Women and Children in Poverty - Poor Women's Health

It is not surprising that poor people suffer from more health problems and receive a lower quality of health care than their nonpoor counterparts. Women, however, suffer disproportionately, first because there simply are more poor women than poor men in the world, and second because, as the bearers of children, women face a different set of potential diseases, illnesses, and injuries related to their reproductive systems.

The Millennium Development Goal of improving maternal health, as opposed to women's health, points to the significance of reproduction in the overall picture of women's health, as well as in the social and economic status of their families. A mother's health typically reflects the health of her entire family, just as a mother's education reflects that of her children (see section below). Of the link between poverty and maternal health, United Nations Population Fund (UNFPA) executive director Thoraya Obaid stated in October 2005: "If women are healthy then they can jump start the life of their family and the economy" ("Women's Health Fuelling Poverty," BBC News, October 12, 2005, http://news.bbc.co.uk/2/hi/health/4331996.stm).

Reproductive Health and Poverty

In State of World Population 2005. The Promise of Equality: Gender Equity, Reproductive Health, and the MDGs the UNFPA cites illnesses of the reproductive system as the leading cause of death and disability of women globally and the second most common cause of poor health in the world after communicable diseases. According to an estimate by the Alan Guttmacher Institute, women's reproductive health issues result in the loss of as much as 250 million years' worth of productive time each year and a 20% reduction of women's overall productivity ("The Benefits of Investing in Sexual and Reproductive Health," Issues in Brief, 2004). The UNFPA reported in 2005 that complications of pregnancy and childbirth kill one woman every minute and injure twenty others—99% of them in developing countries. Figure 7.4 provides a breakdown of the causes of maternal death as reported by the World Health Organization (WHO) in 2005. According to the State of the World Population, several aspects of reproductive health have wide-reaching and long-term socioeconomic effects on families, communities, countries, and even entire regions.

Because most maternal deaths occur in already impoverished countries that are clustered together geographically, their regional impact is particularly acute. At the most personal level, children who lose their mothers tend to experience emotional problems that eventually may make them less productive as adults, and households lose valuable income without an adult female wage earner; many families, in fact, are pushed over the brink of poverty as a result of the

FIGURE 7.4 Causes of maternal death "Figure 4.1. Causes of Maternal Death," in The World Health Report 2005: Make Every Mother and Child Count, World Health Organization, 2005, http://www.who.int/whr/2005/whr2005_en.pdf (accessed April 10, 2006)

TABLE 7.4 Economic effects of fatal illness in the household, 1992 Margaret E. Greene and Thomas Merrick, "Table 1. Economic Effects of Fatal Illness in the Household," in Poverty Reduction: Does Reproductive Health Matter?, HNP Discussion Paper 33399, The World Bank, The International Bank for Reconstruction and Development, July 2005, http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2005/08/22/000012009_20050822094645/Rendered/PDF/333990HNP0Gree1tyReduction01public1.pdf (accessed April 10, 2006). Data based on Over et al., 1992.

TABLE 7.4
Economic effects of fatal illness in the household, 1992
Timing of Impact
Type of effects	Before illness	During illness	Immediate effect of death	Long term effect of death
SOURCE: Margaret E. Greene and Thomas Merrick, "Table 1. Economic Effects of Fatal Illness in the Household," in Poverty Reduction: Does Reproductive Health Matter?, HNP Discussion Paper 33399, The World Bank, The International Bank for Reconstruction and Development, July 2005, http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2005/08/22/000012009_20050822094645/Rendered/PDF/333990HNP0Gree1tyReduction01public1.pdf (accessed April 10, 2006). Data based on Over et al., 1992.
Effect on production and earnings	Organization of economic activity Residential location	Reduced productivity of ill adult Reallocation of labor	Lost output of deceased	Lost output of deceased Reallocation of land and labor
Effect on investment and consumption	Insurance Medical costs of prevention Precautionary savings Transfer to other households	Medical cost of treatment Dissaving Changes in consumption and investment	Funeral costs Transfers Legal fees	Changes in type and quantity of investment and consumption
Effect on household health and composition	Extended family Fertility	Reduced allocation of labor to health maintaining activities	Loss of deceased	Poor health of surviving household members Dissolution or reconstitution of household
Psychic costs		Disutility of ill person	Disutility to person Grief of loved ones

high cost of health care when a mother becomes sick. (See Table 7.4.) Communities feel the loss because women in developing countries perform so many essential unpaid tasks, such as caring for children and elders, growing and harvesting food, and gathering fuel and water. High rates of maternal deaths affect the overall economic situation in a region in terms of lost productivity and lost potential for economic, cultural, and technological expansion.

WHO's World Health Report 2005: Make Every Mother and Child Count warns that if progress on improving maternal health continues at the slow rate it has seen since the 1990s, the Millennium Development Goals will not be met by 2015. Of the 136 million births every year, 529,000 result in the death of the mother; as of 2005, 300 million women were experiencing illnesses brought on by pregnancy or childbirth. WHO maintains that most of those deaths could be prevented with increased access to skilled care during and following childbirth. In 2005, 43% of mothers and newborns received some care at birth, but not enough to prevent the complications that often arise. Additionally, WHO reports that increased public expenditures on health care, higher wages for health care workers, and universal access to medical care are essential to reaching the MDGs, especially those that relate to women and children.

Table 7.5 illustrates the link between reproductive rights and the MDGs. Included in reproductive rights are issues such as violence against women and the rights to marry voluntarily, space children as desired, receive clear and accurate information about the reproductive process, and benefit from scientific progress. For women living in low-income countries, these rights cannot be TABLE 7.5 Reproductive rights and the MDGs (Millennium Development Goals) "Reproductive Rights and the MDGs," in State of World Population 2005, United Nations Population Fund, 2005, http://www.unfpa.org/swp/2005/pdf/en_swp05.pdf (accessed April 8, 2006)

TABLE 7.5
Reproductive rights and the MDGs (Millennium Development Goals)
Elements of reproductive rights	Examples of rights-based actions	Relevance to specific Millennium Development Goals (MDGs)
SOURCE: "Reproductive Rights and the MDGs," in State of World Population 2005, United Nations Population Fund, 2005, http://www.unfpa.org/swp/2005/pdf/en_swp05.pdf (accessed April 8, 2006)
Right to life and survival	Prevent avoidable maternal and infant deaths End neglect of and discrimination against girls that can contribute to premature deaths Ensure access to information and methods to prevent sexually transmitted infections, including HIV	Promote gender equality and empower women (MDG 3) Reduce child mortality (MDG 4) Improve maternal health (MDG 5) Combat HIV/AIDS, malaria and other diseases (MDG 6)
Right to liberty and security of the person	Take measures to prevent, punish and eradicate all forms of gender-based violence Enable women, men and adolescents to make reproductive decisions free of coercion, violence and discrimination Eliminate female genital mutilation/cutting Stop sexual trafficking	Eradicate extreme poverty and hunger (MDG 1) Promote gender equality and empower women (MDG 3) Reduce child mortality (MDG 4) Improve maternal health (MDG 5) Combat HIV/AIDS, malaria and other diseases (MDG 6)
Right to seek, receive and impart information	Make information about reproductive health and rights issues and related policies and laws widely and freely available Provide full information for people to make informed reproductive health decisions Support reproductive health and family life education both in and out of schools	Promote gender equality and empower women (MDG 3) Combat HIV/AIDS, malaria and other diseases (MDG 6)
Right to decide the number, timing and spacing of children	Provide people with full information that enables them to choose and correctly use a family planning method Provide access to a full range of modern contraceptive methods Enable adolescent girls to delay pregnancy	Eradicate extreme poverty and hunger (MDG 1) Achieve universal primary education (MDG 2) Promote gender equality and empower women (MDG 3) Ensure environmental stability (MDG 7)
Right to voluntarily marry and establish a family	Prevent and legislate against child and forced marriages Prevent and treat sexually transmitted infections that cause infertility Provide reproductive health services, including for HIV prevention, to married adolescent girls and their husbands	Achieve universal primary education (MDG 2) Promote gender equality and empower women (MDG 3) Reduce child mortality (MDG 4) Improve maternal health (MDG 5) Combat HIV/AIDS, malaria and other diseases (MDG 6)
Right to the highest attainable standard of health	Provide access to affordable, acceptable, comprehensive and quality reproductive health information and services Allocate available resources fairly, prioritizing those with least access to reproductive health education and services	Eradicate extreme poverty and hunger (MDG 1) Promote gender equality and empower women (MDG 3) Reduce child mortality (MDG 4) Improve maternal health (MDG 5) Combat HIV/AIDS, malaria and other diseases (MDG 6)
Right to the benefits of scientific progress	Fund contraceptive research, including female-controlled methods, microbicides and male methods Offer a variety of contraceptive options Provide access to emergency obstetric care that can prevent maternal deaths and obstetric fistula	Promote gender equality and empower women (MDG 3) Reduce child mortality (MDG 4) Improve maternal health (MDG 5) Combat HIV/AIDS, malaria and other diseases (MDG 6)
Right to non-discrimination and equality in education and employment	Prohibit discrimination in employment based on pregnancy, proof of contraceptive use or motherhood Establish programmes to keep girls in schools Ensure pregnant and married adolescent girls, and young mothers, are able to complete their education	Eradicate extreme poverty and hunger (MDG 1) Achieve universal primary education (MDG 2) Promote gender equality and empower women (MDG 3) Combat HIV/AIDS, malaria and other diseases (MDG 6)

taken for granted. In fact, many are prohibited from using contraception—or from even receiving information about it—and must marry whomever their families choose for them. In some cultures, going against these conventions can place the woman in a position that results in physical and emotional violence. The inability to decide how many children to have or how many years apart to have them can easily overwhelm a family's finances, particularly a family that is already poor. There are also health considerations: a woman who can control her reproductive choices is more likely to receive adequate health care, and thus less likely to die in childbirth.

In Poverty Reduction: Does Reproductive Health Matter? (World Bank Health, Nutrition and Population, July 2005), Margaret E. Greene and Thomas Merrick argue that controversy over reproductive rights—namely, abortion and birth control—has hit poor women particularly hard. According to Greene and Merrick, the issue has actually harmed poor women's health: governments have been pressured to cut funding for medical care and family planning, and the United Nations was forced to drop the goal of achieving universal reproductive health care from the Millennium Declaration. The United Nations Population Fund reports in State of the World Population 2005 that as of 2005 the world's women suffered disproportionately from sexual and reproductive health problems—nearly 35% of women globally versus less than 20% of men.

Figure 7.5 shows the percentages of the poorest and wealthiest women who give birth with the attendance of skilled medical personnel in selected low-income countries. Poor women are far less likely to have a skilled attendant present during the births of their children. In Vietnam, where 100% of the richest women have access to medical personnel during childbirth, only 58% of the poorest women do. In Ethiopia just 1% of the poorest FIGURE 7.5 Births attended by skilled personnel among the poorest and richest women, selected countries, 2004 "Figure 2. Births Attended by Skilled Personnel among the Poorest and Richest Women," in State of World Population 2005, United Nations Population Fund, 2005, http://www.unfpa.org/swp/2005/pdf/en_swp05.pdf (accessed April 8, 2006). Data from World Bank, 2004, Round II Country Reports on Health, Nutrition, and Population Conditions among the Poor and the Better-Off in 56 Countries.women receive medical attendance at childbirth, versus 25% of the wealthiest women. These numbers demonstrate that the world's poorest women do not have reproductive rights equal to those of their nonpoor counterparts.

Lack of family planning options most strongly affects poor young women, who may not be prepared for pregnancy and parenthood physically, emotionally, or financially. Figure 7.6 shows the disparity of contraceptive use among the poorest and richest women in Ghana, Yemen, Guatemala, the Philippines, India, and Kazakhstan. In Guatemala, for example, only 5% of the nation's poorest women use contraceptives compared with 60% of wealthy women. Figure 7.7 compares childbearing among the poorest and richest women under age eighteen in Niger, Nicaragua, Nepal, Tanzania, Kenya, Bolivia, and Turkey. In Niger nearly three-quarters (72%) of poor women had given birth by age eighteen, FIGURE 7.6 Contraceptive use according to wealth, selected countries, 2004 "Figure 3. Contraceptive Use according to Wealth," in State of World Population 2005, United Nations Population Fund, 2005, http://www.unfpa.org/swp/2005/pdf/en_swp05.pdf (accessed April 8, 2006). Data from World Bank, 2004, Round II Country Reports on Health, Nutrition, and Population Conditions among the Poor and the Better-Off in 56 Countries.compared with two-fifths (39%) of wealthy women. In reviewing economic and sociological publications on the link between poverty and early childbearing, Greene and Merrick cite the following points of connection:

• Poor health outcomes for the young mother and her child: higher risk of obstetric complications, leading to higher maternal mortality and morbidity (illness or disease) if she survives; increased risk of abortion and abortion complications if the abortion is unsafe; and low birth weight and other problems for the newborn
• Poor educational outcomes for both the mother and her child, including dropping out of school and less schooling for the child
• Lower and/or altered investment and spending patterns in the mother's immediate and extended family (costs of medical care and child care, for example, can make it difficult or impossible to save money)
• Possibly lower labor force participation by the young mother, with less opportunity to contribute to household income
• Reduced community participation and greater chances of divorce or single parenthood

Early childbearing tends to occur more often in poor countries but even in wealthier countries the highest rates of fertility among adolescents are found among the FIGURE 7.7 Childbearing among the poorest and richest adolescents, selected countries, 2004 "Figure 4. Childbearing among the Poorest and Richest Adolest Adolescents," in State of World Population 2005, United Nations Population Fund, 2005, http://www.unfpa.org/swp/2005/pdf/en_swp05.pdf (accessed April 8, 2006). Data from Rani, M. and E. Lule, 2004, "Exploring the Socioeconomic Dimension of Adolescent Reproductive Health: A Multicountry Analysis" International Family Planning Perspectives, 30 (3): 112.poorest groups. Greene and Merrick reported that in 2004, for example, out of a sample of fifty-five countries, the average adolescent fertility rate (the number of women who had given birth before age twenty) for the richest group was 62.6 per 100,000 population, versus 148.6 per 100,000 population for the poorest group. The highest regional rates for adolescent poor women were in Latin America and the Caribbean (172.6 births per 100,000 population), followed by sub-Saharan Africa (169.6). The sampled region with the lowest adolescent fertility rate was East Asia, at forty-six births per 100,000, but it is important to note that in that region only four countries were sample, compared with twenty-nine countries in sub-Saharan.

