Statement to ECOSOC: Maternal Mortality and the MDGs

The approach of the Millennium Development Goals (MDG) Summit in September provides a key opportunity for states and the international community to reassess their progress and confront challenges to achieving the MDGs. The Center for Reproductive Rights thus welcomes the United Nations Economic and Social Council’s (ECOSOC) decision to dedicate the 2010 Annual Ministerial Review (AMR) to examining progress toward the MDGs through the lens of gender equality and empowerment. Nowhere is the need for this gender lens clearer than in regard to MDG 5: Improve Maternal Health. According to the World Health Organization (WHO), 536,000 women died of pregnancy and child birth-related complications in 2005.¹    It is estimated that another 10 million women suffer from chronic injuries, infection, disease and disability related to pregnancy and child birth every year.²

Even in countries that have made progress on many of the MDGs, efforts to reduce maternal mortality continue to be inadequate. Brazil, which is making a National Voluntary Presentation at the AMR this year, is one such country. According to the WHO, Brazil has a maternal mortality ratio of 110 deaths per 100,000 live births.³    While the Government of Brazil calculates its maternal mortality ratio to be significantly lower – 53.4 deaths per 100,000 live births in 2005⁴ – it also acknowledges that under-reporting makes it difficult to accurately assess rates of maternal death.⁵    Both estimates, however, indicate that Brazil’s maternal mortality ratio is higher than those of countries in the region with comparable socio-economic status and are far above the WHO’s acceptable rate of 10-20 deaths per 100,000 live births. These deaths are not inevitable: The Government of Brazil itself notes that 90 percent of these maternal deaths could be prevented with adequate medical care.⁶

Brazil’s failure to effectively address maternal mortality jeopardizes its progress on all of the MDGs, including Goal 3 on gender equality and empowerment. While the United Nations Development Program’s (UNDP) MDG Monitor notes that Brazil has already achieved Goal 3,⁷ the country’s high maternal mortality rates suggest otherwise. Preventable maternal mortality is both a form and a symptom of discrimination against women and deprives women of their right to live a healthy life on a basis of equality with men.

Maternal Mortality in Brazil

Brazil is a middle-income country with a health care system that guarantees universal free access to services. Hospital births account for 96 percent of all births, and in urban centers, this rate increases to more than 99 percent.⁸    Yet, broad access to hospitals for delivery has not translated into safe pregnancy for many Brazilian women, indicating the failure of the government to ensure equitable access to high quality services.

At the facility level, quality of care is often shockingly low. Many medical practitioners continue to rely on unnecessary, painful and potentially harmful delivery practices, such as the use of forceps for certain deliveries and over-reliance on caesarean sections.⁹    Numerous studies have documented women’s complaints of neglect and verbal abuse by health care providers during labor.¹⁰    Unsurprisingly, many women experience these types of practices as a threat to their emotional and physical integrity, and they often compromise the quality of care that women receive.¹¹

Additionally, Brazil’s referral systems are purported to “function so poorly, [that] pregnant women sometimes scramble to find an available hospital bed when they enter labor.”¹²    A recent profile of health-care facilities conducted by the Brazilian Institute of Geography and Statistics revealed that the number of hospital beds in public and private hospitals actually declined between 1986 and 2005, and significant differences in terms of size and technological capacity of hospitals persist, with the North and Northeast having far fewer beds and well-equipped facilities than the southern regions.¹³ Brazil also does not meet WHO guidelines¹⁴ for the number and distribution of emergency and basic obstetric care facilities for women in rural and poor regions, essential components of any program to reduce maternal mortality.¹⁵

These problems stem from larger issues of inequality within Brazil’s health system. The transfer of federal funds to states and municipalities tends to favor richer states, particularly in the South and Southeast, to the detriment of poorer states with greater health care problems, because the transfers are generally dependent on existing infrastructure, as opposed to actual health needs.¹⁶ Additionally, the reliance of high-income groups on the public health system for more complicated and expensive procedures not covered by private providers has raised the cost of services for the poor and limits the ability of the health care system to expand the coverage of regular services for low-income populations. Because of this situation, the Brazil UN Country Team has called for a reallocation of resources to better serve the needs of the country’s poor.¹⁷

