Chapter 3: Women and Health

Overview

By Lori S. Ashford

Women’s health can be a barometer of a nation’s progress. Countries afflicted by poverty, corruption, war or weak governance often neglect their most vulnerable citizens. Frequently these are women. When women are unhealthy, their productivity is lowered and their children and families are less secure. This has an economic impact. So investing in women’s health makes sense from both an economic and a human rights perspective.

Unequal in Health

Women live longer than men, statistics show, but they may spend a greater proportion of their lives in poor health for a variety of reasons, attributable less to biological differences than to poverty and gender discrimination. Poor families may invest less in their daughters, giving them less nutrition, health care and education than their sons. Such disadvantages early in life have long-term consequences for girls’ health and well-being. For example, adolescent childbearing, common in countries and communities that condone child marriage, poses health risks and limits life prospects for the teen mothers and their children. If women are undernourished they risk having low birth-weight babies who, in turn, face a higher risk of early death and poor health. An added threat to the health of women and girls exists in countries where there is a cultural preference for sons, such as China and India. Sex-selective abortions and female infanticide are responsible for millions of “missing girls.” The resulting shortage of women relative to men can have alarming social repercussions. An April 2011 report in The Economist cited evidence that a skewed sex ratio in India has led to increased trafficking of girls, among other abuses. Data from U.N. Population Fund studies also support this (UNFPA, 2004).

Pregnancy and childbirth take a heavy toll on women’s health in the developing world. According to 2010 estimates by the World Health Organization (WHO), 358,000 women die of preventable causes related to pregnancy and childbirth every year; 99 percent of these deaths are in developing countries. In contrast, in developed countries where women deliver their babies in hospitals and have access to care for pregnancy complications, maternal deaths are extremely rare.

The vast majority of the world’s maternal deaths occur in the two poorest regions: sub-Saharan Africa and South Asia. In sub-Saharan Africa, where high fertility multiplies the dangers that mothers face over a lifetime, one in 31 women is likely to die as a consequence of pregnancy or childbirth (WHO, 2010). In developed countries, that chance is one in 4,300. Outside of Africa, Afghanistan is the riskiest place on earth to become pregnant and bear children, with a one in 11 lifetime chance of dying from pregnancy-related causes.

Millions of women suffer physical injuries or long-term disabilities, such as incontinence or ruptured organs, resulting from lack of proper care during pregnancy and childbirth. Many of these disabilities go unreported because women in developing countries consider them normal. The technology and knowledge to prevent needless deaths and injuries has long been available, but geography, substandard health systems, gender bias and political inertia all create barriers to making motherhood safer.

The HIV/AIDS pandemic also threatens women’s health in poor countries and communities. Where the virus is spread through heterosexual contact, women are more vulnerable to infection than men for physiological and social reasons, such as women’s economic dependence on men, their lack of power to ask male partners to practice safer sex and — too often — coerced sex. According to a 2009 UNAIDS report, “An estimated 50 million women in Asia are at risk of becoming infected with HIV from their intimate partners … men who engage in high-risk sexual behaviours.”

Recent Trends Encouraging

The good news is that today women are marrying later throughout the developing world. They are delaying first births and having fewer children than their mothers did. These trends reflect the fact that more girls are staying in school and more women and couples are practicing family planning. But there still is a large unmet need for family planning: According to a 2009 report from the Guttmacher Institute, more than 200 million women worldwide who want to avoid pregnancy do not use modern contraception. This contributes to tens of millions of unplanned births and unsafe abortions annually, often among the poorest women, who are least able to obtain and use the health services they need.

Estimates from WHO in 2010 revealed that maternal deaths dropped by about one-third globally from 1990 to 2008, thanks to a number of factors such as increased availability of contraception, prenatal care and skilled assistance during childbirth. Countries as diverse as Bolivia, China, Eritrea, Iran, Romania and Vietnam have made remarkable progress. Much more work remains to be done, however, for all countries to meet the Millennium Development Goal to reduce maternal deaths by three-fourths (compared with 1990 levels) by 2015.

More to be Done

Where countries have prioritized women’s health in national policy, great progress has been made. Women should be encouraged to recognize and speak out about their health care needs, so policymakers may learn and take action. Concern about women’s issues, including health care, prompted President Obama to appoint Melanne Verveer the first ambassador-at-large for women’s issues, to help address such problems. Secretary of State Hillary Rodham Clinton has made global women’s issues a high priority of the U.S. State Department. In 2009 President Obama designated $63 million — to be spent over six years — for the Global Health Initiative, a partnership among U.S. agencies to boost health care in the developing world, particularly for women and children. HIV/AIDS treatment projects such as mothers2mothers, which is highlighted in this chapter, are funded by the U. S. Agency for International Development and the U.S. President’s Emergency Plan for AIDS Relief.

