHR, including women’s right to decide when and if to have children and to go safely through pregnancy, abortion, and childbirth, has made more challenging its prioritization by governments in the context of the 2030 Sustainable Development Agenda. Anti-rights engagement in the international arena operates to obstacle undercut the operation of human rights systems (AWID 2017). Women’s sexual reproductive health rights have been at the center of conservative attacks in many UN global and regional forums.
On the other side, effective human rights mechanisms to hold governments accountable, as well as human rights-based health and population policies, domestic laws, and health practices, are necessary conditions for people’s realization and enjoyment of the highest standard of health and well-being, especially more vulnerable and marginalized groups at national level. In the last decades, considerable conceptual progress has been made in several areas, most notably in General Recommendations and Concluding Observations issued by Human Rights Treaty Monitoring Bodies and Human Rights Council resolutions on maternal mortality and morbidity (UN Human Rights Council Resolutions 11/2 2009; 18/2 2011; UN OHCHR Technical Guidance 2012).
In the last decades, multiple human rights-based approaches to legal and policy frameworks have been adopted by different UN agencies, international organizations, and governments as an effort to implement international human rights principles in national and local contexts (Yamin 2017). The interpretations made by different human rights bodies have served the dual purpose of ensuring accountability and also clarifying the nature and extent of states’ obligations to guarantee sexual and reproductive health rights. At the national level too, increased litigation and greater involvement by human rights mechanisms have contributed to promotion and protection of these rights. Human rights accountability is a concept increasingly used in the area of maternal health to address or prevent human rights violations during health care. The framework requires looking beyond violations and punishment to individuals to address institutional and systemic factors that reflect a pattern of violations affecting certain groups of population (Yamin 2010).
The human rights approach to maternal morbidity and mortality makes it possible to hold health authorities, managers, health professionals, and government agencies accountable for violations of rights in each preventable individual case of maternal death. In addition to the search for individual accountability for violations, the theoretical framework of human rights can be used to design and to monitor the implementation of public policies through progress indicators and for the evaluation of maternal health policies and programs. The definition of these human rights criteria should guide the practice of health professionals. Also, it enables the measurement on whether and to what extent there are effective and effective policies to ensure equal access to health for all women without discrimination, including women in contexts of vulnerability.
The application of human rights-based approaches to policies and programs looks at people’s needs in their specific contexts instead of looking at certain health outcome or health condition. Its goal is the enjoyment of every woman of a live with dignity and not just the reduction of rates of preventable deaths in statistic and quantitative figures in general (Yamin 2017).
The fact that only women can become pregnant and have to face the risk of dying from maternal mortality in pregnancy, childbirth, and puerperium reveals gender inequality in the context of accessibility to good quality of health care According to the UN Committee on the Elimination of Discrimination Against Women, women have their own biological characteristics, and only women become pregnant. Therefore, states should ensure women’s right to safe motherhood including access to safe and equitable emergency obstetric care services, during pregnancy, childbirth, and the puerperium (CEDAW General Recommendation No. 24 1999).
In 2011, the United Nations Human Rights Council resolution on preventable maternal mortality and morbidity and human rights recognized that maternal mortality and morbidity are pressing human rights concerns and that addressing these issues requires effective protection of the human rights of women and girls (UN Human Rights Council Resolution 18/2 A/HRC/18/L.8). This global decision to address the issue not only from a public health but also a human rights perspective is significant and necessary since maternal death victims are mostly low-income, non-white, single mothers, living in the poor regions of their countries. These conditions are the risk factors for preventable deaths and injuries and affect women’s human rights to gender equality and nondiscrimination, as well as their ability to exercise other human rights related to reproductive self-determination (Cook et al. 2001).
In 2000, the international community agreed to Millennium Development Goal 5 as to “Improve maternal health” and is measured against a target to “Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio” and to “Achieve, by 2015, universal access to reproductive health”. Brazil, among 189 countries, signed a commitment in 2000 to meet the so-called Eight Millennium Development Goals (MDGs) by the year 2015. At the global level, despite some progress after the expiration of Millennium Development Goals in 2015, challenges still persisted and remained slow in some regions and countries (Lule et al. 2005).