Regional disparities also intersect with racial and ethnic inequality. According to Brazil’s health ministry, Afro-Brazilian women are 50 percent more likely to die of obstetric-related causes than are white women.¹⁸    Risk of maternal death also disproportionately affects indigenous and low- income women, especially adolescents and women from rural areas.¹⁹    Women from these groups tend to receive fewer health services and lower quality of care, contributing to their vulnerability to maternal mortality.²⁰    According to a U.N. study, nationwide, 66 percent of black women and 74 percent of indigenous women received fewer than six prenatal visits, compared to only 45 percent of white women.²¹    Black women were also provided with less information about pregnancy, delivery and post-natal care of children, including signs of labor, importance of early breastfeeding and importance of prenatal examinations.²²

Unsafe abortion is also a leading cause of maternal mortality, accounting for more than nine percent of maternal deaths in Brazil.²³    Abortion is illegal except in cases of rape or danger to a woman’s life. However, an estimated 1 million abortions, the vast majority of which are illegal, are performed in the country every year,²⁴ and approximately 250,000 women and girls are hospitalized for complications of these procedures annually.²⁵    Rates of abortion and abortion– related complications are higher in poorer regions of the country and among more disadvantaged racial and ethnic groups, contributing significantly to the vulnerability of these women to maternal death and injury.²⁶

The government of Brazil has launched several policies and programs to address maternal mortality, including establishing nearly 300 regional, municipal and hospital-based maternal mortality committees to monitor the number and causes of maternal deaths. Brazil’s limited progress on MDG Goal 5, however, demonstrates that these measures have fallen short of addressing the underlying issues of discrimination and inequality that contribute to maternal mortality in Brazil.

Addressing Maternal Mortality Worldwide

Brazil’s failure to adequately address issues of discrimination and inequality that underlie maternal mortality is not unique, nor is the path to preventing these deaths unknown. The Center urges the international community to recognize that addressing maternal mortality both requires and is essential to achieving gender equality and empowerment, and to take the following steps to address this issue:

Access to maternal health care, including skilled delivery and emergency obstetric care, is recognized as essential to maternal health. States should invest greater resources in improving the accessibility, acceptability, affordability and quality of these health care services and referral systems, particularly in poor and rural areas.

States must recognize and address socio-economic, racial, ethnic and other factors that contribute to differential vulnerability to maternal mortality, and undertake special measures to ensure that these groups are empowered to access comprehensive sexual and reproductive health care.

States should develop and implement effective monitoring and accountability mechanisms in order to accurately and effectively account for and address maternal deaths.

Complications of unsafe abortions are estimated to account for 13 percent of maternal deaths worldwide. States must liberalize their abortion laws and take proactive steps to ensure that women can access both safe abortion and post-abortion care services.

Footnotes:

1. WORLD HEALTH ORGANIZATION ET AL., MATERNAL MORTALITY IN 2005: ESTIMATES DEVELOPED BY WHO, UNICEF, UNFPA AND THE WORLD BANK 1 (2007) [hereinafter WHO, MATERNAL MORTALITY IN 2005]. The Center welcomed the release of new worldwide data on maternal mortality in the Lancet in April 2010. In this written submission, however, the Center has chosen to rely on the most recent official data on maternal mortality from the United Nations. The Center looks forward to the United Nations’ release of updated data later this year and to a continued discussion of the best methodologies for accurately measuring rates of maternal mortality.


2. UK All Party Parliamentary Group on Population, Development and Reproductive Health, Better off Dead? A Report on Maternal Morbidity, at 3 &amp, 10 (May 2009), available at www.health- e.co.za/uploaded/2abf4f8cc84c760af51ea81585badf01.pdf.


3. WHO, MATERNAL MORTALITY IN 2005, supra note 1, at 23.


4. PRESIDENCY OF THE REPUBLIC OF BRAZIL, MILLENNIUM DEVELOPMENT GOALS: NATIONAL MONITORING REPORT 78 (2007) [hereinafter BRAZIL, MDG NATIONAL MONITORING REPORT 2007].


5. Id.


6. Implementation of the International Covenant on Economic, Social and Cultural Rights: Second periodic report submitted by States parties under articles 16 and 17 of the Covenant, Brazil, para. 418, U.N. Doc. E/C.12/BRA/2 (Jan. 28, 2008).


7. United Nations Development Programme (UNDP), MDG Monitor, www.mdgmonitor.org/country_progress.cfm?c=BRA&amp,cd=76 (last accessed April 27, 2010) [Notes that current status of each Goal is in accordance with national Government reporting].


8. See Simone Grilo Diniz et al., Empowering women in Brazil, 370 Lancet1596, 1596-1597 (November 10, 2007) [hereinafter Empowering women in Brazil].


