Women and Health biological medical social gender medical But women's health is more than a medical issue. health and human rights

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1 C H A P T E R Women and Health 1 1 There are obvious differences between male and female patterns of sickness and health. Not surprisingly, these arise in part from biological differences between the sexes. These can give rise to specific reproductive illnesses ranging from pre-term delivery to cervical and breast cancer. These can be referred to as the medical health needs of women. But there are also health needs which are a result of the social conditions of women's lives e.g. the amount of work they do at home and in the fields, the heavy responsibility they carry in caring for children, the amount of unemployment amongst women, the kind of jobs that employed women do. In every country, women continue to face discrimination and inequality because of their gender - the way society perceives and treats them because they are women. The social conditions of women s lives, are also shaped by their race/ethnicity and their social class. These factors can influence why some women are more vulnerable to ill health than others - poor women, for example, are much more likely to suffer from cervical cancer. Health workers usually find it easier to focus on the medical conditions specific to women and the medical health needs of women. But women's health is more than a medical issue. It is equally important to recognise that women's health needs are closely related to their living conditions and to the customs and attitudes towards women in their society. Unfortunately, women have an inferior status to men in most societies and cultures and this is reflected in many ways. For example, there are unequal job opportunities for women, women often receive less pay than men for the same work, women are often expected to do all the domestic housework for their families. The inferior status of women is also reflected in medical services e.g. it has taken a long time for maternal and child health to become a health care priority. All these conditions make women's lives difficult and contribute to their ill-health. This chapter will discuss both the medical health problems of women and the non-medical health problems related to their social status and their living conditions. This will include a discussion of women's working load and the added problems that women in the rural areas experience. Women s health and well-being will only improve significantly when women's social conditions improve. In order to achieve their potential for health, women need equal status and rights with men, both at work and at home - including equal education and job opportunities, voting rights, paid maternity leave, better access to safe contraception and methods of child spacing, and better access to child care. Thus, it is important that health care workers not simply treat the medical health problems of women, but that they also try to recognise the important links between health and human rights.

2 Women's health is more than a medical issue Many people think that women's health is mainly concerned with their reproductive system and their gynaecological functions e.g. pregnancy, childbirth, menstruation. But this is only part of women s health needs. Like men, women's health is affected by their living conditions, their working conditions, their life styles, as well as their political and economic realities. Women have less status than men in most communities and attitudes towards women have an enormous effect on their health. Pauline is a 36 year old woman who lives in a remote rural village. Her husband is a migrant worker and does not always send her money. She now has 4 children aged between 3 years old and 16 years old. Over the past few years 2 of her children died, one from malnutrition and the other from measles. The nearest clinic is about 20 km away and she cannot easily afford to pay for transport to get there when she needs medical help. Florence is a 32 year old woman who lives in Soweto. She works as a cleaner at a large hospital and has to leave home at 5 am to get to work by 6 am. She has three daughters, two are at school. Her mother lives with the family and cares for the youngest child while she is at work. Her husband works as a driver. She suffers from high blood and has recently been getting many headaches. She has started taking the contraceptive pill because she does not want to fall pregnant again. But she has to hide the pills so that her husband does not discover she is on contraception. He wants a son and keeps asking her if she is pregnant yet. c What are the causes of the ill health of these women and their children? Are they medical or social? c What must be done to improve these women's health? Whose responsibility is it? c What could you as PHCWs do for these women? In most societies, cultures and religions, women have an inferior status to men, within the family, in the community and in society in general. This lower status causes many problems for women. In many ways, women are disadvantaged because they were born females. For example, in some cultures in Southern Africa, boys get the opportunity to go to school before girls and male children are sometimes better fed than female children. In many societies, couples are happier if the woman gives birth to a boy rather than a girl - the girl babies are sometimes neglected, abandoned and even killed.

