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
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First published 2011

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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 1
Discrimination and the causes of child mortality 3

2. The human, economic and development costs of

gender discrimination 8
The human cost – more mothers and babies dying 8
The economic cost – losses in productivity 8
The development cost – failure to achieve the MDGs 9

3. Four snapshots of gender discrimination and its impact 11

Foeticide and infanticide 11
Early pregnancy 12
Lack of household decision-making power 16
Discriminatory health services 17

4. Interventions – a multi-sector approach 22

Changing norms 22
Increasing opportunities for girls and women 25
Delivering equitable health services 27

Conclusion and recommendations 29

Appendix 32
Endnotes 35
the story in numbers
$88 billion
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
$15 billion
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
51 million
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
16 million
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
iv
1 million
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.
358,000
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
830
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.
143 girls
vs. 100 boys
In south Asia, for every 100 male
childhood deaths, 137 female children
died in 1990. By 2008 the figure
was 143.
90%
90% of all women in the fistula hospital
in Addis Ababa, Ethiopia, are survivors
of child marriage or female genital
mutilation (FMG).
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.
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 in 3
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
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.
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.   Baroness Kinnock of Holyhead
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
vii
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

viii
executive summary
In 2000, governments committed to make a two-
thirds 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, under-
five 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 Secretary-
General’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.
ix
an equal start
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, under-
five 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
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.
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
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.
xi
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.
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
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.
xii
Gender relations of power
constitute the root causes of
gender inequality and are among
the most influential of the
social determinants of health.
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
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
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

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,
introduction
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.
xiii
1
The impact of gender
discrimination on
child survival

The interdependence of In 2008, 358,000 women died during or shortly

after pregnancy. Developing countries accounted for
maternal and child health 99% (355,000) of these deaths. Sub-Saharan Africa
and south Asia alone accounted for 87% of global
A child’s survival is intimately connected to the
maternal deaths.30
health and wellbeing of her or his mother. A stark
example of this comes from Afghanistan where
Maternal death and ill health have been described
75% of infants who survive their mother’s death
as a “problem essentially only for the poor, and one
die within their first year of life.24 Conversely, when
virtually eliminated for people with the means and
women have better access to and can choose
status to access healthcare”.31 To some extent this
to use reproductive health services and family
is true; most maternal deaths are directly related
planning, this improves newborn, infant and child
to obstetric complications – including post-partum
health considerably.25
haemorrhage, infections, eclampsia and prolonged
obstructed labour – and complications resulting
Management of complications during pregnancy
from unsafe abortion.32 Up to 80% of these deaths,
and labour are vitally important to the survival of
as well as a large number of infant deaths, could
the foetus and newborn baby.26 A mother’s long-
be averted if women had access to good-quality
term nutritional status, dietary intake and health
healthcare.33
during pregnancy also affect her baby’s chances of
survival as they determine birth weight; babies born
But improving maternal health is not just about
weighing less than 2.5kg account for up to 90% of
improving health systems and removing supply-
newborn deaths.27
side barriers. It is also about tackling intermediate
and underlying factors (or demand-side barriers)
A mother’s health affects her children’s chances
that prevent a woman seeking out healthcare. For
of survival throughout childhood. It can affect the
example, a pregnant woman may not get to a health
care the child receives, their nutrition and their
centre in time to prevent herself or her child dying
long-term development. A study in Bangladesh
because she is not allowed to make independent
found that a child whose mother dies has only a
decisions about when and how she accesses
24% chance of surviving to the age of ten, but an
healthcare.34
89% chance of living to ten if the mother remains
alive.28 Another study in Haiti found that when a
The control of a husband – or his family, including
mother dies, there is a 55% increased risk of one or
other women – over his wife’s access to health
more children in the family dying before the age of
information and services stems from social and
12, partly because children are significantly less likely
cultural attitudes about the roles, power and
to receive routine immunisations.29
influence of men and women. These expectations

1
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 Under-five mortality Maternal mortality ratio*

(1 = worst)
(Gender inequality index, out of 139)

1 Sierra Leone (125) Sierra Leone (125)

2 Afghanistan (134) Niger^ (136)

3 Chad (–) Afghanistan^ (134)

4 Equatorial Guinea (–) Chad (–)

5 Guinea Bissau (–) Angola (–)

6 Mali (135) Rwanda (83)

7 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) Central African Republic^^^ (132)

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

16 Angola (–) Mali (135)

17 Guinea (–) Lesotho (102)

18 Cameroon (129) Tanzania (–)

19 Somalia (–) Guinea (–)

20 Liberia (131) 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

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: 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
Adapted from Save the Children (2009) The Next Revolution: Giving every child the chance to survive
1 The impact of gender discrimination on child survival
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
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
3
an equal start
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 supply-
and 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

160
Under-5 mortality rate (%)

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
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
Women’s household responsibilities usually include
preparing food and collecting water (even during
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
Underlying causes of child mortality
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.

