Human Rights and Maternal Health: Exploring the Effectiveness of the Alyne Decision

Alyne da Silva Pimentel Teixeira (deceased) v. Brazil, CEDAW/C/49/D/17/ 2008, August 10, 2011, available at <http://www.worldcourts.com/cedaw/eng/decisions/2011.07.25_da_Silva_Pimentel_v_Brazil.pdf> (last visited February 13, 2013) [hereinafter cited as Alyne].

Convention on the Elimination of All Forms of Discrimination Against Women, adopted December 18, 1979, G.A. Res. 34/180, UN GAOR, 34th Sess., Supp. No. 46, at 193, U.N. Doc. A/34/46, 1249 U.N.T.S. 13 (entered into force September 3, 1981) (ratified by Brazil Feb. 1, 1984) available at <http://www.un.org/womenwatch/daw/cedaw/text/econvention.htm> (last visited February 13, 2013) [hereinafter cited as the Convention].

See Alyne, supra note 1, at ¶¶ 7.3, 7.6–7.7.

Optional Protocol to the Convention on the Elimination of All Forms of Discrimination against Women, opened for signature December 10, 1999, 2131 UNTS 83 (entered into force December 22, 2000), Article 2 (ratified by Brazil June 28, 2002, without any reservations) available at <http://www.un.org/womenwatch/daw/cedaw/protocol/text.htm> (last visited February 13, 2013) [hereinafter cited as OP CEDAW].

World Health Organization, Trends in Maternal Mortality: 1990 to 2010: Estimates Developed by WHO, UNICEF, UNFPA and the World Bank (Geneva: WHO, 2012), at 4 (footnotes omitted), available at <http://www.unfpa.org/webdav/site/global/shared/documents/publications/2012/Trends_in_maternal_mortality_A4-1.pdf> (last visited February 13, 2013) [hereinafter cited as WHO Trends Report].

Id., at 19.

Id., at 32.

Last J. M. , ed., A Dictionary of Epidemiology, 4th ed. (Oxford: Oxford University Press, 2001), at 110–111.

See WHO Trends Report, supra note 5, at 19.

See WHO Trends Report, supra note 5, at 19.

See WHO Trends Report, supra note 5, at 32.

World Health Organization and UNICEF, “Global Estimates of the Causes of Maternal Deaths, 1997–2007,” Figure 6 in Building a Future for Women and Children: The 2012 Report (Geneva: World Health Organization, 2012), at 20; see also 16–20, available at <http://www.countdown2015mnch.org/documents/2012Report/2012-Complete.pdf> (last visited February 13, 2013) [hereinafter cited as WHO UNICEF 2012 Report].

Desai M. , “Epidemiology and Burden of Malaria in Pregnancy,” The Lancet Infectious Diseases 7, no. 2 (February 2007): 93–104; Menéndez C. D'Alessandro U. , and ter Kuile F. O. , “Reducing the Burden of Malaria in Pregnancy by Preventive Strategies,” The Lancet Infectious Diseases 7, no. 2 (February 2007): 126–135.

McIntyre J. , “Mothers Infected with HIV: Reducing Maternal Death and Disability during Pregnancy,” British Medical Bulletin 67, no. 1 (2003): 127–135; Ronsmans C. and Graham W. , on behalf of The Lancet Maternal Survival Series steering group. “Maternal Mortality: Who, When, Where, and Why,” The Lancet 368, no. 9542 (September 30, 2006): 1189–1200, at 1194–1195.

See WHO UNICEF 2012 Report, supra note 12, at 20, Figure 6.

Barros F. C. , “Recent Trends in Maternal, Newborn and Child Health in Brazil: Progress toward Millennium Development Goals 4 and 5,” American Journal of Public Health 100, no. 10 (October 2010): 1877–1889, at 1883.

See WHO Trends Report, supra note 5, at 19 and 26.

See WHO Trends Report, supra note 5, at 26; for alternative estimates averaging 273,465 maternal deaths in 2011 and 409,053 in 1990, see Lozano R. , “Progress towards Millennium Development Goals 4 and 5 on Maternal and Child Mortality: An Updated Systematic Analysis,” The Lancet 378, no. 9797 (September 24, 2011): 1139–1165, at 1152.

See WHO Trends Report, supra note 5, at 26.

See WHO Trends Report, supra note 5, at 38.

Martins A. L. , “Mortalidade materna de mulheres negras no Brasil [Maternal Mortality among black women in Brazil],” Cadernos de Saúde Pública 22, no. 11 (November 2006): 2473–2479, at 2476, available at <http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0102–311X2006001100022&lng=en&nrm=iso&tlng=en> (last visited February 13, 2013); Center for Reproductive Rights, “Supplementary Information on Brazil,” letter of January 30, 2011 to CEDAW, available at <http://www2.ohchr.org/english/bodies/cedaw/docs/ngos/CenterReproductiveRights_for_the_session_Brazil_CEDAW51_en.pdf> (last visited February 13, 2013), for CEDAW's 51st Session on Brazil, held February 15, 2012, for which the Concluding observations are available through Brazil section of <http://www2.ohchr.org/english/bodies/cedaw/cedaws51.htm>(last visited February 13, 2013). The differential maternal mortality rate is not unique to Brazil. In the U.S., “African American women die in pregnancy or childbirth at three to four times the rate of white women,” cited in the Center for Reproductive Rights et al., “Report on the United States' Compliance with Its Human Rights Obligations in the Area of Women's Reproductive and Sexual Health” to the United Nations Universal Periodic Review, Ninth Session of the UPR Working Group of the Human Rights Council, November 22-December 3, 2010, available at <http://reproductiverights.org/sites/crr.civicactions.net/files/documents/CRR%20UPR%20Report-US-2010.pdf> (last visited February 13, 2013); see also Amnesty International, Deadly Delivery: The Maternal Health Care Crisis in the USA (London: Amnesty International, 2010), at 19–34, available at <http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf> (last visited February 13, 2013).

