How Gender Impacts Safe Motherhood Explain that to more systematically take into account gender norms and roles—and to design program interventions that take these gender norms and roles into account—it is important to have an overall general framework of key questions and steps to guide this process. Explain that in this presentation, we will first review key components of gender analysis—and then we will discuss how to use this in the context of developing and implementing programs (i.e., in “gender integration”). IGWG Training Taskforce: Gender and Safe Motherhood

Safe Motherhood Basics To start, we will review some of the basics of safe motherhood and maternal mortality.

Childbirth: life-threatening risk for women in the developing world As of 2005, it is estimated that 536,000 women die yearly from causes related to pregnancy and birth. 99% of those deaths occur in the developing world Another 10–20 million women every year face severe health problems, such as obstetric fistula. Childbirth remains an unnecessarily dangerous and life-threatening risk for women throughout the developing world. A cross-national study of 79 developing countries found that women’s status is a strong predictor of maternal mortality (Shen, C. and Williamson, J.B. 1999. Maternal Mortality, Women's Status, and Economic Dependency in Less Developed Countries: A Cross-National Analysis. Social Science & Medicine 49: 197–214). Women and girls residing in East and West Africa face the highest risks of maternal mortality; women living in some parts of Asia also are at high risk: Of the estimated 536,000 maternal deaths in 2000, 95 percent occurred in Africa and Asia, while only 4 percent occurred in Latin America and the Caribbean and less than 1 percent in the more developed regions of the world. In terms of the maternal mortality ratio (MMR), the world figure in 2005 was estimated to be 402 per 100,000 live births. By region, the MMR was highest in Africa (Africa overall 824, Northern 157, sub-Saharan 905), followed by Oceana (427), Asia (329) and Latin America and the Caribbean (LAC) (132), and the developed countries (9). Although there has been a reduction of maternal mortality since 1990 in Asia (19.7%) and LAC (26.3%), there has been almost no change in sub-Saharan Africa (-1.8%). Hill K, K Thomas, C AbouZahr et al. 2007. “Estimates of Maternal Mortality Worldwide Between 1990 and 2005: An Assessment of Available Data.” Lancet 370: 1311–1319. Another 10–20 million have severe health problems every year, including obstetric fistula. UNFPA Facts about Safe Motherhood. Accessed November 18, 2008 at http://www.unfpa.org/mothers/facts.htm.

Common causes of maternal death globally There are many causes of maternal mortality and morbidity. Ask the group what it thinks are the main causes of maternal death. Review that more than 80 percent of maternal deaths worldwide are due to five direct causes. Globally, the relative proportions of each of these causes are: hemorrhage (severe bleeding) (21%), unsafe abortion (14%), hypertensive disease of pregnancy (eclampsia) (13%), sepsis (infection) (8%), and obstructed labor (8%) (UNFPA, “Facts about Safe Motherhood”). Note for facilitator: Indirect causes include anemia, malaria, and heart disease. (UNFPA. 2008. “Providing Emergency Obstetric and Newborn Care to All in Need.” Retrieved November 19, 2008, from http://www.unfpa.org/mothers/facts.htm.) Mention that there is variation among regions in terms of the relative proportion of deaths that each of these main causes contributes. In Africa and Asia, hemorrhage remains the leading cause of death, whereas in LAC the leading cause is hypertensive disorders. (K . Khan , D . Wojdyla, L . Say, A.M. Gülmezoglu, and P.F. Van Look. 2006. “WHO Analysis of Causes of Maternal Death: A Systematic Review.” Lancet. 367(9516):1066–74.)

The three deadly delays 1. Recognizing signs and deciding to seek care 2. Identifying and reaching a medical facility 3. Receiving adequate and appropriate treatment “Timing proves to be critical in preventing maternal death and disability: Although post-partum hemorrhage can kill a woman in under two hours, for most other complications, a woman has between 6 and 12 hours or more to get life-saving emergency care. The “three delays” model has proved to be a useful tool to identify the points at which delays can occur in the management of obstetric complications and to design programs to address these delays. The first two “delays” (delay in deciding to seek care and delay in reaching appropriate care) relate directly to the issue of access to care, encompassing factors in the family and the community, including transportation. The third “delay” (delay in receiving care at health facilities) relates to factors in the health facility, including quality of care.” As we will explore in the next part of this session, gender plays a large role in all of these delays. (UNFPA. 2008. “Providing Emergency Obstetric and Newborn Care to All in Need.” Retrieved November 19, 2008, from http://www.unfpa.org/rh/mothers/index.htm.)