3 Women's health is more than a medical issue. Their health is affected by their living and working conditions, as well as the political and economic realities of their lives. A woman's work is never done Most women work very hard to care for their families and to provide for the physical and emotional needs of their families. In urban areas, many women work in factories and offices and many do domestic work for other families. When they return home at night, they still have to prepare food, do their own housework and care for the children and the men. Woman often have very physical tasks to do. In rural areas, women do an enormous amount of physical work; they fetch and carry firewood and water for long distances, work the fields for food and prepare and cook the food. Many rural women carry these heavy burdens alone while the men are in the towns working. They also have to care for their children and the aged members of their families.they often have little money and they live under great physical and emotional stress in the face of their difficult lives. Women often suffer from chronic tiredness and fatigue, they may be under emotional stress and many women are also depressed. Many women come to PHC clinics complaining of general aches and pains and exhaustion. It is not only women's physical health that is poor, but very often their mental and emotional health is also poor. Women work longer hours than men - many people say that women have a double shift, one at work, the other at home. Women have been fighting for men to recognise this and share the work load of running the home and caring for the children. Women generally live longer than men, they have fewer accidents from work, and lower risk of cardiovascular diseases and illnesses related to alcohol and cigarette smoking. Although they may live longer, women's health is not better than men's. The health of women can be improved in many ways. One of the most effective ways to do so involves decreasing the work load of women or, even better, sharing the work load at home with men. This could help to reduce the chronic fatigue that women experience throughout their lives. Of course, there are many other ways of improving women's health. Women's groups, community organisations, self-help co-operatives, family and friends can play an important role in helping women cope with their emotional problems and worries.

4 With your colleagues and trainers, discuss ways in which women in your area can decrease the workload that burdens them. What can women do? What help would they need? Can you as PHCWs play a role here? Women's problems in the rural areas In many parts of the developing world, a large proportion of people live in rural areas - and for many reasons, including male labour migrancy, women often make up the majority of these rural dwellers. These women often have to look after large families without much support and they are faced with very heavy responsibilities. Alone, they have to bring up the children, care for the aged, feed and clothe the children, labour in the fields, fetch water and firewood. They do this hard physical work, even though they are often malnourished and anaemic. Many women receive money from their male partners in the cities but many do not. Many women only see their-husbands once or twice a year and they face their difficult lives with little emotional or financial support. For all these reasons, women's lives in the rural areas can be extremely stressful, physically and emotionally. In many rural areas the woman as required to do heavy manual labour as well as looking after the home. Medical services are usually inadequate, far away and too expensive for many rural inhabitants. Often health workers lecture women about balanced diets when they do not have money or fertile land to grow healthy food. This makes women feel that they are responsible for their own illnesses and those of their families. With your colleagues, discuss ways in which the health (physical, emotional and mental) of rural women can be improved.what role can PHCWs play in this? In what ways must the health services change to meet the health needs of rural women?

5 Problems of employed women Women who go to work in factories, offices, on farms, in other people's homes etc. have problems which do not often affect men. Many working women feel that they are discriminated against because they are women. Some of the ways that they are discriminated against include: c Women often receive lower wages than men - or equal work. c Employers often prefer to give jobs to men rather than women because women need to take leave for childbirth and child rearing. c Few employers offer adequate maternity leave or working hours that make child rearing easier for women. c Creches are seldom available at the work place. c Many women lose their jobs if they become pregnant or if they take time off to care for their children's needs. c Women may experience sexual harassment at the workplace and risk losing their jobs if they bring attention to the problem. Women workers throughout the world are fighting for better working conditions, equal pay with men, maternity rights and creches, and laws which them from sexual harassment. Violence against women Violence against women is an enormous problem in South Africa, as it is in every society in which it has been studied. It is closely related to the discrimination and low value placed on women and girls within society, and therefore it affects women across society - regardless of social class, race/ethnicity, and age. Such violence takes many forms, including emotional, sexual, and physical abuse. Violence against women is usually a hidden problem, due to the social stigma associated with it, and the tendency to dismiss it as a private problem which should be kept within the home. But because such violence threatens the health and survival of women, it is now recognised as an important public health issue, as well as a human rights issue. Nurses and other healthcare workers may be well-positioned to help women in violent relationships, because such women almost always have some contact with the health care system. Within South Africa and elsewhere, new training approaches are being developed to help nurses learn how they can be of help to women in abusive relationships. As a primary health care worker, it should be possible to find out if there are any local services available to help your women patients. In some instances, concerned nurses have been important in organising and developing such services where they did not previously exist.

