Recommendation

Because of the paucity of evidence available, additional research is recommended. 

 

Publication history

First published: May 2015

Updated: No update planned

Assessed as up-to-date: May 2015

 

Remarks

• The GDG affirms as a matter of principle the importance for MNH programmes to inform women about their right to health and to access quality skilled care and to continue to empower them to access such care.

 

Background

In 2003 the World Health Organization (WHO) published “Working with individuals, families and communities to improve maternal and newborn health”, (1) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (2) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons – over and above what happens in clinical services – why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter’s health promotion components(2) were translated into MNH programme language and 12 promising interventions – identified through reviews of country experiences and the literature – were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

Human rights are considered as a guiding principle of the IFC Framework and within WHO strategies as a fundamental component of maternal and newborn health. Sexual and reproductive health (SRH) programmes and MNH programmes support the principle that women who are aware of their sexual and reproductive rights are in a better position to exercise their reproductive choices and determine how they negotiate family and community dynamics, how they are able to access health care and how they are treated by health services.(3)

Families, communities, health providers and other stakeholders who know and respect human rights, in particular sexual and reproductive health and rights, will support women in better taking care of themselves and their children. Therefore, in addition to working with an individual pregnant woman, programmes often address her family, the broader community, service providers, managers and other health systems stakeholders to increase awareness of the right to health or to skilled care. Programmatic inputs include education materials or other visual aids, mass media campaigns and work with groups or public meetings and often focus content on what should be improved to ensure quality services.

Respecting women’s human rights, their sexual and reproductive health and rights and their rights to access quality care are part of human rights-based approaches to health that are affirmed and recommended by national governments and international consensus agreements, including those endorsed by WHO and the United Nations more broadly, such as the Programme of Action of the International Conference on Population and Development (1994) and the Beijing Declaration and Platform of Action (1995). Considering the Office of the High Commissioner for Human Rights’ Technical guidance on a human rights-based approach to maternal mortality and morbidity(4) as well as the UN Commission on Information and Accountability, the importance of considering interventions that promote awareness of rights for women as a fundamental part of maternal newborn health is timely.

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, guided by the GRADE approach.(5) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(6)

A systematic review was conducted on interventions to promote awareness of human rights, sexual reproductive rights and/or the right to quality skilled care.(7) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

• What interventions to promote awareness of human rights or sexual and reproductive rights or right to access to quality care are effective in increasing birth with a skilled birth attendant and in improving other key maternal and newborn health outcomes?

 

Evidence summary

Evidence on interventions to promote awareness of human rights, sexual reproductive rights and/or the right to quality skilled care was extracted from a systematic review conducted by George, Branchini and Portela (forthcoming).(7) In the literature many studies were found mentioning rights or discussing a rights-based approach. Most references discussed the importance of rights or the violation of rights or interventions but few documented promoting awareness of rights. Documents that did detail promoting awareness of rights largely did so without any explicit methodology or any tracking of effects on health outcomes. Three studies were found to have health outcome data to evaluate the effects of interventions to promote awareness of human rights and/or sexual reproductive rights and/or the right to quality skilled care. These include two cluster RCTs and one before and after study. Two of these studies report qualitative findings. There was not sufficient evidence to determine which of the modes of delivery of the intervention were most effective. Outcome measures for two of the studies included birth in a facility and all studies reported on use of antenatal care.

For the outcome of birth in a facility, the quality of the evidence ranged from very low to moderate.

One cluster RCT (Bjorkman and Svensson, 2009) conducted in Uganda reports a significant increase in facility births, reported as additional births at the facility on average per month. Moderate-quality evidence.(8)

One pre-post programme evaluation (Sinha, 2008) reported on a significant increase in the number of women giving birth in primary health centres and government hospitals, with a significant decrease in births at private clinics. Very low-quality evidence.(9)

For the outcome of use of antenatal care, the quality of evidence was rated as very low.

Two cluster RCTs had varied results. One trial in Uganda (Bjorkman and Svensson, 2009) reports a non-significant increase in additional ANC visits per month on average. The other in India (Pandey et al., 2007) reports a significant increase in prenatal examinations at year 1. Very low-quality evidence.(8)

One pre-post programme evaluation (Sinha, 2008) reports improved ANC care-seeking with significant differences between baseline and endline in women who made at least one and women who made more than three visits. Very low-quality evidence.(9)

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/172427/2/9789241508742_tables_eng.pdf?ua=1

 