How can maternal deaths be prevented? Priority interventions include: Skilled attendance at all births Emergency obstetric care Reproductive health and family planning services, including safe abortion Also, greater focus on postnatal care Given these causes of maternal mortality, ask participants what they see as the priority health-sector interventions. Explain that a broad international consensus emerged in the 18–24 months leading up to the October 2007 Women Deliver conference that priority health sector interventions include Skilled attendance at all births Emergency obstetric care Reproductive and family planning services, including safe abortion. (Starrs, A.M. 2007. “Delivering for Women.” Lancet 370: 125 – 87.) In addition, attention to the post natal period is critical. Most maternal deaths (61%) take place during labor, delivery, or in the immediate postpartum period. (UNFPA, “Facts About Safe Motherhood.” Accessed November 18, 2008 at www.unfpa.org/mothers/facts.htm.) Within 1 day of delivery: 45% of maternal deaths occurs 15–45% of newborn deaths occur (Gill K, Pande R and Malhorta A. 2007. “Women Deliver for Development.” Lancet 370: 1347–1355).

How can maternal deaths be prevented? (cont.) Global estimates indicate that maternal mortality could be reduced… By 75%, with skilled attendance at all births backed by emergency obstetric care By 33%, with voluntary family planning By 13%, with access to safe abortion More specifically, estimates suggest that: Skilled attendance at all births, backed by emergency obstetric care, could reduce maternal deaths by 75 percent. (Obaid, TA. 2007. “No Woman Should Die Giving Birth.” Lancet vol. 370, October 13, 2007: 1287–88.) Voluntary family planning alone could reduce maternal death by 33 percent and child deaths by as much as 35 percent. (Obaid, 2007) Unsafe abortions account for 13 percent of maternal deaths (WHO. 2004. “Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in the Year 2000.” Geneva: WHO, Gill K., R. Pandi, and A. Malhorta, 2007.) Note to facilitator on a slight discrepancy in estimates: the WHO citation estimates that abortions account for 13 percent of worldwide maternal births, and the UNFPA citation from slide four using another source estimates 14 percent.

Who does maternal mortality and morbidity affect? Women Children of women who die in childbirth 2–10 times greater likelihood of death within first two years Family, community, and country Decreased economic contributions to household, paid and nonpaid Psychological and social impact on family, including increased number of children leaving school US$15 billion estimated cost of maternal mortality Maternal complications have severe consequences not only for the woman’s health/life but also for the well-being of their children, partners, families, and communities. For example: Infant and child mortality: Almost half—about 3.4 million out of 8 million—of infant deaths per year result from poor maternal health and inadequate delivery care. (UNFPA, “Fast Facts,” ibid). Newborn babies whose mothers die in childbirth are 2–10 times more likely to die within 2 years than those whose mothers survive. (Editoral. “Women: More than Mothers,” Lancet Vol. 370, October 13, 2007: 1283.) Maternal mortality and morbidity affect women at the prime of their lives when they have the greatest ability to contribute to the economy and society. For example: Women are important economic contributors to the household; death and disability reduces their ability to contribute economically in both paid and unpaid labor (food production, water collection, health care, caring for children) Maternal illness or death is linked to increased depression and psychological problems in the family and increased number of children leaving school early to help earn income. The estimated global cost of maternal mortality is US $15 billion per year. (Gill K., R. Pande, and A. Malhorta, 2007)

Key Gender-Related Barriers Explain that we will now more explicitly consider gender-related barriers to safe motherhood. Ask participants to brainstorm what some key gender-related barriers to safe motherhood might be. Ask participants to keep these in mind and to be prepared to identify others, as they watch the short film set in Mexico called “Step by Step: Towards Safe Motherhood.” Explain that we will discuss their reactions and observations after the movie. Provide background on the movie, noting that it is from Mexico (with English subtitles) and was made by a non-governmental organization (NGO) named La Casa de La Mujer Rosario Castellanos.

