Association between gender inequality index and child mortality rates: a cross-national study of 138 countries
This study confirmed that there were significant positive associations between gender
inequality index and neonatal, infant as well as under-five child mortality rates,
after adjusting for the effects of major economic and health service variables.
Strengths and limitations
GII is a relatively new index, and this study is the first of its kind to analyse
the global association between GII and child mortality rates. Strengths of our study
were including complete and most recent data available from the official sources,
and employing multivariate statistics as well as non-parametric models. As the presence
of influential outliers among social and health indices is common in global data-bases,
appropriate non-parametric robust regression models are necessary to investigate such
data. We should acknowledge the following limitations. Firstly, gender inequality
is a complex multidimensional phenomenon, and the definition of GII is still evolving
8]. Secondly, all ecological studies have a potential limitation of ecological fallacy, which is an association observed between the study variables on an aggregate level,
not necessarily representing the association that exists at an individual level. Thirdly,
causal associations can only be speculated from this cross-sectional study design.
However, the longitudinal data on GII were not available at the time of these analyses.
Fourthly, there may be a possibility of some LMICs under-reporting their child mortality
rates, and not regularly updating their maternal mortality rates 21]. Furthermore, we did not include many potential confounding variables in our multiple
robust regression models, because their availability is limited in LMICs, or there
are concerns related to multi-collinearity. We did not adjust for the low birth weight
rates, because they are involved in the causal pathway between GII and childhood mortality
rates.
Pathways connecting gender inequality and child mortality
Gender inequality harms children during antenatal, perinatal, postnatal periods and
during further development. GII may cause child mortality in one of the following
direct pathways,
1. Female infanticide and female circumcision contribute to a small but ominous proportion
of child mortality 2].
2. LMICs with high GII have higher prevalence of maternal under-nutrition 22]. Consequent intrauterine growth retardation leads to more LBW babies and biologically
disadvantaged children, who are vulnerable to infectious diseases. Our results have
supported such positive association between GII and U5MR due to infectious diseases.
3. Maternal exposure to domestic violence increases the risk for LBW and preterm births
11]. Witnessing domestic violence against their mothers brings up more psychosocially
disadvantaged children.
4. Reduction of 4.2 million deaths of children below five years, between the years
1970 and 2009, was attributed to the better educational attainment of women 15]. Women with inequitable access to education cannot aid the survival of their children
by appropriate feeding and preventive health practices.
5. Our findings confirmed the positive association between GII and U5MR due to HIV
and AIDS. Gender violence 23] increases the risk of women acquiring HIV infection and other sexually transmitted
diseases. Lack of autonomy hinders women equitably accessing health education and
preventive as well as curative health services 24],25] to prevent transmission of disease to their children.
6. Women’s control over household economy can help reducing child mortality 26]. Mothers, lacking economic autonomy, cannot guide their household finances towards
better nutrition and health of their children 27].
7. Prevalence of malnutrition is higher among girls than boys in many countries 22]. Such deprivation and the negative social environment compromise the survival of
female children.
There are numerous indirect pathways connecting gender inequality and child mortality
22].
Socioeconomic perspectives of GII
Gender inequality is connected with many social evils and makes them heritable across
generations. As a detailed discussion of all negative social consequences of GII is
beyond the scope of this short report, we briefly discuss three germane social issues,
which largely influence child mortality rates, especially in LMICs. First, son preference is widely prevalent in many societies and is associated with high female perinatal
as well as infant mortality rates 28],29]. Unwanted girls, born to multiparous women without any living sons, have significantly
less odds to survive or they grow up in adverse psychosocial circumstances 30]. Secondly, Dowry is a social practice, in which a girl’s parents are forced to offer material riches
to groom’s family to conduct her marriage 31]. Female suicides and homicides due to dowry harassment are not uncommon in LMICs.
This social evil incites the daughter aversion, and many female infanticides 32]. Thirdly, Mathew effect, explains the persistence of high child mortality rates in LMICs with poor macroeconomic
indicators 33],34]. Our results have confirmed the significant inverse correlation between per capita
GDP and U5MR and have indicated the role of GII in this vicious cycle. The relationship
between per capita GDP and GII can be bidirectional 35]. Countries, where women have higher educational attainment and more labour participation,
prosper economically and attain further reductions in their child mortality rates.
