Last month, Half the Sky hit bookstores all across the country. Written by Nicholas Kristof and Sheryl WuDunn, the first married couple to jointly win a Pulitzer Prize in journalism, Half the Sky is an extraordinarily exciting book. It examines the economic potential that could be realized by relieving oppression against women, effectively emancipating them and bringing their intelligence, energy and enterprise into the formal economy.
To tell their story, the authors - both of whom have an intimate knowledge of the developing world - have identified three key areas in which women are kept down: sex slavery and forced prostitution; violence against women (including honor killings and mass rape); and maternal mortality.
It's this last area that should be of particular concern to anyone familiar with Millennium Development Goal number five: reducing maternal mortality. The sad fact is that for nearly a decade, women's health has gained no traction. More than 500,000 women still die in childbirth each year (about one woman every minute), and hundreds of millions who want to use modern family planning have no access to it. In development circles in sub-Saharan Africa, it's the clinch issue when wonks talk about the sustainability of doing anything, economic or otherwise: "Who cares if we create opportunities for tens of thousands if the population will double in 17 years?"
As I read Half the Sky, I realized this book and its message have come at a most critical time. With scarcely an exception, countries with dismal maternal mortality figures in 1990 have made no progress to date. Despite ever-increasing US investments in aid, women have simply not been beneficiaries of the billions of American taxpayer dollars spent in the developing world. This must change.
A keystone to reducing maternal mortality and morbidity, family planning has been traditionally difficult to address, but it must be if anything is to change. Unchecked fertility carries enormous health risks. Here in Rwanda, we have seen some gains in the past few years: in 2008 the average woman had 5.5 children during her lifetime, down from 6.1 in 2005, with contraceptive use increasing over the same period. However, by last year, only an estimated 27% of married women were using modern contraception. Government provides contraception for free but half the health centers in the country are run by the Catholic Church, which has been sluggish to allow family planning to enter their doors. This frighteningly high fertility rate, combined with reductions in childhood mortality, is accelerating population growth in a country that is already the most densely populated in Africa. Simply producing enough food for these children is getting harder and harder in Rwanda, home to the smallest farm plots in Africa.
A reduction in maternal mortality requires a well functioning health care system. My experience here in Rwanda and elsewhere has shown me that as health center management improves, more and more women choose to deliver at the health center--a huge and essential first step in improving mother and child survival. Phones, ambulance service, access to drugs, electronic record-keeping, electricity and running water - these things may seem painfully basic to those of you reading this in places like the U.S. or European Union. Here, they are more than simply basics; they mean the difference between life and death.
Improvement in basic health care management and access to family planning: any less than that and Millennium Development Goal five will not be reached. These two measures will make it possible for Rwanda to achieve this goal - and has the added benefit of giving the Rwandan health care system the foundation it needs to improve health for mothers, their children and everybody else. If this can work in Rwanda, it can serve as model, ready for transplant to other developing nations.
Far too much time and money have been wasted on hand wringing and studying a problem that we already know how to solve, and tangible results have been few. We need to drive the debate forward by proving that a country can achieve a substantial reduction in maternal mortality by 2015. With enough support, we can achieve and even surpass the Millennium Development goal on maternal health in Rwanda.
We who work in international aid and development know what must be done. We have reached out to public officials from the President of the United States to representatives of the State Department to U.S. senators and congresspeople, and still, there is reluctance to move ahead. What Kristof and WuDunn have accomplished with "Half the Sky" is to bring this issue to a broader and committed audience, an audience that - once having read the book - must and will demand action.
Josh Ruxin is Assistant Clinical Professor of Public Health at the Mailman School of Public Health at Columbia University and Director of the Access Project in Rwanda.
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