health Exploring health and inequality We can think of inequality as the difference between the things some groups of people have compared to other people. It’s a bit like looking at how big a slice of cake one person has compared to another. There is inequality between countries in the world. For example, some countries are wealthy while others are extremely poor. There is also inequality within countries. For example, some people in the country may have a lot more money than others. But inequality is not just about money. There can also be inequality in the kinds of opportunities people have in life.

Inequality and maternal health in Ghana This presentation looks at the issue of inequality in maternal health-care provision in Ghana, using case studies and photographs from Oxfam’s work in Ghana in 2011.   Maternal health means the well-being of women during pregnancy, child-birth and the time just after giving birth. Motherhood should be a rewarding and fulfilling time for women and their families. However, it is often associated with suffering, ill health and even death for far too many of the world’s women. Inequality plays a major role in this as it means that these women cannot access proper health services. However, there is also good news. There have been improvements, particularly in Ghana, since maternal health care was made free by the government in 2008. The problem of inequality means these improvements have not been felt everywhere. This presentation looks at the case studies of two new mothers in Ghana and their different experience of these improvements. Photo: Abbie Trayler-Smith/Oxfam

Maternal health goals The countries belonging to the United Nations have agreed to reduce the number of women dying in childbirth. This is one of the targets of Sustainable Development Goal 3 (2015–2030): By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births. In 2000, the 189 member countries of the United Nations agreed to work together to achieve the Millennium Development Goals by 2015. There were eight goals altogether, aiming to dramatically reduce poverty and improve health, education and the environment. Goal 5 aimed to reduce maternal mortality by three-quarters of its 1990 levels by 2015. In the end, the rate of decline was around half of that required to achieve Goal 5. Millennium Development Goal 5 has been superseded by Sustainable Development Goal 3, specifically the following targets: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births. By 2030, end preventable deaths of newborns and children under five years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-five mortality to at least as low as 25 per 1,000 live births. Currently, around 360,000 women die each year during pregnancy and childbirth. Almost all of these deaths occur in sub-Saharan Africa and Asia. If pregnant women and new mothers had access to free, good-quality basic health care, contraception and affordable medicines, then they would be much more likely to survive giving birth.   Data Source: WHO website 2010 bit.ly/aVPGXB. Teacher/facilitator notes: You can find out more about the 2015 Sustainable Development Goals here: https://sustainabledevelopment.un.org You can find out more about the Millennium Development Goals here: Change the World in 8 Steps, Oxfam Education GB 2008: www.oxfam.org.uk/education/resources/change-the-world-in-eight-steps. Discussions about goals to replace the Millennium Development Goals after 2015 resulted in the Sustainable Development Goals. For more information see: www.un.org/millenniumgoals/beyond2015-news.shtml www.beyond2015.org/

Where is Ghana? Ghana is located in West Africa, and in 1957 was first sub-Saharan African country to win independence from colonial rule. It currently has a population of almost 25 million people and is ranked 135th out of 187 countries on the United Nations Human Development Index.   This presentation tells the stories of two new mothers, Selina and Adumporka. Selina lives in the capital city of Accra, located on the southern coast of Ghana. Adumporka lives near Bolgatanga in the dry and rural north of the country, approximately 400 miles away. There is a stark inequality in the experiences of Selina and Adumporka. In Ghana the maternal mortality rate in the Greater Accra region is 355 per 100,000 live births. In the Upper East Region, where Adumporka gave birth, it is more than twice as high, at 802 per 100,000 live births. Other health and education statistics from Ghana show similar significant regional differences. Data sources: WHO (2014) bit.ly/1j1wjdy, UNDP (2013) http://bit.ly/1kYwvXA, UNICEF (2012) http://uni.cf/1w9Hjss, Ghana Statistical Service (2013) http://bit.ly/1qfBAAU pps 19&36 , Millennium Development Goals in Ghana (2013) bit.ly/1qfBAAU. Maps: http://commons.wikimedia.org/wiki/File:LocationGhana.svg.

Ghana compared to the UK Chance a woman will die in childbirth during her lifetime. 1 in 66 1 in 6,900 Health care for pregnant mums in Ghana was made free by the Ghanaian government in 2008. As a result, after just one year 433,000 additional women received health care in hospitals and clinics. To meet this demand the number of nurses in the country has doubled since 2008.   Despite this impressive improvement, Ghana still faces challenges. There are around 10 times more nurses and midwives per 10,000 people in the UK than in Ghana. And the lifetime chance a woman will die in child-birth is 1 in 66 in Ghana compared with 1 in 4,700 in the United Kingdom. Just think for a moment about this difference – it’s so big it can’t be shown to scale on the slide. Selina and Adumporka’s stories will now help to show both what Ghana has achieved and what still needs to be done. Data source: WHO (2014) bit.ly/1sgWDSB pps 31-43 Data source: World Bank (2010) bit.ly/1ruXmR3 The number of nurses and midwives per 10,000 people. 9 101

