AN equal START

an equal start why gender equality matters for child survival and maternal health

an equal start why gender equality matters for child survival and maternal health

Save the Children works in more than 120 countries. We save children’s lives. We fight for their rights. We help them fulfil their potential.

Published by Save the Children UK 1 St John’s Lane London EC1M 4AR UK +44 (0)20 7012 6400 savethechildren.org.uk First published 2011 © The Save the Children Fund 2011 The Save the Children Fund is a charity registered in England and Wales (213890) and Scotland (SC039570). Registered Company No. 178159 This publication is copyright, but may be reproduced by any method without fee or prior permission for teaching purposes, but not for resale. For copying in any other circumstances, prior written permission must be obtained from the publisher, and a fee may be payable. Cover photo: A girl who lives with her family next to a railway line in Delhi while they look for work (Photo: Raghu Rai/Magnum for Save the Children) Typeset by Grasshopper Design Company Printed by Page Bros Ltd

contents

The story in numbers iv Acknowledgements vi Foreword vii Abbreviations viii Executive summary ix Introduction xi

1. The impact of gender discrimination on child survival 1 The interdependence of maternal and child health Discrimination and the causes of child mortality

1 3

2. The human, economic and development costs of gender discrimination 8 The human cost – more mothers and babies dying The economic cost – losses in productivity The development cost – failure to achieve the MDGs

8 8 9

3. Four snapshots of gender discrimination and its impact 11 Foeticide and infanticide Early pregnancy Lack of household decision-making power Discriminatory health services

11 12 16 17

4. Interventions – a multi-sector approach 22 Changing norms Increasing opportunities for girls and women Delivering equitable health services

22 25 27

Conclusion and recommendations 29 Appendix Endnotes

32 35

the story in numbers $88 billion

1 million

In 2010 the UN Secretary-General’s Global Strategy estimated that an additional US$88 billion is needed between now and 2015 if we are to have any hope of meeting MDGs 4 and 5.1

1 million infants born to adolescent girls die before their first birthday.6 Infants born to mothers under the age of 20 have a 73% higher mortality rate than infants born to older mothers.

$15 billion

358,000

Maternal and newborn deaths lead to global productivity losses of US$15 billion each year.

106 million Recent estimates suggest that the number of women ‘missing’ as a result of foeticide and infanticide is about 106 million.2

Every year, 358,000 women die during pregnancy or when they are giving birth.

7,999 In a study of hospital abortions in Mumbai, India, 7,999 of 8,000 aborted foetuses were female.7

51 million

830

Worldwide, more than 51 million adolescent girls aged 15–19 are married.3 In south Asia 48% of women 15–24 were married before the age of 18. In Africa the figure is 42% and in Latin America and the Caribbean 29%.4

In India there are an average of 914 girls aged 0–6 for every 1,000 boys. In the state of Haryana it is 830.

16 million

143 girls vs. 100 boys

16 million girls aged between 15 and 19 give birth every year – 11% of global births. Of these, 70,000 die during pregnancy and childbirth.5

In south Asia, for every 100 male childhood deaths, 137 female children died in 1990. By 2008 the figure was 143.

iv

90%

1 in 3

90% of all women in the fistula hospital in Addis Ababa, Ethiopia, are survivors of child marriage or female genital mutilation (FMG).

In only one in three countries do half or more women participate in all household decisions, including those taken in regard to their own healthcare.12 In Burkina Faso 75% of husbands make decisions about their wives’ healthcare. In Nigeria it is 73% and Nepal 51%.13

75% In Afghanistan 75% of infants who survive their mother’s death die within their first year.8

30% Women’s groups in Nepal have reduced child mortality by 30% and maternal mortality significantly.9

25% A quarter of women in 41 countries gave not having a female health provider as a reason why they did not go to a health facility to give birth.

1 in 7 Demographic and Health Survey data in six developing countries suggest that one in seven girls marry before the age of 15 and nearly 50% are expected to marry by their 20th birthday. At this pace, 100 million girls will be married in the next ten years.14

8 Every eight minutes a woman dies due to abortion-related complications. That adds up to 70,000 deaths a year, and 18.4% of maternal mortality.

25% According to the World Health Organization one in five women experienced sexual abuse during childhood.10 Over 30% of women in Bangladesh, Namibia, Peru, Samoa and Tanzania said their first sexual experience was forced.11

1 For every one-year increase in the education of women of reproductive age, child mortality decreases by 9.5%.15

v

acknowledgements

This report was written by Jessica Espey (Research and Policy Adviser) and Nadja Dolata (Gender and Diversity Adviser) of Save the Children UK. A number of colleagues and partners contributed to the report. Particular thanks are due to Milo Vandermootele of the Overseas Development Institute (ODI) for much of the quantitative analysis; to Zubair Faisal Abbasi, Seona Dillon McLoughlin, Adele Fox and Zoe Davidson for their assistance with the literature review; to Sita Michael Bormann and Juliet Bedford (Anthrologica) for collating some of the case studies; and to Kitty Arie for her project management and helpful guidance throughout. Thanks to Nicola Jones (ODI) and Dan Seymour (UNICEF) for peer reviewing the report and

vi

to Save the Children colleagues Anne Tinker, Brad Kerner, Sita Michael Bormann, Alice Fay, Adele Fox, Jennifer Grant, Sarah Williams, Daphne Jayasinghe and Joanne Grace for providing helpful comments throughout. For facilitating the initial roundtable for the report, thanks to Alfhild Petren and colleagues at Save the Children Sweden. Thanks too to Save the Children staff in Ethiopia (particularly Genet Kebede, Meena Gandhi and Katy Webley) for facilitating the authors’ country visit and setting up interviews. And thanks to the staff at the Population Council Ethiopia and the African Network for Prevention and Protection against Child Abuse and Neglect (ANPPCAN) Ethiopia for their assistance during the visit.

foreword

While it is well known that gender discrimination is both pervasive and deeply entrenched, how it actually compromises our chances of meeting the Millennium Development Goals is much less understood. Is gender discrimination slowing progress towards achieving these goals? In particular, how is it affecting our pursuit of MDG 4 (on reducing child mortality) and MDG 5 (on reducing maternal mortality)? This report, An Equal Start, presents evidence on the impact of gender discrimination on child mortality and maternal health. It adds an important dimension to the global debate on how to reduce child and maternal mortality. Unless the unequal status of women is tackled, further efforts to reduce maternal and child mortality are likely to be undermined. Failing to tackle gender discrimination is already resulting in lives being lost unnecessarily, economic potential wasted and progress held up on MDGs 4 and 5. Research presented in this report suggests that, although child mortality is on the decline, gender disparities are increasing. More girls than boys are dying during childhood, and the gap is widening.  

This report demonstrates that gender inequality affects child survival through discriminatory practices like foeticide and infanticide. Gender inequality also perpetuates systematic discrimination against women and girls in a number of other ways that contribute to child and maternal mortality. It limits their livelihood options, leads to greater social exclusion and poverty, and denies them a voice and marginalises them in national governance and the global political economy. These symptoms of gender inequality limit women’s power in society and in the home, and can lead to discriminatory practices, such as son preference, and child and maternal malnutrition. And they compromise women’s and girls’ bargaining power and physical integrity, and their equitable access to available, appropriate and good-quality healthcare services. An Equal Start challenges us to place women and girls at the centre of our work, and to break the cycle of discrimination.

Glenys Kinnock Baroness Kinnock of Holyhead

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abbreviations

AIDS

acquired immune deficiency syndrome

ANPPCAN African Network for the Prevention of and Protection against Child Abuse and Neglect CEDAW Convention on the Elimination of All Forms of Discrimination against Women DHS Demographic and Health Survey DRC Democratic Republic of Congo EGLDAM Ye Ethiopia Goji Limadawi Dirgitoch Aswogaj Mahiber – an organisation working for the eradication of harmful traditional practices in Ethiopia FGM/FGC

female genital mutilation/female genital cutting

GAVI Global Alliance for Vaccines and Immunisation GDI Gender-related Development Index GDP

gross domestic product

HIV

human immunodeficiency virus

ICPD International Conference on Population and Development ICRW International Center for Research on Women IRIN International Research and Information Network MDG Millennium Development Goal NGO

non-governmental organisation

ODI Overseas Development Institute (UK) STI

sexually transmitted infection

UNCRC United Nations Convention on the Rights of the Child UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization

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executive summary

In 2000, governments committed to make a twothirds reduction in the under-five mortality rate and a three-quarter reduction in the maternal mortality ratio by 2015 – goals 4 and 5 of the United Nations Millennium Development Goals (MDGs). Despite considerable progress on MDG 4, underfive mortality is still too high, with 8 million children dying of preventable causes every year. The rate of reduction – 28% since 1990 – is well below the 67% reduction required to meet the goal. Deaths during the first month of life – the neonatal period – constitute 40% of child deaths, and most result from inadequate maternal healthcare before birth and during delivery. Of all the MDGs, MDG 5 is the furthest off track. Although maternal deaths have dropped by 34% since 1990, every day approximately 1,000 women die from complications during pregnancy or childbirth. Save the Children welcomes the UN SecretaryGeneral’s Every Woman, Every Child strategy on women’s and children’s health. More resources, improved health service infrastructure and better service delivery are vitally important. But unless the unequal status of women is tackled, further efforts to reduce maternal and child mortality are likely to be undermined. Failing to tackle gender discrimination is resulting in lives lost unnecessarily, wasting economic potential and slowing progress on MDGs 4 and 5. Research conducted for Save the Children suggests that,

although child mortality is on the decline, gender disparities are increasing. More girls than boys are dying during childhood, and in some regions gender disparities are increasing. Social institutions like ‘son bias’ result in female foeticide and infanticide, and more subtle forms of discrimination such as preferential feeding for boys. One estimate suggests that the world is missing 106 million women as a result of sex-selective abortions. Discrimination forces girls into child marriage. Worldwide, 51 million girls between the ages of 15 and 19 are married. It limits many women’s mobility, their ability to seek profitable employment and their power to make household decisions. It also makes girls and women more vulnerable to violence. Each of these factors affects a woman’s ability to seek healthcare, compromising her own health and that of her children. Tackling gender discrimination requires women’s full, equal political participation; their social and economic empowerment; sexual and reproductive healthcare and rights; equal access to education and justice; and security, including from all forms sexual and gender-based violence. Multi-sector initiatives that include protection, educational support, livelihood activities, legislative implementation and healthcare have proved successful and should be scaled up. Some of these will have an immediate effect, while others will require long-term investment.

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Long-term investments should include; • support for girls and women’s empowerment (for example, through microcredit, income generation, education and training) • improved funding allocations for maternal, newborn and child health, and the delivery of services across a continuum of care • improvements in data collection and reporting. UN Women (the UN organisation dedicated to gender equality and the empowerment of women) and the UN Commission on Information and Accountability for Women’s and Children’s Health (led by the World Health Organization) should play a pivotal role in this. Governments need to make efforts to harmonise national laws in accordance with internationally agreed conventions and frameworks. National laws should be accompanied by adequate funding, strategies for implementation, and space for civil society engagement and support.

x

The international community must fully recognise the scale and impact of gender inequality and address it as an integral part of the global momentum to reduce child and maternal mortality. Efforts to obtain a comprehensive understanding of the scope and effect of gender inequality through data collection and research need to be increased. And gender must be mainstreamed into every stage of international programmes addressing child and maternal mortality – from assessment, design and implementation through to monitoring and evaluation. With strategic interventions and cross-sector alliances, Save the Children believes we can challenge gender discrimination and get to some of the root causes of child and maternal mortality. We can prevent many health complications before they happen, speed up progress on MDGs 4 and 5, and ensure that women and girls reach their full health potential during the course of their lives.

introduction

In 2000, governments committed themselves to make a two-thirds reduction in the under-five16 mortality rate and a three-quarter reduction in the maternal mortality ratio by 2015 – goals 4 and 5 of the UN Millennium Development Goals (MDGs). Despite considerable progress on MDG 4, underfive mortality is still high, with 8 million children dying of preventable causes every year. The rate of reduction – 28% since the baseline year of 1990 – is well below the 67% reduction required to

meet the goal.17 Deaths during the first month of life – the neonatal period – constitute 40% of child deaths, and most result from inadequate maternal healthcare before birth and during delivery.18 Of all the MDGs, MDG 5 is the furthest off track. Since 1990, maternal deaths worldwide have dropped by only 34%. Every day approximately 1,000 women die from complications related to pregnancy or childbirth.19

Gender discrimination – compromising health and denying human rights Women and children’s health is recognised as a fundamental human right in the International Covenant on Economic, Social and Cultural Rights the UN Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and the UN Convention on the Rights of the Child (UNCRC). In addition, the Human Rights Council has adopted a specific resolution on maternal mortality. And General Comment No. 14, adopted by the Committee on Economic, Social and Cultural Rights in 2000, enshrines the right to health and the right to the underlying determinants of health, including gender equality.

When gender discrimination compromises a child or woman’s health (eg, through preferential feeding or by limiting a woman’s access to healthcare) this is in direct contravention of CEDAW, which has been ratified by 186 countries. Article 2 of the Convention obliges states parties to “pursue by all appropriate means and without delay a policy of eliminating discrimination against women”. CEDAW reaffirms the equal rights of women and men in society and in the family, obliges states parties to take action against the social causes of women’s inequality, and calls for the elimination of laws, stereotypes, practices and prejudices that impair women’s wellbeing.

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an equal start

Every Woman, Every Child, the global strategy on women’s and children’s health launched by the UN Secretary-General in September 2010, recognises the interconnectedness of maternal, newborn and child health. The strategy is an ambitious plan that seeks to galvanise different sectors – from country governments and non-governmental organisations (NGOs) to the private sector – to build on progress so far and improve the health of women and children through better financing, policy and service delivery.

Gender relations of power constitute the root causes of gender inequality and are among the most influential of the social determinants of health.

Save the Children welcomes the strategy. We consider increased resources, health service infrastructure and improved service delivery to be vitally important to reducing maternal and child mortality. But we also believe that these structural approaches and supply-side improvements can only go so far. As Save the Children’s 2010 report, A Fair Chance at Life: Why equity matters for child mortality, has demonstrated, it is also vitally important to consider demand-side barriers to accessing healthcare, such as women not being able to make independent decisions.20

Across the world, gender-based discrimination limits many women’s mobility, their ability to seek profitable employment, and their household decision-making power. It also makes girls and women more vulnerable to violence. Each of these factors has a potent effect on a woman’s ability to seek healthcare, compromising her own health and that of her children.22

The unequal status of women and men is perhaps the most pervasive and entrenched inequality and a major barrier to maternal and child health. It does not result from sex or biological difference, but from discrimination based on gender – a social construct that defines what is considered feminine and masculine. Gender roles and responsibilities are the socially-determined activities considered appropriate for women and men.21

Gender equality and gender equity Gender equality refers to the equal rights, responsibilities and opportunities of women, men, girls and boys. Gender equity refers to fairness of treatment for women, men, boys and girls according to their respective needs.

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G Sen and P Östling (2007) Unequal, Unfair, Ineffective and Inefficient – Gender Inequity in Health: Why it exists and how we can change it, Final Report to the WHO Commission on Social Determinants of Health

Gender also affects children’s health and their chances of survival directly. Discriminatory social institutions such as ‘son bias’ can result in the infanticide of girl children and more subtle forms of neglect such as preferential feeding for boys. Gender discrimination is universal and knows no boundaries. However, because gender is a social construct, discrimination against women and girls varies from country to country and within different religions and cultures. It also often intersects with other forms of discrimination (based on race, sexuality, indigenous status, disability and age). All the forms of discrimination discussed in this report are therefore influenced by specific social and cultural contexts, and are experienced differently by different women and girls around the world. Chapter 1 describes how discrimination on the basis of gender affects child and maternal health, and how the two are linked. As well as the direct causes of maternal and child mortality, it examines the surrounding conditions that increase a child’s likelihood of ill-health and death. Chapter 2 examines the human, economic and development costs of gender discrimination. As

introduction

well as causing the deaths of millions of mothers and children, it is impeding economic growth and development, slowing progress towards achieving MDGs 4 and 5 and presenting a moral challenge to the way we do business Chapter 3 explores four stark examples of the impact gender discrimination can have on girls’ chances of survival and the health of their mothers – foeticide and infanticide; early pregnancy; lack of control over household decision-making; and lack of access to appropriate and good-quality healthcare. Chapter 4 identifies innovative interventions for tackling gender discrimination as it relates to health. To be effective, interventions need to take a multi-sector approach that includes protection, educational support, livelihood activities, legislative implementation and healthcare. In addition,

interventions should be nested in a broader approach that seeks to enable the full realisation of women’s and children’s rights. This should include full, equal political participation; social and economic empowerment; sexual and reproductive health and rights; equal access to education and justice; and women’s security, including combating all forms of gender-based violence. Finally, the conclusion provides recommendations for policy-makers and practitioners. With strategic interventions and cross-sector alliances, Save the Children believes we can challenge gender discrimination and get to some of the root causes of child and maternal mortality. We can prevent many health complications before they happen, speed up progress on MDGs 4 and 5, and ensure that women and girls reach their full health potential during the course of their lives.