A new global renewed attention has been given to state’s commitments to ensure gender equality and address preventable maternal mortality protecting women’s human right to safe motherhood. The human rights-based approach to address preventable maternal mortality was developed in the United Nations Technical Guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality (UN OHCHR Technical Guidance 2012). This tool is useful to promote accountability and civil society engagement at different levels in policy cycle.
In 2015, the world adopted 17 Sustainable Development Goals (SDGs) as part of the UN 2030 Sustainable Development (UN, Transforming our World 2015). The Sustainable Development Goals are interdependent and include, among other development and human rights issues, access to good health and well-being for people, quality education, gender equality, clean water, sanitation, affordable and clean energy, infrastructure, reduced inequalities, sustainable cities and communities, climate change, social justice, and strong institutions. The Goal 5 on gender equality and empowerment of all women and girls and its target on achieving universal access to sexual and reproductive health and rights (SRHR) is of relevance for health and lives of pregnant women. Without being able to make informed choices and determine when to have children and the spacing between pregnancies as well as on how to experience safe and voluntary pregnancy, abortion, and childbirth, free from discrimination, coercion, and violence, women cannot exercise fully their human rights. Since the International Conference on Population and Development (ICPD Program of Action 1994; UN Report ICDP 1994), international community reached consensus on key population and development objectives and goals, including the reduction of maternal mortality and the adoption of a gender equality and human rights-based approach to population, health, and development policies. Almost 25 years after this consensus, international community has recognized preventable maternal mortality as a human rights violation and that human rights-based approach is necessary to the achievement of achieve equal nondiscriminatory health care and to ensure women’s access to good quality of care during pregnancy. It is also useful to understand the social injustice aspect in each maternal death.
The principle of accountability is central to hold governments accountable for a social injustice behind preventable maternal death.
This article argues that human rights framework is strategic to monitor and foster effective implementation of the UN 2030 Sustainable Development agenda, as it underscores the need to develop an enabling environment through practices, policies, and laws for individuals and groups who face discrimination, social exclusion, and marginalization so that no one is left behind. According to this framework, population groups and individuals should have access to public information, voice their concerns without fear of reprisals, and can seek remedies when their rights are violated (UNFPA 2013). The centrality of the adoption of human rights-based approach to address social injustice and violations to economic and social rights due to preventable maternal mortality and discrimination in access to health care is illustrated in the case of Alyne da Silva Pimentel case vs. Brazil’s, presented before the Committee on the Elimination of Discrimination Against Women (CEDAW Committee) by the nongovernmental organizations Center of Reproductive Rights and Advocacy Human Rights and Citizenship Litigation in 2007 (Alyne da Silva Pimentel v. Brazil (Communication No. 17/2008)). The case is considered a best practice in the use of human rights approach toward achieving gender equality and equitable access to maternal health.
Maternal Mortality and Human Rights
Although great progress has been made in some countries and for selected programs, the availability of comprehensive and high-quality reproductive health services remains an unrealized goal in many settings (Lule et al. 2005). Maternal mortality rates have been declining globally, but inequalities persist between and within countries and regions, and the fact that many of the leading causes of premature death and disability for women in birth are preventable is an evidence of numerous violations of women’s human rights (Alkema et al. 2004). Thus the CEDAW Committee in its 2011 landmark decision in the Alyne case recognized that high rates of maternal mortality and morbidity are a consequence of gender inequality, intersectional and multiple discrimination, health inequities, and the state’s failure to comply with its international human rights obligations to respect, protect, and fulfill several of women’s human rights.
The recognition of preventable morbidity and maternal mortality as consequence of a series of human rights violations is a new political paradigm. In previous years, the achievement of maternal mortality reduction was addressed at the UN Millennium Development Agenda as a public health outcome. Moreover, in some of the developing countries, progress was slow regarding the achievement of the Millennium Development Goal (MDG) 5 – reducing maternal mortality and achieving universal access to reproductive health. This is explicable in terms of the relatively low value placed by states on the lives of women and girls and their limited voice in setting public priorities. The MDG targets related to Goal 5 included Target 5.A, reducing the maternal mortality ratio by three quarters from 1990 to 2015, and Target 5.B, universal access to reproductive health by 2015. After years, only half of pregnant women in developing regions received the recommended minimum of 4 antenatal care visits, and maternal mortality ratio in the developing regions was found to be 14 times higher than in the developed regions (UN Millennium Development Goals Report 2015).