6 Female Genital Mutilation Female genital mutilation (also called female circumcision ) is a deeply rooted traditional practice in many cultures. However it is a form of violence against women and girls that has serious health effects, including infertility, urinary complications, and severe pain and infection (including the risk of transmitting Hepatitis B and HIV/AIDS through unclean cutting instruments). It also frequently causes psychological problems and pain and lack of satisfaction during sexual intercourse, as well as problems in childbirth. Although it is very difficult to change people s attitudes and cultural practices, there is growing awareness and education about this issue. The World Health Organisation (WHO) has expressed its commitment to the abolition of all forms of female genital mutilation. Special medical health needs of women Women have special health needs around gynaecological problems, menstruation and menopausal problems, breast conditions and cancer of the cervix. Women also need special care during pregnancy, childbirth and breast feeding. Infertility and sexually transmitted diseases are also problems of concern to many women. These are some of the common medical problems that are specific to women but many of these problems are made worse by women's social conditions. For example, many women in underdeveloped areas suffer from anaemia because of menstruation or pregnancy and poor diets. Anaemia makes women tired but they still have a heavy work load to do. So these women suffer doubly from exhaustion - from both anaemia and hard work. This section will look briefly at the main physical health needs of women. Maternal health during pregnancy and childbirth Pregnancy is generally a healthy process but it can be dangerous to the mother. Some health risks caused by pregnancy and childbirth include: c women sometimes die from childbirth c childbirth can cause many injuries to women e.g. severe tears c ectopic pregnancies c abortions c post partum haemorrhage and infection Pregnancy problems are worse in women who come from underdeveloped areas or poor environments. Pregnant women with malnutrition become anaemic and get infectious diseases more easily. Their babies are often small and under-weight and these babies often die in the first year of life. Mothers often feel guilty and ashamed if their infants die.

7 Pregnancy amongst teenagers is becoming more common and causing many problems. There are no obvious solutions to these problems. c Why do you think that more teenage girls are becoming pregnant these days? c many of the health risks of pregnancy and childbirth are discussed in Chapters 4 and 5 of this manual. Child spacing (family planning) and contraception Health risks from pregnancy and childbirth are also made worse when women have too many babies too close to each other. Child spacing (family planning) and contraception can help women avoid some of these health risks. But many women cannot get safe, appropriate and cheap contraception, often their husbands do not want them to use child spacing (family planning) and contraception. So once again, many women suffer unnecessary health risks. c With your colleagues discuss why you think many men do not want women to use family planning and contraception. c Refer to the manual on CHILD SPACING for more information on this subject. Gynaecological problems Women are affected by many gynaecological conditions. Menstrual disorders, abortions, pelvic inflammatory disease, ectopic pregnancy and menopausal problems are some of the important gynaecological problems which will be covered in this manual. Cancers common in women Cancer of the breast and the cervix are common in women. It is very important to detect these cancers as early as possible. Health care workers can screen women for,these cancers and teach women how to examine their own breasts.these subjects will be covered in Chapters 8 and 11 of this manual. Early stage Late stage A small cervical erosion can progress to a large cancer if left untreated Abortions In many countries, abortions are illegal and are therefore often done in unhygienic conditions. As a consequence, many women develop infections and complications. Sometimes these complications can lead to death. The situation in South Africa has recently changed, as termination of pregnancy in the first months has been legalised. However, in many places ensuring access to these services remains difficult. If safe and effective contraception is made easily available for women, they would not have to seek 'backstreet' abortions. Termination of pregnancy is discussed in more detail in Chapter 4.

