Alicia Ely Yamin

The Power of Numbers: A Critical Review of Millennium Development Goal Targets for Human Development and Human Rights

Abstract The Millennium Development Goals (MDGs) were heralded as opening a new chapter in international development, and have led to the use of global goals and target-setting as a central instrument defining the international development agenda. Despite this increased importance, little is understood about how they influence policy priorities of key stakeholders, and their broader consequences. While quantification is the key strength of global goals, it also involves simplification, reification and abstraction, which have far-reaching implications for redefining priorities. This paper highlights the key findings and conclusions of the Power of Numbers Project, which undertook 11 case studies of the effects of selected MDG goals/targets, including both the empirical effects on policy priorities and normative effects on development discourses, and drew specifically on human rights principles and human development priorities. While the Project found that the effects varied considerably from one goal/target to another, all led to unintended consequences in diverting attention from other important objectives and reshaping development thinking. Many of the indicators were poorly selected and contributed to distorting effects. The Project concludes that target-setting is a valuable but a limited and blunt tool, and that the methodology for target-setting should be refined to include policy responsiveness in addition to data availability criteria.

Will we take suffering seriously? Reflections on what applying a human rights framework to health means and why we should care.

Since this journal was first published, rights-based approaches to health have prolferated in the health and development communities. At the same time, human rights advocacy organizations, courts, and UN actors have increasingly been engaged in applying rights norms in health contexts. Together with others in this issue, this article is a call not to lose sight of the radical potential of using a human rightsparadigm to promote health--even as we go about the pragmatic work of translating rights frameworks into practice in our research, advocacy, litigation strategies, program planning, and service delivery. Drawing together points made in other pieces in this issue, the article describes certain conceptual and practical implications of a transformative engagement between health and human rights. It argues that an appropriate starting point is to take suffering seriously; in so doing, approaches in both health and rights will necessarily shift. A human rights approach challenges biological individualism in both clinical medicine and public health, and builds on work in social epidemiology by providing frameworks for accountability. At the same time, using rights to advance the health of marginalized peoples around the world requires critiquing and expanding limited approaches to human rights, in theory and practice.

How do courts set health policy? The case of the Colombian Constitutional Court.

Alicia Ely Yamin and Oscar Parra-Vera discuss the case of Colombia, where a recent constitutional court decision demonstrates the involvement of the court in protecting fundamental rights to health.

The future in the mirror: incorporating strategies for the defense and promotion of economic social and cultural rights into the mainstream human rights agenda.

Drawing on a case in Peru, this article examines four strategies used by human rights NGOs in their work. In so doing, it connects external challenges to the promotion of economic, social, and cultural (ESC) rights with internal challenges to the way the human rights movement chooses to see itself. First, the value of using data and indicators in documentation has not been widely realized. Second, important advances have been achieved with respect to enforcing ESC rights, but there are limitations to court-centric approaches, which are relevant to all human rights. Third, shifting advocacy beyond the adversarial dyad with the state to address moresystematically the roles of non-state actors implies rethinking some underlying assumptions. Fourth, strategies for promoting participation and building alliances call for reexamining traditional ideas about politicization.

Health policies and politicized health? An analysis of sexual and reproductive health policies in Peru from the perspective of medical ethics, quality of care, and human rights

Health professionals view medical ethics as a discipline that provides the basis for more adequate patient care. In recent years the concepts of quality of care and human rights - with their attending discourses - have joined the concept of medical ethics among the paradigms to consider in care for humans both at the individual and health policy levels. The current study seeks to analyze such paradigms, based on a case study of sexual and reproductive health policies in Peru in the last 10 years.

Intergenerational impacts of maternal mortality: Qualitative findings from rural Malawi

BackgroundMaternal mortality, although largely preventable, remains unacceptably high in developing countries such as Malawi and creates a number of intergenerational impacts. Few studies have investigated the far-reaching impacts of maternal death beyond infant survival. This study demonstrates the short- and long-term impacts of maternal death on children, families, and the community in order to raise awareness of the true costs of maternal mortality and poor maternal health care in Neno, a rural and remote district in Malawi.MethodsQualitative in-depth interviews were conducted to assess the impact of maternal mortality on child, family, and community well-being. We conducted 20 key informant interviews, 20 stakeholder interviews, and six sex-stratified focus group discussions in the seven health centers that cover the district. Transcripts were translated, coded, and analyzed in NVivo 10.ResultsParticipants noted a number of far-reaching impacts on orphaned children, their new caretakers, and extended families following a maternal death. Female relatives typically took on caregiving responsibilities for orphaned children, regardless of the accompanying financial hardship and frequent lack of familial or governmental support. Maternal death exacerbated children’s vulnerabilities to long-term health and social impacts related to nutrition, education, employment, early partnership, pregnancy, and caretaking. Impacts were particularly salient for female children who were often forced to take on the majority of the household responsibilities. Participants cited a number of barriers to accessing quality child health care or support services, and many were unaware of programming available to assist them in raising orphaned children or how to access these services.ConclusionsIn order to both reduce preventable maternal mortality and diminish the impacts on children, extended families, and communities, our findings highlight the importance of financing and implementing universal access to emergency obstetric and neonatal care, and contraception, as well as social protection programs, including among remote populations.

