Wf3RP'25 7151y )2q4 Public Disclosure Authorized

256 121WorldK Bank Discussion Papers

Public Disclosure Authorized WVomen'sHealth and Nutrition

Making a Difference Public Disclosure Authorized

Anne Tinker Patricia Daly Cynthia Green Helen Saxenian Rama Lakshminarayanan Kirrin Gill Public Disclosure Authorized Recent World Bank Discussion Papers

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No. 201 Urbanization,Agricultuiral Development, and Land Allocation.Dipasis Bhadra and Antonio Salazar P. Bran&io

No. 202 MakirngMotherhood Safe. Anne Tinker and Marjorie A. Koblinsky

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Women's Health and Nutrition

Making a Difference

Anne Tinker Patricia Daly Cynthia Green Helen Saxenian Rama Lakshminarayanan Kirrin Gill

The World Bank Washington, D.C. Copyright C 1994 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A.

All rights reserved Manufactured in the Urited States of America First printingJuly 1994

Discussion Papers present results of country analysis or research that are circulated to encourage discussion and comment within the development community. To present these results with the least possible delay, the typescript of this paper has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. Some sources cited in this paper may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee th, accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. Any maps that accompany the text have been prepared solely for the conveniencc of readers; the designations and presentation of material in them do not imply the expression of any opinion whatsoever on the part of the World Bank, its affiliates, or its Board or member countries concerning the legal status of any country, territory, city, or area or of the authorities thereof or concerning the delimitatio n of its boundaries or its national affiliation. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to the Office of the Publisher at the address shown in the copyright notice above. The World Bank encourages dissemination of its work and will normally give permission promptly and, when the reproduction is for noncommercial purposes, without asking a fee. Permission to copy portions for classroom use is granted through the Copyright Clearance Center, Inc., Suite 910, 222 Rosewood Drive, Danvers, Massachusetts 01923, U.S.A. The complete backlist of publications from the World Bank is shown in the annual Index of Publications, which contains an alphabetical tide list (with full ordering information) and indexes of subjects, authors, and countries and regions. The latest edition is available free of charge from the Distribution Unit, Office of ths Publisher, The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, U.S.A., or from Publication, The World Bank, 66, avenue d'Iena, 75116 Paris, France.

ISSN: 0259-210X

Anne Tinker is senior health specialist and Helen Saxenian is senior economist in the World Bank's Population, Health, and Nutrition Department. Patricia Daly, Cynthia Green, and Kirrin Gill were consultants to the Department. Rama Lakshminarayanan is in the World Bank's Young Professionals Program.

Library of Congress Cataloging-in-Publication Data

Women's health and nutrition: making a difference / Anne Tinker ... [et al.]. p. cm. - (World Bank discussion papers ; 256) Includes bibliographical references (p. ). ISBN 0-8213-2991-X 1. Women's health services-Developing countries. 2. Women- Health and hygiene-Developing countries. 3. Women-Developing countries-Nutrition. 4. Women-Developing countries-Social conditions. I. Tinker, Anne G. II. Series. RA564.85.W6667 1994 362.1'98'091724-dc2O 94-28769 CIP Contents

Foreword vii Acknowledgments viii List of Abbreviations x Abstract xi Executive Summary 1 1. Why Invest in Women's Health and Nutrition? 4 Differentials in Health 4 Biological determinants of women's health 5 Socioeconomic influences on women's health 5 Widespread Impact of Women's Health 6 Child survival 6 Productivity, family welfare, and poverty reduction 7 The Cost-Effectivenessof Women's Health Interventions 8 2. An Overview of Women's Health and Nutrition 11 Global Trends 11 Women's Burden of Disease 11 Women's Health and Nutrition throughout Life 12 Infancy and childhood 12 Adolescence 13 Reproductive years 14 Post-reproductive years 15 Additional Health Problems 16 3. Health and Nutrition Interventions for Women 18 Essential Health Interventions 18 Prevention and management of unwanted pregnancies 18 Family planning services 20 Management of complications from unsafe abortion and safe services for pregnancy termination 21 Pregnancy services 22 Prenatal care 22 Safe delivery 23 Postpartum care 23 Prevention and management of sexually transmitted diseases 23 Condom promotion and distribution 24 Prenatal screening and treatment for syphilis 24 Symptomatic case management 25 Targeted screening and treatment of commercial sex workers 25

iii iv Women'sHealth and Nutrition:Making a Difference

Essential Behavior Change Interventions 25 Promotion of positive health practices 25 Delayed childbearing among adolescents 26 Safe sex 26 Adequate nutrition 27 Increased male support 27 Eliminating harmful practices 28 Gender discrimination 28 Genital mutilation 29 Domestic violence and rape 29 Expanded Health Interventions 30 Expansion of Essential Services 30 Increased choice of contraceptive methods 30 Enhanced maternity care 31 Expanded screening and treatment of sexually transmitted diseases 32 Nutrition assistance for vulnerable groups 32 Screening, treatment, and referral for victims of violence 33 Cancer screening and treatment 34 Cervical cancer 34 Breast cancer 34 Expanded Behavior Change Interventions 34 Health education for early prevention 35 Increased efforts to reduce gender discrimination and violence 35 Women beyond reproductive age 36 4. Issues for National Program Planning 37 Broadening Policy Support 37 Improving the Equity and Efficiency of Health Financing 38 Selecting interventions for public finance 39 Cost recovery and targeting public expenditures to the poor 39 Protecting poor women 39 Strengthening Service Delivery 40 Increasing women's access to care 40 Designing delivery strategies to meet women's needs 40 Strengthening the health care delivery infrastructure 41 Improving the quality of services for women 41 Increasing the number of female health care providers 42 Delegating responsibility to non-physicians 42 Integrating Women into Health Planning and Implementation 43 Strengthening Collaboration with the Private Sector 43 Nongovernmental organizations 43 For-profit providers 44 Intensifying Public Education 44 Promoting health services and healthy behaviors 45 Advocacy for policy change 45 Behavior change 45 Meeting Information Needs 45 Health status indicators 45 Program design 46 Program monitoring and evaluation 47 5. The Role of International Assistance 48 World Bank Programs in Women's Health and Nutrition 48 Partnership 50 Conte,7ts v

