Sustainable Development Goal (SDG) 3 seeks to ensure healthy lives and promote wellbeing for all, at all ages. Within the maternity care context this requires a reduction in maternal mortality rates by securing universal access to facility-based care and skilled attendance during labour and childbirth.
However, research focused on obstetric violence, humanisation of birth, mistreatment, and disrespect and abuse during childbirth demonstrates that gaining access to health care facilities and surviving childbirth are not enough. For many birthing women health care facilities are the sites of human rights abuses, where gender, power, and inequality intersect in particularly harmful ways resulting in all kinds of abusive, disrespectful or violent treatment. These range from physical, verbal, emotional and psychological abuse, coercive care, and medical interventions without informed consent. Thus, women may have access to facilities and survive childbirth but will live with long or short term physical, emotional and psychological harms.
Dr Princess Nothemba Simelela, World Health Organization Assistant Director-General for Family, Women, Children and Adolescents recognises that:
“[t]o meet Sustainable Development Goal 3 of ensuring healthy lives and promoting well-being for all at all ages, we cannot keep our focus solely on survival. High quality care for all pregnant women and their newborns, throughout pregnancy, childbirth and the postnatal periods, is essential to ensure that mothers and children both survive and thrive.”
It is without a doubt that human rights have a role to play in bridging the gap between merely surviving childbirth and ensuring respectful, women-centred maternity care. This link has been recognised by Obstetric Violence Observatories, the World Health Organization, and by others working in law, and public health. The White Ribbon Alliance developed the Respectful Maternity Care Charter which outlines how human rights are implicated in the childbearing process and affirms their application to childbearing women by drawing on relevant extracts from established international and regional human rights instruments.
Despite it being widely accepted that human rights play a fundamental role during childbirth, there is no binding universal instrument which establishes how human rights are implicated during the childbirth process or how these should be applied to the childbirth context. As a result of this gap, there is no international guidance regarding the most appropriate strategies which should be employed at national and regional levels in order to ensure the application of human rights to this unique facet of women’s lives. Further, there is no direction regarding how to ensure accountability, who or what should be held to account, and which processes should be adopted to bring about accountability.
This gap is a serious concern and has resulted in the development of strategies which are not adequately inclusive, causing some women to be left behind and excluded from mainstream discourses regarding how to respond to this issue. The primary response to abuse and violence during childbirth is a health system’s response. A health system’s response is one that seeks to reform care through the application of various programmes (Safe motherhood Initiative) and through development and employment of important evidence-based guidelines (World Health Organization’s Recommendations: Intrapartum Care for a Positive Childbirth Experience). These are extremely important initiatives as they are directed at improving quality of care and help to chip away at the structures that sustain disrespect and abuse in maternity care settings. However, even though most health system reform measures are founded on women’s human rights they are not binding. Further, they are focused on improving health systems for the benefit of women who will birth in the future rather than on women who have already experienced human rights violations during childbirth.
We must recognise that there is more to human rights than merely supporting a health system’s approach to disrespect, abuse and violence during childbirth. Human rights violations are experienced by women individually and we need to consider how women can use their human rights in cases where guidelines are not adhered to, when they are neglected or intentionally abused during facility-based births, when adherence to evidence-guidelines results in a loss of agency, or when a state’s budgeting is inadequate resulting in substandard care.
How are human rights serving women, as individuals, in these contexts? This question has not been explored or answered because most of our focus is on the health system and we have lost sight of the individual women therein.
This blog is the fourth in a series capturing discussions in the context of a British Academy project, Working Together: Human Rights and the Sustainable Development Goals, which explores the potential of human rights to realize the SDGs. The project is being led by Professor Sandra Fredman, Fellow of the British Academy.