According to Greene and Merrick, studies have shown that poor women of all ages experience more difficulties with pregnancy and childbearing, but adolescent mothers have more extreme problems because their bodies may not be developed enough to sustain the physical challenges of giving birth. In developing countries women aged fifteen to nineteen are twice as likely to die from complications of childbirth than women in their twenties. Women in poor countries tend to marry and begin having children earlier than women in wealthier countries. This is partly the cause of the significantly higher number of maternal deaths in underdeveloped and developing regions. (See Table 7.6.) In fact, as Table 7.6 illustrates, the total number of maternal deaths increased annually from 515,000 in 1995 to 529,000 in 2000. Developing regions overall saw an increase from 512,000 in 1995 to 527,000 in 2000, with Asia experiencing the greatest increase. Figure 7.8 shows the various factors that link early pregnancy with poverty. Factors such as a lack of education, childhood and adult illness and malnutrition, a lack of access to natural resources and involvement in the global economy, and high mortality rates can all be linked to higher fertility rates, which in turn lead to lower per capita income.

OBSTETRIC FISTULA

One of the most serious health and social consequences of childbirth in poor countries—particularly in sub-Saharan Africa and South Asia—is the development of obstetric fistula. This childbirth-related injury is caused by exceptionally long labor, often as long as five to seven days, that cuts off blood flow to the vagina, bladder, and/or rectum. The resulting holes in the tissue leave women unable to control the flow of TABLE 7.6 Comparison of 1995 and 2000 regional and global totals of maternal mortality Margaret E. Greene and Thomas Merrick, "Table 5. Comparison of 1995 and 2000 Regional and Global Totals," in Poverty Reduction: Does Reproductive Health Matter?, HNP Discussion Paper 33399, The World Bank, The International Bank for Reconstruction and Development, July 2005, http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2005/08/22/000012009_20050822094645/Rendered/PDF/333990HNP0Gree1tyReduction01public1.pdf (accessed April 10, 2006). Data from AbouZahr and Wardlaw, 2004.

TABLE 7.6
Comparison of 1995 and 2000 regional and global totals of maternal mortality
Region	2000		1995
	Maternal mortality ratio	Maternal deaths (in thousands)	Maternal mortality ratio	Maternal deaths (in thousands)
*Developed regions include Canada, United States of America, Japan, Australia and New Zealand, which are excluded from the regional averages.
SOURCE: Margaret E. Greene and Thomas Merrick, "Table 5. Comparison of 1995 and 2000 Regional and Global Totals," in Poverty Reduction: Does Reproductive Health Matter?, HNP Discussion Paper 33399, The World Bank, The International Bank for Reconstruction and Development, July 2005, http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2005/08/22/000012009_20050822094645/Rendered/PDF/333990HNP0Gree1tyReduction01public1.pdf (accessed April 10, 2006). Data from AbouZahr and Wardlaw, 2004.
World total	400	529,000	400	515,000
Developed regions*	20	2,500	21	2,800
Europe	28	2.2	36	3.2
Developing regions	440	527,000	440	512,000
Africa	830	251,000	1,000	273,000
Northern Africa	130	4,600	200	7,200
Sub-Saharan Africa	920	247,000	1,100	265,000
Asia	330	253,000	280	217,000
Eastern Asia	55	11,000	60	13,000
South-central Asia	520	207,000	410	158,000
South-eastern Asia	210	25,000	300	35,000
Western Asia	190	9,800	230	11,000
Latin America & the Caribbean	190	22,000	190	22,000
Oceania	240	530	260	560

FIGURE 7.8 Channels linking early pregnancy and childbearing to poverty Margaret E. Greene and Thomas Merrick, "Figure 2. Channels Linking Early Pregnancy and Childbearing to Poverty," in Poverty Reduction: Does Reproductive Health Matter?, HNP Discussion Paper 33399, The World Bank, The International Bank for Reconstruction and Development, July 2005, http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2005/08/22/000012009_20050822094645/Rendered/PDF/333990HNP0Gree1tyReduction01public1.pdf (accessed April 10, 2006). Data from Ruger et al., 2001.urine and feces, which leak out constantly. Nerve damage to the legs, severe infections, and kidney disease are also common among fistula sufferers.

According to the Fistula Foundation (www.fistulafoundation.org/) and the United Nations Population Fund (UNFPA), more than two million women in the developing world are known to suffer from obstetric fistula, which was virtually eradicated in wealthier countries when caesarian sections became commonplace in the late nineteenth century. The actual number of women who live with the condition is believed to be much higher, since it is rarely discussed and most women who suffer from it never get medical help. WHO estimates that in Nigeria alone, for example, as many as 800,000 women have fistulas, with 20,000 more developing the condition every year ("545 Women Operated on during 'Fistula Fortnight,'" March 7, 2005). Globally, obstetric fistula is believed to occur in 50,000 to 100,000 women per year, most of them under the age of twenty.

According to UNFPA's Campaign to End Fistula (www.endfistula.org/):

Poverty, malnutrition, poor health services, early marriage, and gender discrimination are interlinked root causes of obstetric fistula. Poverty is the main social risk factor because it is associated with early marriage and malnutrition and because poverty reduces a woman's chances of getting timely obstetric care.

Obstetric fistula is a cause of poverty among women as well as a consequence. Sufferers are often abandoned by their husbands and families and ostracized by their communities because of the stigma attached to their condition. Many are driven from their homes and left to survive or die on their own. The condition can, however, be repaired with surgery, which has about a 93% cure rate, according to the Fistula Foundation. However, few women in affected regions either know about the surgery, which costs from $100 to $400, or have access to it, and most cannot afford it.

In 2003 the first major report on fistula—Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries—was published jointly by the UNFPA and the nonprofit organization EngenderHealth. Focusing on the countries most affected by obstetric fistula, the report identified seven critical needs of regions with the highest numbers of fistula sufferers, including education about the physical dangers of early marriage and pregnancy, family planning and maternal health; increased medical care in the form of prevention and treatment; social support services to address the physical and psychological needs of fistula sufferers.

EDUCATION: A TOOL TO LIFT WOMEN OUT OF POVERTY

The Beijing Platform declared that education is an essential human right that contributes to economic development at all levels of society—a declaration that has been supported by the UN, UN Educational, Scientific, and Cultural Organization (UNESCO), the World Bank, and most nongovernmental organizations. However, according to the Education for All Global Monitoring Report 2006: Literacy for Life (2005, http://portal.unesco.org/education/en/ev.php-URL_ID1/443283&URL_DO1/4DO_TOPIC&URL_SECTION1/4201.html), at least 771 million adults over the age of fifteen—one-fifth of the world's adult population—cannot read or write at a functional level; at least two-thirds of them are women.

In its State of the World Population 2002: People, Poverty, and Possibilities (2002, http://www.unfpa.org/swp/2002/english/ch1/), the United Nations Population Fund (UNFPA) reports that 31% of women had no formal education in 2000, versus 18% of men. There are many reasons for this disparity, and poverty is chief among them: although women are almost universally less likely to attain high levels of education, being female and poor is, according to the UNFPA report, a "double disadvantage." In rural areas the long walking distances to schools discourage families from sending girls because they fear girls will be sexually assaulted on the way. Fees for attendance, books, and uniforms can also affect whether girls are sent to school. Again, girls in some regions are vulnerable to sexual exploitation from wealthier men who offer to pay for girls' schooling in exchange for sex. Early marriage and pregnancy also cause millions of girls to drop out of school every year. Many families decide to keep daughters at home to help tend and harvest crops, do housework, and care for elders and young siblings. The costs associated with educating girls are generally not seen as worthwhile because girls are not expected to continue their education or earn a living when they grow up. More simply, in many cultures girls are not valued in the same way that boys are, so to many impoverished families educating them seems like a waste of time and money—and in some places it is altogether forbidden.

Barbara Herz and Gene B. Sperling report in What Works in Girls' Education: Evidence and Policies from the Developing World (2004, http://www.cfr.org/content/publications/attachments/Girls_Education_full.pdf) that education for girls in developing countries is essential for economic success at all levels of society. The benefits of educating girls are seen from families to nations, in the forms of higher wages, faster economic growth, and more productive farming. This in turn results in decreased levels of malnutrition; women having smaller, healthier, more educated families; reducing the spread of HIV/AIDS; reducing rates of violence against women; and fostering democratic participation in society.

According to Herz and Sperling, when girls attend school just one year beyond the average, they eventually earn 10% to 20% more than average as adults. On the macroeconomic level, even modest increases in the number of women receiving a secondary education can lead to an increase in annual per capita income of 0.3%; likewise, as per capita growth continues, more girls achieve higher levels of education—a cycle that is beneficial, ultimately, for everyone. Similarly, the more education women have, the lower their rates of fertility will be. In Brazil, for example, illiterate women have an average of six children each, whereas literate women average 2.5 children each. Lower overall fertility rates lead to healthier, better-educated children. In fact, infant mortality rates are between 5% and 10% lower among girls who stay in school just one year longer than average. In countries where girls receive as many years of schooling as boys, infant mortality rates are 25% lower than in countries that do not have educational gender parity (equality).

Herz and Sperling conclude that governments of low-income countries can encourage families to educate their daughters and increase overall educational gender parity by eliminating school fees, providing local schools with flexible schedules that are safe for girls, and focusing on providing a quality education that realistically takes into account the needs of girls and their families.

Table 7.7 shows which countries achieved the Millennium Development Goal of gender parity in education as of 2002, those that are likely to achieve the goal by 2005, those that are likely to achieve the goal by 2015, and those countries that are in danger of not achieving the goal by 2015.

VIOLENCE AGAINST WOMEN

Violence against women happens in every economic class of every culture around the world. While it is a TABLE 7.7 Country prospects for the achievement of gender parity in primary and secondary education by 2005 and 2015 "Table 2. 10. Country Prospects for the Achievement of Gender Parity in Primary and Secondary Education by 2005 and 2015," in Education for All Global Monitoring Report 2006: Literacy for Life, United Nations Educational, Scientific and Cultural Organization, 2005, http://www.unesco.org/education/GMR2006/full/chapt2_eng.pdf (accessed April 8, 2006). Copyright © UNESCO, 2005multifaceted social problem, many experts consider it to be largely a health issue because of the physical and emotional havoc it wreaks on its victims; the other dimension of violence against women is that it is a human rights issue. Amnesty International calls it "a major human rights scandal and a public health crisis" ("Women, Violence, and Health," March 2004, http://www.web.amnesty.org/library/Index/ENGACT770012005?open&of1/4ENG-366). Although hard data are difficult to obtain because of the covert nature of the problem, there is a known link between violence against women and poverty. Figure 7.9 shows percentages of women in selected low-income countries who believed wife-beating was justified as of 2004. The reasons given—presented in the graph's "Note"—are indicative of the status of women in these cultures.

In Addressing Violence against Women and Achieving the Millennium Development Goals (2005, http://www.who.int/gender/documents/MDGs&VAWSept05.pdf), the WHO cites two main reasons poor women are more vulnerable to violence than their nonpoor counterparts: fewer resources—in terms of both money and support services—to help women avoid or escape violence; and the stressors of poverty, such as hunger, unemployment, and lack of education, that may lead some men to become violent or exacerbate an already violent situation. In addition, women who work in unregulated, informal employment are often subject to physical, sexual, or psychological abuse by their employers. In both developing and developed countries, social standards and enforced gender roles contribute to the incidence of violence.

The WHO report recommends several global economic actions that can affect women who are routine victims of violence:

• Promote increased access to postprimary, vocational and technical education for women
• Address gender gaps in earnings as well as barriers to accessing credit for women
• Extend and upgrade childcare benefits to enable women's full participation in the paid labor market
• Address issues of occupational segregation that often translate into inferior conditions of employment for women

FIGURE 7.9 Women who believe wife beating is justified for at least one reason, selected countries, 2004 "Figure 5. Women Who Believe Wife Beating Is Justified for at Least One Reason," in State of World Population 2005, United Nations Population Fund, 2005, http://www.unfpa.org/swp/2005/pdf/en_swp05.pdf (accessed April 8, 2006). Data from Kishor, S. and K. Johnson, 2004, Profiling Domestic Violence: A Multicountry Study, Calverton, MD: ORC Macro, Measure DHS+:66.

• Ensure social protection and benefits for women in precarious employment situations—often those involved in informal employment

The WHO report notes, however, that increasing women's economic and social opportunities can actually put them at greater risk of violence, as such opportunities can breed resentment from the men in their lives. The WHO emphasizes that a well-funded and developed social support system is essential if poor women are to permanently escape violence. Educational programs are particularly important, for both women and men, if perceived gender roles are to be expanded to include advancement for women without the danger of violence.