An Agenda for Women's Health and Nutrition 50 Policy priorities 51 Institutional base 51 Targeted research 51 Support for cost-effective services 51 Behavior change 52 Women's participation 52 Regional Problems and Priorities 52 Sub-Saharan Africa 52 South Asia 53 East and Southeast Asia 53 Middle East and North Africa 54 Latin America and the Caribbean 54 Eastern Europe and Central Asia 54 Moving from Rhetoric to Action 55 Annexes Annex A. Working Papers and External Consultations 57 Annex B. Life Cycle of Women's Health 59 Annex C. Recommended Interventions for Women's Health and Nutrition 75 Annex D. Indicators of Women's Health and Nutrition 92 Annex E. World Bank Population, Health, and Nutrition Projects with Women's Health and Nutrition Components (FY 1986-93) 102 Annex F. Glossary 110 Bibliography 113 Figures Figure 1.1 Determinants of Women's Health Status 5 Figure 1.2 Children's Probability of Dying Rises Sharply with their Mother's Death, Matlab, Bangladesh, 1983-89 7 Figure 1.3 Intergenerational Cycle of Growth Failure 7 Figure 2.1 Burden of Disease by Region for Females and Males Aged 15 to 44 in 1990 12 Figure 2.2 Health and Nutrition Problems Affecting Women Exclusively or Predominantly during Specific Stages of the Life Cycle 13 Figure 2.3 Burden of Disease in Females Aged 15 to 44 in Developing Countries 14 Figure 3.1 Rates of Contraceptive Use, Abortion Mortality, and Hospitalization for Abortion Complications, Chile, 1964-78 21 Figure 5.1 World Bank-Supported Population, Health, and Nutrition Projects with Women's Health Components, FY1986-93 49 Tables Table 1.1 Major Health Problems in Developing Countries with Interventions of High to Medium Cost-Effectiveness 9 Table 3.1 Major Health Problems among Females in Developing Countries and the Cost-Effectivenessof Interventions, 1990 19 Table 3.2 Essential Services for Women's Health 20 Table 3.3 Expanded Servicesfor Women's Health 30 Boxes Box 1.1 World Development Report 1993, Investing in Health 10 Box 2.1 Gender Violence Throughout the LifeCycle 16 Box 3.1 Reaching Adolescents 26 Box 3.2 Eliminating Female Genital Mutilation 29 Box 3.3 Inappropriate Practices in Women's Health 31 Box 4.1 Women's Health and Human Rights 38 Box 4.2 A Continuum of Care at the District Level 41 ; -~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~;v

~~~~~ht crdt:A htgah rmWrdBn/utCreak Foreword

Women's Health and Nutrition: Making a Difference opportunities for women, and dedicated effoits to comes at an important time. The health risks women involve women more fully in the develop mnent face due to their disproportionate poverty, low social process. The paper recommends special emphasis on status, and reproductive role merit increased atten- the adolescent girl, since it is in this transitional tion. The World Bank recognizes that improving stage when the intergenerational cycle of early women's health and nutrition contributes signifi- childbearing, poor health and nutrition, and cantly to poverty alleviation and human resource poverty can be broken. development. Investing in women's health makes This paper was prepared to assist World Bank staff sense on both humanitarian and economic grounds. and their colleagues in borrowing countries with This paper examines women's health problems tools for analysis and planning to improve wornen's from infancy to old age and sets forth a strategy for health and nutrition. It is hoped that others who developing countries and their partners to improve have a professional concern for women's health and women's health and nutrition through a set of cost- nutrition in donor governments, international agen- effective essential health services that address the cies, and nongovemmental organizations will find it major causes of death and disability among women useful in the design, implementation, and monitor- in developing countries. Because social and cultural ing of women's health and nutrition programs. factors influence women's health and well-being, In partnership, governments, donor and other the paper also recommends policy reforms and pub- international agencies, and local communities have lic education programs that promote positive health considerable power to improve the health and riutri- practices and reduce gender discrimination. Vitally tion of women. Working together, we can make a important to this effort in the longer term are difference for women of this generation and their increased education for girls, greater employment daughters who follow.

Janet de Merode Director Population, Health and Nutrition Departmeit Human Resources Development and Operations Policy

vii Acknowledgments

This report has been prepared by a team led by Anne Philippines, Tunisia, and Zimbabwe. Representa- Tinker and composed of Patricia Daly, Cynthia tives from international organizations who attended Green, Helen Saxenian, Rama Lakshminarayanan, or provided comments included those from the and Kirrin Gill. The report benefitted from contri- Carnegie Corporation, Center for Midwifery Practice butions and advice from a large number of people. in England, Commonwealth Medical Association, Throughout the planning and preparation of Family Care International, Intemational Federation this report, an external peer review committee con- of Gynecology and Obstetrics, International Society sisting of Dr. Mahmoud Fathalla, Judith Fortney, of Red Cross and Red Crescent Societies, Interna- Ph.D., Dr. John Kevany, Dr. Ana Langer, and Joanne tional Women's Health Coalition, London School of Leslie, Ph.D. provided technical review and invalu- Hygiene and Tropical Medicine, Marie Stopes Inter- able guidance. national, Medical Women's International Associa- In early 1993, the World Bank commissioned ten tion, the Population Council, the RocKefeller working papers in women's health and nutrition on Foundation, UNFPA, and UNICEF as well as those topics ranging from socioeconomic factors, which from bilateral agencies in Canada, the Netherlands, influence women's access to nutrition and health Norway, Sweden, Switzerland, and the United care, to studies on adolescent reproductive health Kingdom. The assistance of Jill Sheffield, Ann Starrs, and violence against women. The World Bank would and Caryn Levitt in facilitating these two meetings like to acknowledge the contribution of the authors was most helpful. Staff at the World Health who include George Ascadi, Gwendolyn Johnson- Organization, in particular Tomris Turmer, Carla Ascadi, Jill Gay, Lori Heise, Joe Kutzin, Kathleen AbouZahr, Aleya Hammad, Ilona Kickbusch, Carol Merchant, May Post, Judith Senderowitz, Jacqueline Mulholland, Jacqueline Sims, and Carol Vlassoff Sherris, Kajsa Sundstrom, and Mary Eming Young. responded generously to our queries and con- The paper also draws heavily on the recent World tributed to the final product. Comments from Karin Bank Discussion Paper, Making Motherhood Safe, as Edstrom, Mike Favin, Wendy Graham, Marcia well as the disease burden assessment and cost-effec- Griffiths, Theodore King, Christina Larsson, Diana tiveness analysis prepared for the World Development Measham, Michael Strong, Linda Vogel, Judith Report 1993, Investing in Health. Wasserheit, Beverly Winikoff, and Joao Yunes were In May, 1993, the World Bank convened a group also appreciated. of specialists in women's health to review the draft Many Bank staff provided valuable contribu- working papers at the Rockefeller Foundation tions. A special thanks is owed to Janet de Merode, Conference Center in Bellagio, Italy, and to develop Tom Merrick, and Alan Berg for their insightful com- a conceptual framework for this Best Practices paper. ments and continuous support throughc.ut the Participants at this meeting included experts from process. The authors would like to thank Ann Bangladesh, Brazil, India, Kenya, Mexico, Poland, Hamilton, Anthony Measham, and Barbara Herz Tanzania, Turkey, and Zaire as well as representatives who helped start the process, as well as the many of specialized intemational organizations. World Bank colleagues who participated in the An external consultation in London in March, review meetings and provided comments on drafts 1994, contributed to the final document. At this of the document including Alexandre Abrantes, meeting comments were particularly appreciated Michael Azefor, Jayshree Balachander, Jose-Luis from government officials and other experts from Bobadilla, Robert Castadot, Xavier Coll, Willy de Brazil, Ecuador, India, Indonesia, Kenya, Geyndt, Oscar Echeverri, Leslie Elder, Ed Elmendorf,

