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The most common medical problems that cause death and illness among women, and ways to prevent or treat them, are discussed in the chapters that follow. These medical complications, however, are only the most visible signs of deeper problems that put women at risk of death and injury. This chapter discusses some of these deeply-rooted problems, which are related to women's low social and economic status. Recognising that women's health is affected by their education, their income, and their role in the family is an important step in improving the services women receive. It can help health workers be more understanding of the obstacles and constraints that women face. It can also motivate leaders in the community to take action to address some of these deeply-rooted problems. The solutions are rarely clear or simple. But in the long run, doing something about them can save the lives of many women, and improve the quality of life for even more.
POOR NUTRITION
It is a tradition in many families that men and boys eat first (and have the best part of the meal), followed by the girls and finally the mother. In practice, when the family is poor, this often means that girls and women do not get enough to eat, especially of the foods that help them grow and gain strength. As a result, some girls do not grow as big as they could be. When women are small, and especially if their hips are narrow, labour can be difficult and they may not be able to deliver a baby safely.
Poor nutrition can cause other problems as well. Being undernourished makes people weak and more vulnerable to disease. Since poor nutrition is more common among females than males in many places, they are more likely to suffer from this problem. In addition, women have different nutritional needs. Once they begin menstruating, and especially when they are pregnant, they need much more iron in their diets than men do. Without sufficient iron, women become anaemic, especially if they are pregnant. In fact, 50-80% of pregnant women are anaemic in many African countries.
If a woman becomes pregnant when she is already poorly nourished, she is much more likely than a well-fed woman to suffer from complications like infection, severe bleeding, and premature labour (see Figure 2.1). She is also more likely to have a baby that is small and underweight. One out of six infants born in Africa is dangerously underweight (less than 2,500 grams or a little over five pounds). These infants are more than ten times more likely to die than babies of normal weight.
Figure 2.1: Poor Nutrition
During Pregnancy:
Women who are poorly nourished are more likely to suffer complications during pregnancy than well-fed women. They are also more likely to have underweight babies. Women need to eat enough food, and food of the right kind, during pregnancy.
It is important, therefore, to ensure that girls and women get adequate food not only while they are pregnant or breastfeeding, but also during childhood, adolescence, and before and after pregnancy. Chapter 6 provides more information on proper nutrition, especially during pregnancy.
POOR GENERAL HEALTH
There are many diseases and injuries that affect women as well as men. Sometimes women are more likely to get a certain disease because of the type of work they do, or because their bodies are different from men's. For example, women may be more likely to get malaria and schistosomiasis because much of their work (washing clothes, fetching water) requires them to be near water sources where these diseases are most often transmitted. Women are also more vulnerable than men to certain infections, such as sexually transmitted diseases. They can develop illnesses in their reproductive organs that can cause discomfort and even death. Chapter 18 describes the most common sexually transmitted diseases, and how to prevent or treat them. Chapter 20 explains some of the other problems and diseases that can affect women's reproductive systems.
Many women do not know the signs of serious illness, or they just accept that pain and discomfort are their normal lot in life. Even if they do know the symptoms, they may not have time to pay attention to themselves, or they may not want to spend money on their own needs. But women -and their families - need to understand that thinking about themselves is good for the whole family. Because of the many responsibilities they have, it is important for everyone that they be strong and healthy. Health workers, as well as others in the community who talk with women and their families, can help provide information on how to stay in good health, and how to recognise a serious illness. They can also encourage women to get proper medical treatment when a problem develops, and encourage husbands and other family members to be supportive as well.
VIOLENCE AGAINST WOMEN
Violence against women is common throughout the world, although people are very reluctant to talk about it openly. Studies have found that between 25 and 60% of women say that they have been beaten, raped, or abused by their husband or sexual partner. Rape and abuse of young girls and adolescents is also common, although rarely reported. Some studies even indicate that violence is more common when a woman is pregnant.