Exact figures for incidences of violence are almost impossible to obtain, because most violent acts committed against women—especially in developing countries—go unreported. However, it is estimated that 10% to 50% of women around the world have been assaulted by their husbands or male partners at some point. The numbers rise when brothers and other male relatives who perpetrate the violence are counted. In fact, physical and sexual assaults committed by male family members are the most common type of violence against women. In developing countries this type of violence is largely the result of traditional gender norms, most of which have evolved out of men's social and economic dominance over women.

The connection between poverty and violence against women lies primarily in that dominance. In many cultures women are completely dependent on their husbands and male relatives for survival. Amnesty International cites laws that prohibit women from owning or inheriting property and from divorcing abusive husbands; hierarchies that allow fathers, brothers, and husbands to withhold access to food, clothing, and shelter; and customs, such as "wife inheritance" and honor crimes, that force women to obey male relatives or risk exile or death.

In addition, violent conflicts at the village, tribal, and national level reduce millions of women and children to refugee status, leaving them vulnerable to unemployment, disease, starvation, rape, and kidnapping. Millions more women and children (the UN estimates thirty million worldwide) end up as victims of international sex trafficking; the U.S. Department of Health and Human Services' Administration for Children and Families reports that poor women may be lured into the sex trade by promises of a good job in another country, or they may be sold into the trade by their parents, brothers, husbands, or male partners. Others are abducted and forced into the trade. Taken together, these factors leave poor women especially vulnerable to physical, sexual, and psychological violence.

Furthermore, a woman who has suffered domestic violence is more likely to become impoverished. Globally, with as many as one in three women being violently assaulted in her lifetime, the chances of severe, debilitating injury to a large number of abused women are high. In a November 2005 address before the U.S. Congressional Human Rights Caucus, S. K. Guha of UNIFEM noted that violence against women is increasingly acknowledged to be both a consequence and a cause of poverty among women and children. Severely abused women are generally unable to work, especially if they are also responsible for performing the physical labor of harvesting food and gathering fuel and water for their families.

Violence against Women in the United States

In the United States domestic violence is conclusively linked to homelessness among women and children. The American Civil Liberties Union (ACLU) reports that domestic violence was cited by 50% of U.S cities surveyed in 2005 as a primary cause of homelessness (http://www.aclu.org/pdfs/dvhomelessness032106.pdf). Further, the ACLU notes that 50% of homeless women in San Diego, California, reported being the victims of domestic violence, and that in Minnesota, one-third of homeless women indicated that they left their homes to escape domestic violence. Overall, according to the National Network to End Domestic Violence, Domestic Violence (September 2004; http://www.nnedv.org/pdf/Homelessness.pdf), 92% of homeless women in the United States have at some point been the victims of severe physical and/or sexual abuse.

VIOLENCE AGAINST WOMEN ACT 2005

In December 2005 both the U.S. Senate and House of Representatives passed the Violence against Women Act 2005 (VAWA), which was part of the larger Department of Justice authorization bill. The VAWA 2005 is a reauthorization of an earlier act passed in 1994. The 2005 version of VAWA enhanced the provisions of its earlier version, with increased funding for violence-prevention programs, emergency shelter for women and children, and long-term housing solutions for low-income women and their children. The act also mandates that abused women be allowed to take ten days off from work each year to attend court or to look for housing, and it provides greater access to law enforcement and the justice system for abused immigrant woman who would otherwise have no legal recourse and might have to leave the country with abusive partners. Because violent relationships tend to affect poor women disproportionately in the United States, the provisions of the VAWA that allow time off from work and help for immigrant women mean that more poor women will be able to keep their jobs and remain in the country while they make arrangements to leave and/or prosecute their abusers.

POVERTY'S YOUNGEST VICTIMS

According to the report State of the World's Children 2006: Excluded and Invisible (2005, http://www.unicef.org/egypt/sowc06_fullreport.pdf) by the United Nations Children's Fund's (UNICEF), the least developed FIGURE 7.10 The least developed countries are the richest in children, 2004 "Figure 2.1. The Least Developed Countries Are the Richest In Children," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc0506_eps_charts.pdf (accessed April 8, 2006). Data based on calculations from United Nations Population Division.countries in the world are home to the greatest number of children—49% of the total population of least developed countries was under eighteen years old in 2004; in developing countries children under eighteen made up 37% of the total population. (See Figure 7.10.)

Children are more vulnerable to the effects of poverty than any other demographic group, and because their numbers in poor countries are so high, they suffer disproportionately from the disease, hunger, abuse, and exploitation that so often go hand in hand with poverty. UNICEF reports that "more than one billion children suffer from one or more extreme forms of deprivation in adequate nutrition, safe drinking water, decent sanitation facilities, health-care services, shelter, education and information." As Figure 7.11 shows, 30.7% of children in developing countries have no access to a toilet, while 33.9% live in homes with more than five people per room. For 21.1%, there is access only to untreated, potentially hazardous, water sources. Furthermore, 13.1% have never been to school. Underdeveloped and developing countries overall have the highest rates of children not attending school, as shown in Figure 7.12. Whereas 96% of girls and 95% of boys in developed countries are enrolled in primary school, just 65% of girls and 71% of boys in underdeveloped ("least developed") countries are enrolled in primary school. Even fewer poor children are enrolled in secondary school: 26% of girls and 30% of boys in underdeveloped countries, versus 92% of girls and 91% of boys in developed countries.

FIGURE 7.11 Severe deprivation among children in the developing world, by different deprivations, 2003 "Figure 2.1. Severe Deprivation among Children in the Developing World, by Different Deprivations," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/figure2_1_2005.pdf (accessed April 8, 2006). Data from Gordon, David, et al., Child Poverty in the Developing World, The Policy Press, Bristol, UK, October 2003.

FIGURE 7.12 Children living in the poorest countries are most at risk of missing out on primary and secondary school, 2000–04 "Figure 2.2 Children Living in the Poorest Countries Are Most at Risk of Missing Out on Primary and Secondary School," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc0506_eps_charts.pdf (accessed April 8, 2006). Data from Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS)

Table 7.8 lists each country's rank according to its under-five mortality rate, as well as each country's infant and under-five mortality rates, life expectancy, literacy and education rates, and gross national per capita income. In general, life expectancy at birth increases as gross national income per capita increases. Infant and under-five mortality rates improved overall between 1990 and 2004 in least developed, developing, and industrialized countries.

Table 7.9 shows the status of child protection in countries around the world. Western and Central African countries have the overall highest percentage of children involved in child labor (41% of both girls and boys). At 46%, South Asia has the highest rate of child marriage of any geographic region, followed closely by Western and Central Africa, at 45%.

Child poverty is not limited to low-income countries. In eleven out of the fifteen countries belonging to the Organization for Economic Cooperation and Development (OECD), child poverty increased from the period of the late 1980s–early 1990s through the late 1990s–early 2000s. In this group, Mexico had the highest rate of child poverty, rising from 24.7% in the earlier period to 27.7% in the later period. The United States had the second highest rate; even with a drop from 24.3% to 21.9%, the U.S. child poverty rate far exceeded the rate of all other OECD countries except Mexico. In the United Kingdom the drop from 18.5% to 15.4% was due in large part to the commitment

TABLE 7.8 Under-five mortality rank and other development indicators, by country, 1990–2004

TABLE 7.8
Under-five mortality rank and other development indicators, by country, 1990–2004
Countries and territories	Under-5 mortality rank	Under-5 mortality rate		Infant mortality rate (under 1)a		Total population (thousands) 2004	Annual number of births (thousands) 2004	Annual number of under-5 deaths (thousands) 2004	Gross national income per capita (US$)b 2004	Life expectancy at birth (years)c 2004	Total adult literacy rated 2000–2004g	Net primary school enrolment/attendance (percent)e 1996–2004g	Percent share of household Incomef 1993–2003g
		1990	2004	1990	2004								Lowest 40%	Highest 20%
Afghanistan	4	260	257	168	165	28,574	1,395	359	250m	46	—	53l	—	—
Albania	125	45	19	37	17	3,112	53	1	2,080	74	99	95	23	37
Algeria	79	69	40	54	35	32,358	671	27	2,280	71	70	94l	19	43
Andorra	159	—	7	—	6	67	1	0	k	—	—	89	—	—
Angola	2	260	260	154	154	15,490	749	195	1,030	41	67	58l	—	—
Antigua and Barbuda	143	—	12	—	11	81	2	0	10,000	—	—	—	—	—
Argentina	127	29	18	26	16	38,372	685	12	3,720	75	97	—	10	56
Armenia	90	60	32	52	29	3,026	34	1	1,120	72	99	97l	18	45
Australia	162	10	6	8	5	19,942	249	1	26,900	81	—	97	18	41
Austria	172	10	5	8	5	8,171	75	0	32,300	79	—	90	21	39
Azerbaijan	51	105	90	84	75	8,355	132	12	950	67	99	91l	19	45
Bahamas	140	29	13	24	10	319	6	0	14,920m	70	—	86	—	—
Bahrain	148	19	11	15	9	716	13	0	10,840m	75	88	86l	—	—
Bangladesh	58	149	77	100	56	139,215	3,738	288	440	63	41	79l	22	41
Barbados	143	16	12	14	10	269	3	0	9,270m	75	100	100	—	—
Belarus	148	17	11	13	9	9,811	91	1	2,120	68	100	94	21	39
Belgium	172	10	5	8	4	10,400	111	1	31,030	79	—	100	22	37
Belize	81	49	39	39	32	264	7	0	3,940	72	77	99	—	—
Benin	23	185	152	111	90	8,177	341	52	530	54	34	54l	—	—
Bhutan	56	166	80	107	67	2,116	64	5	760	63	—	—	—	—
Bolivia	62	125	69	89	54	9,009	265	18	960	64	87	78l	13	49
Bosnia and Herzegovina	131	22	15	18	13	3,909	37	1	2,040	74	95	86l	24	36
Botswana	41	58	116	45	84	1,769	46	5	4,340	35	79	84l	7	70
Brazil	88	60	34	50	32	183,913	3,728	127	3,090	71	88	95l	8	63
Brunei Darussalam	150	11	9	10	8	366	8	0	24,100m	77	93	—	—	—
Bulgaria	131	18	15	15	12	7,780	67	1	2,740	72	98	90	20	39
Burkina Faso	16	210	192	113	97	12,822	601	115	360	48	13	321	12	61
Burundi	17	190	190	114	114	7,282	330	63	90	44	59	47l	15	48
Cambodia	26	115	141	80	97	13,798	422	60	320	57	74	65l	18	48
Cameroon	25	139	149	85	87	16,038	562	84	800	46	68	75l	15	51
Canada	162	8	6	7	5	31,958	328	2	28,390	80	—	100	20	40
Cape Verde	86	60	36	45	27	495	15	1	1,770	71	76	99	—	—
Central African Republic	15	168	193	102	115	3,986	149	29	310	39	49	43l	7	65
Chad	12	203	200	117	117	9,448	456	91	260	44	26	391	—	—
Chile	152	21	8	17	8	16,124	249	2	4,910	78	96	85	10	62
China	93	49	31	38	26	1,307,989	17,372	539	1,290	72	91	99	14	50
Colombia	113	36	21	30	18	44,915	970	20	2,000	73	94	931	9	62
Comoros	61	120	70	88	52	777	28	2	530	64	56	31l	—	—
Congo	44	110	108	83	81	3,883	172	19	770	52	83	54	—	—
Congo, Democratic Republic of the	8	205	205	129	129	55,853	2,788	572	120	44	65	52l	—	—

TABLE 7.8 Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]