9. Id. at 1596-97, see also BRAZIL, MDG NATIONAL MONITORING REPORT 2007, supra note 4, at 79.


10. See Ana Flávia Pires Lucas d’Oliveira, Simone Grilo Diniz &amp, Lilia Blima Schraiber, Violence against women in health-care institutions: an emerging problem 359 Lancet 1681-82, 1681-1685 (May 11, 2002).


11. Id.


12. See WORLD BANK, Brazil: Maternal and Child Health, ¶ A20 at 63, Report No. 23811-BR (2002), available at www- wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2002/04/12/000094946_02040304022680/Rend ered/PDF/multi0page.pdf (last visited on April 27, 2010) [hereinafter Brazil: Maternal and Child Health], see also Sandra Valongueiro Alves, Maternal Mortality in Pernambuco, Brazil: What Has Changed in Ten Years? 15 (30) Reproductive Health Matters 141, 134-144 (2007).


13. See PAN AMERICAN HEALTH ORGANIZATION (PAHO), Brazil: Health System Profile 35 (2008), available at www.lachealthsys.org/index.php?option=com_docman&amp,task=doc_download&amp,gid=156 (last visited on April 27, 2010).


14. See generally UNICEF, WHO AND UNFPA: GUIDELINES FOR MONITORING THE AVAILABILITY AND USE OF OBSTETRIC SERVICES (1997), available at whqlibdoc.who.int/publications/1997/9280631985.pdf.


15. See INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA (IBGE), ASSISTÉNCIA MÉDICA SANITÁRIA 2005: MALHA MUNICIPAL DIGITAL DO BRASIL: SITUAÇÃO EM 2005.


16. See OECD, Economic Survey of Brazil 2005: Better Targeting Government Social Spending 9 (2004), available at www.oecd.org/dataoecd/12/10/34427527.pdf (last visited on April 27, 2010), see also ANDRE CEZAR MEDICI, Financing Health Policies in Brazil: Achievements, Challenges and Proposals (Inter-American Development Bank 2002), available at idbdocs.iadb.org/wsdocs/getdocument.aspx?docnum=354036 (last visited on April 27, 2010).


17. UNITED NATIONS COUNTRY TEAM BRAZIL, A UN Reading of Brazil’s Challenges and Potential: Common Country Assessment by Brazil’s UNCT, ¶ 46, at 15 (2005), available at www.unodc.org/pdf/brazil/Final%20CCA%20Brazil%20(eng).pdf (last visited on April 27, 2010) [hereinafter UN Reading of Brazil’s Challenges and Potential].


18. BRAZILIAN HEALTH MINISTRY, BRAZIL HEALTH 2006: AN ANALYSIS OF INEQUALITY IN HEALTH (MINISTÉRIO DA SAÚDE, SAÚDE BRASIL 2006 – UMA ANÁLISE DA DESIGUALDADE EM SAÚDE) 366 (2006) [hereinafter BRAZIL HEALTH 2006: AN ANALYSIS OF INEQUALITY IN HEALTH].


19. Id. at 367.


20. MINISTÉRIO DA SAÚDE, POLÍTICA NACIONAL DE ATENÇÃO INTEGRAL A SAÚDE DA MULHER: PRINCIPIOS E DIRETRIZES 26 (2004), Brazil: Maternal and Child Health, supra note 12, para. 2.8 at 20-21.


21. UN Reading of Brazil’s Challenges and Potential, supra note 17, ¶ 41, at 14.


22. Articulación de Organizaciones de Mujeres Negras Brasileñas (AMNB), Dossier Regarding the Situation of Black Women in Brazil, 25 (July 2007).


23. BRAZIL, MDG NATIONAL MONITORING REPORT 2007, supra note 4, at 78.


24. See Ipas Brasil and Instituto de Medicina Social, Magnitude do Aborto no Brasil: uma análise dos resultados de pesquisa (2007), available at www.ccr.org.br/uploads/eventos/mag_aborto.pdf


25. See Ipas Brazil, Unsafe abortion hits hard in Brazil, www.ipas.org/Library/News/News_Items/Unsafe_abortion_hits_hard_in_Brazil.aspx (last accessed April 27, 2010).


26. See    Ipas Brasil, Supplementary information for review of periodic report by State of Brazil during the 42nd CESCR Committee session, 7 (2009), available at www2.ohchr.org/english/bodies/cescr/cescrs42.htm (last accessed April 27, 2010).