This violence has many consequences: some women die, others suffer from broken bones, miscarriages, or other injuries. Many women who are beaten become depressed or anxious, and some even try to commit suicide. Health workers, as well as family members and others in the community, can help by looking for signs of abuse, such as bruises and cuts. They can ask questions about what they see, in a way that is gentle and non-critical, rather than closing their eyes. And they can, of course, provide medical care, counselling, and support to women who are abused.
FEMALE GENITAL MUTILATION
In many areas of Africa, girls are subjected to the sometimes fatal practice often referred to as female circumcision, but which is more accurately called female genital mutilation (FGM). FGM is a traditional practice in which part or all of the external reproductive organs of the female are removed (see Chapter 3).
There are three main forms of genital mutilation. In the mildest form, the tip of the clitoris is cut off. In the second type, the entire clitoris and part of the outer lips of the vagina are removed. In the most extreme form, after the clitoris and the lips of the vagina are cut off, the opening of the vagina is sewn together, leaving only a small hole through which menstrual blood can escape.
This painful practice may be performed on baby girls, girls nearing puberty, adolescents, and sometimes on grown women right before or after they deliver a baby. It is usually performed without anaesthesia, using unclean instruments. If the victim does not die immediately from shock or severe bleeding, she may well die from the infection that often follows. If she survives, she is likely to suffer permanently from painful sexual intercourse because of heavy scarring around the vaginal opening. These scars can also cause serious difficulties during birth.
Different people give various reasons for performing FGM. Some say it is to enhance the sexual pleasure of the man, or to reduce the sexual desire of the woman and ensure that she is faithful to her husband. In some cultures a woman who has not had this operation is considered "unmarriageable". FGM is, however, an extremely dangerous and harmful practice that kills or injures thousands of young girls each year. There is a strong and active movement to abolish it, and many governments have condemned the practice. In areas where it is practised, health workers and local leaders have a responsibility to educate community members about the dangers of FGM, and to find ways to discourage it.
Educating girls and women improves their health and that of their children. Some studies have shown, for example, that high literacy rates among women are more important for reducing the number of infant deaths than having a large number of doctors. Why? Because the more education a woman has, the more likely she is to make the right decisions concerning the health of her children. For example, an educated woman is more likely to:
· Use health services when she herself is sick, seek medical care for her children, and act on information about how to stay in good health;· Take measures to prevent disease (such as following proper hygiene and using mosquito nets) and avoid harmful traditional practices;
· Delay marriage and childbearing until she is prepared for it physically, emotionally, and financially;
· Use family planning to space her pregnancies and limit the total number of children;
· Take advantage of training and credit programmes, participate in income-generating projects, or use other opportunities that can help her earn more income and be more productive;
· Participate in decision-making in the family, such as whether to take someone to a health clinic when he or she is sick.
Despite the clear benefits of female education, many girls do not go to school at all, or leave school early. In Africa, only an estimated 26% of adult women know how to read. Families have many reasons for not sending girls to school; girls are often needed to help with child care, cooking, or other chores. When school fees are high, many families are reluctant to spend money on educating girls. Sometimes parents believe that the topics taught in school are not useful or appropriate for girls, or they may be afraid that the girls will be exposed to "wrong ways" if they attend school.
But if families and local leaders understood the benefits of education, these concerns could be overcome. They might be convinced to allow girls to attend school, and stay in school longer. It is an important investment in their future health and well-being, and that of their children and families. As an African educator said many years ago, "Educate a man, and you educate an individual; educate a woman, and you educate a nation".
Women in Africa tend to marry at a very young age. Often they are married by age 16 or 17, and in some areas even by age 12 or 13. There are many reasons for this practice. For example, if a girl's family is poor her parents may be eager to receive the bride price or to be relieved of the burden of paying for her food, clothing, and general care. In other cases a girl may marry early because her family wants to avoid the risk of an illegitimate birth.
