Commonwealth Foundation Partner’s Forum
Gender issues in the economic crisis recovery and beyond: women as agents of transformation
Barbados 4-5 June 2010
COMMONWEALTH NURSES FEDERATION
MATERNAL HEALTH AND THE MDGs
SLIDE 1
I am pleased to be able to present to you this morning on behalf of the Commonwealth Nurses
Federation (CNF). The CNF is a federation of national nursing associations in Commonwealth
countries. The CNF was established in 1972 and has 41 member associations across six regions of
the Commonwealth: West Africa; the Atlantic; the Pacific; Europe; South Asia; and East, Central and
Southern Africa. The CNF works with its member associations to influence health policy at a
Commonwealth level; strengthen nursing and midwifery in Commonwealth countries; and improve
the health and wellbeing of Commonwealth people.
SLIDE 2
The Millennium Development Goals (MDGs) are a set of comprehensive and specific development
goals. There are eight time limited goals which provide concrete numerical benchmarks for
addressing extreme poverty and improving health. Adopted by world leaders in 2000, the MDGs
provide a framework for the entire international community to work together toward a common
goal - making sure that human development reaches everyone, everywhere. The MDGs are set to
be achieved by 2015. Of the eight goals, three specifically relate to health: MDGs Goals 4, 5 and 6
which are to:
 Reduce child mortality (Goal 4),
 Improve maternal health (Goal 5), and
 Combat HIV and AIDS, malaria and other diseases (Goal 6).
This workshop is about Gender and the Millennium Development Goals. Other speakers will be
discussing Gender Perspectives and HIV and AIDS and Achieving Gender Equality in Education. My
presentation focuses on Maternal Health and the MDGs and I want to specifically address MDG 5:
Improve maternal health and ask the question: why, of all the MDGs, is this the MDG that is the
most unlikely to be achieved?
SLIDE 3
Let me give you some statistics. The World Health Organization in its 2010 publication: World
Health Statistics 2010 states that one woman dies every minute from pregnancy or childbirth
related complications; that is just over half a million women dying each year from pregnancy or
childbirth related complications. Even more frightening is the statistic that 99% of those deaths
occur in developing countries. Why? Why in 2010 is a woman dying every minute from pregnancy
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or childbirth related complications. During this workshop while we sit here in Barbados, one
hundred and thirty women will die; one hundred and thirty women dead in the space of this
workshop.
SLIDE 4
For every woman who dies, twenty more develop infections or other severe disabling problems,
adding up to more than ten million women affected each year.
SLIDE 5
Globally the decline in maternal mortality is 1.3% per year instead of the 5.5% per year required to
achieve MDG 5.
SLIDE 6
Between 2000 and 2008 fewer than half of all pregnant women made the World Health
Organization recommended minimum of four antenatal visits.
SLIDE 7
Fewer than 50% of births in Africa and South Asia where 82% of maternal deaths occur are
attended by a skilled health worker.
SLIDE 8
Maternal death was the leading cause of death for girls aged 15-19 years in developing countries.
SLIDE 9
The funding gap for maternal, newborn and child health will be about US$ 20 billion each year
between 2011 and 2015. If this gap were met it would mean the lives of 1 million women, 4.5
million newborns and 6.5 million children aged 1 month to five years could be saved.
SLIDE 10
At our current rate of progress, the Millennium Development Goal for improving maternal health
will not be achieved until 2045, thirty years later than the goal set by world leaders in 2000.
SLIDE 11
I will argue that the reasons are clear but complex; they are known but neglected; they can be
addressed but are being avoided. One of the major reasons for the high levels of maternal mortality
in developing countries is women’s lack of access to appropriate health care as a result of their
social and economic status, a status that is rooted in public policies of gender inequality.
Women occupy multiple roles in society: they are daughters, sisters, girlfriends, wives, partners,
mothers and wage earners. The World Health Organization 2009 report: Women and health:
today’s evidence, tomorrow’s agenda, found that socioeconomic status is a major determinant of
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health with women in high income countries living longer and less likely to suffer from ill health
than women in low income countries.
SLIDE 12
The position women occupy and the opportunities they have in the society in which they live is
directly related to maternal mortality. In developing countries where women have limited access to
education, employment and health care, maternal mortality is greater than in developed countries.
For example: the chance of suffering a maternal death is 1:6 in Sierra Leone compared with 1:3,800
in the United Kingdom; that is, 900 maternal deaths per 100,000 births in Africa compared with 27
maternal deaths per 100,000 births in Europe.
SLIDE 13
This graph demonstrates maternal mortality in developed countries compared with developing
countries. Reducing maternal mortality in developing countries means government policy must
address women’s access to education, employment and health care.
