Jane Cottingham

Using human rights to improve maternal and neonatal health: history, connections and a proposed practical approach

We describe the historical development of how maternal and neonatal mortality in the developing world came to be seen as a public-health concern, a human rights concern, and ultimately as both, leading to the development of approaches using human rights concepts and methods to advance maternal and neonatal health. We describe the different contributions of the international community, womens health advocates and human rights activists. We briefly present a recent effort, developed by WHO with the Harvard Program on International Health and Human Rights, that applies a human rights framework to reinforce current efforts to reduce maternal and neonatal mortality.

Ensuring the Sexual and Reproductive Health of People Living with HIV: Policies, Programmes and Health Services

IN 2006 there were some 39.7 million people living with HIV half of them under the age of 25.* People living with HIV have sexual and reproductive health needs and concerns some of which are related to having HIV and others which they have in common with their noninfected peers. Yet sexual and reproductive health policies programmes and services often fail to take into consideration the needs and wishes of people living with HIV. Most programmes currently revolve around voluntary testing and counselling for HIV access to antiretroviral and other AIDS-related treatment and hospital and home-based care for those with HIV- and AIDS-related illnesses. In relation to sexual and reproductive health care HIV prevention predominates. There are condom social marketing and other safer sex promotion programmes and recent initiatives to promote family planning for people with HIV. Prevention of mother-to-child transmission of HIV in antenatal and delivery care has also begun to get greater programmaticattention and support. (excerpt)

Advancing sexual health through human rights: the role of the law.

Since the International Conference on Population and Development, definitions of sexuality and sexual health have been greatly elaborated alongside widely accepted recognition that sexual health requires respect, protection and fulfilment of human rights. Considerable progress has also been made in enacting or changing laws that affect sexuality and sexual health, in line with human rights standards. These measures include legal guarantees against non-discrimination and violence, decriminalisation of consensual sexual conduct and guaranteeing availability, accessibility, acceptability and quality of sexual health information and services to all. Such legal actions have had positive effects on health and specifically on sexual health, particularly for marginalised populations. Yet in all regions of the world, laws still exist which jeopardise health, including sexual health, and violate human rights. In order to ensure accountability for the rights and health of their populations, states have an obligation to bring their laws into line with international, regional and national human rights standards. These rights-based legal guarantees, while insufficient alone, are essential for effective systems of accountability, achieving positive sexual health outcomes and the respect and protection of human rights.

Medical barriers to contraceptive use.

Various practices keep women from receiving and using contraception. These medical barriers include those pertaining to eligibility process and regulatory and provider bias. Eligibility barriers place too strict criteria on what women may use a particular contraceptive. For example severe migraine headaches are a relative contraindication for oral contraceptives (OCs) but some community-based distribution programs include headaches without being specific on their checklist resulting in denying OCs to women who have had a recent headache. Blood tests to rule out liver and cardiovascular diseases as a prerequisite for a prescription of combined OCs in some West African countries represent a process hurdle. Yet just a brief medical history can identify women at risk of these diseases. Restricting IUD insertion to physicians in some countries is another example of a medical barrier. Family planning providers or program managers sometimes determine themselves what methods are best suited for various women. This provider bias essentially eliminates womens choice of methods. Until 1992 the US Food and Drug Administration (FDA) had not approved the 3-month injectable contraceptive method Depo-Provera despite many studies confirming its safety. The lack of FDA approval prevented other countries from approving it. Despite 30 years of OC use worldwide Japan still does not allow OC use. According to a WHO survey of 50 collaborating centers the most common medical barrier to contraceptive use is requiring women who use OCs and IUDs to return for follow-up examinations more often than is necessary. This recent survey concludes that no overall standardized information about contraceptives their side effects and who can and cannot use them safely exists. WHO and other groups are developing internationally accepted guidelines to counteract conflicting information and outdated criteria for contraceptive delivery.