In a society that endows maternity, but not women’s lives, with sacred social value, high rates of maternal death from preventable causes continue to be accepted as natural or destined. Greater effort is needed at the global and national levels to hold states accountable for preventable maternal deaths and for violations of mothers’ human rights that states are under obligation to prevent.
In recent decades, human rights mechanisms have been used to hold governments accountable for such violations as well as to foster human rights-based health policies, domestic laws, and health practices, all of which are considered necessary for the realization and enjoyment of high standards of health and well-being by all individuals, including those who belong to marginalized groups. Important advances have been made in this regard, most notably from the General Recommendations and Concluding Observations from Human Rights Treaty Monitoring Bodies as well as Human Rights Council resolutions on maternal mortality and morbidity (OHRC Resolutions 11/8 2009; 18/2 2011; UN OHCHR, Technical Guidance 2012). For example, states’ obligations to prevent harm to pregnant women were interpreted as not subject to progressive realization but take effect immediately (CEDAW Committee General Recommendation No. 24 1999).
The adoption of human rights-based approaches to preventable maternal mortality and injury requires looking beyond violations and punishment to the individuals involved while giving greater attention to institutional and systemic factors behind the pattern of failures that disproportionately affect marginalized populations (Yamin 2010). These approaches, then, are designed to hold governmental agencies accountable for violations of rights in every individual case of preventable maternal death as well as to address the systemic nature of these violations in the context of a dysfunctional health-care system that fails to protect women’s civil, political, social, and economic rights.
lack of emergency obstetric care services or denial of abortion often lead to maternal mortality and morbidity, which in turn constitutes a violation of the right to life or security, and in certain circumstances can amount to torture or cruel, inhuman or degrading treatment. (UN Committee on Economic Social Cultural Rights, General Comment 22 2016, para 10)
In addition to the seek health system’s accountability for violations, the human rights-based framework can be useful to monitor implementation and improve maternal health policies and programs to determine whether the state is de facto protecting their right to safe motherhood and right to live with dignity when they seek health services during pregnancy. For example, human rights indicators should inform the allocation of resources in order to ensure that all women have equal access to health care moving beyond traditional indicators based on health outcomes.
The application of human rights-based approaches to policies and programs involves looking at people’s needs in the specific contexts in which they live rather than at various health targets or health conditions. The goal is for every woman to enjoy a dignified life, above beyond reducing the statistically determined rates of preventable deaths (Yamin and Duger 2016). Thus the ultimate outcome for the successful adoption of a human rights-based approach to preventable maternal mortality is not the reduction of maternal mortality rate per se but rather greater utilization of health-care services by women and girls so that they can have equal access to health care without discrimination and exercise their rights to sexual reproductive health rights and agency over their bodies and lives. Such an outcome requires women’s control over their own sexuality, which involves their rights to information, contraception, timely and high-quality emergency obstetric care, and safe and legal abortion (Yamin and Canton 2014). These complementary human rights-based approaches to legal and policy frameworks that address women’s right to safe motherhood have been developed by various UN agencies, international organizations, and governments as part of an effort to promote international human rights principles in national and local contexts (Yamin 2017).
The United Nations Human Rights Council has issued its first resolution recognizing preventable maternal mortality and morbidity in 2009 as pressing human rights concerns and urging the effective protection of the rights of women and girls. This global commitment to address the issue from the perspectives of both public health and human rights is especially significant and necessary because those who die in childbirth tend to be low-income, non-white, and single residents of the poor regions of the countries in which they live. These risk factors can determine whether women are able to exercise their human rights relating to reproductive self-determination (UN Human Rights Council Resolution 2011).
