R. Rima Jolivet, Charlotte E Warren, Pooja Sripad, Elena Ateva, Jewel Gausman, Kate Mitchell, Hagar Palgi Hacker, Emma Sacks, and Ana Langer
The COVID-19 pandemic has strained health systems and exacerbated system deficiencies and subpopulation vulnerabilities, thus “exposing the damaging impact of inequities, in every society.”1 It has also dramatically altered maternal newborn health (MNH) care delivery; some of the efforts to curb the virus violate the rights of women, their newborns, and families.
In times of crisis, it is a common state practice to restrict some rights, on the grounds they are secondary to security, safety, or emergency resource management.2 However, maintaining the right to essential MNH services, ensuring quality, continuity, and respectful care, is critical to prevent death and disability. Early models estimate significant increases in mortality due to reduced MNH service availability resulting from COVID-19.3
Human rights are indivisible and universal. Rights frameworks provide a firm legal and ethical foundation to guide policy and practice in a pandemic. Solutions that uphold fundamental human rights and best clinical practices, including infection control, contribute to stronger health and human rights outcomes overall. The Respectful Maternity Care (RMC) Charter, published in 2011 and updated in 2019, articulates 10 fundamental rights of childbearing women and newborns based on widely accepted human rights instruments, and provides a framework for high-quality care that supports and upholds the dignity of all parties.4
Members of the RMC Global Council (a network comprising more than 150 organizations and 350 members from 45 countries), have reported numerous violations of the right to RMC during COVID-19, including:
- Exacerbated deficiencies in overwhelmed health systems: lack of personal protective equipment (PPE); personnel diverted from maternity to COVID-19 units; maternity units converted into COVID-19 centers, limiting availability of MNH services5
- Neglect, abandonment, restricted access to care: unavailability of emergency transport, antenatal and postnatal contacts; neglect in facilities due to fear of infection; unavailability of out-of-hospital options for skilled care leading to unattended births 6
- Alteration of proven practices without evidence: mandatory separation of mother and newborn; restriction of breastfeeding; prohibition of a companion during labor and childbirth
- Acts curtailing women’s decision-making autonomy: classification of abortion as non-essential; unavailability of contraceptive services and commodities
- Potentially harmful medical intervention without indication: increased cesarean sections, instrumental deliveries, induction and augmentation of labor, without medical indication
- Exacerbation of care inequities: unequal access to telemedicine or mHealth alternatives.
Healthcare managers, workers, women, and families lack critical information about COVID-19 and need access to evidence-informed standards. Guidance from WHO on quality MNH care has not been widely applied in this crisis.7 Instead, uncertainty about how COVID-19 impacts women and newborns is affecting clinical and interpersonal quality of care. In the absence of clear, consistent, coordinated guidance, measures are implemented based on fear instead of evidence and rights.
Maintaining high-quality, essential MNH service delivery during COVID-19 upholds the rights of women and newborns. The RMC Charter is based on widely accepted human rights instruments and aligns directly with the WHO definition of quality. As members of the RMC Global Council, we suggest how these Universal Rights of Women and Newborns may be applied during COVID-19:
- The right to freedom from harm and ill-treatment: Avoid interventions without clear indication; increase safe options for out-of-hospital birth, e.g. convert hotels into birth centers (ensuring emergency transport), facilitate accreditation of birth centers and access to trained midwives.8
- The right to information, informed consent, respect for choices and preferences including a companion of choice during maternity care, and refusal of medical procedures: Use digital health services, social and other media to share health information, including available care options and birth settings; allow a companion of choice during labor and birth.9
- The right to privacy and confidentiality: Protect personal information; ensure facility infrastructure allows privacy and is well equipped and maintained.
