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A woman in Sierra Leone has a one-in-seven chance of dying in childbirth, while the odds for a woman in Sweden are one in 30,000. To Lynn P. Freedman, who directs the Averting Maternal Death and Disability Program at Columbia's Mailman School of Public Health, "that kind of very stark inequality makes this a global human rights issue."

And one that the Mailman school is doing much to address. The school has long been a leader in maternal mortality issues, building on the pioneering work of Mailman's former dean, the late Allan Rosenfield, and Professor Deborah Maine. For more than 20 years, Mailman researchers have studied ways to reduce the number of deaths in childbirth for women in developing countries. But since receiving a $50 million grant from the Gates Foundation in 1999, the school has saved tens of thousands of lives through innovative, rights-based approaches to this age-old problem.

"Our program focused on ensuring access to lifesaving care for women in high mortality countries," Freedman said. "Given the disastrous state of health systems and the social and economic dynamics surrounding them, we faced not just a technical problem, but a profoundly political problem as well. With human rights, we had a principled basis to address these challenges both in theory and in our practice."

There have been various approaches to cutting the number of deaths in childbirth over the years. Through its own studies, Mailman researchers determined that the old ways—which called for training traditional birth attendants and providing prenatal care—simply didn't work, because they relied on the assumption that pregnancy complications can be foreseen and averted.

"But the epidemiological evidence showed that most of the complications that kill women can't be predicted or prevented, but they can be treated," she said. "That's why so few women die in countries with access to health care. So the fundamental principle of our project became that every pregnant woman needs access to the care that can save her life in the case of emergency—indeed, she is entitled to it as a matter of human rights."

Seventy-five percent of maternal deaths are the result of five causes: hemorrhage; infection or sepsis; hypertensive diseases such as pre-eclampsia; obstructed or prolonged labor; and complications from unsafe abortion. The first four are hard to prevent, but they can be treated with swift access to health care. "Death is so avoidable, yet so common," said Freedman. "It is really a profound injustice that women die at this rate from something they don't have to die from, because the system has failed them."

Working in partnership with United Nations agencies and nongovernmental organizations, AMDD has supported maternal mortality reduction projects in more than 50 countries. A core team from Columbia works with experienced advisers at other health and human rights organizations and ministries of health to make improvements at existing health facilities, enabling more women to use them and increasing the number of facilities overall.

Between 1999 and 2002, the government of Bangladesh increased the number of emergency obstetric clinics to 70 from 45 with help from UNICEF and AMDD. In Bhutan, the government used support from AMDD to increase the number of life-saving procedures that existing facilities could perform. And in Mozambique and a few other countries, AMDD supported the use of non-physician surgical technicians to perform lifesaving surgeries that elsewhere were restricted to specialist physicians.

The $50 million Gates grant ended in 2006, and the AMDD program has since received additional Gates financing, money from the governments of Ireland and Denmark, as well as funding from other sources and various U.N. agencies.

"We were able to be part of the very beginnings of what's come to be called the health and human rights movement," said Freedman, who is also a professor of population and family health. "We've been able to be part of the thinking and practice... It's not just an academic area."

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