Meet Selina – the southern mother The first story is about Selina Fletcher, a 30-year-old mother living in Ghana’s capital, Accra. Here is her story:   Even though she couldn’t read, Selina had heard that health care for pregnant women was now free. So she went straight to the hospital with her best friend, Sarah, once she knew her baby was on its way. This photo shows Selina going to the delivery ward. Photo: Abbie Trayler-Smith/Oxfam

Meet Selina – the southern mother When Selina first arrived at the hospital she was told she should have brought a hair net, a blanket and a bottle of disinfectant with her. Her friend Sarah left Selina at the hospital and went home to ask Selina’s family for money to buy the things she needed. Everything that Sarah bought for Selina is in this bag. So even though health care is free, giving birth is not without its costs. If a mother is poor the items she has to bring to hospital can be very expensive. Photo: Abbie Trayler-Smith/Oxfam

Meet Selina – the southern mother After five hours in labour, Selina gave birth to a baby girl with the help of a nurse and a midwife. The baby was given an injection straight after she was born to keep her healthy. Mother and baby then spent 24 hours resting in the “lying-in” ward so that the midwife and doctors could check their health. They also gave Selina advice about caring for her new baby. After spending 35 hours in hospital, Selina left with her new baby and Sarah to take a taxi home. Both mother and daughter are well after getting free health care from doctors and nurses. However Selina still has to pay towards medicines and a bed fee. There was also a rush for Selina to obtain a national insurance card to show the hospital staff and claim free treatment. Photo: Abbie Trayler-Smith/Oxfam

Meet Adumporka – the northern mother Adumporka is a 23-year-old woman living in rural northern Ghana. Here is her story:   When Adumporka knew that the baby was coming, she went to the health centre in Bolgatanga with 72-year-old Atulepoka, a traditional birthing assistant. They walked the four kilometres to the clinic together. Traditional birthing assistants are encouraged to take women to clinics and hospitals to give birth rather than give birth at home. This is because clinics have more equipment and midwives to help if there’s an emergency. Photo: Abbie Trayler-Smith/Oxfam

Meet Adumporka – the northern mother Here, Adumporka is waiting for her husband to collect her just a few hours after giving birth. There is no space for her to rest at the clinic. When Adumporka first arrived at the hospital, she had to lie on the floor because there were no beds available. She was moved to a bed to give birth and was helped by a trained midwife and a nurse. Next to her are the items that she brought from home, such as blankets, soap and a bottle of disinfectant. Photo: Abbie Trayler-Smith/Oxfam

Meet Adumporka – the northern mother Adumporka and her baby returned home on the back of her husband’s motorcycle. She was very fortunate because many women in the northern Ghana have to walk many kilometres to get to the clinic and make the same journey home on foot with their new babies. Photo: Abbie Trayler-Smith/Oxfam

However, every week 60 women in Ghana still die during child-birth. How is Ghana doing? Free health care saves lives and helps women like Selina and Adumporka to give birth safely. However, every week 60 women in Ghana still die during child-birth. Ghana has made great progress since 2008, when free maternal health care was introduced. However, too many women are still not getting the care they’re entitled to, owing to regional inequalities in services.   Every week around 60 women in Ghana die because of complications during pregnancy and child-birth. The vast majority of these deaths are completely preventable. For women like Adumporka, who live in rural areas, it can be particularly difficult to access medical help close to their homes. Meeting the health targets set by Sustainable Development Goal 3 is a partnership between countries. Here’s how it should work. The government in Ghana should be investing its own money to improve health services and increase the number of health workers, especially in rural areas. The responsibility for providing health care for citizens lies with a country’s government. All governments who made a commitment to invest 0.7% of their national income in overseas aid should keep their pledge. Many poor countries did not have sufficient money to achieve Millennium Development Goal 5 and there is a risk that unless the funding increases, they will not be able to meet the targets set by the new 2015–2030 Sustainable Development Goal 3 either. The investment of aid supports Ghana and other poor countries to improve maternal health care and meet the target of reducing maternal mortality by three-quarters. How Ghana could reduce the gap between women who have access to health care and women who don’t? Is there such inequality in your country? Do you think some regions, places or people benefit less from things the government provides, like health care, education, training or skills development? If yes, why? Teacher/facilitator notes: Learn more about countries promising to give 0.7% of their national income on aid here: www.unmillenniumproject.org/press/07.htm Data source: apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf?ua=1

Thank you! Adumporka’s son safely wrapped in his blanket in northern Ghana.   Thank you for listening! Photo: Abbie Trayler-Smith/Oxfam Terms of use Copyright © Oxfam GB You can use the resources provided for educational purposes. Please ensure that the way you use the material is consistent with all contextual information provided and credit any images used with the named author and Oxfam. All information associated with these images relates to the time and date that project work took place.