Over time the development of human rights-based approaches to maternal health has evolved from developing the meaning of human rights applied to preventable maternal mortality contained in resolutions, declarations, and fact-finding reports to, more recently, advancing the strategic use of human rights-based approach to policies and laws through constitutional litigation. This is of relevance since domestic and international tribunals have the capacity to elaborate legally binding standards of performance from the interpretation of individual cases (Kismodi et al. 2012), thereby generating legal accountability (Cook and Dickens 2012).
In September 2015, UN member states adopted the 2030 Sustainable Development Agenda, and the reduction of maternal mortality is a key component of this agenda, under goal number three: states have agreed to make every effort both to reduce global maternal mortality rates to no more than 70 deaths per 100,000 live births by 2030 and to ensure universal access to family planning (UN General Assembly 2015). In recent decades, domestic litigation and greater involvement by global UN agencies and regional human rights bodies have contributed to the promotion and protection of the right to safe motherhood. Nevertheless, despite these major advances in global-level policies, abuses of human rights persist in many countries and regions where women who belong to disenfranchised groups face remain at high risk of preventable maternal death or injuries compared with women who belong to advantaged groups.
The Facts on the Case
Alyne, a 28-year-old, married black woman living in the city of Belford Roxo in the state of Rio de Janeiro, Brazil, had a 5-year-old daughter and was in the 6th month of her second pregnancy when she began to experience severe nausea and abdominal pain. She therefore sought health care in a health clinic, where the doctor prescribed medicine for her nausea, vaginal cream, and vitamins and scheduled a follow-up examination.
Alyne’s symptoms worsened, however, and she returned to the clinic 2 days later. There she was examined by another doctor, who found no fetal heartbeat. Labor was accordingly induced, and Alyne gave birth to a stillborn fetus. Fourteen hours later, she underwent surgery to remove the remains of the placenta, but her condition deteriorated; she suffered a severe hemorrhage, had low blood pressure, and was disoriented. The doctors at that point decided to transfer her to the better-equipped general hospital in nearby Nova Iguaçu, but at first no ambulance was available. After several hours of waiting, Alyne was at length transferred to the new facility, but without her medical records.
When she arrived at the general hospital, Alyne had to be resuscitated, and her blood pressure was zero. She was then placed in a hallway to await treatment, since no bed was available, where she passed away on 16 November 2001. On 11 February 2003, her family filed a civil damage claim asking for reparations that is currently pending in court.
In August 2011, the CEDAW Committee issued a decision establishing that the Brazilian state failed to protect Alyne’s human right to safe motherhood and violated her right to life, to heath, and to nondiscrimination based on gender, race, and socioeconomic status since she was an afro descendent living in a poor urban area in the state of Rio de Janeiro (CEDAW Committee 2011).
Key Aspects of CEDAW’s Decision
In November 2007, a case on behalf of Alyne da Silva Pimentel against the Brazilian government was presented before the Committee for the Elimination of Violence Against Women (the CEDAW Committee) by the Citizens’ Advocacy for Human Rights (ADVOCACI) and the Center for Reproductive Rights (CRR). This was the first case dealing with preventable maternal death brought by a treaty-monitoring body of the United Nations. The CEDAW Committee monitors and supervises states’ compliance with human rights obligations under the Convention for the Elimination of All Forms of Discrimination Against Women (the CEDAW Convention), which the Brazilian state ratified on 1 February 1984.
In its 2011 decision, CEDAW Committee criticized the Brazilian state for violating the human rights of Alyne and her family expressed in Article 12 (access to health), Article 2 (c) (access to justice), and Article 2 (e) (due diligence in regulating the activities of private health services) in the CEDAW Convention. The case also marked the first time that a United Nations human rights treaty-monitoring body received an individual case against the Brazilian government for failure to comply with its international human rights obligations. Also, it was the first individual case on preventable maternal mortality presented at the UN global human rights system of protection.
Since 2011, the case has been used by advocates in their efforts for advancing reproductive rights in Brazil, Latin America, and worldwide. The case is of particular significance for the global recognition of the right of all women to safe motherhood which includes access to affordable, high-quality essential health services (Cook and Dickens 2009). The case has also been pointed to by black feminist organizations and activists as exemplary of the persistent institutional racism and intersectional discrimination in reproductive health care against minority pregnant women living in such poor urban areas as Baixada Fluminense in the state of Rio de Janeiro. For these women, maternal death has long been considered an act of God, divine will, rather than a consequence of the lack of equal access to care and therefore a matter of reproductive justice. CEDAW’s decision in this case has accordingly served to challenge this normalized and entrenched social norm paradigm (Cook 2013).
