Human Right to Safe Birth: Challenges and Dilemmas

Key note address at the Safe and Supported Birth: A Human Right1
Birth India's Annual Natural Childbirth Conference 21 January 2012 Bangalore, India

Edward Premdas Pinto, Human Rights Advocate

1.0 INTRODUCTION:
Case 1: Raichur, Karnataka
Sunitha (name changed), 23, second time pregnant had come to her maternal home for
her delivery, about 15 kms from the town of Raichur town of Raichur District
(Karnataka). As neither the ANM had visited her and the PHC where she is supposed to
go to is far away, she had consulted a private doctor. She also hoped that the delivery
would be normal or go to Raichur town one day prior to the delivery. However, her
labour pains started two days before the due date and she delivered at home. For long
hours the placenta did not come out and her bleeding continued. They called for 108
(emergency transport for health provided under NRHM) which took half an hour to
reach their place. On the way to the district hospital, the attendant (apparently trained) on
the 108 vehicle tried to get the placenta out, unsuccessful though. She was taken to the
district hospital, after about half an hour of waiting she was referred to the Rajiv Gandhi
Super-speciality Hospital (now under the management of Appllo, hence also known as
Apollo Hospital) about 10 kms away from the district hospital. At the Superspecialty
hospital she was not admitted but was advised that she had to be admitted in the district
hospital itself as the matter could be handled there. She was sent back to the district
hospital where the patient had to be almost forced into the hospital amidst all delays and
non-responsiveness in admitting her. She was admitted. However almost 5 hours of
precious time had elaspsed after the delivery and the bleeding was continuous. The
doctor took some time to arrive. In half an hour Sunitha died leaving behind a just born
baby!
Case 2: Badwani (MP) & Jodhpur (Rajasthan)
A survey in the Barwani district hospital located in Madhya Pradesh revealed at least 25
maternal deaths between April and November 2010, even though the hospital has been
designated a comprehensive obstetric care unit, equipped to deal with child birth
complications day and night. It has been recorded that number of poor pregnant women
are turned away from the community health centres of their villages and were beaten and
abused by nurses and health staff of the district hospitals. The state government of MP
failed to examine the causes of these deaths, despite a central government mandate that
requires states to investigate maternal deaths and take appropriate remedial action. In a
similar case, during February and March 2011, at least 28 pregnant women died in two
government hospitals in Jodhpur, Rajasthan, supposedly after being administered
contaminated intravenous fluids. The government suspended three doctors, a drug
inspector and a storekeeper at one of the hospitals where deaths happened.
These two cases lay before us the raw reality of what happens to a woman in labour,
especially if she happens to be a very poor, Dalit, Tribal, slum dweller, paurakarmika or
domestic worker woman. The common running thread between all these women of
1

This paper is sent for publication to Health Action, Secunderablad (A monthly magazine on Health).

different languages and ethnicity and language is that they are all poor women, they get
turned away from the hospital easily, getting an emergency care is a struggle and coming
out alive from the hospital against all odds will be a miracle.
Context of Safe & Unsafe Births:
The global context: The FACT SHEET by the media and communications branch of
UN Population Fund (UNFPA) on Motherhood and Human Rights highlight the
unacceptably high number of maternal mortality and morbidity, 90% of which is easily
preventable. Most of these deaths occur in poorer countries of Africa and Asia. Almost
all of these women die in developing countries of preventable or treatable complications,
complications that rarely kill in rich countries.
Every minute, another woman dies from pregnancy-related causes. This adds up to
536,000 women per year, and more than 10 million women over a generation. Three
measures could save the lives of 90 per cent of the women who die giving life: Access to
contraceptives for all women, skilled personnel at the time of birth and prompt emergency
obstetric care if things go wrong.
The leading direct causes for maternal deaths in general are hemorrhage, infections,
unsafe abortions, high blood pressure leading to seizures and obstructed labour and in the
context of Africa complications during pregnancy or childbirth are the leading causes of
death for women.
Ten to 15 million women each year suffer severe or long-lasting illnesses or disabilities
caused by complications during pregnancy or childbirth. These range from obstetric
fistula and uterine prolapse to infertility, chronic infection and depression.
Consequences:
Every year, more than a million children are left motherless and vulnerable because
of maternal death. Children who have lost their mothers are up to 10 times more
likely to die prematurely than those who havent.
The risk of a woman dying as a result of pregnancy or childbirth during her lifetime
is about 1 in 7 in Niger and about 1 in 7,300 in developed countries. This
differential is the highest of any public health indicator monitored by the World
Health Organization.
Context of India:
According to the UN Interagency Maternal Mortality Estimates for 1990-2008, released
in September 2010 the absolute number of maternal death in India has fallen from
117,000 to 63,000. The MMR has now declined from 677 in 1980 to 254 in 2008. The
maternal mortality rate or the rate of deaths among women during or after pregnancy, in
India has declined to 212 per 100,000 live births in 2007-09 as against 254 in 2004-06,
according to data released by the Registrar General of India. Though there is a decline of
17% during the period, the country needs to achieve a target of 109 deaths by 2015 to
achieve the United Nations-mandated Millennium Development Goalsa feat already
achieved by Kerala, Maharashtra and Tamil Nadu. NRHMs goal while launching it in
2005 was to reduce maternal mortality to fewer than 100 per 100,000 live births by 2012.

