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Female Morbidity and Mortality in Sub-Saharan Africa

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INSTITUTE OF MEDICINE IDRC - Lily. IN HER LIFETIME Female Morbidity and Mortality in Sub-Saharan Africa Committee to Study Female Morbidity and Mortality in Sub-Saharan Africa Christopher P. Howson, Polly F. Harrison, Dana Hotra, and Maureen Law, Editors Board on International Health INSTITUTE OF MEDICINE '`moo ,1./'f' `Q T " it',, \: rn NATIONAL ACADEMY PRESS Washington, D.C. 1996 h n NATIONAL ACADEMY PRESS 2101 Constitution Avenue., N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this the Institute acts under the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is President of the Institute of Medicine. The project was supported by funds from the Carnegie Corporation (contract nos. B-5269 and D-93065). Additional project support was provided by the Special Programme of Research, Development, and Research Training in Human Reproduction, World Health Organization (contract no. HQ/93/043301); the Kellogg Endowment Fund; and the National Research Council's NAS/NAE independent funds and IOM independentfunds. Library of Congress Catalog Card Number: 95-72800 International Standard Book Number: 0-309-05430-3 Additional copies of this report are available from: National Academy Press Box 285 2101 Constitution Avenue, N.W. Washington, DC 20418 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area) Copyright 1996 by the National Academy of Sciences. All rights reserved. COVER: Oil painting by Ablade Glover. Reprinted, with permission, from the Carnegie Corporation of New York. Ablade Glover is a Ghanaian artist who has exhibited widely in the United States, Switzerland, Zimbabwe, England, Germany, and his home country. He is represented in collections in many countries. He studied art in the United Kingdom and at Kent State University and Ohio State University in the United States. Currently he is associate professor, Department of Art Education, University of Science and Technology, Kumasi, Ghana, on sabbatical in Accra, where he is directing a cooperative gallery called Artists Alliance. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. COMMITTEE TO STUDY FEMALE MORBIDITY AND MORTALITY IN SUB-SAHARAN AFRICA MAUREEN LAW (Chair), Director General, Health Sciences Division, International Development Research Centre, Ottawa, Ontario, Canada UCHE AMAZIGO, Visiting Professor, Department of Zoology, University of Nigeria, Nsukka, Enugu State JUDITH FORTNEY, Corporate Director, Scientific Affairs, and Director, Division of Reproductive Epidemiology and Sexually Transmitted Diseases, Family Health International, Research Triangle Park, North Carolina PHILIP L. GRAITCER, Associate Professor, Center for Injury Control, Rollings School of Public Health, Atlanta, Georgia FRANCOISE F. HAMERS, EIS Officer, Division of STD/HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia H. KRISTIAN HEGGENHOUGEN, Associate Professor, Department of Social Medicine, Harvard School of Medicine, Boston, Massachusetts KARUNGARI KIRAGU, Research and Evaluation Officer, Center for Communication Programs, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland JOANNE LESLIE, Adjunct Assistant Professor, University of California at Los Angeles, School of Public Health, and Co-Director, Pacific Institute for Women's Health, Los Angeles, California WALINJOM F. T. MUNA, Director, General Hospital of Yaounde, Yaounde, Republic of Cameroon JONATHAN E. MYERS, Director, Occupational Health Research Unit, Department of Community Health, School of Medicine, University of Cape Town, South Africa BENJAMIN O. OSUNTOKUN, Professor, Neurology Unit, Department of Medicine, University of Ibadan, Ibadan, Nigeria (Deceased) PATIENCE W. STEPHENS, Demographer, the World Bank, Resident Mission, Accra, Ghana JUDITH N. WASSERHEIT, Director, Division of STD/HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia BELMONT E. O. WILLIAMS, Professor, Clark Atlanta University, and Assistant Clinical Professor, Department of Obstetrics and Gynecology, Morehouse School of Medicine, Atlanta, Georgia Project Staff CHRISTOPHER P. HOWSON, Project