Cook R. J. and Dickens B. M. , “From Reproductive Choice to Reproductive Justice,” International Journal of Gynecology and Obstetrics 106, no. 2 (2009): 249–252.

See United Nations' “Official List of MDG Indicators,” available at <http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm> (last visited February 13, 2013).

Id., at Goal 5.

See WHO Trends Report, supra note 5, at 26.

Id., at 25–27.

Id., at 38.

Id., at 27, 38.

See Barros , supra note 16, at 1878; WHO Trends Report, supra note 5, at 17, 50.

Starrs A. , Preventing the Tragedy of Maternal Deaths: A Report on the International Safe Motherhood Conference, Nairobi, Kenya, February 1987 (Washington D.C.: World Bank/World Health Organization/UNFPA, 1987).

Starrs A. , Inter-Agency Group for Safe Motherhood, 1997. The Safe Motherhood Action Agenda: Priorities for the Next Decade. Report on the Safe Motherhood Technical Consultation, October 18–23, 1997, Colombo, Sri Lanka (New York: UNFPA/UNICEF/ World Bank/WHO/IPPF/Population Council/Family Care International, 1997).

Maternal Health Task Force <http://maternalhealthtaskforce.org/> (last visited Aug. 27, 2012).

The Partnership for Maternal, Newborn & Child Health, available at <http://www.who.int/pmnch/en/> (last visited February 13, 2013).

Shiffman J. and Smith S. , “Generation of Political Priority for Global Health Initiatives: A Framework and Case Study of Maternal Mortality,” The Lancet 370, no. 9595 (October 13, 2007): 1370–1379.

See Cook R. J. and Dickens B. M. . “The Injustice of Unsafe Motherhood,” Developing World Bioethics 2, no. 1 (2002): 64–81; Freedman L. , “Using Human Rights in Maternal Mortality Programs: From Analysis to Strategy,” International Journal of Gynecology and Obstetrics 75, no. 1 (2001): 51–60; Freedman L. , “Strategic Aadvocacy and Maternal Mortality: Moving Targets and the Millennium Development Goals,” Gender and Development 11, no. 1 (2003): 97–108; Freedman L. , “Shifting Visions: ‘Delegation’ Policies and the Building of a ‘Rights-Based’ Approach to Maternal Mortality,” Journal of the American Medical Women's Association 57, no. 3 (2002): 154–158; Yamin A. and Maine D. , “Maternal Mortality as a Human Rights Issue: Measuring Compliance with International Treaty Obligations,” Human Rights Quarterly 21, no. 3 (1999): 563–607.

Cook R. J. and Dickens B. M. , Advancing Safe Motherhood through Human Rights (Geneva: World Health Organization, 2001).

United Nations. Report of the Committee on the Elimination of Discrimination against Women. General Recommendation 24 (Twentieth Session), A/54/38/Rev.1. (New York: United Nations, 1999), available at <http://www.un.org/women-watch/daw/cedaw/recommendations/recomm.htm#recom24> (last visited February 13, 2013) [hereinafter cited as CEDAW Gen Rec 24]; United Nations; see also Committee on Economic, Social and Cultural Rights, General Comment No. 14, The right to the highest attainable standard of health, E/C.12/2000/4, August 11, 2000; available at <http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En> (last visited February 13, 2013); United Nations, Committee on the Elimination of Racial Discrimination, General recommendation No. 25 on Gender Related Dimensions of Racial Discrimination (Fifty-sixth session, 2000) UN Doc. A/55/18, available at <http://www.unhchr.ch/tbs/doc.nsf/0/76a293e49a88bd23802568bd00538d83?Opendocument> (last visited February 13, 2013); United Nations, Human Rights Committee, General Comment No. 28: Equality of Rights between Men and Women (Article 3), March 29, 2000, UN Doc. CPR/C/21/Rev.1/Add.10 (2000), available at <http://www.unhchr.ch/tbs/doc.nsf/0/13b02776122d4838802568b900360e80> (last visited February 26, 2013); United Nations, Committee on Economic, Social and Cultural Rights, General Comment No. 20. Non-discrimination in economic, social and cultural rights (Art. 2, Para. 2 of the International Covenant on Economic, Social and Cultural Rights), UN Doc. E/C.12/GC/20 (2009), available at <http://www2.ohchr.org/english/bodies/cescr/docs/E.C.12.GC.20.doc> (last visited February 13, 2013).

See The Convention, supra note 2, Art. 12(1).

See CEDAW Gen Rec 24, supra note 37, ¶11 (obligation to eliminate discrimination against women by ensuring their access to sex-specific health services), ¶14 (obligation to decriminalize medical procedures that only women need), ¶¶ 17, 26 and 31(c) (obligation to reduce maternal mortality rates and to report on the rates of reduction), ¶27 (obligation to provide free ante-natal, maternity and post-partum services where necessary), ¶29 (obligation to devise a comprehensive national strategy to ensure universal access to a full range of care, including reproductive health services).

For examples of concluding observations regarding the failure to reduce preventable maternal mortality as offending the Convention, see Cook R. and Undurraga V. , “Article 12 [Health],” in Freeman M. Chinkin C. , and Rudolf B. , eds., The UN Convention on the Elimination of All Forms of Discrimination against Women: A Commentary (Oxford: Oxford University Press, 2012): At 311–333 [hereinafter cited as the CEDAW Commentary]; see also Gruskin S. , “Using Human Rights to Improve Maternal and Neonatal Health: History, Connections and a Proposed Practical Approach,” Bulletin of the World Health Organization 86, no. 8 (2008): 589–593.