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1 The impact of gender discrimination on child survival The interdependence of maternal and child health A child’s survival is intimately connected to the health and wellbeing of her or his mother. A stark example of this comes from Afghanistan where 75% of infants who survive their mother’s death die within their first year of life.24 Conversely, when women have better access to and can choose to use reproductive health services and family planning, this improves newborn, infant and child health considerably.25 Management of complications during pregnancy and labour are vitally important to the survival of the foetus and newborn baby.26 A mother’s longterm nutritional status, dietary intake and health during pregnancy also affect her baby’s chances of survival as they determine birth weight; babies born weighing less than 2.5kg account for up to 90% of newborn deaths.27 A mother’s health affects her children’s chances of survival throughout childhood. It can affect the care the child receives, their nutrition and their long-term development. A study in Bangladesh found that a child whose mother dies has only a 24% chance of surviving to the age of ten, but an 89% chance of living to ten if the mother remains alive.28 Another study in Haiti found that when a mother dies, there is a 55% increased risk of one or more children in the family dying before the age of 12, partly because children are significantly less likely to receive routine immunisations.29

In 2008, 358,000 women died during or shortly after pregnancy. Developing countries accounted for 99% (355,000) of these deaths. Sub-Saharan Africa and south Asia alone accounted for 87% of global maternal deaths.30 Maternal death and ill health have been described as a “problem essentially only for the poor, and one virtually eliminated for people with the means and status to access healthcare”.31 To some extent this is true; most maternal deaths are directly related to obstetric complications – including post-partum haemorrhage, infections, eclampsia and prolonged obstructed labour – and complications resulting from unsafe abortion.32 Up to 80% of these deaths, as well as a large number of infant deaths, could be averted if women had access to good-quality healthcare.33 But improving maternal health is not just about improving health systems and removing supplyside barriers. It is also about tackling intermediate and underlying factors (or demand-side barriers) that prevent a woman seeking out healthcare. For example, a pregnant woman may not get to a health centre in time to prevent herself or her child dying because she is not allowed to make independent decisions about when and how she accesses healthcare.34 The control of a husband – or his family, including other women – over his wife’s access to health information and services stems from social and cultural attitudes about the roles, power and influence of men and women. These expectations

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an equal start

vary considerably across communities but are often rooted in religious codes or historical practice and reinforced by the community. When these social norms limit a woman’s power and agency they can affect her healthy pregnancy, safe delivery, her sexual relations and her contraceptive use, as well as her control over household expenditure and investments.

At the global level, the interdependence of maternal and child health is apparent in countries’ slow progress on MDGs 4 and 5. In table 1, countries in bold have a high incidence of both under-five and maternal mortality. The majority of these countries are also among the lowest scoring on the United Nations Development Programme (UNDP) gender inequality index.35 This suggests that gender

Table 1: Alignment of maternal and child mortality Country rank (1 = worst)

Under-five mortality

1

Sierra Leone (125)

Sierra Leone (125)

2

Afghanistan (134)

Niger^ (136)

3

Chad (–)

Afghanistan^ (134)



Maternal mortality ratio*

(Gender inequality index, out of 139)

4 Equatorial Guinea (–)

Chad (–)

5

Guinea Bissau (–)

Angola (–)

6

Mali (135)

Rwanda (83)



Burkina Faso (–)

Liberia (131)

8

Nigeria (–)

Democratic Republic of Congo^^ (137)

9

Rwanda (83)

Burundi^^ (79)

10

Burundi (79)

Guinea Bissau^^ (–)

11

Niger (136) Malawi^^ (126)

12

Central African Republic (132)

Nigeria^^ (–)



13

Zambia (124)

Cameroon (129)



14 Mozambique (111)

7

Central African Republic^^^ (132)

15

Democratic Republic of Congo (137) Senegal^^^ (113)

16

Angola (–)

17

Guinea (–) Lesotho (102)

18

Cameroon (129) Tanzania (–)



19 Somalia (–)

20

Liberia (131)

Mali (135)

Guinea (–) Zimbabwe (105)

Data sources: UNICEF (2009) State of the World’s Children and UNDP Human Development Report 2010 The Gender Inequality Index measures gender inequality across three dimensions, using five indicators: labour market (labour force participation), empowerment (educational attainment and parliamentary representation) and reproductive health (adolescent fertility and maternal mortality). Key: * ranked according to highest lifetime risk of maternal death (adjusted) ^, ^^ or ^^^ means parallel countries received the same ranking  (–) means data unavailable

2

1 The impact of gender discrimination on child survival

discrimination and unequal opportunities are likely to be significant contributory factors. Important to note is that many of these, predominantly sub-Saharan African countries are also least developed countries or fragile states and as such suffer from poor infrastructure and/or governance. This partly serves to partly explain their low rankings. It also helps to explain the absence of south Asian countries, the majority of which have better health infrastructure but continue to suffer acute gender inequality and discrimination.

Discrimination and the causes of child mortality When discrimination compromises a mother’s access to healthcare and food, restricts her mobility or threatens her physical integrity, it affects her children’s wellbeing as well as her own. But gender discrimination also affects children directly. It is an infringement of their rights, including their right to survival, as laid out in Article 24 of the UN Convention on the Rights of the Child (UNCRC).

Figure 1 explains the interconnectedness between gender discrimination and child survival. This framework isolates the causes of child mortality on three separate but inter-related levels – direct causes of death, intermediate causes and underlying causes. Feeding into these levels (see boxes) are examples of gender-related discriminatory practices. These either intensify the vulnerability of girls or boys to a certain cause of death or are themselves a cause.

Direct causes of child mortality Diseases, afflictions and neonatal conditions are the immediate cause of death. Direct causes stemming from gender discrimination affecting a child’s life chances include sex-selective technology,36 foeticide (the termination of a pregnancy pre-birth) and infanticide (child homicide). Child mortality can also be directly affected by the physical security, health and social status of the mother. If an expectant mother is subject to rape or other physical assault, or denied appropriate access to healthcare, the life chances of both the woman and her child can be reduced considerably. In one

Figure 1: Causes of child mortality related to gender

Foeticide/infanticide/pre-conception sex-selection technologies/mother’s physical integrity and health

Inequitable access to services; maternal and female child malnutrition; discriminatory household investment; lack of girls’ education; gendered roles and responsibilities; lack of physical integrity Gendered effects of poverty and women’s limited livelihoods/ discriminatory social institutions/ lack of laws and rights/impunity in conflict-affected fragile states/ inadequate financing/gendered effects of climate change/gender fatigue

Direct causes Pneumonia, measles, diarrhoea, malaria, HIV and AIDS, neonatal conditions Intermediate causes Weak health systems; maternal and child undernutrition; limited access to clean water and safe sanitation; lack of girls’ education; lack of access to family planning, and early pregnancy Underlying causes Poverty, inequality and exclusion; governance, fragile states and conflict; climate change and natural disasters; global political economy

Adapted from Save the Children (2009) The Next Revolution: Giving every child the chance to survive

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study, abused women were found to be twice as likely to delay prenatal care until the third trimester. Abuse was significantly correlated with lower infant birth weights and maternal low weight gain, and with infections, anaemia, smoking and use of alcohol and drugs.37 Similarly, if an expectant mother has undergone a harmful traditional practice such as female genital mutilation or cutting (FGM/FGC) her chances of having a safe pregnancy, healthy child and long life are considerably affected. It is estimated that FGM/FGC is performed on 3 million girls and women every year; between 100 and 140 million have already undergone the practice.38 FGM/FGC heightens chances of obstetric complications such as caesarean sections, post-partum haemorrhaging, prolonged labour, resuscitation of the infant, low birth weight and prenatal death.39

Intermediate causes of child mortality The surrounding conditions that considerably increase a child’s likelihood of ill health and potential death are weak health systems, maternal and child undernutrition, early pregnancy, poor access to water and sanitation, a lack of maternal education, and lack of access to reproductive health services. Each of these causes is heavily influenced by gender dynamics. For example, women often have less access to health services and/or the services they receive are inadequate to meet their reproductive needs; women and children are disproportionately vulnerable to malnutrition; household resources are more commonly invested in boy children; and girls commonly have more domestic responsibilities. Access to health services is affected by both supplyand demand-side barriers. The former might include a lack of female healthcare staff, the distance to the health centre or insensitive service delivery (eg, not respecting the mother’s preference about the sex of the worker she sees or who is allowed into the consultation room with her). Demand-side barriers include women’s unequal power in relation to household decisions. This may limit a woman’s ability to travel to a health centre without the permission of her husband or mean that she simply does not

4

Mothers tackling child malnutrition Mothers are the ones who deliver food into the mouths of children. They are often involved in food production or in securing income for purchasing food, and are almost always responsible for preparing food for children and feeding them. Where HIV and AIDS are prevalent, children who have lost their mothers may be fed by other caregivers, who in most cases will be female. Therefore, any strategies for improving the nutrition of children must tackle gender discrimination and empower women to carry out this critical work. Failure to do this will undermine the impact and cost-effectiveness or any measures taken. Save the Children (2009) Hungry for Change: An eight-step, costed plan of action to tackle global child hunger, Save the Children, London

have the time because of her caregiving obligations in the home. Malnutrition accounts for more than a third of child deaths every year,40 and where there is a bias in favour of sons, girls are particularly vulnerable. Recent research by Save the Children in India found that the medical and nutritional neglect of girls resulted in considerably higher female mortality in children aged one to five years. In 2005–06 the neonatal mortality rate was 47.1 boys to 41.5 girls (boys’ higher rates are the result of their sex-specific neonatal vulnerabilities). However, in under five mortality the rates had changed to 82 boys, to 88.7 girls. This excess female mortality after the neonatal period was attributed to the deliberate medical and nutritional neglect of girls.41 Low birth weight and infant malnutrition can also stem from maternal malnutrition, often the result of poverty but also inequitable food allocation. Girls and women often receive smaller food portions.42

1 The impact of gender discrimination on child survival

Figure 2: Girls’ education saves lives Under-five mortality rate, regional weighted average, by mother’s education, 2004–09 200

Under-5 mortality rate (%)

160

120

80

40

0



south and west Asia

sub-Saharan Africa

No education Primary Secondary or higher Sources: ICF Macro 2010; United Nations (2009) in UNESCO 2011

They are also the first to make nutritional sacrifices in the face of economic shocks.43 In some cultures, mothers are subject to dietary restrictions during pregnancy. Cultural practices, including nutritional taboos, result in pregnant women being deprived of essential nutriments, often leading to iron and protein deficiencies that compromise their own health and the healthy development of their child.44

pregnancy). Nearly 2 million women and children die every year in developing countries from exposure to indoor air pollution as a result of cooking over fires.47 Time spent collecting water and wood can also place women at risk of physical harm – including rape.48

The higher ‘value’ or status placed on men and boys over women and girls can dictate where household investments are made (see below) and affect decisions about food, healthcare, schooling and other essentials. For example, fewer girls are enrolled in or complete their education, but maternal education can determine how often children access health services, their sanitation and cleanliness and their nutritional intake (see Figure 2).45 Recent analysis by Save the Children shows the strong correlations between maternal education and child mortality.46

The social, economic and physical conditions of a child’s family or household also have an impact on her or his chances of survival. For example, a very poor family may not be able to pay for appropriate medical services for their child or, if they live in an area where there is a lack of rainfall or other environmental problems, they might not be able to provide regular food or water, and the mother might not be able to breastfeed. Coupled with gendered norms and relationships, these conditions can make girls even more vulnerable than boys. Long-held discriminatory beliefs can also affect national governance, resulting in women being under-represented in politics and/or there being inadequate anti-discrimination legislation.

Women’s household responsibilities usually include preparing food and collecting water (even during

Underlying causes of child mortality

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Poverty and limited household income, assets and livelihood options can result in gendered household labour patterns, for example, a woman may have to do all the domestic chores and agricultural labour while her husband may be forced to migrate to find paid productive work. Poverty is also a major driver for the perpetuation of traditional practices such as child marriage, son or male bias and patrilineal inheritance.49 Each of these present complex challenges for child and maternal health. Governance is another underlying determinant of child mortality. When governance is gendered, laws, policies and/or budgetary allocations are discriminatory or insufficient to meet one or other sex’s needs. For example, they may limit women’s ownership of assets or resources. In many countries gendered governance results in inadequate budgetary allocations for women’s sexual and reproductive health. Globally there is an estimated shortfall of US$54.8 billion for family planning and reproductive health services.50

A bias for boys ‘Son’ or ‘male bias’ often stems from the belief that men are more likely to enter profitable employment and will therefore be better able to care for their parents in later life. In a fertility survey in Hubei province, China, 51% of respondents said the primary motivation for a son was the desire for old-age support, with continuation of the family line coming a distant second (20%).51 As well as determining a child’s chances of being born and household investment decisions, son bias can also affect the quality of healthcare a child receives. The behaviour and attitudes of health providers and decision-makers can be shaped by male bias and can influence a child’s chances of survival as much as those of their parents (see Chapter 3).

6

This contravenes Article 12 of the 1979 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and Article 10 (2) of the International Covenant on Economic, Social and Cultural Rights. Both these international human rights treaties recognise that women have specific sexual and reproductive health needs, which require due consideration and additional resources if women are to enjoy their equal right to health. Equal political representation can make genderspecific issues within policy, planning and budgeting more visible and therefore more likely to be tackled, but only 19% of parliamentarians around the world are women. In the Arab states it is just 9.5%.52 Good gender-equal governance – such as equal political participation and access to livelihood opportunities – has a positive impact on child survival. Figure 3 contrasts a number of countries’ under five mortality rates with their Genderrelated Development Index (GDI) scores. The GDI is a composite measure that, among other things, captures women’s political participation and labour market status, as proxies for women’s empowerment. For the purposes of this report, global political economy refers to the global commitment, leadership, energy and resources allocated to a particular issue. The MDGs, particularly MDG 3 (on promoting gender equality and empowering women), have done much to raise the visibility of gender equality within global political circles, and to increase funding towards girls’ education and support for female parliamentary representation. However, there has been insufficient attention to more entrenched and hazardous forms of gender discrimination, and inadequate analysis of gender as it relates to health. For example, MDG 4 (on child survival) makes no mention of gender differences despite sexpreference accounting for a significant proportion of under five deaths in some regions. There is also no mention of gender-based violence anywhere in the MDGs despite its profound impact on women

1 The impact of gender discrimination on child survival

Figure 3: Women’s empowerment and under-five mortality Under-5 mortality rate 2008 (deaths per 1,000 live births)

300 Afghanistan 250 Chad Nigeria

200

Equatorial Guinea 150

100

Kenya

Niger

Ethiopia

Gabon Ghana

50

Bolivia India

Bangladesh Nepal

Mexico

Botswana R3 = 0.6862 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Gender-related development index 2007

Source: UNICEF State of the World’s Children 2010 (under-5 mortality rate) and UNDP Human Development Indices: A statistical update 2009 (gender-related development index)

and girls’ physical integrity and development. Failure to recognise these issues means they receive less funding and support. Failing to consider gender dynamics within all efforts to meet the MDGs also compromises the efficacy and longevity of any change achieved. Finally, it is important to note the interconnectedness between the direct, intermediate and underlying causes of child

mortality. For example, a girl’s chance of being born can be determined directly by sex-selected abortion or foeticide. This decision is rooted in discriminatory social relations that, in some cultures, place less value on girls and women. This in turn can affect a mother’s chances of accessing health and other essential services or of controlling her sexual health, physical integrity and agency, which further jeopardises her child’s chances of survival.

