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Monitoring Alternative Report on the Situation of Maternal Mortality in Brazil to the International Covenant on Economic, Social and Cultural Rights

Introduction

The Latin American and Caribbean Committee for the Defence of Woman’s Rights (CLADEM), a non-governmental organisation with Consultative Status at the category II before the United Nations' Economic and Social Commission, and Citizen Litigation for Human Rights - ADVOCACI, a Brazilian non-governmental organization, present this “parallel” report in the context of the presentation of the official Brazilian state report to the United Nations Committee on Economic, Social and Cultural Rights (CESCR).

This report aims to provide additional and supplementary information to the alternative report presented before the CESCR by the Brazilian civil society organizations. It focus mainly on the situation of maternal mortality in Brazil and the status of implementation of the right to non-discrimination and equality in the access to health care and the right to health, under the International Covenant on Economic, Social and Cultural Rights (ICESCR), according to the paragraph 21 of the document “Substantive issues arising in the implementation of the International Covenant on Economic, Social and Cultural Rights (E/C.12/2000/6).

Executive Summary

According to the Brazilian state report to the CESCR, under the ICESCR, maternal mortality rates in Brasil are still significant. It is estimated that 260 maternal deaths occur per 100.000 live births1 in Brazil2. However, the magnitude of maternal mortality in Brazil is still unknown, according to the findings of the Federal Parliamentary Commission of Inquiry (FPCI) on Maternal Mortality, reported on August 20013. This Commission found that 98% of maternal death cases are preventable4 and that maternal mortality rates have not decreased in the last fifteen years, despite subsequent economic improvements.

The FPCI reported that 91,5% of childbirth is performed in public hospitals5. In addition, 65,9% of women that died from maternal mortality causes were totally dependent on the public health system to give birth6. Moreover, Maternal mortality in Brazil has a disproportional impact on afro-descendents, mulatto, indigenous, poor, and single women living in the poorest regions of Brazil, increasing their health risks of dying from preventable maternal death. This scenario demonstrates that the Brazilian state is violating the right to non-discrimination on the grounds of sex (Article 2), the right to equality between men and women(Article 3), and the right to health (Article 12) of ICESCR, due to its neglect and ommission in providing effective access to health care to pregnant women in Brazil.

The present report recommends the following measures seeking the enforcement of FPCI’s recommendations by the Brazilian state, and the compliance with its international obligations under the ICESCR: to establish of Maternal Mortality Commmittees in all states of the country with material and human resources to investigate cases of preventable maternal death; to enact specific legislation aiming to uniformize MMC’s work, methodology and procedures in all regions of the country; to create public regional media campaigns to raise awareness and give visibility to maternal mortality as a matter of social justice.

Table of Contents:

I. A general panorama on maternal mortality in Brazil

II. Comments on maternal mortality under specific articles of the ICESR

III. Conclusions and Recommendations
 

I. A general panorama on maternal mortality in Brazil

The World Health Organisation (WHO), in the tenth revision of the International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-10), define maternal death as the “death of a women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”7.

The information provided in the present Report relies on the FPCI findings, as a source of Brazilian state data and information on maternal mortality. According to these findings, the Brazilian state estimates the occurrence of 3,000 up to 5.000 cases of preventable maternal deaths each year, varying among different states and regions8. Maternal deaths are the eighth cause of women’s death from age 10 to 59 years old in the poor regions of the country: North, Northeast and Center9. In these regions, women face a much higher risk of dying from maternal mortality causes than in the rest of the country.

In 1994 the Brazilian government declared maternal mortality as a priority public health concern, under the decree no. 663 issued by the Health Ministry10. Moreover, the Constitution defines motherhood as a social right in the Article 6º. It enumerates as “social rights: education, health, work, leisure, security, welfare, the protection of motherhood, childhood, and the assistance to helpless people”. Regarding the right to be free from avoidable maternal death this provision can be invoked in combination with other constitutional articles, such as Article 5º, caput, item I and XLI related to equality rights between men and women. In addition, Article 196, protects the right to health through universal and equal access to actions and services for its promotion, protection and recuperation.

II. Comments on maternal mortality under specific articles of the ICESR

Article 2 (2) of ICESR

The Brazilian scenario of maternal mortality demonstrates the extent to which Brazilian state is neglecting to comply with its international obligations under the ICESCR. Epidemiological studies have shown that women with limited access to good quality of health care, education and low income are more vulnerable to maternal mortality and morbidity11. Moreover, in the North, Northeast and Centre regions, the levels of education, rent and access to health are much lower in comparison with other regions12. According to information provided to FPCI, 33% of women in these regions had not completed the first level of education, and 19,3% had completed. The percentage of illiteracy was higher among maternal deaths victims than among the population in general. Moreover, one third of victims families received less than o,75 minimum salary per month.