Brazil's general efforts to reduce maternal mortality are discussed in its 2012 state report to the Committee, CEDAW/C/BRA/7 (¶¶ 276–279) and in CEDAW's Concluding Observations on Brazil, 51st session, U.N. Doc. CEDAW/C/BRA/CO/7, March 23, 2012, (¶¶ 28–29). These documents are available in several languages at <http://www2.ohchr.org/english/bodies/cedaw/cedaws51.htm> (last visited February 13, 2013).

United Nations, Human Rights Council, Preventable maternal mortality and morbidity and human rights, General Assembly, Eleventh session, June 16, 2009, A/HRC/11/L.16/Rev.1, available through <http://ap.ohchr.org/documents/alldocs.aspx?doc_id=15740> (last visited February 13, 2013); United Nations, Human Rights Council, Preventable Maternal Mortality and Morbidity and Human Rights, Eighteenth Session, September 23, 2011, A/HRC/18/L.8, available at <http://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/18/L.8> (last visited February 13, 2013).

United Nations, Human Rights Council, Annual Report of the UN High Commissioner for Human Rights and reports of the Office of the High Commissioner and the Secretary General, Practices in Adopting a Human Rights-Based Approach to Eliminate Preventable Maternal Mortality and Human Rights, Eighteenth Session, July 8, 2011, A/HRC/18/27, available at <http://www2.ohchr.org/english/bodies/hrcouncil/docs/18session/A-HRC-18-27_en.pdf> (last visited February 13, 2013).

United Nations, Human Rights Council, Annual Report of the UN High Commissioner for Human Rights and Reports of the Office of the High Commissioner and the Secretary General, Technical Guidance on the Application of a Human Rights-Based Approach to the Implementation of Policies and Programmes to Reduce Preventable Maternal Morbidity and Mortality, July 2, 2012, A/HRC/21/22 [hereinafter cited as Technical Guidance on Human Rights and Maternal Health], at <http://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session21/A-HRC-21-22_en.pdf> (last visited February 13, 2013); Yamin A. , “Applying Human Rights to Maternal Health: UN Technical Guidance on Rights-based Approaches,” International Journal of Gynecology and Obstetrics 120 (forthcoming 2013).

UN Commission on the Status of Women, 56th session, Elimination of Preventable Mortality and Morbidity and the Empowerment of Women, March 18, 2012, E/CN.6/2011/CRP.8, available at <http://www.un.org/womenwatch/daw/csw/csw55/panels/Panel5-English.pdf> (last visited February 13, 2013).

United Nations, Secretary General Ban Ki-Moon, Global Strategy for Women's and Children's Health (Geneva: Partnership for Maternal, Newborn and Child Health, 2010), available at <http://www.who.int/pmnch/topics/maternal/20100914_gswch_en.pdf> (last visited February 13, 2013).

Human Rights Watch, “Nobody Remembers Us” Failure to Protect Women's and Girls' Right to Health and Security in Post Earthquake Haiti, New York, 2011, available at <http://www.hrw.org/sites/default/files/reports/haiti0811webwcover_0.pdf> (last visited February 13, 2013).

Center for Reproductive Rights (CRR), Maternal Mortality in India: Using International and Constitutional Law to Promote Accountability and Change (New York: CRR, 2008), available at <http://reproductiverights.org/sites/crr.civicactions.net/files/documents/MM_report_FINAL.pdf> (last visited February 13, 2013); Center for Reproductive Rights (CRR) and Human Rights Law Network, Maternal Mortality in India: 2011 Update–Accountability in Action, New York, 2011, available at <http://reproductiverights.org/sites/crr.civicactions.net/files/documents/MM_update_FINAL.pdf> (last visited February 13, 2013); Human Rights Watch, No Tally of the Anguish: Accountability in Maternal Healthcare in India, New York, 2009, available at <http://www.hrw.org/sites/default/files/reports/india1009web_0.pdf> (last visited February 13, 2013).

Center for Reproductive Rights, Failure to Deliver: Violations of Women's Human Rights in Kenyan Health Facilities, New York, 2007; Kenya National Commission on Human Rights, Realising Sexual and Reproductive Health Rights in Kenya: A Myth or a Reality? A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya (Nairobi: Kenya National Commission on Human Rights, 2012), 40–73, available at <http://www.knchr.org/Portals/0/Reports/Final%20Report_%20Sexual_Reprodutcive_health.pdf> (last visited February 13, 2013).

Center for Reproductive Rights, Broken Promises: Human Rights, Accountability, and Maternal Death in Nigeria, New York, 2008, available at <http://reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_nigeria2.pdf> (last visited February 13, 2013).

Yamin A. E. , Deadly Delays: Maternal Mortality in Peru – A Rights-Based Approach to Safe Motherhood (Cambridge: Physicians for Human Rights, 2007), available at <https://s3.amazonaws.com/PHR_Reports/maternal-mortality-in-peru2007.pdf> (last visited February 13, 2013); Amnesty International, Fatal Flaws: Barriers to Maternal Health in Peru (London: Amnesty International, 2009), available at <http://www.amnesty.org/en/library/asset/AMR46/008/2009/en/442a4678-9f6d-4f91-9045-3c47198144d7/amr460082009eng.pdf> (last visited February 13, 2013).

Human Rights Watch, Stop Making Excuses: Accountability for Maternal Health Care in South Africa (New York: Human Rights Watch, 2011), available at <http://www.hrw.org/sites/default/files/reports/sawrd0811webwcover.pdf> (last visited February 13, 2013).

See Amnesty International, supra note 21.

Cook R. J. and Dickens B. M. , “Upholding Pregnant Women's Right to Life,” International Journal of Gynecology and Obstetrics 117, no. 1 (2012): 90–94, at 92–93; Kismodi E. , “Human Rights Accountability for Maternal Death and Failure to Provide Safe, Legal Abortion: The Significance of Two Ground-Breaking CEDAW Decisions,” Reproductive Health Matters 20, no. 39 (2012): 31–38.