In its landmark decision, the CEDAW Committee went beyond recommending to states to address individual reparations to determine state’s human obligations to remedy health inequities developing human rights standards for laws, policies, and evidence-based health practices. These measures were focused on how to advance the right to safe motherhood in the Brazilian’s public health system for black women who have much more risk to face preventable maternal mortality than white women (Martins 2006). They are likely to receive poor quality of care during the pregnancy-puerperal cycle and are thus at greater risk of mortality owing to their race, and this is also aggravated regarding their level of literacy, socioeconomic condition, as well as where they live. The CEDAW Committee found that the state party did not ensure appropriate medical treatment about pregnancy and did not provide timely emergency obstetric care, hence infringing the right to nondiscrimination based on gender, race, and socioeconomic background (CEDAW 2011).
In summary, CEDAW Committee addressed the structural problems in Brazil’s public health system recommending that the government (i) ensure women’s right to safe motherhood and affordable access to emergency obstetric care; (ii) provide adequate professional training for health workers; (iii) ensure that private health-care facilities comply with national and international reproductive health-care standards; (iv) implement Brazil’s National Pact for the Reduction of Maternal and Neonatal Mortality, which includes the establishment of additional maternal mortality committees to monitor maternal deaths; and (v) ensure women’s access to effective remedies when their reproductive rights have been violated (CEDAW 2011).
65. Enhanced legal accountability was sought through the case of Alyne da Silva Pimentel v Brazil filed before the Committee on the Elimination of Discrimination against Women. The applicants alleged that the failure by Brazil to provide maternal health care violated several of its international obligations. The Committee was asked to direct Brazil to prioritize maternal mortality reduction, including by training providers, establishing and enforcing protocols and improving care in vulnerable communities. This case, still pending, is the first individual communication on maternal mortality filed before a United Nations treaty body and is part of a strategy to ensure that rights-holders have access to international mechanisms when domestic remedies fail.
The Committee further urged the state to provide symbolic and material reparations, including monetary compensation, to Alyne’s family (Mesquita and Kismodi 2012).
The decision recalled CEDAW’s General Recommendation No 24 of Article 12 of the Convention (Women and Health) “in which it states that it is the duty of State’s parties to ensure women’s right to safe motherhood and emergency obstetric services, and to allocate to these services the maximum extent of available resources” (CEDAW 2011, paragraph 7.3). This recommendation leaves to state to define the measures to be taken to comply with their obligation to protect women’s right to safe motherhood (Cook and Dickens 2012).
The lack of appropriate maternal health services in the State party that clearly fails to meet the specific, distinctive health needs and interests of women not only constitutes a violation of article 12, paragraph 2, of the Convention, but also discrimination against women under article 12, paragraph 1, and article 2 of the Convention. Furthermore, the lack of appropriate maternal health services has a differential impact on the right to life of women. (CEDAW 2011, paragraph 7.6)
Another important aspect noted by the CEDAW Committee was the gender discrimination in view of several of the medical errors that were made during Alyne’s treatment. Specifically, it held that the “discrimination includes state actions that may have the effect of creating barriers to the enjoyment of human rights, including the right to the highest attainable standard of health.... To ensure the realization of the right to health, states must provide access to quality of care in maternal health services in a non-discriminatory manner” (CEDAW 2011, paragraph 5.9). The Committee had previously considered “distinct aspects and factors that differ for men and women, including the biological factors associated with reproductive health” (CEDAW General Recommendation No. 24 1999) and that “the denial of access to health interventions that only women need is one of discrimination against women” (CEDAW General Recommendation No. 25 2004).