In contrast, high GII keeps countries poor and sustains their child mortality rates.
Why does gender inequality persist in LMICs?
Despite the persistent efforts to curtail gender injustice by the Governments, non-governmental
organizations (NGO) and feminist movements over many decades, gender equality remains
as a distant ideal in many LMICs. Our results showed that LMICs have significantly
higher GII and U5MR than the high income countries. Success of feminism in high income
countries has not been replicated in LMICs, due to the following barriers,
1. Gender stereotypes are culturally ingrained and are sanctified by religions. Gender
initiatives are often viewed as threats to local culture, tradition and religious
beliefs.
2. Despite improving the female literacy rates over the past decades, drop-out rates
from secondary level education and above remain persistently higher among girls in
LMICs 36]. Recent industrialization in LMICs reduces the employment opportunities of girls,
who lack higher education.
3. Our results showed that GII is positively correlated with economic inequality.
Gender equality is one of the many basic human rights denied to poorer sections of
the society by the prevailing high economic inequality in LMICs. Feminist ideology
has reached mostly the affluent and remains alien to many poor rural women in LMICs.
4. Patriarchal family systems and property inheritance sustain son preference and
dowry customs. Many women, beyond their middle ages, get attuned to their gender roles
and collude with authoritarian men to ensure subordination of younger women in their
families.
5. Increasing need for out-of-pocket health expenditures causes inequitable access
to health services 37]. Many poor and less educated women avoid utilizing health services, especially prevention
services, and worsen their health standards, due to the fear of catastrophic health
expenditures 38].
6. Narrow medical perspectives often reduce gender equality to primary care reproductive
health and invest their resources mostly on curative medical interventions 39].
7. Predominant business interests lure the media to endorse the gender stereotypes
of patriarchal societies.
Removing barriers to gender equality
As both sexes are innately equal, gender equality need not be considered as a far-off
ideal. Our results suggest the following to remove the man-made barriers against gender
equality and to aid the survival of more children,
1. Patriarchal societies often concern more about the well-being of their progeny
than that of their women. The relationship between their gender inequality and the
survival of their children should be highlighted in every possible way to make them
feel the need for a social change.
2. GII is positively correlated with per capita GDP. Gender equality cannot be achieved
in isolation in a starving society. Policies envisioning poor national economies to
be stronger and be independent of external aids are essential to progress gender equality.
3. GII is positively correlated with economic inequality index. Inequitable economic
growth can do more harm than good for gender equality. Poor women, who lack skilled
education, rely on agricultural labour and small businesses for their autonomy. Their
interests should be preserved during the current wave of capitalist boom in LMICs.
4. GII is inversely correlated with immunization coverage. Preventive, let alone curative,
medical interventions have limited success to curtail high child mortality rates in
LMICs, where broader social objectives are often less prioritized. Existing health
services should join their hands with social initiatives prioritizing women autonomy
to achieve desired health indicators.
5. Rise in female literacy is not accompanied by corresponding reduction of gender
inequality and gender violence 40] in LMICs. Industrialization of societies demands more skills, than the ability to
read and write, to lead an autonomous life. Education policies for women should emphasize
developing skills, rather than imparting more knowledge. Governments should realize
that spending on higher education of women is a wise investment to accelerate their
economic growth 35], to prevent more child mortality and to reduce their expense on curative health services
15]. Ensuring equitable access to higher education and investigating the determinants
of female higher education dropout rates are essential.
6. Feminist ideology should be tailored to the needs of individual countries 41]. Conflicts with the local culture and religion should be discussed publicly 39] and be resolved with the help of shared motives for the welfare of involved communities.
Feminist movements should move their urban bases in LMICs closer to the poor rural
women, who need their services more. Striving to gain the co-operation of existing
social networks and integrating themselves with the poorer sections of the societies
will aid to realize the vision of feminists in LMICs.
7. Need for out-of-pocket health expenditure connects economic inequality, gender
inequality and the inequities in the delivery of health care to poor women in LMICs.
Minimizing out-of-pocket health expenditures and improving the standards of existing
public health services will ensure better maternal health and survival of children.