The Convention, supra note 2, Article 12(2).

The Convention, supra note 2, Article 12(1).

Xákmok Kásek Indigenous Community. v. Paraguay, Judgment of August 24, 2010 (series C) (Inter-American Court of Human Rights) ¶ 234, 275; see also Tavares v. France, Application No. 16593/90, Decision 12 Sept 1991, European Commission of Human Rights (a claim for wrongful maternal death was inadmissible for technical reasons, but the commission emphasized that the right to life under the European Convention requires states to take steps against unintentional loss of life).

Duna Bai v State of Madhya Pradesh et al, Writ Petition No. 5097/2011, (High Court of Madhya Pradesh, India) interim order of November 11, 2011, requiring State to report on progress on improving services to pregnant women; see “M.P. High Court Finds NRHM Wanting,” The Hindu [newspaper], February 13, 2012, available at <http://www.thehindu.com/todays-paper/tp-national/article2886945.ece?css=print> (last visited February 13, 2013); Sandesh Bansal v Union of India & Ors, Writ Petition No. 9061/2008, Order of February 6, 2012, (High Court of Madhya Pradesh) recognizing a woman's right to survive pregnancy and childbirth as a fundamental right protected under Article 21 (right to life) of the Indian Constitution, ordered immediate implementation of specific directives, available at <http://hrln.org/hrln/reproductive-rights/pils-a-cases/877-high-court-of-madhya-pradesh-recognizes-womans-right-to-survive-pregnancy-and-childbirth-as-a-fundamental-right.html> (last visited February 13, 2013); Subha B. Sri , “An Investigation of Maternal Deaths Following Public Protests in a Tribal District of Madhya Pradesh, Central India,” Reproductive Health Matters 20, no. 39 (2012): 11–20; Centre for Health and Resource Management (CHARM) v. Union of India and Ors , CWJC No.10724 of 2011, March 20, 2011 (High Court of Judicature at Patna) State of Bihar held responsible for failing to fulfill the rights of pregnant women, and required to account for nearly $680 million from the National Rural Health Mission, established to fund maternal health initiatives, available at <http://xa.yimg.com/kq/groups/14696929/322634576/name/200312.pdf> (last visited February 13, 2013). On June 25, 2012, the Court, dissatisfied with Bihar's submission, required quarterly progress reports, available at <http://www.hrln.org/hrln/images/stories/pdf/CHARM-order-MMR-PIL.pdf> (last visited February 13, 2013); see case summary, available at <http://hrln.org/hrln/reproductive-rights/pils-a-cases/956-patna-high-court-not-satisfied-with-bihar-government-orders-quarterly-progress-reports-on-the-nrhm-implementation-and-conditions-of-public-health-care-facilities.html> (last visited February 13, 2013); Center for Reproductive Rights (CRR) and Human Rights Law Network, Maternal Mortality in India: 2011 Update–Accountability in Action, New York, 2011, supra note 48, at 25.

Laxmi Mandal v Deen Dayal Harinagar Hospital and Ors, W.P. (C) No. 8853 of 2008 (High Court of Delhi, June 4, 2010), (the state and federal governments in violation of Shanti Devi's constitutional right to life, and to health as an inalienable component of life, for her preventable death in childbirth due to postpartum hemorrhage), available at <http://lobis.nic.in/dhc/SMD/judgement/04-06-2010/SMD04062010CW88532008.pdf> (last visited February 13, 2013); see Kaur J. , “The Role of Litigation in Ensuring Women's Reproductive Rights: An Analysis of the Shanti Devi Judgement in India,” Reproductive Health Matters 20, no. 39 (2012): 21–30.

Centre for Health Human Rights and Development et. al. v. Attorney General of Uganda , Constitutional Petition No 16 of 2011, June 5, 2012 (Constitutional Court of Uganda) available at <http://www.ulii.org/ug/judgment/constitutional-court/2012/4> (last visited February 13, 2013).

Erdman J. N. , “Human Rights in Health Equity: Cervical Cancer and HPV Vaccines,” American Journal of Law & Medicine 35, No. 2-3 (2009): 365–387, at 369.

See Alyne , supra note 1, ¶ 2.1.

Id., at ¶ 2.2.

Id., at ¶¶ 2.3–2.5.

Id., at ¶ 2.6.

Id., at ¶ 7.3.

Id., at ¶ 7.4.

Id., at ¶ 4.8.

Id., at ¶ 5.16; Barros , supra note 16, at 1878; this problem is eased by the revised classification manual: World Health Organization, The WHO Application of ICD-10 to Deaths during Pregnancy, Childbirth and the Puerperium: ICD-MM (Geneva: WHO, 2012), available at <http://www.who.int/reproductivehealth/publications/monitoring/9789241548458/en/> (last visited February 20, 2013).

See Alyne , supra note 1, ¶ 7.4.

Id., at ¶ 4.9; see also ¶¶ 4.3, 4.6, 5.12, 7.5.

Id., at ¶ 7.4.

Id., at ¶ 7.4.

Id., at ¶¶ 3.14–3.17, 4.10, 5.3.

Id., at ¶ 3.14.

Id., at ¶¶ 6.2, 5.3.

Id., at ¶ 7.8.

Id., at ¶ 7.5.

Id., at ¶ 7.6.

Id., at ¶ 7.7.

Id., at ¶ 7.8.

Id., at ¶ 7.5.

Id., at ¶7.5.

Id., at ¶7.5, referencing articles 196 – 200 of the Brazilian Constitution.

Id., at ¶7.6.

Id., at ¶7.6.

Id., at ¶7.7.