Sexual rights as human rights: a guide to authoritative sources and principles for applying human rights to sexuality and sexual health

Abstract This Guide seeks to provide insight and resources to actors interested in the development of rights claims around sexuality and sexual health. After engaging with the vexed question of the scope of sexual rights, it explores the rules and principles governing the way in which human rights claims are developed and applied to sexuality and sexual health, and how that development is linked to law and made a matter of state obligation. This understanding is critical to policy and programming in sexual health and rights, as it supports calling on the relevant range of human rights, such as privacy, non-discrimination, health or other universally accepted human rights, as well as demanding the action of states under their international and national law obligations to support sexual health. Résumé Ce Guide cherche à transmettre des connaissances et des ressources aux acteurs intéressés par le développement de revendications relatives aux droits autour de la sexualité et la santé sexuelle. Après avoir abordé la question controversée de la portée des droits sexuels, il explore les règles et les principes qui gouvernent la manière dont les revendications fondées sur les droits de l’homme sont développées et appliquées à la sexualité et la santé sexuelle, et comment ce développement est lié à la législation et devient une obligation étatique. Cette compréhension est essentielle pour définir les politiques et la programmation en matière de santé et droits sexuels, car elle soutient les actions exigeant de bénéficier de tout l’éventail des droits de l’homme, comme la protection de la vie privée, la non-discrimination, la santé ou d’autres droits fondamentaux acceptés universellement, tout en demandant aux États de prendre des mesures au titre de leurs obligations juridiques nationales et internationale de soutenir la santé sexuelle. Resumen Esta Guía tiene como objetivo brindar conocimientos y recursos a los actores interesados en la formulación de afirmaciones de derechos relacionados con la sexualidad y salud sexual. Después de abordar la controvertida cuestión del alcance de los derechos sexuales, explora las reglas y principios que rigen la manera en que las afirmaciones de derechos humanos son formuladas y aplicadas a la sexualidad y salud sexual, y cómo esa formulación está vinculada con la ley y pasa a ser cuestión de obligación del Estado. Este entendimiento es fundamental para las políticas y programación en salud y derechos sexuales, ya que apoya hacer un llamado a los diversos derechos humanos pertinentes, tales como privacidad, no discriminación, salud u otros derechos humanos aceptados universalmente, así como exigir que los Estados tomen medidas, de conformidad con sus obligaciones de derecho internacional y nacional, para apoyar la salud sexual.

The World Health Organization’s Safe Abortion Guidance Document

We discuss the history of the World Health Organizations (WHOs) development of guidelines for governments on providing safe abortion services, which WHO published as Safe Abortion: Technical and Policy Guidance for Health Systems in 2003 and updated in 2012. We show how the recognition of the devastating impact of unsafe abortion on womens health and survival, the impetus of the International Conference on Population and Development and its five-year follow-up, and WHOs progressive leadership at the end of the century enabled the organization to elaborate guidance on providing safe abortion services. Guideline formulation involved extensive review of published evidence, an international technical expert meeting to review the draft document, and a protracted in-house review by senior WHO management.

Abortion in Poland: politics, progression and regression

On the 23rd March 2018, tens of thousands of Polish citizens came together to stage protests opposing the “Stop Abortion” bill. In what has become known as the #BlackProtest movement, people dressed in black to mark their solidarity against attempts to restrict abortion. Their protest continues the line of an enduring movement, not only in Poland but across the world, for women’s right to safe abortion. Reproductive Health Matters (RHM) – a long-standing voice in support of women’s right to safe abortion – joined more than 200 other groups from across the world in support of the Polish protest movement to oppose the bill tightening abortion law in Poland. A letter called on members of Poland’s parliament to “listen to the voices of women across Poland and to reject this regressive legislative proposal and protect women’s health and human rights”. The “Stop Abortion” bill was approved for debate in January this year and got through the parliamentary committee in March. If passed, legislation will further confine the grounds on which abortion can be lawfully accessed. Poland has restrictive abortion laws which currently allow the procedure to be legally performed only if there is severe danger to the life of a woman or foetus, or if the pregnancy is a result of a criminal act, such as rape or incest. In the latest attempt to change the law, the ruling party in Poland is seeking to ban abortion in cases where the foetus has a severe abnormality. Slightly over one thousand abortions were legally performed in Poland in 2016. It is believed that there are many more illegal abortions, with estimates lying between 50,000 and 200,000. Women also travel to neighbouring countries in Europe to seek abortion, while others purchase abortion pills from the internet. Modern contraceptive methods are not freely available in Poland. The morning after pill, for example, requires a prescription and a consultation with a doctor. The condom is the only over the counter contraception available. In 2015, the use of modern methods of contraception was 47.7% among married or inunion women aged 15–49 years, one of the lowest in Europe.

