Women, Reproductive Health and International Human Rights

The modern era of rights that can be applied to women's health may be said to have started with the adoption of the United Nations Charter in 1946. The Charter requires the United Nations to encourage "respect for the principle of equal rights" by promoting "universal respect for, and observance of, human rights and fundamental freedoms for all without distinction as to … sex".

In 1948, the Universal Declaration of Human Rights was adopted by the United Nations General Assembly. This Declaration condemned discrimination on the grounds of sex and set out a network of rights relevant to the promotion and protection of health. The Declaration was developed into international human rights law by two general covenants adopted by the General Assembly in 1966, namely the International Covenant on Civil and Political Rights, and the International Covenant on Economic, Social and Cultural Rights.

A number of regional human rights conventions were also derived from the Universal Declaration, including the European Convention for the Protection of Human Rights and Fundamental Freedoms, the American Convention on Human Rights, and the African Charter on Human and Peoples' Rights. These regional conventions all prohibit discrimination on grounds of sex and require respect for various rights related to the promotion and protection of health. Other specialized conventions relevant to women's health also exist, such as the conventions on the Rights of the Child (which includes protection of the rights of girl children), on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (which prohibits the infliction of physical or mental suffering on women), and on the Status of Refugees (which provides protection for refugee women).

The leading modern instrument on women's equal rights, however, is the Convention on the Elimination of All Forms of Discrimination against Women (the Women's Convention), which was adopted in 1979. Derived from the Universal Declaration of Human Rights, the Women's Convention is the first international treaty in which member countries, known as States Parties, assume the legal duty to eliminate all forms of discrimination against women in civil, political, economic, social and cultural areas, including health care and family planning.

The Women's Convention, which has been widely accepted, obliges States Parties in general "to pursue by all appropriate means and without delay a policy of eliminating discrimination against women" and, in particular, "to eliminate discrimination against women in the field of health care in order to ensure … access to health care services, including those related to family planning". When women experience disadvantage in contrast to other members of their families, communities or societies, they will be considered to suffer discrimination because they are women.

The Constitution of WHO, which was drawn up in 1946 and came into force in 1948, describes health as follows: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." It is clear that much more than the provision of medical and nursing services is required to achieve this. Society must therefore pay attention to the full range of human rights, and not just those directly relating to health care, if health as defined by WHO is to be achieved and maintained.

 Health, sex and gender

The concept of health as "physical, mental and social well-being" emphasizes the significance of social welfare. Medical science has a central role in health, but health is the outcome of a combination of factors— biological, genetic, environmental and socioeconomic. In the case of women, social, economic and cultural influences can be seen to play an important role in health status. In some parts of the world women are considered to be relatively insignificant. They may be conditioned to suffer low self-esteem, to accept inferior status as normal, and see the birth of a daughter as a reason for apology and distress. Legal, religious and cultural traditions may reinforce the devaluation of daughters. For instance, if women must leave the family on marriage, there is little point in investing money in their education. The cumulative impact of women's disadvantages results in many women being denied health as defined by WHO.

Neglect of women's health is linked both to their sex and to their gender. Sex is determined by genes and biology, whereas gender is a social construct that relates to feelings, values, behaviours and activities. Women suffer discrimination in health and other matters because of their sex, as for instance in cases of taboos related to menstruation. However, they suffer additional discrimination as roles associated with female gender are often not valued in social and economic terms.

Women's health disadvantages

The disadvantages women suffer in health may be classed as injustices in the light of human rights law. For instance, maternal mortality can be explained as being due to (i) the immediate cause of lack of maternity care, (ii) the underlying causes of exhaustion and anaemia associated with short intervals between births, and (iii) structural causes such as poverty. In the case of (i), the right to health care would require obstetric services to be available. In the case of (ii), the right to education, among other rights, would enable people to become literate and thereby learn of the health benefits of child spacing and having fewer children. And in the case of (iii), states may be legally responsible if they allocate national wealth disproportionately to expenditures that deny populations their basic needs.