Id., at ¶¶ 2.1, 3.15 and 7.9.

Id., at ¶8.1.

Committee on the Elimination of Discrimination against Women, Concluding comments of the Committee on the Elimination of Discrimination against Women: Brazil, August 10, 2007, U.N. Doc. CEDAW/C/BRA/CO/6, available at <http://www.un.org/womenwatch/daw/cedaw/cedaw25years/content/english/CONCLUDING_COMMENTS/Brazil/Brazil-CO-6.pdf> (last visited February 13, 2013).

See Alyne , supra note 1, ¶8.2: the general recommendations are slightly reordered from the Committee decision to deal first with the health systems facts, and then to address those two recommendations dealing with health care providers.

See Alyne , supra note 1, ¶8.

Yamin A. E. , “Power, Suffering and Courts: Reflections on Promoting Health Rights through Judicialization,” in Yamin A. E. and Gloppen S. , eds., Litigating Health Rights: Can Courts Bring More Justice to Health? (Cambridge: Harvard University Press, 2011): 333–372; Howse R. and Teitel R. , “Beyond Compliance: Rethinking Why International Law Really Matters,” Global Policy 1, no. 2 (2010): 127–136; Shany Y. , “Assessing the Effectiveness of International Courts: A Goal-Based Approach,” American Journal of International Law 106, no. 2 (2012): 225–270.

Id. (Yamin), at 337.

Cook R. J. and Dickens B. M. , supra note 22.

Cook and Dickens , “Injustice,” supra note 35.

Rosenfield A. and Maine D. , “Maternal Mortality – A Neglected Tragedy: Where Is the M in MCH?” The Lancet 2, no. 8446 (July 13, 1985): 83–85.

Cook R. J. and Howard S. , “Accommodating Women's Differences under the Women's Anti-Discrimination Convention,” Emory Law Journal 56, no. 4 (2007): 1039–1091; Inter-American Commission on Human Rights, “Access to Maternal Health Care from a Human Rights Perspective,” OEA/Ser.L/V/II. Doc. 69, June 7, 2010, at 15–29, available at <http://cidh.org/women/SaludMaterna10Eng/MaternalHealth2010.pdf> (last visited February 13, 2013).

Romany C. , “Themes for a Conversation on Race and Gender in International Human Rights Law,” in Wing A. K. , Global Critical Race Feminism (New York: New York University Press, 2000): At 53–66.

United Nations. Committee on the Elimination of Discrimination against Women, General Recommendation 28 on the Core Obligations of States Parties under Article 2 of the Convention on the Elimination of All Forms of Discrimination against Women, UN Doc CEDAW/C/GC/28, 16 December 2010, ¶18, available at <http://www.humanrights.ch/upload/pdf/110524General_recomm._no_28_English.pdf> (last visited February 13, 2013) [hereinafter cited as CEDAW Gen Rec 28].

See CEDAW Gen Rec 28, supra note 100, at ¶18.

Erdman J. N. Essajee I. , and Courtright A. , Written Comments to the Committee on the Elimination of Discrimination against Women in relation to L.C. v Peru, Communication No. 22/2009 (International Reproductive and Sexual Health Law Programme, 2011) at 5 (footnotes omitted), available at <http://opcedaw.files.wordpress.com/2012/01/lc-v-peru-heal-clinic-amicus-brief.pdf> (last visited February 13, 2013).

Victora C. G. , “Socioeconomic and Ethnic Group Inequities in Antenatal Care Quality in the Public and Private Sector in Brazil,” Health Policy and Planning 25, no. 4 (2010): 253–261, at 256 (differential access to breast and gynecological examinations, counseling about breastfeeding, prescription of vitamins, blood and urine analyses and ultrasound); do Carmo Leal M. , “Racial, Sociodemographic, and Prenatal and Childbirth Care Inequalities in Brazil,” Revista de Saúde Pública 39, no. 1 (2005): 100–107.

Doyal L. and Payne S. , “Gender and Global Health: Inequality and Differences,” in Benatar S. and Brock G. , eds., Global Health and Global Health Ethics (Cambridge: Cambridge University Press, 2011): 53–62, at 57.

Braveman P. , “Health Disparities and Health Equity: Concepts and Measurement,” Annual Review of Public Health 27 (2006): 167–194; Braveman P. , “Social Conditions, Health Equity and Human Rights,” Health and Human Rights 12, no. 2 (2010): 31–48; Braveman P. and Gruskin S. , “Poverty, Equity, Human Rights and Health,” Bulletin of the World Health Organization 81, no. 7 (2003): 539–545; see Erdman supra note 61, at 367–377.

See Erdman , supra note 61, at 367 (footnotes omitted) (emphasis in the original).

Id., at 368.

See Cook and Undurraga , “Article 12,” supra note 40, at 317.

Chilton A. , “Brazil's Pregnancy Registration Requirement and International Commitments to the Rights of Women,” Journal of Law, Medicine and Ethics 40, no. 3 (2012): 696–700.

Galli Maria Beatriz , correspondence, July 3, 2012.

Dhesca, Brazilian Platform on Human, Economic, Social, Cultural and Environmental Rights, available at <http://www.dhescbrasil.org.br/index.php?option=com_content&view=article&id=735:artigo-10-anos-relatorias-em-direitos-humanos&catid=69:antiga-rok-stories> (last visited February 13, 2013).

Maria Beatriz Galli was appointed Rapporteur on the Human Right to Sexual and Reproductive Health on May 8, 2012, by Dhesca, the Brazilian Platform on Human, Economic, Social, Cultural and Environmental Rights, available at <http://www.dhescbrasil.org.br/> (last visited February 13, 2013).

Relatoria do Direito à Saúde Reprodutiva da Plataforma DHESCA Brasil, Letter of August 10, 2012 to the President of Brazil et al., available at <http://www.dhescbrasil.org.br/attachments/614_alyne_case_english_version.pdf> (last visited February 13, 2013).