TABLE 7.8
Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]
Countries and territories	Under-5 mortality rank	Under-5 mortality rate		Infant mortality rate (under 1)a		Total population (thousands) 2004	Annual number of births (thousands) 2004	Annual number of under-5 deaths (thousands) 2004	Gross national income per capita (US$)b 2004	Life expectancy at birth (years)c 2004	Total adult literacy rated 2000–2004g	Net primary school enrolment/attendance (percent)e 1996–2004g	Percent share of household Incomef 1993–2003g
		1990	2004	1990	2004								Lowest 40%	Highest 20%
Cook Islands	113	32	21	26	18	18	0	0	—	—	—	—	—	—
Costa Rica	140	18	13	16	11	4,253	79	1	4,670	78	96	90	13	52
Côte d'Ivoire	14	157	194	103	117	17,872	661	128	770	46	48	58l	14	51
Croatia	159	12	7	11	6	4,540	41	0	6,590	75	98	89	21	40
Cuba	159	13	7	11	6	11,245	136	1	1,170m	78	100	93	—	—
Cyprus	172	12	5	10	5	826	10	0	17,580	79	97	96	—	—
Czech Republic	185	13	4	11	4	10,229	91	0	9,150	76	—	87	25	36
Denmark	172	9	5	8	4	5,414	63	0	40,650	77	—	100	23	36
Djibouti	31	163	126	122	101	779	27	3	1,030	53	—	36	—	—
Dominica	135	17	14	15	13	79	2	0	3,650	—	—	81	—	—
Dominican Republic	90	65	32	50	27	8,768	211	7	2,080	68	88	92l	14	53
Ecuador	104	57	26	43	23	13,040	296	8	2,180	75	91	100	11	58
Egypt	86	104	36	76	26	72,642	1,890	68	1,310	70	56	83l	21	44
El Salvador	98	60	28	47	24	6,762	166	5	2,350	71	80	90	10	57
Equatorial Guinea	9	170	204	103	122	492	21	4	j	43	84	62l	—	—
Eritrea	54	147	82	88	52	4,232	166	14	180	54	—	63l	—	—
Estonia	152	16	8	12	6	1,335	13	0	7,010	72	100	95	18	44
Ethiopia	20	204	166	131	110	75,600	3,064	509	110	48	42	31l	22	39
Fiji	120	31	20	25	16	841	19	0	2,690	68	93	100	—	—
Finland	185	7	4	6	3	5,235	55	0	32,790	79	—	100	24	37
France	172	9	5	7	4	60,257	744	4	30,090	80	—	99	20	40
Gabon	49	92	91	60	60	1,362	42	4	3,940	54	—	94l	—	—
Gambia	36	154	122	103	89	1,478	52	6	290	56	—	53l	14	53
Georgia	75	47	45	43	41	4,518	50	2	1,040	71	—	89	18	44
Germany	172	9	5	7	4	82,645	687	3	30,120	79	—	83	22	37
Ghana	42	122	112	75	68	21,664	679	76	380	57	54	61l	16	47
Greece	172	11	5	10	4	11,098	102	1	16,610	78	91	99	19	44
Grenada	113	37	21	30	18	102	2	0	3,760	—	—	84	—	—
Guatemala	75	82	45	60	33	12,295	433	19	2,130	68	69	78l	9	64
Guinea	22	240	155	145	101	9,202	383	59	460	54	—	57l	17	47
Guinea-Bissau	10	253	203	153	126	1,540	77	16	160	45	—	41l	14	53
Guyana	67	88	64	64	48	750	16	1	990	64	—	97l	—	—
Haiti	40	150	117	102	74	8,407	253	30	390	52	52	54l	—	—
Holy See	—	—	—	—	1	—	—	—	—	—	—	—	—	—
Honduras	78	59	41	44	31	7,048	206	8	1,030	68	80	87	9	59
Hungary	152	17	8	15	7	10,124	95	1	8,270	73	99	91	23	37
Iceland	192	7	3	6	2	292	4	0	38,620	81	—	100	—	—
India	52	123	85	84	62	1,087,124	26,000	2,210	620	64	61	77l	21	43
Indonesia	83	91	38	60	30	220,077	4,513	171	1,140	67	88	94l	20	43

TABLE 7.8 Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]

TABLE 7.8
Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]
Countries and territories	Under-5 mortality rank	Under-5 mortality rate		Infant mortality rate (under 1)a		Total population (thousands) 2004	Annual number of births (thousands) 2004	Annual number of under-5 deaths (thousands) 2004	Gross national income per capita (US$)b 2004	Life expectancy at birth (years)c 2004	Total adult literacy rated 2000–2004g	Net primary school enrolment/attendance (percent)e 1996–2004g	Percent share of household Incomef 1993–2003g
		1990	2004	1990	2004								Lowest 40%	Highest 20%
Iran (Islamic Republic of)	83	72	38	54	32	68,803	1,308	50	2,300	71	77	86	15	50
Iraq	33	50	125	40	102	28,057	972	122	2,170m	59	—	78l	—	—
Ireland	162	10	6	8	5	4,080	63	0	34,280	78	—	96	19	43
Israel	162	12	6	10	5	6,601	134	1	17,380	80	97	99	18	44
Italy	172	9	5	9	4	58,033	531	3	26,120	80	—	99	19	42
Jamaica	120	20	20	17	17	2,639	52	1	2,900	71	88	95	17	46
Japan	185	6	4	5	3	127,923	1,169	5	37,180	82	—	100	25	36
Jordan	101	40	27	33	23	5,561	150	4	2,140	72	90	99l	19	44
Kazakhstan	60	63	73	53	63	14,839	237	17	2,260	63	100	91l	20	40
Kenya	37	97	120	64	79	33,467	1,322	159	460	48	74	78l	16	49
Kiribati	66	88	65	65	49	97	2	0	970	—	—	—	—	—
Korea, Democratic People's Republic of	71	55	55	42	42	22,384	349	19	h	63	—	—	—	—
Korea, Republic of	162	9	6	8	5	47,645	467	3	13,980	77	—	100	22	38
Kuwait	143	16	12	14	10	2,606	50	1	16,340m	77	83	83	—	—
Kyrgyzstan	64	80	68	68	58	5,204	116	8	400	67	99	89l	20	43
Lao People's Democratic Republic	53	163	83	120	65	5,792	204	17	390	55	69	62l	19	45
Latvia	143	18	12	14	10	2,318	21	0	5,460	72	100	86	20	41
Lebanon	93	37	31	32	27	3,540	66	2	4,980	72	—	97l	—	—
Lesotho	54	120	82	84	61	1,798	50	4	740	35	81	65l	6	67
Liberia	5	235	235	157	157	3,241	164	39	110	42	56	70	—	—
Libyan Arab Jamahiriya	120	41	20	35	18	5,740	133	3	4,450	74	82	—	—	—
Liechtenstein	172	10	5	9	4	34	0	0	k	—	—	—	—	—
Lithuania	152	13	8	10	8	3,443	31	0	5,740	73	100	91	21	40
Luxembourg	162	10	6	7	5	459	6	0	56,230	79	—	90	—	—
Madagascar	35	168	123	103	76	18,113	704	87	300	56	71	76l	13	54
Malawi	19	241	175	146	110	12,608	550	96	170	40	64	76l	13	56
Malaysia	143	22	12	16	10	24,894	549	7	4,650	73	89	93	13	54
Maldives	74	111	46	79	35	321	10	0	2,510	67	96	92	—	—
Mali	7	250	219	140	121	13,124	647	142	360	48	19	39l	13	56
Malta	162	11	6	9	5	400	4	0	12,250	79	88	96	—	—
Marshall lslands	69	92	59	63	52	60	0	0	2,370	—	—	84	—	—
Mauritania	33	133	125	85	78	2,980	123	15	420	53	51	44l	17	46
Mauritius	131	23	15	21	14	1,233	20	0	4,640	72	84	97	—	—
Mexico	98	46	28	37	23	105,699	2,201	62	6,770	75	90	99	10	59
Micronesia (Federated States of)	110	31	23	26	19	110	3	0	1,990	68	—	—	—	—
Moldova, Republic of	98	40	28	30	23	4,218	43	1	710	68	96	98l	18	44
Monaco	172	9	5	7	4	35	0	0	k	—	—	—	—	—

TABLE 7.8 Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]

TABLE 7.8
Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]
Countries and territories	Under-5 mortality rank	Under-5 mortality rate		Infant mortality rate (under 1)a		Total population (thousands) 2004	Annual number of births (thousands) 2004	Annual number of under-5 deaths (thousands) 2004	Gross national income per capita (US$)b 2004	Life expectancy at birth (years)c 2004	Total adult literacy rated 2000–2004g	Net primary school enrolment/attendance (percent)e 1996–2004g	Percent share of household Incomef 1993–2003g
		1990	2004	1990	2004								Lowest 40%	Highest 20%
Mongolia	72	108	52	78	41	2,614	58	3	590	65	98	79l	16	51
Morocco	77	89	43	69	38	31,020	713	31	1,520	70	51	89l	17	47
Mozambique	23	235	152	158	104	19,424	769	117	250	42	46	60l	17	47
Myanmar	45	130	106	91	76	50,004	992	105	220m	61	90	80l	—	—
Namibia	68	86	63	60	47	2,009	56	4	2,370	47	85	78l	4	79
Nauru	95	—	30	—	25	13	0	0	—	—	—	81	—	—
Nepal	59	145	76	100	59	26,591	786	60	260	62	49	74l	19	45
Netherlands	162	9	6	7	5	16,226	190	1	31,700	79	—	99	21	39
New Zealand	162	11	6	8	5	3,989	55	0	20,310	79	—	100	18	44
Nicaragua	83	68	38	52	31	5,376	153	6	790	70	77	80l	15	49
Niger	3	320	259	191	152	13,499	734	190	230	45	14	30l	10	53
Nigeria	13	230	197	120	101	128,709	5,323	1,049	390	43	67	62l	13	56
Niue	—	—	—	—	—	1	0	—	—	—	—	99	—	—
Norway	185	9	4	7	4	4,598	55	0	52,030	80	—	100	24	37
Occupied Palestinian territory	107	40	24	34	22	3,587	136	3	1,110m	73	92	91	—	—
Oman	140	32	13	25	10	2,534	64	1	7,830m	74	74	72	—	—
Pakistan	47	130	101	100	80	154,794	4,729	478	600	63	49	56l	21	42
Palau	101	34	27	28	22	20	0	0	6,870	—	—	96	—	—
Panama	107	34	24	27	19	3,175	70	2	4,450	75	92	100	9	60
Papua New Guinea	48	101	93	74	68	5,772	176	16	580	56	57	74	12	57
Paraguay	107	41	24	33	21	6,017	175	4	1,170	71	92	89	9	61
Peru	97	80	29	60	24	27,562	627	18	2,360	70	88	96l	11	53
Philippines	88	62	34	41	26	81,617	2,026	69	1,170	71	93	88l	14	52
Poland	152	18	8	19	7	38,559	365	3	6,090	75	—	98	20	41
Portugal	172	14	5	11	4	10,441	112	1	14,350	78	—	100	17	46
Qatar	113	26	21	21	18	777	14	0	12,000m	73	89	94	—	—
Romania	120	31	20	27	17	21,790	213	4	2,920	72	97	89	20	41
Russian Federation	113	29	21	23	17	143,899	1,511	32	3,410	65	99	90	21	39
Rwanda	10	173	203	103	118	8,882	365	74	220	44	64	75l	23m	39m
Saint Kitts and Nevis	113	36	21	30	18	42	1	0	7,600	—	—	95	—	—
Saint Lucia	135	21	14	20	13	159	3	0	4,310	73	90	99	—	—
Saint Vincent and the Grenadines	112	25	22	22	18	118	2	0	3,650	71	—	90	—	—
Samoa	95	50	30	40	25	184	5	0	1,860	71	99	98	—	—
San Marino	185	14	4	13	3	28	0	0	k	—	—	—	—	—
Sao Tome and Principe	38	118	118	75	75	153	5	1	370	63	—	78l	—	—
Saudi Arabia	101	44	27	35	21	23,950	665	18	10,430	72	79	54	—	—
Senegal	29	148	137	90	78	11,386	419	57	670	56	39	48l	17	48
Serbia and Montenegro	131	28	15	24	13	10,510	122	2	2,620	74	96	96	—	—

TABLE 7.8 Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]

TABLE 7.8
Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]
Countries and territories	Under-5 mortality rank	Under-5 mortality rate		Infant mortality rate (under 1)a		Total population (thousands) 2004	Annual number of births (thousands) 2004	Annual number of under-5 deaths (thousands) 2004	Gross national income per capita (US$)b 2004	Life expectancy at birth (years)c 2004	Total adult literacy rated 2000–2004g	Net primary school enrolment/attendance (percent)e 1996–2004g	Percent share of household Incomef 1993–2003g
		1990	2004	1990	2004								Lowest 40%	Highest 20%
Seychelles	135	19	14	17	12	80	3	0	8,090	—	92	100	—	—
Sierra Leone	1	302	283	175	165	5,336	245	69	200	41	30	41l	3m	63m
Singapore	192	9	3	7	3	4,273	40	0	24,220	79	93	—	14	49
Slovakia	150	14	9	12	6	5,401	51	0	6,480	74	100	86	24	35
Slovenia	185	10	4	8	4	1,967	17	0	14,810	77	100	93	23	36
Solomon Islands	70	63	56	38	34	466	15	1	550	63	—	—	—	—
Somalia	6	225	225	133	133	7,964	359	81	130m	47	—	11l	—	—
South Africa	65	60	67	45	54	47,208	1,093	73	3,630	47	82	89l	10	62
Spain	172	9	5	8	3	42,646	447	2	21,210	80	—	100	20m	40m
Sri Lanka	135	32	14	26	12	20,570	330	5	1,010	74	90	—	21	42
Sudan	49	120	91	74	63	35,523	1,163	106	530	57	59	53l	—	—
Suriname	81	48	39	35	30	446	9	0	2,250	69	88	90l	—	—
Swaziland	21	110	156	78	108	1,034	30	5	1,660	31	79	72l	9	64
Sweden	185	7	4	6	3	9,008	95	0	35,770	80	—	100	23	37
Switzerland	172	9	5	7	5	7,240	68	0	48,230	81	—	99	20m	40m
Syrian Arab Republic	130	44	16	35	15	18,582	526	8	1,190	74	83	98	—	—
Tajikistan	38	128	118	99	91	6,430	186	22	280	64	99	81l	20	41
Tanzania, United Repubic of	31	161	126	102	78	37,627	1,403	177	330	46	69	82l	18	46
Thailand	113	37	21	31	18	63,694	1,015	21	2,540	70	93	85	16	50
The former Yugoslav Republic of Macedonia	135	38	14	33	13	2,030	23	0	2,350	74	96	91	22	37
Timor-Leste	56	172	80	130	64	887	45	4	550	56	—	—	—	—
Togo	27	152	140	88	78	5,988	233	33	380	55	53	64l	—	—
Tonga	105	32	25	26	20	102	2	0	1,830	72	99	100	—	—
Trinidad and Tobago	120	33	20	28	18	1,301	19	0	8,580	70	98	96l	16m	46m
Tunisia	105	52	25	41	21	9,995	166	4	2,630	74	74	97	16	47
Turkey	90	82	32	67	28	72,220	1,505	48	3,750	69	88	88l	17	47
Turkmenistan	46	97	103	80	80	4,766	107	11	1,340	63	99	85l	16	48
Tuvalu	73	56	51	40	36	10	0	0	—	—	—	—	—	—
Uganda	28	160	138	93	80	27,821	1,412	195	270	48	69	79l	16	50
Ukraine	127	26	18	19	14	46,989	391	7	1,260	66	99	84	22	38
United Arab Emirates	152	14	8	12	7	4,284	67	1	18,060m	78	77	83	—	—
United Kingdom	162	10	6	8	5	59,479	663	4	33,940	79	—	100	18	44
United States	152	12	8	9	7	295,410	4,134	33	41,400	78	—	92	16	46
Uruguay	129	25	17	20	15	3,439	57	1	3,950	76	98	90	14	50
Uzbekistan	62	79	69	65	57	26,209	611	42	460	67	99	80l	23	36
Vanuatu	79	62	40	48	32	207	6	0	1,340	69	74	94	—	—
Venezuela	125	27	19	24	16	26,282	590	11	4,020	73	93	94l	11	53
Vietnam	110	53	23	38	17	83,123	1,644	38	550	71	90	96l	19	45
Yemen	43	142	111	98	82	20,329	826	92	570	61	49	72l	20	41
Zambia	18	180	182	101	102	11479	468	85	450	38	68	68l	11	57
Zimbabwe	30	80	129	53	79	12936	384	50	480m	37	90	79l	13	56

TABLE 7.8 Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED] "Table 1. Basic Indicators," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc06_tables.pdf (accessed April 8, 2006). Data from the United Nations, The World Bank and the World Health Organization.