8 Infertility Infertility is a common problem amongst women (and men). It can cause women a lot of stress and anxiety, especially in societies where women are expected to have many children. There are many causes of infertility, including STDs and poor maternal care. In about half the cases of infertile couples, the man is infertile and not the woman. But the men usually 'blame' the woman for infertility. Chapter 9 in this manual deals with infertility. Sexually transmitted diseases or STDs In women, STDs are often hidden in the genital tract and the signs and symptoms are less obvious. Women often feel guilty and ashamed about STDs and they sometimes do not seek treatment because of this. Pelvic inflammatory disease is a particularly dangerous complication of STDs and it can cause infertility. Also, if pregnant women get STDs, they can infect the foetus or newborn baby e.g. congenital syphilis, gonococcal conjunctivitis. STDs will only be mentioned briefly in this manual. The manual SEXUALLY TRANSMITTED DISEASES covers this subject in detail. Anaemia Anaemia is very common amongst women. In developing countries, about half of all non-pregnant women and about two-thirds of all pregnant women suffer from anaemia. Anaemia causes extreme tiredness which is made worse because of women's heavy workloads. It lowers women's resistance to infection and disease. Many women feel weak, tired and unwell for most of their lives. Anaemia is also covered in more detail in the manual OTHER IMPORTANT DISEASES. Mental health and depression Because of their heavy workload, the stress in their lives and their inferior status in society, many women are often depressed. Anaemia and many of the above medical health needs of women can add to feelings of depression. Hormonal changes during menstruation and menopause can also lead to feelings of depression. There is often inadequate care and recognition of women's mental health needs. Alcoholism and women Abuse of alcohol can be a problem for women as well as men. Many women drink to forget their worries about their children, their loneliness, their financial insecurity and dependence on men, their fatigue etc. Female alcoholism is a carefully hidden problem and many societies judge alcoholic women more harshly than alcoholic men.

9 Many of the medical and non-medical health problems of women have been briefly described above. It is clear that women's rights to better health have not yet been met. What needs to be done to improve women's health? This is covered in the next section. Women's rights to better health have not been met Women make up over half of the world's population, and their health (and ill-health) affects the well-being of their children, their family and society at large. We have seen that there are many social factors that affect women's health and in order to improve women's health (and the health of the whole society) many changes are needed in their living and working conditions. Many women and men are involved in the struggle for better health. They have learned that women from all levels of society need to be included and make themselves and their rights to health heard. It has also been pointed out that men must also be educated about and involved in the struggle for women's health. Both women and men need to be equally involved in making decisions and policies which affect women's advancement and self-development. Women's lives and their health, as well as the health of their children and families, are affected by many decisions e.g. agricultural training programmes, food prices, infant-formula subsidies, health education programmes, child spacing policies, voting rights, marriage laws, transport infrastructures, health services, schooling etc. In many parts of the world, women are organising and claiming their human rights. They are helping men to understand just how and why they oppress women. Men must also understand that it's not in their interests, in their families' interest or in society's interests for their women to be unfairly treated. Women and men need to participate in decisions about all these issues so that they can improve the conditions of their lives and, therefore, their health. Women need equal status with men on all levels - it is a fundamental human right. "A woman's health has to do with her life and the world in which she lives. It has to do with her socio-economic situation, with her level of learning, and whether she is able to make healthy decisions on her own behalf. A woman's health has to do with the community in which she lives, with cultural conditions and what her worth to society is seen to be. A woman's health has to do with women being able to say what their needs are and what services they need. It has to do with all of us - women and men, professional and lay persons- thinking about the many factors which affect the lives of women, their development and their health." Contact, Number 80, August 1984.

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