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2 The human, economic and development costs of gender discrimination The human cost – more mothers and babies dying Every year, 358,000 women die during pregnancy or when they are giving birth and more than 800,000 babies die during childbirth. Millions more newborn babies’ lives are lost in the first month of life and every year 8 million children fail to reach their fifth birthday.53 Many of these deaths result – at least partly – from gender discrimination, but isolating the exact number is very difficult. Women often access health services too late, resulting in the death of their unborn child. Causes of death are recorded as medical complications (such as haemorrhaging) as opposed to the social constraints (such as the woman’s restricted mobility or lack of decisionmaking authority), which may have prevented her seeking health services earlier. Maternal death reviews could bring some of this out, but this is not routine practice. Medicalised reporting and a lack of data on social determinants of health therefore inhibit our awareness of the depth of the problem. However, there are some overt forms of discrimination that can be quantified and some strong proxy indicators. In 1990 the Nobel Prizewinning economist Amartya Sen estimated that 60 million women were ‘missing’ from the global population as a result of infanticide and foeticide, mainly in south and east Asia.54 Revised estimates suggest that the number could now be as great as 106 million.55 In addition, 16 million girls aged between 15 and 19 give birth every year, with 95% 8

of these births occurring in developing countries.56 As a result of early pregnancy, an estimated 70,000 girls aged between 15 and 19 die each year during pregnancy and childbirth and more than 1 million infants born to adolescent girls die before their first birthday.57 Early pregnancy is often the result of gender discrimination, which manifests itself in child marriage, gender-based violence, and women’s limited choices and lack of agency over their sexual and reproductive health. Worldwide, just seven countries account for half of all adolescent births: Bangladesh, Brazil, the Democratic Republic of Congo, Ethiopia, India, Nigeria and the USA.58 All except Brazil and the USA are in the bottom quintile on the Gender-Related Development Index.59

The economic cost – losses in productivity According to the UN Secretary-General’s Every Woman, Every Child strategy, maternal and newborn deaths slow growth and lead to global productivity losses of US$15 billion each year. Similarly, by failing to address undernutrition, a country may have a 2% lower gross domestic product (GDP) than it otherwise would.60 As well as losses in potential productivity, discrimination costs money as it often results in women and children having to seek emergency medical care. One study of 15-year-old girls in six African countries put the total annual cost of

2 The human, economic and development costs of gender discrimination

FGM/FGC-related obstetric complications in those countries at US$3.7 million, ranging from 0.1 to 1% of government spending on health for women aged 15–45 years.61 In contrast, early investment in children’s health leads to high economic returns and offers the best guarantee of a productive workforce in the future. Between 30% and 50% of Asia’s economic growth from 1965 to 1990 has been attributed to improvements in reproductive health and reductions in infant and child mortality and fertility rates.62 Empowering women to have control over their sexual and reproductive health is also highly costeffective. In many countries, every dollar spent on family planning saves at least four dollars that would otherwise be spent treating complications arising from unplanned pregnancies.63

level reveals a mixed picture in relation to gender disparities (see Appendix, Tables 3 and 4). East Asia has been able to eliminate excess female childhood mortality, reducing the female/male gap from 112 female childhood deaths per 100 male childhood deaths to parity (100 female childhood deaths per 100 male childhood deaths). While in Latin America and the Caribbean there was a 3% faster reduction in female childhood mortality compared with males (66% and 63% respectively). Yet, females have lagged behind in the populous region of southern Asia and in western Asia (both by two percentage points) and in North Africa (by one percentage point). Sub-Saharan Africa saw a 20% reduction in child mortality, with relatively equal rates of progress among females and males.

Persistent gender inequity

The development cost – failure to achieve the MDGs Reductions in childhood mortality but persistent gender inequality Although there have been dramatic reductions in child mortality, progress in many regions is gender inequitable and in some regions gender disparities are even rising. Unlike during infancy, when boys are at greater risk of neonatal conditions and early death, there is no biological reason why more girls should die in childhood (between the ages of one and four years), and yet they do. For every 100 male childhood deaths in 1990, 108 female children died. In 2008 the figure was 107 – a negligible reduction. As well as thwarting chances of achieving MDG 4, these disparities present a moral challenge to the way we do business. Between 1990 and 2008, the total number of childhood deaths fell from 3.9 million to 2.8 million. All regions have seen reductions in their childhood mortality rates (see Appendix, Table 2). Absolute reduction may be a result of an overall reduction in childhood mortality from improvements in health systems, and may not ensue from reductions in gender inequity. Examining progress at the regional

In order to reveal the impact of gender inequity, it is important to compare the reduction in the number of excess female deaths with the total number of childhood deaths. Between 1990 and 2008, excess female deaths as a proportion of total childhood deaths declined from 4.4% to 3.6% (see Appendix, Table 3). In southern Asia, for example, while the number of excess female childhood deaths has fallen (from 0.20 million in 1990 to 0.12 million in 2008), gender inequities have widened, with the proportion of excess female deaths relative to total childhood deaths increasing from 15% to 17% (see Appendix, Table 3, and Figure 4 on page 10). In 1990, for every 100 male deaths 137 female children died; by 2008 the figure was 143. This widening gender gap, from an already highly inequitable situation in 1990 and alongside overall improvements in child mortality, indicates that gender inequity has not been considered in child health interventions. A similar trend is observed in North Africa, where the proportion of excess female deaths relative to total childhood deaths increased from 2% to 8% (see Appendix, Table 3) between 1990 and 2008. In 1990, for every 100 male deaths 103 female children died. By 2008, the figure was 127 female childhood

9

an equal start

Figure 4: Inequitable progress on reducing child mortality (per 1,000 live births) in southern Asia 45 41

Child mortality (per 1,000 live births)

40 35 30

30

25 21

20 15

15

10 5 0 1990

Male Female 2008

Calculated from World Health Organization (2010) World Health Statistics, WHO: Geneva

deaths for every 100 male childhood deaths (see Appendix, Table 4). This analysis suggests that reductions in childhood mortality are largely the result of improvements in health systems rather than the specific targeting of gender inequities. Medicalised approaches are failing

10

to tackle the complex social realities that result in better life chances for boys. As under-five and childhood mortality rates come down, and quick technological fixes are exhausted, gender disparities will become more and more overt, slowing progress across regions.

3 Four snapshots of gender discrimination and its impact The four specific forms of gender discrimination explored below are all manifestations of the same problem – the fact that women have more limited power, agency and, in some cultures, social value than men. Although they are discussed separately in this chapter, many of the issues are intimately related and are often experienced concurrently.

Foeticide and infanticide For many children, gender discrimination starts early, affecting their life chances before and as soon as they are born. An early manifestation of gender discrimination against girl children is the abortion of female foetuses. Latest estimates suggest that there are currently about 106 million ‘missing women’ as a result of these practices.64 Sex-selective abortion is prevalent in India, China and South Korea and among the south Asian diaspora in Britain, the USA and Canada.65 In a study of hospital abortions in Mumbai, India, 7,999 out of 8,000 aborted foetuses were found to be female.66 Although the preference for boys over girls is often closely correlated to poverty and limited resources (see below), sex-selective abortion is increasing among the middle classes who can afford expensive medical sex-determination techniques such as ultrasonography.67 The 2010 population census in India showed the effects of this emerging trend, with an average of just 914 girls per 1,000 boys aged nought to six. In the state of Haryana, the figure

is 830.68 In China, there are 117 boys born for every 100 girls as a result of female foeticide.69 As well as starting in the womb, discrimination is also a threat to girls’ survival when they are very young. Although newborn girls have a greater biological chance than boys of surviving to their first birthday,70 many developing countries have high rates of female mortality.71 Discrimination can take the form of inadequate breastfeeding and early weaning, insufficient or delayed medical care, lack of attention causing emotional deprivation, insufficient investment in resources, physical abuse and infanticide.72 The impact of such skewed birth ratios and ‘son bias’ can be profound. In the next 20 years in large parts of China and India, there will be a 10% to 20% excess of young men because of sex selection. This means that a significant percentage of the male population will not be able to marry or have children. Already in China, 94% of unmarried people aged 28 to 49 are male, 97% of whom have not completed high school. There is concern that men’s inability to marry will result in psychological issues and possibly increased violence and crime.73

Social and economic determinants Foeticide and infanticide are most common in parts of Asia and stem from social and economic assumptions about the value and productivity of women. In Punjab, India, a sample of households cited the escalating costs of dowry as the main reason for female foeticide, even though foeticide is illegal. In addition, daughters were thought less

11

an equal start

likely to have paid employment and therefore unable to provide social security for their parents.74 As highlighted above, however, female foeticide and infanticide are increasingly undertaken by the middle classes, in countries such as India. In these cases, discrimination is less the product of economic concerns and more the result of entrenched discriminatory norms, including assumptions about the relative social and economic value of women. In China, female infanticide has been linked to economic policies of the 1980s, including the one child policy.75 A process of de-collectivisation increased the value of male labour by designating the rural household as the basic unit of agricultural production. The bias towards sons was reflected in the smaller land allocations granted to families with daughters during the 1980 land reforms. At the same time, declining social support and services in rural areas have increased the need for sons to provide support.76 Patrilineal inheritance systems – in which sons inherit property – also discriminate against girls. Under these systems girls exhibit patterns of virilocal residence, moving to their in-laws household when they get married. Any parental investment in daughters is therefore considered lost on their departure.77 Shockingly, foeticide and infanticide against girls is often perpetuated by older women who are the traditional keepers or mainstays of social norms and cultural practices. In a study in Tamil Nadu, India, it was found that most of the killings of infant girls were carried out by senior women in the family, usually the paternal grandmother.78

Early pregnancy An estimated 16 million girls and young women aged between 15 and 19 give birth every year, and an estimated 70,000 die during pregnancy and childbirth. More than 1 million infants born to adolescent girls die before their first birthday.79

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Adolescent births make up 11% of all births worldwide, with 95% occurring in developing countries.80 Seven countries account for half of these births: Bangladesh, Brazil, the Democratic Republic of the Congo (DRC), Ethiopia, India, Nigeria and the USA.81 Compared with women over 20 years of age, girls aged 10–14 are five to seven times more likely to die because of childbirth, and girls aged 15–19 are twice as likely.82 In Mali, for example, the maternal mortality rate for girls aged 15–19 is 178 per 100,000 live births, while for women aged 20–34 it is 32 per 100,000.83 In India, maternal mortality among adolescents is 645 per 100,000 live births compared with 342 per 100,000 live births in women aged 20–34.84 As well as jeopardising the life of the mother, early pregnancy has major implications for the survival and health of her child. Babies born to girls in their teens face a risk of dying before age one – that is 50% higher than babies born to women in their twenties.85 Every year 1 million infants of young mothers die as a result of pregnancy and childbirth-related causes.86 Infants born to mothers under the age of 20 have a 73% higher mortality rate than infants born to older mothers. In Mali, the under-five mortality rates are 181 per 1,000 children born to women under the age of 20 and 111 per 1,000 born to mothers aged 20–29 years. In Tanzania, these rates are 164 and 88, respectively.87

Social and economic determinants Early pregnancy often results from child marriage, but also from forced sexual encounters; from women’s lack of bargaining power to insist on contraceptive use, from poverty and desperation resulting in transactional sex and/or from a lack of awareness about sexual and reproductive health. Child marriage Although child marriage is a violation of human rights with many international and national laws banning it, it affects millions of children worldwide.

3 Four snapshots of gender discrimination and its impact

It increases the risk of early pregnancy, which puts infant and maternal health at risk. Worldwide, more than 51 million adolescent girls aged 15–19 are married.88 Child marriages occur most frequently in south Asia, where 48% of women aged 15–24 have been married before the age of 18. In Africa, 42% of women are married before 18 and in Latin America and the Caribbean, 29%.89 The International Center for Research on Women (ICRW) cites shocking figures: one in seven girls in developing countries marries before the age of 15 and nearly 50% are expected to marry by their 20th birthday. If current trends continue, 100 million girls (25,000 more) will be married in the next 10 years.90 Child marriage is strongly associated with early pregnancy91 – hazardous for young mothers and their offspring – and no contraceptive use, increasing the likelihood of exposure to sexually transmitted infections, including HIV and AIDS.92

Early sexual intercourse can also affect a girl’s physical development and ability to deliver safely. In Ethiopia, 42% of respondents to a national survey on the effects of harmful traditional practices cited problems at delivery as a result of child marriage and early sexual initiation. Further research found that 90% of cases in the Addis Ababa Fistula93 Hospital (where women are treated for incontinence and physical injuries caused during childbirth) were survivors of child marriage or FGM/FGC.94 A study in India showed that young women who marry later have more control over their fertility and the birth of their first child. They were more likely than those who had married early to have used contraception to delay their first pregnancy and to have had their first delivery in a health facility. They were also less likely to have lost their baby.95 Poverty is one of the major factors underpinning child marriage.96 Where poverty is acute, a girl may

Figure 5: Child marriage in south Asia and sub-Saharan Africa West/Central Africa

44 36

Eastern/Southern Africa South Asia

49

Middle East/North Africa

18

East Asia/Pacific* Latin America/Caribbean CEE/CIS

19 N/A 11 40

Sub-Saharan Africa** Developing countries*

36

Least developed countries

49

0 10 20 30 40 50 60 Percentage of women aged 20–24 years who were married or in union before they were 18 years old, 1998–2007 * Excludes China ** Sub-Saharan Africa comprises the regions of eastern/southern Africa and west/central Africa Source: UNICEF The State of the World’s Children (2009); Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other National Surveys

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an equal start

be regarded as an economic burden. Her marriage to a much older – even elderly – man (a practice common in some Middle Eastern and south Asian societies) is a family survival strategy, and even seen as in the girl’s interests.97 Dowry or bride price is another example of the economic incentives associated with marriage. Making the husband’s family pay for their daughter is important to the family’s status and how the daughter is received by the husband’s family.98 For very poor men the cost of ‘buying a wife’ can be prohibitive. In some rural areas of Ethiopia, it is reported that men unable to pay the bride price abduct and rape adolescent girls in order to marry them.99 Another motivation for marrying girls early is their asset insecurity. In patrilineal societies, girls are prevented from inheriting or controlling their parents’ assets, such as land or a house.100 They are therefore less likely to stay near the family home. It is also assumed that girls will have greater security when they become the wife of a man who can accumulate and share his own independent assets.

“Join me in fighting child marriage,” Sosna, Ethiopia

Non-consensual sex Women and girls’ status, when seen as commodities intended for sexual and reproductive purposes and without the right to independent assets, affects their marital and sexual bargaining power.102 Without such power, girls and women are often unable to stipulate when, with whom and how often they have sexual intercourse, or to negotiate the use of contraceptives. According to one recent report, up to 30% of women in some countries said their first sexual experience was forced,103 and the World Health Organization (WHO) reports that one in five women experienced sexual abuse during childhood.104 Within relationships, without the power to insist on the use of contraception, women are unable to plan birth-spacing – with considerable effects on their own health and the survival chances of their children. Babies born less than 18 months after their preceding sibling are almost three times more likely to die than children born after a three year gap.105 As well as a violation of human rights, forced sexual encounters bring with them a variety of physical

PHOTO: grethe markussen/Save the Children denmark

Sosna, comes from a poor family in North Wollo, Ethiopia, and was married when she was about 13. She became pregnant soon afterwards but lost her baby during the birth, which also left her with fistula101 – a hole between her vagina and bladder. Like many girls who suffer from fistula, Sosna got divorced and was ostracised by her family. With help from the office of Women and Children’s Affairs, she received medical treatment and at 18 got married again. Once again she got pregnant, once again her baby died during birth and again she was left suffering with fistula. She got divorced from her second husband and is now living alone, supporting herself as best she can through petty trade.

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“It must stop here,” she says, referring to child marriage. “I would appreciate it if people would join me in fighting this problem.” Sosna is part of Save the Children’s Protecting Girls and Women from Harmful Traditional Practices project.