- The right to be treated with dignity and respect for one’s personhood from the moment of birth and the right to an identity and nationality from birth: Ensure that any isolation of women and newborns due to COVID-19 is respectful and dignified; adopt virtual birth registration.10
- The right to equality, freedom from discrimination and equitable care: Practice universal precautions and treat every woman and newborn, regardless of COVID-19 status, without stigma or discrimination; provide universal health coverage, regardless of insurance or immigration status.11
- The right to healthcare and to the highest attainable level of health: Maintain essential MNH services, including abortion, contraceptive care and commodities; increase telehealth, community healthcare, and access to out-of-hospital birth.12
- The right to liberty, autonomy, self-determination and freedom from arbitrary detention: Ensure any restrictions, including quarantine for women and newborns with COVID-19, are strictly necessary, the least intrusive and restrictive available, and based on evidence.13
- The right of children to be with parents or guardians: Keep mothers and newborns together regardless of COVID-19 status if neither requires intensive care; apply guidance for home care of affected family members, i.e., use of PPE, handwashing.
- The right to adequate nutrition, clean water and sanitation: Promote breastfeeding for optimal nutrition and passive immunity. Ensure water, sanitation, and hygiene (WASH) and PPE access for infection prevention and control.
Innovation and flexibility to deliver essential MNH services safely should be encouraged, if grounded in evidence, quality, and progressive realization of fundamental human rights in health.14 Contextualizing best practices to circumstances and protecting vulnerable groups is necessary. Understanding local supply- and demand-side factors is essential in deciding which policies and practices make sense operationally. If rights must be limited in extreme circumstances, limitations must adhere to human rights law, requiring they be strictly necessary, proportionate, reasonable, and the least restrictive available.15 While undermining rights exacerbates inequities and further disempowers disadvantaged groups, upholding them through best practices that protect women, newborns, and health workers alike promotes a more just health system for all.
Every crisis presents opportunities. The COVID-19 crisis has highlighted deficiencies within and beyond health systems, but provides opportunity for critical examination to strengthen and improve the quality and equitability of MNH care. Mechanisms to protect, uphold, and fulfill the rights of women and newborns while reducing the spread of infection demand collective efforts from all actors to meet their obligations as duty bearers and rights holders. Crises call on us to elevate our highest principles, never to undermine or abandon them. Jawarlal Nehru stated, “Failure comes only when we forget our ideals, objectives, and principles,” to which we add, “our evidence base”. If we abandon these foundations out of fear, the failure we risk is the lives of women and newborns.
R. Rima Jolivet directs the Improving Maternal Health Measurement Project at the Women and Health Initiative of the Harvard Chan School, and specializes in health system strengthening, quality improvement, and respectful maternity care. Email: firstname.lastname@example.org
Charlotte E Warren is a senior social scientist at Population Council, focusing on respectful maternal and newborn health care.
Pooja Sripad is social and health systems researcher in the Reproductive Health Program at the Population Council.
Elena Ateva is Advocacy Manager at White Ribbon Alliance and Maternal Health lead for the USAID/Health Policy Plus Project, and is an attorney and human rights advocate.
Jewel Gausman is a Senior Research Associate at the Women and Health Initiative at the Harvard Chan School, specializing in social epidemiology and sexual and reproductive health
Kate Mitchell is a doctoral candidate at Boston University School of Public Health and a public health consultant specializing in improving quality of maternal and newborn health care.
Hagar Palgi Hacker is a public health lawyer, and an MPH student at the Milken Institute School of Public Health at the George Washington University.
Emma Sacks is Associate Faculty in the Department of International Health at the Johns Hopkins School of Public Health and a Consultant with the World Health Organization.
Ana Langer leads the Women and Health Initiative at the Harvard Chan School and is a global reproductive health expert.
- United Nations Human Rights Office of the High Commissioner. COVID is “a colossal test of leadership” requiring coordinated action, High Commissioner tells Human Rights Council: Statement by Michelle Bachelet, UN High Commissioner for Human Rights 2020 [Available from: https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=25785&LangID=E accessed 4/21/2020.