Improving women’s health starts by recognizing that women have different needs from men and unequal access to health care. Focusing a “gender lens” on health services is necessary to reveal and address the inequalities between men’s and women’s care. This means paying more attention to girls, adolescents and marginalized women who suffer from poverty and powerlessness and changing the attitudes and practices that harm women’s health. Also, men should be partners in promoting women’s health, in ensuring that sex and childbearing are safe and healthy and in rearing the next generation of young leaders — both girls and boys.

Lori S. Ashford, a freelance consultant, has written about global population, health and women’s issues for 20 years. Formerly with the Population Reference Bureau (PRB), she authored the widely disseminated PRB “Women of Our World” data sheets and “New Population Policies: Advancing Women’s Health and Rights” for the Population Bulletin, among other publications.

PROFILE: Salwa Al-Najjab – Palestinian Health Care Activist

By Naela Khalil

Salwa Al-Najjab was the best female math student in her class, and her passion for mathematics would have led her to study at the College of Engineering, but for her Russian math teacher’s advice to study medicine: “With your intelligence and your strong personality, you will be of more benefit to the women of Palestine as a doctor than as an engineer,” the teacher said. Salwa Al-Najjab followed her teacher’s advice, and today she is changing medical care in the Palestinian Territories.

The hospital environment stirred Al-Najjab’s curiosity and her love of knowledge. She hadn’t realized that her medical career also would show her that many women lived in very different circumstances from her own. Al-Najjab admits: “The hospital and the medical profession opened my eyes wide to conditions which I hadn’t realized were as bad and as difficult as they were.” Her lifelong professional and personal battle to support women’s rights and to help provide better health care for women started when she began practicing medicine in 1979 at Al-Maqasid Hospital in Jerusalem.

She expanded her efforts to create better conditions for women in the mid-1980s. Carrying her physician’s bag and instrument case, Al-Najjab visited Palestinian villages and refugee camps to give women medical check-ups and treatment. She volunteered her time under the most difficult and complex conditions. She was creating change on the ground.

Today, after more than 30 years of work in hospitals and clinics in different parts of the Palestinian Territories, Al-Najjab heads the Juzoor (Roots) Foundation for Health and Social Development, based in Jerusalem. She continues to enthusiastically pursue her dream, although now, she says, it is more difficult “to influence health care policy decisionmakers to improve and develop the level of health care services provided to women, and to bridge the gap between service providers and recipients.”

Al-Najjab’s optimism is infectious. She maintains her smile despite the challenges she has faced in her life. During her early school years, she attended eight different schools in Ramallah, Hebron and Jordan. Her father worked first at the Jordanian Ministry of Education, then at UNESCO, so her family moved frequently. This meant she and her three siblings often changed schools, making it difficult to maintain long-term friendships. However, it was always easy for her to maintain her academic excellence.

Al-Najjab traveled to Russia to attend Moscow University in 1971. After one year of Russian language study, she enrolled at Kuban Medical School in Krasdnada. Dealing with her fellow students was more difficult than learning a new language or other demanding subjects. Some Arab students looked at her disapprovingly; others underestimated her ability to succeed because she was a woman. She persevered in her studies, defying those who doubted her, and became a model of academic success. She became a mentor to Palestinian women studying abroad.

Her first job at Al-Maqasid Hospital presented her with major challenges. She was the only female resident doctor, and she began working in the obstetrics and gynecology section. It was difficult for the male doctors to accept a female colleague and professional competitor. The hardest thing for Al-Najjab was that the female nurses did not accept her either, because they were accustomed to dealing with male doctors. They believed that a male doctor was more competent and professional than his female counterpart. The atmosphere at the hospital reflected this masculine bias in the way they divided the work: Al-Najjab would do routine examinations of female patients at the hospital clinic, while the male doctors would perform surgical operations and circumcisions. They did not expect that this quiet, beautiful young woman would resist this arrangement, nor that the section head would support her.

Al-Najjab says: “I refused to accept their masculine [-biased] division of labor, and I stuck to my position: ‘I will participate in surgical operations, and I will perform circumcisions on boys.’ This didn’t please them, and they nicknamed me ‘the rooster.’”