Babies, Borders and Big Business

Today, someone with money, woman or man, who is unable to have a child for whatever reason, can buy the services of a “gestational surrogate” somewhere in the world. This woman –most likely quite poor and from a low-middle income country – will have the egg from another woman, which has been fertilised by the sperm of a known or unknown man, implanted in her uterus. She will gestate it for nine months then give birth and the person will arrive in her country to take the baby for their own. It sounds easy. And yet, questions start to crowd in. Is the baby in good health? Will bottle-feeding be easy? What about getting a passport for the baby? Will she/ he automatically get the nationality of the intended parent? Will he/she develop normally? What, if anything, should be told to her/him about their origins? And what about the surrogate? Was she really paid adequately? Was she given proper medical care? What does her family think? What about the egg donor, the sperm donor? Will they have any interest in this genetic offspring of theirs at some future date? And how much money is the fertility clinic making? These questions and many others are the focus of this new anthology, Babies for sale: transnational surrogacy, human rights and the politics of reproduction, edited by Miranda Davies, launched in April 2017. In her introduction, Davies explains that the collection of papers from leading academics and activists in the field seeks to offer a fresh approach to the complex ethical questions surrounding this increasingly recognised method of procreation. In particular, priority is given to the concerns and experiences of the women, men and children most directly involved, and it highlights the work of national feminist organisations from India, Mexico, Sweden and the USA, often the voices that are not well heard in the debate. A central topic, too, is the interests – both psychological and legal – of the children who are born from commercial surrogacy arrangements, and frequently absent from international debate.

Historical Note: How Bringing Women's Health Advocacy Groups to WHO Helped Change the Research Agenda

Abstract The politics of population control and its sometimes coercive methods in developing countries documented during the 1960s, 70s and 80s, gave rise to strong opposition by womens groups, and put into question the safety of contraceptive methods that were being developed and introduced into countries. In 1991, the Special Programme on Human Reproduction at the World Health Organization, a research programme focused on development of new methods and safety assessments of existing fertility regulation methods, started a process of “dialogue” meetings between scientists and womens health advocacy groups which lasted for nearly a decade. This paper describes the process of these meetings and what they achieved in terms of bringing new or different research topics into the agenda, and some of the actions taken as a result. Résumé Les politiques de régulation de la population et leurs méthodes parfois coercitives dans les pays en développement, documentées dans les années 60, 70 et 80, ont suscité une forte opposition parmi les groupes de femmes et remis en question la sécurité des méthodes contraceptives qui étaient développées et introduites dans les pays. En 1991, le Programme spécial de l’Organisation mondiale de la Santé sur la reproduction humaine, un projet de recherche axé sur la mise au point de nouvelles méthodes et les évaluations de la sécurité des méthodes existantes de régulation de la fécondité, a lancé un processus de réunions de « dialogue » entre les scientifiques et les groupes de plaidoyer pour la santé des femmes qui a duré près d’une décennie. Cet article retrace le cycle des réunions et ce qu’elles ont obtenu pour imposer des thèmes de recherche nouveaux ou différents, et il décrit certaines des mesures prises en conséquence. Resumen La política de control de la población y sus métodos a veces coactivos en los países en desarrollo, documentados durante las décadas de los sesenta, setenta y ochenta, suscitaron fuerte oposición por parte de grupos de mujeres, quienes cuestionaron la seguridad de los métodos anticonceptivos que estaban siendo creados e introducidos en los países. En 1991, el Programa Especial sobre Reproducción Humana de la Organización Mundial de la Salud, un programa de investigación enfocado en la creación de nuevos métodos y en la evaluación de la seguridad de los métodos existentes de regulación de la fertilidad, inició un proceso de reuniones de “diálogo” entre científicos y grupos promotores de la salud de las mujeres, el cual duró casi una década. Este artículo describe el proceso de esas reuniones y lo que lograron en cuanto a incluir en la agenda nuevos o diferentes temas de investigación, así como algunas de las acciones tomadas como resultado.

