Birth and death

Over half a million women die in childbirth every year in Africa and Asia. And the world total is probably very much higher. In Latin America, for instance, three out of every thousand mothers in Ecuador and up to 20 out of every thousand in Honduras die before they can look into their new baby’s face or hold it in their arms.

Though thousands die, many millions survive and have to live on with the scars of a difficult pregnancy: displaced or weak wombs, cycles of debilitating infection, exhaustion, incontinence and bleeding. An estimated 25 million women a year are seriously ill after having their babies.

The dangers are increased by the weak state many women’s bodies are in by the time they feel the first pains of labour: thin from lack of food, exhausted from work and the demands of previous pregnancies. Two-thirds of women in Asia, half of African women and a sixth of women in Latin America are anaemic, proportions which increase markedly when they are pregnant, when two out of every three women in the poor world have the haemoglobin-starved blood of anaemia.

These women are suffering from nutritional anaemia’, caused simply by lack of the right kind of food. In India, for instance. though rich women eat around 2,500 calories a day and put on an average of 12.5 kilogrammes of weight during their pregnancies, poor women eat around 1,400 calories a day and gain only 1.5 kilogrammes during those crucial nine months. Little wonder, then, that such women bear tiny. underweight babies. One-sixth of all babies weigh under 2,500 grammes when they are

born and 95 per cent of these take their first uncertain breaths in the poor world, where they account for one- third of all infant deaths.

Vulnerability of women

It is not only the illnesses surrounding pregnancy that affect women, however. At least one person in three harbours some species of parasitic worm; one in 20 has bilharzia; and malaria, once thought to be on the decline, has made a massive comeback to gnp one person in six in its fevers.

There is now more information available on the health of women that ever before. In fact, WHO reports that their commitment to the aims of the Decade for Women has led some governments to start sponsoring research and gathering statistics to discover more about women’s particular vulnerability to certain diseases. Over a quarter of the 76 countries reporting to WHO now monitor all health statistics of men and women separately, and 54 per cent collect mortality and nutrition figures separately.

And the evidence indicates that discrimination against women begins as soon as they are born. A Bangladesh survey found more girls than boys under five years old were malnourished because they were allocated smaller portions of food, and that infant girls were 21 per cent more likely than boys to die in their first year of life. In Nepal the picture is similar, with more malnourished girls than boys under five years old and with women 50 per cent more likely than men to go blind as a result of chronic lack of food. Other research shows that, in some countries, when girls fall ill they are less likely to be taken to the health centre than boys.

Primary health care

The Decade for Women saw the launching of what WHO calls ‘the most optimistic statement of purpose ever made by the world community’. In September 1978, 134 nations met at Alma Ata in the USSR and pledged their support for a world-wide effort to bring ‘health for all by the year 2000’. Primary health care was to be the key to the success of this effort. The principles were simple enough. If 80 per cent of all illness in the world is caused by the lack of clean drinking water and sanitation, then improving water and sanitation would have to become a priority. With malnutrition affecting one in four people and making them more vulnerable to disease, basic nutrition would also have to be part of the package.

Suddenly the eyes of health planners have begun to turn towards women: as cooks and feeders of children: as fetchers of water and firewood; as custodians of cleanliness and hygiene; as teachers of healthy habits; as people who bear babies, who breast-feed and wean them; who care for the sick, the disabled and the old - in other words as a vital resource on whom the world’s health depends and whose own health, therefore, needs preserving above all.

Forty-eight out of 70 countries reporting to WHO in 1983 have now formulated a national primary health care policy and a further eight are putting their emphasis on rural areas.

Maternal and child health

A major advance for women, arising from the new emphasis on primary health care in many countries, is the increasing attention paid to providing better care for pregnant mothers and their babies. Maternal and child health (MCH) involves pre-natal check-ups. immunisation and advice on child-care, breastfeeding and weaning foods. Forty-two governments reported that they have expanded their MCH activities during the Decade, with Senegal actually restructuring its entire Ministry of Health to incorporate this new commitment.

Proponents of MCH in the US have estimated that 2.7 million dollars spent on pre-natal services would save between ten and 12 million dollars currently spent keeping premature, low birth-weight babies alive in intensive care units. And when prenatal consultations in Portugal rose eightfold - from 19,000 in 1975 to 150,000 in 1982 - maternal and infant mortality rates plummeted by 12.9 and 12 per thousand respectively.

Water and sanitation

The Decade for Women saw the launch of another major worldwide initiative: the International Drinking Water Supply and Sanitation Decade in November 1980. WHO estimates that, in the developing world (excluding China), 25 per cent of people in cities and 71 per cent of those in the countryside are without safe water to drink and 47 per cent of town-dwellers and 87 per cent of people in rural areas have no adequate sanitation.

The consequences of being without these basic amenities are ill health for all and great hardship for women, who often have to walk long distances to fetch water. A person needs around five litres of water a day for cooking and drinking, and a further 25 to 45 litres to stay clean and healthy. But the most a woman can carry in comfort is 15 litres. Even if she lives near a standpipe, that means about 15 journeys a day with a full bucket. Small wonder that an estimated eight million children die each year of diseases that might have been prevented by sufficient clean water from a nearby tap.

