29 August 2021
WHO recommendation on interventions to promote awareness of human, sexual and reproductive rights and the right to access quality skilled care
Because of the paucity of evidence available, additional research is recommended.
First published: May 2015
Updated: No update planned
Assessed as up-to-date: May 2015
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.
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.
For this recommendation, we aimed to answer the following question:
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:
The GDG identified that further research on the following high-priority questions is needed:
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)
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.