BMJ  2005;331:708-709 (1 October), doi:10.1136/bmj.331.7519.708

Editorial

Meeting millennium development goals 3 and 5

Gender equality needs to be put on the African agenda

A recent World Health Organization report warns that the health related millennium development goals (MDGs) will not be met without a dramatic increase in investments in national health systems.¹ Assessments of progress towards the goals to date have found that we have made the least progress towards MDG 5—to improve maternal health—particularly in sub-Saharan Africa. In some African countries the situation has got worse; maternal mortality in Malawi has almost doubled between 1992 and 2000 despite increased resources for health.² Women's lifetime risk of pregnancy related death in Malawi is now 1 in 7, compared with 1 in 2800 in industrialised countries.³ It is critical and timely to lobby for more resources, but this is insufficient without attention to the issues of gender and power which underlie maternal morbidity and mortality, both within communities and within health systems.

Every minute, a woman dies in pregnancy or childbirth.⁴ Nearly half of these deaths (47%) occur in Africa, and the vast majority are avoidable through skilled care in delivery and access to emergency obstetric care.³ For every woman who dies because of obstetric complications, 30-50 women suffer morbidity and disability.³ MDG 5 rightly focuses attention on urgent action to address this unacceptable situation. It is widely agreed that the high maternal mortality ratio in many sub-Saharan African countries is a reflection of the status of women in these societies, since it vividly illustrates how acceptable a society finds such avoidable deaths.³ Meeting goal 5 is therefore inextricably linked to meeting goal 3—to promote gender equality and empower women.

The links between gender inequalities and maternal morbidity and mortality in sub-Saharan Africa are many and often unrecognised. The low priority accorded to girls' and women's wellbeing throughout their life cycles contributes towards poor nutrition and ill health, which increase the health risks to women in pregnancy and childbirth.⁵ Women's lack of control over their reproductive capacities and exposure to violence further intensify these risks through early, multiple, and unwanted pregnancies.⁶ Low levels of education and literacy, access to and control over resources, and limited autonomy within the family and community limit poor women's ability to use healthcare services in pregnancy or delivery.⁷ Even if these women reach services, healthcare providers are often uncaring, judgmental, or abusive, which stems from broader health system failures.⁸ Women's poor health and low control over their reproductive capacities in turn exacerbate gender inequities—for example, girls are often withdrawn from school to care for sick family members.

Failure to address these gender dimensions adequately is an important reason why we are falling so short of meeting MDG 5 in Africa. Women's rights to control their bodies remain a battleground between a religious conservative alliance and the radical vision of social change laid out in the agreements made at the landmark conferences on population policy in Cairo (1994) and on women in Beijing (1995). The multiple interconnections between women's rights and maternal morbidity and mortality point clearly to the need for access to the full range of sexual and reproductive health services outlined in the Cairo and Beijing agreements, in order both to improve maternal health and to reduce the maternal mortality ratio by three quarters. However, the goal of access to reproductive health services for all people of appropriate ages was removed from the final millennium development goals, due to pressure from an alliance of social conservatives led by the United States.⁹ This powerful lobby is also active in campaigns to undermine implementation of existing sexual and reproductive health programmes, for example by removing contraceptive provision from programmes to prevent obstetric fistula.¹⁰

Another reason for falling short of meeting the goals is the negligence of the world's richest countries and African governments in failing to commit sufficient resources to meet women's rights for reproductive health. Maternal health services are chronically underfunded.¹¹ Money is not enough, however. Translating resource commitments into concrete improvements in the lives of women requires a commitment to gender equality within and beyond the health sector; this threatens many vested interests and will therefore require new alliances to be forged within and beyond African states to drive change. Participatory approaches to making responsive relationships between health sector actors and poor women (relationships that seek to engage men) are crucial to ensuring the development of quality, accessible, and accountable health services.

Action for gender equality beyond the health sector is also vital to meet not only MDG 5 and MDG 3, but all the millennium development goals. Meeting the target of eliminating gender disparity in primary and secondary education would contribute towards the goal of gender equality but will not enable us to reach it. There is an urgent need to take a holistic approach to achieving gender equality and women's empowerment, including guaranteeing women's property and inheritance rights, reducing discrimination in labour markets, increasing women's representation in political bodies, and ending violence against women.¹²

(bertha{at}equi-tb-malawi.org)
Research for Equity and Community Health Trust, PO Box 1597, Lilongwe, Malawi

Research for Equity and Community Health Trust, PO Box 1597, Lilongwe, Malawi

Hope for the African Child Initiative, Ghana, PMB CT 162, Cantonments, Accras Ghana

Liverpool School of Tropical Medicine, Liverpool L3 5QA

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Competing interests: None declared.

References

1. Ress P. UN millenium health goals will not be achieved, report warns. BMJ 2005;331: 474.[Free Full Text]
2. National Statistical Office, Malawi. Malawi Demographic and Health Survey, 2000. www.nso.malawi.net/data_on_line/demography/dhs/main_report/Contents.pdf (accessed 24 Sep 2005).
3. UN Millenium Project, Task Force Child Health and Maternal Health. Who's got the power? transforming health systems for women and children: achieving the millenium development goals. 2005. www.unmillenniumproject.org/reports/tf_health.htm (accessed 24 Sep 2005).
4. Liljestrand J, Gryboski K. Women who die needlessly: maternal mortality as a human rights issue. In: Murphy E, Hendrix-Jenkins A, eds. Reproductive health and rights—reaching the hardly reached. PATH, 2002. www.path.org/publications/pub.php?id=515 (accessed 24 Sep 2005).
5. Mirsky J. Call for a human rights approach to tackle high levels of maternal death and disability. Panos Institute/Medianet, 2001. www.eldis.org/static/DOC15124.htm (accessed 24 Sep 2005).
6. Barnett B, Stein J. Women's voices, women's lives: the impact of family planning. Family Health International, 1998. www.fhi.org/en/RH/Pubs/wsp/synthesis/index.htm (accessed 24 Sep 2005).
7. Lule E, Ramana GNV, Ooman N, Epp J, Huntington D, Rosen JE. Achieving the millennium development goal of improving maternal health: determinants, interventions and challenges. New York: World Bank, 2005. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION /Resources/281627-1095698140167/LuleAchievingtheMDGFinal.pdf (accessed 24 Sep 2005).
8. Prevention of Maternal Mortality Network. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Stud Family Plan 1992;23: 279-91.
9. Standing, H. Towards reproductive health for all? Reflections on international development commitments. In: Black R, White H, eds. Targeting development: critical perspectives on the millennium development goals. London: Routledge, 2003.
10. Center for Health and Gender Equity. Rep Chris Smith guts program to save women's lives. Press release 25 July 2005: www.genderhealth.org/pubs/PR20050720.pdf (accessed 31 Aug 2005).
11. Goodburn E, Campbell O. Reducing maternal mortality in the developing world: sector-wide approaches may be the key. BMJ 2001;322: 917.[Free Full Text]
12. 2 Millennium Project Task Force. Interim report on gender equality. 2004. www.unmillenniumproject.org/documents/tf3genderinterim.pdf (accessed 24 Sep 2005).

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