5
an equal start
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 gender-
specific 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 Gender-
related 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 sex-
preference 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

300
Under-5 mortality rate 2008 (deaths per 1,000 live births)

Afghanistan

250

Chad

200 Nigeria

Equatorial Guinea
150 Niger Kenya

100
Ethiopia Gabon
Ghana Bolivia
50 India
Bangladesh Mexico
Nepal
R3 = 0.6862 Botswana
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 mortality. For example, a girl’s chance of being
to recognise these issues means they receive less born can be determined directly by sex-selected
funding and support. Failing to consider gender abortion or foeticide. This decision is rooted in
dynamics within all efforts to meet the MDGs discriminatory social relations that, in some cultures,
also compromises the efficacy and longevity of any place less value on girls and women. This in turn can
change achieved. affect a mother’s chances of accessing health and
other essential services or of controlling her sexual
Finally, it is important to note the health, physical integrity and agency, which further
interconnectedness between the direct, jeopardises her child’s chances of survival.
intermediate and underlying causes of child

7
2
The human, economic and
development costs of
gender discrimination

The human cost – more of these births occurring in developing countries.56

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 decision-
making 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 Prize-
winning 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%
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

8
 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 cost-
effective. 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
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
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
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
40
Child mortality (per 1,000 live births)

35

30
30

25
21
20

15
15

10

5
Male
0 Female
1990 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
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.

10
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
12
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

Eastern/Southern Africa 36

South Asia 49

Middle East/North Africa 18

East Asia/Pacific* 19

Latin America/Caribbean N/A

CEE/CIS 11

Sub-Saharan Africa** 40

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

13
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
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.
14
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
“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 sub-
Saharan 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
16
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 non-
communicable 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
17
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 out-
of-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
18
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.
“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
PHOTO: louise dyring nielsen
[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.
“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.”
19
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
“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
20
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 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.”
21
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.

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 decision-
making 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
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.
4 Interventions – a multi-sector approach
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
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%.
23
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.”
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.

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
“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.”
Male mentor, Addis Birhan

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)

24

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.
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
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
4 Interventions – a multi-sector approach
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, good-
quality 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 awareness-
raising 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.
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.
25
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
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
26
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
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.

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
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%.
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
4 Interventions – a multi-sector approach
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
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.
27
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
28
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.
29
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
30
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.

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.
Conclusion and recommendations
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.
31
appendix

Table 2: Child mortality – percentage change from 1990 to 2008

MDG region n* % of global Progress Progress Difference

population 1990–2008 1990–2008 (M–F)
(Females) (Males)

CIS 12 3% -55% -57% -3%

Developed regions 35 9% -42% -28% 14%

Eastern Asia 3 15% -65% -61% 4%

Latin America &

33 8% -66% -63% 3%
the Caribbean

Northern Africa 5 3% -76% -77% -1%

Oceania 12 0% -31% -29% 2%

South-eastern Asia 11 9% -60% -62% -2%

Southern Asia 9 28% -51% -53% -2%

Sub-Saharan Africa 48 20% -20% -20% 0%

Transition countries of
7 0% -67% -71% -4%
south-eastern Europe

Western Asia 14 3% -59% -61% -2%

Total 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* Excess of female % of n* Excess of female % of

childhood deaths childhood deaths childhood deaths childhood deaths
1990 in 1990 2008 in 2008

CIS 12 -4,095 10.9% 12 -777 6.0%

Developed regions 33 -1,034 4.8% 34 -2,752 21.3%

Eastern Asia 3 11,322 5.4% 3 -327 0.6%

Latin America &

33 -2,198 1.7% 33 -1,296 3.3%
the Caribbean

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

Oceania 10 -144 3.5% 10 -79 2.2%

South-eastern Asia 11 -27,731 10.3% 11 -7,830 6.7%

Southern Asia 9 197,536 14.9% 9 116,240 16.7%

Sub-Saharan Africa 48 -1,550 0.1% 48 -3,105 0.2%

Transition countries of
7 -426 11.9% 7 -102 14.9%
south-eastern Europe

Western Asia 14 -4,029 6.3% 14 -782 2.6%

Total 185 169,283 4.4% 186 100,361 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* Female:Male n* Female:Male

(1990) childhood mortality (2008) childhood mortality
ratio 1990 ratio 2008

CIS 12 0.78 12 0.91

Developed regions 30 0.93 31 0.67

Eastern Asia 3 1.12 3 1.00

Latin America &

28 0.95 28 0.90
the Caribbean

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
6 0.79 7 0.85
south-eastern Europe

