Alyne, a poor, 28-year-old Afro-Brazilian woman, visited a private health clinic in the state of Rio de Janeiro. Despite presenting symptoms of a high-risk pregnancy, her doctor sent her back home. During the course of the following two days, her symptoms worsened, and she returned to the clinic. By that time, doctors were unable to detect a fetal heartbeat, and her delivery was induced six hours later, producing a stillborn fetus. The surgery to extract her placenta occurred fourteen hours later, though it should have occurred immediately after the delivery was induced. As Alyne’s health was steadily deteriorating, it was necessary to transfer her to a higher tier public health care institution; however, she had to wait more than eight hours to be transferred, as the institution refused to send its only ambulance to transport her. Upon arriving at the other facility, she was forced to wait over twenty hours in a makeshift waiting area without receiving any medical attention, where she eventually died. After four years had passed without a decision from the Brazilian judiciary in domestic claims, the Center for Reproductive Rights and Advocacia Cidada pelos Direitos Humanos submitted an international claim before the CEDAW Committee.
The Committee determined that Brazil had violated Articles 2(c) (right to access justice), 2(e) (due diligence obligation to regulate activities of private actors) and 12 (right to health) of CEDAW, read in conjunction with Article 1 (discrimination). The Committee found that Brazil had failed to ensure that Alyne received appropriate services in connection with her pregnancy, in violation of Article 12(2).
The CEDAW Committee applied the due diligence obligation in Article 2(e) of CEDAW to reject the state’s argument that is was not responsible for the actions of a private health care provider. In doing so, the CEDAW Committee made clear that the “State is directly responsible for the action of private institutions when it outsources it medical services, and that furthermore, the State always maintains the duty to regulate and monitor private health-care institutions,” explaining that the state has a due diligence obligation to ensure that private parties rendering health services develop appropriate activities in accordance with article 2 of CEDAW.
In recognized that Alyne had not been ensured appropriate services in connection with her pregnancy, the CEDAW Committee recounted the series of delays in administering health care; the delays in transferring Alyne to a better-equipped health facility, including the hospital’s refusal to end its only ambulance to transport her; that when Alyne was eventually transferred, it was without her medical records; and that Alyne was left unattended in a makeshift area in the hallway, where she died. The CEDAW Committee affirmed states’ obligation to ensure that policies “must be action- and result-oriented as well as adequately funded,” and “must ensure that there are strong and focused bodies within the executive branch to implement such policies.” The CEDAW Committee found that the lack of appropriate maternal health services failed to meet the specific, distinctive health needs and interests of women, amounting to violations of article 12(2) and constituting discrimination against women under Article 12(1) and Article 2 of the Convention.
The CEDAW Committee further recognized that Alyne was discriminated against on multiple grounds, including on the basis of her sex, her status as a woman of African descent, and her socioeconomic background. The Committee reiterated its recognition of de facto forms of discrimination against women in Brazil, and that “discrimination against women based on sex and gender is inextricable linked to other factors,” such as race, ethnicity, age, health and class, among others. In this regard, the CEDAW Committee affirmed states’ obligation to ensure the provision of timely, quality maternal health care to all women, regardless of race or income, and that it is insufficient for states to take measures to improve maternal health which neglect marginalized sectors of the population.
Finally, noting the prolonged delay of Alyne’s legal case that was brought by her mother after her death in a domestic court, the Committee found a violation of Article 2(c) for the state’s failure to comply with its obligation to ensure effective judicial action and protection.
The Committee called on the state to:
- provide Alyne’s family reparations, including financial compensation;
- ensure women’s right to safe motherhood and affordable access to emergency obstetric care;
- provide adequate professional training for health workers on women’s reproductive rights,
- ensure that private health care facilities comply with relevant national and international standards on reproductive health care;
- ensure access to effective remedies in case where women’s reproductive health rights have been violated; and
- effectively implement the national program on maternal mortality at federal and municipal levels by establishing maternal mortality committees.
Alyne v. Brazil is the first maternal death case to be decided by a United Nations treaty monitoring body. The decision by the Committee established that governments have a human rights obligation to guarantee that all women in their countries—regardless of income or racial background—have access to timely, non-discriminatory, and appropriate maternal health services. This case further affirmed the principle of vicarious liability for private actors, finding that when governments outsource health services to private institutions, they remain directly responsible for their actions and have a duty to regulate and monitor such institutions.