Human Rights and MCH

Human Rights and MCH

• The Universal Declaration of Human Rights is not legally binding, but states that all humans are born free and equal in dignity and rights
• Humans are endowed with reason and conscience, and should act towards one another in a spirit of brotherhood
• Dignity constitutes an inherent right or value that every person possesses simply by being human
• Negative rights imply that others have negative duties to avoid certain actions like persecution
• Protection includes the right not to be subjected to persecution by another person or group
• This encompasses freedom of religion, speech, and property rights
• Positive rights imply that other people have positive duties to take certain actions
• These include the right to education and legal counsel and to bear arms
• Inter-agency working groups on Reproductive Health in Crises (IAWG) is an international coalition advancing sexual and reproductive health and rights in humanitarian settings
• IAWG created the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health (SRH)
• The Convention on the Elimination of all forms of discrimination against women (CEDAW) includes 79 signatories and has been ratified by 99 states in the UN, but not the US

Mistreatment During Childbirth

• Physical abuse includes hitting, slapping, pushing, sexual abuse, and rape during facility-based childbirth
• Non-consented care is the failure to seek and receive consent before a procedure
• Non-confidential care involves a lack of physical and/or privacy of information
• Non-dignified care includes verbal abuse, negative gestures, and comments
• Discrimination involves differential treatment based on personal attributes
• Abandonment is the neglect of a woman and delivering alone and failure to monitor women in life-threatening situations
• Detention in facilities involves detaining a patient until payment is made or demanding bribes
• Poor rapport involves ineffective communication, lack of supportive care, and loss of autonomy between women and providers
• Health system constraints include a lack of resources, policies, and a poor facility culture

Drivers and Predictors of Disrespectful Care and Abuse

• Disrespect and abuse during childbirth is normalized
• There is a lack of community engagement and oversight
• Financial and educational barriers prevent women from knowing their rights
• Lack of autonomy and empowerment and a lack of governmental support/protection further exacerbate disrespectful care and abuse
• Social customs also are drivers
• Patient-specific predictors include age, education, religion, marital status, occupation, wealth, and place of residence
• Health service-specific predictors encompass the travel time to the facility, referral, complications during or after delivery, delivery time, birth attendant, number of ANC visits, and previous deliveries at the facility

Measuring and Mitigating Disrespect and Abuse

• Quantitative approaches measure the prevalence of disrespect and abuse/mistreatment
• In Ethiopia there are 353 maternal deaths per 100,000 live births
• Poor provider attitudes and negative experiences at primary health care centers deter women from seeking childbirth services
• Women perceive healthcare providers as insensitive, harsh, and unresponsive to community beliefs
• Qualitative approaches understand drivers and descriptions of disrespect and abuse and mistreatment
• Specifically this approach aims to understand Cultural, religious/spiritual effects
• Implementation research promotes approaches to advance Respectful Maternity Care (RMC)
• Disrespect and abuse can be mitigated by capturing the breadth and scope of disrespectful and abusive maternity care
• Reinforcing how mistreatment, poor quality of care, and human rights abuses are linked to the uptake of facility-based childbirth (MDG 5)
• Health should be seen as a human right, not a charity or privilege, which will empower women to make informed decisions about their bodies
• Health systems must uphold dignity, autonomy, equity, and access to care without discrimination
• Care must be integrated across stages of life
• Six key components of Respectful Maternity Care include adequate supplies, staff motivation, client overload, client privacy, shortage of staff, and inadequate client/provider relationships
• Integrated care and systems approach promotes gender equality and supporting physiological processes
• It focuses on increasing coverage and services, and providing a full spectrum of services
• This approach includes Shifting tasks which needs a range of advanced practice clinicians is also important
• Community-based events, like Open Birth Days, invite women to tour maternity wards, meet staff, and learn about what to expect during childbirth which encourages facility births and reduces fear/stigma