Implementation considerations

• Promotion of awareness of rights may be better documented for some areas of SRH including family planning, post-abortion care, FGM and the right to have children for women living with HIV. Lessons learned could be reviewed from these areas and applied to MNH programmes.
• Awareness-raising on human rights should be an ongoing process involving women, families and communities through the life course and not limited only to the period of pregnancy, childbirth and after birth.
• Information regarding human rights should be provided in language and formats accessible to them and should target women both at the facilities and at the community level. Learning how to put rights awareness into practice is necessary, i.e., either through peer-counselling and/or practising to gain skills in negotiation, etc.
• Materials used to raise awareness of rights do not necessarily raise awareness by themselves. They are effective when they act as tools to foster interactive learning and dialogue within a specific context.
• Rights awareness-raising efforts may need the flexibility to embed themselves strategically within existing broader approaches that may already be facilitating community demand for services.
• To link the promotion of awareness of rights to realizing change in terms of access to maternal and newborn health services, it is vital for initiatives to be grounded in concrete actions and operational plans, with adequate follow-up and monitoring and evaluation to ensure that they realize goals and are not solely aspirational. Monitoring and accountability mechanisms oriented to rights promotion should be available within the health systems to review and respond to changes as needed.
• Awareness of rights is not just about stakeholders being more informed, but is also about supporting a critical consciousness that builds individual and collective capacity to support actions that realize rights to more accessible and responsive care. Initiatives therefore need to support the capacity of both rights holders and rights bearers.
• Creating partnerships and negotiating strategic alliances are neither easy nor predictable processes: they require fostering a common language and clarifying the rules of engagement to counter power imbalances. Nonetheless, those efforts that pursue multi-level, stakeholder and sectoral pathways to underpin the promotion of rights awareness are likely to build synergies that sustain and transform awareness into critical consciousness and action that supports improved access to quality services and better health outcomes.
• Training and capacity-building of health care providers on human rights is essential to ensure promotion and protection of the human rights ofwomen to ensure women's access to quality of care. Health teams need to understand the meaning of the right to quality of care and the right to health. A situation analysis to understand the context in which providers work in is essential, as the lack of time, lack of structural inputs and large patient loads can inhibit provider motivation and ability to support promotion of rights awareness.
• It is important to motivate health care providers to integrate a rights perspective in their own practice as a means of promoting the right to health for the population but also to improve the work environment.

 

Research implications

The GDG identified that further research on the following high-priority questions is needed:

• Further consideration of the opportunity to explicitly integrate promoting awareness of rights and compliance with rights into current health promotion efforts is warranted. Unless one is not using the explicit language of rights due to strategic reasons, many projects that build individual and community capacity to improve demand for and access to quality maternal health services can lend themselves to also promoting awareness of rights and measure its effect as part of this package. The mapping of potential intervention combinations that need to be further explored and evaluated is recommended. Based on this mapping, prioritization of a research agenda and operational steps to fulfil it are required.
• Currently the evidence base for how this intervention supports improved health outcomes is limited to rural populations: primarily India and one study in Uganda. We need research evaluating experiences from other regions of the world, in different settings (e.g., urban) and with varied populations that may face particular forms of discrimination and oppression (migrants, nomadic groups, young people, institutionalized populations, people with disabilities, etc.) in order to better understand how to reach these populations.
• Qualitative research on values and preferences regarding interventions that promote awareness of rights, particularly on how these rights are understood, how they are adapted or not and applied to settings where rights may not be understood or rights may have different meanings is needed. Further examination of harms, benefits, unintended consequences and ethical issues that arise when promoting awareness of rights that contest existing power relations is required.
• Existing interventions that promote awareness of rights need to be better described. Projects must improve documentation of how they promoted awareness of rights, with whom and in what contexts. Numerous projects stated they were promoting awareness of rights but had very little description of how this was done. Guidance on supporting process evaluations and case studies for this type of interventions would be helpful. This would include the application of theories of change informed by on the ground experience and theoretical frameworks that help us to better understand the pathways, inputs and adaptations required for this kind of intervention.
• Funding and partnerships need to facilitate more and better quality evaluations of interventions that promote awareness of rights. Many examples of promoting awareness of rights for quality maternal health services exist but they are not always evaluated or, if evaluated, not in ways that support quality evidence generation. Standardizing measures used for the monitoring and evaluation of interventions that promote rights awareness, specifying the range of health and social outcomes that are of interest is critical so that evidence is comparable across studies. Improved capacity-building and support for the development of research methodologies more suited to these types of interventions that tracks change longitudinally, in participatory ways, that understands complexity and takes into consideration equity concerns is necessary.

 

 Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015) - full document and evidence tables

 

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

Newborn Health

 

Supporting systematic reviews:

George A, Branchini C, A. P. Interventions that promote awareness of human rights, sexual and reproductive rights and/or rights to access quality care as a means to increase demand for or use of health care to improve maternal and newborn health outcomes: A systematic review. (Unpublished)

 

References

1.         Working with individuals, families, and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. [26 November 2014] http://wwwwhoint/maternal_child_adolescent/documents/who_fch_rhr_0311/en/.

2.         The Ottawa Charter for Health Promotion [website]. Geneva: World Health Organization; 1986. [30 March 2014] http://wwwwhoint/healthpromotion/conferences/previous/ottawa/en/.

3.         Mirsky J. Birth rights: new approaches to safe motherhood: Panos Institute; 2001.

4.         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. New York: United Nations Human Rights Council; 2012. [26 November 2014] http://www2ohchrorg/english/issues/women/docs/AHRC2122_enpdf.

5.         WHO Handbook for Guideline Development - 2nd edition. Geneva: World Health Organization; 2014. World Health Organization. 2014.

6.         WHO recommendations on health promotion interventions for maternal and newborn health 2015: World Health Organization; 2015.

7.         George A, Branchini C, A. P. Interventions that promote awareness of human rights, sexual and reproductive rights and/or rights to access quality care as a means to increase demand for or use of health care to improve maternal and newborn health outcomes: A systematic review. (Unpublished).

8.         Björkman M, Svensson J. Power to the people: evidence from a randomized field experiment on community-based monitoring in Uganda. The Quarterly Journal of Economics. 2009;124(2):735-69.

9.         Sinha D. Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh: Population Council; 2008.

 

Citation: WHO recommendation on interventions to promote awareness of human, sexual and reproductive rights and the right to access quality skilled care (2015). WHO Reproductive Health Library; Geneva: World Health Organization.