viii ix Women'sHealth and Nutrition:Making a Difference

Catherine Fogle, Rae Galloway, James Greene, Peter Coquereaumont, and Bruce Ross-Larson, and the Heywood, Janet Hohnen, Gillian Holmes, Nuria support staff, supervised by Sharon Isaac, included Homedes, Dean Jamison, Jean-Louis Lamboray, Yvette Atkins, Coni Benedicto, Katya M. Guti&rrez, Sandy Lieberman, Judith McGuire, Elizabeth Morris- Susan Sebastian, Odell Shoffner, Trina Haynes, and Hughes, Alice Morton, Norbert Mugwagwa, Phil Christopher Wilson. Musgrove, Jane Nassim, Minhchau Nguyen, Indra Financial support for this document was pro- Pathmanathan, Elaine Patterson, Frances Plunkett, vided by the World Bank, the Swedish International Wendy Roseberry, Julian Schweitzer, James Socknat, Development Authority, the Swiss Development Susan Stout, Caby Verzosa, Harry Walters, Juliana Corporation, and the Overseas Development Weissman, and Anthony Wheeler. Finally, editorial Administration of the United Kingdom. assistance was received from Beth Sherman, Meta de List of Abbreviations

AIDS Acquired Immune Deficiency Syndrome ARI Acute Respiratory Infection CHW Community Health Worker DALY Disability-Adjusted Life Year ECA Europe and Central Asia EME Established Market Economies FSE Formerly-Socialist Economies of Europe HIV Human Immunodeficiency Virus IEC Information, Education, and Communication IUD Intrauterine Device KAP Knowledge, Attitudes, and Practices LAC Latin America and the Caribbean MCH Maternal and Child Health MENA Middle East and North Africa NGO Nongovernmental Organization PAHO Pan American Health Organization PID Pelvic Inflammatory Disease RTI Reproductive Tract Infection SSA Sub-Saharan Africa STD Sexually Transmitted Disease TB Tuberculosis TBA Traditional Birth Attendant UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USSR Union of Soviet Socialist Republics WHO World Health Organization WDR World Development Report WID Women in Development

x Abstract

From poverty reduction to intergenerational bene- logical problems, the paper addresses the broader fits and economic efficiency, the arguments for social issues that affect health, such as gender dis- investing in women's health and nutrition are com- crimination and violence against women. pelling. Many health interventions directed specifi- Offering a rational basis to improve women's cally at women are among the most cost-effective health that works within the constraints faced by health interventions available today. Improving developing countries, the paper provides guidance women's health has multiple external benefits that for policy makers and program planners on how to enhance the survival and well-being of children and redirect scarce resources to the most cost-effective the productive capacity of the economy. And invest- interventions. The Essential Services for womnen's ment in women's health can help remedy health dis- health described in the paper are interventions that advantages that are rooted in women's low have widespread benefits of sufficient importar.ce to socioeconomic status and reproductive functions justify public funding, even in the poorest countries. and responsibilities. The Expanded Services consist of additional inter- This paper provides an overview of women's ventions that can be implemented by middle health and nutrition by considering the entire life income countries-and by poorer countries to the cycle of the women-a meaningful approach extent resources permit. The paper also reviews because problems and behaviors that begin in child- country experiences and recommends actions gov- hood and adolescence have cumulative conse- ernments can take-and the kind of support inter- quences that can profoundly affect a woman's national organizations can provide-to make a health in later life. Previously neglected periods of a difference in the health and nutrition of women in women's life, such as adolescence and the post- developing countries. reproductive ages, are examined. In addition to bio-

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_ _ Executive Summary

The arguments for accelerating investment in * In Africa each year, an estimated 2 million young women's health and nutrition are compelling: such girls, most between four and eight years of age, investments promote equity, widespread benefits for are subject to genital mutilation (removal of part this generation and the next, and economic effi- or all of the external genitals). ciency. Women's disproportionate poverty, low * The pregnancy rate among unmarried adoles- social status, and reproductive role expose them to cents is at an all-time high in many countries. high health risks, resulting in needless and largely * Women between the ages of fifteen and twenty- preventable suffering and premature death. A five now account for 70 percent of HIV infec ions woman's health and nutritional status is both a among females worldwide. national and an individual welfare concern because * Anemia is highly prevalent throughout the it affects the next generation, through its impact on developing world and appears to be worsening in her children, as well as her productivity at the house- Sub-Saharan Africa and South Asia, where it hold level and in the informal and formal sectors of affects 40 to 60 percent of women fifteen to forty- the economy. Because many of the interventions nine years old. that address women's health problems are highly * Women's lack of access to contraceptives results cost-effective, any national health investment strat- in more abortions than live births in parts of egy based on achieving the greatest health gains at Eastern Europe and Central Asia. Worldwide, the least cost will give considerable emphasis to complications from unsafe abortion are a major interventions directed at women. Special attention cause of maternal death. is warranted to reach women during adolescence, * While infant mortality rates have dropped by when reproductive and other lifestyle behaviors set half over the last three decades, maternal inor- the stage for later life. tality ratios have lagged substantially, with little evidence of progress in the least developed Women's Health throughout the Life Cycle countries. * Cancer of the cervix, which peaks among wo men A life cycle approach to women's health takes into between forty and fifty years of age, accounts for account both the specific and the cumulative effects more new cases of cancer each year in develop- of poor health and nutrition. Many of the health ing countries than any other type of cancer. problems affecting women of reproductive age, their * Recent evidence reveals that domestic violence, newboms, and older women begin in childhood and rape, and sexual abuse are a significant cause of dis- adolescence. For example, inadequate diet in youth ability among women; between 20 and 60 percent and adolescence can lead to anemia or stunting, of women surveyed in various countries report which contribute to complications in childbirth and that they have been beaten by their partners. underweight babies, and insufficient calcium can lead to osteoporosis later in life. Essential Servicesfor Women The following examples sketch a picture of some of the health and nutrition problems women face