However women throughout the country particularly Dalit women, tribal women, women
from slums still lack equitable, affordable and quality maternal health care.
The human rights violations: These facts and figures, case studies and the global
context of place before us the dual nature of the human rights challenge in question of
safe and supported birth:
Unacceptably high mortality and morbidity among poor women a gross
human rights violation against the life & dignity of women: Those who are
coming from the higher economic countries or strata of society and those who are
poor, vulnerable. While for the poor and pregnant women in dispossessed
contexts inaccessible or non-existent public health care and unaffordable private
health care resulting in exclusion and denial remains the single most reason for
unsafe birth, in the richer countries and for women who can afford over-intrusion
of technology into human life by way of unnecessary diagnostics, irrational
medication has resulted in making the hospitals or health care centres unsafe for
safe birth.
Unnecessary interventions & intrusions into the bodies of women a violation
of the right to dignity of women: The campaigns for natural birth, out-of
hospital or home birth movements in USA, Australia are reactions to the
experiences of the violations of their dignity and humanity. The challenges in
our discourse of human right to safe birth ranges from the inhumanity and
smearing of human dignity due to exclusion and non-availability of supportive
structures and technical assistance to the violations of human rights experienced
due to over medicalisation of the process of birth. The Cesarean surgery rate in
India's urban areas (according to preliminary studies), is approximately 50% and
is estimated to be as high as 80% or more in some private hospitals. The World
Health Organization deems it should be no higher than 5 - 15% and this is true of
most of the urban areas and countries which are rich and affluent.
2.0 HUMAN RIGHT TO SAFE BIRTH APPROACH AND PERSPECTIVES:
2.1 Perspectives of Human Rights:
Human rights are "commonly understood as inalienable fundamental rights to which a
person is inherently entitled simply because she or he is a human being."
All human beings irrespective of their class, caste, creed, gender, sexual orientation, are
entitled to certain basic and inalienable rights under any circumstances. These include
certain civil liberties and political rights, the most fundamental of which is the right to life
and physical safety as instruments to uphold human dignity. Human rights also include
economic, social and cultural rights such as right to work, shelter, education, health, etc.
There is now near-universal consensus that all individuals are entitled to certain basic
rights under any circumstances. These include certain civil liberties and political rights,
the most fundamental of which is the right to life and physical safety. Human rights are
the articulation of the need for justice, tolerance, mutual respect and human dignity in all
of our activity. Speaking of rights allows us to express the idea that all individuals are
part of the scope of morality and justice. To protect human rights is to ensure that people
receive some degree of decent, humane treatment. To violate the most basic human rights,
on the other hand, is to deny individuals their fundamental moral entitlements. It is, in a

sense, to treat them as if they are less than human and undeserving of respect and
dignity. (Michelle Maiese of the Conflict Research Consortium)
Human rights are thus conceived as universal (applicable everywhere) and egalitarian (the
same for everyone). These rights may exist as natural rights or as legal rights, in both
national and international law. The doctrine of human rights in international practice,
within international law, global and regional institutions, in the policies of states and in
the activities of non-governmental organizations, has been a cornerstone of public policy
around the world.
Basic Elements
It upholds human dignity and equality in an unequivocal way: All human beings are
born free and equal in dignity and rights. They are endowed with reason and
conscience and should act towards one another in a spirit of brotherhood. (Article 1
of the United Nations Universal Declaration of Human Rights (UDHR)

It Fixes State obligations: The human rights regime fixes the responsibility of
safeguarding human dignity on the state
o Protect, respect and promote/fulfill human rights:
o Prevention:
o Reparation:
It is the foundation of social justice and Peace: recognition of the inherent dignity
and of the equal and inalienable rights of all members of the human family is the
foundation of freedom, justice and peace in the world. (Preamble to the
Universal Declaration of Human Rights, 1948). There cannot be peace without
justice
All rights are equal, interrelated and complementary: Historically, a greater
emphasis has been placed on civil and political rights rather than on social,
economic and cultural rights, which are central to womens everyday lives.
However in 1993 the Vienna Declaration on Human Rights asserted that there is
no hierarchy in human rights, all have equal status in international law.
Protected by International Law: The foundation of the United Nations and the
provisions of the United Nations Charter would provide a basis for a
comprehensive system of international law and practice for the protection of
human rights. The term "international human rights law" is often used as a
category of reference to describe these systems, but this can be a source of
confusion as there is no separate entity as "international human rights law" but an
interlocking system of non-binding conventions, international treaties, domestic
law, international organisations and political bodies
Human Rights is an approach which holds human dignity and equality as the core of
all development based on natural justice as the foundational principle.
2.2 Human Rights Approach Applied to Safe and Supported Birth: The approach to
safeguard pregnant women has been dominated and led by various approaches so far. The
focus initially was on population control with undue focus on, contraception, coercive

