CEDAW/C/49/D/17/2008 3.7 The author maintains that the lack of access to quality medical care during delivery is emblematic of systemic problems in the way human resources are managed in the Brazilian health system more generally. The provision of skilled care during pregnancy is critically dependent on a functioning health system , 4 and this requires an adequate number of skilled attendants deployed where they are needed; satisfactory pay scales and career advancement opportunities; supportive supervision mechanisms; functioning mechanisms for quality improvement; and a working transport and referral system to ensure timely access to hi gh-level care, especially in an emergency. Studies by United Nations agencies reveal that Brazil ’s national health system has considerable weaknesses in each of these areas. Problems relating to low staff qualifications, an excess of poorly qualified staff and a shortage of well-qualified staff are said to be greater at the municipal level, for example, in health centres such as the Casa de Saúde Nossa Senhora da Glória de Belford Roxo, than at the state or federal level. 3.8 The author maintains that Brazil has failed to ensure timely access to emergency obstetric care in violation of articles 2 and 12 of the Convention. At least three indicators relating to accessibility and the quality of emergency obstetric care are particularly relevant, given the specific failures in this case and the more systemic failures of the State party in eliminating preventable maternal deaths. The indicators to which the author refers are included in the guidelines for monitoring the availability and use of obstetric services (October 1997) of the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the United Nations Population Fund (UNFPA), as follows: (a) Equitable geographic distribution of emergency obstetric care facilities (four basic emergency obstetric care facilities and one comprehensive emergency obstetric care facility for every 500,000 persons in the population); (b) Women’s need for emergency obstetric care met (at a minimum, most women who need emergency obstetric care should be receiving services); (c) The proportion of women with obstetric complications who are admitted to a facility with emergency obstetric care services a nd die should be no more than 1 per cent. The author argues that a negative result in any of the three cate gories suggests that a State is not complying with its obligation to provide maternity care. 3.9 The author claims that the facts of the present case and data from studies on maternal mortality in Brazil demonstrate non-compliance with the obligation to provide maternity care. Evidence shows that emergency obstetric care facilities are inequitably distributed geographically (indicator 1), that women have higher than acceptable levels of unmet need (indicator 2) and that obstetric deaths in facilities occur at higher than acceptable rates (indicator 3), thereby demonstrating the failure of the State party to ensure accessibility and quality of emergency obstetric care as per its obligations on the right to health under article 12 of the Convention. 3.10 Owing in part to the uneven distribution of higher-level health facilities, Ms. da Silva Pimentel Teixeira faced serious challenges in gaining access to a __________________ 4 6 See “Making pregnancy safer: the critical role of the skilled attendant”, a joint statement by the World Health Organization (WHO), the International Confederation of Midwives and the International Federation of Gynaecology and Obstetrics (2004). 11-51699