The worst offenders are in sub-Saharan Africa, where women die in childbirth at rates 160 times those of Canada -- approximately one fatality in every one hundred pregnancies. The overall chance of dying during pregnancy in Canada is 1 in 7,700; in Africa as a whole, 1 in 21. The ten countries with the highest annual rates of death in childbirth are: Sierra Leone, Afghanistan, Bhutan, Guinea, Somalia, Angola, Chad, Mozambique, Nepal, and Yemen.

Who is responsible?

For the most part, Gendercide Watch is skeptical of including individual-level killings, let alone "agentless" ones, under the rubric of "gendercide." It is important to understand, however, that negligence and conscious oversight can themselves be means of inflicting murder on a genocidal scale. Human Rights Watch has noted in the case of communal violence that "a pattern of [government] discrimination" may be evident if conduct "is intended to or can be reasonably expected to lead to intercommunal conflict." The discrimination may include:

• failure to provide physical protection for vulnerable communities under attack from private actors;
• failure to prosecute those responsible for attacks on targeted communities, whether these are state agents or private actors;
• persistent official representation of members of a targeted community, in media and official comments, as less than full citizens or as deserving of less than full respect;
• suppression of dissent by those (of whatever origin) who oppose attacks on or discrimination against the targeted community;
• and discriminatory legislation, which denies full status and recourse to members of the targeted community with regard to their rights as citizens of the nation. (Human Rights Watch, Slaughter Among Neighbors: The Political Origins of Communal Violence [Yale University Press, 1995], p. 10.)

Such a framework can be "gendered" to encompass the institutional discrimination, leading to physical victimization, that occurs on a massive scale with maternal mortality in the underdeveloped world. Fundamental is the failure of most states to provide physical protections, in the form of access to a safe and hygienic natal environment. The suppression and marginalization of women in most respects, and in most countries of the world, is brought about in precisely the way Human Rights Watch describes. The tools at the disposal of the government and ruling elites include control over the mechanisms and policies of the state administration (and thus the possibility to implement or not implement safe conditions for women and their children). They also include control over the "commanding heights" of the culture -- the ability to selectively choose the subjects and viewpoints that will be presented for discussion, and the allowable range of debate. Such strategies have long been used to keep women as "second-class citizens" over most of the world.

To make every pregnancy a spin of fortune's wheel is to consign women during their prime reproductive years to profound insecurity, and to the ever-present threat of excruciating death or debilitating injury. As one midwife stated: "If hundreds of thousands of men were suffering and dying every year, alone and in fear and in agony, or if millions upon millions of men were being injured and disabled and humiliated, sustaining massive and untreated injuries and wounds to their genitalia, leaving them in constant pain, infertile and incontinent, and in dread of having sex, then we would all have heard about this issue long ago, and something would have been done."

Those primarily responsible, therefore, are the governments and ruling elites who can always find money for weapons, but only rarely for hospitals and clinics and midwives; who systematically deny other resources (educational, legal, contraceptive) to women; and who thereby deny them rights that every human being should have to control their bodies and their destinies. The failure of the developed world to contribute meaningfully to the development of the poorer countries is obviously an important factor. But the Cuban example (see below) demonstrates that even poor countries, by humanely allocating the limited resources they control, can reduce maternal mortality to levels approximating those of the wealthiest countries in the world. "Even in the largest and poorest nations," notes UNICEF,

there are usually health units and district hospitals with the doctors, midwives, nurses, drugs, and equipment that can provide obstetric care when needed. If they cannot, then this usually reflects a lack of priority, or a lack of relatively small amounts of funds for basic training and equipment, rather than the inherent impossibility of the task. ... Action on this issue has been paralysed for too long by the idea that only the building of hundreds more hospitals and the training of thousands more expensive obstetricians can make the right kind of care available to [those] who need it. But the fact is that properly trained health workers and midwives, working in modern health units with inexpensive equipment and reliable supplies of relatively cheap drugs, can usually cope -- and know when to call in obstetricians if a caesarean section is necessary. ... Reducing maternal deaths and injuries is therefore not a matter of possibilities but of priorities. The strategies that work have been identified. And the resources will follow if priority lights the way.