in Most of the leading causes of death and disability of developing countries: women in developing countries can be prevented or * In a clinic in Asia, 7,999 of 8,000 abortions per- treated through highly cost-effective interventions. formed after parents leamed the sex of the fetus Any national package of interventions designed averted the birth of girls. on the basis of cost-effectiveness and the disease bur- 2 Women'sHealth and Nutrition:Making a Difference den would include the following Essential Services * Nutrition assistance for vulnerable groups for women: * Cervical and breast cancer screening and . Preventionand managementof unwanted pregnan- treatment cies. Family planning services, treatment for * Increased attention to early prevention complications of unsafe abortion, and safe abor- * Increased policy dialogue and strategic eftorts to tion services can greatly reduce death and illness reduce gender discrimination and violence among women. * Greater attention to the health problcms of * Safe pregnancy and delivery services. Prenatal care, women beyond reproductive age. safe delivery, and postpartum care can have a Many of these interventions require collaboration significant impact on the health of women and between health and other agencies in the public and their newborn children. Services should include private sectors, including private insurers and private tetanus toxoid immunization, micronutrient providers. Even when governments finance the supplementation, counseling, and the detec- Essential Services, they do not necessarily have to tion, prompt referral, and treatment of obstetric provide them. Publicly financed services can be pro- complications. vided by public or private providers. And to ensure * Prevention and management of sexually transmit- coverage of those who have private health insurance, ted diseases. Promoting condom use can help governments can mandate that private health insur- prevent the spread of sexually transmitted dis- ance benefits always include the Essential Services. eases (such as syphilis, gonorrhea, chlamydia, and HIV/AIDS), and timely management of What National Health Programs Can Do such diseases can avert both acute and long- term complications. Governments have considerable power to improve e Promotion of positive health practices, including the health outlook for their female citizens if they delayed childbearing, safe sex, and adequate nutri- are willing to enact and promote gender-sensitive tion. Public education programs and counseling policies and to strengthen women's health services. by health workers can help to change social Effective policy reform must include not only norms and encourage girls and women to adopt changes in the health delivery system but also healthful behaviors and seek medical help when efforts to redress social, educational, and eccnomic needed. Schools can explore these topics in the inequities. classroom. Existing services can be improved, extended, and - Prevention ofpractices harmful to health, such as less tailored to fit local conditions. For example, where food and health care for girls than boys and violence cultural norms discourage women from receiving against women. By raising awareness among pol- care from men, governments could recruit and train icymakers, health providers, and the public of more female health providers. In the design and the harmful health consequences of these prac- implementation of health prog.ams, attentiDn can tices, governments can be a positive force for be paid to factors that have particular relevance to change. women because of biological and social influences: Even in the poorest countries, governments can access, quality (including provider competence, help to establish these Essential Services and ensure counseling, continuity of care, and privacy), num- access to them by financing health interventions for ber of female health providers, and responsibilities the poor in the national package and interventions of nonphysicians, such as midwives. Collecti3n and to change behavior for the entire population. analysis of gender-specific information on health Services beyond the national package should be care utilization and health status can guide govem- financed from private sources. ments in the design and implementation of Where resources permit a more comprehensive women's health services. national package of interventions against a larger By working closely with the private seztor to number of diseases and conditions, the Essential deliver information and services to irnprove Services could be expanded and upgraded to include: women's health and nutrition, governmeiits can * A wider choice of short- and long-term contra- help derive the greatest benefits from national ceptive methods health resources. Nongovernmental organizations * Enhanced maternity care that are well-respected in the community can be * Expanded screening for and treatment of sexu- helpful in reaching and representing disadvantaged ally transmitted diseases women. Private for-profit providers can supplement ExecutiveSummarv 3

government programs by offering a broader range of examples of experience in many countries will services to those who can afford to pay for them. spark fruitful discussion on policy and program National education programs can be used to options, stimulate action, and improve the coordi- promote positive health behaviors and to change nation needed to make a difference in the health of attitudes and conduct that are harmful to women. women throughout the world. Such programs have been effective in changing a To guide the reader, the following summary wide range of health behaviors related to family describes the paper's contents by chapter and planning, nutrition, AIDSprevention, and tobacco intended audience: consumption. * Why Invest in Women's Health and Nutrition? Chapter 1 presents reasons for financing inter- What AssistanceAgencies Can Do ventions to improve women's health and nutri- tion. It may be especially useful for policy By increasing policymakers' awareness of the real dialogue. social and economic gains from improvements in * An Overview of Women's Health and Nutrition. women's health, foreign assistance agencies- Chapter 2 summarizes key health problems including the World Bank-can have an impact far affecting women. It provides a framework for beyond their monetary contribution. International policy decisions and program planning. agencies can help by informing national decision- * Health and Nutrition Interventions for Wotnen. makers about lessons gleaned from worldwide expe- Chapter 3 lists the essential and expanded health rience and by supporting interventions that have services recommended to address women's proved cost-effective.External inputs may be partic- health problems in low- and middle-income ularly helpful in the design of demonstration pro- countries. It may be useful to program planners jects and the expansion of women's health programs and managers as well as policymakers. to a national scale. * Issues for National Program Planning. Chapter 4 discusses key aspects of program planning and Overviewof Women's Health and Nutrition: implementation, including the impact of gov- Making a Difference ernment policies, the need for governrrent financing, collaboration with the private sector, Education, employment opportunities, and other quality of care, and data requirements. It may be factors outside the health sector have an important helpful to health professionals at all levels as bearing on women's health. Although this paper well as to national decisionmakers and program addresses actions that can be taken by the health planners. sector, it also provides recommendations for * Role ofIntemationalAssistance. Chapter5 suggests broader efforts. Its recommendations for invest- ways that the World Bank and other assistance ments to address the key health problems affecting agencies can contribute to improvements in women at different stages of life are based on con- women's health services through policy ,iia- cerns for human welfare and economic efficiency. logue, sector work, project preparation, funding The paper suggests essential clinical and public for research, and donor coordination. It also dis- health interventions and emphasizes the special cusses women's health problems and potential benefits derived from targeting programs to the strategies on a regional basis. It is intended pri- young. Finally, it discusses factors to be considered marily for staff of the World Bank and other assis- in planning and implementing government pro- tance agencies. grams and describes ways that assistance agencies More detailed information needed for program can support such programs. The hope is that the planning is included in the annexes. Chapter One Why Invest in Women's Health and Nutrition?