TABLE 7.8
Under-five mortality rank and other development indicators, by country, 1990–2004 [CONTINUED]
Countries and territories	Under-5 mortality rank	Under-5 mortality rate		Infant mortality rate (under 1)a		Total population (thousands) 2004	Annual number of births (thousands) 2004	Annual number of under-5 deaths (thousands) 2004	Gross national income per capita (US$)b 2004	Life expectancy at birth (years)c 2004	Total adult literacy rated 2000–2004g	Net primary school enrolment/attendance (percent)e 1996–2004g	Percent share of household Incomef 1993–2003g
		1990	2004	1990	2004								Lowest 40%	Highest 20%
Notes: "—" indicates data not available.
aProbability of dying between birth and exactly one year of age expressed per 1,000 live births.
bGross national income (GNI) is the sum of value added by all resident producers plus any product taxes (less subsidies) not included in the valuation of output plus net receipts of primary income (compensation of employees and property income) from abroad. GNI per capita is gross national income divided by mid-year population. GNI per capita in US dollars is converted using the World Bank Atlas method.
cThe number of years newborn children would live if subject to the mortality risks prevailing for the cross-section of population at the time of their birth.
dPercentage of persons aged 15 and over who can read and write.
eDerived from net primary school enrolment rates as reported by UNESCO/UIS (UNESCO Institute of Statistics) and from national household survey reports of attendance at primary school or higher. The net primary school attendance ratio is defined as the percentage of children in the age group that officially corresponds to primary schooling who attend primary school or higher.
fPercentage of income received by the 20 percent of households with the highest income and by the 40 percent of households with the lowest income.
gData refer to the most recent year available during the period specified in the column heading.
hRange $825 or less.
iRange $826 to $3,255.
jRange $3,256 to $10,065.
kRange $10,066 or more.
lNational household survey.
mIndicates data that refer to years or periods other than those specified in the column heading or refer to only part of a country.
nCentral and Eastern Europe/Commonwealth of Independent States (formerly the USSR).
SOURCE: "Table 1. Basic Indicators," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc06_tables.pdf (accessed April 8, 2006). Data from the United Nations, The World Bank and the World Health Organization.
Summary indicators
Sub-Saharan Africa		188	171	112	102	697,561	28,263	4,833	611	46	60	60	12	57
Eastern and Southern Africa	167	149	105	95	348,833	13,371	1,992	836	46	63	65	11	59
Western and Central Africa	209	191	119	109	348,728	14,892	2,844	399	46	58	55	13	53
Middle East and North Africa	81	56	59	44	371,384	9,620	539	2,308	68	67	79	17	46
South Asia		129	92	89	67	1,459,305	37,052	3,409	600	63	58	74	21	43
East Asia and Pacific		58	36	43	29	1,937,058	29,932	1,078	1,686	71	90	96	16	47
Latin America and Caribbean	54	31	43	26	548,273	11,674	362	3,649	72	90	93	10	59
CEE/CISn		54	38	44	32	404,154	5,570	212	2,667	67	97	88	20	41
Industrialized countries		10	6	9	5	956,315	10,839	65	32,232	79	—	95	19	42
Developing countries		105	87	72	59	5,166,574	119,663	10,411	1,524	65	77	80	15	50
Least developed countries		182	155	115	98	741,597	27,823	4,313	345	52	54	60	18	46
World		95	79	65	54	6,374,050	132,950	10,503	6,298	67	78	82	18	43

TABLE 7.9 Child protection by selected characteristics, selected years 1986–2004

TABLE 7.9
Child protection by selected characteristics, selected years 1986–2004
Countries and territories	Child labour (5-14 year) 1999–2004a, g			Child marriage 1986–2004b, g			Birth registration 1999–2004c, g			Female genital mutilation/cutting 1998–2004d, g
										Womene (15-49 years)			Daughtersf
	Total	Male	Female	Total	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total
Afghanistan	34h	31h	38h	43	—	—	6	12	4	—	—	—	—
Albania	23	26	19	—	—	—	99	99	99	—	—	—	—
Angola	22	21	23	—	—	—	29	34	19	—	—	—	—
Armenia	—	—	—	19	12	31	97	100	94	—	—	—	—
Azerbaijan	8	9	7	—	—	—	97	98	96	—	—	—	—
Bahrain	5	6	3	—	—	—	—	—	—	—	—	—	—
Bangladesh	7	10	4	65	44	72	7	9	7	—	—	—	—
Benin	26h	23h	29h	37	25	45	70	78	66	17	13	20	6
Bolivia	21	22	20	26	22	37	82	83	79	—	—	—	—
Bosnia and
Herzegovina	11	12	10	—	—	—	98	98	99	—	—	—	—
Botswana	—	—	—	10	13	9	58	66	52	—	—	—	—
Brazil	7h	9h	4h	24	22	30	76	—	—	—	—	—	—
Burkina Faso	57h	—	—	52	22	62	—	—	—	77	75	77	32
Burundi	24	26	23	17h	36h	17h	75	71	75	—	—	—	—
Cambodia	—	—	—	25	19	26	22	30	21	—	—	—	—
Cameroon	51	52	50	43	30	51	79	94	73	1.4	1	2	—
Central African Republic	56	54	57	57	54	59	73	88	63	36	29	41	—
Chad	57	60	55	71	65	74	25	53	18	45	43	46	—
Colombia	5	7	4	21	18	34	91	95	84	—	—	—	—
Comoros	28	27	29	30	23	33	83	87	83	—	—	—	—
Congo, Democratic Republic of the	28h	26h	29h	—	—	—	34	30	36	—	—	—	—
Costa Rica	50h	71h	29h	—	—	—	—	—	—	—	—	—	—
Cote d'lvoire	35	34	36	33	24	43	72	88	60	45	39	48	24
Cuba	—	—	—	—	—	—	100	100	100	—	—	—	—
Dominican Republic	9	11	6	41	37	51	75	82	66	—	—	—	—
Ecuador	6h	9h	4h	26h	21h	34h	—	—	—	—	—	—	—
Egypt	6	6	5	19	11	24	—	—	—	97	95	99	47
El Salvador	—	—	—	27	—	—	—	—	—	—	—	—	—
Equatorial Guinea	27	27	27	—	—	—	32	43	24	—	—	—	—
Eritrea	—	—	—	47	31	60	—	—	—	89	86	91	63
Ethiopia	43h	47h	37h	49	32	53	—	—	—	80	80	80	48
Gabon	—	—	—	34	30	49	89	90	87	—	—	—	—
Gambia	22	23	22	—	—	—	32	37	29	—	—	—	—
Georgia	—	—	—	—	—	—	95	97	92	—	—	—	—
Ghana	57h	57h	58h	28	18	39	21	—	—	5	4	7	—
Guatemala	24h	—	—	34	25	44	—	—	—	—	—	—	—
Guinea	—	—	—	65	46	75	67	88	56	99	98	99	54
Guinea-Bissau	54	54	54	—	—	—	42	32	47	—	—	—	—
Guyana	19	21	17	—	—	—	97	99	96	—	—	—	—
Haiti	—	—	—	24	18	31	70	78	66	—	—	—	—
India	14	14	15	46	26	55	35	54	29	—	—	—	—
Indonesia	4h	5h	4h	24	15	33	55	69	43	—	—	—	—
Iraq	8	11	5	—	—	—	98	99	97	—	—	—	—
Jamaica	2	3	1	—	—	—	96	95	96	—	—	—	—
Jordan	—	—	—	11	11	12	—	—	—	—	—	—	—
Kazakhstan	—	—	—	14	12	17	—	—	—	—	—	—	—
Kenya	26	27	25	25	19	27	48h	64h	44h	32	21	36	21
Korea, Democratic
People's Republic of	—	—	—	—	—	—	99	99	99	—	—	—	—
Kyrgyzstan	—	—	—	21	19	22	—	—	—	—	—	—
Lao People's Democratic
Republic	24	23	25	—	—	—	59	71	56	—	—	—	—
Lebanon	6	8	4	11	—	—	—	—	—	—	—	—	—

of the government to eliminating child poverty by entirely by 2020 (see Chapter 6)

UNICEF's 2000 publication Poverty Reduction Begins with Children (http://www.unicef.org/publications/files/pub_poverty_reduction_en.pdf) emphasizes the special challenges of children who live in poverty and discusses how child poverty differs from poverty in general. Because childhood—particularly the first few months of a person's life—is a time of key developmental changes physically, emotionally, and intellectually, neglect in any of these areas can be a permanent detriment to future well-being. According to UNICEF, impoverished children become "transmitters" of poverty to the next generation when they become parents themselves. The report maintains that this cycle can be broken only when poverty is considered a human rights violation instead of simply a matter of income deprivation.

TABLE 7.9 Child protection by selected characteristics, selected years 1986–2004 [CONTINUED]

TABLE 7.9
Child protection by selected characteristics, selected years 1986–2004 [CONTINUED]
Countries and territories	Child labour (5-14 year) 1999–2004a, g			Child marriage 1986–2004b, g			Birth registration 1999–2004c, g			Female genital mutilation/cutting 1998–2004d, g
										Womene (15-49 years)			Daughtersf
	Total	Male	Female	Total	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total
Lesotho	17	19	14	—	—	—	51	41	53	—	—	—	—
Liberia	—	—	—	48h	38h	58h	—	—	—	—	—	—	—
Madagascar	30	35	26	39	29	42	75	87	72	—	—	—	—
Malawi	17	18	16	47	32	50	—	—	—	—	—	—	—
Maldives	—	—	—	—	—	—	73	—	—	—	—	—	—
Mali	30	33	28	65	46	74	48	71	41	92	90	93	73
Mauritania	10h	—	—	37	32	42	55	72	42	71	65	77	66
Mexico	16h	15h	16h	28h	31h	21h	—	—	—	—	—	—	—
Moldova, Republic of	28	29	28	—	—	—	98	98	98	—	—	—	—
Mongolia	30	30	30	—	—	—	98	98	97	—	—	—	—
Morocco	11h	—	—	16	12	21	85	92	80	—	—	—	—
Mozambique	—	—	—	56	41	66	—	—	—	—	—	—	—
Myanmar	—	—	—	—	—	—	65h	66h	64h	—	—	—	—
Pakistan	—	—	32	21	37	—	—	—	—	—	—	—	—
Namibia	—	—	—	10	9	10	71	82	64	—	—	—	—
Nepal	31	30	33	56	34	60	34	37	34	—	—	—	—
Nicaragua	10h	—	—	43	36	55	81	90	73	—	—	—	—
Niger	66	69	64	77	46	86	46	85	40	5	2	5	4
Nigeria	39h	—	—	43	27	52	30	53	20	19	28	14	10
Occupied Palestinian territory	—	—	—	—	—	—	98	98	97	—	—	—	—
Pakistan	—	—	32	21	37	—	—	—	—	—	—	—
Paraguay	8h	10h	6h	24	18	32	—	—	—	—	—	—	—
Peru	—	—	—	19	12	35	93	93	92	—	—	—	—
Philippines	11	12	10	14	10	22	83	87	78	—	—	—	—
Romania	1h	—	—	—	—	—	—	—	—	—	—	—	—
Rwanda	31	31	30	20	21	19	65	61	66	—	—	—	—
Sao Tome and Principe	14	15	13	—	—	—	70	73	67	—	—	—	—
Senegal	33	36	30	36	15	53	62	82	51	—	—	—	—
Sierra Leone	57	57	57	—	—	—	46	66	40	—	—	—	—
Somalia	32	29	36	—	—	—	—	—	—	—	—	—	—
South Africa	—	—	—	8	5	12	—	—	—	—	—	—	—
Sri Lanka	—	—	—	14h	10h	15h	—	—	—	—	—	—	—
Sudan	13	14	12	27h	19h	34h	64	82	46	90	92	88	58
Suriname	—	—	—	—	—	—	95	94	94	—	—	—	—
Swaziland	8	8	8	—	—	—	53	72	50	—	—	—	—
Syrian Arab Republic	8h	10h	6h	—	—	—	—	—	—	—	—	—	—
Tajikistan	18	19	17	—	—	—	75	77	74	—	—	—	—
Tanzania, United Republic of	32	34	30	39	23	48	6	22	3	18	10	20	7
Thailand	—	—	—	21h	13h	23h	—	—	—	—	—	—	—
Timor-Leste	4h	4h	4h	—	—	—	22	32	20	—	—	—	—
Togo	60	62	59	31	17	41	82	93	78	—	—	—	—
Trinidad and Tobago	2	3	2	34h	37h	32h	95	—	—	—	—	—	—
Tunisia	—	—	—	10h	7h	14h	—	—	—	—	—	—	—
Turkey	—	—	—	23	19	30	—	—	—	—	—	—	—
Turkmenistan	—	—	—	9	12	7	—	—	—	—	—	—	—
Uganda	34	34	33	54	34	59	4	11	3	—	—	—	—
Uzbekistan	15	18	12	13	16	11	100	100	100	—	—	—	—
Venezuela	7	9	5	—	—	—	92	—	—	—	—	—	—
Viet Nam	23	23	22	11	5	13	72	92	68	—	—	—	—
Yemen	—	—	—	48	39	53	—	—	—	23	26	22	20
Zambia	11	10	11	42	32	49	10	16	6	—	—	—	—
Zimbabwe	26h	—	—	29	21	36	42	56	35	—	—	—	—

Children's Health and Mortality

Improving children's health and reducing rates of child mortality is an implicit factor of the Convention on the Rights of the Child and is explicitly listed as one of the Millennium Development Goals. The most fundamental and important indicators of poverty among children are the state of their health and their rates of mortality. Child mortality rates are also a major indicator of the overall social and economic stability of nations. How much a country invests—or does not invest—in measures to cut back preventable deaths and diseases of children is ultimately indicative of its commitment to its own economic development.

