13.1 The Health of Women

I. INTRODUCTION, THE POVERTY ISSUE

Why have a unit on this topic in medical anthropology? Two of three women around the world today live in poverty. They suffer chronic anemia, malnutrition, and severe fatigue. Measured in dollar terms, people in poverty have less access to nutritious food, clean water, adequate clothing and shelter. Engaged in the deadly struggle of day-to-day survival, the poor cannot enjoy the privilege of preventive health care. They lack access to education and political clout needed to improve their condition. We call these tools empowerment. In these societies, women are last and least.

The health risks of poverty are greater for females than for males. In every country and at every socioeconomic level, women control fewer productive assets than do men. Women tend to work longer hours for less, yet are responsible for meeting 40 to 100% of a family's basic needs.

Lacking alternatives, women are more often compelled to do seasonal, labor-intensive jobs with considerable occupational risk. (My note: we revisit this issue is a separate article, Nine to Nowhere.) Poverty among females is more intractable than among males, and their health is even more vulnerable to adverse changes in social and environmental conditions.

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In the United States, 40 percent of African American women and one-fourth of all women in the United States do not receive prenatal care in the first trimester of pregnancy. (My note: as I write this ((11/99)) approximately 43 million Americans are without health insurance and that number is increasing at a million year--in a time of unprecedented prosperity.)

Households headed by women have increased in many countries in the last decade. When households are headed by women, annual income is less for them than for society as a whole. The net result is a dramatic increase in the number of children living in poverty. Women cope by putting their own needs last. They sacrifice their own health by devoting an increasing proportion of personal resources to support their families--and care for sick and elderly relatives.

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II. GLOBAL LIFE EXPECTANCY

Global life expectancy among females has risen from forty-nine years in 1950-1955 to sixty-five years in 1985-1990. Much of that gain however--for both males and females--is due to drastic reductions in infant mortality, improvements in nutrition, sanitation, and disease prevention. In developed countries, the male-female age differential is about seven years. In developing countries the differential is three to five years

Other figures are more revealing. Mortality for young girls is markedly higher than for boys in many countries in the Middle East, North Africa, and India. In Africa, fifteen percent of all women are literate; thirty-three percent of all men can read.

Why is this significant? There is a strong correlation between female literacy and age of first delivery. Education is an effective measure in giving women control of family size.

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III. AN INVISIBLE WORKFORCE

A quick illustration will drive home the point. Consider a married couple here with several children and one employed male as 'head of household.' In financial and employment statistics, the woman is not counted as productive. (My note: many years ago my wife had a Christmas savings account in her name. The bank paid it off in a check . . . in my name! Need I tell you that she switched banks?)

Feminists say that much of women's work is invisible. Any husband who has to take over at home soon learns otherwise! In Third World countries, it is worse. Women earn critical economic support in agriculture, 'informal' labor markets, and emerging industries. They are either unpaid or paid in cash 'under the table'.

When they enter the work force, their duties at home are rarely diminished--especially if they are head of household. They retain exclusive responsibility for child care and housework. In India 40% of the economy is agriculture and 90% of women in central India are in some way involved in it. Much of that contribution is 'invisible' in financial statistics.

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Environmental degradation in the Third World often hits women first and hardest. If you recall the statement from cultural anthropology that women foragers provide most of the caloric value in the diet you will quickly grasp the issue here.

Rural women are constantly occupied in the collection of natural resources. The burden of providing water for family needs falls to women and girls. They are also responsible for firewood collection. As fresh water supplies are overused or polluted, forests are destroyed, and soil fertility is reduced--it is more work to provide the same basic necessities. We take piped, safe water for granted. At least a billion people lack access to safe water. The problems are most severe in countries prone to drought as in Africa where procuring water is women's work.

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V. MATERNAL HEALTH: IS THERE A PROBLEM?

Of 500,000 women who die per year in childbirth, 99 percent of those deaths occur in developing countries. The lifetime chance of maternal death in North America is 1 in 6,366. In Africa, the lifetime chance is 1 in 21! The causes are well documented: hemorrhage, obstructed labor, infection, hypertensive disorders (known is this country as eclampsia), and septic abortion. Most shocking is that these are preventable. High levels of obstructed labor are found in Bangladesh and India. The causes are young age, primiparity (first birth--the hardest), and short stature. We will expand upon these matters shortly in another section on nutrition.

These are documented deaths. Researchers suspect that the real numbers are much greater. In developing countries, 50 percent of pregnancies are delivered by relatives or traditional birth attendants. Many of these untimely deaths go unreported.

Another area of under documentation are problems during pregnancy and after delivery. At first glance, women in this country seem much more unhealthy than those in developing countries. The reason, however, is better reporting in this country.

One final issue is voiced by women themselves. Foreign aid and government assistance seem primarily directed at reducing population growth instead of improving women's health. They find the aid misdirected and consider the intent misguided, to say the least.

