Maternal Mortality as a Human Rights Issue: Measuring Compliance with International Treaty Obligations

I. Introduction

In too many places around the globe, not much has changed since Martin Luther wrote, in the sixteenth century, “And even if women bear themselves weary or they bear themselves out that does not hurt. Let them bear themselves out. This is the purpose for which they exist.” ¹ Women in developing countries are bleeding to death after giving birth, writhing in the convulsions of eclampsia, and collapsing from days of futile contractions, knowing that they have suffocated their babies to death. ² The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) estimate that close to 600,000 women and girls die each year from complications of pregnancy or childbirth, despite the fact that technology that has been available for decades could have been used to avoid these deaths. ³

Maternal mortality is the leading cause of premature death and disability among women of reproductive age in developing countries. ⁴ Furthermore, the burden of maternal mortality is not evenly distributed. Ninety-nine percent of pregnancy-related deaths occur in developing countries ⁵ —and of course, only women are at risk of this fate. Moreover, according to the World Bank, although men and women between the ages of fifteen and forty-four lose approximately the same number of years of healthy life due to disease, there is no single cause of death and disability for men that comes close to the magnitude of maternal death and disability. ⁶

The discourse of human rights enables us to place an issue such as maternal mortality on the agenda of public concern and keep it there. Moreover, it provides another crucial reason to be concerned about maternal mortality—beyond even the tragic deaths themselves, women’s instrumental role in raising children, and the loss of women’s productivity. A rights framework emphasizes that women affected by maternal mortality possess an inherent dignity that makes their preventable deaths a disgraceful social injustice.

As valuable as the rights perspective is, however, it is not sufficient. Without a sound understanding of the epidemiology of maternal mortality (and therefore, the interventions that can prevent it), the concept of a human right to be free from avoidable death during pregnancy and childbirth will remain meaningless. Without a clear understanding of the causal chain leading to maternal mortality (and how to break it), programs intended to reduce maternal deaths are likely to be ineffective.

Indeed, one of the principal problems in implementing economic and social rights (as opposed to civil and political rights, which generally have their basis in national judicial systems and, which often can be measured by counting violations) is that the interpretation and enforcement of economic and social rights requires expertise external to the international legal community. ⁷ In 1993, the United Nations Centre for Human Rights convened a group of experts to discuss the use of indicators to monitor economic and social rights (the Seminar on Appropriate Indicators), which concluded, in the words of the rapporteur, that although indicators are definitely needed, “the development of [such] indicators requires the conceptualization of the scope of each of the enumerated rights and the related obligations of States Parties. Thus, it is not yet possible to . . . assess progressive realization of these rights.” ⁸

Rather than beginning with the abstract concept of the right to health and looking for indicators that might infuse substantive meaning into the progressive realization of that right, this article begins with the very tangible problem of maternal mortality. From that standpoint, it argues that certain recently developed indicators can be assessed according to human rights criteria and selectively adopted as monitoring tools by national and international institutions in order to evaluate compliance (or noncompliance) with treaty obligations. ⁹

Specifically, staff at UNICEF and the Center for Population and Family Health (CPFH) at the Columbia University School of Public Health developed a set of indicators for use in monitoring the availability and use of medical services by women with life-threatening obstetric complications. ¹⁰ These indicators, and the guidelines for their use...