Adolescent Reproductive and Sexual Health

• Population Council initiatives focus on improving health, education, and protection for girls in low- and middle-income countries
• Key issues targeted include child marriage, early pregnancy, GBV, increased risk of HIV/STIs, lack of education, and high school dropout rates
• These factors collectively limit girls’ autonomy, opportunities, and long-term well-being
• Girls are disproportionately disadvantaged in adolescence, especially where poverty and harmful gender norms prevail
• Millions of girls are "invisible" in policy and data which includes those:
  • Out of school
  • Married early
  • Living apart from parents
  • Engaged in domestic labor
• Programs often fail to reach the most vulnerable girls because they aren't designed with their specific realities
• Normative pressures contribute to early school dropout and health risks
• Adolescent girls (10–14) are often ignored in broader youth interventions
• Ages 14-16 is described as a "window of opportunity" where interventions can transform life trajectories
• Interventions are more impactful during this period on continued education
• The Population Council implements evidence-based, girl-centered programs using a multi-sectoral approach
• This includes providing sexual and reproductive health education, improve access to youth-friendly health services, and address HIV prevention through empowerment and information
• Furthermore there is additional focus on creating incentives and support for girls to remain in school, implement community engagement to challenge norms, and strengthen safe learning environments
• To build girls’ social, health, and economic assets and facilitate mentorship, you have to engage community gatekeepers
• You also need to encourage girls to imagine and plan for futures and support vocational training
• The Population Council prioritizes marginalized girls, including domestic workers, girls in migration contexts, trafficked girls, and girls without adult supervision
• These groups often fall outside traditional intervention models

Global MCH Framework and Response: History and Impact

• Colonialism impacted healthcare systems like the UK, which structured it more compartmentally, and France, which localized it more
• New infections and diseases were killing native and colonizing populations sparking the start of tropical medicine
• Colonial medicine focused on controlling populations rather than fostering equitable health systems
• Vertical programs emerged from colonial medicine, often ignoring broader determinants of sexual and reproductive health
• Post-WWII, the League of Nations was expanded to the UN
• The UN promotes world peace through health and the eradication of poverty
• Sustainable Development Goals (SDGs) were signed in 2015 with 17 goals to be expired by 2030
• The UN's legal framework is based on charter agreements and soft power rather than enforcement
• Voluntary contributions from member states and donors provide funding
• Earmarked funding can limit flexibility
• The WHO provides evidence-based guidelines for MCH
• The International Confederation of Midwives (ICM) focuses on supporting and expanding midwifery by using education and refulation
• UNFPA provides guidelines for MCH, GBV and FP, and implement
• The Human Rights-Based Approach (HRBA) is a conceptual framework for human development based on international human rights standards
• HRBA promotes the protection and fulfillment of human rights which empowers marginalized groups so that duty-bearers meet their obligations
• Key principles of HRBA include participation, accountability, non-discrimination, empowerment, and legality of rights

Approaches to Global Health

• The global health system has transitioned from vertical to more integrated and rights-based approaches
• Integrated approaches combine services and programs to address health needs more efficiently
• Vertical approaches are disease-specific and often siloed
• Holistic and Life Course Approaches emphasize health needs across a person’s entire life span
• Social Determinants recognizes that health is influenced by factors like education, income, gender, and social conditions
• Social Norms addresses cultural and societal expectations that influence health behaviors and access to care
• HRBA promotes equity, participation, and accountability in health programming
• Community-Based approaches involves local populations in designing and implementing culturally relevant health programs
• GBN Accreditation is a voluntary process of meeting established standards and enabling sustainability
• It aims to improve health outcomes, identify strengths and gaps, promote communication, and foster a culture of quality and safety
• This accreditation process emphasizes participatory evaluation
• This includes respect for women’s autonomy, dignity, and rights in childbirth and co-production of care between users and providers
• Also it encourages accountability and transparency through indicators that reflect rights-based outcomes
• The Obstetrical Transition is a shift in global maternal health focus
• Previously it focuses on reducing mortality through emergency interventions.
• This has shifted to improving quality and respectful care in lower-mortality settings which emphasizes autonomy and addressing social determinants
• It emphasizes continuity of care and women-centered approaches rather than just biomedical outcomes
• Reductive Approaches includes emphasis on SBAs and facility-based births and Adopting a lifecourse, women-centered approach
• Over-medicalization and one-size-fits-all strategies LIMITS community-centered innovation
• Current SRH policies remain highly politicized
• Conservative backlash can also limit SRH
• Even Global health governance is often limited by political agendas and funding priorities

Strengthening Reproductive Health

• Traditional quality approaches include facility improvements, provider training, and technical capacity
• They can be often externally imposed and reinforce power imbalances
• Global MCH efforts have historically centered on family planning and emergency response strategies which contributed to a 40% drop in mortality since 1990
• However, evidence emerged of widespread disrespect, abuse, and poor quality of care during this period
• Current shift in focus is on quality and respectful care
• the WHO defines as both the provision and the experience of care specifically with clinical effectiveness, respectful treatment, and dignity
• Maternal health services must be person-centered, responsive to women's needs, and rooted in community trust