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VI. WOMEN'S NUTRITION THROUGH THE LIFE CYCLE

In many developing countries, low birth weight is a frequent problem. Often this is being born of overworked, malnourished mothers. For little girls this insult is compounded in cultures that prefer boys. Girls get less nutritious food, grow slowly, and don't go to school. They remain at home to help with housework and childcare.

By tradition they marry early and may have their first baby at fourteen even before they are fully developed. At adolescence, pelvic bones are misshapen and stature is short from malnutrition. After a difficult first birth, other pregnancies follow with problems aggravated by anemia, hookworm, and malaria. They don't get to health centers; there is no time and they are too far away. Old in their thirties, they may have a prolapsed uterus, but don't seek family planning. The husband would never allow it.

Conservative estimates in 1985 suggest that 500 million women were stunted as a result of childhood nutritional deprivation. It is a vicious cycle. Read the next paragraph slowly.

It is well known that maternal size constrains fetal growth during the final stages of pregnancy. (My comment: this is well documented. You can easily see how this a functional adaptation.) Small maternal size caused by stunting during her growth will result in a smaller fetus--who is now itself at risk due to a low birth rate. The most critical time period for growth is gestation through three months.

Full development of the pelvis--and the birth canal is not achieved until after age eighteen in most cases. Low birth weight is greatest in extremely young mothers. "Too young, too many, and too close" contribute to the nutritional depletion of Third World mothers.

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VII. THE SEX TRADE

This topic appears in the media frequently. Only a few details will introduce this subject here. In some Asian countries, women and girls are sold into prostitution by their families. In Africa, some childless women are chased away by their husbands, others are divorced, widowed or otherwise in financial straits. The implications speak for themselves.

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VIII. THE PRACTICE OF ABORTION

No society has been able to eliminate induced abortion as an element of fertility control. Induced abortion is the oldest, and according to some experts, perhaps the most widely used method of fertility control. The numbers are staggering. Between one-fifth and one-third of all pregnancies world wide are intentionally terminated. In developing countries, unsafe induced abortion is the greatest single cause of mortality for women. Deaths per 100,000 abortions are from 50 to 100 in undeveloped countries, and 0.1 in developed countries.

Ethical and religious issues are a discussion in themselves and are beyond the scope of this article.

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IX. DOMESTIC VIOLENCE

The most endemic form of violence against women is abuse of women by intimate male partners. Severe and ongoing woman abuse is documented in almost every culture in the world, except for a very few small-scale societies. Former Surgeon General C. Everett Koop estimated that three to four million American women are battered each year; roughly half are single, separated, or divorced. Between 21 and 30 percent of U.S. women will be beaten by a partner at least once in their lives. In the U.S. the number of injuries exceed those from auto accidents, mugging, and rapes--combined.

In a recent year, 50% of all women murdered in Bangladesh were wives killed by husbands. were murdered. In Canada, the percentage of all women murdered 67% were a wife of the assailant.

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X. DOWRY DEATHS

"Bride burning" is a get rich quick scheme in parts of India. Husbands (and their mothers on occasion) express their displeasure with a small dowry by splashing the young bride with kerosene and setting her alight. Police, who want no part of this touchy situation, report these as 'kitchen accidents.' Women's groups who use the reported police figures of about 5000 per year estimate that the true numbers are much greater.

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XI. INCLUDING WOMEN IN CLINICAL TRIALS

Historically there has been a marked preference for the use of males as subjects for health research. Why? One rule occasionally cited is like the sinking Titanic in reverse: men first, women and unborn children last. This is not a malicious as you may think. One of the big concerns in clinical drug trials is unreported pregnancy. Some drugs are teratogenic in pregnant women. Examples are thalidomide for miscarriage and isotretinoin for acne. This has led to federal guidelines for the blanket exclusion of women of childbearing age even if they used birth control pills or some other form of contraception.

Since 1990, health policy in the U.S. has since shifted toward allowing, and in some cases requiring, investigations to be more inclusive of women. The teratology question still remains, however. This will require more animal studies in advance of clinical trials involving women. Legal scholars have argued that the failure to test drugs in women carries liability at least as great as that due to harming a fetus. These issues remain unresolved.

..... CJ '99

Resources

Doyal, L. What Makes Women Sick New Brunswick: Rutgers University Press, 1995.

Holloway, M. "Trends in Women's Health A Global View" Scientific American August, 1994 pp 76-83.

Koblinsky, M., Timyan, J., and Gay, J. eds. The Health of Women A Global Perspective

Boulder: Westview Press, 1993.

Sargent, C. and Brettell, C. Gender and Health An International Perspective Upper

Saddle River: Prentice Hall, 1996.

"'To be born female is to be born high risk,'UNICEF director reports" Chicago Tribune July 23, 1997.

"National Survey of Women's Health-July, 1993" http://www.cmwf.org/women.whhilite.html