Al-Najjab says that the first time she experienced discrimination against women was at the hospital: “I grew up in a family that offered the same opportunities to both sexes. Even my grandfather, back in the 1960s, allowed my aunts to study in Britain, to work outside of the house and to spend the night away from home. Therefore, the attitude that I faced from my colleagues at the hospital astonished me.”

Al-Najjab also learned about the unequal status of women. She says, “I felt that I was getting to know my society for the first time. I would feel distraught when I delivered the baby of a girl who was no older than 15, or when I heard women affirming to me, unprompted, that men had a monopoly over decisions regarding who their daughters would marry, whether or not to use contraceptives or how many children they would have.” Al-Najjab adds, “Women don’t have the right to defend their own right to an education … It’s a cycle that must be broken.”

Al-Najjab’s family valued knowledge. Her father defied convention by sending her to study in Russia. Although her mother hadn’t completed her studies, she encouraged her four children, girls and boys alike, to continue their education. All of them graduated from college.

“Unlike other mothers, mine never talked to me about marriage. Instead, she would always talk to me about the importance of education for a woman’s life,” Al-Najjab recalls.

After seven years at Al-Maqasid Hospital, during which time she helped establish several high-quality clinics in Jerusalem and its suburbs, Al-Najjab left the hospital to work in the field. “I discovered that only a small number of people go to hospitals, either due to poverty or ignorance,” she says. “If I wanted to provide health care to women, I had to go to them, wherever they were.”

In 1985, Al-Najjab and a group of health professionals began visiting villages and refugee camps to provide health care. People’s reactions were positive, but some doctors criticized her for damaging doctors’ “prestige” by going to the patients rather than insisting that people come to the doctor.

By breaking this rule of prestige, Al-Najjab and her colleagues found conditions that they did not encounter in well-organized clinics equipped with winter heating and summer fans. They met people in far-flung places who suffered from a severe lack of health care compounded by the complex political conditions resulting from the Israeli-Palestinian conflict. Al-Najjab says, “I treated women who had no bathrooms in their homes and others living in homes unfit for human habitation. I came into contact with a bitter reality that overturned all of my convictions regarding the concept of health: I realized that it wasn’t only a question of physical well-being, but that health is also related to economic, social and psychological conditions, and to the environment.”

She has fought many battles and continues to do so. Her convictions and her decisions are sometimes contrary to social traditions that limit women’s rights. Al-Najjab is an activist who gets things done. She co-founded the Women’s Social and Legal Guidance Center in Ramallah. The center shelters women who are victims of violence, offers them legal assistance, refers their cases to the police and refers them to a safe house for their protection.

“I used to believe that as the years went by, change for the better would take place. But what I am noticing today is the opposite. In this social environment of political frustration and poverty, fundamentalist movements have strengthened and are actively working to move society backwards at every level. Women and women’s rights are the most prominent victims,” she says.

Besides leading the Juzoor Foundation, which seeks to influence health care policies, Al-Najjab heads the Middle East and North Africa Health Policy Forum, where she continues to strive for change. She was nominated by the U.S. Consulate General in Jerusalem for the U.S. Department of State’s 2010 International Women of Courage award.

With a husband and three children, in addition to her medical practice and activism, Dr. Salwa Al-Najjab has a full life. Her prescription for success is this: “We cannot but be optimistic about life.”

Naela Khalil is a Palestinian journalist. She won the 2008 Samir Kassir Award for freedom of the press.

PROJECT: Mothers2mothers – Help for HIV-Positive Women

By Maya Kulycky

Teresa Njeri, a single mother in Kiambu, a northern suburb of Kenya’s capital, Nairobi, has a dream. She wants to build a home for herself and her six-year-old son. Recently, Teresa bought a plot of land. When she looks out over it she pictures the house she plans to build, with three bedrooms, a “big kitchen” and a yard where her son can play. Teresa is confident and optimistic. But planning for a bright future, and having the means to make it a reality, is a big change for her. Ten years ago Teresa was convinced that she and her son were going to die.

In 2001, Teresa was diagnosed as HIV-positive when she was five months pregnant. “The first thing that came to my mind was death,” says Teresa. “All of my hopes were shattered.” The nurse at the clinic told Teresa she could protect her baby from HIV, but the nurse “wasn’t convincing, she was not very sure.” Regardless, Teresa joined a prevention of mother-to-child transmission (PMTCT) program. Meanwhile, she disclosed her status to her husband, who also tested HIV-positive. Like others who were afraid of the stigma associated with HIV, the couple hid their status. They separated shortly after the birth of their son, who is HIV-negative.