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
1
UNSG (2010) Every Women, Every Child, UN Secretary General
Global Strategy on Maternal and Child Health
2
Klasen and Wink (2002) ‘A turning point in gender bias in
mortality? an update on the number of missing women’, Population
and Development Review
3
ICRW (2003) Too Young to Wed: The lives, rights and health and young
married girls, Washington: ICRW
4
N M Nour (2006) ‘Health Consequences of Child Marriage in
Africa’ Emerging Infectious Diseases, Vol. 12, No. 11, p1644
5
Save the Children (2004) The State of the World’s Mothers 2004:
Children having children, Connecticut: Save the Children
6
Save the Children (2004) The State of the World’s Mothers 2004:
Children having children, Connecticut: Save the Children
7
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
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
9
S D Manandha et al (2004) ‘Effect of participatory intervention
with women’s groups on birth outcomes in Nepal: cluster-
randomised controlled trial’, The Lancet, 364: 970–79
10
WHO (2010) Violence against women, Fact sheet 239, November
2009, WHO: Geneva
11
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.
12
UNICEF (2007) The State of the World’s Children 2007: Inequalities
in the Household, UNICEF: New York.
13
ibid
14
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
15
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
Introduction
16
In this report, child mortality refers to under-five mortality unless
otherwise stated. Childhood mortality figures relate to children
aged one to four years.
17
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://
19
www.who.int/mediacentre/factsheets/fs348/en/index.html
20
Save the Children (2010) A Fair Chance at Life:Why equity matters
for child mortality, Save the Children UK: London
21
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.
22
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
1 The impact of gender discrimination on
child survival
24
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
25
Population Reference Bureau (2009) Family Planning Saves Lives,
Fourth Edition, Washington DC: Population Reference Bureau
26
N Datta et al (1988) ‘Validation of causes of infant death in the
community by verbal autopsy’, Indian Journal of Pediatrics, 55
27
E Lawn et al, (2006) ‘Estimating the causes of 4 million neonatal
deaths in the year 2000’, International Journal of Epidimiology, 35, 3
28
H Yusuf and H Atrash (2010) ‘Parents’ death and survival of their
children’, The Lancet, 375, 9730, pp 1944–1946
29
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
WHO (2010) Trends in Maternal Mortality: 1990 to 2008, Estimates
30
developed by WHO, UNICEF, UNFPA and The World Bank
31
C Ronsmans et al (2006) ‘Maternal mortality: who, when, where
and why’, The Lancet, 368.
35
an equal start
32
UNICEF (2009) The State of the World’s Children: Maternal and
newborn health, UNICEF: New York, page 10
33
ibid, p. 2
34
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
35
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.
36
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)
37
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
38
World Health Organization (2006) ‘A factual overview of female
genital mutilation’, Progress in Sexual and Reproductive Health
Research, number 72
39
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
40
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
41
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.
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
43
R Holmes, N Jones and H Marsden (2009) ‘Gender
vulnerabilities, food price shocks and social protection responses’,
ODI Background Note, ODI: London
44
OHCHR (1995) Fact Sheet No.23, ‘Harmful Traditional Practices
Affecting the Health of Women and Children’
36
45
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.
46
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.
World Bank (2003) Gender Equality and the Millennium
47
Development Goals, Gender and Development Group, World Bank:
Washington, pp.19.
48
See, for example, UNHCR (2001) Evaluation of the Dadaab
Firewood Project, Kenya, Evaluation and Policy Analysis Unit.
49
See OECD Social Institutions and Gender Index and/or Jones
et al., (2011)
50
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
51
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
See Inter-Parliamentary Union (2010) Women in Politics paper,
52
www.ipu.org/wmn-e/classif.htm (accessed 29/01/08)
2 The human, economic and development
costs of gender discrimination
53
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
54
Development Goals, Action Aid UK: London.