3 Four snapshots of gender discrimination and its impact

The impact of HIV and AIDS Although AIDS emerged as a condition that primarily affected men, the proportion of infected women and girls compared to men and boys has steadily increased from 35% in 1990 to over 50% in 2010. Young women are particularly vulnerable, representing 67% of all new cases of HIV among people aged15 to 24.106 In subSaharan Africa, young women aged 15–24 years are as much as eight times more likely than men to be HIV positive. According to the United Nations Population Fund (UNFPA), more than four-fifths of new HIV infections in women occur in marriage or long-term relationships with primary partners, largely because women lack sufficient power to ask their husband to use a condom. In two districts of Uganda, only 26% of women said it was acceptable for a married woman to ask a husband to use a condom.107

and mental health effects that can jeopardise a girl or woman’s safe pregnancy, delivery and ability to care for her child. A paper on marital rape cites a long list of major health consequences from forced sexual intercourse. These include: contraction of HIV and other sexually-transmitted infections; vaginal bleeding or infection; genital irritation, pain during sex, chronic pelvic pain and urinary tract infections; complications during pregnancy, resulting in health problems for both women and their children; depression, anxiety, emotional distress and suicidal thoughts.111 Further physical or sexual violence during the course of pregnancy can also prove fatal for a mother or child. A study of 400 villages in rural India found a correlation between violence during pregnancy and maternal and infant mortality.112 Similarly, a 2002 study in Nicaragua found that approximately 16% of low birth weight in infants was related to physical abuse by a partner during pregnancy.113

HIV and AIDS pose a particular threat to pregnant mothers, newborn babies and infants. If HIV-positive pregnant women are not diagnosed early and do not receive effective medication then the risk of spontaneous miscarriage increases by 67%.108 Without effective treatment of mother and baby, one out of two HIV-infected infants will die before the age of two.109 Findings from a 1999 study in Kenya indicate that the rapid spread of HIV, mainly through heterosexual contact and mother-to-child transmission, contributes to the increasing rates of infant and under-five mortality in a number of Kenyan provinces. Additionally, a Ugandan cohort study of the impact of HIV and AIDS has demonstrated that when the mother dies this too lowers the child’s chances of survival.110

Transactional sex Girls who are systematically disadvantaged by gendered social and community norms, denied control over independent assets and/or have limited livelihood opportunities are more likely to participate in hazardous income-generating activities such as transactional sex.114 Transactional sex carries with it the risk of STIs, increased exposure to violence, and a heightened chance of pregnancy, all of which can jeopardise maternal and child health. A recent survey by the Population Council in Ethiopia found that 71% of female sex workers are aged between 15 and 24 years. The majority had come from severely disadvantaged backgrounds, and lacked financial support, income-earning alternatives and a decent education; 38.5% said they had resorted to sex work to escape other forms of abusive work, including domestic work. Startlingly, 87% were already divorced, reflecting the ostracisation experienced by divorced women in Ethiopian society.115 15

an equal start

Sexual violence in conflict-affected and fragile states 44% of child deaths happen in countries considered fragile,116 and nearly 70% of the countries with the highest child mortality rates are currently experiencing or have experienced armed violence in the last two decades.117 This is partly due to a lack of or breakdown in health services, but is also the result of sexual violence – carried out with impunity and used as a weapon of war – which in many cases leaves women injured and unable to care for their children. The brutal conflict in the DRC has been called ‘a war against women’ and a ‘war within a war’.118 The UK Department for International Development referred to it as ‘the worst country in the world to be a woman’.119 Girls and young women are disproportionately affected. A March 2009 UN report found that 45–60% of rape

Lack of household decision-making power Evidence from 30 countries – drawn from Demographic and Health Surveys (DHSs) – reveals that in many households, women have little influence over important household decisions. In only 10 of the 30 countries surveyed did 50% or more of women participate in all household decisions, including those taken in regard to their own healthcare, major household purchases, daily household spending and visits with family or relatives outside of the household.122 For example, in Sudan only 2% of women interviewed said they could make the decision to seek healthcare by themselves if obstetric complications arose. Depending on their cultural background either their husband’s or their family make the decision. 123 In Burkina Faso 75% of husbands make decisions about their wives’ healthcare on their own, without

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survivors were under 17 years of age, and that of these, 10% were less than ten.120 Similar reports of sexual violence are emerging from Côte d’Ivore. The International Rescue Committee (IRC) reports that out of 300 women attending discussion groups in a Liberian refugee camp, 26 found the courage to say that they had been raped.121 Human Rights Watch’s senior West Africa researcher, Corinne Dufka, told the International Research and Information Network (IRIN): “During times of political upheaval sexual violence has a clear political link, but unfortunately the general sense of lawlessness in Côte d’Ivoire for the past decade has led to a disturbing increase in sexual violence countrywide.”

consultation. In Nigeria the figure is 73% and in Nepal 51%.124 Evidence from India suggests that women with greater freedom of movement obtain higher levels of antenatal care. Women’s autonomy over the use of healthcare appears to be as important as other known determinants such as education.125 Not being able to influence household decisions can also affect a woman’s food intake,126 the nutritional and health status of her and her children, the accumulation of assets and a household’s investment in children.127 A study in south Asia concluded that there is a clear correlation between a woman’s power and status and her child’s nutritional status. The study estimated that if women and men had equal status, the under-three child underweight rate would drop by approximately 13 percentage points, meaning 13.4 million fewer malnourished children in this age group alone.129

3 Four snapshots of gender discrimination and its impact

“I can’t say much…” 19-year-old married woman,Vietnam “Husbands are the ones who take care of great matters [such as loans], so I can’t say much… He didn’t tell me anything about the loan. He thinks a wife knows nothing. I didn’t talk to him about the [loan repayment] deadline or the interest because it would make my husband’s family worry too, and I was afraid it would upset him. He says I don’t know anything so I couldn’t ask. I was too afraid to ask him.”128

Social and economic determinants Marriage and the formation of a household is a particularly important moment determining power relations and decision-making authority between a husband and wife. Ownership of or control over assets such as land, capital and property are a crucial bargaining chip. A higher proportion of pre-wedding assets held by the wife and directed towards the husband at marriage reduces child morbidity, regardless of child sex.130 However, only 1–2% of land titles globally are held by women and other assets, such as livestock, financial capital and labour all show similar patterns of gender difference.131 Child marriage in particular disadvantages girls and women, limiting their ability to accumulate assets and independent income, and to develop a voice and independent decision-making. Evidence from India suggests that women married early are more likely than other women to consider wife-beating justifiable, a finding also observed in other places. Another factor that perpetuates women’s lack of decision-making power within the household is perceptions about their economic value, their ability to earn an income and to provide for other family members (see above).

More girls die in Pakistan Girls and young women in Pakistan are more likely than males to die of noncommunicable diseases. These include cardiovascular diseases, diabetes, cancer and chronic respiratory diseases. The reason is their lack of decision-making power to access health services and other necessities (such as food) as and when needed, their lack of mobility (most women are not allowed to travel on their own to seek healthcare), and their lack of monetary resources.132

Discriminatory health services Gender discrimination not only affects women and girls’ ability to access health services, it also affects the quality of the care they receive.

Inadequate sexual and reproductive health services The UN’s General Comment 14 on the right to health, adopted by the Committee on Economic, Social and Cultural Rights in 2000, recognises that women have specific needs relating to their reproductive and sexual health. Inadequate attention to and provision for these needs is a denial of women’s rights as it severely compromises their health as well the survival and healthy development of their children. Despite this recognition, financing for maternal, newborn and child healthcare is disastrously insufficient. The UN Secretary-General’s Global Strategy estimated that an additional US$88 billion is needed between 2010 and 2015 if we are to have any hope of achieving MDGs 4 and 5.133, 134 The results of this financing deficit are profound. Every year, 48 million women give birth without

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an equal start

someone present who has recognised midwifery skills.135 More than 2 million women give birth completely alone, without even a friend or relative present to help them, making labour and childbirth among the most dangerous time of their lives.136 The global shortage of 350,000 midwives137 means that many women and babies die from complications that could easily be prevented by a health worker with the right skills, the right equipment and the right support. Every year, 358,000 women die during pregnancy or childbirth, and more than 800,000 babies die during childbirth. Millions more newborn lives are lost in the first month of life. If births were routinely attended by midwives and skilled birth attendants with the right training and support, the lives of 1.3 million newborn babies a year could be saved.138 Similar financial and resource challenges are hindering progress on women’s reproductive health services. Despite increases in recent years, an estimated 215 million women who want to avoid a pregnancy are not using an effective method of contraception.139 Approximately 20 million women have unsafe abortions each year, and 3 million of the estimated 8.5 million who need care for subsequent health complications do not receive it. Since 1999, 70,000 women have died every year as a result of unsafe abortions – that means one woman dying every eight minutes. Over half (54%) of these deaths occur in sub-Saharan Africa and 34 % in south-central Asia.140 For many women, especially given their lack of economic power, reproductive healthcare is prohibitively expensive. In the United States, women of reproductive age pay 68% more in outof-pocket health expenditures than men. In Chile, private insurance premiums are 2.5% higher for women of reproductive age than for men; in four Latin American countries out-of-pocket health expenditures for women are 16–40% higher than for men.141

Gendered service delivery As well as women being denied adequate reproductive and maternal health services, those

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health services that are provided are often not gender-sensitive or geared towards women. For example, a 2009 analysis of Demographic and Health Surveys from 41 developing countries found that nearly a quarter of women listed not having a female health provider as a reason why they did not go to a health facility to give birth. In Afghanistan, an assessment found that women were unable or unwilling to receive potentially lifesaving tetanus toxoid vaccinations because it was considered shameful to expose their arm to a male vaccinator. And in northern Ethiopia, a study found that one reason women would not seek treatment for malaria was that the community health workers were male.142 Gendered service delivery can also affect boys and men. In 2008, for example, the Global Alliance for Vaccines and Immunizations (GAVI) discovered that boys were less likely to be immunised in parts of sub-Saharan Africa due to concerns about subsequent sterility.143

Social and economic determinants Women’s health and gender discrimination are not a national priority Insufficient services and inadequate levels of maternal and reproductive health staff are most commonly the result of inadequate resources for health and/or poor national prioritisation. Even when countries are exceptionally cash strapped they can still make efforts to ensure that discrimination is not a barrier to healthcare and/or make considerable strides with cheaper, non-medical interventions such as community health awareness raising.144 However, many governments lack the political will or momentum, often because state institutions mirror society. For example, a study on gender equity in China’s health service reforms showed a marked deterioration of services aimed at women’s health issues. The number of publicly funded reproductive health clinics declined significantly from 1995 to 2004 and many private firms cancelled regular reproductive health examinations for women

3 Four snapshots of gender discrimination and its impact

Too little, too late Mariama, 17, lives with her aunt in Kuntoloh, outside Freetown, Sierra Leone. At 16, she lost twins who, unbeknown to her, had been dead for some time before she eventually received a caesarean section. “The pregnancy was unexpected. I used injections as contraception, but I missed one injection and got pregnant. I was two months pregnant when I found out, but I didn’t want to have an abortion, so I decided to carry through with the pregnancy. When my aunt found out, she told me I could no longer live with her, so I moved to my boyfriend’s parents. I had some antenatal check-ups in the community health centre, but they didn’t really examine me much and they didn’t tell me anything about the pregnancy. They just gave me some paracetamol, even though I was not really in pain, and then they told me to go home.

“When I woke up from the operation, they had already removed the dead twins, but they didn’t tell me the babies where stillborn – they just said that the babies were in the neo-natal department and that I couldn’t see them. For more than two months I thought that my babies were still alive in the hospital because that’s what my aunt and the medical staff told me. But this was not true. I kept asking my aunt for permission to go to the hospital and see my twins, but she didn’t allow me. One day I went to the hospital myself without asking her, but when I got there, nobody could help me, so I had to go back to my aunt. In fact, I only learned about the death of my twins by coincidence when a friend visited us while my aunt was out. The friend said she was really sorry to hear that my babies were stillborn. When she told me that, I got a shock! I was very confused, and I got furious at my aunt because she had been lying to me all that time! “Now, I’m OK – I’m no longer sad. I focus on the future. I want to finish school and continue to high school. I want to become a nurse, so that I can help other people.”

PHOTO: louise dyring nielsen

“At the last check-up, when the pregnancy had lasted for much more than nine months, I was worried, but they just told me to go back home and wait for the birth to start. ‘Your time will come,’ they said. But the birth never started and my aunt told me to come back to Freetown so she could take me to the hospital there. When I reached the hospital, they examined me properly and told me that I needed an operation

[caesarean] immediately. I didn’t know it was twins and I had no idea that they were dead inside my stomach. This was my first pregnancy so I didn’t have the experience.

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an equal start

employees. As a result, the rate of examinations for women dropped to or remained at just under 40% over the past 40 years.145 Entrenched discrimination in the health system Health policies are seldom gender sensitive146 and in some countries overtly compromise women’s rights over their bodies and reproductive decisions. For example, in Peru the 1997 Health Law criminalises abortion and makes it a criminal offence to fail to report suspected cases of abortion, forcing healthcare providers to break

client–patient confidentiality. This legislation has led to a proliferation in the number of illegal, backstreet abortions, which are now responsible for 10–30% of maternal deaths in Peru.147 In addition, health services are often delivered in ways that reflect discrimination in society. For example, in Koppal, south India, the maternal mortality rate is still high, despite pregnant women accessing a range of health services. This has been put down to systemic gender biases in the delivery of obstetric services, including medical orderlies ignoring the woman’s point of view.148

“I was frightened I might die” Hawa*, 19, lives in Genete Kebele, Ethiopia. She was married at 17 and lost her first baby during childbirth. Pregnant again, she is worried about what will happen this time. “My labour started at 7pm. I laboured the whole night but the baby didn’t come out. From home, they took me to the health centre on a wooden stretcher. It took one hour. It was very painful and I felt the baby was coming out. When we arrived at midnight they took me to the bed and a nurse wore a glove and checked. She said my uterus was too small, so told me to go to hospital. I didn’t feel anything when they said that, I was very tired so I was not thinking. They gave us a piece of paper [referral letter] and we hired transport and went to Akesta. It cost 400 Birr [US$23]. “I went with six people, my father, my mother, my husband, my sister and two neighbours. I don’t remember how long the journey took, maybe one hour. I don’t remember anything about it. I just woke up when the baby was arriving and they cut me. When they pulled the baby out, it was already dead. * not her real name

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“I had never been to hospital before. I stayed there for five days and my mother stayed with me. Then I came back to my mother’s house and stayed for six months before I went home to my husband. Nobody said anything about the baby. I didn’t ask anybody, only my mother who said she didn’t know what had happened. We left the baby at the hospital to be buried there. “After being at home with my husband for six months I became pregnant with this baby. When I was with my family, at my mother’s house, I used to see my period, but at my husband’s house it didn’t come, so I realised at three months, and went for a check-up at the health centre. They checked my urine and told me I was pregnant, but they didn’t give me any more information. When they told me, I remembered the previous pregnancy and thought I might die. “I’m frightened about the labour, but I haven’t said anything about it or asked anybody. For the first pregnancy, I never thought about it, but after that experience, I’m concerned something will happen to me. I told my mother I would die this time if I had the same experience. But she said

3 Four snapshots of gender discrimination and its impact

“I was frightened I might die” continued don’t think that, just go for your check-ups and take your vaccinations. In the third month I had a vaccination at the health post. “In the fourth month, I went to Akesta hospital to get rid of the baby. Nobody knew. I just went alone by bus. I sold my jewellery to pay for the transport and the medication. At the hospital, they said it was four months and the baby was already strong so they couldn’t do anything. I wanted to get rid of it because I was frightened I might die. I went as soon as I could after I found out I was pregnant at three months, but it took some time to sell the jewellery. I cried when they told me and the nurse said don’t be like that, just follow your appointments and take your vaccinations. “After another month, the baby started to move. So, I come to the health post for vaccinations now. I don’t feel any pain. I’ll go to my mother’s house and make preparations to go straight to the health centre when the labour starts. Since my first experience was bad, I’ll ask them to

prepare the stretcher ahead of time. I would prefer to be at home. In our area we only go to the health centre if the labour takes a long time. So I’ll start the labour at home and see how it goes. “I’ve never explained to the health extension worker or the nurse at the health centre about the first pregnancy. Whenever I come I want to tell them, but nobody has asked me. Unless they ask, I won’t tell them because I’m afraid. “I’ve never used contraceptives. I don’t really know about them, although I’ve heard others talk about a three-month injection. I’d like to use contraceptives after this baby and I‘ll tell my husband. When the first baby died, he felt very bad, although I didn’t feel anything. He wanted another baby straight away. I told him when I was pregnant again, and I told him I was frightened. He said, ‘Don’t worry, you won’t die.’ I didn’t tell him about going to Akesta. Even now he doesn’t know.”

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4 Interventions – a multi-sector approach Gender inequality is a huge and pervasive challenge. Tackling it requires a multi-sector approach that includes protection, educational support, livelihood activities, legislative implementation and healthcare. Although initiatives using this approach are often small-scale and project based, there is compelling evidence to suggest that they bring about change.149 However, to ensure sustainability, they need continued efforts that are scaled up and properly monitored. Forms of gender discrimination vary and also intersect with other forms of discrimination based on disability, sexuality, race, age and indigenous status. Programmes to address child and maternal mortality must therefore be based on a gender analysis of the local context and take into account the issues specific to each country, region, society and culture. The interplay between top down and bottom up approaches is key to facilitating change. Rights for mothers and newborn babies can only be protected, respected and fulfilled, and gender equality achieved, when legal and policy frameworks are supported at community and individual levels.

Changing norms Reforming laws and policy Most countries are signatories to the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).150 Governments should therefore ensure that domestic legislation is harmonised with the Convention and be held accountable. This requires awareness-raising about rights and legal aid151 to address unequal access

22

to legal protection and justice. This is also pivotal to ending impunity for violence against women and girls.152 Sierra Leone’s 2007 harmonisation of customary and formal law is a good example of the effective alignment of a national law with CEDAW. This reform grants women the right to acquire and dispose of property in their own name and apply for child maintenance in case of divorce.153 Similar reforms took place in Ethiopia, when women previously denied property and inheritance rights were awarded the right to 50% of property after divorce. This also increased their economic and social status.154 Implementing such laws remains a challenge, but putting appropriate laws in place is a necessary first step. To improve poor legal implementation, in 1974 FIDA Uganda (the Ugandan women lawyers’ association) started to set up national offices and mobile clinics to provide legal aid and education, as well as conducting advocacy and research programmes.155 In 2009 alone, 2,405 cases were reported to their clinics. Innovative approaches like mobile courts have also had some success in implementing law in remote rural areas in poor countries. These have been piloted, for example, by EGLDAM (an organisation working for the eradication of harmful traditional practices in Ethiopia) in Amhara, Ethiopia156 and by the American Bar association in South Kivu, DRC, in an attempt to end impunity for rape.157 So far, such projects have been small-scale and temporary. However, implemented on a large scale and supported by government, they can improve women’s status and end impunity for gender-based violence.

4 Interventions – a multi-sector approach

Changing social norms and attitudes Bringing communities together on an equal basis (including men and boys, women and girls) can build momentum for social change. It can improve health,158 support the implementation of legislation, increase women’s household decisionmaking powers and protect children from harmful practices.159 Stepping Stones160 has pioneered this approach. In South Africa, it has been successful in decreasing risk behaviour, such as men’s increased use of contraception, and it has improved attitudes around gender-based violence.161 Save the Children’s work in community-based child protection uses this low-cost approach.162 In North Wollo, Ethiopia, Save the Children is working with local partner ANPPCAN (the African Network for the Prevention of and Protection against Child Abuse and Neglect) to stop harmful traditional practices like FGM/FGC and child marriage by working with community-based child protection systems, combining protection and health work.