Evidence from around the world has demonstrated Differentials In Health that investment in people's health is fundamental to improving a country's general welfare and economic Fertility and infant and child mortality rates have growth, as well as to reducing poverty (World Bank dropped substantially in developing countries over 1993c). This report focuses on how public invest- the past three decades. From 1962 to 1992 infant ment in women's health and nutrition, in particu- mortality in the developing world dropped by 50 lar, can contribute to balanced sustainable economic percent, and fertility rates fell by 40 percent (UN growth by: 1993). Fertility regulation has contributed to * Improving equity and the quality of life. Initiatives women's health by reducing the number of preg- to improve women's health could save millions nancies-and their associated risks-and giving of women from needless suffering or premature women more control over their lives. death and enable them to lead fully productive Progress has been much slower in other areas sig- lives. Today, women in many countries suffer a nificant to women's health. Maternal mortality ratios disproportionate share of avoidable disability and rates reflect the widest disparity in human devel- largely because of their low socioeconomic status opment indicators between developed and develop- and reproductive role. ing countries., In Sub-Saharan Africa, where the ratio * Conferring widespread benefits. Investments in is 700 maternal deaths per 100,000 live births, a women's health have multiple payoffs. In woman runs a one in twenty-two risk of dying from addition to improving individual well-being pregnancy-related causes during her lifetime; in and the actual and potential economic contri- South Asia, the risk is one in thirty-four; and in South bution women make, families, communities, America, one in 115-the risk drops in Northern and the national economy also significantly Europe to one in 10,000 (UN 1993; Herz and benefit. In particular, women's health has a Measham 1987). Except in countries with relatively major impact on child survival, family well- low maternal mortality ratios (fewer than 100 rnater- being, and the health and productivity of nal deaths per 100,000 births), the World Hlealth future generations. Organization has found scant evidence o- any * Improving efficiency. Redirecting public spending progress in reducing maternal mortality in recent to highly cost-effective interventions will years (WHO 1992c). In Bangladesh, for example, improve allocative efficiency. Health interven- although the total fertility rate declined by one-third tions that address women's health problems are and child mortality by almost one-half in just over among the most cost-effective available in devel- two decades, the maternal mortality ratio remained oping countries. More than half of the years lost virtually unchanged (Khan, Farida, and Begum 1986; to poor health by women up to age forty-five World Bank 1992d; World Bank 1993b). could be partially or substantially saved through As it now stands, most women in the developing low-cost health interventions. world lack ready access to a selection of fertility con-

1. The matemal mortality ratio is the number of women dying in pregnancy and childbirth per 100,000 live bir:hs. It measures the risk women face of dying once pregnant. The maternal mortality rate is the number of women dying in pregnancy or childbirth per 100,000 women age 15-49. The rate reflectsboth the maternal mortality ratio and tfe fer- tility rate.

4 WhyInvest in Women'sHealth and Nutrition? 5 trol methods and to basic maternity care. Many less recognized. Menstruation, for example, renders countries have largely neglected interventions to women more susceptible than men to iron- control other problems to which women are partic- deficiency anemia. Certain conditions can be exac- ularly vulnerable, such as sexually transmitted dis- erbated by pregnancy, including anemia, protein eases, malnutrition, and gender violence. Moreover, -energy malnutrition, hepatitis, malaria, tuberculo- the women's health initiatives that are in place are sis, sickle cell disease, diabetes and heart disease. inadequate and tend to focus on married, child- Complications of pregnancy may also cause perma- bearing women. Girls, adolescents, older women, nent damage, such as uterine prolapse and obstetric and unmarried or childless women of reproductive fistulae. age rarely receive the attention of public health Due to biological factors, women have a higher administrators. risk per exposure than men of becoming infected Women's health status is affected by complex with sexually transmitted diseases including HIV In biological, social, and cultural factors that are highly addition, because women with sexually transmitted interrelated (Figure1.1). To reach women effectively, diseases are more likely than men to have no symp- health systems must take into account the biologi- toms, they may delay treatment until an advanced cal factors that increase health risks for women and stage, with more severe consequences. Hurman such sociocultural determinants of health as age of papillomavirus infection results in genital cancer marriage and attitudes towards adolescent sexuality, much more frequently in women than in men and as well as psychological factors, such as depression is the single most important risk factor for cancer of arising from gender violence. Over the longer term, the cervix. Cancer of the cervix accounts for more broader efforts-particularly increased female edu- new cases of cancer each year in developing coun- cation-will help reduce many of the barriers to tries than any other type of cancer (Parkin et al. women's health. 1988). And although women of reproductive age are thought to receive some protection against cardio- Biological determinants of women's health vascular disease from the hormone estrogen, their risk increases after menopause. By age sixty-five, a Under optimal conditions for both men and women higher proportion of women than men die as a con- a woman's life expectancy at birth is 1.03 that of sequence of cardiovascularconditions (Lopez1993). men (Coale and Demeny 1983;World Bank 1993c). Though the reasons are not well understood, Many countries show a considerably higher advan- women tend to have fewer injuries than men. The tage to females; in most industrialized countries behavior patterns of men, including higher alcohol their life expectancy is over 1.06 that of men, and as consumption, place them at a higher risk for most high as 1.10 in Canada. In most developing coun- injuries, though biology may also play a role tries, however, the ratio is much lower, even drop- (Stansfield et al. 1993). ping below one in parts of Asia, to a low of 0.97 in Bhutan-a sign of socioeconomic conditions partic- Socioeconomic influences on women's health ularly inimical to women and girls (Keyfitz and Flieger 1990). The cultural and socioeconomic environment While the major health risks related to preg- affectswomen's exposure to disease and injury, their nancy are well known, other health problems asso- diet, their access to and use of health services, and ciated with women's reproductive biology may be the manifestations and consequences of disease. Indoor cooking, for example, is one of the most seri- Figure 1.1: Determinantsof women'shealth status ous occupational health and environmental hazards in the developing world because of the acute and behaviorand chronic-and sometimes fatal-consequences of psychological inhalation of smoke and toxic gases, as well as acci- factors dental burnings (WHO 1986; World Bank 1992d). A Social, study in India found women's exposure to cooking Biological Women'shealth status economic,and fumes to be equivalent to smoking twenty packs Df factors cuinfluences cigarettes a day (Smyke 1991).