Reproductive health and human rights: the way forward

The term “reproductive health” was first adopted at the International Conference on Population and Development (ICPD) in 1994 and heralded a major shift in thinking and approach to population issues – from pure population control through family planning, to a much wider field encompassing not only fertility control but safe sex and pregnancy free from coercion, discrimination and violence. This volume is a collection of 16 critical essays by leading scholars and practitioners in the field of sexual and reproductive health and rights. Each author analyses the legacy of ICPD from a different perspective or focuses on a particular topic. They examine strengths, weaknesses and whether and how the ICPD mandate can still be used to improve sexual and reproductive health. Given the complexities and challenges of implementing and continuing to take forward the ICPD agenda after more than 15 years, the undertaking in this volume is laudable. The essays, however, are somewhat uneven in the depth of treatment, yet all contain some dimension that should be of interest to a variety of readers. Some provide historical background which might otherwise be forgotten. Several other authors point out that the absence of reproductive health in the initial targets for the Millennium Development Goals was a serious setback. While the target of “universal access to reproductive health” has since been added, Tom W Merrick (author of the “Mobilizing resources for reproductive health” chapter) points out that a strong evidence base is needed to demonstrate that poor reproductive health outcomes do, in fact, undermine the chances of the poor to escape poverty. Most of the authors find that ICPD has left a landmark legacy and remains an essential tool in work to improve sexual and reproductive health globally. Mindy Jane Roseman (“Bearing human rights: maternal health and the promise of ICPD”) describes how the connection between human rights and health outcomes forged at ICPD “remains vital, resilient and indispensable” and maintains that the enduring legacy of ICPD is that it articulated the fact that “reproductive health requires functioning and accountable health, education, judicial and other state systems”. Sofia Gruskin (“Approaches to sexual and reproductive health and HIV policies and programs: synergies and disconnects”) notes that one of the weaknesses of ICPD was that it poorly addressed HIV, focusing almost exclusively on prevention and control. This was partly because few organizations and individuals engaged in HIV-related efforts were present at ICPD to help forge a stronger agreement. However, she goes on to show that ICPD was a landmark for legitimizing the use of human rights in both sexual and reproductive health and HIV programming and laid much of the groundwork for subsequent international agreements. While agreeing that ICPD remains a momentous achievement, some of the essays focus on its failures. Marge Berer’s essay (“The Cairo ‘compromise’ on abortion and its consequences for making abortion safe and legal”) analyses the impact of the ICPD’s failure to include reference to the need for safe and legal abortion, one of the most commonly used methods of fertility regulation and a major cause of avoidable mortality and morbidity in women. She argues that making abortion safe, legal and accessible is the only way to reduce this morbidity and mortality. Alaka Basu (“Situating reproductive health within the academy”) shows how reproductive health as conceived of in ICPD has not been translated into curriculum design for medical or paramedical practitioners, and elaborates how this could be done. An important dimension in several essays is an analysis of the United Nations process, demonstrating the political forces at work that contributed to shaping the ICPD Programme of Action and subsequent events. Francoise Girard (“Advocacy for sexuality and women’s rights: continuities, discontinuities, and strategies since ICPD”) gives insights into the negotiating process of ICPD and subsequent follow-up meetings, concluding that “new, bolder agreements are not likely in the near future” as there is “little or no appetite for them at the intergovernmental level”. Frances Kissling (“Examining religion and reproductive health: constructive engagement for the future”) describes the negative influence of the Vatican and some fundamentalist Christian groups on stifling support for ICPD but argues that the world’s religions could be one of the most significant forces for the implementation of ICPD rather than the most significant obstacle. She concludes that “our common commitments to human dignity and poverty alleviation” can forge some of the bonds necessary for moving the agenda forward with representatives of world religions. The concluding essay by Firestone, Reichenbach and Roseman (“Conceptual successes and operational challenges to ICPD: global reproductive health and rights moving forward”) acts like an editorial on the whole volume, highlighting commonalities and differences in the previous essays. It strongly argues in favour of the “enduring value of ICPD’s legacy”, particularly with regard to its core principles and the emphasis on human rights. It suggests three areas, emerging from the essays collectively, for further work by any and all who care about reproductive health and rights: improving measurement and accountability; creating and renewing alliances for strengthened advocacy; and new strategies for mobilizing resources. This is a highly readable volume which should be of interest to anyone – advocate, practitioner, scholar, policy-maker – who is concerned about sexual and reproductive health and human rights. It has an extensive bibliography and an excellent index.