Women’s health and human rights
‘The health of mothers and their children is the key to achieving development and equity’ – Deputy President Cyril Ramaphosa at the World Health Organization (WHO)’s Partnership for Maternal, Newborn and Child Health Forum held in Johannesburg during July 2014.1 Indeed, the health and economic status of women and children usually provide an accurate overview of national viability.
As September 2015 rapidly approaches, it is obvious that inadequate progress has been made towards achieving the three inter-related Millennium Development Goals (MDGs) concerning women, as set out by members of the United Nations (UN) in 2002.2 These MDGs are: MDG 3 (promote gender equality and empower women); MDG 5 (improve maternal health, reducing maternal mortality, and universal access to reproductive health), and MDG 6 (combating HIV/AIDS and other diseases). Lack of progress in any of these goals undermines progress in the others.3
South Africa (SA) is not on track to meet these goals.4 HIV/AIDS has been the major health issue affecting women of reproductive age and maternal health in SA since 2000, when HIV infection meant certain death, and health policy was based on the AIDS denialist stance of the government of that time.5 There was no national programme providing access to antiretroviral drugs, either for treatment of HIV-positive adults and children, or for prevention of mother-to-child transmission (PMTCT). Instead of progressing towards the MDG targets, SA has been retrogressing from 2000 to date. The mortality rate among women of reproductive age has increased, and maternal deaths continue to rise.6 MDG 5 sets a target to reduce maternal mortality by 75% from the 1990 levels. In SA, evidence suggests that maternal deaths quadrupled between 1998 and 2007.7 Failure to address MDG 6 in terms of a public sector antiretroviral programme, means that achieving MDG 5 in the proposed timeframe is not possible.
Failure to effectively fight against HIV/AIDS has also undermined MDG 4 to reduce the ‘under-5 mortality rate’ by two-thirds. Subsequently, the absence of a national PMTCT programme resulted in thousands of preventable child deaths.8 Deaths of both parents from HIV/AIDS have orphaned their numerous surviving, but orphaned, children.
SA is now emerging from these desperate times. However, as health workers in the state sector will readily acknowledge, there remains much more to be achieved. Although HIV infection is still the most common cause of maternal mortality, there have been many positive changes. Eligibility for highly active antiretroviral therapy (HAART) has expanded since the national roll-out in 2004. SA now has the largest antiretroviral therapy (ART) programme in the world.9 Since 2013, all pregnant and breastfeeding women have become eligible to initiate HAART, irrespective of their CD4+ count.10 It was announced in July 2014 that all pregnant women may continue lifelong HAART.11 The vertical transmission rate of HIV is 2.7% at 6 weeks’ gestation, which underscores the effectiveness of the PMTCT programme.12
What is the way forward after the MDGs? Global health priorities must still include women and children beyond 2015. Attention is now focused on health issues and women’s empowerment from a human rights’ perspective.13 The 2009 UN Human Rights Council Resolution on Maternal Mortality recognised that preventable maternal mortality is not just a public health issue, but also a human rights issue.14 High rates of maternal morbidity and mortality are therefore seen not only as unacceptable, but also as a violation of human rights. Priorities for health should involve addressing universal coverage of healthcare; inequity in access to care; educating and empowering women; gender equality; and poverty reduction.
Reproductive rights and responsibilities are central to enabling women to manage and control their fertility, continue their education, and fully participate in economic, social and political life. The right to control reproductive health means that unmet needs for contraception must be targeted.15 Within a human rights framework, this means that women need to have the ability and knowledge to make informed choices about contraceptive methods and have accessible services. Reproductive rights are also central to reducing maternal deaths; unintended pregnancies have a higher rate of maternal mortality and morbidity, as well as late presentation to antenatal care.
Prioritising women’s rights
means that health workers need to look beyond the medical
issues in their interactions with patients. The human rights
context of healthcare also needs to be considered. The
International Federation of Gynecology and Obstetrics (FIGO)
has developed a framework for integrating human rights and
women’s health.16 This includes looking at how
the healthcare system supports or infringes upon human rights,
in terms of women’s health, and how healthcare encounters
could be improved to
respect human rights, and ensure quality healthcare. In terms
of improving women’s health in SA, this provides a roadmap for
the way forward.
1. South African Press Association (SAPA). Maternal child health ‘key to equity’. Cape Times, 1 July 2014.
2. United Nations. Millennium Development Goals. http://www.un.org/millenniumgoals (accessed 29 July 2014).
3. Gerntholtz L, Gibbs A, Willan S. The African Women’s Protocol: Bringing attention to reproductive rights and the MDGs. PLoS Med 2011;8(4):e1000429. [http://dx.doi.org/10.1371/journal.pmed.1000429]
4. Government of South Africa. Millennium Development Goals: Country Report 2010. http://www.statssa.gov.za/news_archive/Docs/MDGR_2010.pdf (accessed 21 July 2014).
5. Cullinan K, Thom A, eds. The Virus, Vitamins and Vegetables. Johannesburg: Jacana Media, 2009.
6. National Committee on Confidential Enquiries into Maternal Deaths. Saving Mothers 2008 - 2010: Fifth Report on the Confidential Enquiries into Maternal Deaths in South Africa. Pretoria: National Department of Health, 2012. http://www.doh.gov.za/docs/reports/ (accessed 3 July 2013).
7. Garenne M, McCaa R, Nacro K. Maternal mortality in South Africa: An update from the 2007 community survey. J Popul Res (Canberra) 2011;8(1):89-101.
8. Chopra M, Daviaud E, Pattinson R, Fonn S, Lawn J. Saving the lives of South Africa’s mothers, babies and children: Can the health system deliver? Lancet 2009:374:835-846. [http://dx.doi.org/10.1016/S0140-6736(09)61123-5]
9. Mayosi BM, Lawn JE, van Niekerk A, et al. Health in South Africa: Changes and challenges since 2009. Lancet 2012;380:2029-2043. [http://dx.doi.org/10.1016/50140-6736 (12)61814-5]
10. National Department of Health. The South African antiretroviral treatment guidelines 2013. PMTCT Guidelines. http://www.sahivsoc.org/upload/documents/2013%20ART%20Guidelines-Short%20Combined%20FINAL%20draft%20guidelines%2014%20March%202013.pdf (accessed 23 July 2014).
11. Cullinan K. Lifelong ARVs for pregnant women says Health Minister. Health e-news, 24 July 2014. http://www.health-e.org.za/2014/07/24/lifelong-arvs-pregnant-women-says-health (accessed 29 July 2014).
12. National Department of Health. Effectiveness of the National Prevention of Mother-to-Child Transmission (PMTCT) Programme in South Africa. 2011 National SAPMTCT Survey Results. http://www.mrc.ac.za/healthsystems/SAPMTCTEExecSummary2012.pdf (accessed 23 July 2014).
13. World Health Organization. Targets for ending preventable maternal mortality. Consensus statement. http://who.int/reproductivehealth/publications/maternal_perinatal_health/consensus-statement.pdf?ua=1 (accessed 23 July 2014).
14. United Nations Human Rights Council. Eleventh session. Resolution 11/8. Preventable maternal mortality and morbidity and human rights. http://www.who.int/pmnch/events/2010/A_HRC_RES_11_8.pdf (accessed 23 July 2014).
15. World Health Organization. Ensuring human rights in the provision of contraceptive information and services. Guidelines and recommendations. 2014. http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf?ua=1 (accessed 23 July 2014).
16. Global Library of Women’s Medicine. http://www.glowm.com/womens_health_rights (accessed 29 July 2014).
S Afr Med J 2014;104(9):635. DOI:10.7196/SAMJ.8725
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