Working with boys and men “Because we’re boys we’re expected to protect our family honour. This involves us in fighting. But we don’t really like it.” Iqbal, eight, Pakistan163

PROMUNDO in Brazil164 and the global network MenEngage,165 which has developed from the recognition that working with men and boys is as important to tackling gender inequality as working with girls and women.166 The most successful of these interventions include community education approaches, and frank and open discussions about gender roles and masculinity, in an effort to transform gender norms.167 Many focus on dialogue, self-exploration and expression of feelings, and engage men in exercises to help them question their own discriminatory practices, reflect on the social construction of masculinity, and consider the methods they use to exercise power. Topics are tailored to local contexts but generally include gender roles and masculinities, relationships, caring for children and families, drugs and alcohol, HIV and AIDS, sexual and reproductive health, and violence.168 Interventions have led to a change in attitudes around gender roles and responsibilities in the home, with men and boys undertaking more household work and sharing decision-making.169 Attitudes around violence against girls and women, including rape, have also been improved170 and communication between husbands and wives has also increased.171

Save the Children is supporting a relatively new body of work led by organisations like

CHOICES – changing gender norms among children in rural Nepal Recognising that gender discrimination leads to lack of mobility, gender-based violence and early marriage for girls in Nepal, Save the Children developed a curriculum to tackle gender norms. Nine activities encourage children to talk about their hopes and dreams, respect and communication, and about what is fair and unfair. The activities take place in community-based clubs for children aged between 10 and 14 years and are facilitated by ex-club members aged 18 to 20.

The activities have brought about positive changes in attitudes to gender norms, roles and responsibilities. For example, the proportion of children thinking it was ‘OK for a man to hit his wife’ dropped from over 40% to less than 5%. The proportion of boys and girls agreeing that both men and women can make decisions about financial matters went up from 40% to 80%, and the number of children thinking that boys who help out with chores are weak dropped from 60% to 20%.

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an equal start

Addis Birhan: involving husbands to end gender inequality and change harmful traditional practices Addis Birhan was started in 2008 in Amhara, Ethiopia, by the Amhara Regional Bureau of Youth and Sports and the Population Council to work with men to change harmful traditional practices and increase gender equality. Male mentors meet with men in rural villages once a week for three to four months, following a locally adapted curriculum developed from models by PROMUNDO (see page 23) and Engenderhealth (an international reproductive health organisation). The modules include discussions around sexual and reproductive health, caring practice, non-violence and gender relations. Pictures are used since most participants cannot read. Meetings are held in the community and include around 25–30 men. So far the project has reached 50,000 men. Successes include better communication between husband and wife, taboos around family planning and reproductive health have been broken, and increased sharing of decision-making in the household. The most significant change has been in the extent to which men help out with domestic chores. Traditionally men did no household work and were not involved in the care of their children. As one husband said, “Before I was making my wife do a lot and manage all the responsibilities. I’m highly regretful. It would have been better if I had cared for my children too. I used to call them her children, but they are also mine.” And as one 16-year-old wife said of her husband, “Before [attending Addis Birhan] he was using money for drinking. Now we discuss and decide things together. Before he didn’t allow me to use contraception and I would hide it from him. When

he found out he would beat me. Now we go together to the health centre to discuss family planning and contraception.” “Our fathers are now involved in helping my mother in the household and taking care of children.” Daughter of participant, 12

Multi-sector implementation and community conversation success factors A number of supporting initiatives are being implemented in the same region, which has helped to reinforce the programme messages. For example, national-level legislation is being implemented across the region and the Population Council is implementing two additional projects in the same area. Meserete Hiwot, a mentoring programme to help break married girls’ isolation, has been working with the Christian Orthodox community to develop a ‘development bible’ in Amharic. The bible is used to train priests to include messages about health, equality and HIV prevention in their weekly sermons. Health professionals and schools are also involved. This multi-sector response is key to Addis Birhan’s success. However, the implementation of legislation is slow, and community-based schemes are said to be the main ingredient in creating change in Ethiopia. All of this work brings together communities and fosters understanding, on communities’ own terms and in their language. “The law supports us, but the most important part is the mentoring programme and raising awareness so that people are able to understand the law.”

Sources: Erulkar A (2011), ‘Men’s health and gender program in rural Ethiopia: results of midterm evaluation’, presentation made at Global Health Council annual conference, Washington DC, June 14, 2011; Population Council (2009), ‘Addis Birhan (‘New Light’): Fostering husbands’ involvement and support in Amhara region, Ethiopia’, Population Council Program Briefs, Ethiopia; field research by Save the Children (2011)

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Male mentor, Addis Birhan

4 Interventions – a multi-sector approach

Increasing opportunities for girls and women Interventions in this area include programmes aimed at increasing girls’ enrolment and retention in school, micro-credit, cash transfers and ‘safe space’ programmes – where livelihood activities like vocational training and micro-credit are combined with life-skills training and a space for girls to meet and support each other. These initiatives improve women’s and girls’ ability to make independent decisions about their own health and that of their children. They also increase women’s role in household decision-making. In addition, expanding women’s and girls’ livelihood options reduces their vulnerability to child marriage, urban migration and transactional sex,172 each of which increase the likelihood of unplanned pregnancies and vulnerability to gender-based violence.

Education Girls’ and women’s education is key to decreasing maternal and child mortality.173 It lowers fertility, increases women’s power in the household and lowers rates of domestic violence.174 As well as providing the financial means, goodquality education and an appropriate environment for girls to go to school, it is often necessary to change attitudes about the value of girls’ education. In southern Sudan, campaigning and awarenessraising about the importance of girls’ education resulted in the female enrolment rate doubling from 19,740 in 2007 to 30,196 in 2008 in Save the Children programme areas.175 Cash transfers have also been used to encourage increased schooling for girls, although there is conflicting evidence about whether these should be conditional. Evidence from Latin America suggests that conditional cash transfers are the best mechanism,176 but a recent study by the World Bank found that unconditional cash transfers worked best in Malawi,177 suggesting that what is appropriate depends on the context.

Increasing girls’ secondary school enrolment by 350% The Female Secondary School Assistance Programme is behind a 350% increase in girls’ enrolment in secondary schools in Bangladesh. Enrolment jumped from 1.1 million in 1991 to 3.9 million in 2005. Additional benefits have included fewer early-age marriages and reduced fertility rates, better nutrition, and more females employed with higher incomes. The programme, launched with International Development Association funding in 1993, supported a government programme to improve access to secondary education for girls. A key innovation was the transfer of

stipends directly into individual girls’ bank accounts. It also improved the quality of schools by providing teacher training, performance incentives to schools and students, and water and sanitation facilities. Following success in 121 of Bangladesh’s 507 sub-districts, the government scaled up the programme to the whole country, focusing particularly on girls in remote areas. While the project has been heralded as global best practice and girls’ enrolment is increasing, there is still a need to address the quality of education delivered.

Source: J Raynor and K Wesson (2006) ‘The Girls’ Stipend Program in Bangladesh’, Journal of Education for International Development 2.2 July; World Bank (2007) World Development Report: Development and the next generation, Washington DC: World Bank; Empowerment Case Studies: Female Secondary School Assistance Project, Bangladesh, World Bank; www.worldbank.org/IDA

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an equal start

Micro-finance The main aim of micro-finance initiatives targeted at women and girls is to increase their access to and control over assets and resources and to bridge the historical disadvantage they have had in this respect, relative to boys and men.178 But experience has shown that building social capital is as important as economic capital.179 As a result, other activities are usually attached to the credit, like life-skills and vocational training and HIV-prevention activities. As well as building important skills, these activities also help girls and women build community networks. Micro-credit initiatives for girls and women have had mixed results. For example, in many instances where gender norms have not been considered in the design of micro-finance programmes women and girls have been made to take loans and then hand the money to male relatives and spouses, so losing control of the asset.180 Those that have been successful have had positive economic effects, and also increased women’s power and agency, changing gender norms and attitudes. They have increased knowledge, control of non-land assets and strengthened financial outcomes.181 They have also expanded women’s role in household decision-making182 and their power in relationships, including over contraceptive use.183 One study found that micro-credit programmes contributed to reductions in intimate partner violence.184

As well as improving women’s own wellbeing, increasing the share of assets they control has positive outcomes for the household, including food security, child nutrition and education (see page 16).185 In Bangladesh, for example, it was found that women’s assets at marriage have a positive and significant effect on the amount spent on children’s clothing and education.186

Safe spaces One of the ways in which girls’ isolation and vulnerability – particularly that of married girls – is being addressed is through the creation of ‘safe spaces’ where they can build social networks and learn marketable skills. Typically, groups include activities like reproductive health education, vocational training and credit or savings programmes. These have been shown to help girls gain confidence, delay the age at which they get married, keep them in school and provide them with skills to earn a living.187 One such example is Israq Israhi, set up by Save the Children and the Population Council to provide new opportunities for adolescent girls in conservative rural areas of Upper Egypt. The curriculum focused on education and health. As a result, 92% of those who were out of school when they entered the programme went on to pass the government literacy exam and 68.5% of participants entered or re-entered school. Another positive outcome was that the proportion of participants who believed that FGM/FGC was necessary decreased from 71% to 18% from baseline to end-line.188

Empowering women through cash transfers – evidence from Save the Children’s programmes Save the Children’s cash transfer programmes in Zimbabwe have had a positive impact on household dynamics, improving communication between wives and husbands, and promoting joint decision-making. During the 2007–08 drought 90% of those registered to receive cash were women as part of a deliberate strategy to empower women and ensure that the cash

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was used to meet their and their children’s needs. Concerns that distributing cash to women in male-headed households would lead to gender-based violence proved unfounded. The main challenge at the household level was ‘generational’ – with children demanding their share of the money even though it was intended to benefit the whole household.

4 Interventions – a multi-sector approach

Delivering equitable health services Equitable access to available, accessible, appropriate and good-quality health services189 is essential to achieving MDGs 4 and 5. Supportive policy frameworks, gender-responsive budgeting, health workers and women’s groups have a particular role in overcoming the challenges to deliver equitable health services.

Health policy In the past decade, Bangladesh and Nepal have achieved dramatic reductions in maternal and child mortality (see box below). In both countries efforts to improve reproductive health and reduce

child mortality have long been part of national health policy frameworks, which have supported multi-sector interventions. In Nepal, since the 1980s this has included training female health workers, making services more accessible and supporting women’s groups.190 In Bangladesh, sexual and reproductive health has been a key part of national policy frameworks since independence. Following the 1994 International Conference on Population and Development, reproductive health and family planning services were included in the national health strategy. During the five years that the strategy was in place there was a 27% reduction in maternal mortality. Although many gains were lost with the government change in 2001, the current policy framework also

Reducing maternal and child mortality in Bangladesh and Nepal Both Bangladesh and Nepal have brought about significant decreases in maternal and child mortality. Bangladesh is on track to achieve MDG 5. In both countries behaviour change is cited as the major driver. Bangladesh – increased use of health facilities for delivery and management of obstetric complications between 2001 and 2010 is linked to: • 40% decline in maternal mortality • direct obstetric deaths – down 45% • women delivering in a health facility – up from 9% to 23% • births attended by a skilled practitioner – up from 12.2 % to 26.5% • women seeking treatment for labour complications – up from 53% to 68%.

Nepal – change in behaviour is linked to better outreach of services and (between 1996 and 2006): • a nearly 50% decline in maternal mortality • 33% decline in child mortality • eight-fold increase in female community health volunteers • 640% increase in number of people serviced • average age at first marriage up from 16 to 16.9 years • mean number of children born down from 3.4 to 3. Underlying causes In Nepal, the number of women with no education has gone down from 80% to 62% between 1996 and 2006. In Bangladesh, educational investment since 2001 has halved the proportion of mothers with no education and the proportion of mothers with secondary education has nearly doubled.

Sources: UNESCAP (2008) ‘Workshop in addressing multisectoral determinants of maternal mortality in the ESCAP region’; P D Pant et al (2008) Improvements in Maternal Health in Nepal: Further analysis of the 2006 Nepal Demographic and Health Survey, SSMP; Bangladesh Maternal Mortality and Healthcare Survey (2010) Summary of key findings and implications

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an equal start

focuses on improving maternal health, and maternal mortality rates are continuing to drop.191 Gender-responsive budgeting192 – a method used for analysing budget allocation with respect to gender – provides an effective tool for analysing public policy, advocating for equitable health spending and diverting funds to reproductive health services.193

Health workers There is currently a global shortfall of 3.5 million health workers, which means that millions of women, particularly in rural communities, have no access to healthcare.194 We urgently need to train up more doctors, nurses and midwives. Community health workers are also vital if we are to fill this gap. Community health workers can provide basic advice, treat certain complications and encourage women to go to health clinics if there is a problem.195 Save the Children and partners are supporting efforts to increase the number of community health workers, in some countries focusing particularly on female health workers.196 Pakistan’s Lady Health Workers are village-based community health workers trained to provide maternal and child healthcare and education to local women in their own homes. The initiative has the best reach of any health facility in the country, with 80% coverage in Punjab and 64% nationwide.197 It has greatly increased vaccination coverage and contraception use,198 as well as the percentage of births attended by a skilled health worker.199 The programme has also had a positive effect on the wellbeing and empowerment of women health workers themselves.200 In 2004, the Ethiopian

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government committed to hiring 35,000 female health extension workers in rural areas. Preliminary evaluations show similar improvements in contraceptive use, hygiene and immunisation rates.201 Health workers need to be trained to understand and tackle gender discrimination, otherwise they can perpetuate it.202 The Health Workers for Change initiative in sub-Saharan Africa and Latin America is a good example of how attitudes and treatment can be improved.203 Through workshops, it uses role play and story-telling to challenge gender stereotyping and improve relationships between health workers and patients. Results have shown changes in attitude, better privacy for patients and less time spent waiting in health facilities.204

Women’s groups Women’s groups are an empowering, sustainable and low-cost intervention that can reduce maternal and child mortality. They can help the poorest women and children, and can produce wide-ranging and long-lasting benefits, particularly in rural areas.205 In India and Nepal, women’s groups have reduced neonatal mortality by around 30%206 and maternal mortality significantly. The greatest impact was derived from communal learning about hygiene and care practices. Women in in project areas were more likely to have antenatal care, institutional delivery, trained birth attendance and to practise hygienic care.207 These changes are highly sustainable. Women’s groups have the potential to improve their community’s capacity to deal with the health and development problems stemming from poverty and social inequalities.208 They are also easy to attach to existing health programmes.

Conclusion and recommendations Gender inequality is pervasive and its many forms hamper child and maternal health. It is a fundamental breach of human rights and is slowing down progress on MDGs 4 and 5. It affects child survival directly through discriminatory practices like foeticide and infanticide. It also perpetuates systematic discrimination against women and girls by limiting livelihood options, sustaining social exclusion and poverty, denying them a voice and marginalising them in national governance and the global political economy. This limits women’s power in society and in the home, and can lead to discriminatory practices like son preference and child and maternal malnutrition. It compromises women’s and girls’ bargaining power and physical integrity, and their equitable access to available, appropriate and good-quality healthcare services, all of which contribute to child and maternal mortality. The scale and impact of gender inequality needs to be fully recognised as an integral part of the global momentum to reduce child and maternal mortality. There needs to be a dramatic increase in efforts to obtain a comprehensive understanding of its scope and effect through data collection and research. Programmes to address child and maternal mortality must mainstream gender into all stages of assessment, design, implementation and monitoring and evaluation. Save the Children calls for policies and strategies to be rooted in the right to health and based on the ‘continuum of care’ model, which addresses health needs across the life cycle. Women and girls must be provided with opportunities to control their own health, seeking the healthcare they need for their own wellbeing and that of their children. It is important to work with communities and legislators

to change social and legal norms that uphold gender inequalities, and to support the health of girls and women during pregnancy, labour and throughout their lives. With only four years left to achieve MDGs 4 and 5, Save the Children is calling for urgent action as well as long-term investment, both pivotal to any serious attempt to address child and maternal mortality.

Quick wins National governments should take urgent action by building on and scaling up existing successful initiatives. This should also be part of a programme of long-term investment.

Listen to women and girls As services are developed and delivered they need to demonstrate sensitivity to the local context and the social challenges which may prohibit many women from seeking the care they need, and men from participating in childcare. Women, girls and communities should be consulted to ensure that they inform service development.

Scale up interventions working with communities to change social norms Evidence suggests that transformative approaches at the community level are effective at changing gender norms and attitudes.209 Developing curricula for community education is relatively low cost to implement and can be easily replicated. They should also be integrated as modules in existing health and protection programmes.

