Gender and reproductive health

by Kalimi Mworia

The term gender refers to social meanings given to being male or female. This translates into cultural and social life roles, patterns and options for both men and women. A quick glance at the table on page 81 shows how enormous the gender gap can be in terms of life options. In developing countries today, for every ten males enrolled in secondary school, there are only seven females; for every ten men employed in the formal labour force, there are only five women; for every ten male parliamentarians there is only one female.

A recent UNESCO study showed that women do two thirds of the world's work, earn 10% of the world's income and only own 1% of the world's wealth. In most of sub-Saharan Africa, where the majority of income is derived from agriculture, 80% of production and hence of the economy is in women's hands. This responsibility is in addition to women's multiple roles as child bearer, childrearer, carer and feeder of the family which in most cases include the extended family. Women also fetch water, gather firewood, often miles away from home, and sell the farm's produce. The total health of the women is crucial for the survival of the child and family, as well as the sustenance of the national economy and development. The health of these women must be seen in its totality. It includes not only the physical, but also the mental, social and economic well-being. These conditions in turn depend on her ability to regulate her fertility. Regrettably, women's reproductive health and other basic needs have been given minimal attention in national development plans. Worse still regarding agriculture, education, health and the economy is non-existent.

Gender issues can be subtle, because men and women act out their assigned roles unconsciously. In most cultures, gender roles have evolved over a long time and are, therefore, embedded in culture, folklore and religion. Because they are so deeply seated, they are difficult to change in spite of advances in education and modem technology. Many cultural traditions and roles assigned to women are detrimental to women's sexual and reproductive health. In many developing country cultures, women's value is tied to the number of children they bear. Hence the desire by women and their spouses to produce 'as many children as God permits', thus putting the health and life of women at risk. The situation is exacerbated by high infant mortality which leads women in many developing countries to repeated and frequent pregnancies.

Factors threatening women's health

By virtue of women's dual role within society, that of reproducer and producer, the definition of women's health must necessarily encompass these two functions. Only recently, and really only in the developed world, have specific needs of women come to the forefront of health policies and programmes. In the developing world the status of women's health remains deplorable and, unfortunately, virtually ignored. The disparity between the developed and developing world is most blatant when considering levels of maternal mortality. Woridwide some 500 000 women die annually due to complications associated with pregnancy. 98% of those women are in the developing world. That statistic translates approximately into 1 in every 200 pregnancies leading to the death of the mother. Clearly, the greatest risk to a women's health in the developing world is related to her role as reproducer.

Poor reproductive health also inhibits women's ability to fulfil their role as producers. For example, in Kenya and Senegal, women spend 47% of their reproductive years, meaning between ages 15 and 49, either pregnant or breastfeeding. Throughout these 35 years when women should be most productive, their mental and physical well-being is impaired because of their reproductive role. This would never happen if we were willing to make adequate and meaningful investment in women's reproductive health and child survival.

Research, and just basic common sense, can tell us which factors are associated with maternal mortality: inadequate maternity care, lack of access to safe abortion, and inability to space or stop childbearing when desired. It quickly becomes evident how comparatively easy it is to prevent maternal deaths. For example, increasing access to proper health facilities during pregnancy can have a direct effect on the number of women dying due to obstructed labour and haemorrhaging, or anaemia, or botched abortions, which together account for approximately 80% of maternal deaths in the developing world. Africa and southern Asia have the highest rates of maternal mortality: approximately 650 women die per 100 000 live births, compared to the figure of 30 in the developed world. One major reason is that only 30-40%of women in Africa and Southern Asia receive maternity care compared to 100% in the developed world.

Of course maternal care is not the sole answer. A recent World Bank study indicated that 50% of maternal deaths in Southern Asia could be averted if those women who did not want any more children had used effective contraception. The potential benefit of contraception in reducing maternal mortality is particularly promising for teenagers in Africa for many of whom illicit and unsafe abortion is the only option to avoid expulsion from school. The statistics are frightening: 44% of female secondary school students in the capital city of the Central African Republic have undergone an abortion; the average age of women hospitalised due to abortion complications is 19 years in Benin and 22 years in Congo; 60% of abortion patients in Nairobi (Kenyatta National Hospital) are either schoolgirls or unemployed women, while in a smaller city in Kenya, 64% of women hospitalised due to abortion complications are between 14 and 20 years old. These unsafe abortions lead to infertility or permanent damage to their reproductive system, or even death. Safe and early abortions would prevent not only 25-50% of the maternal deaths occurring every year, but also reduce the tremendous drain on health systems imposed by septic abortions.

The interrelationship between maternal health and the health of children must be underscored as well to illustrate the cyclical nature of morbidity and mortality: for example, women who had low pregnancy weight or low caloric intake during pregnancy have a 50% chance of bearing children with low-birthweight, which in turn greatly increases the child's risk of dying. Consequently, those women who suffer high rates of infant death will have shorter birth intervals and have less time to recuperate between pregnancies,, thus leading to low pre-pregnancy weight, and the cycle begins once again.

