The article Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5, released in The Lancet last week, records a global reduction in maternal mortality rates. A reduction is certainly welcomed. At the same time, whatever the exact reduction – be it indicated by these figures or from the soon to be released U.N. figures – the reduction is not enough. The remaining deaths are largely avoidable, and progress in reducing maternal mortality has been slow.We know that discrimination (including discrimination against HIV+ women), lack of education, poor nutrition and lack of access to reproductive health services, family planning, ante-natal care, skilled birth attendants, effective referral systems and emergency obstetric care lead to maternal death. These are human rights issues.A human rights approach – a right to health approach to maternal mortality – would provide a dynamic model that can be applied in diverse contexts, as outlined by Paul Hunt, UN Special Rapporteur on the Right to the Highest Attainable Standard of Health (2002-2008), in?Supplementary Note on the UN Special Rapporteur's Report on Maternal Mortality in India (doc).?This model is concerned with factors/issues such as:

• The well being of women and newborns being at the centre of all maternal health services and facilities;
• A sufficient number of skilled birth attendants, providers of back-up emergency care, and technical senior managers in maternal health;
• Equality and non-discrimination: maternal health services and facilities that are accessible (in law and fact) to all, including women living in poverty, indigenous and minority women, those with disabilities, and adolescents;
• Transparency, with privacy: public access to all relevant health information (but not at the expense of confidentiality), such as the amount of public funds devoted to maternal health;
• Information: for example, so that women know the importance of skilled care at birth, and have the freedom and means to access that care;
• Accountability (such as through maternal health audits), with the cause of each maternal death being determined and corrective action taken to prevent avoidable deaths in the future;
• Maternal health facilities that are culturally appropriate and provide sexual and reproductive health services and education, family planning, ante-natal care, skilled birth attendance, and referral to/availability of emergency obstetric care;
• Women’s participation in policymaking, implementation and accountability;
• A maternal health strategy (integrated into the comprehensive national health plan) that is based on an up-to-date maternal health situational analysis informed by suitably disaggregated data, and promotes the integration of services, for example HIV/AIDS, ante-natal care, and PMTCT.

(See also the PHR report?Deadly Delays Maternal Mortality in Peru. A Rights-Based Approach to Safe Motherhood and accompanying video.)The Lancet paper confirms what we all know about important indirect causes of maternal death (pre-existing conditions aggravated by pregnancy and childbirth) – if you are pregnant and HIV positive, in the absence of ARVs, you are more likely to die.In the U.S., the Obama Administration’s Global Health Initiative seeks to improve coordination and integration of programs and increase women’s access to care. This is laudable. However, within the Initiative it is essential that funding for ARVs not be scaled back or flatlined, but rather continue to receive significant annual increases. In the presence of discrimination against women in many countries, including PEPFAR countries, the risk that pregnant HIV positive women will not receive the necessary ARVs is too great. The Administration must not curtail its commitment to PEPFAR in the process of implementing the Initiative as access to ARVs will help save these women’s lives.