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an equal start

Link protection and health programmes These policy and programming areas need to be integrated to tackle harmful practices and improve maternal and child health. This means increasing cooperation between ministries of health and those with a remit for protection (such as the justice or women’s affairs ministries). Community child protection committees should work to raise awareness of harmful practices and liaise with local health services to identify cases and track incidence.210 Community health workers should be made aware of local discriminatory practices so that they can support women and men to understand how they can affect girls’ and women’s health. They should also be trained so that they can identify cases of abuse and exploitation and report them to protection services.

Long-term investment Building initiatives over time will pay off in generations to come and help to sustain advancements made by quick wins.

Create conducive policy and governance environments National level policy frameworks (particularly for health and protection) need to be grounded in CEDAW, the UNCRC and the ICDP.211 They should be accompanied by adequate funding (including donor support), legal frameworks and strategies for implementation and space for civil society engagement and support. Legal implementation – despite being outlawed, practices like child marriage, foeticide and FGM/ FGC are still widely practised. Continuous and scaled-up monitoring is required, as well as support for innovative solutions, such as the mobile courts being trialled by EGLDAM in Ethiopia and the American Bar Association in South Kivu.212 Building women’s and girls’ leadership is crucial for sustained improvements in gender equality and child and maternal health. Invest in

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programmes to build confidence and leadership skills for girls and women over time. This can include training women to run for elections on different levels.

Increase and scale up initiatives that provide opportunities for and empower girls and women Initiatives that provide opportunities for girls and women – including microcredit, income generation, education and training – can help to strengthen women’s agency, their decision-making and ultimately improve their health-seeking behaviour. A number of good practice initiatives already exist and should be replicated and scaled up, particularly those linked to: • increased livelihood opportunities • better control over and ownership of assets • better access to sexual and reproductive health services • better sexual and reproductive health choices and control over their own bodies • improving girls’ primary and secondary education and vocational training.

Fund and provide appropriate and adequate maternal, newborn and child health services Funding: Resources for maternal and child health are on the increase,213 but more international aid needs to be channelled to maternal, newborn and child health. National governments must also improve their budgetary allocations to maternal, newborn and child health. An estimated $88 billion funding gap needs to be filled to meet MDG 4 and MDG 5. Service delivery: Healthcare services should be delivered across a continuum of care that reflects the stages of an adolescent’s, mother’s and infant’s life. This means adequate and appropriate reproductive health services, maternal healthcare, emergency obstetric care and infant healthcare. Women, girls and communities should inform the design of services.

Conclusion and recommendations

Improve programme monitoring and the development of gender statistics Reporting: There is still a global shortage of data to adequately understand and respond to gender discrimination. Statistical offices, governments, international and civil society organisations should collect, analyse and present data disaggregated by sex and use gender-sensitive indicators.214 The creation of UN Women, presents an opportunity to formalise and centralise data collection mechanisms, and better facilitate data sharing and dissemination. The Commission on Information and Accountability for women and children’s health215 should take a global lead on monitoring gender equality in maternal and child health progress. By incorporating indicators of gender and other socio-economic measures of equality in their data collection, analysis and reporting.

Renew efforts to mainstream gender We reiterate the call from the 1995 Beijing Declaration and Platform for Action216 that the international community give due recognition to gender equality and women’s and girls’ human rights. These goals will only be achieved by making gender equality an objective, by empowering women and mainstreaming gender into all stages of policy and programme work, including planning, budgeting, implementation, monitoring and evaluation. Tackling gender inequality that affects maternal and child health cannot be an isolated task, but requires a multi-sector response.

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appendix

Table 2: Child mortality – percentage change from 1990 to 2008 MDG region n* % of global population CIS

Progress Progress Difference 1990–2008 1990–2008 (M–F) (Females) (Males)

12

3% -55% -57% -3%

Developed regions 35

9% -42% -28% 14%

Eastern Asia

3

15% -65% -61% 4%

33

8% -66% -63% 3%

5

3% -76% -77% -1%

12

0% -31% -29% 2%

South-eastern Asia 11

9% -60% -62% -2%

Latin America & the Caribbean Northern Africa

Oceania

Southern Asia

9

28% -51% -53% -2%

Sub-Saharan Africa 48

20% -20% -20% 0%

Transition countries of south-eastern Europe Western Asia

Total

7

0% -67% -71% -4%

14

3% -59% -61% -2%

189 100% -49% -48% 1%

* ‘n’ represents the number of countries in the region included in analysis, given data availability. Population weighted Calculated from World Health Organization (2010) World Health Statistics, WHO: Geneva

32

appendix

Table 3: Excess female mortality in 1990 and 2008 (absolute and relative results) MDG region n* CIS

Excess of female % of n* childhood deaths childhood deaths 1990 in 1990

Excess of female % of childhood deaths childhood deaths 2008 in 2008

12 -4,095 10.9% 12

-777

6.0%

Developed regions 33 -1,034

4.8% 34 -2,752 21.3%

Eastern Asia

5.4%

Latin America & the Caribbean

3

11,322

33 -2,198

3

-327

0.6%

1.7% 33 -1,296 3.3%

Northern Africa 5 1,632 2.2% 5 1,170 8.2%

Oceania

10

South-eastern Asia

11

Southern Asia

-144

-27,731

9 197,536

Sub-Saharan Africa 48 -1,550 Transition countries of south-eastern Europe Western Asia

Total

3.5% 10

10.3%

11

-79

-7,830

14.9% 9 116,240

2.2%

6.7%

16.7%

0.1% 48 -3,105 0.2%

7 -426 11.9% 7 -102 14.9%

14

-4,029

185 169,283

6.3%

14

-782

4.4% 186 100,361

2.6%

3.6%

* ‘n’ represents the number of countries in the region included in analysis, given data availability. A negative figure indicates excess male childhood deaths, while a positive figure indicates excess female childhood deaths. Columns titled ‘% of childhood deaths’ represent the excess of female/male deaths as a proportion of total childhood deaths in 1990 and 2008. Calculated from World Health Organization (2010) World Health Statistics, WHO: Geneva

33

an equal start

Table 4: Female to male mortality ratio 1990 and 2008 MDG region n* (1990) CIS

Female:Male n* Female:Male childhood mortality (2008) childhood mortality ratio 1990 ratio 2008

12 0.78 12 0.91

Developed regions 30 0.93 31 0.67

Eastern Asia 3 1.12 3 1.00 Latin America & the Caribbean

28 0.95 28 0.90

Northern Africa 5 1.03 5 1.27

Oceania

7 0.99 7 1.00

South-eastern Asia 9 0.80 9 0.76

Southern Asia 9 1.37 9 1.43

Sub-Saharan Africa 48 0.99 48 1.00 Transition countries of south-eastern Europe

6 0.79 7 0.85

Western Asia 12 0.81 12 0.87

Total

169 1.08 171 1.07

* ‘n’ represents the number of countries in the region included in analysis, given data availability. Population weighted (1990 results do not include Andorra and Serbia) Calculated from World Health Organization (2010) World Health Statistics, WHO: Geneva

34

endnotes

The story in numbers

Introduction

1

UNSG (2010) Every Women, Every Child, UN Secretary General Global Strategy on Maternal and Child Health

16

Klasen and Wink (2002) ‘A turning point in gender bias in mortality? an update on the number of missing women’, Population and Development Review

17

2

ICRW (2003) Too Young to Wed: The lives, rights and health and young married girls, Washington: ICRW

3

N M Nour (2006) ‘Health Consequences of Child Marriage in Africa’ Emerging Infectious Diseases, Vol. 12, No. 11, p1644

4

Save the Children (2004) The State of the World’s Mothers 2004: Children having children, Connecticut: Save the Children

5

Save the Children (2004) The State of the World’s Mothers 2004: Children having children, Connecticut: Save the Children

6

S N Tandon and R Sharma (2006) ‘Female foeticide and infanticide in India: an analysis of crimes against girl children’, International Journal of Criminal Justice Sciences, vol 1 issue 1. See also The Economist (2011) ‘Gendercide in India: add sugar and spice’, April 7th 2011, http://www5.economist.com/node/18530101 7

8 L A Bartlett, S Mawji et al (2005) ‘Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002’, The Lancet pp 365, 9462

S D Manandha et al (2004) ‘Effect of participatory intervention with women’s groups on birth outcomes in Nepal: clusterrandomised controlled trial’, The Lancet, 364: 970–79

9

WHO (2010) Violence against women, Fact sheet 239, November 2009, WHO: Geneva 10

WHO Multi country study (2006) p. 52; Action Aid (2010) Hit or Miss: Women’s rights and Millennium Development Goals, Action Aid UK: London, p.28. 11

UNICEF (2007) The State of the World’s Children 2007: Inequalities in the Household, UNICEF: New York. 12

13

ibid

J Bruce (2007) ‘Child marriage in the context of the HIV epidemic’, Promoting healthy, safe, and productive transitions to adulthood, Brief 11, Population Council, pg 4 14

E Gakidou, K Cowling, R Lozano and C J L Murray (2010) ‘Increased educational attainment and its effects on child mortality in 175 countries between 1970 and 2009: a systematic analysis’, The Lancet, volume 376, issue 9745, pp 959–974 15

In this report, child mortality refers to under-five mortality unless otherwise stated. Childhood mortality figures relate to children aged one to four years. Save the Children (2010) A Fair Chance at Life: Why equity matters for child mortality, Save the Children UK: London

18

ibid

WHO (2010) Maternal Mortality, Fact Sheet, No. 348, see http:// www.who.int/mediacentre/factsheets/fs348/en/index.html

19

Save the Children (2010) A Fair Chance at Life:Why equity matters for child mortality, Save the Children UK: London

20

For more definitions and information see World Bank, Gender and Development: A trainer’s manual, Glossary of Gender Terms, http://info.worldbank.org/etools/docs/library/192862/index.html# Last accessed 4.5.2011. See also WHO, Gender, Women and Health, http://www.who.int/gender/whatisgender/en/index.html Last Access 4.5.2011.

21

S Bloom, O Wypu and M Das Gupta (2001) ‘Dimensions of women’s autonomy and the influence on maternal healthcare utilisation in a North Indian City’, Demography volume 38, number 1, pp. 67–78; Smith, L C, U Ramakrishnan, A Ndiaye, L Haddad and R Martorell (2003) The Importance of Women’s Status for Child Nutrition in Developing Countries, International Food Policy Research Institute

22

1 The impact of gender discrimination on child survival L A Bartlett, S Mawji et al (2005) ‘Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002’, The Lancet pp 365, 9462

24

Population Reference Bureau (2009) Family Planning Saves Lives, Fourth Edition, Washington DC: Population Reference Bureau

25

N Datta et al (1988) ‘Validation of causes of infant death in the community by verbal autopsy’, Indian Journal of Pediatrics, 55

26

E Lawn et al, (2006) ‘Estimating the causes of 4 million neonatal deaths in the year 2000’, International Journal of Epidimiology, 35, 3

27

H Yusuf and H Atrash (2010) ‘Parents’ death and survival of their children’, The Lancet, 375, 9730, pp 1944–1946

28

F Anderson et al (2007) ‘Maternal mortality and the consequences on infant and child survival in rural Haiti’, Maternal and Child Health Journal, 11 (4) pp 395–401

29

WHO (2010) Trends in Maternal Mortality: 1990 to 2008, Estimates developed by WHO, UNICEF, UNFPA and The World Bank

30

C Ronsmans et al (2006) ‘Maternal mortality: who, when, where and why’, The Lancet, 368.

31

35

an equal start

UNICEF (2009) The State of the World’s Children: Maternal and newborn health, UNICEF: New York, page 10 32

33

ibid, p. 2

In Burkina Faso 75% of husbands make decisions about their wives’ healthcare on their own, without consultation, while in Nigeria it is 73% and Nepal 51% of husbands. UNICEF (2007) The State of the World’s Children 2007, UNICEF: New York 34

The UNDP Gender Inequality Index is a composite measure reflecting inequality in achievements between women and men in three dimensions: reproductive health, empowerment and the labour market. 35

Sex selection refers to the practice of using medical techniques to choose the sex of offspring. The term sex selection encompasses a number of practices including selecting embryos for transfer and implantation following IVF, separating sperm, and selectively terminating a pregnancy (WHO, ‘Sex selection and discrimination’ in ‘Gender and genetics’, www.who.int/genomics/gender/en/index4. html#Genetic%20technologies%20for%20sex%20selection, accessed 3.5.2011) 36

See MacFarlane et al (1996) ‘Abuse during pregnancy: associations with maternal health and infant birth weight’, Nursing Research, January/February 1996, volume 45, issue 1, pp 37–42; Åsling-Monemi et al (2003) ‘Violence against women increases the risk of infant and child mortality: a case-referent study in Nicaragua’, Bulletin of the World Health Organization, volume 81, number 1, WHO: Geneva 37

World Health Organization (2006) ‘A factual overview of female genital mutilation’, Progress in Sexual and Reproductive Health Research, number 72 38

One study across six African countries estimated that the human cost of FGM/FGC was tantamount to 130,000 life years. This is equivalent of each of the 2.8 million 15-year-olds in the six African countries losing half a month from their lifespan. See T Adam et al (2010) ‘Estimating the obstetric costs of female genital mutilation in six African countries’, Bulletin of the World Health Organization, 88, pages 281–288 39

One child in three in developing countries is stunted, and malnutrition accounts for 35% of child deaths every year. Malnourished children who survive are more vulnerable to infection, don’t reach their full height potential and experience impaired cognitive development. This means they do less well in school, earn less as adults and contribute less to the economy. See Save the Children (2009) Hungry for Change: An eight-step, costed plan of action to tackle global child hunger, Save the Children UK: London 40

See Save the Children (2010) Inequalities in Child Survival: Looking at wealth and other socio-economic disparities in developing countries, Research Paper, Save the Children UK: London. 41

42 See, for example, A Quisimbung and J Maluccio (2000) ‘Household allocation and gender relations: new empirical evidence from four developing countries’, FCND Discussion Paper No. 84, IPFRI: Washington

Evidence from Nigeria suggests that the mother’s education is the single most important factor determining under-five mortality. In 2010 The Lancet concluded that “for every one year increase in the education of women in reproductive age the child mortality decreases by 9.5%” (see Caldwell (1979) ‘Education as a factor in mortality decline: an examination of Nigerian data’, The Lancet; ‘Increased educational attainment and its effects on child mortality in 175 countries between 1970 and 2009: a systematic analysis’, The Lancet, volume 376, issue 9745, page 959–974). Note that even a modest amount of adult education can bring about dramatic changes in child survival. A study of 25 developing countries found that, all else being equal, one to three years of maternal schooling would reduce child mortality by about 15%: World Bank (2003) Gender Equality and the Millennium Development Goals, Gender and Development Group, World Bank: Washington.

45

For the purposes of informing this report Save the Children commissioned ODI to undertake quantitative analysis of the key gender bias variables which affect child and infant mortality. While the analysis was unable to include perception indices, such as control over household decision-making or attitudes to violence, due to methodological limitations, it was able to correlate the following variables with under-five mortality: education, urbanisation, poverty, female labour force participation and available medical facilities. Across the analysis high correlations were found between under-five mortality, male and female education, and access to medical services. Using a Pearson and Spearman correlation model where any figure above 0.70 is considered to be high and any value before 0.40 is considered low, we found both male and female education and under-five mortality to have a correlation value of 0.76.

46

World Bank (2003) Gender Equality and the Millennium Development Goals, Gender and Development Group, World Bank: Washington, pp.19.

47

See, for example, UNHCR (2001) Evaluation of the Dadaab Firewood Project, Kenya, Evaluation and Policy Analysis Unit.

