|HDD-(PHN)FLASH, newsletter on Population, Health and Nutrition of the Worldbank Human Development Department (WB)|
|PHNFLASH 2 December 6, 1993|
Electronic Newsletter on Population, Health and Nutrition
Population, Health and Nutrition (PHN) Department, World Bank
Women, Health, and Development
Here are excerpts from a paper presented by Anne Tinker, Senior Health Advisor during a conference on Women's Health and Nutrition held last May at the Rockefeller Foundation Center in Bellagio, Italy:
Since the 1960's several initiatives have influenced women's health status in developing countries. Understanding of the important, but previously largely undervalued, role of women has increased greatly during the past 15 years, stimulated in large part by the United Nations Decade for Women. The Safe Motherhood Initiative, launched in Nairobi in 1987, successfully focused world attention on the magnitude of maternal mortality in developing countries and the need to improve maternal care.
Family planning efforts are increasingly oriented toward providing women with reproductive choice and the ability to avoid unwanted and poorly timed pregnancies. Recently, child survival efforts have recognized the significant impact of maternal health and nutritional status on infant outcome; this is reflected in the inclusion of maternal mortality goals in the recommendations of the World Summit for Children, held in 1990. While the family planning and child survival initiatives have been successful in bringing about dramatic reductions in fertility and infant mortality, there has not been comparable progress in improving women's health and nutrition, not even in reducing maternal mortality, which has received specific attention. Since the Nairobi Safe Motherhood Conference, over three million women have died from pregnancy-related causes. The annual number of maternal deaths has actually increased; although women's risk of dying as a result of pregnancy or childbirth has fallen by five percent during the past five years, the number of births has increased by seven percent over the same period.
It is appropriate that development policies and programs to improve women's health place special emphasis on pregnancy and childbirth in developing countries, due to the proportion of the life span spent in reproduction, its associated risks, and the high mortality and morbidity that result from largely preventable and/or manageable pregnancy-related complications. At the same time, these activities need to be increasingly complemented over the longer term by efforts to improve women's health and nutritional status more broadly. This requires attention to problems that often begin in infancy due to the lower status of girls, such as poor nutritional status due to discrimination in the allocation of food. Reproductive health problems include unplanned pregnancy and sexually transmitted diseases (STDs).
Several other gender-specific health ISSUEs will require increased attention in certain cultures, such as chronic diseases in transition societies where older women form a growing proportion of the population, occupational hazards that place women at particular risk, and violence in societies where physical or sexual abuse are prevalent.
That women's health has received scant attention in development programs is reflected in high levels of persistent, but largely preventable, morbidity and mortality. In sub-Saharan Africa, a woman runs a one in 21 risk of dying from pregnancy-related causes during her lifetime; in Asia, it is one in 54; and in Latin America, it is one in 73. This compares to one in 10,000 in Northern Europe. Over 50 million women in developing countries are estimated to suffer acute pregnancy-related complications every year, and an uncounted number of women suffer pregnancy-related disabilities long after delivery. In addition, some of the deleterious effects of infectious diseases common to both men and women, such as malaria and hepatitis, are exacerbated by pregnancy.
The majority of women in the developing world go through pregnancy with no prenatal care and deliver without the assistance of appropriately trained health care providers. Most women of reproductive age also lack regular access to a range of modern methods of contraception. This frequently results in poorly timed or unwanted pregnancies [which] lead to between 36 and 53 million abortions around the world every year. Pregnancy termination under unsafe conditions is the cause of 115,000 to 200,000 maternal deaths each year. In Latin America, the complications of unsafe abortion are the main cause of death among women between the ages of 15 and 39 and absorb as much as 50 percent of some hospital maternity budgets.
In addition to problems associated with pregnancy, other conditions such as anemia, malnutrition, AIDS and other sexually transmitted diseases, and reproductive cancers impose a high toll on women's health and productivity. The number of women with HIV/AIDS is accelerating rapidly. In Africa alone, nearly four million adult women were already infected by the end of 1992.
Current estimates are that equal numbers of women and men are infected in Africa, and predictions suggest that more women than men will be infected by the end of the decade. Women with HIV risk passing the virus to their newborns, and they themselves usually die while their children are still growing up. Cervical cancer is the leading cause of death from all cancers (affecting both men and women) in developing countries-about half a million new cases are diagnosed each year worldwide, more than three-quarters of which are found in developing countries. Virtually only women are affected by breast cancer, yet it is the third most common cancer worldwide.
It is estimated that less than 20 percent of government health budgets are allotted to maternal and child health and family planning, and most of that amount is for child health. The resources allocated for women's health are not commensurate with the clearly demonstrated need.
Women's poor health is a reflection of their low status in many developing countries. Worldwide, women have a longer life expectancy than men [but] despite this, females have higher morbidity and physical disability levels than males throughout the life cycle. The differential in health status often begins in childhood, when girls receive less nutrition and health services than their brothers.
Women's lack of education and disadvantaged social position help perpetuate poor health and high fertility, as well as a continued cycle of poverty. Because women tend to be less educated and have less access to information, they are less apt to recognize problems or understand the value of or seek out preventive and curative care. Among other benefits, female education, especially through the secondary level, is associated with greater use of contraception and increased age of marriage, both of which improve women's health by reducing their exposure to pregnancy and early childbearing.