But there are good reasons to delay marriage. As discussed in Chapter 7, it is better for a girl to wait at least until the age of 18 before becoming pregnant, because her body is better able to survive the demands of pregnancy and childbirth. Also, an early start to childbearing almost always means many children; too many pregnancies, too close together, can pose a serious threat to a woman's health and survival.
In addition, getting married and becoming pregnant often means a girl has to stop going to school. This limits her future opportunities and deprives her of the benefits of education. Finally, marriage at a young age for girls means their husbands are usually older, often by many years. Young wives are likely to be shy and dependent; for example, they may be reluctant to ask a husband for money to go to a health facility, and they may be less likely to talk about what they want or need. Since early marriage usually deprives girls of the opportunity to gain knowledge and skills for themselves, this dependence on others can be life-long.
In general, therefore, early marriage carries various risks to the health and future of a girl, and parents should protect their daughters from these consequences. Health workers can help prevent these problems by talking to parents about this issue, and explaining to them the dangers of childbearing at too young an age.
Almost all women in Africa work very hard. Some studies have shown that the average work day for a woman in a rural area is twice as long as a man's. Whether a woman works as a farmer in the village or a professor in the capital city, she is likely to spend from dawn until night taking care of the house and children, as well as growing crops or earning money. Often this work is very demanding physically. In most cases, work begins at a young age; girls are usually working hard by the age of seven or eight, helping to care for younger children, cleaning, cooking, gathering firewood, and collecting water.
Figure 2.2: Heavy
Workload
Working too hard can make a woman tired and strain her body. This can lead to complications during pregnancy and childbirth. Women should be encouraged to avoid work that is too demanding physically. Family members can help by taking on such tasks.
The burden of these duties creates a number of problems for girls and women. First, it means that they are tired and worn out much of the time. Overwork, especially in combination with poor nutrition, makes women more likely to get sick. Chapter 6 provides guidelines on diet, rest, and workload for women during pregnancy; many of these guidelines can be used when women are not pregnant as well.
Second, too much work means women and girls have less time to attend school or adult education classes, less time to go to a health facility if they are ill, and less time to join a cooperative or a women's group. Staying in good health requires time, attention, and information, as well as money; many women do not have enough of any of these things, especially if they are working too hard on daily chores.
Women's workloads can be reduced by having family members help women more, or by using machines or technologies that save women time and ease their work. These include water pumps, milling machines, and stoves that use less fuel. Within both the family and the community, much could be done to help reduce the amount of time and energy women must spend on their daily tasks, and to help them earn more money as well.
"Women's status" means the way women are treated, how they are viewed in their community, what they are able to do, and what their legal rights are. The most important aspects of women's status are whether women have access to money, training, credit, and other resources, and how much freedom they have to make decisions for themselves and their families. Status also depends on how the members of a woman's family and community view her; in many parts of Africa, for example, how much respect a woman receives depends largely on how many children she has. The desire for status can lead women to continue having children even when pregnancy and childbirth carry serious health risks. In addition, it is a sad truth that most tasks that are viewed as "women's work", such as housework, child care, farming, gathering fuel and water, and in some cases teaching and nursing, are seen as less important to the family and community than "men's work".
LACK OF CONTROL OVER RESOURCES
In many families, women have very little say over how money is spent, even if they helped earn it. Studies have shown, however, that women are more likely than men to spend money for the good of the family. Both women and their families would benefit if women played a larger role in deciding how money is spent in the family and the community. If a woman has no money, she may not be able to go for antenatal care, get medicines, or buy more food when she needs it (for example, while she is pregnant or breastfeeding).
Women also have little access to other types of resources, such as training or credit programmes, machines or equipment that could make their tasks easier (plows, water pumps, fuel-efficient stoves), or technical advice and supplies (seeds, fertiliser, pesticides). Even general information, which is also an important resource, may not be available to them. For example, surveys have shown that women tend to know less than men about how to protect themselves against diseases such as AIDS.