According to the Brazilian census, 44% of the Brazilian population is of afro-descendents13. Afro-descendent women have less access to education, lower social and economic status, worse housing and living conditions than of white women. In regard to reproductive health aspects, they have less access to contraceptive methods and have more pregnancies than white women. In the North, Northeast and Centre regions concentrate the majority of maternal deaths (56,2%) of afro-descendents, indigenous and mullato women.

In relation to the maternal death’s victims marital status, the majority was found to be of single mothers (62,9%)14. The existence of high rates of maternal mortality and its disproportional impact on women’s lives, specially in the above mentioned states, is an evidence of a systematic pattern of discrimination on the grounds of sex, race, marital status and geographic location in their acess to health care.

Article 3 of ICESCR

According to the UNDP Report on Human Development, Brazil is the 79ª country in relation to education and the 95º, in regard to health conditions of population. Social inequality is considered to be highly disproportional, with the 10% of the rich having 48,7 times more than the 10% of the poor (1997)15. The Brazilian scenario indicates women’s lack of accessibility, availability, acceptability and quality in health care, and therefore state’s violation to women’s human right to equality in accessing health care.

The fact that only women can be pregnant and have to face the risk of dying from maternal mortality in situations of pregnancy, childbirth and post childbirth requires state should adopt specific measures to prevent maternal death, guaranteeing equal access related to men.

Article 12 of ICESCR

The CESCR General Comment 14 on Article 1216 establishes, on its first paragraph: “Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conductive to living a life with dignity.” Accordingly, the main causes of maternal deaths in Brazil are preventable and relates to women’s lack of availability, accessibility, quality of services, and equality in accessing health services. This is central for them to enjoy liberty, security, equality, privacy and human dignity17. In relation to the right to maternal, child and reproductive health, it states on paragraph 14 that “The provision for the reduction of the stillbirth rate and of infant mortality and for the healthy development of the child. 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”.

An exemplary case of preventable maternal death: Alyne da Silva Teixeira

Alyne died on 16/11/2002 in the Hospital of Posse, in Belford Roxo municipality, in the state of Rio de Janeiro. In 11/11/2002 she went to the hospital to seek health care alleging nausea. On 13/11/2002, she went back alleging the same symtons. She was placed in the hospital and discovered in the exam that her foetus was already death. In 16/11/2002 she underwent the procedure to expelling the foetus. Her death can be attributed, among other factors, to the eight-hour delay in her transfer to another hospital with more resources for her treatment. ADVOCACI presented a judicial action against the state seeking indemnization for her death on behalf of her five year-old daughter and her husband, which is pending in the Rio de Janeiro state court since February 2003, under no. 20030010157742.

There are other conditions that increase women’s risk of dying in Brazil, such as the realization of unsafe and clandestine abortion procedures due to the illegality of abortion in the Brazilian criminal law. Economic, social, cultural, racial conditions also contribute to devalue the health status of women and increase their risk of dying from maternal mortality causes18. Under the human rights standards, a national legislation that criminalizes a medical procedure that only women need is per se discriminatory19. Abortion is the third cause of maternal mortality in Brazil20. Despite the fact that abortion is legally restricted in Brazil21, around 1 to 1,2 million of women undertake this procedure each year and 250.000 women are treated in public hospitals due to abortion complications. In the majority of the cases, there are complications related to the unsafe conditions that can lead to infection, one of the main causes of maternal deaths. Moreover, the practice of clandestine abortions can be responsible for high incidence of maternal deaths among women in the age from 15 to 19 years old. Poor women cannot afford expensive private clinics and face a higher risk of dying from maternal mortality related causes. In addition, women still lack access to abortion even in cases whether is legally permitted due to the lack of availability of these services22.

III. Recommendations

The following recommendation focus on the implementation of the right to non-discrimination and equality on pregnant women’s access to health care, and the right to health. Accordingly, the CESCR General Comment 14 states that “Violations of the right to health an also occur through the omission or failure of States to take necessary measures arising from legal obligations. Violations through acts of omission include the failure to take appropriate steps towards the full realization of everyone’s right to the enjoyment of the highest attainable standard of physical and mental health (...).”23. The state’s neglect in enforcing the FPCI’s recommendations is an evidence of its omission in taking effective steps to reduce maternal mortality.

A) Implementation of Maternal Mortality Commmittees in all states of the country with material and human resources to investigate cases of preventable maternal death

B) Enactement of legislation aiming to uniformize MMC’s work, methodology and procedures in all regions of the country

Brazilian state established, among other relevant policies to deal with maternal mortality, Maternal Mortality Committees and neonatal committees, as well as hospital infection commissions24. The development of state, regional and municipal Committees of Maternal Mortality have been implemented in the country since 1987. However, many of them still lack implementation and operational conditions to work25. An example of the Brazilian state’s neglect in relation to the situation of maternal mortality is the fact that only 14 of these Committees are active, among the 24 initially established in the country.