Table 7.10 and Table 7.11 show basic human development indicators in industrialized and developing countries, respectively. Notice that in industrialized countries the percentage of moderately or severely underweight children under five is negligible, while in developing countries the rate is high, at 27%. Additionally, rates of childhood immunization differ markedly in the two income categories. In industrialized countries at least TABLE 7.9 Child protection by selected characteristics, selected years 1986–2004 [CONTINUED] "Table 9. Child Protection," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc06_tables.pdf (accessed April 8, 2006). Data from Multiple Indicator Cluster Survey (MICS) and Demographic and Health Surveys (DHS).92% of children are immunized against measles, diphtheria/pertussis/tetanus, polio, and haemophilus influenzae, while, at most, 79% of children in developing countries have been immunized against these common illnesses.

TABLE 7.9
characteristics, selected years 1986–2004 [CONTINUED]
Countries and territories	Child labour (5-14 year) 1999–2004a, g			Child marriage 1986–2004b, g			Birth registration 1999–2004c, g			Female genital mutilation/cutting 1998–2004d, g
										Womene (15-49 years)			Daughtersf
	Total	Male	Female	Total	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total
Notes: "—" indicates data not available
aPercentage of children aged 5 to 14 years of age involved in child labour activities at the moment of the survey. A child is considered to be involved in child labour activities under the following classification: (a) children 5 to 11 years of age that during the week preceding the survey did at least one hour of economic activity or at least 28 hours of domestic work, and (b) children 12 to 14 years of age that during the week preceding the survey did at least 14 hours of economic activity or at least 42 hours of economic activity and domestic work combined. Child labour background variables: Sex of the child; urban or rural place of residence; poorest 20% or richest 20% of the population constructed from household assets; mother's education, reflecting mothers with and without some level of education.
bPercentage of women 20-24 years of age that were married or in union before they were 18 years old.
cPercentage of children less than five years of age that were registered at the moment of the survey. The numerator of this indicator includes children whose birth certificate was seen by the interviewer or whose mother or caretaker says the birth has been registered. MICS data refer to children alive at the time of the survey.
dFemale genital mutilation/cutting (FGM/C) involves the cutting or alteration of the female genitalia for social reasons. Generally, there are three recognized types of FGM/C: clitoridectomy, excision and infibulation. Clitoridectomy is the removal of the prepuce with or without excision of all or part of the clitoris. Excision is the removal of the prepuce and clitoris along with all or part of the labia minora. Infibulation is the most severe form and consists of removal of all or part of the external genitalia, followed by joining together of the two sides of the labia minora using threads, thorns or other materials to narrow the vaginal opening.
eThe percentage of women aged 15 to 49 years of age who have been mutilated/cut.
fThe percentage of women aged 15 to 49 with at least one mutilated/cut daughter.
gData refer to the most recent year available during the period specified in the column heading.
hIndicates data that differ from the standard definition or refer to only part of a country but are included in the calculation of regional and global averages.
iExcludes China.
jCentral and Eastern Europe/Commonwealth of Independent States (formerly the USSR).
SOURCE: "Table 9. Child Protection," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc06_tables.pdf (accessed April 8, 2006). Data from Multiple Indicator Cluster Survey (MICS) and Demographic and Health Surveys (DHS).
Summary indicators
Sub-Saharan Africa	36	37	34	40	25	48	38	55	33	38	31	42	24
Eastern and Southern Africa	32	34	29	36	21	43	32	44	28	—	—	—	—
Western and Central Africa	41	41	41	45	28	56	41	59	35	29	29	29	19
Middle East and North Africa	9	9	7	—	—	—	—	—	—	—	—	—	—
South Asia	14	14	15	46	27	54	30	47	25	—	—	—	—
East Asia and Pacific	10i	11i	10i	20i	12i	25i	65h	77i	56i	—	—	—	—
Latin America and Caribbean	11	11	8	25	24	31	82	92	80	—	—	—	—
CEE/CISj	—	—	—	—	—	—	—	—	—	—	—	—	—
Industrialized countries	—	—	—	—	—	—	—	—	—	—	—	—	—
Developing countries	18i	18i	17i	36i	22i	45i	45h	62i	35i	—	—	—	—
Least developed countries	28	29	26	50	33	57	32	44	28	—	—	—	—
World	18i	18i	17i	36i	22i	45i	45h	62i	35i	—	—	—	—

INFANT MORTALITY

The WHO's World Health Report 2005 states that of the approximately 136 million babies born each year, at least 3.3 million are stillborn, more than four million die before they are twenty-eight days old, and 6.6 million die before their fifth birthday. The WHO estimates that 98% of all newborn deaths happen in the developing world—28% in sub-Saharan Africa and 36% in Southeast Asia. As of 2005, newborn deaths accounted for more than half of all infant deaths and 40% of all deaths of children under five. As a region, Southeast Asia had the highest overall number of stillbirths and newborn deaths—1.3 million and 1.4 million, respectively—but sub-Saharan Africa had the highest newborn death rate, at about forty-five newborn deaths per 1,000 live births in that region.

By comparison, in the United States the infant death rate (counting all infants under twelve months old) was 6.84 per 1,000 live births in 2003, down slightly from the 2002 rate of 6.95, according to the Rights for Disease Control (CDC) in "Infant Mortality Statistics from the 2003 Period Linked Birth/Infant Death Data Set" (National Vital Statistics Reports, vol. 54, no. 16, May 3, 2006). Wide disparities in infant death rates exist among racial and ethnic groups in the United States, ranging from a low of 4.83 per 1,000 live births for Asians and Pacific Islanders to a high of 13.6 per 1,000 live births for African-Americans. In addition, infants born to teenagers and women over forty have higher rates of mortality than those in the middle years of childbearing age. Likewise, infant death rates decrease among women with higher levels of education, and rates tend to be higher among unmarried women. According to the CDC report, all of these risk factors may be linked to a mother's socioeconomic status, which is in itself a major risk factor in infant death. Lower-income women are less likely to have the financial means to get early prenatal care, and their babies are also less likely to receive quality health care.

TABLE 7.10 Basic indicators of human development in industrialized countries, selected years 1986–2004 "Industrialized Countries," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/regional_stat_sum_s21_ic.pdf (accessed April 8, 2006)

TABLE 7.10
Basic indicators of human development in industrialized countries, selected years 1986–2004
Indicator	Region	World	Indicator	Region	World
aData refer to the most recent years available during the period specified.
bExcludes China.
SOURCE: "Industrialized Countries," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/regional_stat_sum_s21_ic.pdf (accessed April 8, 2006)
Demographic indicators			Economic indicators
Total population (2004)	956,315,000	6,374,050,000	Gross national income per capita (US$, 2004)	32,232	6,298
Population under 18 (2004)	205,133,000	2,181,991,000	Percentage of population living on less than $1 a day (1993–2003a)	—	21
Population under 5 (2004)	54,200,000	614,399,000	Percentage share of central government expenditure (1993–2004a) allocated to:
Survival			Health	16	13
Life expectancy at birth (2004)	79	67	Education	4	5
Infant mortality rate (under 1), per 1,000 live births (2004)	5	54	Defence	11	11
Under-5 mortality rate, per 1,000 live births (2004)	6	79	Percentage share of household income (1993–2003a):
Under-5 mortality rate, average annual rate of reduction (1990–2004)	3.6	1.3	Lowest 40 percent	19	18
Maternal mortality ratio, per 100,000 live births (2000, adjusted)	13	400	Highest 20 percent	42	43
Health and nutrition			Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS)
Percentage of infants with low birthweight (1998–2004a)	7	16	Adult prevalence rate (15–49 years, end 2003)	0.4	1.1
Percentage of under-5s who are moderately or severely underweight (1996–2004a)	—	26	Estimated number of adults and children (0-49 years) living with HIV/AIDS (2003)	1,600,00	37,800,000
Percentage of population using improved drinking water sources (2002)	100	83	Estimated number of children (0-14 years) living with HIV/AIDS (2003)	170,000	2,100,000
Urban	100	95
Rural	100	72
Percentage of population using adequate sanitation facilities (2002)	100	58	Estimated number of children (0-17 years) orphaned by HIV/AIDS (2003)	—	—
Percentage of 1-year-old children immunized (2004) against:			Child protection
Tuberculosis (BCG) (bacillus of Calmette and Guerin)	—	84	Birth registration (1999–2004a)	—	45b
			Urban	—	62b
Diphtheria/pertussis/tetanus (DPT3)	96	78	Rural	—	35b
Polio (polio3)	94	80	Child marriage (1986–2004a)	—	36b
Measles	92	76	Urban	—	22b
Hepatitis B (hepB3)	63	49	Rural	—	45b
Haemophilus influenzae (Hib3)	92	—	Child labour (5-14 years, 1999–2004a)	—	18b
Education			Male	—	18b
	Female	—	17b
Percentage of primary school entrants reaching grade 5 (administrative data; 2000–2004a)	—	79	Women
Net primary school attendance ratio (1996–2004a)			Adult literacy parity rate (females as a percentage of males, 2000–2004a)	—	86
Male	—	76	Antenatal care coverage (percentage, 1996–2004a)	—	71
Female	—	72	Skilled attendant at delivery (percentage, 1996–2004a)	99	63
Net secondary school attendance ratio (1996–2004a)			Lifetime risk of maternal death (2000) 1 in …	4,000	74
Male	—	40b
Female	—	37b
Adult literacy rate (2000–2004a)	—	78

Although the overall U.S. infant mortality rate is significantly lower than rates in developing countries, the U.S. rate is more than double that of the countries with the lowest infant mortality. According to statistics reported by the UNDP in its Human Development Report 2005, Hong Kong, Singapore, Iceland, Japan and Sweden had the lowest rates in 2003 at three per 1,000 live births, and Sierra Leone had the highest with 182 deaths per 1,000 live births in 2003.

MORTALITY OF CHILDREN UNDER FIVE

Children's health programs begun in the 1970s and 1980s have significantly reduced certain diseases and illnesses. Incidence of polio, for example, went from 350,000 cases reported in 1988 to 1,185 cases reported in 2005, thanks to the success of polio vaccination programs (World Health Report 2005). However, approximately 10.6 million children per year still die before their fifth birthday. Table 7.12 ranks countries according to their under-five mortality rate ("value" refers to the number of deaths per 1,000 live births; countries are listed in worst-to-best order).

Figure 7.13 shows that progress has been made since 1970 in reducing the mortality rate of children under five years old. In 1970 the worldwide mortality rate for young TABLE 7.11 Basic indicators of human development in developing countries, selected years 1986–2004 "Developing Countries," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/regional_stat_sum_s21_ic.pdf (accessed April 8, 2006)children was 146 per 1,000 live births; by 2003 it was 79 per 1,000. Still, more than 70% of child deaths in 2003 occurred in just two regions: Africa and Southeast Asia. The WHO further notes in World Health Report 2005 that half of all deaths of children under five in 2003 occurred in just six countries: China, the Democratic Republic of the Congo, Ethiopia, India, Nigeria, and Pakistan.

