A/HRC/18/27 increase in the use of antenatal care, and a 62 per cent increase in institutional childbirths was reported. 70. In 2007, the Mexico City Federal District reformed its Penal Code to permit legal abortion in the first trimester of pregnancy. Whereas adolescent and adult women previously sought expensive clandestine abortions in the District, today public hospitals and clinics provide women residing in the district with free and safe legal abortion care; women from other parts of the country can also receive services according to a sliding payment scale.60 71. In the 2009 case of Xákmok Kásek Indigenous Community v Paraguay, the InterAmerican Court of Human Rights found human rights violations where the absence of special measures to protect pregnant women contributed to the pregnancy-related deaths of indigenous women. The Court rebuked Paraguay for it failure to implement policies to train skilled birth attendants, provide pregnancy-related care and document cases of maternal mortality. It ordered the State to establish immediate measures to provide health care for pregnant women and directed it to conduct a study with community involvement, identifying means for adapting maternal care to community needs. The Court mandated broad stakeholder participation in developing policies to combat maternal death. 72. In Peru, the Vertical Childbirth Care/Delivery project supported by UNICEF aims to increase access to institutionalized services for indigenous pregnant women. An integrated strategy was developed to address the financial, geographical and cultural barriers that historically limited the access of rural and indigenous communities to health care.61 Financial barriers were addressed by creating a health insurance strategy and providing subsidies for individuals under the age of 18, pregnant women and targeted groups of adults. To address geographical distances, maternal waiting homes were established and services were adapted to users’ cultural preferences regarding childbirth. 73. Similar initiatives could give effect more fully to a human rights-based approach by targeting women and girls most at risk, involving indigenous local leaders, traditional care providers and community women’s organizations in identifying the required interventions to increase utilization of health services, as well as ensuring culturally appropriate care for indigenous communities and seeking an alternative and more acceptable model. 74. The Ombudsman of Peru also has a dedicated women’s rights unit to investigate and document complaints against health-care centres and hospitals for irregularities; for example, it has investigated violations of the right to contraceptive services free from coercion.62 V. Conclusions 75. The present report has identified key interventions known to reduce maternal mortality and morbidity. The examples demonstrate that interventions are more effective when stakeholders apply principles of a human rights-based approach to address the needs of the most poor and marginalized in their societies. They also demonstrate the need to incorporate fully, through consistent and systematic actions, an even more holistic and comprehensive human rights-based approach, covering all seven principles, into integrated strategies to combat maternal mortality and morbidity. Strong community-based efforts hold Governments and other actors 60 IPAS USA submission. UNICEF submission. 62 Center for Reproductive Rights submission. 61 18