SLIDE 14
The adverse impact on health of low socioeconomic status is compounded for women by gender
inequities. In many countries and societies, women and girls are treated as socially inferior. Social
norms and sometimes legislation perpetuate the subjugation of females and condone violence
against them. Unequal power relations between women and men translate into differential access
to and control over health resources. Gender inequalities in the allocation of resources, such as
income, education, health care, nutrition and political voice, are strongly associated with poor
health and reduced well-being. The WHO report that in some settings, gender inequity is associated
with particular forms of violence against females - including violence by an intimate partner, sexual
violence by acquaintances and strangers and child sexual abuse. The WHO report that girls are far
more likely than boys to have been subjected to sexual abuse, with one girl in four reporting such
abuse in the course of their lives. Women and girls are also vulnerable to less well-documented
forms of abuse or exploitation, such as human trafficking or ‘honour killings’ for perceived
transgressions of their social role. These acts are associated with a wide range of health problems in
women such as injuries, unwanted pregnancies, abortions, depression, anxiety and eating
disorders, substance use, sexually transmitted infections and, of course, premature death.
SLIDE 15
Many of the health problems faced by adult women, leading to an increased vulnerability to
maternal mortality, have their origins in childhood. Malnutrition is an important determinant of
health, both in childhood and beyond. The nutritional status of girls is of particular importance due
to their future reproductive role and the intergenerational effects of poor female nutrition. Girls
and women face particular health risks due to harmful practices such as female genital mutilation
(FGM). Millions of girls and women are estimated to have undergone FGM, which involves partial or
total removal of the female external genitalia or other injury to the female genital organs for
nonmedical reasons. The WHO estimate that 92.5 million girls and women above the age of 10
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years in Africa are living with the consequences of FGM. Of these, 12.5 million are girls between 10
and 14 years of age. Each year, some three million girls in Africa are subjected to FGM and data
indicate a marked increase in the proportion of girls who undergo FGM before the age of five years.
SLIDE 16
Women face particular problems in disasters and emergencies. Available WHO data suggest a
pattern of gender differentiation at all stages of a disaster: exposure to risk, risk perception,
preparedness, response, physical impact, psychological impact, recovery and reconstruction.
Countries affected by conflict or facing other forms of instability have the highest maternal and
neonatal mortality rates. Periods of conflict and instability bring women many additional problems
such as violence, trauma and injury, disruption of primary health care services, and poor access to
health care and place them at greater risk of sexual coercion and rape resulting in unwanted
pregnancy leading to maternal and perinatal mortality.
SLIDE 17
While women’s political participation is growing in some countries, men still predominantly have
political control in most societies and therefore have social and economic control as well. Women
are particularly vulnerable to income poverty because they are less likely than men to be in formal
employment and much of their labour is unpaid. In many developing countries, a large proportion
of agricultural workers are women and many are unpaid as this is part of their role within the
family. The WHO report that employment ratios, the number of employed persons as a percentage
of the population of working age, are significantly higher for men than for women and even when
in formal employment, women generally earn less than men. Because they are less likely to be part
of the formal labour market, women lack access to job security and the benefits of social
protection, including access to health care. Within the formal workforce, women often face
challenges related to their lower status, suffer discrimination and sexual harassment, and have to
balance the demands of paid work and work at home, giving rise to work-related fatigue, infections,
mental ill-health and other problems.
SLIDE 18
The socioeconomic and gender based inequalities that women face affect their access to and use of
health care services. The poorest women are least likely to use health care services which may be
unavailable, or inaccessible because of cost or lack of affordable transport.
SLIDE 19
The major causes of maternal deaths: haemorrhage (25%); infections (15%); eclampsia (12%);
obstructed labour (8%); unsafe abortion (13%); other direct causes (8%); other indirect causes
(20%) can be avoided with the provision of skilled health personnel, such as midwives, nurses and
doctors, to provide quality antenatal and birthing services.
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There are health worker shortages in 57 countries. More than 4 million health workers are needed
to bridge the gap with 1.5 million health workers needed just for Africa. The financial cost to bridge
the health worker gap is substantial. It will take and additional 2.6 billion a year between 2008 and
2015 to educate and train the 1.5 million health workers needed for Africa alone. Subsequent
employment and retention of staff will incur additional costs.
An adequate supply of health professionals to deliver primary health care is a necessary
prerequisite to a country achieving the health MDGs. The World Health Organization notes a direct
relationship between the ratio of health workers to population and survival of women during
childbirth and children in early infancy. As the number of health workers declines, survival declines
proportionately. The Global Health Workforce Alliance claims that the health worker shortage has
been a major impediment to making progress on meeting the Millennium Development Goals. The
United Nations High Level Meeting on the MDGs in September 2008 recognised that an adequate
health workforce is fundamental to ensuring progress on improving maternal and child health and
achieving the MDGs. Health workers provide essential, life-saving interventions such as care for
pregnant women and safe childbirth.
SLIDE 20
Countries which have a higher health worker ratio have better outcomes in reducing maternal
mortality. The graphs show those countries with the highest and lowest infant mortality and the
highest and lowest maternal mortality and plot the percentage of skilled personnel who attend
births in that country.
SLIDE 21
The graphs clearly demonstrate the inverse relationship between maternal mortality and the
percentage of skilled personnel who attend birthing mothers.