methods for population control in the initial stage. Later, the focus shifted to RCH Reproductive and Child Health the focus was on the reproductive functions of women
and certain reproductive rights such as safe and legal abortions etc. Over the years the
focus has slowly shifted to maternal health and right to safe birth, both of which have
been influenced by the discourses on womens rights and maternal rights.
Clarifications:
Human Right to Safe Birth - does not include human right to birth: Birth is not a human
right. Millions of women around the world are infertile or have other conditions and
complications that prevent them from giving birth, even if they wish to do so. There is no
guaranteed right to be able to get pregnant and give birth.
Human Right to Safe Birth implies that women who do get pregnant and decide to have
children should have what we consider to be the basic human right of humane and
evidence-based maternity care, is entitled to all physical conditions to be able to have safe
delivery upholding her own and the infants dignity. Its not about the right to give
birththere is no such rightits about the right to receive appropriate care when you
do.

The implication of the human rights centred/based approach is that as a

society, nation we do everything to respect, protect, promote the dignity of the
pregnant woman and take all systemic, policy and programmatic measures to
avoid printable deaths and morbidity and create an atmosphere which will be
humane and safe to facilitate the process of birth safeguarding life and
dignity of mother and the infant before during and after birth.
Some examples for the measures to be taken:
Improve monitoring, accountability and redress in relation to maternal mortality.
The state has to be accountable to every life lost. (Compare: person traveling in the
aircraft is insured, KSRTC collects Rs.1 as insurance and in cases of accidents
insurance is given).
Allied entitlements complimenting the right to dignity and safe motherhood: safe
drinking water, nutritious food, rest, adequate ante-natal and post natal care,
access to technical assistance, need for a companion at the birthing process, right
to education on birth and maternity process.
Adequate public health care for the prevention, promotion, protection of human right
to safe birth.
3.0 ARTICULATION OF HUMAN RIGHT TO SAFE BIRTH IN THE
INTERNATIONAL LAW AND POLICIES:
Most of the documents are very generic in nature stating and upholding the dignity of the
person, and are addressing the societal structural issues such as gender inequity, gender
discrimination, patriarchal bias against women etc. Late 80s the issues of womens rights
and specificities emerged.
3.1 World Health Organisation (WHO: Health is a state of complete physical, mental
and social well being and not merely the absence of disease or infirmity. The enjoyment

of the highest attainable standard of health is one of the fundamental rights of every
human being without distinction of race, religion, and political belief, economic or social
condition. The issue of social condition includes the gender stereotypes, patriarchy and
gender discrimination.
3.2 CEDAW- Convention on the Elimination of All Forms of Discrimination Against
Women conceptualizes the reproductive health & rights with family planning with
equality and gender equality as the core of womens human rights. It envisages
elimination of discrimination against women in the field of health care, to ensure access
to health care services & facilities such as information, counseling and family planning.
Womans right to be informed and free & responsible choice, access to education and
information to be able to decide are to be made possible by the state intervention.
Article 12
1. States Parties shall take all appropriate measures to eliminate discrimination
against women in the field of health care in order to ensure, on a basis of equality of
men and women, access to health care services, including those related to family
planning.
2. States Parties shall ensure to women appropriate services in connection with
pregnancy, confinement and the post-natal period, granting free services where
necessary, as well as adequate nutrition during pregnancy and lactation.
Article 14
2. States Parties shall take all appropriate measures
(b) To have access to adequate health care facilities, including information,
counseling and services in family planning;
(c) To benefit directly from social security programmes; (h) To enjoy adequate living
conditions, particularly in relation to housing, sanitation, electricity and water supply,
transport and communications.
The HUMAN RIGHTS of women to safe birth
Article 12 of Convention on the Elimination of all Forms of Discrimination Against
Women requires States parties to ensure to women appropriate services in
connection with pregnancy, confinement and the post-natal period
Preventable maternal death compromises a number of established rights: to life, to
health, to family and to education, among others.
International law does not expect countries to instantaneously provide all goods,
services and facilities needed to protect the right to health. What is expected depends
on the resources available. Countries are expected to take concrete and deliberate
steps to progressively realize this right, with the assistance of higher-income
countries.
In societies where men traditionally control household finances, the health of women is
often not considered a priority.
Though the right to decide if, when and with whom to marry, and to determine the
number, spacing and timing of children is well-established, women are frequently
not able to exercise these rights.
In countries with similar levels of economic development, maternal mortality is
inversely proportional to women's statusthat is, the higher the status the lower the
mortality rates. The poorer the household, the greater the risk of maternal death.
Early marriage, female genital mutilation/cutting, un-wanted childbirths and violence
constitute violations of a womans right to make decisions regarding her own body.