Unfortunately, even when services are available which can provide the care necessary to break this cycle and reduce the risk of maternal mortality, government policies and cultural and medical barriers prevent women from reaping the benefits. In some parts of Africa and Southern Asia, women cannot obtain effective contraception without authorisation from their husbands, while unwed women cannot even think of entering a family planning clinic. Even harder to believe is the fact that in those same countries, a woman suffering from obstructed labour cannot receive medical treatment until the husband approves, and she may even be amused of infidelity which would prohibit treatment until she names her lover.

Another tragedy afflicting women in some parts of Africa is the harmful traditional practices such as female genital mutilation (FGM). Almost 84 million worldwide, who have undergone this operation, suffer from unnecessary complications during pregnancy which can lead to lifelong morbidity and possibly mortality. The majority of these cases are in Africa, where girls undergo the operation between ages 1-13. It is these same girls who marry early, often through arranged marriages, and risk early pregnancy along with its complications. Apart from the obvious implications for reproductive health, the potential spread of HIV/AIDS through FGM is real. Yet this practice continues. FGM is completely preventable and can be eradicated. Surprisingly, with rare exceptions, the medical profession which is aware of the negative ramifications of FGM, has done little to publicise the plight of these women or to advocate the eradication of this practice.

What do women need in order to improve their health ?

These examples represent individual elements which, when put together, generate a full picture of pain, unwarranted pain, and illustrate the enormous amount of work still to be done to ensure good reproductive and sexual health for women. The framework of reproductive and sexual health goes beyond the act of reproduction, ie. contraception, to encompass the physical, emotional and social consequences of sexual activity. This includes preventing transmission of STD's, including HIV/AIDS, addressing infertility, ensuring safe termination of unwanted pregnancies, reducing prevalence of genital mutilation, and promoting sexuality as a positive force, which adds to individual well-being and enriches human relations. Included in this concept is freedom from sexual abuse and exploitation, which is related to issues of gender and power relations.

As defined here, women's reproductive and sexual health covers a broad range of issues, and is necessarily broader in scope than those activities prescribed for

'pure' family planning programmer. the general framework for activities remains the same: advocacy, information and education, and service delivery. At present, most family planning programmes cover these three components; in the future these programmes must consider broadening their mandate and enriching their content by addressing the issues of sexual and reproductive health.

In order to reach out and successfully touch upon all these dimensions of women's lives, it is essential to identify women's exact needs. The term unmet need was initially coined with respect to demographic indicators describing the number of women who are not using contraception but want to delay or stop future childbearing.

A broader and more encompassing interpretation of unmet need can be formulated to emphasise the broader reproductive needs of women. This redefinition of unmet need logically calls for the development of reproductive health programmer that incorporate:

-the underserved married couples, especially those excluded by poverty in rural or urban slums:

-young people and unmarried individuals of all ages;

-women with unwanted pregnancies, including those who seek abortion;

-women lacking and seeking access to reliable methods:

-women lacking access to counselling and who are using inappropriate methods.

Essentially, this comes down to the assertion that quality and access to reproductive and sexual health services must be assured for all women because, to quote The Centre for Reproductive Law and Policy, 'Women's reproductive rights are indeed human rights... in that control over their own reproduction is integral to women's capacity to work, raise and nurture an existing family, obtain education and generally to participate fully in social, economic and political life.' This basic right cannot be reserved for a select group of women only.

The role of men in sexual and reproductive health

We must be careful, however, that in this struggle we do not dichotomise along gender lines. Men, as much as women, must assume responsibility for the consequences of unprotected sex. In other words, they need to protect themselves and their partners against sexually transmitted diseases, especially HIV/AIDS, as well as against an unwanted pregnancy. In this regard, effective communication between spouses must be encouraged. One must, however, take into consideration the culture of sex in the African or Asian context, where traditionally women have no say in sexual matters. For instance, in a survey conducted by the Family Planning Association of Kenya (FPAK), men reported that they would like to use condoms but women would not consent. Women interviewed separately said the same thing about men. Research shows that, contrary to initial assumptions, male attitudes towards family planning are not uniformly negative; rather, lack of communication between spouses lead women to assume that their husbands disapprove of contraception.

Another critical step in increasing male responsibility regarding family planning is getting men to talk to men, outside the traditional clinic setting where most information about contraception is provided. Men can be reached at their work place, recreational centres and social clubs. Innovative strategies for communication and service delivery are needed to open up the area of family planning to include men, so that it really is a family issue. Throughout the developing world many men are reluctant to accept family planning because they fear that women will go off and have affairs if they are not at risk of getting pregnant. To ignore such issues, risks generating resentment and misunderstanding amongst men and women and underscores the need to include men as partners and full participants.
K.M.

The meeting of modern and traditional medicine reveals ambiguities by Didier Fassin

Long ignored or fought against, traditional medicines have been the subject of increasing attention from international institutions since the mid-1970s, particularly in sub-Saharan Africa. But, this worthwhile venture gives rise to ambiguities.