Director POLLY F. HARRISON, Senior Program Officer DANA HOTRA, Research Associate DELORES SUTTON, Project Assistant JAMAINE TINKER, Financial Associate CAROLINE MCEUEN, Contract Editor BERYL BENDERLY, Contract Writer iii Dedication The Committee to Study Female Morbidity and Mortality in Sub-Saharan Africa dedicates this report to Patricia Rosenfield and Rosalee Karefa-Smart of The Carnegie Corporation. Their vision, hard work, and strong commitment to the life span perspec- tive and female health made this project possible. Acknowledgments Although this book is cited as a report of the Committee to Study Female Morbidity and Mortality in Sub- Saharan Africa, the committee chair and Institute of Medicine wish to acknowledge the following committee members, IOM staff, and outside experts as primary authors: Chapter 1 (Beryl Benderly, consultant science writer; Polly Harrison; Christopher Howson); Chapter 2 (Kristian Heggenhougen; Polly Harrison; Dana Hotra); Chapter 3 (Joanne Leslie; Bibi Essama, University of California at Los Angeles); Chapter 4 (Judith Fortney; Karungari Kiragu); Chapter 5 (Benjamin Osuntokun); Chapter 6 (John Orley and Giovanni de Girolamo, World Health Organization); Chapter 7 (Walinjom Muna); Chapter 8 (Philip Graitcer); Chapter 9 (Jonathan Myers); Chapter 10 (Uche Amazigo); Chapter 11 (Judith Wasserheit; Francoise Hamers); and Appendix A (Christine Costello, National Academy of Sciences; Douglas Ewbank, University of Pennsylvania; Christopher Howson; Patience Stephens). For their part, the committee gratefully acknowledges the valuable contributions of the following people to their report: F. C. Okafor, Maureen Obi, and N. Ivoke, University of Nigeria, for their help with Chapter 10; Richard Rothenberg and Sevgi Aral, Centers for Disease Control and Prevention, for their insightful comments and suggestions regarding Chapter 11; and Susan Scrimshaw, University of Illinois at Chi- cago, for her sage editorial advice on the report as a whole. The committee owes a special debt of gratitude to Caroline McEuen, contract editor, for her substantive and creative editing of the final document. The committee also thanks those individuals whose vision and hard work contributed to the early develop- ment of this project in 1986, including Polly Harrison, Jill Gay, April Powers, and Belkis Giorgis, Institute of Medicine; Susan Scrimshaw, University of Illinois at Chicago; Judith Bruce, the Population Council; Elayne Clift, Academy for Educational Development; Carol Corillon, National Academy of Sciences; Joan Dunlop, Interna- tional Women's Health Coalition; Patrice Engle, Institute of Nutrition of Central America and Panama; Ruth Bamela Engo-Tjega, Labor Ministry-Cameroon; Benjamin Gyepi-Garbah, Barbara Hertz, and Althea Hill, the World Bank; Don Hopkins, the Carter Center; Sandra Huffman, Center to Prevent Childhood Malnutrition; Angela Kamara, Columbia University; Marjorie Koblinsky, the Ford Foundation; Michael Latham, Cornell Uni- versity; Haydee Lopez, Chilean Medical Association; Cathie Lyons, The United Methodist Church; Ken McIn- tosh, Harvard Medical School; Henry Mosely, The Johns Hopkins University; Isabel Nieves, the Institute of Nutrition of Central America and Panama; Judy Norsigian and Norma Svenson, Boston Women's Health Book Collective; Adhiambo Odaga, Oxford University; Chloe O'Gara, U.S. Agency for International Development; Freda Paltiel, Canadian Ministry of Health; Barbara Pillsbury, University of California at Los Angeles; Barry Popkin, University of North Carolina; Eva Rathgeber, International Development Research Centre; Allan vii Viii ACKNOWLEDGMENTS Rosenfield, Columbia University; Nawal El Saadawi and Irene Santiago, Oxfam; Judith Timyan, International Center for Research on Women; and Ann Tinker, the World Bank. The committee also thanks the many people who provided information, critical analysis, advice, and informal review in the last two years of the project, including Margaret R. Becklake, McGill University; Mark Belsey, World Health Organization; Ronald Blanton, Case Western Reserve University; Barry Bloom, Albert Einstein College of Medicine;
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