For examples of other issues about Brazil's compliance with the Alyne decision, see Center for Reproductive Rights' letter to CEDAW, “Supplementary Information on Brazil,” supra note 21.

See CEDAW Gen Rec 28, supra note 100, at ¶ 23.

See Alyne, supra note 1, at ¶ 8.1.

Relatoria do Direito à Saúde Reprodutiva da Plataforma DHESCA Brasil, A Victory in Alyne's Case, available at <http://www.dhescbrasil.org.br/index.php?option=com_content&view=article&id=649:victory-alynes-case&catid=69:antiga-rok-stories> (last visited February 13, 2013).

See supra note 88.

See Technical Guidance on Human Rights and Maternal Health, supra note 44, ¶¶ 69–73.

Hunt P. , Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, to the United Nations Economic and Social Council 62nd session (March 3, 2006), E/CN.4/2006/48 ¶¶ 54–56, available through <http://www2.ohchr.org/english/bodies/chr/sessions/62/listdocs.htm> (last visited February 13, 2013) [hereinafter cited as Hunt Report].

See the Convention, supra note 2, Article 12(1).

CEDAW Gen Rec 24, supra note 37, ¶ 17; regarding maternal mortality ratios (MMRs), see WHO Trends Report, supra note 5, at 6.

World Health Organization and United Nations Population Fund, National-Level Monitoring of the Achievement of Universal Access to Reproductive Health: Conceptual and Practical Considerations and Related Indicators, Report of a WHO/UNFPA Technical Consultation (Geneva: WHO, 2008) at 8–22, available at <http://www.who.int/reproductivehealth/publications/monitoring/9789241596831/en/index.html> (last visited February 20, 2013) [hereinafter cited as WHO/UNFPA “National Monitoring”].

See the Convention, supra note 2, Article 12(2); CEDAW Gen Rec 24, supra note 37, ¶¶ 26–27; Tobin J. , The Right to Health in International Law (Oxford: Oxford University Press, 2012): at 287–291.

See Hunt Report, supra note 120, at ¶ 54.

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 69.

See the Convention, supra note 2, Article 12(1).

Cottingham J. , “Using Human Rights for Sexual and Reproductive Health: Improving Legal and Regulatory Frameworks,” Bulletin of the World Health Organization 88, no. 7 (2010): 551–555.

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 70.

World Health Organization et al., Monitoring Emergency Obstetric Care: a Handbook, Geneva, 2009, at 5–6, 26–39, available at <http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/obstetric_monitoring.pdf> [hereinafter cited as WHO Monitoring]; See also WHO/UNFPA “National Monitoring,” supra note 123, at 8–22; World Bank, “Selected Indicators and Data Sources for Monitoring Projects Aimed at Improving Maternal Health,” in Reducing Maternal Mortality: Strengthening the World Bank Response (World Bank, 2009), Table 1, at 12–13, available at <http://siteresources.worldbank.org/INTPRH/Resources/376374-1278599377733/MaternalHealth-62910PRINT.pdf> (last visited February 13, 2013).

FIGO Safe Motherhood and Newborn Health Committee, “FIGO Guidelines: Prevention and Treatment of Post Partum Hemorrhage in Low-Resource Settings,” International Journal of Gynecology and Obstetrics 117, no. 2 (2012): 108–118.

See the Convention, supra note 2, at Article 12(2); CEDAW Gen Rec 24, supra note 36, at ¶¶ 26–27.

See the Hunt Report, supra note 120.

See WHO Monitoring, supra note 130, at 5–6, at 39, updating and revising United Nations Children's Fund, World Health Organization and United Nations Population Fund, Guidelines for Monitoring the Availability and Use of Obstetric Services (New York: UNICEF, 1997), cited in Alyne ¶ 3.8.

See Alyne , supra note 1, at ¶ 3.8.

MacDonald S. D. Lutsiv O. Dzaja N. , and Duley L. , “A Systematic Review of Maternal and Infant Outcomes Following Magnesium Sulfate for Pre-Eclampsia/Eclampsia in Real-world Use,” International Journal of Gynecology and Obstetrics 118, no. 2 (2012): 90–96.

Dabash R. Blum J. Raghavan S. Anger H. , and Winikoff B. , “Misoprostol for the Management of Postpartum Bleeding: A New Approach,” International Journal of Gynecology and Obstetrics 119, no. 3 (2012): 210–212; Oladapo O. , “Misoprostol for Preventing and Treating Postpartum Hemorrhage in the Community: A Closer Look at the Evidence,” International Journal of Gynecology and Obstetrics 119, no. 2 (2012): 105–110.

Starrs A. and Winikoff B. , “Misoprostol for Postpartum Hemorrhage: Moving from Evidence to Practice,” International Journal of Gynecology and Obstetrics 116, no. 1 (2012): 1–3, at 1.

See Starrs and Winikoff , supra note 138, at 1.

International Federation of Gynecology and Obstetrics, FIGO Guidelines-Prevention of Postpartum Hemorrhage with Misoprostol, International Journal of Gynecology and Obstetrics 119, no. 3 (2012): 213–214.

Id., at 215–216.

See Starrs and Winikoff , supra note 138, at 1.

Brazil, Ministry of Health, Relação Nacional de Medicamentos Essenciais (Rename) (5th edition, 2007) lists “ocitocina” at 71, 118; discusses use at 255, available at <http://portal.saude.gov.br/portal/arquivos/pdf/rename2006.pdf> (last visited February 26, 2013). See also Formulário Terapêutico Nacional (2008) at 740, available at <http://portal.saude.gov.br/portal/arquivos/multimedia/paginacartilha/docs/FTN.pdf> (last visited February 26, 2013).