Sexual and Reproductive Health in Disaster Settings: Terminology

• Emergency is defined as sudden-onset events that cause immediate threats to life and well-being
• SRH implications are that these are often neglected and need contraception and sexual violence support
• Emergency SRH responses include Minimum Initial Service Package (MISP) and safe delivery services
• Humanitarian action is broader than just emergencies and includes conflicts, displacement, and food insecurity, etc.
• The SRH implications include recognizing that SRH constitutes a human right
• Humanitarian SRH responses include community outreach, and maternal health services
• Recovery involves rebuilding and stabilizing systems after an emergency and investing in long-term SRH systems
• Development involves long-term efforts to improve health and governance, which includes implementing family planning strategies
• The Humanitarian-Development-Peace Nexus connects short-term responses with long-term development and promotes integrated programming and partnership with governments

Initial SRH Responses

• Emergency phases involve preventing maternal/newborn deaths, managing sexual violence, and preventing HIV transmission
• Post-emergency includes comprehensive SRH services, worker training, and integrating mental health services
• Recovery phases involve rebuilding facilities and integrating SRH into development plans
• Nexus phases integrate SRH into national strategies and focus on human rights

MISP in Disaster Zones

• The six objectives of the MISP are to identify an organization to lead implementation, prevent sexual violence, prevent HIV transmission, prevent excess maternal/newborn morbidity/mortality, prevent unintended pregnancies, and plan for comprehensive SRH services
• First priority → delivering life-saving SRH services at the onset of emergencies which includes preventing sexual violence, providing clinical care, and establishing confidential referral systems
• To address HIV and STIs you must prevent transmission, establish universal access to condoms, and ensure safe blood transfusions
• Also essential is to provide Maternal and Newborn Mortality through EmONC, deliveries, and referral pathways

SRH Care in Humanitarian Settings

• Ensure access to contraceptives and provide planning options for unintended pregnancies
• Antenatal care, safe abortion, and needs assessments are important for comprehensive SRH
• Assessments need to be performed in a humanitarian setting and data must be collected
• MISP provides has a calculator tool for data
• The UN uses the cluster approach to coordinate responses during emergencies
• In these clusters there should be specific lead agencies in charge of covering sector, and addressing identify gaps and procedures
• Collaboration, equity, and protecting vulnerable populations is key

Crisis Situations in Low vs High income countries

• Low-Income Countries (LICs) are more severely impacted and have weaker infrastructures:
  • Have a higher reliance on support and need MISP implementation, along with NGOs, aid, and agencies
• High-Income Countries (HICs) have stronger systems where emergency still disrupt SRH services
  • HRBA, Skilled attendants, and system improvements are needed

Refugees and Internally Displaced Persons (IDPs)

• IDPs often live in overcrowded shelters with high risk of GBV, maternal issues, and family planning needs
• Humanitarian responses must ensure inclusion and dignity for these populations
• Actions to take: prioritize coordination, define the minimum package, and establish systems (supply chain, HR, infrastructure, SOPs)
• SRH coordinator needs to synergize and define priorities

The Medical and the Midwifery Model of Care

• The medical model views birth as potentially pathologic and is hierarchical where care is focused on the medical aspects with mind/body separation
• The midwifery model views birth as a normal, social event where women are encouraged to be persons engaged and there is equal decision making
• Care is focused on education, prevention and the normal birth process is focused on

Midwifery Centers

• Midwifery centers are health care facilities serving women through their life course
• They must be home-like, ensuring emergency maternal and neonatal care and be responsive
• MWH specifically target the Three Delays (Deciding to seek care, Delay in reaching appropriate facility care, Delay in receiving adequate care at the facility)
• MWHs allow longer observational periods for patients better treatment planning and improve health system is detection

Midwives for Haiti and Crisis Planning

• Midwives for Haiti incorporates 3 Birth centers, MWHs, 12 community clinics, Matwon training which includes a local community overseer
• Haiti uses Jean Baptiste Birth Center, which is govt initated with and IDP presence and also the “Tissie Birth Center” which is community-initiated
• The need for MFH depends of if there is a time of crisis when women need midwifery and birth center support
• In a plan for midwifery centers consider resource security, kidnapping plans, where they are in the stages of conflict, and what they can offer

Planning Strategies During Conflict

• 70% of women in conflict zones are affected by gender-based violence (GBV)
• Provide integrated healthcare packaging and build a community around addressing child sexual exploitation, with a cultural lens
• Always enhance safety by remaining neutral and working with local staff, and provide safe birth option and support