A/HRC/21/22 B. Example of identified problem: adolescent girls are suffering from disproportionately high rates of maternal morbidity and death 59. The first step is to analyse not only why adolescent girls suffer from high rates of maternal morbidity and death, but also why they are becoming pregnant. A human rights-based approach defines the problem and addresses it in terms of both the immediate and underlying causes of maternal mortality and morbidity, given that they determine the possibilities for resolving concrete problems at the local level. Amidst many other factors, adolescent pregnancy might be due to a lack of comprehensive sexuality education; gender norms that reinforce early pregnancy; early marriage; high levels of sexual violence and/or transactional sex; a lack of youth-friendly health services; lack of affordable and accessible contraception; or a combination of the above. Disproportionately high rates of morbidity and death may be attributable to, inter alia, late arrival at health facilities or failure to seek care for any of the reasons noted in the example above. Among adolescents, there might also be a disproportionately high rate of selfinduced abortion and fear of criminal sanctions; a marked lack of awareness relating to obstetric alarm signals; perceived and actual insensitivity to youth in facilities; or a combination of the above. 60. The second step is to identify responsibility for each factor, which may transcend the health sector. For example, if gender norms reinforce early pregnancy, there may be lack of awareness of girls’ rights to education and equality among family members and of the health risks of pregnancy for young adolescents; lack of positive leadership by community elders, local teachers and political leaders regarding gender roles; lack of education regarding women’s rights and gender equality in national school curricula, coupled with forced pregnancy testing in schools or other policies that reinforce gender norms; national legislation that directly discriminates against women and girls or has a disproportionate adverse impact on them; economic pressures that contribute to early marriage and pregnancy; or a combination of the above. 61. The third step is to suggest and prioritize actions by different duty-bearers required for each factor causing the problem. For example, national legislation that directly discriminates against women and girls or has a disproportionate adverse impact on them, including in relation to age of marriage, education, land title and inheritance, or employment, in addition to health, should be modified. Legislation, policies and regulations directly affecting the health sector, including overly restrictive criminalization of services used by women, third-party authorization or unregulated conscientious objection, should be modified, and newly established obligations of providers and rights of individual users should be disseminated. Among other things, the national Government should undertake media and other awareness-raising campaigns targeted at adolescents, adults and disadvantaged groups, as well as at key stakeholders, such as community leaders and school teachers, to disseminate messages promoting gender equality and changes in legislation that may require funding from external donors in addition to cooperation with civil society. 62. The more specific the identification of the problem and the reasons for it, the more likely it is that duty-bearers may be held effectively responsible; this can only be done effectively at the local level. 63. The deliberation process itself is critical to understanding the complexities of addressing maternal mortality and morbidity and the responsibilities of duty-bearers, as well as to developing effective and sustainable solutions that are legitimate to the public. Local diagnoses will be conducted by an array of actors in contextually contingent ways, and not all of them will involve all stakeholders. Nevertheless, the meaningful participation of affected communities is essential, in particular of women from 13