Brazil, Ministry of Health, Relação Nacional de Medicamentos Essenciais (Rename) (7th edition, 2010) lists misoprostol at 55, 72, 85, 86, and discusses use at 146–8, available at <http://portal.saude.gov.br/portal/arquivos/pdf/rename-2010final.pdf> (last visited February 26, 2013). See also “Nota Tecnica 35/2011: Aquisição do medicamento Misoprostol pelo Ministério da Saúde,” available at <http://www.saude.ms.gov.br/controle/ShowFile.php?id=107159> (last visited February 26, 2013).

Shaw D. and Cook R. , “Applying Human Rights to Improve Access to Reproductive Health Services,” FIGO World Report on Women's Health, International Journal of Gynecology and Obstetrics 119, Supp. 1 (2012): s55–s59.

Ministry of Health of Brazil, Brazilian National Pact for the Reduction of Maternal Mortality, 2004, available at <http://dtr2002.saude.gov.br/proesf/Site/Arquivos_pdf_word/pdf/Pacto%20Aprovado%20na%20Tripartite.pdf> (last visited February 14, 2013).

For details about the Stork Network in Portuguese, see “Diretrizes Gerais e Operacionalis da Rede Cegonha,” available at <http://portal.saude.gov.br/portal/saude/Gestor/visualizar_texto.cfm?idtxt=37082> (last visited February 13, 2014).

Statement by H.E. Minister Nilcea Friere, Special Secretary on Policies for Women, Federative Republic of Brazil to the 54th Commission on the Status of Women (March 2, 2010), available at <http://www.un.org/womenwatch/daw/beijing15/general_discussion/Brazil.pdf> (last visited February 14, 2013).

See CEDAW, supra note 90, at ¶ 30.

Brazilian Law n. 8.080, September 19, 1990.

National Report of the State of Brazil submitted to the Universal Periodic Review Mechanism of the United Nations Human Rights Council, Session 13, March 7, 2012, UN Doc.A/HRC/WG.6/13/BRA/1 reference 44, available through “Session 13”: <http://www.upr-info.org/-State-reports-.html> (last visited February 14, 2013) [hereinafter cited as Brazil UPR Report 2012].

See Brazil UPR Report 2012, supra note 151, at ¶ 31.

See Alyne , supra note 1, at ¶ 7.6, referencing CEDAW Gen Rec 28 supra note 100, ¶ 28; Malajovich L. , “Budget Transparency on Maternal Health Spending: A Case Study in Five Latin American Countries,” Reproductive Health Matters 20, no. 39 (2012): 185–195.

See Hunt Report, supra note 120, at ¶¶ 23–34.

See Alyne , supra note 1, at ¶ 7.6.

Cook R. J. and Bevilacqua Galli M. B. , “Invoking Human Rights to Reduce Maternal Deaths,” The Lancet 363, no. 9402 (2004): 73.

See Alyne , supra note 1, at ¶ 5.17.

Victora C. G. , “Maternal and Child Health in Brazil: Progress and Challenges,” Lancet 377, no. 9780 (2011): 1863–1876, at 1866.

World Health Organization, “Evaluating the Quality of Care for Severe Pregnancy Complications: The WHO Near-Miss Approach for Maternal Health,” Geneva, 2011, at 5, available at <http://whqlibdoc.who.int/publications/2011/9789241502221_eng.pdf> (last visited February 14, 2013).

See WHO Trends Report, supra note 5, at 6; CEDAW Gen Rec 24, supra note 37, at ¶ 17.

WHO Monitoring, supra note 130.

See Alyne , supra note 1, at ¶ 7.5.

Byrnes A. , “Article 2 [Obligations]” in the CEDAW Commentary supra note 40, at 71–99, 87.

A.T. v. Hungary, CEDAW Communication No. 2/2003, ¶ 9.2–9.4, U.N. Doc. CEDAW/C/32/D/2/2003 (2005); Fatma Yildrim v. Austria, CEDAW Communication No. 5/2005, ¶ 12.1.2, U.N. Doc CEDAW/C/39/D/6/2005 (2007); Sahide Goekce v. Austria, CEDAW Communication No. 5/2005, U.N. Doc CEDAW/C/39/D/2005 (2007).

See Alyne , supra note 1, at ¶4.9.

See Ministry of Health of Brazil, supra note 146.

See, e.g., WHO Monitoring, supra note 130.

Alyne , supra note 1, at ¶¶ 3.8 and 3.9; CEDAW Gen Rec 24, supra note 37, at ¶¶ 17, 31(d).

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 75(d).

See Alyne , supra note 1, at ¶¶ 3.4–3.6.

See Barros , supra note 16, at 1884; Bhutta Z. A. , “Countdown to 2015 – Decade Report (2000–10): Taking Stock of Maternal, Newborn, and Child Survival,” The Lancet 375, no. 2032 (2010): 2040–2041.

Alves Valongueiro S. , “Maternal Mortality in Pernambuco, Brazil: What Has Changed in Ten Years,” Reproductive Health Matters 15, no. 30 (2007): 134–144, at 141.

See, e.g., Trevo de Quatro Folhas, Brazil, Strategy for the reduction of maternal, perinatal and infant morbidity and mortality (Panama City: UNICEF, 2011) 15, available at <http://www.unicef.org/lac/TREBOL_-_INGLES%282%29.pdf> (last visited February 14, 2013); Brazil, Ministério da Saúde, Actions and Programs, SAMU 192 and UPA 24 <http://portalsaude.saude.gov.br/portalsaude/index.cfm/?portal=pagina.visualizarTexto&codConteudo=2207&codModuloArea=518&chamada=Actions-and-Programs> (last visited February 14, 2013).

See supra note 131.

See Alves Valongueiro , supra note 172, at 140.