48

See OECD Social Institutions and Gender Index and/or Jones et al., (2011)

49

A Pavao and Miguel Ongil (2010) Euromapping 2010: Mapping European Development Aid and Population Assistance, German Foundation for World Population (DSW) & European Parliamentary Forum on Population and Development (EPF), http://www. euroresources.org/fileadmin/user_upload/Euromapping/EM2010/ Euromapping2010_LoRes.pdf

50

W Ding and Y Zhang (2009) ‘When a son is born: the impact of fertility patterns on family finances in rural China’, Institutions and Governance Program, Berkeley, CA: University of Berkeley

51

See Inter-Parliamentary Union (2010) Women in Politics paper, www.ipu.org/wmn-e/classif.htm (accessed 29/01/08)

52

2 The human, economic and development costs of gender discrimination

43

R Holmes, N Jones and H Marsden (2009) ‘Gender vulnerabilities, food price shocks and social protection responses’, ODI Background Note, ODI: London

53

44 OHCHR (1995) Fact Sheet No.23, ‘Harmful Traditional Practices Affecting the Health of Women and Children’

54

36

Save the Children (2011) No Child Born To Die: Closing the gaps, Save the Children UK; Save the Children (2011) Missing Midwives, Save the Children UK. Action Aid (2010) Hit or Miss: Women’s Rights and the Millennium Development Goals, Action Aid UK: London.

endnotes

Klasen and Wink (2002) ‘A turning point in gender bias in mortality? an update on the number of missing women’, Population and Development Review

55

WHO (2008) Adolescent Pregnancy, NPS Notes, http://www.who. int/making_pregnancy_safer/documents/mpsnnotes_2_lr.pdf 56

57

Save the Children (2004) The State of the World’s Mothers 2004

WHO (2009) ‘Adolescent pregnancy: a culturally complex issue’, Bulletin of the World Health Organization, volume 87, number 6, http:// www.who.int/bulletin/volumes/87/6/09-020609/en/index.html 58

UNDP (2010) Human Development Report, The Real Wealth of Nations: Pathways to Human Development. The Gender-related Development Index (GDI) measures achievement in the same basic capabilities as the Human Development Index does, but takes note of inequality in achievement between women and men. The methodology used imposes a penalty for inequality, such that the GDI falls when the achievement levels of both women and men in a country go down or when the disparity between their achievements increases. The greater the gender disparity in basic capabilities, the lower a country’s GDI compared with its HDI. The GDI is simply the HDI discounted, or adjusted downwards, for gender inequality. 59

K Fuse and E Crenshaw (2005) ‘Gender imbalance in infant mortality: A cross-national study of social structure and female infanticide’, Social Science & Medicine 62/2, January 2006, pp 360–74 and, eg, I Waldron (1998) ‘Sex Differences in Infant and Early Childhood Mortality: Major Causes of Death and Possible Biological Causes’ in Too Young to Die: Genes or gender? United Nations

70

Action Aid (2010) Hit or Miss: Women’s rights and the Millennium Development Goals, Action Aid UK: London; Klasen and Wink (2002) ‘A turning point in gender bias in mortality?: an update on the number of missing women’, Population and Development Review.

71

For a literature review of determinants of child mortality in India see S Jatrana (2003) Explaining Gender Disparity in Child Health in Haryana State of India, Asian MetaCentre Research Paper Series, number16. See also S M George (1997) ‘Female infanticide in Tamil Nadu, India: from recognition back to denial?’, Reproductive Health Matters, volume 5, issue 10, pages 124–132

72

73 T Hesketh, L Lu, and Z Wei Xing (2011) ‘The consequences of son preference and sex-selective abortion in China and other Asian countries’, Canadian Medical Association Journal DOI: 10.1503/ cmaj.101368

A Walia (2005) ‘Female foeticide in Punjab: exploring the socioeconomic and cultural dimensions’, IDEA, 9 August 2005, volume 10, number 1 74

60

UNSG (2011) Every Woman, Every Child

FGM/FGC was also found to have considerable human costs; in the current population of 2.8 million 15-year-old women in the six African countries, a loss of 130,000 life years is expected owing to FGM/FGC’s association with obstetric haemorrhage. This is equivalent to losing half a month from each lifespan. See Adams et al (2010) 61

UNSG (2010) Every Woman, Every Child, http:// everywomaneverychild.com/press/20100914_gswch_en.pdf 62

UNSG (2010) Every Woman, Every Child, http:// everywomaneverychild.com/press/20100914_gswch_en.pdf 63

3  Four snapshots of gender discrimination and its impact

The one-child policy (literally ‘policy of birth planning’) refers to the one-child limitation applying to a minority of families in the Population Control Policy of the People’s Republic of China (PRC). The Chinese government refers to it under the official translation of family planning policy. The policy was introduced in 1978 and initially applied to first-born children in the year of 1979. It was created by the Chinese government to alleviate social, economic, and environmental problems in China. The policy is controversial both within and outside China because of the manner in which the policy has been implemented, and because of concerns about negative social consequences. The policy has been implicated in an increase in forced abortions, female infanticide, and underreporting of female births, and has been suggested as a possible cause behind China’s gender imbalance.

75

64

Klasen and Wink (2002) ‘A turning point in gender bias in mortality? an update on the number of missing women’, Population and Development Review

76

J W Anderson and M Moore, ‘Oppressed: women in the developing world face cradle to grave discrimination and poverty’, Washington Post. 14 February 1993; S M George (1997) ‘Female infanticide in Tamil Nadu, India: from recognition back to denial?’, Reproductive Health Matters, volume 5, issue 10, pages 124–132

77

65

66 S N Tandon and R Sharma (2006) ‘Female foeticide and infanticide in India: an analysis of crimes against girl children’, International Journal of Criminal Justice Sciences, vol 1 issue 1. See also The Economist (2011) ‘Gendercide in India: add sugar and spice’, April 7th 2011, http://www5.economist.com/node/18530101 67 S M George (1997) ‘Female infanticide in Tamil Nadu, India: from recognition back to denial?’, Reproductive Health Matters, volume 5, issue 10, pages 124–132

The Economist, ‘An aversion to having daughters is leading to millions of missing girls’, 7 April 2011 68

T Plafker (2002) ‘Sex selection in China sees 117 boys born for every 100 girls’, British Medical Journal 324:1233 doi:10.1136/ bmj.324.7348.1233/a. 69

N Jones, C Harper and C Watson (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre, ODI: London. N Jones, C Harper and C Watson (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre, ODI: London, p. 54; D P Mehotra, (2003) ‘Key learnings and insights for integration of gender concerns in a reproductive health program’, New Delhi: CARE India; J Bayisenge (2009) ‘Early marriage as a barrier to girls education: a developmental challenge in Africa’, Butare: National University of Rwanda

S M George (1997) ‘Female infanticide in Tamil Nadu, India: from recognition back to denial?’, Reproductive Health Matters, volume 5, issue 10, page 125. In addition a recent base line survey conducted by CARE International Ethiopia identified that ‘many women have even more inequitable views than men – a reflection of persistent cultural norms’. Save the Children UK interview with Yusef Alemu (Sexual and Reproductive health operations manager, CARE International), Conducted on 29 March 2011. 78

79

Save the Children (2004) The State of the World’s Mothers 2004

WHO (2009) ‘Adolescent pregnancy: a culturally complex issue’, Bulletin of the World Health Organization, 87:410–411

80

37

an equal start

WHO (2009) http://www.who.int/bulletin/ volumes/87/6/09-020609/en/index.html 81

UNICEF (200) Equality, Development and Peace, page 19, www.unicef.org/publications/files/pub_equality_en.pdf 82

K G Santhya et al (2010) ‘Associations between early marriage and young women’s marital and reproductive health outcomes: evidence from India’, International Perspectives on Sexual and Reproductive Health, 36 (3) page 132

95

See for example evidence from Nepal, Bajracharya and Amin (2010) Poverty, Gender and Youth: Poverty, Marriage Timing, and Transitions to Adulthood in Nepal: A longitudinal analysis using the Nepal Living Standards Survey, Working Paper Number 19, Population Council: New York

96

N M Nour (2006) ‘Health Consequences of Child Marriage in Africa’, Emerging Infectious Diseases, volume 12, number 11, pg 1646 83

V K Paul et al (2011) ‘Reproductive health, and child health and nutrition in India: meeting the challenge’, The Lancet, 377, pg 341 84

Save the Children (2004) The State of the World’s Mothers 2004: Children having children, Connecticut: Save the Children 85

86

Save the Children (2004) The State of the World’s Mothers 2004

N M Nour (2006) ‘Health Consequences of Child Marriage in Africa’, Emerging Infectious Diseases, volume 12, number 11, pg 1647 87

ICRW (2003) Too Young to Wed: The lives, rights and health and young married girls, Washington: ICRW 88

N M Nour (2006) ‘Health Consequences of Child Marriage in Africa’, Emerging Infectious Diseases, volume 12, number 11, pg 1644 89

UNICEF (2001) Early Marriage: Child spouses, Innocenti Digest No. 7, p.6

97

N Jones, C Harper and C Watson (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre, ODI: London, page 18.

98

N Otoo-Oyortey and S Pobi (2003) ‘Early Marriage and Poverty: Exploring Links for Policy and Programme Development’, London: Forum on Marriage and the Rights of Women and Girls; N OtooOyortey and S Pobi (2003) ‘Early marriage and poverty: exploring links and key policy issues’, Gender & Development 11 (2), 42­–51

99

N Jones, C Harper and C Watson (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre, ODI: London, Chapter 3 100

International Centre for Research for Women (2007) ‘New Insights on Preventing Child Marriage: A global analysis of factors and programs’, page 4

90

For example, in India, almost half (44.5%) of women aged 20 to 24 years are married before they the age of 18 and 22% of all 20–24-year-old women have given birth by the age of 18: A Raj et al (2010) ‘The effect of maternal child marriage on morbidity and mortality of children under 5 in India: cross-sectional study of a nationally representative sample’, British Medical Journal, 340:b4258, pg 1 91

T Hampton (2010) ‘Child marriage threatens girls’ health’, The Journal of American Medical Association, 4 August 2010, volume 304, number 5, page 509; K G Santhya et al (2010) ‘Associations between early marriage and young women’s marital and reproductive health outcomes: evidence from India’, International Perspectives on Sexual and Reproductive Health, 36 (3) page 132

101

See note 93.

102 Bird and Espey (2011) ‘Power, patriarchy and land: examining women’s land rights in Uganda and Rwanda’, in S Chant (ed) (2011) The International Handbook of Gender and Poverty, pp.360–366 103 Action Aid (2010) Hit or Miss: Women’s rights and Millennium Development Goals, Action Aid UK: London, p.28

92

A fistula is a hole between an internal organ and the outside body. An obstetric fistula is a hole between a woman’s birth passage and one or more of her internal organs. This hole develops over many days of obstructed labour, when the pressure of the baby’s head against the mother’s pelvis cuts off blood supply to delicate tissues in the region. The dead tissue falls away and the woman is left with a hole between her vagina and her bladder, and sometimes between her vagina and rectum. This results in permanent incontinence of urine and/or faeces. Fistula can also be the result of sexual violence. Many women who develop fistulas are ostracised from their communities and suffer from skin infections, kidney disorders and even death if left untreated. The WHO estimates that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa, with between 50,000 to 100,000 women worldwide developing obstetric fistula every year. Obstetric fistula can largely be avoided by delaying the age of first pregnancy, by the cessation of harmful traditional practices and by timely access to quality obstetric care. The Panzi Hospital in Congo is a pioneer in treating victims of traumatic fistula. 90% of patients at the Addis Ababa fistula hospital are survivors of child marriage or FGM/FGC. 93

EGLDAM and Save the Children Norway (2008) ‘Follow-Up National Survey on Harmful Traditional Practices’, EGLDAM: Addis Ababa, page 85 and 141

94

38

WHO (2010) Violence against women, Fact sheet 239, November 2009, WHO: Geneva

104

105 S O Rutsein (1984) ‘Effects of preceding birth intervals on neonatal, infant and under five mortality and nutritional status in developing countries’, International Journal of Gynaecology and Obstetrics, Supp 1:S7 – 24 106

UNFPA (2005) The State of the World Population

107

ibid

Note: this is the case for women infected with HIV-1, the most common type. C D’Ubaldo (1998) ‘Association between HIV-1 infection and miscarriage: a retrospective study’, AIDS, 12: 9, pp. 1087–1093

108

109

UNICEF (2008) Children and AIDS: Third stocktaking report, 2008

J Nakiyingi, M Bracher, J Whitworth et al (2003) Child survival in relation to mother’s HIV infection and survival: evidence from a Ugandan cohort study, AIDS, volume 17, issue 12, pp 1827–34 110

111 African Population and Health Research Centre (2010) Marital Rape and its Impacts: A policy briefing for Kenyan Members of Parliament, No. 13, APHRC: Nairobi.

B R Ganatra, K J Coyaji and VN Rao (1998) ‘Too far, too little, too late: a community-based case-control study of maternal mortality in rural west Maharashtra, India’, WHO Bulletin OMS, volume 76, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2312494/pdf/ bullwho00389-0066.pdf

112

endnotes

113 UN General Assembly 2006 in N Jones, C Harper and C Watson (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre, ODI: London. 114 Note that there is evidence to suggest that girls partake in transactional sex for a range of other reasons, not only as a result of systemic exclusion, such as peer pressure and/or gifts. See, for example, N Luke and K Curtz (2002) Cross-generational and Transactional Sexual Relations in Sub-Saharan Africa: Prevalence of behavior and implications for negotiating safer sexual practices, ICRW and PSI: Washington. 115 W Girma and A Erulkar (2009) Commercial Sex Workers in Five Ethiopian Cities: A baseline survey for USAID targeted HIV prevention programe for most-at-risk populations, Population Council and USAID 116 Based on data for child mortality and live births in 2008 from UNICEF, The State of the World’s Children, and a list of 29 countries made up of those countries that appeared on at least three of five externally-generated lists of fragile and failed states between 2005 and 2007: Top 32 countries in the Failed States Index (The Fund for Peace); DFID Proxy List of Fragile States; Bottom Quintile of the Index of State Weakness (Brookings Institution); World Bank List of Fragile States; and CIFP Top 40 Fragile States. India and China, which make up 25% of child deaths, are not included in the list of fragile states.

Based on the UCDP/PRIO Armed Conflict Dataset, taking all of the Countdown to 2015 countries that have experienced armed conflict between 1990 and 2008 (latest data available) 117

Sir John Holmes, cited in J Gettleman, ‘Rape epidemic raises trauma of Congo war’, New York Times, 7 October 2007 118

DFID, Country profiles: Democratic Republic of Congo, http:// www.dfid.gov.uk/where-we-work/africa-west--central/congodemocratic-republic/?tab=0 119

120 UNSG Report (S/2009/160) March 2009, para 69 states that during the reporting period of the cases of rape reported to them, 35% to 50% were aged between 10 and 17 years of age and in addition a further 10% of cases were under the age of 10.

The Guardian (2011) Poverty Matters Blog: In Ivory Coast, when conflict starts women become targets, http://www.guardian.co.uk/ global-development/poverty-matters/2011/apr/13/ivory-coastwomen-targets-of-rape?intcmp=239 121

UNICEF (2007) The State of the World’s Children 2007: Inequalities in the Household, UNICEF: New York 122

L C Smith, U Ramakrishnan. A Ndiaye, L Haddad and R Martorell (2003) The Importance of Women’s Status for Child Nutrition in Developing Countries, International Food Policy Research Institute 123

124 UNICEF (2007) The State of the World’s Children 2007: Inequalities in the Household, UNICEF: New York 125 S Bloom, O Wypu and M Das Gupta (2001) ‘Dimensions of women’s autonomy and the influence on maternal healthcare utilisation in a North Indian City’, Demography volume 38, number 1, pp. 67–78

In Ethiopia women eat lower quantities and less variety of foods than their husbands. Women also showed the lowest food consumption throughout the different stages of recent food price hikes. Men were eating food with greater dietary diversity. For example, in Asti Wonberta, Ethiopia, men consumed an average 126

of 7 different items at the outset of the food crisis, while women were consuming 5.2 different items. At the peak of the crisis men were reporting eating only an average of 4.1 different foodstuffs in comparison to women’s 3.5. After the peak when the situation improved, men were eating 5 different items compared with women consuming 3.6. See Z B Uraguchi (2010) ‘Food price hikes, food security, and gender equality: assessing the roles and vulnerability of women in households of Bangladesh and Ethiopia’, Gender & Development, pp. 491–501, Oxfam Journal 127 Note that access to health is not only dictated by gender. Income and disposable resources are also key; in Bangladesh, skilled health personnel attend more than 40% of births among the richest fifth of the population while among the poorest fifth this figure falls to just 3.5%. For poor women, low economic and social status particularly inhibits them from seeking urgently needed medical support. Action Aid (2010) Hit or Miss: Women’s Rights and the Millennium Development Goals, Action Aid UK: London. 128 N Jones and Tran Thi Van Anh (2010) ‘Gendered Risks, Poverty and Vulnerability in Viet Nam: A case study of the National Targeted Programme for Poverty Reduction’

L C Smith, U Ramakrishnan, A Ndiaye, L Haddad and R Martorell (2003) The Importance of Women’s Status for Child Nutrition in Developing Countries, International Food Policy Research Institute 129

130 Hallman (2000) Mother–Father Resource Control, Marriage Payments, and Girl–Boy Health in rural Bangladesh, FCND Discussion Paper No. 93, IPFRI: New York 131 USAID (2003) ‘Women’s property and inheritance rights: improving lives in changing times’, final synthesis and conference proceedings paper, Washington DC: USAID and Women in Development; N Jones, C Harper and C Watson (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre, ODI: London, page 55 132 S Shehzad (2006) ‘Gender-Aware Policy Appraisal: Health sector’, Prepared for the Gender Responsive Budget Initiative Project 133 UNSG (2010) Every Women, Every Child, UN Secretary General Global Strategy on Maternal and Child Health 134 In recent years total ODA for MNCH has increased helping to compensate for a small part of this deficit. In 2007 and 2008 US$4.7 billion and $5.4 billion (constant 2008 US$), respectively, were disbursed as ODA in support of maternal, newborn, and child health activities in all developing countries. These amounts reflect an impressive 105% increase between 2003 and 2008, but no change relative to overall ODA for health, which also increased by 105%. Of this approximately 30% was directed to maternal and newborn healthcare, versus 70% for child health. In 2009 the HighLevel TaskForce on International Innovative Financing for Health Systems estimated the mean additional annual funding needs for maternal, newborn, and child health in 49 low-income countries was between $2.0 billion and $3.0 billion above 2006 levels from 2009 to 2015. An additional $9.9–26.5 billion would be required on average per year to strengthen health systems. In view of these estimated requirements, ODA for maternal, newborn, and child health in 2008, which constitutes a $1.5 billion increase from 2006, shows both substantial progress and persisting unmet needs. See C Pitt, G Greco, T Powell-Jackson and A Mills (2010) ‘Countdown to 2015: Assessment of official development assistance to maternal, newborn, and child health, 2003–08’, The Lancet, 17 September 2010

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135 UNICEF, The State of the World’s Children 2011. 35% of 136,712,000 births were not attended by someone with midwifery skills.