States parties’ compliance with article 12 of the Convention is central to the health and well-being of women. It requires States to eliminate discrimination against women in their access to health-care services throughout the life cycle, particularly in the areas of family planning, pregnancy and confinement and during the post-natal period. (CEDAW General Recommendation No. 24 1999)
The Committee accordingly found that the state had failed to fulfill its obligation “to take all appropriate measures to eliminate discrimination against women by any person, organization, or enterprise”, as established by Article 2(e) of the CEDAW Convention. It went on to recognize the distinction between de facto and de iure discrimination and “that measures to eliminate discrimination against women are inappropriate in a health-care system which lacks services to prevent, detect and treat illnesses specific to women” (CEDAW 2011, paragraph 7.3) (Para 7.3).
Her complaints of severe nausea and abdominal pain during her sixth month of pregnancy were ignored by the health centre, which failed to perform an urgent blood and urine test to ascertain whether the foetus had died.(...) the curettage surgery was only carried out 14 hours after labour (...) in order to remove the afterbirth and placenta, which had not been fully expelled during the process of delivery and could have caused the haemorrhaging and ultimately death. (CEDAW 2011)
CEDAW Committee’s general recommendations have yet to be fully implemented at national level. Civil society organizations have been monitoring and continued to challenge the lack of implementation and the health-care system’s culture of attributing to destiny and treating as natural black women’s preventable maternal deaths as well as institutional racism that has permeated reproductive care in Brazil’s public health services for many decades. It is thus precedent-setting with respect to the state’s accountability for women’s right to safe motherhood under international human rights law.
Conclusions and the Way Forward
Recommendations from human rights treaty-monitoring bodies (UN TMBs) have been increasingly recognized as authoritative interpretations or more recently as being legally binding (Engström 2018). This means that UN TMBs provisions are applicable in certain contexts, which is why various bodies have taken a more formalistic approach to overseeing implementation by states. The judgments of human rights bodies in individual cases represent opportunities for public learning and for mobilizing civil society to hold states accountable on both the national and global levels.
Alyne’s case is emblematic of strategic litigation for advancing women’s right to safe motherhood to address a pattern of structural failures within the public health system. The necessity of such litigation is demonstrated by the high maternal mortality rates in Brazil, which reflect both the persistence of inequalities and reproductive injustice affecting black and low-income women, as well as the consistent failure of measures designed to address the root causes and underlying social determinants of unequal health-care outcomes and human rights violations.
The CEDAW Committee’s decision clearly has the potential to generate a ripple effect in other countries in which the health-care systems are facing challenges. In this regard, assessment of the Brazilian state’s compliance should not be measured solely in terms of inequalities in health outcomes but should instead take into account political processes generated by dialogues involving multiple stakeholders and by the establishment of an interministerial group to discuss the next steps in the implementation process with civil society organizations.
The success of the 2030 Sustainable Development agenda does not depend only on governments’ political will and formal compliance with its international commitments only but also relies on the full engagement of a multi-stakeholder partnership including civil society, private sector, and local authorities to demand accountability of their international human rights obligations regarding sexual reproductive health and rights, including the right to safe motherhood. In this regard, citizens and civil society have a common responsibility to engage with reality and translating the SDGs into policy actions, monitoring their progress, and holding governments accountable. Human rights framework should be promoted in order to achieve goals 5 and also goal 17 Goals and address preventable maternal mortality and morbidity in order to left no one behind in preventable maternal mortality is related to many factors including lack of access to education, transportation, enjoyment of basic social economic and social rights, including right to sexual autonomy, bodily integrity, and other sexual reproductive health and rights. It reflects a huge gap between developed and developing countries and unequal power on gender relations in society and consequently the devaluation of women’s lives. Civil society organizations have a key role to play in monitoring and evaluation policy implementation, using strategic litigation and applying human rights-based frameworks to promote laws, health policies, and practices holding governments accountable. In the near future, the engagement of different stakeholders in monitoring the implementation of international commitments through concrete and developing measurable and comprehensive indicators will be a central strategy to succeed in the effective implementation of the 2030 Sustainable Development Agenda.