The World Health Organization states that health workers are inequitably distributed throughout
the world, with severe imbalances between developed and developing countries. Sub Saharan
Africa faces the greatest challenges. While Sub Saharan Africa has 11% of the world’s population
and 24% of the global burden of disease, it has only 3% of the world’s health workers. The World
Health Organization points to a direct relationship between the ratio of health workers to
population and survival; as the number of health workers declines, survival declines
proportionately.
SLIDE 22
A primary strategy therefore in government action plans to achieve the MDGs should be a focus on
the health workforce: its sufficiency, its skills mix and its deployment.
The WHO considers it a paradox that health services are so often inaccessible to women or
unresponsive to their needs when health systems are so highly dependent on women. Women are
the main providers of care within the family and provide the bulk of health care worldwide, both in
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the formal health care setting as well as in the informal sector and in the home. Yet women’s own
needs for health care are often poorly addressed. Women tend to be concentrated in occupations
that may be considered to have lower status - such as nursing, midwifery, and community health
services - and are a minority among the highly trained professionals. Nursing, midwifery, the
community health workforce and other front-line providers remain predominantly female almost
everywhere while men continue to dominate among doctors and dentists. Typically, more than 70%
of doctors are male while more than 70% of nurses are female - a marked gender imbalance.
Female health workers face several work-related health problems. Because there are more women
in the health-care workforce and because female health-care workers are often working with
sharps, women account for about two-thirds of all global hepatitis B and C infections and HIV
infections due to needlestick injuries. Women are also prone to musculoskeletal injuries (caused by
lifting) and burn-out. Female health workers are exposed to hazardous drugs that are mutagenic
and possibly carcinogenic, and to chemical hazards which cause asthma as well as adverse
reproductive outcomes such as spontaneous abortion and congenital malformations.
So these are the problems: clear but complex, known but neglected, which can be addressed but
which are being avoided. The WHO recommends four overarching strategies.
SLIDE 23
The first is leadership. They state that: bold, participatory leadership with a clear and coherent
agenda for action is the key to moving forward: leadership that addresses all the issues that affect
women’s lives and where progress has not been made or has been too slow. The WHO considers
the participation of civil society, and particularly women’s health advocates and leaders, to be
critical to success. The meaningful engagement of civil society at all levels of assessment, priority
setting and implementation should be championed and their ability to bring decision-makers to
account strengthened.
SLIDE 24
The second is responsive health services. The WHO states that health systems reflect the societies
that create them. To avoid a situation where they contribute to perpetuating health inequities, they
must become more responsive to the needs and expectations of women as both consumers and
producers of health care. This means eliminating gender biases and discrimination in health
services, and making sure that women are not excluded from sexual and reproductive health
services such as access to contraception. Health care providers also need to take firm action and
speak out against practices that violate the rights and harm the health of women and girls - such as
intimate partner violence, sexual violence, female genital mutilation and early marriage and
childbearing. According to the WHO, a key primary health care reform is equitable access to health
care through the provision of universal coverage and access to a full range of health services with
social health protection for all; and that is not just a matter of increasing the supply of services but
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also eliminating financial barriers to the use of services. Universal coverage carries particular significance for women as they face higher health costs than men due to their greater use of health
care, and they are also more likely to be poor, unemployed or else engaged in part-time work or
work in the informal sector, which can increase health risks while offering no health benefits.
SLIDE 25
The third is positive public health policies and practices which take into account the social context
in which women live and removing gender based differentials in accessing health services and
achieving positive health outcomes. Both sex and gender have a significant impact on the health of
women and must be considered when developing appropriate strategies for health promotion and
for the prevention and treatment of ill-health. Gender inequality, both alone and in combination
with biological differences, increase women’s vulnerability or exposure to certain risks and limit
women’s access to resources and to health care information and services. Broader strategies such
as poverty reduction, increased literacy, training and education, and increased opportunities for
participation in economic, social and political activities will contribute to progress in women’s
health.
SLIDE 26
The final strategy is monitoring outcomes. The WHO acknowledges that the weakness of many
countries health information and statistical systems means that reliable data on critical aspects of
women’s health are not available. Maternal mortality, for example, a powerful indicator both of
women’s health and the status of a health system is poorly measured in most low income settings.
Improvements in planning and implementing policies for women’s health and in monitoring results
depend on investments in strategic information systems for the collection and use of data
disaggregated by sex and age, and the tracking of progress towards global targets and other
indicators relevant to women’s health and survival.
SLIDE 27
In conclusion, our failure to make significant progress toward improving maternal health and
achieving MDG 5 by 2015 has its roots in gender inequality. Improving maternal health is
dependent on the same value being placed on women as it is on men in all aspects of human life
and giving them equal opportunity to health, education, employment and economic and political
participation. The evidence is clear. We only have to look at the differential outcomes for women
between developed and developing countries to know where the solution lies.
SLIDE 28
As women and as leaders it is our role and responsibility to be champions for women and call our
governments to account and to take action to improve maternal health and meet MDG 5 by 2015.
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