A/HRC/45/19 impact on individual women’s human rights, such practices also contribute to the risk of maternal morbidities by creating an environment in which women will be less likely to seek out other types of sexual and reproductive health services, including antiretroviral treatment, and more likely to turn to untrained individuals for medical assistance. 45 4. Underlying determinants 61. The health of women and girls during pregnancy and childbirth is highly affected by social and economic factors, which are further influenced by gender discrimination. A woman’s living environment is directly related to her overall health, which is correlated to a likelihood to suffer a maternal morbidity in pregnancy or childbirth. 46 62. Typically, those living in wealthier households, having higher education or living in urban areas have lower levels of morbidity and higher use of adequate maternal health care than those living in poverty, with less education or living in rural areas. Worldwide, women’s low rates of literacy and education are linked to rates of maternal morbidity and mortality and to other indices of maternal health, including fertility rates, utilization of prenatal care, unmet need for contraception and age at first birth. 47 Furthermore, discriminatory practices, such as denying women and girls equal access to food, combined with the reality of food shortages at particular times of year, result in undernourishment or malnutrition, which can lead to a higher risk of poor pregnancy outcomes. 48 5. Social and economic consequences of maternal morbidity 63. Stigma, shame and isolation are often associated with specific forms of maternal morbidities, and can manifest as ostracization or changes in social status, with adverse effects on women’s psychological, economic and social well-being.49 For example, women who experience obstetric fistula suffer constant incontinence, which often leads to their isolation from their families and communities and results in mental health issues, such as depression and low self-esteem (A/73/285, para. 4). Similar impacts have been documented concerning women who suffer from uterine prolapse. 50 Furthermore, fear of not being understood or being perceived to be “defective” can prevent women with postpartum depression from seeking care. Infertility as a result of complications during pregnancy and childbirth is highly stigmatized maternal morbidity, leading to discrimination, ostracism and even violence. Stigmatization can be extreme in some countries, where infertile women are viewed as a burden on the socioeconomic well-being of a community. This amplifies the guilt and shame felt by the woman.51 A common thread across various forms of maternal morbidities is that women are blamed for bringing on the conditions on themselves, leading to further stigmatization. 64. Various factors can affect the willingness and ability of women to seek health care, leading to conditions worsening without treatment.52 For instance, surgical repair can treat most cases of obstetric fistula; however, poverty, social stigmatization, misconceptions about the condition and a lack of surgical capacity make treatment unattainable for most women with fistula.53 45 46 47 48 49 50 51 52 53 14 Robert Yates, Tom Brookes and Eloise Whitaker, “Hospital detentions for non-payment of fees: a denial of rights and dignity” (Chatham House, 2017), p. 5. UNDP, “A social determinants approach to maternal health”, (2011). UNFPA, “Rich mother, poor mother: the social determinants of maternal death and disability” (2012). Isabelle Lange and others, “What maternal morbidities are and what they mean for women: a thematic analysis of twenty years of qualitative research in low and lower-middle income countries”, PLOS ONE (2019), p. 10; Amnesty International, Unnecessary Burden, p. 44. Lange and others, “What maternal morbidities are”, p. 14. See, for example, Amnesty International, Unnecessary Burden. WHO, “Mother or nothing: the agony of infertility”, Bulletin of the World Health Organization, vol. 88, No. 12 (2010). Lange and others, “What maternal morbidities are”, p. 15. See, for example, William Murk, “Experiences with obstetric fistula in rural Uganda”, Yale Journal of Biology and Medicine, vol. 82, No. 2 (June 2009).