A worldwide programme

In 1976, for the first time, the World Health Organisation recognised the importance of traditional medicine, which, two years later, at the conference in Alma Ata, it proposed should be included in primary health care. The idea was both to assert the beneficial role which traditional medicine played as far as people in the Third World were concerned and to incorporate it into the basic medical system which there was then a drive to develop '. This move was the consequence of realizing the shortcomings of modern health systems, in particular in rural areas, and of wanting to rehabilitate native practices which had so far been neglected.

Among the initiatives taken as part of this programme, three appear particularly significant. First, there was the creation of centres of traditional medicine offering consultations and in some cases running ethnic-pharmacological research into plants. Second there was training to teach healers and traditional nurses the rudiments of medicine and hygiene so as then to involve them in primary health services. Finally the programme involved the establishment of so-called traditional practitioners associations, which were given official status by the authorities. Without claiming to make a full evaluation of the many and diverse schemes run (an undertaking which none of the organisations concerned seems to have risked making), we can to try to go beyond intentions and facts and analyse what happened at the historic meeting of modem and traditional medicine.

Medicines and traditions

Words here can be confusing. Talking about traditional medicines seems to involve two, equally false ideas. The first of these is that they are unified, so that the same thinking and solution can be applied to both. But what do the Senegalese witch-hunter and the Hindu ayervedic, the Arab marabout and the Amazonian Shaman have in common other than that -and this is a negative definition -they practice an art which is not that of modern medicine? The second idea is that, as the name suggests, traditional medicine belongs to a timeless tradition which is impermeable to the effects of history. Here too, all the ethnological studies show that knowledge evolves, that practices are sensitive to outside influences and that many rites, which seem to have existed for all time, are in fact only imports or innovations dating back a few decades 2, So it is this diversity and these historical implications which must be borne in mind when embarking upon a dialogue, or collaborating with traditional medical practitioners.

Even more important is to take account of the fact that traditional medicine is not just medicines and that it tends to do more than just treat diseases. Of course, the herbalists and bonesetters found in every society are mainly healers. But most of those who are styled healers also have magic, religious and sometimes political functions 3. Because of their understanding of local contexts and cultural codes, they play an essential part in the life of society, giving a meaning to disorders of body and mind, relating them to the history of the patient or those around him and calming tensions within the group.

Revaluation and assimilation

In trying to incorporate them into a primary care system, to use the official terminology, the idea was to reduce traditional medicines to their therapeutic benefits or, more likely, to the only dimension which could be measured scientifically. In order to do this, the pharmacopoeias, which were easier to handle objectively, were separated from the rest of the representations and practices involved in the medical act. The only things retained from the healers' consultations were the basic plant recipes which went with them and the broader functions related to divine manifestation and ritual practices were left aside. Of traditional therapy, all that was kept were the roots, an attempt being made to highlight their active principles, but not to understand the meaning of the procedures which surrounded the harvesting or prescribing of them 4. It was believed that, in this way, they could be included in the official system of care. it was even thought that a healer could easily hold consultations alongside other traditional practitioners in specialised centres, or alongside nurses or midwives in dispensaries.

The interest in traditional medicine and the desire to capitalise on the knowledge on which it is based is understandable from the public health point of view, just as it is perfectly legitimate for people in many parts of the world claim recognition for the knowledge which they have. However, the effects of a policy of revaluation and assimilation, of the sort undertaken here, are equivocal.

On the one hand, corpuses of local pharmacopoeias have been Heated and ethnic-pharmacological studies conducted. Training for healers and traditional nurses have probably made it possible to reduce some dangerous practices, in particular when it comes to hygiene. Experience of the joint treatment of the mentally sick by healers and psychiatrists have updated the conception of madness and how to treat it. But on the other hand, the cognitive foundation of traditional medicine has been overturned by the introduction of principles of validation which are foreign to it. The serial bases have also been undermined bv the introduction of other methods of legitimisation and it is generally the therapists who are the least distinguished in their own environment and have the most links with the modern world who have got the most out of their involvement in these programmes, where they earned recognition. 'Tradi-practitioners' who have been promoted in this way no longer have much in common with those said to be great healers.

The story continues...

That is no doubt only an episode in the already long story of traditional medicine. It would be wrong to give these things more importance than they actually have. The changes going on in the societies in Africa, America and Asia are more far-reaching. New values, which are the effect of cultural transformation, not political will, have to be imposed in everyday life. Conversely, it is often young people who have been through school and sometimes have health diplomas who try to return to their roots - the meaning of which they change, obviously, in comparison to the symbolic world of their ancestors. The revaluation and assimilation programmer are just one component of this trend.

So is the meeting of modem and traditional medicine condemned to produce effects which are different from and sometimes even oppositie to those anticipated ? Will it not just hasten the end of belief and knowledge already suffering from the changes which these societies are experiencing? Let there be no mistake. Representations and practices are more likely to change than disappear. Other rites, other remedies and other traditions are being invented all the time.

Programmes aimed at improving people's health through traditional medicine can only be expected to generate a better understanding of what their intervention involves and draw more attention to the main movements of society - to which the social sciences can contribute. If we were more attuned to the aspirations and claims of the people, perhaps we would discover that the greatest hopes placed in modem medicine and health policies relate to access and standard of care.

D.F.