A few months later, Teresa was hospitalized and told she had AIDS. When her father discovered her status from the hospital staff, he told her family, who isolated her and took her son away to live in the family’s village. “So I was left alone, all alone in the world,” Teresa remembers.

Teresa fled, sought treatment and volunteered to speak to others with AIDS. But she says she still “didn’t have any focus in life. I didn’t have any hope. I didn’t know what to do.” Then Teresa found mothers2mothers, thanks to nurses in the hospital where she volunteered. They told her that mothers2mothers was seeking to hire women trained in PMTCT. Teresa applied and became a mothers2mothers mentor mother.

International Partnerships

Mothers2mothers — funded by USAID, PEPFAR (U.S. President’s Emergency Plan for AIDS Relief) and the CDC (U.S. Centers for Disease Control), the Elton John AIDS Foundation, Johnson & Johnson and other corporate and foundation partners — trains and employs HIV-positive mothers to be “mentor mothers” to provide counseling, education and support to newly diagnosed HIV-positive pregnant women and new mothers. It is an innovative, sustainable model of care at the forefront of prevention of mother-to-child HIV transmission. Mothers2-mothers operates 680 sites in nine sub-Saharan African countries, reaching about 85,000 new pregnant women and new mothers a month.

The African continent is struggling under the burden of HIV/AIDS. Of the 33 million people carrying HIV worldwide, 22 million live in sub-Saharan Africa. Ninety percent of HIV-infected babies are born in the region and 75 percent of the world’s HIV-positive pregnant women live in 12 African countries, according to studies done by AVERT (www.avert.org), the UNAIDS Regional Support Team for Eastern and Southern Africa (http://www.unaidsrstesa.org/unaids-priority/2-preventing-mothers-dying-and-babies-becoming-infected-h) and the World Health Organization Universal Access Report 2010. Meanwhile, the region is desperately short of doctors and nurses.

Mothers2mothers fills a gap by enlisting HIV-positive mothers to counsel pregnant women about how testing and treatment can ensure their babies are born healthy and that, if necessary, they can get medication. Mentor mothers work beside doctors and nurses in health care facilities, helping patients understand, accept and adhere to the interventions that are prescribed. They are paid members of the medical team.

Empowering Women, Protecting Children

The results are clear. In Lesotho, data collected by mothers2mothers show that 92 percent of pregnant women who attended the organization’s instruction sessions three or more times took antiretroviral (ARV) medication during pregnancy, compared to 71 percent of those who attended once. Adhering to the ARV regime is critical to decreasing mother-to-child transmission of HIV. Furthermore, 97 percent of frequently-attending mothers2mothers clients get CD4 tests, which determine the number of T-helper cells with which the body combats infections. A CD4 test shows how advanced an HIV infection is and is a first step toward receiving the life-saving highly active antiretroviral treatment (HAART).

Women are empowered by the support they receive in mothers2mothers programs. They become peer educators who are role models in their communities, while earning a salary and gaining valuable work experience.

Teresa credits mothers2mothers with giving her a sense of purpose. Her mothers2mothers colleagues encouraged her to pursue her college degree. She is studying community health and development. “I feel like God created me … to talk to these women, and help them, empower them, encourage them,” she says.

Teresa points to her success in helping a pregnant woman from the traditional African religion of Wakorino, whose adherents often eschew professional medical care. “I saw her when I was coming to work,” she says. She gave the woman her telephone number, and “the following day she called me and said, ‘I am here at the [hospital] gate.’” The woman tested HIV-positive. “I told her, ‘Don’t worry, because you are going to live a very long time.’ I disclosed my status to her.” Teresa convinced her to adhere to PMTCT treatment and deliver in the hospital. The woman gave birth to an HIV-negative child. “I feel like a star,” Teresa laughs.

Mothers2mothers is working to expand its reach to women in more countries and in countries where it currently operates. The impact is clear and the method is simple — a woman talking to another woman can help prevent mother-to-child transmission of HIV.

Maya Kulycky is the global communications manager at mothers2mothers. She also lectures in political journalism at University of Cape Town, South Africa. She previously reported for ABC News and CNBC. A graduate of Johns Hopkins University, she received a master’s degree from the University of London, Goldsmith’s College, and a law degree from Yale Law School.