C) Establishment of Ombudsmen within the health care system’s structure to receive families’ complaints related to preventable cases of maternal death

The Brazilian state should ensure women’s non-discrimination and equality in acessing health care in certain regions of the country to avoid discriminatory and disproportional impact on women’ health. The Brazilian scenario contributes to increase women’s risk of dying from preventable causes of maternal mortality in certain regions of the country. In order to achieve this goal, the Brazilian state should provide the victim’s family access to administrative and judicial mechanisms to foster accountability in preventable cases of maternal death, through the creation of maternal mortality ombusmen. The ombudsmen would have a strong role in promoting accountability and strengthening the role of Maternal Mortality Committees to prevent maternal death pursuing institutional responsibilities and providing reparative measures.

D) Establishment of public regional media campaigns to raise awareness and give visibility to maternal mortality.

The Brazilian state should establish regional educational and preventive campaigns on maternal mortality to inform women on the main causes of preventable maternal death,especially in the Centre, North and Northeast, where women lack accessibility, availability, acceptability and quality of health services. The campaigns should inform the population about human rights applied to maternal mortality, giving orientation on the role of Maternal Mortality Committees, Ombudsmen and the Public Prosecutors to seek institutional responsibilities and reparation for violations to women’s economic, social and cultural rights.

NOTES:

1. Maternal Mortality in 1995:Estimates Developed by WHO, UNICEF & UNFPA, 2001, 42-47.

2. The rates of maternal mortality is expressed for each 100.000 alive births. The WHO used to qualify the maternal mortality rates as Low: until 20/100.000 alive births; Median, from 20 to 49/100.000; High, from 50 to 149/100.000 and Very High, more than 150/100.000.However, the real number of deaths and births are in general sub-notified.

3. The Federal Parliamentary Commission of Inquiry on Maternal Mortality was installed on April 27 2000 by the Legislative Power aiming to investigate and map the situation of maternal mortality in the country.

4. Preventable maternal death are deaths that could be prevented if women had access to health care during pregnancy, childbirth and post childbirth.

5. Brazilian Health Ministry, Assistência à Saúde da Mulher do Ciclo Gravídico-Puerperal SUS 1994-1997 (www.saude.gov.br)

6. CPI Report page 46.

7. See Birth Rights, New Approaches to Safe Motherhood, The Panos Institute, 2001, at page 6.

8. See Brazilian Health Ministry website: Assistência da Mulher do Ciclo Gravídico-Puerperal SUS 1994-1997 (www.saude.gov.br)

9. Brazilian Feminist Network on Health and Reproductive Rights, Maternal Mortality Dossier. By contrast, maternal deaths are considered the last causes of women’s death in developed countries.

10. Berquó E.and Cunha E., Morbimortalidade Feminina no Brasil (1979 to 1995), Campinas, Unicamp, 2000.

11. See Relatório CPI da Mortalidade Materna Federal (Parliamentary Commission of Inquiry Report) at page 44. The Report is available at www.cfemea.org.br last accessed 7 March 2003.

12. (CPI Report page 44 to 46)

13. Pinto E. and Souzas R., A Mortalidade Materna e a Questão Raça/Etnia: Importância da Lei do Quesito Cor no Sistema de Saúde, in Perspectives on Health and Reproductive Rights, The John and Catherine T. MacArthur Foundation, São Paulo, May 2002.

14. See CPI report on page 52.

15. See Human Development Report 2001, United Nations Development Population (www.undp.org.br).

16. CESCR, General Comment 14, UN ESCOR, 2000, Doc. No. E/C.12/2000/4.

17. The CESCR Committee also developed, in paragraph 12, the scope of the right to health, which includes availability, accessibility, acceptability and quality of health services.

18. See Cook R.,“International Protection of Women’s Reproductive Rights”, NYU Journal of Int’l Law & Politics (1992) 645-672.

19. CEDAW General Recommendation No. 24.

20. See supra note 3.

21. Penal Code, articles 124 to 128. Abortion is legal only in cases in which pregnancy results from rape or woman’s life is at risk. However, the jurisprudence has increasingly recognised the right to abortion in cases of foetus anomaly.

22. Apropos, in 1998, the Health Ministry enacted a Technical Norm to “Prevent and Treat Harms Resulted from Sexual Violence against Women and Adolescents” that was a significant mechanism to guarantee rape victims’ access to legal abortion services and emergency contraception.

23. CESCR, General Comment 14, at paragraph 49.

24. Health Ministry decrees Nbrs. 3.016 of June 19, 1998; 3.017 of June 19, 1998; 3.018 of June 19, 1998; 3.477 of August 20, 1998; 3.482 of August 20, 1998.

25. In 1999, a national survey on the work of these Committees found that from 26 state committees, 4 were not functioning and 5 were under reform. In addition, the committees that were considered effectively working were found in the states of: Acre, Roraima, Amazonas, Tocantins, Bahia, Sergipe, Ceará, Pernambuco, Rio Grande do Norte, Rio de Janeiro, São Paulo, Minas Gerais, Paraná, Santa Catarina, Rio Grande do Sul, Goiás, Mato Grosso e Distrito Federal, ibid.

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