Maternal mortality, women's status, and economic dependency in less developed countries: a cross-national analysis

Abstract

While much has been written about the medical, economic, and social causes of cross-national differences in some mortality related phenomena such as in life expectancy and infant mortality, much less attention has been given to maternal mortality, the focus of the present study. In the studies of maternal mortality that have been done, there has been very little effort to assess the potential relevance of the gender stratification and dependency theory perspectives. Using lagged cross-sectional and path analysis with a sample of 79 less developed countries, this article focuses on the impact of predictors linked to three theoretical perspectives – modernization, economic dependency, and gender stratification. We find that women's status, as measured by indicators such as level of education relative to men, age at first marriage, and reproductive autonomy, is a strong predictor of maternal mortality. We find that economic dependency, especially multinational corporate investment, has a detrimental effect on maternal mortality that is mediated by its harmful impacts on economic growth and the status of women. We also find support for developmental theory, a variant of modernization theory.

Introduction

According to what we consider the most reliable data source currently available (WHO, 1996), globally approximately 585,000 women died from pregnancy-related causes in 1990. Rates of maternal mortality show a greater disparity between rich and poor nations than do any of the other commonly used public health indicators, including infant mortality rate, the indicator which is most often taken as the primary measure of comparative disadvantage Royston and Armstrong, 1989, WHO, 1996. Women who become pregnant in developing countries face a risk of death due to pregnancy that is 80 to 600 times higher than women in developed countries (United Nations, 1991). In 1990, the average maternal mortality rate in the developed countries was 27 per 100,000 live births, while in countries such as Angola, Bhutan, Chad, Guinea, Nepal, Sierra Leone, and Somalia the rates were at least 1500 per 100,000 live births (WHO, 1996). In most developing countries, between a quarter and a third of the deaths of women in their reproductive years can be attributed to pregnancy-related causes (Royston and Armstrong, 1989). In some rural areas of Africa and South Asia, of every two women who die, one dies from pregnancy related causes.

Very often, the death of a woman in childbirth is described as a tragic misfortune due to the risky process of childbirth and is accepted as unavoidable. But such a description does not give adequate attention to the many factors that influence the level of risks associated with pregnancy and childbirth. Maternal mortality is a particularly sensitive indicator of inequality and social development as well as health. Due to the importance of maternal mortality as an indicator of social development for developing countries, the reduction of maternal mortality has been established as a goal for the health of women and children by both the World Health Organization and the United Nations; it has also been described as one of the major public health goals at several recent international conferences (WHO, 1996).

Among the major direct causes of high maternal mortality in developing countries are: births not attended by trained personnel, lack of availability or access to backup services for high-risk pregnancies, and malnutrition among pregnant women (United Nations, 1991). Much of the literature on maternal mortality focuses on its medical, social, and cultural causes that vary among countries and geographical regions (e.g., Chen et al., 1974, India, 1981, Fortney et al., 1986, Walker, 1986, Hertz et al., 1994). It is of note that in cross-national quantitative studies on maternal mortality in less developed countries (LDCs), two important perspectives have been largely overlooked.

One is the examination of the impact of women's status on maternal mortality. Maternal mortality tends to be attributed to causes such as poverty and underdevelopment typically assumed to put both men and women at the same disadvantage with respect to health status. Even though women's educational status has long been recognized as an important factor affecting fertility, infant mortality, and maternal mortality (Caldwell, 1979, Caldwell, 1993), sex discrimination in general as a contributory factor has not been given much attention (Royston and Armstrong, 1989). With the increased data availability in recent years, some studies have used indicators other than education to study issues related to women's status and autonomy in LDCs Marshall et al., 1988, Osirim, 1992, Boehmer and Williamson, 1996. However, very few cross-national quantitative studies have examined maternal mortality with these measures.

The second is the effects of economic dependency and the globalization of the world economy on maternal mortality in LDCs. Economic dependency theory has been applied in a number of cross-national studies dealing with basic human needs provision such as fertility, infant and child mortality and women's social status (Ward, 1984, Ward, 1985, London and Williams, 1990, Wimberly and Bello, 1992, Shen and Williamson, 1997). But very few cross-national quantitative studies have analyzed the effects of economic dependency on maternal mortality in LDCs.

Our study examines the effects of several key external and internal factors on cross-national variation of maternal mortality in LDCs. We call these factors `causes behind the direct causes'. We are interested in how women's status affects maternal mortality in societies with similar economic development level and in how economic dependency impacts maternal mortality directly and indirectly via other key predictors of maternal mortality.