 In a joint statement delivered to the Human Rights Council in March 2009, 83 countries
called for action to address the unacceptably high number of maternal deaths.
3.3 Human Right to & Supported Safe Birth as part of Human Right to Health:
The Universal Declaration of Human Rights and International Covenant on Economic
Social and Cultural Rights define health as the highest attainable standard of physical
and mental health. General Comment 14 further explicitates the same which is relevant to
right to safe birth:
a) Availability: Functioning public health and health-care facilities, goods and services,
as well as programmes, have to be available in sufficient quantity within the State party. safe and potable drinking water and adequate sanitation facilities, hospitals, clinics and
other health-related buildings, trained medical and professional personnel, essential drugs.
(b) Accessibility: Health facilities, goods and services have to be accessible to everyone
without discrimination
Non-discrimination: health facilities, goods and services must be accessible to all,
especially the most vulnerable or marginalized sections of the population without
discrimination.
Physical accessibility: health facilities, goods and services must be within safe
physical reach for all sections of the population, especially vulnerable or
marginalized groups, such as ethnic minorities and indigenous populations,
women, children, adolescents, older persons, persons with disabilities and
persons with HIV/AIDS. Accessibility also implies that medical services and
underlying determinants of health, such as safe and potable water and adequate
sanitation facilities, are within safe physical reach, including in rural areas.
Accessibility further includes adequate access to buildings for persons with
disabilities.
Economic accessibility (affordability): health facilities, goods and services must be
affordable for all.
Information accessibility: accessibility includes the right to seek, receive and impart
information and ideas on health issues.
(c) Acceptability: All health facilities, goods and services must be respectful of medical
ethics and culturally appropriate
(d) Quality: Health facilities, goods and services must also be scientifically and medically
appropriate and of good quality. This requires killed medical personnel, scientifically
approved and unexpired drugs and hospital equipment, safe and potable water, and
adequate sanitation.
Article 12.2 (a): The right to maternal, child and reproductive health: "The
provision for the reduction of the stillbirth rate and of infant mortality and for the healthy
development of the child" (art. 12.2 (a)) may be understood as requiring measures to
improve child and maternal health, sexual and reproductive health services, including
access to family planning, pre- and post-natal care, emergency obstetric services and
access to information, as well as to resources necessary to act on that information.
International Conference on Population and Development (ICPD) 1994 (Cairo), Beijing
Platform for Action 1995, ICPD plus 1999 stress on access to quality abortion services,

couples right to decide on family planning without coercion, discrimination and

violence.
3.4 United Nations Human Rights Council Resolutions:
In June, 2009 the UN HRC adopted a landmark resolution by name Preventable Maternal
Mortality and Morbidity and Human Rights (Resolution 11/8) and for the first time UN
body officially recognized maternal mortality as a human rights concern and,
Recognised that unacceptably high rates of maternal mortality and morbidity is a
human rights issue
Acknowledges among other things elimination of maternal mortality and morbidity
requires the effective promotion and protection of womens and girls human
rights right to life, dignity, education, to be free to seek, receive and impart
information, to enjoy the benefits of scientific progress, to freedom from
discrimination, to enjoy the highest attainable standard of physical and mental
health, including sexual and reproductive health.
Calls for strategies to redouble existing efforts to fulfill human rights obligations, to
incorporate human rights centered approach to programmes and policies to
eliminate preventable maternal mortality and morbidity.
In October 2010, the UNHRC adopted a follow-up resolution calling on the states to
renew their political commitment to eliminate preventable maternal mortality and
morbidity at the local, national, regional and international levels. It focuses on the
underlying causes such as poverty, malnutrition, harmful practices, lack of accessible and
appropriate healthcare services, lack of information and education on gender inequality
and to eliminate all forms of violence against women. Unfortunately, India has not
sponsored this resolution (though Sri Lanka and Nepal have done the same). However,
government is still obligated to take concrete measures to comply with the resolution. The
UNHRC resolutions provides advocates with powerful tools for demanding government
accountability for failure to protect and promote every womans basic human right to safe
and healthy pregnancy and child birth from a human rights-centred approach.
3.5 2010 OHCHR Study on Preventable Maternal Mortality and Morbidity and
Human Rights
Highlights: The study by OHCHR states unequivocally that maternal mortality and
morbidity are matters of human rights and that a human rights based approach is essential
to addressing these serious global problems. The preventable maternal mortality and
morbidity reflects inequality, discrimination, violence faced by women and girls
throughout their life-time. Only an approach guaranteeing the full range of womens
human rights, including sexual and reproductive rights can ensure the dignity of womens
lives.
The report emphasizes international human rights an obligation needs to be taken in
legislative, administrative and judicial action also for positive action through maximum
available resources to prevent maternal mortality and morbidity.
All programmes and policies should include seven human rights principles:
Accountability
Participation
Transparency