TABLE 7.11
Basic indicators of human development in developing countries, selected years 1986–2004
Indicator	Region	World	Indicator	Region	World
aData refer to the most recent years available during the period specified.
bExcludes China.
SOURCE: "Developing Countries," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/regional_stat_sum_s21_ic.pdf (accessed April 8, 2006)
Demographic indicators			Economic indicators
Total population (2004)	5,166,574,000	6,374,050,000	Gross national income per capita (US$, 2004)	1,524	6,298
Population under 18 (2004)	1,925,281,000	2,181,991,000	Percentage of population living on less than $1 a day (1993–2003a)	22	21
Population under 5 (2004)	548,486,000	614,399,000	Percentage share of central government expenditure (1993–2004a) allocated to:
Survival			Health	4	13
Life expectancy at birth (2004)	65	67	Education	11	5
Infant mortality rate (under 1), per 1,000 live births (2004)	59	54	Defence	10	11
Under-5 mortality rate, per 1,000 live births (2004)	87	79	Percentage share of household income (1993–2003a):	15	18
Under-5 mortality rate, average annual rate of reduction (1990–2004)	1.3	1.3	Lowest 40 percent
Maternal mortality ratio, per 100,000 live births (2000, adjusted)	440	400	Highest 20 percent	50	43
Health and nutrition			Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS)
Percentage of infants with low birthweight (1998–2004a)	17	16	Adult prevalence rate (15–49 years, end 2003)	1.2	1.1
Percentage of under-5s who are moderately or severely underweight (1996–2004a)	27	26	Estimated number of adults and children (0-49 years) living with HIV/AIDS (2003)	34,900,00	37,800,000
Percentage of population using improved drinking water sources (2002)	79	83	Estimated number of children (0-14 years) living with HIV/AIDS (2003)	2,100,000	2,100,000
Urban	92	95	Estimated number of children (0-17 years) orphaned by HIV/AIDS (2003)	—	—
Rural	70	72	Child protection
Percentage of population using adequate sanitation facilities (2002)	49	58	Birth registration (1999–2004a)	45b	45b
Percentage of 1-year-old children immunized (2004) against:			Urban	62b	62b
Tuberculosis (BCG) (bacillus of Calmette and Guerin)	84	84	Rural	35b	35b
Diphtheria/pertussis/tetanus (DPT3)	76	78	Child marriage (1986–2004a)	36b	36b
Polio (polio3)	79	80	Urban	22b	22b
Measles	74	76	Rural	45b	45b
Hepatitis B (hepB3)	76	49	Child labour (5-14 years, 1999–2004a)	18b	18b
Haemophilus influenzae (Hib3)	—	—	Male	18b	18b
Education			Female	17b	17b
Percentage of primary school entrants reaching grade 5 (administrative data; 2000–2004a)	78	79	Women
Net primary school attendance ratio (1996–2004a)			Adult literacy parity rate (females as a percentage of males, 2000–2004a)	84	86
Male	76	76	Antenatal care coverage (percentage, 1996–2004a)	71	71
Female	72	72	Skilled attendant at delivery (percentage, 1996–2004a)	59	63
Net secondary school attendance ratio (1996–2004a)			Lifetime risk of maternal death (2000) 1 in …	61	74
Male	40b	40b
Female	37b	37b
Adult literacy rate (2000–2004a)	77	78

According to the WHO, just six illnesses account for 70% to 90% of the deaths of young children: 19% are from acute lower respiratory infections (typically pneumonia), 17% from diarrhea, 8% from malaria, 4% from measles, 3% from HIV/AIDS, and 37% from neonatal conditions. Africa by far accounts for the most deaths of children from malaria and HIV/AIDS (90%), measles (more than 50%), and pneumonia and diarrhea (40%). (See Figures 7.14 and 7.15.)

Child Labor

Children from poor families frequently must go to work to contribute income to their household, and of all the poverty-related abuses and deprivations children suffer, child labor is among the worst, resulting in physical and psychological damage and, frequently, premature TABLE 7.12 Mortality rankings, children under five, 2004death. The United Nations, the International Labor Organization (ILO), and other NGOs distinguish, however, between "child work" (economic activity by children at least twelve years old that is not hazardous and does not interfere with their education) and "child labor" (all work by children under age twelve; hazardous work by children aged twelve to fourteen; and all work defined as "worst forms of child labor"). "Worst forms of child labor," as defined by the ILO, include:

TABLE 7.12
Mortality rankings, children under five, 2004
	Under-5 mortality rate (2004)			Under-5 mortality rate (2004)			Under-5 mortality rate (2004)
Value	Rank	Value	Rank	Value	Rank
Sierra Leone	283	1	Kiribati	65	66	Bulgaria	15	131
Angola	260	2	Guyana	64	67	Mauritius	15	131
Niger	259	3	Namibia	63	68	Serbia and Montenegro	15	131
Afghanistan	257	4	Marshall Islands	59	69	Dominica	14	135
Liberia	235	5	Solomon Islands	56	70	Saint Lucia	14	135
Somalia	225	6	Korea, Democratic People's Republic of	55	71	Seychelles	14	135
Mali	219	7				Sri Lanka	14	135
Congo, Democratic Republic of the	205	8	Mongolia	52	72	The former Yugoslav Republic of Macedonia	14	135
			Tuvalu	51	73
Equatorial Guinea	204	9	Maldives	46	74	Bahamas	13	140
Guinea-Bissau	203	10	Georgia	45	75	Costa Rica	13	140
Rwanda	203	10	Guatemala	45	75	Oman	13	140
Chad	200	12	Morocco	43	77	Antigua and Barbuda	12	143
Nigeria	197	13	Honduras	41	78	Barbados	12	143
Côte d'lvoire	194	14	Algeria	40	79	Kuwait	12	143
Central African Republic	193	15	Vanuatu	40	79	Latvia	12	143
Burkina Faso	192	16	Belize	39	81	Malaysia	12	143
Burundi	190	17	Suriname	39	81	Bahrain	11	148
Zambia	182	18	Indonesia	38	83	Belarus	11	148
Malawi	175	19	Iran (Islamic Republic of)	38	83	Brunei Darussalam	9	150
Ethiopia	166	20	Nicaragua	38	83	Slovakia	9	150
Swaziland	156	21	Cape Verde	36	86	Chile	8	152
Guinea	155	22	Egypt	36	86	Estonia	8	152
Benin	152	23	Brazil	34	88	Hungary	8	152
Mozambique	152	23	Philippines	34	88	Lithuania	8	152
Cameroon	149	25	Armenia	32	90	Poland	8	152
Cambodia	141	26	Dominican Republic	32	90	United Arab Emirates	8	152
Togo	140	27	Turkey	32	90	United States	8	152
Uganda	138	28	China	31	93	Andorra	7	159
Senegal	137	29	Lebanon	31	93	Croatia	7	159
Zimbabwe	129	30	Nauru	30	95	Cuba	7	159
Djibouti	126	31	Samoa	30	95	Australia	6	162
Tanzania, United Republic of	126	31	Peru	29	97	Canada	6	162
Iraq	125	33	El Salvador	28	98	Ireland	6	162
Mauritania	125	33	Mexico	28	98	Israel	6	162
Madagascar	123	35	Moldova, Republic of	28	98	Korea, Republic of	6	162
Gambia	122	36	Jordan	27	101	Luxembourg	6	162
Kenya	120	37	Palau	27	101	Malta	6	162
Sao Tome and Principe	118	38	Saudi Arabia	27	101	Netherlands	6	162
Tajikistan	118	38	Ecuador	26	104	New Zealand	6	162
Haiti	117	40	Tonga	25	105	United Kingdom	6	162
Botswana	116	41	Tunisia	25	105	Austria	5	172
Ghana	112	42	Occupied Palestinian Territory	24	107	Belgium	5	172
Yemen	111	43	Panama	24	107	Cyprus	5	172
Congo	108	44	Paraguay	24	107	Denmark	5	172
Myanmar	106	45	Micronesia (Federated States of)	23	110	France	5	172
Turkmenistan	103	46	Viet Nam	23	110	Germany	5	172
Pakistan	101	47	Saint Vincent and the Grenadines	22	112	Greece	5	172
Papua New Guinea	93	48	Colombia	21	113	Italy	5	172
Gabon	91	49	Cook Islands	21	113	Liechtenstein	5	172
Sudan	91	49	Grenada	21	113	Monaco	5	172
Azerbaijan	90	51	Qatar	21	113	Portugal	5	172
India	85	52	Russian Federation	21	113	Spain	5	172
Lao People's Democratic Republic	83	53	Saint Kitts and Nevis	21	113	Switzerland	5	172
			Thailand	21	113	Czech Republic	4	185
Eritrea	82	54	Fiji	20	120	Bhutan	80	56
Lesotho	82	54	Bosnia and Herzegovina	15	131	Timor-Leste	80	56

• All forms of slavery or practices similar to slavery, such as the sale and trafficking of children, debt bondage and serfdom and forced or compulsory labor, including forced or compulsory recruitment, of children for use in armed conflict
• The use, procuring or offering a child for prostitution, for the production of pornography or for pornographic performances

TABLE 7.12 Mortality rankings, children under five, 2004 [CONTINUED] "Under-Five Mortality Rankings," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc06_tables.pdf (accessed April 8, 2006)

TABLE 7.12
Mortality rankings, children under five, 2004 [CONTINUED]
	Under-5 mortality rate (2004)			Under-5 mortality rate (2004)			Under-5 mortality rate (2004)
Value	Rank	Value	Rank	Value	Rank
SOURCE: "Under-Five Mortality Rankings," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc06_tables.pdf (accessed April 8, 2006)
Bangladesh	77	58	Romania	20	120	Norway	4	185
Nepal	76	59	Trinidad and Tobago	20	120	San Marino	4	185
Kazakhstan	73	60	Albania	19	125	Slovenia	4	185
Comoros	70	61	Venezuela	19	125	Sweden	4	185
Bolivia	69	62	Argentina	18	127	Iceland	3	192
Uzbekistan	69	62	Ukraine	18	127	Singapore	3	192
Kyrgyzstan	68	64	Uruguay	17	129	Holy See	No data	—
South Africa	67	65	Syrian Arab Republic	16	130	Niue	No data	—
Jamaica	20	12	Finland	4	185
Libyan Arab Jamahiriya	20	120	Japan	4	185

FIGURE 7.13 Reducing child mortality, selected regions, 1970–2003 "Figure 1.1. Slowing Progress in Child Mortality: How Africa Is Faring Worst," in The World Health Report 2005: Make Every Mother and Child Count, World Health Organization, 2005, http://www.who.int/whr/2005/whr2005_en.pdf (accessed April 10, 2006)

• The use, procuring or offering of a child for illicit activities, in particular for the production and trafficking of drugs

According to the ILO in Every Child Counts: New Global Estimates on Child Labor (April 2002, http://www.ilo.org/public/english/standards/ipec/simpoc/others/globalest.pdf), approximately 352 million children aged five to seventeen (about 23% of the total 1.5 billion children in the world) were working in 2000. Of this number, approximately 246 million children under age seventeen were counted as child laborers; 186.3 million of them were younger than fifteen years old, and 110 million were younger than age twelve.

Child labor occurs everywhere in the world. According to UNICEF in Child Protection from Violence, Exploitation, and Abuse (http://www.unicef.org/protection/index_childlabour.html), East Asia and the Pacific have the highest number of child laborers: an estimated 19% of children in the region work, with 127.3 million of them in the five-to-fourteen age group. Sub-Saharan Africa has approximately forty-eight million child laborers (29% of all children under age fifteen in the region). In Latin America and the Caribbean about 17.4 million children work (16% of all children in the region). In the Middle East and North Africa about 15% of children work. In the developed world (including Europe and the United States) about 2.5 million children work, and in transition economies about 2.4 million work. Figure 7.16 shows the percent of male and female child workers in different world regions between 1999 and 2004.

According to the ILO, as of 2000 approximately 171 million children aged five to seventeen were involved in "hazardous work." Hazardous work as defined for children includes occupations that result in physical deformities of young, undeveloped bodies; chronic illnesses such as respiratory diseases in children who work in mines and factories; injuries that can include severe burns, disfigurement, and amputated limbs; vision and hearing impairment; and chronic headaches and gastrointestinal illnesses. UNICEF's State of the World's Children 2006 reports that as many as 70% of laboring children work in agriculture, an industry that puts children at high risk of accidents and exposure to pesticides.

Injuries and impairments of individual children are not the only risks of child labor, however, which also FIGURE 7.14 Major causes of death among children five under years old and among children less than one month old, 2000–2003 "Box 6.1. What Do Children Die of Today?", in The World Health Report 2005: Make Every Mother and Child Count, World Health Organization, 2005, http://www.who.int/whr/2005/whr2005_en.pdf (accessed April 10, 2006)has long-term global economic consequences. The more hours children spend working, the less time they spend in school, which in turn affects their ability to improve their economic status later in life. This in effect traps these children—and later their children—in the cycle of poverty and prolongs the economic instability of poor countries. According to the State of the World's Children 2006, the total international economic benefit of ending child labor would be $5,106.4 billion. Even after subtracting the cost of eliminating child labor—estimated at $760.3 billion—the net benefits would still total $4,132.5 billion. (See Table 7.13.)

Both children's economic activity and child labor can be direct results of poverty. Child labor, however, is far more insidious, dangerous, and disturbing. Experts often comment that child labor robs children of their childhood, not only because it usually means exceptionally long hours performing difficult, often crippling, work for very little pay but also because it exploits children—typically to satisfy the needs or desires of adults. Children sometimes are abducted, sold, or drawn into prostitution or pornography, armed conflict, forced or bonded labor, drug trafficking, and other illicit activities.

The ILO estimates that about 8.4 million children are employed in the unconditional worst forms of child labor. As of 2000 about 5.7 million children worked in forced or bonded labor (in other words, forms of slavery); 1.8 million were in prostitution and pornography; 1.2 million were trafficked; 300,000 were involved in armed conflict; and 600,000 were engaged in other illicit activities. (See Figure 7.17 and Table 7.14.)

