Gender and Health Outcomes

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This section describes the links between key gender considerations and health.

Couple Communication and Decision-Making

The role of men and women in household decisions about finances, food consumption, childcare, healthcare or travel often reflect power relations in the home. When power relations are unequal, it results in not only underutilization of RMNCH services but also can increase risky sexual behavior and intimate partner violence (Blanc, 2001; Chapagain, 2005). While it is important for women to play a larger role in important household decisions, such as financing, men should also become more involved in healthcare and household decisions around health.

Couple communication and joint decision-making have a positive impact on health outcomes, for example:

Gender Considerations	Supporting Evidence Includes:
Integrating men into healthcare responsibilities has a positive effect on family planning use and maternal health outcomes.	A study found that men’s involvement in pregnancy care was greatest when men and women engaged in joint decision-making (Mullany, Hindin, & Becker, 2005).
When men and women discuss household and health-related issues, RMNCH outcomes improve.	Couples that communicate more (both about RMNCH topics, as well as overall) are more likely to use contraception than those who do not communicate with one another (Harman et al., 2014). They are also more likely to continue to use a family planning method without stopping (Mosha et al., 2013). Additionally, when men and women discuss family planning specifically, use of family planning increases as well as receipt of antenatal care (Furuta & Salway, 2006).
Women’s involvement in important household decisions, such as large purchases or control over earnings, has a greater effect than on isolated issues such as family planning alone.	Women with a greater say in these larger decisions are more likely to use contraceptives, receive prenatal care and to have a skilled attendant present at birth (Ahmed, Creanga, Gillespie, & Tsui, 2010; Corroon et al., 2014). Children are also more likely to be fully vaccinated when women are involved in household decisions (Singh, Bloom, & Brodish, 2013). Based on findings from a recent literature review on data from low- and middle-income countries, women’s increased role in decision-making and gaining greater access to household resources may also improve children’s nutrition, reduce stunting and increase the likelihood that they will receive preventative care (Richards et al., 2013).

Gender Considerations

Supporting Evidence Includes:

Integrating men into healthcare responsibilities has a positive effect on family planning use and maternal health outcomes.

A study found that men’s involvement in pregnancy care was greatest when men and women engaged in joint decision-making (Mullany, Hindin, & Becker, 2005).

When men and women discuss household and health-related issues, RMNCH outcomes improve.

Couples that communicate more (both about RMNCH topics, as well as overall) are more likely to use contraception than those who do not communicate with one another (Harman et al., 2014).

They are also more likely to continue to use a family planning method without stopping (Mosha et al., 2013).

Additionally, when men and women discuss family planning specifically, use of family planning increases as well as receipt of antenatal care (Furuta & Salway, 2006).

Women’s involvement in important household decisions, such as large purchases or control over earnings, has a greater effect than on isolated issues such as family planning alone.

Women with a greater say in these larger decisions are more likely to use contraceptives, receive prenatal care and to have a skilled attendant present at birth (Ahmed, Creanga, Gillespie, & Tsui, 2010; Corroon et al., 2014).

Children are also more likely to be fully vaccinated when women are involved in household decisions (Singh, Bloom, & Brodish, 2013).

Based on findings from a recent literature review on data from low- and middle-income countries, women’s increased role in decision-making and gaining greater access to household resources may also improve children’s nutrition, reduce stunting and increase the likelihood that they will receive preventative care (Richards et al., 2013).

Access to Opportunities and Resources

Gender-related factors also affect health outcomes through differential access to opportunities and resources like education, employment and healthcare.

