Epidemiological research supports a correlation between increased strength of democracy and improved population health. In their recent article, “Democracy Matters for Child Health,” Hoops and colleagues build on this existing evidence base to demonstrate that democracy improves child health in particular.Reference Hoops ¹ The authors analyze four attributes of democracy — representation, rights, rule of law, and participation — and find that improvements in each domain were associated with decreases in mortality for female children under five years of age. They conclude that public health and child health advocates must pay attention to and resist ongoing threats to democracy across the world.

We agree that improving the scope and quality of democratic participation should be a focus for child health advocates. However, some efforts in this regard promise greater benefits for child health than others. Most notably, laws and policies that protect and expand women’s democratic participation are associated with proportionally greater improvements in child health. As such, public health and child health advocates should be particularly concerned with antidemocratic threats to women’s rights and policies that undermine gender equity. Antidemocratic movements are often deeply entangled with opposition to gender equality, and efforts to roll back women’s social, political, and economic rights are often one of the first signs of democratic erosion. Thus, a focus on women’s political and social rights is crucial for protecting both democracy and child health.

According to many measures, democracy has been in decline globally for the past two decades.Reference Repucci and Slipowitz ² At the same time, nearly a quarter of the world’s countries report a backlash against the rights of women and girls. ³ This is no coincidence; inequality, particularly durable categorical inequality organized according to marginalized groups based on gender, race, ethnicity, and similar classifications, poses a serious threat to democracy.Reference Tilly ⁴ Opposition to gender equality has been a significant factor in democratic backsliding, erosion, and de-democratization. As Karlberg and colleagues have noted elsewhere:

Protecting global democracy therefore requires specific attention and emphasis on protecting the rights of marginalized groups, including women and girls.

The democratic empowerment of women is also deeply connected to protecting child health. The United Nations has identified gender inequality as one of the root causes of child mortality. ⁶ In general, women bear a greater responsibility for the health and well-being of children. Globally, women provide three-quarters of the world’s unpaid care work, which includes childcare. ⁷ What is more, women’s empowerment produces well-documented improvements in child health.Reference Abreha and Zereyesus ⁸ Increasing their access to social and political resources improves child health by increasing the investment women can make in child well-being.

The protection of women’s democratic civil and political rights is crucial to realizing these benefits for child health. Kellard and colleagues have found that improving women’s economic rights alone can lead, counterintuitively, to worse child health outcomes since expanding women’s right to work can force women to spend more time on work and less on childcare. (Of course, there are independent arguments for protecting women’s economic freedom regardless of its impact on child health.) When women gain democratic empowerment in both civil society and public administration, however, they generally improve social infrastructure to support and protect children. Women legislators are more likely than men to prioritize policies that improve healthcare, sanitation, and environmental protections. ⁹ At the same time, women working in public administration “place a relatively greater weight on child welfare, as well as on the provision of public goods needed for child health and compliance with public health measures.”Reference Kellard ¹⁰ When women have access to positions of power within civil society and public administration, they work to increase social protections for children and families. This investment in social support for children and families fills the gap in childcare that can be created if women are offered increased economic freedom alone. Obtaining the benefit to child health through women’s empowerment requires commensurate democratic rights for women in civil society and public administration.

In summary, then, there is significant value in child health advocates looking beyond traditional improvements in clinical and community medicine (as important as those are) to the larger sociopolitical climate underlying democratic engagement. As Hoops and colleagues convincingly demonstrate, democracy matters for child health. However, democracy for women matters disproportionately for child health. Applying a gendered lens is crucial because women are, as a matter of empirical fact, primarily responsible for childrearing and children’s health within the family. Since women’s political and, to a lesser extent, economic empowerment produces well-documented improvements in child health and mortality, any discussion of the relationship between democracy and children’s health can only be strengthened by applying a gendered lens.