Delivery starts with women
The brutal rape and subsequent death of a young woman in India at the end of last year was a shocking reminder of the violent subjugation that women continue to face around the world. Less shocking—but perhaps no less insidious—are the routine discrimination and less obvious violence that “keep women in their place” and deny them the opportunity to participate in the public and private decisions that affect their lives.
Years of working with girls and women around the world have taught us that real change starts with addressing the pervasive gender inequality that undermines their health and well-being throughout life. To deliver healthcare and other social services effectively, we must enable poor and socially marginalized women to negotiate directly with healthcare providers and other officials. Only then can women realize their equal rights to high-quality, respectful, responsive services.
To be sure, transforming restrictive gender roles and addressing deeply rooted power inequities can be a slow and gradual process. But at the Cooperative for Assistance and Relief Everywhere, or CARE, we have learned that important shifts in gender dynamics can be achieved in a relatively short amount of time, and that these changes lead to concrete, measurable improvements in the lives of women and their families. Women-led social-accountability approaches, such as those described below, can and do result in measurable improvements in both equity and service quality.
Consider the case of Meeta, a young woman from Madhopur, India. For her, the ability to exercise her right to quality healthcare was powerfully constrained by inequitable gender norms that limited her freedom and life choices.
When staff members at CARE met Meeta in 2010, she had an infant in her arms, another child on the way, and a heavy load of daily chores. She was expected to subordinate her needs to those of her family members, and often did not get enough food or rest to meet the needs of her pregnant body. Meeta had been taught to be passive and ignorant about sex and her body in general. Her lack of decision-making power limited her ability to negotiate for family planning with her husband and put her at risk for forced sex. Restraints in her mobility and a lack of control of household funds made it difficult for her to seek health services.
CARE invited Meeta, her husband Ramkishore, and other couples in the village to join a series of maternal-health meetings. These meetings helped couples learn how to protect the health of mothers and infants. They also provided a safe space to discuss how men and women were sharing decision making and work in the household. For Meeta and her husband, these meetings helped them to start sharing household responsibilities in a more equitable way, including decisions around family planning. This was a profound change—not only for Meeta but also for her husband. In their village, men seldom helped around the house and often taunted other men who did. Ramkishore even became an activist in the community, organizing theater performances and film screenings to foster dialogue about how gender inequity affected women’s health and well-being.
These maternal-health meetings, which benefit many in Meeta’s community, were built using learning and evidence from the Inner Spaces, Outer Faces Initiative (ISOFI), a groundbreaking research project implemented by CARE from 2007 to 2009 in two districts in the Indian state of Uttar Pradesh. ISOFI complemented prenatal and maternal-care services with women’s empowerment efforts that challenged existing gender norms.
Women learned to protect their health and know their rights. They discussed the gender discrimination they faced at home and in the village. Couples and new parents came together to openly talk about gender and sexuality. Public ISOFI events used theater and puppet shows to spark dialogue about gender-related discrimination in India. ISOFI even worked with healthcare providers to help them recognize women’s rights and increase their willingness to address gender and sexuality with their clients.
Researchers found that many couples who were part of ISOFI saw real changes in their lives and health. Compared with women who received only traditional health services, those who were part of ISOFI were significantly more likely to have the freedom to go out alone, to have their own money to spend, and to believe they had the right to refuse unwanted sex. Power dynamics and communication patterns also changed.
Couples involved in ISOFI were more likely to discuss sexuality and to make household decisions together, such as decisions about how to manage household finances. The proportion of women using family planning rose sharply, from 7 percent among women who did not take part in ISOFI programs to 35 percent among women who did.
In addition, the number of women delivering their babies with a trained provider—one of the most critical factors in keeping both mother and child safe—more than doubled. These increases were much greater than those among women who only received standard health services. In short, as women became empowered, they were more likely to seek and use reproductive healthcare.
Research confirms what CARE has learned though programs like ISOFI: increasing access to family planning and improving the health of women and their families will require much more than training clinicians or getting supplies to the right places. Real change will come from empowering women to make autonomous decisions about their health and sexuality.
Take the example of a CARE child-nutrition project in Bangladesh, Strengthening Household Ability to Respond to Development Opportunities (SHOUHARDO). In addition to feeding children, the program gathered women in 408 villages and 20 urban slums to explore gender-related barriers that limited their freedom and choices. These barriers included restrictions on their mobility and decision-making power along with the prevalence of child marriage and gender-based violence.
The women in these villages worked together to make important changes. By negotiating with the men in their villages to address and reduce harassment, noticeably more girls and women were able to walk freely in the community. They also collaborated with local police to prevent illegal child marriages. Researchers evaluating SHOUHARDO were able to quantify women’s growing influence in their communities and families. For example, they found a 46 percent increase in the proportion of women who participated in decisions about how to spend money from loans and savings.
So what does empowering women have to do with child nutrition? A lot, it turns out. SHOUHARDO reduced the proportion of young children with “stunting”—a measure of shortfall of growth due to malnutrition—by an astonishing 28 percent in just four years. And empowering women played a critical role in enabling change. We found that women who took part in the empowerment sessions were better nourished and taller than those who received only food rations.
By empowering women we enable them to claim their right to respectful and responsive care. In the Peruvian highlands, CARE helped indigenous women identify barriers to seeking life-saving emergency obstetric care. Notably, these barriers included discriminatory treatment by providers. Both women and healthcare workers learned about women’s health rights. Clinics improved the quality of their care and their referral systems and also adopted more culturally respectful treatment protocols. For example, clinics hired Quechua-speaking staff, began to offer bilingual information for both women and their family members, and provided traditional birth options such as “vertical births.”
The results were striking: the number of women seeking life-saving maternal care increased, and maternal deaths fell by a remarkable 49 percent in just four years. In another part of Peru, CARE helped establish a cadre of “social monitors” who visited hospitals and pharmacies to monitor care. Women’s satisfaction with the quality of maternal care increased dramatically, as did their use of these services. In a single year, the number of women delivering in health facilities jumped by 33 percent.
So as we reflect on the “art of delivery,” let’s challenge ourselves to think beyond just strengthening healthcare systems and services. If we want to improve healthcare delivery, we must tackle not only the technical and logistical barriers that hinder women; we must also challenge restrictive gender norms and empower all women to claim their right to responsive, high-quality healthcare.