55
Klasen and Wink (2002) ‘A turning point in gender bias in
mortality? an update on the number of missing women’, Population
and Development Review
56
WHO (2008) Adolescent Pregnancy, NPS Notes, http://www.who.
int/making_pregnancy_safer/documents/mpsnnotes_2_lr.pdf
57
Save the Children (2004) The State of the World’s Mothers 2004
WHO (2009) ‘Adolescent pregnancy: a culturally complex issue’,
58
Bulletin of the World Health Organization, volume 87, number 6, http://
www.who.int/bulletin/volumes/87/6/09-020609/en/index.html
59
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.
60
UNSG (2011) Every Woman, Every Child
61
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)
62
UNSG (2010) Every Woman, Every Child, http://
everywomaneverychild.com/press/20100914_gswch_en.pdf
63
UNSG (2010) Every Woman, Every Child, http://
everywomaneverychild.com/press/20100914_gswch_en.pdf
3  Four snapshots of gender discrimination
and its impact
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
65
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
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
68
millions of missing girls’, 7 April 2011
69
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.
endnotes
70
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
71
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.
72
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
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
74
A Walia (2005) ‘Female foeticide in Punjab: exploring the socio-
economic and cultural dimensions’, IDEA, 9 August 2005, volume 10,
number 1
75
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.
76
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.
77
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
78
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.
79
Save the Children (2004) The State of the World’s Mothers 2004
WHO (2009) ‘Adolescent pregnancy: a culturally complex issue’,
80
Bulletin of the World Health Organization, 87:410–411
37
an equal start
81
WHO (2009) http://www.who.int/bulletin/
volumes/87/6/09-020609/en/index.html
UNICEF (200) Equality, Development and Peace, page 19,
82
www.unicef.org/publications/files/pub_equality_en.pdf
83
N M Nour (2006) ‘Health Consequences of Child Marriage in
Africa’, Emerging Infectious Diseases, volume 12, number 11, pg 1646
84
V K Paul et al (2011) ‘Reproductive health, and child health and
nutrition in India: meeting the challenge’, The Lancet, 377, pg 341
85
Save the Children (2004) The State of the World’s Mothers 2004:
Children having children, Connecticut: Save the Children
86
Save the Children (2004) The State of the World’s Mothers 2004
87
N M Nour (2006) ‘Health Consequences of Child Marriage in
Africa’, Emerging Infectious Diseases, volume 12, number 11, pg 1647
88
ICRW (2003) Too Young to Wed: The lives, rights and health and
young married girls, Washington: ICRW
89
N M Nour (2006) ‘Health Consequences of Child Marriage in
Africa’, Emerging Infectious Diseases, volume 12, number 11, pg 1644
90
International Centre for Research for Women (2007) ‘New
Insights on Preventing Child Marriage: A global analysis of factors
and programs’, page 4
91
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
92
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
93
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.
EGLDAM and Save the Children Norway (2008) ‘Follow-Up
94
National Survey on Harmful Traditional Practices’, EGLDAM: Addis
Ababa, page 85 and 141
38
95
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
96
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
UNICEF (2001) Early Marriage: Child spouses, Innocenti Digest
97
No. 7, p.6
98
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.
99
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 Otoo-
Oyortey and S Pobi (2003) ‘Early marriage and poverty: exploring
links and key policy issues’, Gender & Development 11 (2), 42­–51
100
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
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
WHO (2010) Violence against women, Fact sheet 239,
104
November 2009, WHO: Geneva
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
108
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
109
UNICEF (2008) Children and AIDS: Third stocktaking report, 2008
110
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
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.
112
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

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.
117
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)
118
Sir John Holmes, cited in J Gettleman, ‘Rape epidemic raises
trauma of Congo war’, New York Times, 7 October 2007
DFID, Country profiles: Democratic Republic of Congo, http://
119
www.dfid.gov.uk/where-we-work/africa-west--central/congo-
democratic-republic/?tab=0
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.
121
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-coast-
women-targets-of-rape?intcmp=239
122
UNICEF (2007) The State of the World’s Children 2007: Inequalities
in the Household, UNICEF: New York
123
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
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
126
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
endnotes
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’
129
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
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 High-
Level 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
39
an equal start
135
UNICEF, The State of the World’s Children 2011. 35% of
136,712,000 births were not attended by someone with midwifery
skills.
136
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.
137
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
Save the Children (2010) Missing Midwives, Save the Children UK:
138
London, pp.vii
A recent survey in India highlighted that the unmet need for
139
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.
140
Guttmacher Institute (2009) Abortion Worldwide: A decade of
uneven progress
‘Gender Equity in Health,’ Women, Health and Development
141
Program, Pan-American Health Organisation, pg 6
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.
144
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
40
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
145
healthcare policy reforms’, Feminist Economics 13 (3–4), July/October
2007, pg 199
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
148
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
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: cluster-
randomised 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
151
N Jones et al (2010) Stemming Girls’ Chronic Poverty: Catalysing
development change by building just social institutions, Chronic Poverty
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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
153
N Jones et al (2010) Stemming Girls’ Chronic Poverty: Catalysing
development change by building just social institutions, Chronic Poverty
Research Centre, p. 23–24.
154
D Barne (2010) ‘Ethiopian women gain status through
landholding’, Gender Equality as Smart Economics, October 2010,
World Bank
155
FIDA Uganda (2009) Walking with the Women of Uganda: Annual
report 2009
156
EGLDAM (2010) ‘Integrated approach to protect female children
against sexual abuse and violence’, progress report to Oakwood
Foundation
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

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
162
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
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/
166
Save the the Children (2007) Boys for Change: Moving towards
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an equal start

cover photo: Raghu Rai/Magnum for Save the Children

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