Gender Considerations	Supporting Evidence Includes:
Education: Gender roles often restrict both boys’ and girls’ access to education which can have long-term effects on health outcomes. For example, more educated women and formally employed women are more likely to use family planning, which reduces the risk of unwanted pregnancy and potentially, the need for abortion.	These associations have been established in studies in many different countries, including data from Egypt, South Asia and sub-Saharan Africa. Interestingly, women’s education and employment often have a stronger relationship with use of contraceptives than do measures of empowerment that focus on decision-making, autonomy or freedom of movement (Al Riyami et al., 2004). Families with more educated women have also been shown to have improved child survival (Richards et al., 2013).
Employment: In many contexts, women’s traditional responsibilities are primarily domestic and they do not work outside the home. When they do, they are often part of the informal economy, in lower-paid and less-skilled jobs without opportunities to join unions or trade organizations that advocate for better pay or rights (Shields al., 1996). When women do work outside the home, they are still often expected to bear the full burden of household tasks, such as cooking, cleaning and caring for the children. Men may be reluctant to take on these responsibilities, since gender norms dictate these are outside their domain.	In Cameroon, inequalities between women’s and men’s incomes has been shown to play an important role in poor household nutrition (Pemunta & Fubah, 2014). In contrast, women who had paid employment were less likely to have an unmet need for family planning and were more likely to use family planning and antenatal care. These trends have been found in a wide range of countries like Oman, Nepal and Ethiopia, and have been shown repeatedly in studies using DHS data (Al Riyami, Afifi, & Mabry, 2004; Furuta & Salway, 2006; Wado et al., 2013).
Healthcare: Women’s mobility may limit their access to health services and existing programs intended to increase knowledge of family planning or other health information. Men often do not go to health clinics for their own care or with their partner because pregnancy and child health are seen as a “woman’s domain.”	Healthcare providers often reinforce stereotypes by failing to encourage men to participate and, in some instances, by not welcoming them at all. In many areas, men do not see HIV counseling and testing (HCT) as “masculine,” and thus they are less likely to be tested or receive other HIV/AIDS-related care (Underwood et al., 2014).

Gender Considerations

Supporting Evidence Includes:

Education: Gender roles often restrict both boys’ and girls’ access to education which can have long-term effects on health outcomes. For example, more educated women and formally employed women are more likely to use family planning, which reduces the risk of unwanted pregnancy and potentially, the need for abortion.

These associations have been established in studies in many different countries, including data from Egypt, South Asia and sub-Saharan Africa. Interestingly, women’s education and employment often have a stronger relationship with use of contraceptives than do measures of empowerment that focus on decision-making, autonomy or freedom of movement (Al Riyami et al., 2004).

Families with more educated women have also been shown to have improved child survival (Richards et al., 2013).

Employment: In many contexts, women’s traditional responsibilities are primarily domestic and they do not work outside the home. When they do, they are often part of the informal economy, in lower-paid and less-skilled jobs without opportunities to join unions or trade organizations that advocate for better pay or rights (Shields al., 1996).

When women do work outside the home, they are still often expected to bear the full burden of household tasks, such as cooking, cleaning and caring for the children. Men may be reluctant to take on these responsibilities, since gender norms dictate these are outside their domain.

In Cameroon, inequalities between women’s and men’s incomes has been shown to play an important role in poor household nutrition (Pemunta & Fubah, 2014). In contrast, women who had paid employment were less likely to have an unmet need for family planning and were more likely to use family planning and antenatal care.

These trends have been found in a wide range of countries like Oman, Nepal and Ethiopia, and have been shown repeatedly in studies using DHS data (Al Riyami, Afifi, & Mabry, 2004; Furuta & Salway, 2006; Wado et al., 2013).

Healthcare: Women’s mobility may limit their access to health services and existing programs intended to increase knowledge of family planning or other health information. Men often do not go to health clinics for their own care or with their partner because pregnancy and child health are seen as a “woman’s domain.”

Healthcare providers often reinforce stereotypes by failing to encourage men to participate and, in some instances, by not welcoming them at all. In many areas, men do not see HIV counseling and testing (HCT) as “masculine,” and thus they are less likely to be tested or receive other HIV/AIDS-related care (Underwood et al., 2014).

Social, Cultural and Gender Norms

Norms related to gender, such as gender preference, masculinity and fertility, also influence health outcomes. For example:

Gender Considerations	Supporting Evidence Includes:
Gender Preference: In India, China, and to a certain extent in some African countries, there is a gender bias in child healthcare (Khera, Jain, Lodha, & Ramakrishnan, 2014; Pemunta & Fubah, 2014). Preference for boys can lead to financial resources for education and other services, like healthcare, being differentially allocated within households. Reasons for this preference vary, and include the perception that boys will financially support their parents when they are older, and that families are obliged to pay dowries when their daughters marry.	In India, gender-selective abortion has resulted in fewer female children being born. Among those girls who are born, preferential treatment of boys often comes at the expense of the girls, who may be deprived of nutrients during important developmental stages, which can lead to stunting and malnutrition (Khera et al., 2014). Data from India indicates that young girls are less likely to be immunized and to receive medical care (Khera et al., 2014). Interestingly, a study on son preference in Nepal found that disparities in immunization between girls and boys did not exist (Leone, Matthews, & Zuanna, 2003). Other analyses on data from Nepal have revealed that those who reported a preference for sons were less likely to use contraception and had higher rates of fertility than those with no preference (Leone et al., 2003; Raj et al., 2013; Rai et al., 2014).
Fertility: In many areas, a woman’s value is often measured by her ability to have children. This can lead women to put their own health or the health of their family at risk by starting pregnancy too early, when not yet physically matured, and giving birth without proper spacing or having more children than the household can support. For couples facing fertility issues, women often bear the brunt of household and community-level stigma and abuse for failing to conceive.	This has been documented routinely by researchers in the Middle East and South Asian countries like Pakistan (Inhorn, 2003; Mumtaz, Shahid, & Levay, 2013).
Masculinity: Masculine ideas associating men with strength, virility, dominance and power may increase the number of sexual partners and inhibit the use of condoms, thereby increasing the risk for unwanted pregnancy or the transmission of STIs or HIV through unprotected sex or sexual violence. These masculine norms also may promote or normalize violence against women (Stern & Buikema, 2013).	Experience of violence has a direct effect on health outcomes, with increased risk of STI and HIV transmission, as well as risk of unwanted pregnancy and limited use of family planning commonly experienced (Blanc, 2001). Women who reported greater acceptance of gender-based violence were also shown to be less likely to use available maternal healthcare services (Sado, Spaho, & Hotchkiss, 2014). In fact, a study in Ghana, Kenya, Tanzania and Uganda found that women living in areas with more accepting attitudes toward gender-based violence were less likely to use a skilled birth attendant or receive well-timed antenatal care (Adjiwanou, 2014).

Gender Considerations

Supporting Evidence Includes:

Gender Preference: In India, China, and to a certain extent in some African countries, there is a gender bias in child healthcare (Khera, Jain, Lodha, & Ramakrishnan, 2014; Pemunta & Fubah, 2014). Preference for boys can lead to financial resources for education and other services, like healthcare, being differentially allocated within households. Reasons for this preference vary, and include the perception that boys will financially support their parents when they are older, and that families are obliged to pay dowries when their daughters marry.

In India, gender-selective abortion has resulted in fewer female children being born. Among those girls who are born, preferential treatment of boys often comes at the expense of the girls, who may be deprived of nutrients during important developmental stages, which can lead to stunting and malnutrition (Khera et al., 2014).

Data from India indicates that young girls are less likely to be immunized and to receive medical care (Khera et al., 2014). Interestingly, a study on son preference in Nepal found that disparities in immunization between girls and boys did not exist (Leone, Matthews, & Zuanna, 2003).

Other analyses on data from Nepal have revealed that those who reported a preference for sons were less likely to use contraception and had higher rates of fertility than those with no preference (Leone et al., 2003; Raj et al., 2013; Rai et al., 2014).

Fertility: In many areas, a woman’s value is often measured by her ability to have children. This can lead women to put their own health or the health of their family at risk by starting pregnancy too early, when not yet physically matured, and giving birth without proper spacing or having more children than the household can support. For couples facing fertility issues, women often bear the brunt of household and community-level stigma and abuse for failing to conceive.

This has been documented routinely by researchers in the Middle East and South Asian countries like Pakistan (Inhorn, 2003; Mumtaz, Shahid, & Levay, 2013).

Masculinity: Masculine ideas associating men with strength, virility, dominance and power may increase the number of sexual partners and inhibit the use of condoms, thereby increasing the risk for unwanted pregnancy or the transmission of STIs or HIV through unprotected sex or sexual violence. These masculine norms also may promote or normalize violence against women (Stern & Buikema, 2013).

Experience of violence has a direct effect on health outcomes, with increased risk of STI and HIV transmission, as well as risk of unwanted pregnancy and limited use of family planning commonly experienced (Blanc, 2001).

Women who reported greater acceptance of gender-based violence were also shown to be less likely to use available maternal healthcare services (Sado, Spaho, & Hotchkiss, 2014). In fact, a study in Ghana, Kenya, Tanzania and Uganda found that women living in areas with more accepting attitudes toward gender-based violence were less likely to use a skilled birth attendant or receive well-timed antenatal care (Adjiwanou, 2014).

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