Epidemiological and other data show how lack of basic obstetric services, antenatal care and related reproductive health services result in unnecessarily high rates of maternal mortality and morbidity. Evidence also confirms the danger to health presented by pregnancies that come too early, too late, too often and at intervals that are too closely spaced. Unsafe abortion procedures can endanger life, health and future fertility. Unwanted infertility, often a consequence of infection resulting from poor health care, leads to unmarriageability, divorce or abandonment and the health disadvantages associated with them. All these conditions can be seen as infringements of human rights, as understood within the terms of widely accepted international human rights treaties.

At the same time, fear of sexual relationships that lead to unwanted pregnancy, often linked to the physical dangers of pregnancy, impairs women's enjoyment of health as defined by WHO. Women may also be disadvantaged in protecting themselves against sexually transmitted infections, including the human immunodeficiency virus (HIV), through lack of information, through lack of power to refuse to have intercourse with their partners, or because they cannot insist that their partners use condoms. Thus, rights may be contravened even by the attitudes and customs of the communities where women live.

In order to address the health disadvantages of women, action is needed in a number of areas—many of them relating to empowerment. For instance:

• women must have greater freedom to determine their own health and life choices within families and communities;

• women must have opportunities to learn about their rights and their health;

• women must have access to accurate information about their health as well as to high-quality women-centred care;

• women must have greater access to education and economic opportunities;

• adolescent girls must have the opportunity to develop the life skills so that they can act to protect their own health;

• men must be made aware of their role in expanding women's choices in households and communities, and in ensuring responsible sexual and family life;

• women must be supported by policies and laws that promote and ensure reproductive health and gender equality;

• training of health care providers must stress the importance of preserving women's rights.

Rights and reproductive health

Preventing reproductive ill-health in women is an issue of social justice and human rights. Redefining women's reproductive ill-health as a "social injustice" rather than as a "health disadvantage" provides the legal and political basis for governments to ensure reproductive health care for all women. The challenge is to characterize women's health disadvantages as injustices that governments are obliged to remedy through political, health and legal systems.

Efforts to advance women's reproductive health through human rights must build on the existing framework of human rights, as recognized in most national constitutions and international human rights treaties. These rights include:

• the rights to life, liberty and the security of the person (these rights require governments to ensure access to appropriate health care, and to guarantee that citizens can choose when and how often to bear children);

• the rights that relate to the foundation of families and of family life (these rights require governments to provide access to health care and other services women need to establish families and enjoy life within their families);

• the rights to health care and the benefits of scientific progress, including health information and education (these rights require governments to provide reproductive and sexual health services and information to women);

• the rights to equality and nondiscrimination (these rights require governments to ensure that all women and girls have access to services such as education and health care—regardless of age, marital status, ethnicity or socioeconomic status).

What do these rights mean in practice? It could be argued, for example, that a woman's right to life entitles her access to appropriate health services and that laws that obstruct this violate her human rights. It can be said that her right to liberty is infringed if she is not given full information about an intervention that affects her reproductive health—such as the failure rate or side-effects of a method of fertility regulation. And the right to security of the person is not respected if a girl or young woman is subjected to female genital mutilation.

The right to found a family means much more than the right to conceive and bear a child. The Convention on the Elimination of All Forms of Discrimination against Women, for instance, goes beyond this. The Convention requires states that are signatory to it to ensure that women enjoy "rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights".

The right to health care is infringed if there are legal barriers to a woman's access to health services. But the right may also be said to be infringed if a government fails to provide necessary health services to women who cannot obtain them through their own means. It could further be argued that the right is violated when a woman is deterred from using health services because she will not be treated with dignity and respect, or because she fears the lack of confidentiality and privacy. The right to the benefits of scientific progress requires that women should have access to treatments and technologies based on the results of scientific research. Failure to provide such treatments and technologies for no good reason could be interpreted as a violation of this right.

The rights to equality and nondiscrimination mean that a woman should not be disadvantaged in any way, legally or otherwise, simply because of the fact of being a woman. These rights are infringed, for instance, if a woman is required to obtain another person's authorization before she can access health services.

States have a legal obligation to account for their practices regarding human rights by reporting to human rights treaty bodies. Where states do not take all appropriate means to bring laws, policies and practices into compliance with the human rights of women, they have been held, and can continue to be held, accountable by constitutional courts and treaty monitoring bodies for denying women their human rights.

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