Now 26 countries are making a special effort to look into women’s particular needs in their attempts to meet the targets of the Water Decade.

Women as health workers

It is not only as recipients of health care that women have benefitted in recent years. As providers, too, their traditional contribution is at last beginning to be recognised. As part of their normal domestic role women everywhere do, as WHO acknowledges, provide more health care than all the world’s health services put together. And, in the majority of societies with no regular access to modern medical facilities, it is women who often emerge as especially committed and skilled to become the village healer or midwife - the dai in India, the hilot in the Philippines, the panbolan in Thailand. Sierra Leone’s 13,600 traditional midwives, for example, deliver 70 per cent of births; and 80 per cent of births in Honduras are delivered by such women.

In the past these women have found themselves looked down on as dangerous and ignorant quacks by the - largely male - medical profession. In the not-so-distant past, they were even burnt in Europe as witches. With the advent of primary health care, however, such women’s skills have at last begun to be appreciated and these women are now being trained all over the world in the principles of primary health care. In 1972 only 37 per cent of developing countries reporting to WHO had launched training programmes. By 1982, 82 per cent had done so.

Costing less than two per cent of the money it takes to train a doctor, the logic is clear. The benefits are clear too. In one part of India, for instance, deaths for neo-natal tetanus were reduced from 90 to ten per 100,000 in the three years following the launch of the dai training programme there.

Resistance from doctors

But here their involvement stops. In the higher ranks of the health services - among the doctors, the health ministry officials, the hospital administrators - where the high pay and the power reside, women are grossly under-represented. Yet this is where the policy decisions get taken, and where the money is distributed from. And that money tends to stay just where it is, Three-quarters of the world’s health problems could be solved by primary health care. But three-quarters of developing countries’ health budgets are spent on doctors and hospitals.

TORIL BREKKE from Norway went to KENYA The hut belongs to the husband I look at Sophie, who sits now in the grass before me: 28 years old, mother of five, her belly large with number six. She alone has the responsibility for her children: her husband, like many others, has moved to the city in search of work. I ask if she has anyone to help her, now that she is heavy with child. She shakes her head and wipes her brow. She’s sweating: a different kind of sweat that has nothing to do with the sun. Is she ill? Is the child on its way? I ask her, and she replies with a grimace. Then she looks at me - an appraising look. ‘My husband was home recently’, she says. I do not understand. What has the recent visit of her husband to do witb her sitting here, sweating and in pain? Sophie will say no more. Laboriously she climbs to her feet and waddles accross to Rachel, who sits weaving in front of her house. A picture of the courtyard, encircled by huts and houses; the drainpipe that carries the water off the roofs and down into a large tub in the rainy season; the jacaranda bushes with their violet flowers; the sedate cows; the wizened old man in the brown cap in the background; two women in the foreground. Sophie and Rachel: the one big with child and sway-backed; the other easy and lithe. Rachel gesticulates; she strokes her friend’s arm. Together they disappear into Rachel’s sleeping-hut They emerge a few minutes later, Sophie clutching a small bundle in her fist They’re speaking a language I do not understand and Rachel holds one of Sophie’s hands in both of hers. She releases it, and Sophie leaves: out between the huts she goes, slowly, down the dry, red road. So many stories. Rachel stands before me, washing clothes. She works fast, with snappy movements. Her voice is low and angry. Men in bars. African men of all ages; side by side on the bar-stools, and at small tables packed with bottles and glasses. Men digging deep in their pockets for a few shillings, money that changes hands, money for beer and bard liquor. Loud-mouthed men. Men with hungry looks; indifferent looks; nonchalant looks at the few women who share the bar; women who have moved away from their men; women who have been chased away - prostitutes. Men on their way home in the dark. Men stumbling into their huts to their wives; stumbling over sleeping children; throwing themselves on the women they own to have what they desire. Does she refuse his body? Dare she say ‘No’? ‘That’s the way it is’, says Rachel. ‘Remember us talking about circumcision? We have never practised it. But what difference does it make, when it’s all a question of fear? Fear of being pregnant again; fear of being sick. The men do as they like. They go to anyone they fancy. A man can have two, three, four wives, but he can still go to other women if be wants. We live in the man’s hut. The hut belongs to him. We belong to him. ‘When my sister became a widow her husband’s brothers emptied the hut completely. As their brother was dead they claimed that everything belonged to them... KENYA at a glance Infant mortality Male 90, Female 76 per 1,000 live births Fertility rate 8.22 children Adult literacy Male 30%. Female 10% National government 169 Male representatives 3 Female representatives ‘You ask me about love. Look at Sophie. While she was away at school a man came to her parents and paid them the bridal fee. When she came home she was told to go to him: she was married to a man she didn’t know; a man she didn’t want. And be forced her to stay with him for days, until he was sure he’d made her pregnant. Now he lives in the city and works in a restaurant and be’s been to see her twice in the last few years. The first time he made her pregnant again. The second time he made her ill...’ Rachel rinses out the clothes and hangs them out to dry over some bushes. I wonder if African women ever cry. Ex-journalist and typesetter, Toril Brekke lives in Oslo and is now a full-time novelist. Jenny was Fired, published in 1976, is about unemployent in Norway, and her most recent book, The Film on Chatella is set in a Lebanese Refugee Camp.