- Alkema L et al (2004) A systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet 387(10017):462–474Google Scholar
- CEDAW General Recommendation No. 25 on article 4, para 1, of the Convention (temporary special measures) (2004) para 8. Available at: http://www.un.org/womenwatch/daw/cedaw/recommendations/General%20recommendation%2025%20(English).pdf
- Cook R, Dickens B et al (2001) Advancing safe motherhood through human rights. World Health Organization, Geneva. http://apps.who.int/iris/bitstream/handle/10665/66810/WHO_RHR_01.5.pdf;jsessionid=0F9C9910E9D82A4F036CBDE0662E95DA?sequence=1Google Scholar
- Engström V (2018) Spanish supreme court bringing UN treaty bodies one step closer to international courts? Int’l J. Const. L. Blog. Available at: http://www.iconnectblog.com/2018/08/spanish-supreme-court-bringing-un-treaty-bodies-one-step-closer-to-international-courts
- Galli R, Queiroz (2014) Caso Alyne Pimentel: Relatório Sobre Mortalidade Materna no Contexto do Processo de Implementação da Decisão do Comitê CEDAW Contra o Estado Brasileiro. Plataforma de Direitos Humanos-Dhesca Brasil; UNFPA Report. Available at: https://www.researchgate.net/publication/280624768_Caso_Alyne_Pimentel_Relatorio_sobre_Mortalidade_Materna_no_context_de_implentacao_da_decisao_do_Comite_CEDAW_contra_o_estado_brasileiro
- Hessini L, Galli B (2015) Taking action to combat state-sanctioned violence against women worldwide. Available at: https://rewire.news/article/2015/05/28/taking-action-combat-state-sanctioned-violence-women-worldwide/
- Human Rights Council (2011) Practices in adopting a human rights-based approach to eliminate preventable maternal mortality and human rights. A/HRC/18/27. Available at: http://www2.ohchr.org/english/issues/women/docs/WRGS/A-HRC-18-27_en.pdf
- Lule E, Ramana GNV, Ooman N, Epp J, Huntington D, Rosen JE (2005) Achieving the millennium development goal of improving maternal health: determinants, interventions and challenges. Health, Nutrition and Population (HNP) discussion paper. World Bank, Washington, DC. © World Bank https://openknowledge.worldbank.org/handle/10986/13744Google Scholar
- Martins AL (2006) Mortalidade materna de mulheres negras no Brasil. Cad Saúde Pública 22(11): 2473–2479. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2006001100022&lng=en. https://doi.org/10.1590/S0102-311X2006001100022CrossRefGoogle Scholar
- Mesquita JB, Kismodi E (2012) Maternal mortality and human rights: landmark decision by United Nations human rights body. Bull World Health Organ 90:79–79A. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302558/CrossRefGoogle Scholar
- Shameem N (2017) AWID OURs. Rights at risk. Observatory on the universality of rights. Trends Report. Available at: https://www.awid.org/sites/default/files/atoms/files/rights-at-risk-ours-2017.pdf
- UN (2015) Transforming our world: the 2030 agenda for sustainable development, general assembly. Available at: https://sustainabledevelopment.un.org/post2015/transformingourworld
- UN CEDAW Committee (2011) Alyne da Silva Pimentel v. Brazil: Communication No 17 (2008) at 7.6, U.N. Doc. CEDAW/C/49/D/17/2008. Available at: http://www.worldcourts.com/cedaw/eng/decisions/2011.07.25_da_Silva_Pimentel_v_Brazil.pdf
- UN Committee on Economic, Social and Cultural Rights (CESCR) (2016) General Comment No 22 on the Right to sexual and reproductive health. (Article 12 of the International Covenant on Economic, Social and Cultural Rights) (E/C.12/GC/22). Available at: https://www.escr-net.org/resources/general-comment-no-22-2016-right-sexual-and-reproductive-health
- UN Committee on the Elimination of Discrimination Against Women (CEDAW) (1999) CEDAW General Recommendation No. 24: Article 12 of the Convention (Women and Health). A/54/38/Rev.1, chap. I. Available at: http://www.refworld.org/docid/453882a73.html
- UN Committee on the Elimination of Discrimination against Women (CEDAW) (n.d.) Alyne da Silva Pimentel v. Brazil (Communication No. 17/2008). CEDAW/C/49/D/17/2008. Available at: https://www.escr-net.org/sites/default/files/CEDAW-C-49-D-17-2008.pdf