Id.

See CEDAW Gen Rec 24, supra note 37, at ¶¶ 22, 31(e).

George A. Chopra M. Seymour D. , and Marchi P. , “Making Rights More Relevant for Health Professionals,” The Lancet 375, no. 9728 (May 22, 2010): 1764–1765.

Cook R. J. Dickens B. M. , and Fathalla M. F. , Reproductive Health and Human Rights: Integrating Medicine, Ethics and Law (Oxford: Oxford University Press, 2003): 255–261, 393–401.

See the Convention, supra note 2, at Article 5(a).

Freedman L. P. , “Human Rights, Constructive Accountability and Maternal Mortality in the Dominican Republic: A Commentary,” International Journal of Gynecology and Obstetrics 82, no. 1 (2003): 111–114, at 112.

See Cook Dickens , and Fathalla , supra note 179, at 128–139.

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 75(a).

See Freedman , supra note 181, at 112.

Yamin A. E. , “Toward Transformative Accountability: A Proposal for Rights-Based Approaches to Fulfilling Maternal Health Obligations,” Sur: An International Journal 7, no. 12 (2010): 95–122, at 96.

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 75.

See text at notes 162–169.

Technical Guidance on Human Rights and Maternal Health, supra note 44, ¶ 75.

See supra note 106.

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 75(b).

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 75(c).

George A. , “Using Accountability to Improve Reproductive Health Care,” Reproductive Health Matters 11, no. 21 (2003): 161–170, at 166.

See Technical Guidance on Human Rights and Maternal Health, supra note 44, at ¶ 75(c).

See Martins Alaerte Leandro , supra note 21.

Maternal Health Task Force and Global Health Visions, UN Commission on Life Saving Commodities for Women and Children: Country Case Studies, 2012, at 6–7, 20–25, available at <http://can-mnch.ca/wp-content/uploads/2012/06/Life-Saving-Commodities-New_Concept_Note1.pdf> (last visited February 14, 2013).

Hoffman F. F. and Bentes F. R. N. M. , “Accountability for Social and Economic Rights in Brazil,” in Gauri V. and Brinks D. M. , eds., Courting Social Justice – Judicial Enforcement of Social and Economic Rights in the Developing World (Cambridge: Cambridge University Press, 2008): At 100–145, at 100, 122, 126–127, 136–138, 144.

Minister of Health v Treatment Action Campaign (No. 2) [2002] 5 SA721; Berger J. , “Litigating for Social Justice in Post-Apartheid South Africa: A Focus on Health and Education,” in Gauri V. and Brinks D. M. eds., supra note 196, at 38–99.

Houtzager P. and White L. E. , “The Long Arc of Pragmatic Economic and Social Rights Advocacy,” in White L. E. and Perelman J. , eds., Stones of Hope: How African Activists Reclaim Human Rights to Challenge Global Poverty (Palo Alto, CA: Stanford University Press, 2011): 172–195.

See Alyne , supra note 1, at ¶ 7.7.

See CEDAW Gen Rec 28, supra note 100, at ¶18.

See Alyne , supra note 1, at ¶ 9; OP CEDAW, supra note 4, Art. 7(4).

See Martins Alaerte Leandro , supra note 21.

United Nations, Committee on the Elimination of Discrimination against Women (CEDAW), General Recommendation No. 25, on Article 4(1) on Temporary Special Measures of the Convention on the Elimination of All Forms of Discrimination against Women, thirtieth session, 2004, at ¶12, available at <http://www.un.org/womenwatch/daw/cedaw/recommendations/General%20recommendation%2025%20(English).pdf> (last visited February 14, 2013).

Raday F. , “Article 4” in the CEDAW Commentary supra note 40, 123–139, at 131.

See Alyne , supra note 1, at ¶¶ 2.14, 3.14, 3.15, 3.17, 4.10, 5.3, 6.2, 7.8.

Brazilian Constitution, 5 October 1988 as amended 4 June 1998, [hereinafter cited as Brazilian Constitution] Articles 196–200; Article 196 reads, “Health is the right of all and the duty of the State and shall be guaranteed by social and economic policies aimed at reducing the risk of illness and other maladies and by the universal and equal access to all activities and services for its promotion, protection and recovery.”.

The Brazilian Constitution, supra note 206, at Article 6 reads, “Education, health, work, leisure, security, social security, protection of motherhood and childhood, and assistance to the destitute, are social rights, as set forth by this Constitution.” (Chapter II – Social Rights).

See the Brazilian Constitution, supra note 206, at Article 5(i) – general principle of equality between men and women; Article 201(ii)- protection of maternity, especially women while pregnant.

See the Brazilian Constitution, supra note 206, at Article 3(iv) – promote the well-being of all, without prejudice as to origin, race, sex, colour, age and any other forms of discrimination; Article 5 (xlii) – the practice of racism is a non-bailable crime, with no limitation, subject to the penalty of confinement, under the terms of the law.

See Alyne , supra note 1, at ¶7.5.

Ferraz Motta O. L. , “Brazil: Health Inequalities, Rights and Courts: The Social Impact of the Judicialization of Health,” in Yamin A. E. and Gloppen S. , eds., Litigating Health Rights, supra note 91, at 76–102; see also in this issue Prado M. M. , “The Debatable Role of Courts in Brazil's Health Care System: Does Litigation Harm or Help?” Journal of Law, Medicine and Ethics 41, no. 1 (2013): 124–137.

See Ferraz , supra note 211, at 94; emphasis is in the original.

See Hoffman and Bentes , supra note 196, at 100–145, at 121–122.

Id., at 122.

Id.

See Shany , supra note 93, at 251.

See Howse and Teitel , supra note 93, at 131–132.

See, for example, supra notes 37 and 134.

See WHO Trends Report, supra note 5, at 27.