Empowerment
Sustainability
Non-discrimination
International assistance and cooperation

Correcting Systemic Failure: Regular monitoring of the health system and the
underlying physical and socio-economic determinants that affect womens health and
ability to exercise their rights is essential to correct systemic failures in reducing maternal
mortality and morbidity. Effective access to remedies and reparation is a must towards a
constructive accountability framework to prevent and redress maternal death and
disabilities.
Commission on Information and Accountability for Womens and Childrens Health
for developing a framework for global reporting, oversight, and accountability regarding
womens and childrens health which includes the union minister as the member at the
national level.
3.6 Millennium Development Goals (MDGs) and human right to safe birth: Putting
safe birth on the international agenda
All the nations of the world are currently working to achieve the Millennial Development
Goals laid out by the United Nations. Goal Number 5 proposes to reduce by three
quarters, between 1990 and 2015, the maternal mortality rate, and to increase the
proportion of births attended by skilled health personnel. Right now, only 60% of the
women in the world have a midwife, or doctor or nurse with midwifery skills to assist at
their childbirths.
Ban Ki-moon, UN Secretary-General, seemed to hint that this was indeed a human rights
issue when he made this statement: Ours is the generation that can achieve the
development goals and free our fellow men, women and children from the abject and
dehumanizing conditions of extreme poverty.
The bad news is that, globally, maternal mortality ratios essentially have not changed
since the 1990 estimates, denoting more than 500,000 maternal deaths annually for a
world rate at an estimated 400/100,000 live births , with 14 countries having a rate more
than 1,000/100,000. The five direct causes of nearly two-thirds of maternal deaths
worldwide are all things we have learned to prevent, treat or correct, making it all the
more unjust that woman are dying of these childbirth complications. They are:
Hemorrhage
Sepsis
Obstructed labor
Eclampsia
Complications of abortions
Every single minute that we delay in taking action, a mother somewhere in the world is
dying from complications related to pregnancy and childbirth. Yet maternal deaths can be
prevented. The midwife model of care is a powerful tool, when used in conjunction with
World Health Organization standards and protocols for advanced skills in midwifery.
Mercy in Actions model birth centers have proven this in the Philippines.

3.7 ICPD and the Millennium Development Goals

At the 1994 International Conference on Population and Development (ICPD), the
participating countries agreed to reduce maternal mortality to 75 per cent below 1990
levels by 2015. In 2000, the international community used this same benchmark as an
indicator for the Millennium Development Goal 5 (improve maternal health). In 2005, the
international community acknowledged the need to do more to protect maternal health, by
adding universal access to reproductive health as another target. Among the eight goals,
progress on MDG5 is lagging furthest behind. Globally, the rate of death from pregnancy
and childbirth has declined just one percent between 1990 and 2005. Meeting the target
would have required an annual decline of 5.5 per cent.
4.0 CHALLENGES FOR AND DILEMMAS IN HUMAN RIGHT TO SAFE
BIRTH:
4.1 Equity and Justice
Irrespective of the place of birth, the important factor in whether childbirth are safe or
unsafe for a woman is three-fold: the overall health of the woman, her place in society,
and the presence of a skilled birth attendant. Poor women, those who come to the place of
birth malnourished and often unattended, die 100 times more often than their wealthier
counterparts. Women in rich countries can die in childbirth too with the overuse of
cesarean delivery and labor induction is driving up the maternal mortality rate as is the
case in the United States. While maternal mortality can happen anywhere and due to
various factors, the lifetime risk of maternal death in the United States is 1 in 2,500 in
comparison to a lifetime risk in Sierra Leone and Afghanistan of 1 in 6.
Yet even within poor countries, the disparity between richer and poorer women is a
matter of injustice based on economic restraints. In Bangladesh, for example, among the
richest 20% of women, almost half have a skilled birth attendant at the time of giving
birth. Among the poorest 20% of women in Bangladesh, only 4% are helped by any
trained person. In Peru, almost all rich women have a midwife or doctor attend their birth,
while only 20% of the poor get this basic right. In India, the upper middle class and
women from Upper class and caste go to a private health centre and the poor have only to
depend on the not optimally functioning primary health centre.
The inequity in India is intrinsically linked to rural urban divide, the challenges faced by
the poor in rural areas and the challenges faced by the poor in urban areas, status of
women based on caste and ethnicity (majority of the women who are anemic and die in
child births are belonging to the scheduled castes and scheduled tribes, women in slums,
agricultural labourers). While the public system is weak, the women from affordable
classes and forward castes expose themselves to the dangers in the private health centers.
The human rights challenge is to ask ourselves IS IT ACCEPTABLE TO LET WOMEN
AND POORER WOMEN DIE? IS IT LEGITIMATE FOR THE UPPER MIDDLE
CLASS AND UPPER CLASS TO BE OVER MEDICALISED, SUBJECT TO
UNNECESSARY DIAGNOSITCS?
4.2 Corruption and Maternal Health:
Corruption within the healthcare system has prevented benefits promised under various
schemes from reaching the majority of BPL women who are not in a position to demand