Families and communities also frequently underestimate the social and economic worth of women, and, therefore, their health needs. In Senegal, for example, a study which examined the low utilization of maternal health services found that only two percent of the women interviewed said they would decide for themselves to seek care in the event of pregnancy-related complications.
A number of other health problems associated with women's low socioeconomic status must also be addressed by health and development programs. Gender-specific violence provides an example. In Papua New Guinea, a survey found that 67 percent of rural women were victims of wife abuse. Dowry deaths and bride burning in India and female circumcision in parts of Africa and the Middle East are further examples of gender-specific cultural practices deleterious to women's health. Occupational health hazards are also an increasing concern. Women's low status, particularly lack of education, exacerbated by economic hardship, is leading to increasing prostitution, for example. This, in turn, is contributing to the rapid spread of STDs, including AIDS.
The health of women is integrally related to their overall status in society. Expanded opportunities in health and education will allow women greater control over their health and lives and enable them to exercise more productive and visible roles in socioeconomic development.
A woman's ill health or death affects not only her own opportunities and potential but those of her children. A mother's death in childbirth is a virtual death knell for her newborn, and it often has severe consequences for her other young children. At least 60 percent of women who die from pregnancy-related complications are already mothers, and a study in Bangladesh found that when a mother died, the chances that her children up to the age of 10 would die were sharply increased-by more than three times for her girl children.
Women's poor health also affects the welfare and productivity of their households and communities. Ironically, the poorer the family, the greater its dependence on women's economic contribution. Women are the sole breadwinners in some 30 percent of the world's households, and at least 25 percent of other households depend on female earnings for more than 50 percent of total income.
Women also play a critical role in their national economies, and their physical well-being determines their ability to be productive. Data on women's contribution to development, while still tentative, indicate that women are responsible for up to three-quarters of the food and cash crops produced annually in the developing world. In Africa, women produce 80 percent of the food consumed domestically and at least 50 percent of export crops. Women also constitute one-third of the world's wage labor force and one-fourth of the industrial labor force. However, women's wages for the same or similar work are substantially lower than men's. In parts of Asia and Africa, women earn 50 percent less than men. Women work longer hours than men in every country except Australia, Canada and the United States. Therefore, female ill health has a substantial impact on productivity and economic development.
Ill health impedes women's ability to work and earn money, and burdens them and the economy with increased health care costs. Investments in women's health programs not only improve a woman's health status and the survival and health of her family, such investments increase the labor supply, productive capacity and economic well-being of communities.
Improvements in women's health are not only critical to development, they are feasible and affordable. Of the many health sector interventions discussed in the World Development Report, safe motherhood interventions were found to be among the most cost-effective. Safe motherhood interventions include family planning to raise age at first delivery, space births, and prevent unwanted pregnancy, tetanus toxoid immunization, micronutrient supplementation, and improved prenatal and delivery care.
Strategies to protect women from sexually transmitted diseases can also have a cost-effective impact. Biologically, women are more susceptible to STDs; the probability of transmission in a single contact of unprotected vaginal intercourse is greater from infected male to uninfected female than the reverse. Moreover, because the duration and severity of STDs (other than HIV) are greater in women than in men, preventing a single case of an STD in a woman is estimated to be 20 percent more effective than preventing a single case in a man. Preventing and curing STDs in women also helps to reduce prenatal transmission. The most cost-effective strategy is to combine information, education, and communication with condom subsidies and STD treatment targeted to core groups of males or females who engage in unsafe sex with multiple partners.
The evidence suggests that improving women's health is a sound investment. Women's health programs are not only feasible and cost-effective, but their broader benefits stretch far beyond the woman and have important effects on the household and community development.
Despite their higher life expectancy, women suffer from more health problems than men. Beginning in infancy, females often receive less and lower-quality food and, when sick, receive treatment less often and at a more advanced stage of disease. Because of their reproductive function, women run risks of morbidity and mortality which men do not face. Their health is also adversely affected by gender-specific cultural practices, such as female circumcision and physical abuse.
The development response must be a life cycle approach to women's health. Policies and programs need to address both the biological and cultural determinants of women's poor health status. To address gender discrimination that begins in infancy and childhood, education, communications and health service outreach strategies will be needed to promote more equitable intra-household food allocation and health service use. To reduce the prevalence of early childbearing and improve adolescents' productive potential and reproductive health, strategies must be developed to target them with information and services on reproductive health, family planning and nutrition, as well as to expand educational opportunities and postpone age of marriage.
Innovative approaches are needed since traditional maternal and child health and family planning programs have had limited impact on adolescents. For all women of reproductive age, an integrated approach is necessary to ensure protection against unwanted pregnancy, AIDS and other sexually transmitted diseases. Appropriate food and micronutrient supplementation, prenatal health services, safe delivery and referral care are essential services for pregnant women. Detection and treatment of cervical cancer (and in some countries, breast cancer) will need to be considered as a priority for older women.
Improvements in women's health, while beneficial in their own right, contribute to development through improved productivity, reduced costs of medical care, and a healthier generation to follow. At the same time, development leads to improved health of women if the benefits of development are shared equitably.
Women comprise over one-half the human race. Investing in their health is an investment in development today; it is also an investment in the generations of tomorrow.
[Reprinted with the author's permission from Bank's World, Volume 12/Number 11, November 1993]