Healthand Women's disadvantaged social position, which is nutrition often related to the economic value placed on fami1- services ial roles, helps perpetuate poor health, inadequate 6 Women'sHealth and Nutrition:Making a Difference diet, early and frequent pregnancy, and a continued than to men in seeking medical care (Mwabu, cycle of poverty. Parents may invest less in girls Ainsworth, and Nyamete 1993; Gertler and Van der because they perceive them to have less economic Gaag 1990). potential, since girls often become part of another The strongest evidence of gender differentials in family at marriage and generally earn less income. As health status and use of health services has been doc- a result, from infancy, females in many parts of the umented for both children and adults in Soulh Asia. world receive less food and food of lower quality and A study in India found that protein-energy malnu- are treated less often when sick, and then only at a trition was four to five times more prevalent among more advanced stage of disease. In countries where girls, and yet boys were fifty times more likely to be women are less educated, receive less information hospitalized for treatment (Das Gupta 1987). than men, and have less control over decision- Community-based studies in India found that making and family resources, they are also less apt to women had a higher rate of illness and disease than recognize health problems or to seek care. Cultural men in the same household, but used health services factors, such as restrictions on women travelling less often (World Bank 1992d). Studies ir. other alone or being treated by male health care providers, countries also have found that even where there is restrict women's use of health services in some no apparent gender difference in prevalence, Middle Eastern countries, for example. women may be less likely than men to seek care for Women's low socioeconomic status can also infectious disease. In Colombia and Thailand, for expose them to physical and sexual abuse and men- example, about six times as many adult men as tal depression. Unequal power in sexual relation- women attend malaria clinics for treatment (Vlassof ships exposes women to unwanted pregnancy and and Bonilla 1992; Ettling et al. 1989). sexually transmitted diseases, including HIV/AIDS. With changing social values and economic pres- Widespread Impact of Women's Health sures, girls are engaging in sexual relationships at an increasingly earlier age. The worst manifestation of Improving women's health has significant benefits this phenomenon is the growing number of young not only for women but for their children a nd the girls forced into prostitution, especially in Asia. national economy. Yet standard cost-effectiveness The general level of underdevelopment may calculations applied to health interventions gener- pose additional health risks for women. Poor roads ally fail to take these positive extemalities into and lack of transport, as well as inadequate obstetric account. Pregnancy care is an exception, however, facilities, hinder women from receiving timely med- since the main health benefits included in the cost- ical treatment for obstructed labor, hemorrhage, and effectiveness calculations are derived from improve- other pregnancy-related complications. Inadequate ments in the health of the baby. water supply, lack of electricity, and poor sanitation impose extra hardships and burdens on women Child survival because of their household responsibilities such as fetching water and fuelwood, cooking, and caring To a large extent, the well-being of children depends for children. on the health of their mother. In developing coun- Because women represent a disproportionate tries, a mother's death in childbirth means almost share of the poor (UN 1991b), poverty further cur- certain death for a newly born child and severe con- tails their access to health services. They have less sequences for her older children. A recent study in disposable income to spend on health because their Bangladesh of children up to age ten founcl that a wages for the same or similar work are substantially mother's death sharply increases the chances that lower than men's and because much of their work her children will die within two years, especially her is outside the formal sector and not financially daughters. Children whose mothers die are three to remunerated. Furthermore, because of their multi- ten times more likely to die within two years than ple tasks and responsibilities, women face high those with living parents (Figure 1.2). A father's opportunity costs for time spent on health care. death only has a significant effect on the survival Girls begin working at an earlier age than boys and prospects of his children between the ages of five spend more hours working each day (paid and and nine, and the impact is just half that of the unpaid), throughout their lives, in all regions (UN mother's death (Strong 1992). 1991b). Studies in Kenya and Peru confirm that dis- When mothers are malnourished, sickly, or tance and user fees are a larger obstacle to women receiving inadequate prenatal and delivery care, Why Invest in Women'sHealth and Nutrition; 7 their children face a higher risk of disease and pre- economic development. Women's current contr;bu- mature death. The effect on perinatal outcomes is tions are substantial, although only partially particularly strong. Each year, seven million infants reflected in official economic statistics, and their die within a week of birth and twenty-one million potential is underutilized. Women are responsible for low-birth-weight babies are born. The prospects for up to three-quarters of the food produced annually many of these babies could be improved by improv- in the developing world. In parts of Africa, women ing women's health and nutrition and providing produce 80 percent of the food consumed domesti- good maternity care (WHO 1993a; WHO and cally and at least 50 percent of export crops. Women UNICEF1992). also constitute one-third of the world's wage-labor Maternal anemia and small pelvic size among force and one-fourth of the industrial labor force. women whose growth has been stunted increase the Much of women's work-both inside and outside the risk of both maternal and infant mortality. Iodine- home-is unpaid and, therefore, not counted. If the deficient mothers are at greater risk of giving birth gross domestic product included domestic work., it to infants with severe mental retardation and other would increase by 25 percent (UN 1991). congenital abnormalities. Pregnancy in early ado- Poor health reduces women's productive capac- lescence has additional harmful effects, from low- ity to carry out their multiple productive and repro- birth-weight babies to premature cessation of the ductive responsibilities. Studies of women tea mother's growth, setting in motion an intergenera- workers in Sri Lanka and cotton mill workers in tional cycle of ill health and