10

them; no legal accountability for corrupt practices; significant amount of money allocated
to schemes and maternal audits remain underutilized indicating a troublesome
management. The cost burden on women and families of accessing healthcare services to
address potentially life-threatening medical complications including relating to pregnancy
deal a crushing blow to families throwing them into cycle of indebtedness and extreme
poverty.

FACT SHEET ON IMPORTANT FACTORS IN MATERNAL MORTALITY AND MORBIDITY

(Source: UNFPA)
Young people
Girls aged 15-20 are estimated to be twice as likely to die in childbirth as those in their twenties and girls under
the age of 15 are five times more likely to die from maternal causes.
Girls aged 15-19 account for one in four unsafe abortionswhich adds up to five million each year.
Complications during pregnancy or childbearing are the leading cause of death for girls aged 15-19 in
developing countries.
Less than 20 per cent of all sexually active young people in Africa use contraception.
Pregnancy-related disability

Obstetric fistula, caused by prolonged obstructed labour, is one of the worst pregnancy outcomes. It leaves
women incontinent, and they often end up ostracized by their families and communities. A million women
are thought to be living with the condition.
Two to 10 per cent (depending on countries) of women of reproductive age suffer from prolapsed uterus
(commonly referred to as fallen womb). Severe cases require surgical interventions, which are often
beyond the means of women in low-income countries to access.
Perinatal depression is a severe disorder associated with maternal physical morbidity, substance abuse and
suicide. The consequences of maternal depression affect children as well.
Complications from unsafe abortion account for the largest proportion of hospital admissions for gynaecological
services in the world. According to the Guttmacher Institute, five million women each year are admitted to
hospital for treatment of unsafe abortion complications, including trauma to the vagina, uterus and
abdominal organs, reproductive tract infections, shock, and infertility.

4.3 Severe Human Rights Violations During Delivery:

In-human treatment at the clinics:
Recent anthropological ethnographies describe
women in India, Mexico, Tanzania, Papua New Guinea, Croatia, Canada and elsewhere
saying the same thing about the care they receive in biomedical clinics and hospitals:
They expose you, they shave you, they cut you, they leave you alone and dont come
when you call, and they wont allow your relatives to be with you.
Anthropologist Pauline Kolenda describes birth in a hospital in a hospital near a small
village in India:
Before entering the hospital we have first to decide how much money we have to
give. We are not admitted unless we first give them money. When the woman
enters into the hospital, the doctor behaves rudely with her. Sometimes nurses beat
her. They do not let close and affectionate relatives, who came from home with us,
stand at our side. They themselves do not stay near us. We wish that somebody
[would] hold us by the waist when pains come, but they do not do it. We have not
even to moan, lest they talk sarcastically, make fun of us, which is very [hurtful]
still we have to bear. If we moan too much, they may sometimes slap us. If we
happen to say something, they retort by asking us whether they had invited us to
come. Why have you come then? You may go back home! In hospital, we have to
lie down on the bed to get delivered. In the hospital they excise the vaginal wall
with a blade for enlarging it. The body gets damaged unnecessarily. After delivery
we feel terribly hungry, but we consider ourselves lucky if we get a cup of tea.