Costs of Inaction on Maternal Mortality: Qualitative Evidence of the Impacts of Maternal Deaths on Living Children in Tanzania

Background Little is known about the interconnectedness of maternal deaths and impacts on children, beyond infants, or the mechanisms through which this interconnectedness is established. A study was conducted in rural Tanzania to provide qualitative insight regarding how maternal mortality affects index as well as other living children and to identify shared structural and social factors that foster high levels of maternal mortality and child vulnerabilities. Methods and Findings Adult family members of women who died due to maternal causes (N = 45) and key stakeholders (N = 35) participated in in-depth interviews. Twelve focus group discussions were also conducted (N = 83) among community leaders in three rural regions of Tanzania. Findings highlight the widespread impact of a woman’s death on her children’s health, education, and economic status, and, by inference, the roles that women play within their families in rural Tanzanian communities. Conclusions The full costs of failing to address preventable maternal mortality include intergenerational impacts on the nutritional status, health, and education of children, as well as the economic capacity of families. When setting priorities in a resource-poor, high maternal mortality country, such as Tanzania, the far-reaching effects that reducing maternal deaths can have on families and communities, as well as women’s own lives, should be considered.

Consequences of maternal mortality on infant and child survival: a 25-year longitudinal analysis in Butajira Ethiopia (1987-2011)

AbstractaBackgroundMaternal mortality remains the leading cause of death and disability for reproductive-age women in resource-poor countries. The impact of a mother’s death on child outcomes is likely severe but has not been well quantified. This analysis examines survival outcomes for children whose mothers die during or shortly after childbirth in Butajira, Ethiopia.MethodsThis study uses data from the Butajira Health and Demographic Surveillance System (HDSS) site. Child outcomes were assessed using statistical tests to compare survival trajectories and age-specific mortality rates for children who did and did not experience a maternal death. The analyses leveraged the advantages of a large, long-term longitudinal dataset with a high frequency of data collection; but used a strict date-based method to code maternal deaths (as occurring within 42 or 365 days of childbirth), which may be subject to misclassification or recall bias.ResultsBetween 1987 and 2011, there were 18189 live births to 5119 mothers; and 73 mothers of 78 children died within the first year of their child’s life, with 45% of these (n=30) classified as maternal deaths due to women dying within 42 days of childbirth. Among the maternal deaths, 81% of these infants also died. Children who experienced a maternal death within 42 days of their birth faced 46 times greater risk of dying within one month when compared to babies whose mothers survived (95% confidence interval 25.84-81.92; or adjusted ratio, 57.24 with confidence interval 25.31-129.49).ConclusionsWhen a woman in this study population experienced a maternal death, her infant was much more likely to die than to survive—and the survival trajectory of these children is far worse than those of mothers who do not die postpartum. This highlights the importance of investigating how clinical care and socio-economic support programs can better address the needs of orphans, both throughout the intra- and post-partum periods as well as over the life course.

Reproductive health without rights in Peru

One case of a surgical procedure that led to the death of a woman where one of the charges was a failure to obtain fully informed consent was debated at length by the UK General Medical Council last year. What about a quarter of a million cases? Between 1996 and 2000 more than 250 000 women the overwhelming majority poor and from the remote rural areas of the Andean sierra and Peruvian Amazon underwent sterilisation without a proper consent process during the implementation of a family planning public-health policy in Peru. The Peruvian government was found responsible by the Inter-American Human Rights Commission in one emblematic case in which Mamerita Mestanza Chavez had been forcibly sterilised and died as a result of the operation. Clearly the promotion of the right to health requires different approaches for different audiences and actors but analysis of specific cases such as that of reproductive health in Peru can play a part in advancing this agenda. (authors)

The impacts of maternal mortality and cause of death on children's risk of dying in rural South Africa: evidence from a population based surveillance study (1992-2013).

BackgroundMaternal mortality, the HIV/AIDS pandemic, and child survival are closely linked. This study contributes evidence on the impact of maternal death on children’s risk of dying in an HIV-endemic population in rural South Africa.MethodsWe used data for children younger than 10 years from the Agincourt health and socio-demographic surveillance system (1992 – 2013). We used discrete time event history analysis to estimate children’s risk of dying when they experienced a maternal death compared to children whose mother survived (N=3,740,992 child months). We also examined variation in risk due to cause of maternal death. We defined mother’s survival status as early maternal death (during pregnancy, childbirth, or within 42 days of most recent childbirth or identified cause of death), late maternal death (within 43-365 days of most recent childbirth), any other death, and mothers who survived.ResultsChildren who experienced an early maternal death were at 15 times the risk of dying (RRR 15.2; 95% CI 8.3–27.9) compared to children whose mother survived. Children under 1 month whose mother died an early (p=0.002) maternal death were at increased risk of dying compared to older children. Children whose mothers died of an HIV/AIDS or TB-related early maternal death were at 29 times the risk of dying compared to children with surviving mothers (RRR 29.2; 95% CI 11.7–73.1). The risk of these children dying was significantly higher than those children whose mother died of a HIV/AIDS or TB-related non-maternal death (p=0.017).ConclusionsThis study contributes further evidence on the impact of a mother’s death on child survival in a poor, rural setting with high HIV prevalence. The intersecting epidemics of maternal mortality and HIV/AIDS – especially in sub-Saharan Africa – have profound implications for maternal and child health and well-being. Such evidence can help guide public and primary health care practice and interventions.