Estimated from DHS data from 40 countries for which data on assistance during delivery was available (Measure DHS data was accessed 7 March 2011). The estimate was obtained by comparing the percentage of women who reported ‘no one’ in this category for births in three years preceding the survey, with the most recent total births figures from UNICEF, The State of the World’s Children 2011. 136

International Confederation of Midwives, News Release: ‘350,000 more midwives needed to reduce unnecessary deaths and injury in childbirth’, 30 April 2010 www. internationalmidwives.org/ Portals/5/2010/IDM%202010%20News%20Release%20-%205%20 May%202010.pdf 137

Save the Children (2010) Missing Midwives, Save the Children UK: London, pp.vii 138

A recent survey in India highlighted that the unmet need for contraception among young unmarried women was high: 27% for 15–19 year olds and 21% for 20–24 years. See V K Paul et al (2011) ‘Reproductive health, and child health and nutrition in India: meeting the challenge’, The Lancet, 377, pg 339.

society organisations and networks, falls in the fertility rate over the past three decades and expanding job opportunities for women have all contributed to a narrowing of disparities between the sexes. Save the Children (2010) Inequalities in Child Survival: Looking at wealth and other socio-economic disparities in developing countries, Research Paper, Save the Children UK: London, p.21. L Chen and H Standing, ‘Gender equity in transitional China’s healthcare policy reforms’, Feminist Economics 13 (3–4), July/October 2007, pg 199 145

146 J Hanefield (2008) ‘How have global health initiatives impacted on health equity?’ Promotion and Education, 15, 19 147 S Rousseau (2007) ‘The politics of reproductive health in Peru: gender and social policy in the global South’, Social Politics 14 (1), pg 103

A George, A Iyer and G Sen (2005) ‘Gendered health systems biased against maternal survival: preliminary findings from Koppal, Karnataka, India’, IDS Working Paper 253, pg 1

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139

Guttmacher Institute (2009) Abortion Worldwide: A decade of uneven progress 140

‘Gender Equity in Health,’ Women, Health and Development Program, Pan-American Health Organisation, pg 6 141

142

Save the Children (2010) The State of the World’s Mothers

143 Sex differentials in immunisation coverage were found to exist in a range of contexts (against both boys and girls); such differentials were often exacerbated in the hardest to reach populations; and there were major sex differentials in the burden of diseases across vaccine-amenable diseases. Considerable regional difference was evident, highlighting the importance of local tailored analysis and service delivery. In south and south-east Asia there was an apparent bias against girls coverage ranging from a 13.4% gap in India to a 4.3% gap in Nepal. Sub-Saharan Africa showed variation between countries. In Gabon and the Gambia, there was also a bias against girls, with a gender gap of 7.2% and 6.7%, respectively. However, in Madagascar, Nigeria and Namibia, there was a bias against boys of 12%, 7.9% and 5.6%, respectively. It has been suggested that this bias against boys owes to fears that vaccinations may reduce male fertility. See N Jones, C Walsh and K Buse (2008) Gender and Immunization Abridged Report: A knowledge stocktaking exercise and independent assessment of the GAVI Alliance, report commissioned by the Global Alliance for Vaccines and Immunizations (GAVI) Secretariat.

In Bangladesh a historical cultural tradition of son preference has meant that boys were more likely to receive lifesaving interventions than girls. However, in the last ten years, sex differentials in the coverage of measles vaccination have largely disappeared and child mortality rates have significantly improved. From 1993 to 2007, the child mortality rate fell by on average 5.3% annually, and the gap between boys’ and girls’ prospects of survival closed. Improved equity in health service coverage cannot be attributed to any single initiative, but to a series of steps aimed at empowering women and improving health service access. Microcredit schemes, improved female education (driven partly by increased use of stipends for girls’ secondary schooling), the growth of vibrant women’s civil 144

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4  Interventions – a multi-sector approach 149 S D Manandha et al (2004) ‘Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: clusterrandomised controlled trial’, The Lancet, 364: 970–79 150 Countries that haven’t signed or ratified the convention are for example the Vatican, Iran, Somalia, Sudan and Tonga. http://treaties. un.org/Pages/Treaties.aspx?id=4&subid=A&lang=en

N Jones et al (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre 151

152 Amnesty International (2010) ‘Six-point checklist on Justice for violence against women’, http://www.amnesty.org/en/library/asset/ ACT77/002/2010/en/4c736156-f18a-40c7-95a9-9e8677c562b9/ act770022010en.pdf

N Jones et al (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Chronic Poverty Research Centre, p. 23–24. 153

154 D Barne (2010) ‘Ethiopian women gain status through landholding’, Gender Equality as Smart Economics, October 2010, World Bank

FIDA Uganda (2009) Walking with the Women of Uganda: Annual report 2009 155

EGLDAM (2010) ‘Integrated approach to protect female children against sexual abuse and violence’, progress report to Oakwood Foundation 156

157 American Bar Association, Democratic Republic of Congo, http:// apps.americanbar.org/rol/africa/democratic_republic_congo.html 158 M E Greene (2010) Synchronizing Gender Strategies: A cooperative model for improving reproductive health and transforming gender relations, USAID, IGWG, PRB, EngenderHealth 159 S Goldstein, S Usdin, E Scheepers and G Japhet (2005) ‘Communicating HIV and AIDS: what works? A report on the impact evaluation of Soul City’s fourth series’, Journal of Health Communication, 10, 465–83 160

Stepping Stones website, http://www.steppingstonesfeedback.org

endnotes

161 USAID (2003) The Synergy Project – Men and reproductive health programmes: Influencing gender norms; Jewkes et al (2006) ‘A cluster randomised trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behavior amongst youth in the rural eastern Cape, South Africa’, Tropical Medicine and International Health, 11, 3–16; R Jewkes et al (2006) ‘Rape perpetration by young, rural South African men: prevalence, patterns, risk factors’, Social Science and Medicine, 63, number 11, 2949–61

176 World Bank (2009) Conditional Cash Transfers: Reducing present and future poverty 177 World Bank (2010) Cash or Condition? Evidence from a cash transfer experiment, Impact Evaluation Series No. 45 178 N Jones et al (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Manchester: Chronic Poverty Research Centre, pp 53

Amosu et al (2011) ‘To what extent are multidimensional micro finance groups, which target the ultra poor, able to support civic activism among ultra poor women?’, Working Paper 191, March, Manchester: Chronic Poverty Research Centre 179

Save the Children (2009) What are we Learning about Protecting Children in the Community? An inter agency review of evidence on community based child protection mechanisms, executive summary 162

163 Save the Children (2007) Boys for Change: Moving towards gender equality, p. 10 164

Promundo website, http://www.promundo.org.br/

165

MenEngage website, http://www.menengage.org/

Save the the Children (2007) Boys for Change: Moving towards gender equality 166

G Barker et al (2007) Engaging men and boys in changing genderbased inequity in health: Evidence from programme interventions, Geneva: WHO; WHO (2010) Policy Approaches to Engaging Men and Boys: In achieving gender equality and health equity; PROMUNDO (2010), Engaging Men and Boys in Gender Equality and Health: A toolkit, New York: UNFPA, MenEngage, PROMUNDO

180 L Mayoux (2006) Women’s Empowerment through Sustainable Micro Finance: Rethinking best practice 181 J Bruce and K Hallman (2008) ‘Reaching the girls left behind’, Gender and Development, volume 16, number 2 182 A Morrison and S Sabrawal (2008) The Economic Participation of Adolescent Girls and Young Women. Why does it matter? PREM notes no. 128, Washington, World Bank

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168 USAID (2003) The Synergy Project – Men and reproductive health programmes: Influencing gender norms

USAID (2003) The Synergy Project – Men and reproductive health programmes: Influencing gender norms; Save the Children (2011) Interviews with programme beneficiaries in Addis Birhan, EngenderHealth (men as partners) http://www.engenderhealth.org/ our-work/gender/men-as-partners.php, 169

170 USAID (2003) The Synergy Project – Men and reproductive health programmes: Influencing gender norms 171 Hartmann et al (2010) ‘Changes in Couples’ Communication as a Result of a Male Involvement Family Planning Intervention’, Family Health International and Save the Children

W Girma and A Erulkar (2009) Commercial Sex Workers in Five Ethiopian Cities: A baseline survey for USAID targeted HIV prevention programe for most-at-risk populations, Population Council and USAID 172

J C Cladwell (1979) ‘Education as a factor in mortality decline: an examination of Nigerian data’, Population Studies, volume 33, number 3, pp. 395–413; UNESCO (2011) The Hidden Crises: Armed conflict and education, Education For All (EFA) Global Monitoring Report; E Gakidou, K Cowling, R Lozano and C J L Murray (2010) ‘Increased Educational attainment and its effects on child mortality in 175 countries between 1970 and 2009: a systematic analysis’, The Lancet, volume 376, issue 9745, pp 959–974 173

174 Plan (2009) Because I’m a Girl: The State of the Worlds Girls 2009. Girls in the global economy – adding it all up, Woking: Plan International; N Jones (2010) Stemming Girls’ Chronic Poverty: Catalysing development change by building just social institutions, Manchester: Chronic Poverty Research Centre 175 Save the Children (2008) Rewrite the Future: Annual report Southern Sudan (summary sheet)

IPPF, UNFPA and Young Positives (2007) Change, Choice and Power: Young women, livelihoods and HIV prevention 183

J C Kim et al (2007) ‘Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa’, American Journal of public health, no. 10: 1794–1802 184

A Quisumbing (ed) (2003) Household Decisions, Gender and Development: A synthesis of recent research, Washington DC: IFPRI 185

A Quisumbing (2010) ‘Gender and household decision-making in developing countries: A review of evidence’, in S Chant (ed) The International Handbook of Gender and Poverty: Concepts, research, policy, Cheltenham, UK: Edward Elgar Publishing Ltd, pg 162 186

187 J Bruce and K Hallman (2008) ‘Reaching the girls left behind’, Gender and Development, volume 16, number 2; Save the Children (2010) ‘Strengthening girls’ voices’, Malawi, sustainability evaluation report to the Nike Foundation; Save the Children (2010) “Kishoree Kontha”, Evaluation, Nike 188 Population Council and Save the Children (2008) ‘Providing new opportunities to adolescent girls in socially conservative settings: The Ishraq program in rural Upper Egypt’

Physicians for Human Rights, PHR Toolkits, AAAQ framework, http://phrtoolkits.org/toolkits/medical-professionalism/the-humanrights-basis-for-professionalism-in-health-care/aaaq-framework/ 189

190 P D Pant et al (2008) Improvements in Maternal Health in Nepal: Further analysis of the 2006 Nepal Demographic and Health Survey, SSMP

R Jahan (2003) ‘Restructuring the health system: experiences of advocates for gender equity in Bangladesh’, Reproductive Health Matters, 11(21):183–191; R Jahan (2007) ‘Maternal and infant health in diverse settings’, American Journal of Public Health, volume 97, number 7 191

192

UN Women http://gender-budgets.org

193 Mexico Ministry of Health (2004), Guide for the Formulation of Public Budgets in the Health Sector using a Gender Perspective;

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UNIFEM/UNFPA (2006) Gender Responsive Budgeting and Women’s Reproductive Rights 194 Save the Children (2011) No Child Born to Die: Closing the gaps; Save the Children (2010) The State of the World’s Mothers: Women in the front lines of healthcare 195

Save the Children (2011) Missing Midwives

UNICEF (2008) The State of the World’s Children: Child survival; WHO (2010) Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A systematic review, country case studies, and recommendations for integration into national health systems 196

197

207 M Ezzati (2004) ‘Influencing birth outcomes in Nepal’ The Lancet, Vol 364 208 K Azad et al (2010) ‘Effect of scaling up women’s groups on birth outcomes in three rural districts in Bangladesh: a clusterrandomised controlled trial’, The Lancet, Vol 375

UNICEF (2008) The State of the World’s Children: Child survival

198 M Douthwaite and P Ward (2005) ‘Increasing contraceptive use in rural Pakistan: an evaluation of the lady health workers programmes’, Health Policy and Management, 20(2):117–123 199 S Shehzad (2006) ‘Gender-Aware Policy Appraisal: Health sector’, Prepared for the Gender Responsive Budget Initiative Project, The Ministry of Finance, Government of Pakistan with the technical and UNDP 200 Oxford Policy Management (2009) ‘Lady health workers: study of socio-economic benefits and experiences’, an external evaluation of the national programme for family planning and primary healthcare

Save the Children (2010) The State of the World’s Mothers: Women on the Front Lines of Healthcare 201

Save the Children’s research in Ethiopia showed that men traditionally have been alienated from participating in healthcare activities related to maternal and child health. 202

S Fonn and M Xaba (2001), ‘Health Workers for Change: developing the initiative’, Health Policy and Planning, 16 (Suppl. 1): 13–18 203

Onyango-Ouma et al (2001) “An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool”, Health Policy and Planning, 16 (Suppl. 1): 24–32 204

205 Testifying to their affordability, in Nepal this intervention worked out at a saved cost per life of $111, considerably below the $127 recommended by the World Bank as most cost effective in S D Manandha et al (2004) ‘Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: clusterrandomised controlled trial’, The Lancet, 364: 970–79

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206 S D Manandha et al (2004) ‘Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: clusterrandomised controlled trial’, The Lancet, 364: 970–79; P Tripathy et al (2010) ‘Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial’, The Lancet 2010; 375: 1182–92

Conclusion and recommendations E M Greene (2010) ‘Synchronising gender strategies: a cooperative model for improving reproductive health and transforming gender relations’, Interagency Working Group (IGIW), USAID, PRB, EngenderHealth. 209

210 Save the Children (2009) What are we Learning about Protecting Children in the Community? An inter agency review of evidence on community based child protection mechanisms, executive summary

International Conference on Population and Development in Cairo, http://www.un.org/popin/icpd2.htm 211

EGLDAM (2010) ‘Integrated Approach to Protect Female Children Against Sexual Abuse and Violence’, Progress report to Oakwood Foundation; http://apps.americanbar.org/rol/africa/ democratic_republic_congo.html 212

Pitt, G Greco, T Powell-Jackson, A Mills, (2010) ‘Countdown to 2015: assessment of official development assistance to maternal, newborn, and child health, 2003–08’, The Lancet, Vol. 376 No. 9751 pp. 1485–1496 213

214 UNECE (2010 Developing Gender Statistics: A practical tool, United Nations, Geneva 215 See WHO, ‘Accountability Commission for health of women and children’, http://www.who.int/topics/millennium_development_goals/ accountability_commission/en/

UN Women, ‘The United Nations Fourth World Conference on Women’, http://www.un.org/womenwatch/daw/beijing/platform/ plat1.htm 216

why gender equality matters for child survival and maternal health

“This Save the Children report powerfully demonstrates the huge costs of failing to tackle gender inequality. Gender discrimination results in unnecessary loss of lives, in wasted economic potential and slow progress on the Millennium Development Goals. Considering gender inequality and other social barriers to health is essential for equal and sustained progress on MDGs 4 and 5; as well as overall development and empowerment of families, communities and nations. “An Equal Start provides startling evidence to suggest that although child mortality is on the decline, discrimination against females persists. For every 100 boys’ deaths in 1990, 108 girls died. In 2008 the figure was 107 – a negligible reduction. Looking at specific examples of discriminatory practice, like child marriage, the report shows how entrenched and pervasive inequalities are, with considerable effects upon maternal and child health. Worldwide, 51 million girls between the ages of 15 and 19 are married. But babies born to girls in their teens face a 50% higher risk of dying before age one that is than babies born to women in their 20s. “This report calls for global recognition of the impact of gender discrimination upon maternal and child health. It asks donors, national governments and other relevant actors to pay due consideration to gender inequalities within their health service delivery. It also calls for protection and health services to be better connected and for women for be empowered so that they are free to make independent decisions about their own sexual and reproductive health. It challenges us to place women’s and girls’ leadership at the centre of our work. “An Equal Start is a must-read – and a must-ACT – for all those who believe in equal rights and opportunities for men and women, and for all those working towards a reduction in child and maternal mortality.” Nyaradzayi Gumbonzvanda General Secretary World YWCA

savethechildren.org.uk

cover photo: Raghu Rai/Magnum for Save the Children

an equal start