11

4.4 Shrinking and Weakened Public Health Care System: Poor health infrastructure
not equipped to handle the normal deliveries and hence the lives of estimated 15%
women likely to experience complications related to pregnancy is a high risk factor; Lack
of emergency obstetric services; Scarcity of specialists; Low government budgetary
allocation for health; lack of pre/ante natal care; inadequate access to safe abortions etc.
4.5 Corporatised and Commercialised Unaccountable Unregulated Private Health
Care System: In India 78% health care expenditure is out of pocket expenditure,
meaning majority of the health care provision is in the private sector. The private sector is
not regulated by any law as regards the standard of treatment protocols, pricing of
services etc which has easily led to clinical trials, irrational diagnostics, over use of Csection etc. The ethical and human rights standards are severely compromised in such a
free and unaccountable atmosphere.
Policies and practices not based on Evidence Based Care: Good practices in many
developing countries (such as China, Cuba, Egypt, Jamaica, Malaysia, Sri Lanka,
Philippines, Thailand and Tunisia) have reversed the rate of maternal mortality and
morbidity showing that it is possible to make a difference by strengthening healthcare
systems. Many of these countries have halved their maternal deaths in the space of a
decade, showing what can be accomplished when the political will and resources are in
place.
4.6 Societal Responsibility and Changing Context: A birth of a child or the delivery
takes place in a given socio cultural context. In the traditional societies this process of
giving birth was always socially, culturally and economically supported by the family and
neighborhoods. For the first delivery always the girl would go back to her mothers house
and experienced women, traditional birth attendants would prepare her, assist her and
help her through that process. In this supportive environment a woman had recourse to
natural birth.
However, today the context has so much changed. Families are becoming nuclear and the
couples are employed. Hence taking time off and having delivery in the secure
environment of a family are becoming lesser. The would-be parents to a large extent also
depend on the supportive medical profession and they do not have either the time or the
access to information to find out if the medical professionals are always correct.
While the above is true for a middle class and upper middle class or richer sections of the
society, the reality is different for the lower middle class, poorer households. All women
are fully human and deserving of respect and dignity. However, the situation is such that
it has been said that, in developing countries, the most dangerous occupation is
motherhood. Conscientious people have a duty to act on human rights violations, once
those violations have been made known and act upon for better conditions.
Dilemmas: Conference themes focus on the human rights angle and also point towards
the dilemmas and the complexity of the issue.
The dilemmas of over-medicalization for some and little access to health care for the
majority, the urban-rural and rich-poor divide which is a major factor in deciding
the access to and quality of care, informed consent and challenges in getting an
informed consent due the social, cultural, educational status of women in either
having recourse to surgical interventions or facilitating natural birth process.
When and how much of bio-medical and when natural birth process in the

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context of majority of the poor women are anemic and havent had any or
adequate ante-natal care.
Promote institutional deliveries or oppose them when there are no trained birth
attendants, sub-centres do not work and the PHCs are bad enough.
Do we demand for at least some public health care system or demand quality care
The chasm between doctors and health care providers and people is of vulnerability,
helplessness and people do not have much bargaining power in an highly
unaccountable and unethical practice in the hospitals, dilemma is should we fight
for the mother or for the reform in the health care system?
5.0 TOWARDS PROMOTING THE HUMAN RIGHT TO SAFE AND
SUPPORTED BIRTH
Efforts to prevent maternal deaths and to achieve access to reproductive health for all
requires broad partnerships as well as political and financial commitments to long-term
and targeted efforts to strengthen health systems. Human Right to safe and supported
birth needs to include more specifically, among others, the following as a larger canvass
of means to attain this right.
Advocate for the right of women and their children to survive pregnancy and
childbirth.
Facilitation of informed and educated family planning to prevent unintended or too
closely spaced births. Every additional birth multiplies a womans risk of dying.
Invest in midwives: Hundreds of thousands of lives could be saved by getting
midwives in communities.
Ensure that all women experiencing complications have prompt access to quality
emergency obstetric care.
Bolster the training and incentives of health care workers so that skilled attendance
at birth is available to all women.
Make sure that necessary supplies, equipment and logistical systems to ensure
quality care during pregnancy and childbirth are available to birth attendants.
Provide the couple, especially the woman, with the opportunity to make informed
choices regarding their sexual lives, marriage and pregnancy.
Integrating traditional practices in natural birth/ Evidence on traditional birth
practices, midwifery and birth practices, integrating emotional and physical
support in mainstream care, re-training physicians and nurses and integrating
midwives in hospital births
Suggested Steps for the best practice towards safe birth with human rights
approach*:
Step 1 - Treat every woman with respect and dignity, fully informing and involving her in
decision making about care for herself and her baby in language that she understands, and
providing her the right to informed consent and refusal.
Step 2 - Possess and routinely apply midwifery knowledge and skills that enhance and
optimize the normal physiology of pregnancy, labour, birth, breastfeeding, and the
postpartum period.