growth failure (Figure China, for example, have documented the reduced 1.3). Proper nutrition and health care can interrupt productivity associated with iron deficiency and he this intergenerational cycle. positive effects of iron supplementation on work output (Edgerton et al. 1979 and Ruoweiet al. 1994). Productivity, family welfare, and poverty reduction Frequent pregnancies and poor health not onaly drain their productive energy, but also contribute to Reducing fertility and improving women's health their poverty. A study in one area of India found that can improve individual productivity and family well- the female labor force was reduced 22 percent due to being and, particularly when combined with educa- disability. Illness was also found to be the second tion and accessto jobs, can also accelerate a nation's highest cause of indebtedness in India-affecting women most profoundly since they predominate in Figure 1.2: Children'sprobability of dying rises sharply the ranks of the poor (Chatteryee 1991). with their mother'sdeath, Matlab, Bangladesh, Women's he is Ceral nt ltwe 1983-89 1983-89 ~~~~~~~~~Women'shealth is central not only to wagye- probabilityof dyingwithin two years earning but also to the performance of their many 0.8 household tasks. Within the family, women bear <1n month principal responsibility for maintaining the home and caring for society's dependents-children an-d the elderly. They collect water and fuel (Tanzanian 0.6 women, for example, use up to 20 percent of their Children'sage at startof observation caloric intake collecting water) cook for and feed the family, and perform other tasks essential to 0.41monthshousehold maintenance. 0.4 months As the principal providers of family health ca.e, women tend to the sick and disabled and protect clil-

0.2 Figure 1.3: Intergenerationalcycle of growth failure 1-4 years Child growth failure

0 _ _rt _h-__ Low Earlyteenage Lowweight and otS o' os orS oe5' x' .e,S ;x6$ birth-weight pregnancy + height in teels <;v° 09

Smalladult women * Sons O Daughters Source:Strong 1992. Source:UN/ACC/SCN 1992b. 8 Women'sHealth and Nutrition:Making a Difference

dren's health. Although not officially recognized as Investing in women's health fits fully within the health workers, women are responsible for 70 to 80 World Bank's two pronged strategy for poverty percent of all the health care provided in developing reduction, which includes (a) the introduction of countries. Therefore, improving their health status broad-based, labor-absorbing economic growth to and educating them to prevent and detect infectious generate income-earning opportunities for the poor diseases and practice proper hygiene and nutrition is and (b) improved access to education, health care a cost-effective approach to improving family health and other social services to help the poor take advan- (Leslie et al. 1986). Women's familial responsibilities tage of these opportunities (World Bank 1994). The carry high opportunity costs, reflected in absenteeism adverse effects of ill-health, both on income and on from the workforce associated with pregnancy or the personal and household welfare, are the greatest for caring of sick children, for example. the poor. There is evidence that improved health A woman's health status affects not only the and nutrition reduces infant and child mortality and health of her children but also other aspects of their contributes to demand for smaller families. Smaller welfare. The preliminary results of a study in family size in turn has a positive impact on poverty Tanzania suggest that a woman's death has an by saving household resources. A growing body of important influence on children's education, partic- research also points to the positive effects of health ularly at the secondary school level. In households and nutrition on the labor productivity of the poor where an adult woman had died within the last 12 (Behrman 1990). To the extent that women are over- months, children spent one-half the time in school represented among the poor, interventions for than did those where such a death had not occurred. improving women's health and nutrition are, there- The effect did not appear significant when an adult fore, critical to efforts for poverty reduction male died (Over et al. forthcoming). Women are more likely than men to spend their The Cost-Effectivenessof Women's Health income on family welfare. In Guatemala, it takes fif- Interventions teen times more spending to achieve a given improvement in child nutrition when income is For the major causes of death and disability for males earned by the father than when it is eamed by the and females by age group in developing countries, mother (World Bank 1993c). there is a greater convergence of relative disease bur- Evidence suggests that efforts to improve the den and cost-effective interventions for females health and nutritional status of women could be than for males (Table 1.1). Highly cost-effective critical to the goal of poverty reduction. The weight interventions-those costing less than US$ 100 per of poverty falls more heavily on women. In addition disability-adjusted life year saved (DALY)-can ben- to low health and nutritional status, poor women efit more females between the ages of five and forty- have low education levels. In the developing world four than males in the same age group (Annex B, there are only 86 females per 100 males in primary Table B.2). The health problems of women fifteen to schools, 75 in secondary schools, and 64 in tertiary forty-four years old-especially those related to education. Finally, women have less access to remu- reproduction-are particularly responsive to cost- nerative activities. Evidence form diverse country effective prevention and treatment. For these rea- settings-Burkina Faso, Cameroon, India, Lebanon, sons, many of the interventions included in the Nepal, and the Philippines-suggests that when the World Development Report minimum package (Box time spent on home production is valued, women 1.1) are directed to girls and women, either as bene- contribute between 40 to 60 percent of household ficiaries or as the means to improve infant health. In income (World Bank 1994). Among the poor, low-income countries, for example, one-third of the women-headed households, especially, are at a cost of the recommended minimum package is greater economic disadvantage than male or joint- accounted for by family planning, maternity care, headed households because of the lower earnings of and management of sexually transmitted diseases; women and the dual nature of their work burden, in middle-income countries, these interventions which imposes severe time constraints, restricting account for half of the estimated costs. The Bank rec- their access to social and health services ommends that governments ensure that, at the (Rosenhouse 1989). Women-headed households are least, poor populations have access to these services. becoming more prevalent and already represent 20 This will require, at a minimum, shifting public percent of all households in Africa, Latin America spending from services outside the package to those and the Caribbean. in the package (World Bank 1993c). Table 1.1: Major health problemsin developing countrieswith interventions of high to medium cost-effectiveness Greater Similar Greater Agegroup/ Females among amongmales among Males maincauses of diseaseburden only females andfemales males only Ages0-4 Respiratoryinfections High Perinatalcauses High Diarrhealdisease High Childhood cluster* High Malaria High Protein-energymalnutrition High Vitamin A deficiency High Iodine deficiency High STDsand HIV High Ages5-14 Intestinal helminths High Childhood cluster High Respiratoryinfections High Diarrheal disease High Tuberculosis High Malaria High Anemias High STDsand HIV High Ages15-44 Maternal Causes High STDs High Tuberculosis High HIV High Depressivedisorders Medium Respiratoryinfections High Anemia High Ages45-59 Tuberculosis High Ischemicheart disease Medium Cataracts High Chronic obstructive pulmonary diseases Medium Diabetesmellitus Medium Cancerof the cervix High Malignant neoplasm High Ages60+ Ischemic heart disease Medium Respiratoryinfections High Diabetesmellitus Medium Tuberculosis High Cataracts High Malignant Neoplasms- trachea, bronchus, lung High Note: Thecauses ot diseaseburden shown here have been chosen trom the ten maincauses ot diseaseburden among women andthe ten maincauses among men on the basisot availabilityot anintervention ot high or mediumcost-effectiveness. A causeot diseaseis consideredto begreater among temales it the ratioot temaleto maleburden ot diseaseis 0.8 or less. Malesand temales are considered to be equallyaffected by a diseaseit the ratio ot temaleto maleburden ot diseaseis between0.8 and 1.2. Cost-effectivenessvaluations: High -<5100/DALY saved Medium- 5100-S999/DALYsaved WVaccine-preventablediseases ot childhood. Source:World Bank1993c. 9 10 Women'sHealth and Nutrition:Making a Difference