Gender-related barriers to safe motherhood Poor nutrition Girls Pregnant women Early first pregnancy Early marriage Pregnancy-related deaths are the leading cause of mortality for 15–19 year-old girls worldwide. There are social/cultural norms related to gender that contribute to maternal mortality. Poor maternal nutrition is very common in many countries. Due to women’s low status, they are often served less nutritious foods, where husbands and sons receive better food. Poor nutrition in girls can stunt growth and thus limit the size of pelvises. Women who are underweight are also less likely to have healthy pregnancies. Improvements in maternal weight can be achieved by delaying age of first pregnancy, an issue linked closely to marital age. Globally, 36 percent of women ages 20–24 are married or in union before they reached their 18th birthday (UNICEF. 2007. The State of the World’s Children 2007: Women and Children: The Double Dividend of Gender and Equality. NY: UNICEF). The rate of early marriage is particularly high in Asia and Africa. Among women ages 15 – 24, 48 percent are married before the age of 18 in South Asia (9.7 million girls), 42 percent in Africa, and 29 percent in Latin America and the Caribbean (UNICEF. 2005. Early Marriage: A Harmful Traditional Practice. A Statistical Exploration. NY: UNICEF). Girls ages 10–14 are five times more likely to die in pregnancy or childbirth than women aged 20–24, while girls ages 15–19 are twice as likely to die. (UNICEF. 2001. Early Marriage: Child Spouses. Florence: UNICEF Innocenti Research Centre). (Citation for last bullet on slide: Otoo-Oryortey, N. and S. Pobi. 2003. “Early Marriage and Poverty: Exploring Links and Key Policy Issues.” Gender and Development 11(2):42–51.)

Gender-related barriers to safe motherhood (cont.) Lack of information and education Restriction of women’s movement outside the home Gendered division of household labor Lack of education and information also take a toll on women’s health. Women’s education is strongly correlated with positive maternal health outcomes. High rates of illiteracy/low rates of school attendance among women and girls, common in many parts of the world, contribute to high maternal mortality. Restriction of women’s movement outside the home, in some societies, limits their access to services or ability to seek services. Gendered division of household labor in most societies, rooted in social norms and values, means that women bear most of the domestic, farming, and childcare tasks. This work responsibility continues through many women’s and girls’ pregnancies and is sometimes resumed immediately after delivery. This heavy workload can have negative impacts on the mother’s health.

Gender-related barriers to safe motherhood (cont.) Gender-based violence Intimate partner violence against women may increase during pregnancy Female genital cutting Gender-based violence, which disproportionately affects girls/women, greatly contributes to maternal mortality. Some women experience violence for the first time during pregnancy. Intimate partner violence against women may increase during pregnancy. Women who suffer intimate partner violence in pregnancy are more likely to miscarry, which can cause complications. Female genital cutting, which is prevalent in some countries, can also complicate childbirth, leading to, for example, obstetric fistula.

Gender-related barriers to safe motherhood (cont.) Lack of decisionmaking power Resources for healthcare How many children to have Spacing between pregnancies Use of contraception 1. Women, in many societies, lack decisionmaking power over how money and other resources are used. Women do not always have the power to spend money on their own antenatal care or to decide if the money can be spent on emergency obstetrical care and transportation to hospital/health center. In many societies, it is up to her male partner or other family members, especially mothers in-law. Due to a woman’s low status, family members sometimes decide her health is not worth the expense. 2. Women also do not always have a say in how many children they would like to bear, how to space their children, or in the use of contraception. Women who do not space births face consequences to their health. 13

Gender-related barriers to safe motherhood (cont.) Exist at many different levels Individuals Couples Families and communities Health service and other institutions Policies Gender barriers exist at many different levels, including in healthcare systems and the policy arena. Sometimes gender barriers are more readily identified at the level of families and the community. Yet, they exist across multiple levels: Health systems are social institutions with complex dynamics of power, including those based on gender and other inequalities. These gender-related barriers affect the degree to which health systems can function and deliver high-quality, timely care to pregnant women. Gender discrimination also affects the degree to which policy decisions—at multiple levels from the family and community to government systems—do or do not get made to prioritize safe motherhood.

Safe motherhood related to women’s status Even though women are honored in all cultures as the givers of life, they are also often dishonored as human beings. In short, women’s status is a strong predictor of maternal mortality. In summary, mothers may be considered to be at increased of maternal mortality and morbidity because they are women. A cross-national study of 79 developing countries found that women’s status is a strong predictor of maternal mortality. Women’s low status relative to men in society contributes to maternal mortality. Women’s low status also contributes to a lack of political will and priority placed on reducing barriers needed to ensure safe motherhood. (Shen, C., and J.B. Williamson. 1999. “Maternal Mortality, Women's Status, and Economic Dependency in Less Developed Countries: A Cross-National Analysis.” Social Science & Medicine 49: 197–214.)

Thank You!