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Step 3 - Inform the mother of the benefits of continuous support during labour and birth,
and affirm her right to receive such support from companions of her choice, such as
fathers, partners, family members, doulas, or others. Continuous support has been shown
to reduce the need for intrapartum analgesia, decrease the rate of operative births and
increase mothers satisfaction with their birthing experience.
Step 4 - Provide drug-free comfort and pain-relief methods during labour, explaining
their benefits for facilitating normal birth and avoiding unnecessary harm, and showing
women (and their companions) how to use these methods, while respecting womens
preferences and choices.
Step 5 - Provide specific evidence-based practices proven to be beneficial in supporting
the normal physiology of labour, birth, and the postpartum period.
Step 6 - Avoid potentially harmful procedures and practices that have no scientific
support for routine or frequent use in normal labour and birth. When considered for a
specific situation, their use should be supported by best available evidence that the
benefits are likely to outweigh the potential harms and should be fully discussed with
the mother to ensure her informed consent.
Step 7 - Implement measures that enhance wellness and prevent emergencies, illness,
and death of Mother or child. (Including education about and foster access to good
nutrition, clean water, clean and safe environment, emotional and physical health,
education to methods of disease prevention etc.
Step 8 - Provide access to evidence-based skilled emergency treatment for lifethreatening complications.
Step 9 - Mainstream non- bio medical and natural birth environment including
traditional birth attendants and others who attend births out of hospital in this continuum
of care which is culturally sensitive.
Step 10 - Safe and Supported Birth is a fundamental human rights issue and the State
should take all steps to implement and institutionalize the international commitment to
protect, promote and fulfill the rights of the mother and the child which includes all the
best practices to safe birth. This is crucial to reduce infant and maternal mortality keeping
in mind our commitment to Millennium Development Goals.
(* adapted from the International MotherBaby Childbirth Initiative IMBCI- of International MotherBaby
Childbirth Organisation, IMBCO, accessible at www.imbci.org)

6.0 CONCLUSION
For more than 30 years, a significant part of the womens health movement has
repeatedly asked for a re-appropriation of womens bodies while birthing, coupled with a
request for the de-medicalization of this important event for women. More recently,
womens rights have been emphasized in the domain of sexuality and reproductionfor
instance, the right to decide, to be adequately informed and to have bodily integrity. In
June 2009, the UN Human Rights Council passed a landmark resolution that recognizes
preventable maternal mortality and morbidity as a pressing human-rights issue that
violates a womans rights to health, life, education, dignity and information. More
recently, Amnesty International released a report entitled Deadly Delivery: The Maternal

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Child Health Crisis in the USA demonstrating that even resource-rich countries have not
put practices in place that treat women with dignity, respect and appropriate care.
Birth itself is not a human right, but humane and evidence-based care during birth is a
human right, just as humane and evidence-based care is a human right for every person
who seeks health care. Its time for all women, men, midwives, nurses, doulas and care
providers to see birth as a human rights issue. In this human rights consciousness, losing
about 5, 00,000 women in the world with almost 1/5 accounted in India while leaving
large numbers disabled in various ways represents a terrible injustice, reflect entrenched
discrimination against women and imply a failure at some level to fulfill the human rights
of expecting mothers by the society and by the community of conscious, conscientious
and people with human rights consciousness.
Most of these deaths and disabilities are avoidable with due political commitment and
integrating evidenced based care and best practices around the world. While maternal
death is a gross human rights violation from the part of the state, a conducive and
assuring atmosphere for safe birth to survive childbirth is a human rights imperative of
fundamental significance. Every year, the world misses out on $15 billion in lost
productivity by letting women die or become disabled as a result of childbearing, it cost
only $6 billion to provide the health services to save women's lives.
References:
1. Human Rights Law Network (HRLN), Claiming Dignity Reproductive Rights
and the Law, New Delhi: HRLN, 2009
2. Dr T. K. Sundari Ravindran, Mainstreaming Gender and Rights in Reproductive
Health Care within a Public Health System A Reviw of Women-Centred Health
Project, Mumbai, Vododara: SAHAJ, 2004
3. United Nations, Human Rights Council, Report f the Office of the UNHCHR on
Preventable Maternal Mortality and Morbidity and Human Rights (available at
www.ohchr.org)
4. Centre for Reporductive Rights, Maternal Mortality in India: Using International
and Constitutional Law to Promote Accountability and Change, New Delhi:
HRLN, 2011
5. Various Articles in Midwifery Today, Issue 94 (Summer 2010) available at
http://www.midwiferytoday.com/magazine/issue94.asp
6. Fact Sheet: Motherhood and Human Rights published by UNFPA (available at
http://www.unfpa.org/public/factsheets/pid/3851)
7. Universal Declaration of Human Rights, International Covenant on Economic,
Social and Cultural Rights (available at http://www.un.org/en/documents)
8. Convention on Elimination of All Forms of Discrimination Against Women
CEDAW, (available at http://www.un.org/womenwatch/daw/cedaw)
9. IMBCI the Ten Steps, International MotherBaby Childbirth Initiative (available
at www.imbci.org

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