This lack of access to resources makes women's work harder and less productive, and contributes to their lower income and their poor health. A woman is especially likely to lack access to resources when she is alone (because she is widowed or divorced, or because her husband has other wives or is working somewhere else). In many countries a woman is not allowed to have custody of her children, own or inherit property, earn income, or participate in public affairs without the permission of her husband or father. Since 25-45% of households in sub-Saharan Africa are run by a woman who is not married or whose husband is away, these restrictions on women's activities limit their ability to take care of themselves and raise their children properly.
ROLE IN DECISION-MAKING
Often, women are not consulted when decisions are being made about the family or the community. Men usually make the major decisions about where to live, what to buy, whether the children go to school, and whether money can be spent on things like health care. Often it is the man alone who decides whether or not family planning should be used to limit the number of children or space births. In many countries a woman may not be able to get services from a family planning clinic or even a health centre without permission from her husband. In some communities, committees made up only of men decide about things like whether a water pump is installed, or a maternity clinic is built. Often, therefore, women's needs and preferences are neglected, and their knowledge and experience are not used to help guide decisions in the community.
In many countries the status of women is gradually changing. More women and girls are being educated, which helps them gain respect and makes it more likely that they will be able to participate in decision-making in the family and community. Attitudes toward women are also changing as women join local organisations and are elected as leaders in their communities. Laws affecting women and families are being modified to give women more freedom and recognise their rights.
But there is much more that could be done. Health workers and others in the community can help by talking to people about the issues involved, and explaining the benefits of raising women's status and improving their health. More specifically, they can give advice and encouragement to husbands and families so that women will be able to go for medical care when necessary, participate in educational programmes, and have fewer children if they want to. Women themselves can help by raising their children to appreciate women's abilities and recognise the value of their contributions in the home and the community. These changes come slowly, and they must respect and conform to local cultures; but the changes must come, for the sake of women and their children.
Figure 2.3: A Happy, Healthy
Family
Having the number of children that the family can afford helps ensure that the mother, father, and children are happy and healthy.
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Summary: Root Causes of Poor Health Social and economic conditions can contribute to the health problems of girls and women, especially during and after pregnancy. These conditions include: POOR NUTRITION: Girls and women often get less food than they need. Once they have reached adolescence, they have special nutritional needs that are different from those of males. This is especially true during and just after pregnancy. Poor diet and inadequate nutrition can make girls and women weak, and more vulnerable to illness. POOR GENERAL HEALTH: Women are exposed to many diseases; they are especially vulnerable to diseases in their reproductive organs. In addition, in some parts of Africa they are subjected to female genital mutilation, which can cause severe health problems or even death. Violence against women, including beatings by husbands, can be a major cause of injury and death. LACK OF EDUCATION: Girls are less likely to go to school than boys. This means that they do not have the chance to gain the basic knowledge and skills which would help them earn money, take care of themselves, and participate in decisions in the family and community. EARLY AGE AT MARRIAGE: In many countries girls get married very young. This means that they become pregnant at too young an age, which can increase the risk of complications. Also, early marriage usually means that they have to leave school, and often leaves them dependent on their husbands. HEAVY WORKLOAD: Women and girls spend long hours working at home, in the fields, or in offices. These long hours leave them with little time to take care of themselves. The demands of work may also make them tired and more likely to become ill, especially if they are pregnant. LOW SOCIAL, LEGAL, AND ECONOMIC STATUS: Women are rarely allowed to influence decisions in the family or community. They often have few rights under traditional laws, and have little control over money or other resources. These problems contribute to women's poor health by preventing them from getting medical care and limiting the amount of money they can spend on food or other necessities for themselves. It is important for health workers to understand the obstacles women face in their daily lives, and how these can affect women's health and well-being. Recognising the problems is also important for others in the community, so that they can try and address these problems. Governments, non-governmental groups, and individuals can and should work together to improve the conditions of women's lives, so that women and their families benefit. |
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