- Chi PC, Urdal H, Umeora OU, et al. Improving maternal, newborn and women’s reproductive health in crisis settings. Cochrane Database of Systematic Reviews 2015(8).
- Riley T, Sully E, Ahmed Z, et al. Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health In Low-and Middle-Income Countries. International Perspectives on Sexual and Reproductive Health 2020;46:73-76.
- White Ribbon Alliance. Respectful Maternity Care Charter: Universal Rights of Mothers and Newborns 2020 [Available from: https://www.whiteribbonalliance.org/respectful-maternity-care-charter/ accessed 4/21/2020.
- Rocca-Ihenacho L, Alonso C. Where do women birth during a pandemic? Changing perspectives on Safe Motherhood during the COVID-19 pandemic. J Glob Health Sci 2020;2.
- European Roma Rights Centre. 9 Month Pregnant Romani Woman Dies After Waiting Six Hours for Covid-19 Test Results to get Emergency Care 2020 [Available from: http://www.errc.org/news/9-month-pregnant-romani-woman-dies-after-waiting-six-hours-for-covid-19-test-results-to-get-emergency-care accessed 4/21/2020.
- World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience Geneva2018 [Available from: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=6455FCF783CB268CE5D73E38927EABA1?sequence=1 accessed 4/24/2020; World Health Organization. Standards for improving quality of maternal and newborn care in health facilities 2016 [Available from: https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-eng.pdf?sequence=1 accessed 4/24/2020.
- Summers H. NHS urged to turn hotels into birth centres during crisis: The Guardian; 2020 [Available from: https://www.theguardian.com/society/2020/apr/01/nhs-urged-to-turn-hotels-into-birth-centres-during-coronavirus-crisis accessed 4/23/2020; New York State Governor Andrew Cuomo. Executive Order Continuing Temporary Suspension and Modification of Laws Relating to Disaster Emergency 2020 [Available from: https://www.governor.ny.gov/news/no-20211-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency accessed 4/23/2020; Harding R. NY launches COVID-19 maternity task force, eyes more birth centers: Auburnpub.com; 2020 [Available from: https://auburnpub.com/news/local/govt-and-politics/ny-launches-covid-19-maternity-task-force-eyes-more-birth-centers/article_953ba624-70b1-5e6f-850d-006404cb456b.html accessed 4/23/2020; Webster P. Virtual health care in the era of COVID-19. The Lancet 2020;395(10231):1180-81.
- Syckle KV, Caron C. Women Will Not Be Forced to Be Alone When They Are Giving Birth: The New York Times; 2020 [Available from: https://www.nytimes.com/2020/03/28/parenting/nyc-coronavirus-hospitals-visitors-labor.html accessed 4/23/2020.
- Know your rights: Registering a birth during COVID-19 2020 [Available from: https://whatsnew.citizensinformation.ie/2020/04/23/know-your-rights-registering-a-birth-during-covid-19/ accessed 4/24/2020.
- Agenda for zero discrimination in health-care settings 2017 [Available from: https://www.unaids.org/en/resources/documents/2017/2017-agenda-zero-discrimination-health-care accessed 4/23/2020.
- Rocca-Ihenacho L, and Alonso C (See note 5).
- Boggio A, Zignol M, Jaramillo E, et al. Limitations on human rights: are they justifiable to reduce the burden of TB in the era of MDR-and XDR-TB? Health Hum Rights 2008:121-26.
- Council of Europe. The impact of the COVID-19 pandemic on human rights and the rule of law 2020 [Available from: https://www.coe.int/en/web/human-rights-rule-of-law/covid19?fbclid=IwAR0k4b5jQ9UoB_3hs_iViKaV_pnrLh1a5opYaWyn6nmNjtxP-sRDac_GCr4 accessed 4/21/2020.
- UN Economic and Social Council. Siracusa Principles on the Limitation and Derogation of Provisions in the ICCPR, UN Doc. No. E/CN. 1984.