- UN Committee on the Elimination on All Forms of Discrimination against Women (CEDAW) (n.d.) Report of the Committee on the Elimination of Discrimination against Women on its twenty-eighth session. CEDAW/C/2003/I/1. Available at: https://documents-ddsny.un.org/doc/UNDOC/GEN/N03/468/20/PDF/N0346820.pdf?OpenElement
- UN General Assembly (2015) Transforming our world: the 2030 Agenda for Sustainable Development, G.A. Res. 70/1, Goal 5.6, at 18, U.N. Doc. A/RES/70/1. Available at: http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E
- UN Human Rights Council (HRC) Resolution 11/8 (2009) Preventable maternal mortality and morbidity and human rights. Available at: http://ap.ohchr.org/documents/E/HRC/resolutions/A_HRC_RES_11_8.pdf
- UN Human Rights Council (HRC) Resolution 18/2 A/HRC/18/L.8 (2011). Available at: https://documents-dds-ny.un.org/doc/RESOLUTION/LTD/G11/162/25/PDF/G1116225.pdf?OpenElement
- UN Millennium Development Goals Report (2015). Available at: http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20%28July%201%29.pdf
- UN Millennium Project Task Force on Child Health and Maternal Health (2005) Who’s got the power? Transforming health systems for women and children. United Nations Development Programme, New York. http://siteresources.worldbank.org/INTTSR/Resources/maternalchild-complete.pdfGoogle Scholar
- UN OHCHR (2012) Technical guidance on human rights based approach to preventable maternal mortality and morbidity (technical guidance). A/HRC/21/22. Available at: https://www2.ohchr.org/english/issues/women/docs/A.HRC.21.22_en.pdf
- UN Report of the International Conference of Population and Development (1994) Program of action. Available at https://www.unfpa.org/sites/default/files/pubpdf/programme_of_action_Web%20ENGLISH.pdf
- UN Sustainable Development Knowledge Platform, Sustainable Development Goals (n.d.). https://sustainabledevelopment.un.org/?menu=1300
- UNFPA (2013) Empowering people to ensure a sustainable future for all – UNFPA Proposals for Post-2015 Development Agenda. UNFPA Proposals for Post-2015 Development Agenda. Available at: https://www.populationmatters.org/documents/empowering_people.pdf
- United Nations (2005) 4th world conference on women: Beijing declaration. Available at: http://www.un.org/womenwatch/daw/beijing/platform/declar.htm
- United Nations, Human Rights Council (2011) Practices in adopting a human rights-based approach to eliminate preventable maternal mortality and human rights. A/HRC/18/27. Available at: http://www2.ohchr.org/english/issues/women/docs/WRGS/A-HRC-18-27_en.pdf
- Yamin AE (2017) Power, suffering, and the struggle for dignity. In: Human rights frameworks for health and why they matter. University of Pennsylvania. Available at: https://humanrights.harvard.edu/publications/power-suffering-and-struggle-dignity-human-rights-frameworks
- Yamin AE, Canton (2014) Between insurrectional discourse and operational guidance: challenges and dilemmas in implementing human rights-based approaches to health. J Hum Rights Pract 6(3):451–455. https://academic.oup.com/jhrp/article/6/3/451/2188795CrossRefGoogle Scholar
- Yamin AE, Duger A (2016) Adjudicating health-related rights: proposed considerations for the United Nations Committee on economic, social and cultural rights, and other Supra-National Tribunals. Chic J Int Law 17(1):3. http://chicagounbound.uchicago.edu/cjil/vol17/iss1/3Google Scholar
- Yamin AE, El Falb K (2012) Counting what we know; knowing what to count; sexual and reproductive rights, maternal health and MDGs. NJHR 30(3):350–371. https://www.idunn.no/ntmr/2012/03/counting_what_we_know_knowing_what_to_count_-_sexual_and_rGoogle Scholar
- Yamin AE, Galli B, Valongueiro S (2018) Implementing international human rights recommendations to improve obstetric care in Brazil. Int J Gynecol Obstet 143(1):114–120. https://doi.org/10.1002/ijgo.12579. Epub 2018 Jul 23. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30035298CrossRefGoogle Scholar