On an individual level, those who accept and help to entrench the patriarchal frameworks that deny women adequate nutrition, education, and health care must shoulder a large portion of the blame for perpetuating this gendercide against women. Jenifer Joseph gives a good sense of how patriarchal cultural values translate directly into maternal death:

Pregnant women in Benin would rather suffer days of obstructed labor than ask for help during childbirth and risk being seen as weak. In parts of Ghana, troubled labor is seen as a sign of infidelity, so women stall in calling for emergency care while they try to appease the gods to help with their delivery. In southern Papua New Guinea, women are expected to give birth by themselves, a tradition stemming from a belief that female blood is contaminated and could sicken or even kill a birth attendant.

"Why is it that a woman dies every minute?" asks World Bank President James Wolfensohn. "The answer is that people don't care. We assume that women are there. We have never taken enough concern about the rights of women."

Resistance sometimes comes from unexpected quarters. Adamson writes: "It might have been expected that the voice of the women's movement would have been raised on behalf of the millions of women who suffer for reasons that are related solely to the fact of being a woman. But with honourable exceptions, this is an issue on which the women's movement in the industrialized nations has raised scarcely more than a murmur. When asked, many of the women who work with maternal death and injuries in the developing world will offer the same explanation: for most Western women, feminism is in large part a fight against the circumscribing of a woman's opportunities by her reproductive role; many who are engaged in that struggle have therefore been reluctant to take on an issue which seems to centre on women as mothers rather than women as women."

Doing it differently: Cuba

Maternity ward in Cuba.
Cuba is a "Third World" country, with limited economic resources. But as a result of policy priorities evident from the early days of the 1959 revolution, maternal mortality, along with a wide range of other health crises, have been reduced to "First World" levels. The difference has been a revolutionary regime willing to place the priorities of rural citizens on an equal footing with urban ones, and to grant all Cubans, urban or rural, similar standards of health care. Susan Eckstein writes that "Cuba's experience under Castro highlights possible social if not economic benefits of socialism. Its demographic profile has come to resemble that of highly industrial countries more than Third World nations. Policies that address islanders' needs from cradle to grave, and that have opened employment opportunities for women, contributed to a 'demographic revolution.'" The structure emphasizes grassroots delivery of health services:

The administration of health was centralized and made more uniform while the delivery of services was decentralized. A well-organized system of health centers, known as polyclinics, was initiated to provide ambulatory care throughout the country. The polyclinic-based system delivered a fairly standard set of services and aimed at universal coverage within territorially defined districts. Doctors and support staff were given responsibility for a given group of families within their assigned district. ... In the context of Latin America, Castro's Cuba alone offered a universal, institutionalized system of free rural and urban health care. ... In the capitalist countries in the region, public and private medical facilities remain more doctor-oriented, more concentrated in the major cities, and less accessible to the masses, and government-subsidized health care is available, in the main, only to the fraction of the labor force who work for the state or formal-sector private firms. Also, the diversity of Cuba's health care offerings were exceptional by regional and Third World standards: the high-tech along with low-tech curative and preventive care. (Eckstein, Back from the Future: Cuba Under Castro, pp. 130-32.)

As a result, "average life expectancy rose from fifty-nine years before the revolution to seventy-six years in 1992. Cuban life expectancy came to be exceptional even by industrial Western and former Eastern European-bloc standards. In fact, in the early 1990s men tended to die younger in the United States than in Cuba." Meanwhile, infant mortality plunged from 36 per 1,000 live births before the revolution to 8 in 1996, and "with nearly 100 percent of all babies born in hospitals, staff were on hand to attend to any birth-related problems." (Eckstein, Back from the Future, pp. 136-37.) For its part, maternal mortality stood in 1996 at 2.4 per 10,000 births -- barely above North American rates. The Cuban system has come under enormous strain, as with all other aspects of Cuban society and infrastructure, in the decade following the collapse of the country's former patron, the Soviet Union. But these health gains have largely been preserved, and even improved.

Globalizing Cuba's grassroots approach would mean training some 850,000 health workers, according to UNICEF and World Health Organization reports, as well as the necessary drugs and equipment. The total cost would be US \\$200 million, about the price of half a dozen jet fighters.

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