Child Trafficking

Poor children are especially vulnerable to child trafficking—the illegal moving of children across cities, countries, or borders for the purpose of using them in various kinds of labor. Children may be abducted, sold, or coerced into the underground world of trafficking. Or they may go willingly, believing that a better life awaits them elsewhere. While exact numbers are impossible to ascertain because of the secretive nature of trafficking, UNICEF and other agencies believe approximately 1.2 million children are trafficked each year. Usually, they are forced into the commercial sex trade (prostitution and/or pornography); are sold as child brides; work as domestic slaves or in mines, factories, or sweatshops; or serve in one of the many instances of ongoing armed conflict across the globe.

FIGURE 7.15 Major causes of death among children under five years old, by region, 2000–2003 "Box 6.1. What Do Children Die of Today?", in The World Health Report 2005: Make Every Mother and Child Count, World Health Organization, 2005, http://www.who.int/whr/2005/whr2005_en.pdf (accessed April 10, 2006)

The ILO report Facts on Trafficking of Children (March 2003, http://www.ilo.org/public/english/standards/ipec/publ/download/factsheets/fs_trafficking_0303.pdf) notes that trafficked children typically come from poor, usually rural, areas and have parents who are uneducated and illiterate. The majority are from marginalized ethnic groups. The ILO identifies the following "supply factors" in the trafficking of children, meaning that they are factors that perpetuate the supply of children for trafficking:

• Poverty and the need to earn a living or to support the family
• The desire for a better life
• Ignorance or lack of understanding of the children, parents, or other caregivers of the negative consequences that may be associated with children leaving their homes to work
• Lack of schools or means to pay for education
• Lack of appreciation on the part of parents or children on the value of education
• Family violence or other dysfunction
• Political conflict or natural disasters that devastate local economies
• Traditions of migration for labor, land, or fodder
• Traditions of placement of rural children with urban-based relatives (particularly in Africa);
• Gender discrimination
• Being a member of a marginalized ethnic group or subservient caste

CHILDREN AT WAR

One of the less common but most horrific uses of trafficked children is as soldiers in armed combat. Children as young as nine have been kidnapped and forced to participate in the world's many conflicts and civil wars. Or children may willingly join in combat to escape poverty or abuse at home. Exact numbers are unknown, but it is thought that tens of thousands of children in regions all over the world are trafficked for the purposes of combat. According to the Child Soldiers Global Report 2004 (2004, http://www.child-soldiers.org/document_get.php?id=966), from 2001 to 2004 children under age eighteen were used as soldiers in ongoing armed conflicts in Afghanistan, Angola, Burundi, Colombia, the Democratic Republic of the Congo (DRC), Côte d'Ivoire, Guinea, India, Iraq, Israel and the Occupied Palestinian Territories, Indonesia, Liberia, Myanmar, Nepal, Philippines, the Russian Federation, Rwanda, Sri Lanka, Somalia, Sudan, and Uganda. Children are used in armed combat, to lay mines and explosives, as spies and decoys, for cooking and domestic labor, and as sex slaves for older soldiers. As of August 2004, seventy-seven countries had FIGURE 7.16 Percentage of children ages 5-14 involved in child labor activities, 1990–2004 "Figure 3.6. Child Labor in the Developing World," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc0506_eps_charts.pdf (accessed April 8, 2006). Data from Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS).ratified the 2002 Optional Protocol to the UN Convention on the Rights of the Child that sets eighteen as the legal age at which people are eligible to participate in combat operations. The International Criminal Court's Rome Statute defines all recruitment of children under age eighteen a war crime.

THE SEX INDUSTRY

Also illegal under international law is trafficking in children for the commercial sex industry, which has grown significantly since the 1980s. In fact, according to Trafficking in Women, Girls, and Boys. Key Issues for Population and Development Programmes (October 2002, http://www.unfpa.org/upload/lib_pub_file/266_filename_Trafficking.pdf), the UNFPA reports that TABLE 7.13 Total economic costs and benefits of eliminating child labor over the period 2000–20 "Figure 3.4. Total Economic Costs and Benefits of Eliminating Child Labor over the Period 2000#2020," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc0506_eps_charts.pdf (accessed April 8, 2006). Data from International Labour Organization, Investing in Every Child: An Economic Study on the Costs and Benefits of Eliminating Child Labour, International Programme on the Elimination of Child Labour, ILO, Geneva, 2004. Copyright © 2005, International Labour Organization.FIGURE 7.17 Children in unconditional worst forms of child labour and explotation, 2002 "Figure 3.7. Children in Unconditional Worst Forms of Child Labour and Exploitation," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc0506_eps_charts.pdf (accessed April 8, 2006). Data from International Labour Organization, Every Child Counts: New Global Estimates on Child Labour, ILO, International Programme on the Elimination of Child Labour, Statistical Informational and Monitoring Programme on Child Labour, April 2002. Copyright © 2005, International Labour Organization.TABLE 7.14 Estimated number of children in the worst forms of child labor, 2000 "Estimated Number of Children in Unconditional Worst Forms of Child Labour," in Every Child Counts: New Global Estimates on Child Labour, International Labour Organization, International Programme on the Elimination of Child Labour/Statistical Information and Monitoring Programme on Child Labour, International Labour Office, April 2002, http://www.ilo.org/public/english/standards/ipec/simpoc/others/globalest.pdf (accessed April 8, 2006)70% of trafficked women and children end up working in the sex industry, and those working in other industries are also at risk of sexual exploitation. Children who end up forced into prostitution are usually girls between the ages of twelve and eighteen, but children as young as five have been found working as sex slaves. According to UNICEF inState of the World's Children 2006, trafficking children for the commercial sex industry is most common in East Asia and the Pacific, South Asia, Europe, and Latin America and the Caribbean. Many of the trafficked children who end up working as prostitutes are poor and go willingly with their traffickers because they are offered legitimate-sounding work as waitresses or maids. By the time they have been moved to unfamiliar cities or countries, where they may not speak the language, they have no choice but to work as prostitutes. Of those forced into commercial sexual exploitation worldwide, 98% are women or girls and 2% are men or boys. (See Figure 7.18.)

TABLE 7.13
Total economic costs and benefits of eliminating child labor over the period 2000–20
	US$ billion, at purchasing power parity
SOURCE: "Figure 3.4. Total Economic Costs and Benefits of Eliminating Child Labor over the Period 2000#2020," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc0506_eps_charts.pdf (accessed April 8, 2006). Data from International Labour Organization, Investing in Every Child: An Economic Study on the Costs and Benefits of Eliminating Child Labour, International Programme on the Elimination of Child Labour, ILO, Geneva, 2004. Copyright © 2005, International Labour Organization.
Economic costs
Education supply	493.4
Transfer implementation	10.7
Interventions	9.4
Opportunity costs	246.8
Total costs	760.3
Economic benefits
Education	5,078.4
Health	28.0
Total benefits	5,106.4
Net economic benefit (total benefits—total costs)	4,346.1
Transfer payments	213.6
Net financial benefit (net economic benefit—transfer payments)	4,132.5

TABLE 7.14
Estimated number of children in the worst forms of child labor, 2000
Unconditional worst form of child labor	Global estimate (in thousands)
*The total excludes the category of trafficked children because of the risk of double-counting.
SOURCE: "Estimated Number of Children in Unconditional Worst Forms of Child Labour," in Every Child Counts: New Global Estimates on Child Labour, International Labour Organization, International Programme on the Elimination of Child Labour/Statistical Information and Monitoring Programme on Child Labour, International Labour Office, April 2002, http://www.ilo.org/public/english/standards/ipec/simpoc/others/globalest.pdf (accessed April 8, 2006)
Trafficked children	1,200
Children in forced & bonded labor	5,700
Children in armed conflict	300
Children in prostitution & pornography	1,800
Children in illicit activities	600
Total	8,400*

International tourism and the widening poverty gap are at least partly responsible for the rise in trafficking and child prostitution in the early twenty-first century. Developing countries are heavily dependent on their tourism industries for economic growth, and demand for prostitutes is typically high in tourist regions. Trafficking in Women, Girls, and Boys cites studies from Japan, Sweden, the United States, the Ukraine, and Moldova that find that most customers of trafficked prostitutes are married men of all races, nationalities, and ages. The common thread in the studies was the ability to pay for services—meaning that a relatively stable economic situation was necessary to maintain the market for prostitutes. The UNFPA reports that countries that have experienced expanding economies and growing middle classes—along with growing lower classes—have seen the greatest increase in prostitution. However, the FIGURE 7.18 Forced commercial sexual exploitation, 2005 "Figure 3.5. Forced Commercial Sexual Exploitation, 2005," in The State of the World's Children 2006, United Nations Children's Fund, 2005, http://www.unicef.org/sowc06/pdfs/sowc0506_eps_charts.pdf (accessed April 8, 2006). Data from International Labour Organization, "A Global Alliance against Forced Labour," ILO, Geneva, 2005. Copyright © 2005, International Labour Organization.demand for younger and younger "prostitutes"—some just four or five years old—is due to men's fears and superstitions about HIV/AIDS: men who frequent prostitutes are willing to pay for sex with children so young they cannot possibly give them AIDS.

IN THE UNITED STATES

In January 2006 President George W. Bush signed into law the Trafficking Victims Protection Reauthorization Act of 2005, which expanded and strengthened the Trafficking Victims Protection Act (TVPA) of 2000. According to the U.S. Department of State's Trafficking in Persons Report 2005 (June 2005, http://www.state.gov/documents/organization/47255.pdf), an estimated 18,000 to 20,000 people, most of them women and children, are trafficked to the United States annually.

Debt Bondage and Forced Labor

Debt bondage (also called bonded labor, forced labor, or indentured servitude), is a way for people to pay off their debts to others with labor instead of money. This definition, however, fails to express the true nature of debt bondage, which is essentially a form of modern slavery, according to the UN and other international agencies. It is not unusual for very poor families—particularly in underdeveloped and developing countries—to place their children into debt bondage to pay off money they owe. Families also may sell a child into bonded labor for an advance of money, believing that they will be able to buy the child back when they earn enough money or when the child performs enough work to cover the cash advance. However, poor families can rarely buy their children back, and often debt bondage crosses gen-erations—with children sold into labor to pay off the debts or loans of their grandparents or great-grandparents.

The reason debt bondage is common in the developing world is that poor countries generally lack systems of credit and bankruptcy, so there may be no other way for poor families to repay debts. The ILO includes any kind of work done by children under debt bondage in its classification of unconditional worst forms of child labor. Debt bondage sometimes overlaps with trafficking, as people performing debt bondage—again, usually women and children—may be trafficked to other countries or overseas; conversely, trafficking victims may later be sold into debt bondage.

The study Forced and Bonded Child Labor (2006, http://www.dol.gov/ILAB/media/reports/iclp/sweat2/bonded.htm) by the U.S. Department of Labor's International Labor Affairs Bureau (ILAB) names Asia and Latin America as the regions where debt bondage and forced labor of children are most common and most extreme. In South Asia as many as one million children are bonded to work in the carpet-making industry of India, Pakistan, and Nepal. Children from age five to fifteen are forced to work up to twenty hours a day, seven days a week. They are not allowed to go outside, and they may be made to sleep and eat in the same room in which they work. They are punished brutally for any transgressions, from crying to making mistakes in weaving to trying to escape. Reports of children being chained to carpet looms are not uncommon.

Millions of children also perform forced and bonded labor in South Asia's glass-making factories, stone quarries, silk manufacturers, lock-making factories, brass industry, fireworks industry, brick kilns, and cigar makers. Children in Thailand and the Philippines are forced to labor in sweatshops, although number estimates are uncertain. In China the numbers of children being kidnapped and bonded to work in textile factories and mines are believed to be on the rise.

According to the ILAB in Forced and Bonded Child Labor, in Latin American countries entire families—including children of all ages—are bonded in Brazil's charcoal manufacturing industry and Peru's gold mines. As with all bonded labor, working conditions for these families are essentially those of slavery. Families working in Brazil's charcoal operations are commonly shipped hundreds of miles from their homes, to remote areas with no schools or medical facilities, and they may be kept at the charcoal plants by armed guards. They are also forced to buy food and supplies from their employers, who inflate the prices to keep the families in debt. Injuries and malnourishment are common among these families. In Peru malaria is one of the many ailments suffered by the children who pan for gold in the Madre de Dios riverbed. Recruiters use deception to convince Peruvian children to go to work at the gold mines; when the children agree to work, the gold mine employers break their promises, knowing the children have no labor rights, and the children become indentured.

FORCED LABOR IN THE UNITED STATES

According to Hidden Slaves: Forced Labor in the United States (September 2004, http://www.hrcberkeley.org/download/hiddenslaves_report.pdf), the University of California-Berkeley's Human Rights Center notes that at any given time there are at least 10,000 people—particularly young women and girls—being forced to labor against their will in the United States. The majority are from China, Mexico, and Vietnam, although victims are known to have been brought to the United States from at least thirty-eight countries (see Table 2.3 in Chapter 2), and there have been cases of young U.S. citizens being held captive and forced to labor, particularly in prostitution rings. Once in the United States, most victims end up in large states with many immigrants; forced laborers and/or people in debt bondage have been discovered in at least ninety U.S. cities. (See Figure 2.4 in Chapter 2.) The most common sectors forced laborers work in are prostitution and sex services (46%), domestic service (27%), agriculture (10%), sweatshop/factory (5%), and restaurant and hotel work (4%). Others become involved in the sexual exploitation of children (as victims or perpetrators; 3.1%), the entertainment industry (3.1%), or become mail-order brides (0.8%).