An analysis of the eighteen most cost-effective from interventions that target health problems interventions that affect the leading causes of death exclusive to women, such as matemity-related prob- and disability for both sexes found that childhood lems or cervical cancer. interventions have similar benefits for males and In sum, improvements in women's health females. Men can benefit more than women from increase personal and family well-being and pro- the treatment of tuberculosis after age fifteen and for ductivity today and help to ensure healthier prevention of conditions related to tobacco and generations tomorrow. National economies, com- alcohol consumption after age forty-five. From age munities, and households-all of theni highly five onward, however, females benefit more than dependent on women's paid and unpaic labor- males from the prevention and treatment of sexu- benefit from investment in women's health. ally transmitted diseases and iron-deficiency ane- Improving women's health is a critical component mia. In addition, women derive substantial benefits of sustainable economic growth.

Box 1.1: World Development Report 1993, Investing in Health

Assessments of the relative importance of different ventions to determine which were the most cost- health problems are usually based on how many effective. Based on this analysis, it proposed a mini- deaths they cause. Many health problems, however, mum package of essential health services which are not fatal, but cause much disability. As part of included: background work for the World Development Report * Public health services-immunization, school 1993, the World Bank, in collaboration with WHO, health, AIDS prevention, tobacco and alcohol carried out a comprehensive analysis of the amount control, and other public health programs of both premature death and disability due to spe- (including family planning, health, and nutrition cific diseases and injuries. The burden of disease pre- information). sented in the report was measured in terms of *Clinical services-short-course chemotherapy for disability-adjusted life years (DALYs).The burden of tuberculosis, management of the sick child, pre- disease measures the present value of the future natal and delivery care, family planning, treat- stream of DALYslost as a result of death, disease, or ment of sexually transmitted diseases, and limited injury in 1990. It is based on events (premature care for adults. death or new cases of disability) that occurred in Where instituted, this minimum package, which is 1990 but includes future disability-adjusted life estimated to cost US$12 per capita in low-income years. Calculation of disease burden was based on countries and US$22 per capita in middle-income several assumptions: disability weights (to value the countries, could reduce the burden of disease in low- severity of an illness relative to loss of life), dis- income countries by more than 30 percent and counting (to value future years of healthy life rela- about 15 percent in middle-income countries. Public tive to the present), and age weights (to give years finance is needed to ensure the availability of public lost at different ages different relative values). health interventions to the population, given that Disease burden was calculated for over 100 causes of such services are so nearly public goods that private ill health by age, sex, and region. Preliminary results markets will provide too little of them. Govemments of the disease burden assessment appear in the WDR must also finance clinical services in the minimum 1993. A full accounting will be published jointly by package for the poor. In middle-income countries, WHO and the World Bank. where resources are much less constrained than in Disease burden estimates can be used to monitor low-income countries, additional public expendi- global and country-level progress in improving ture can either go to extending coverage to the non- health, and, in combination with information on poor or to expansion beyond the minimum package cost-effectiveness, to help set priorities for the health to a national package of health care that includes sector. somewhat less cost-effective interventions against a Using this method, the World Bank assessed the larger number of diseases and conditions. This costs and benefits of a wide range of health inter- would further improve women's access to services. Chapter Two An Overview of Women's Health and Nutrition

Women are much healthier in some countries than * Smallerfamilies. Women are spending less time in in others. Their health may even vary widely among reproduction. In developing countries with rela- different regions of the same country. What makes tively low fertility rates, such as Indonesia and the difference are such factors as the local prevalence Mexico, the average woman spends fifteen years of disease, health-related behaviors, women's edu- between her first and last birth, or less than 20 cational attainment, exposure to health informa- percent of her lifetime. In countries with higher tion, their influence on decision-making, and the fertility and lower life expectancy, such as Kernya availability of health care in general and to women and Senegal, the average interval is nineteen to in particular. Poverty, environmental degradation, twenty years, or about 40 percent of a woman's civil conflict, and migration also influence women's lifetime. Comparable intervals are eight years for health, if less directly. the United States and two years for Japan (Freedman and Blanc 1991). Global Trends * Longerlife expectancy. Life expectancy at birth Ihias increased, primarily because of improved sur- In the developing world, women's health status is vival of infants and young children. As a result, changing in response to several emerging trends: health problems that emerge later in life, such as * More education.Girls who have attended school, cervical and breast cancer, as well as cardiovas- especially through the secondary level, are more cular disease, are becoming more prevalent, likely to adopt healthy behaviors such as delayed shifting health care concerns to those associated marriage and childbearing, smaller family size, with chronic diseases, for which health inter- use of health care facilities,and appropriate child ventions tend to be less effectiveand more costly. health care (Schulz 1989). Women constitute a majority of the elderly. - Later marriage. In most countries, women are * Increased labor force participation. Women a.e marrying later. Later marriage generally entering the formal labor force in growing nuni- implies postponed childbearing and permits bers. Along with the positive benefits of women to stay in school longer. It also implies increased income and, in some settings, social that growing numbers of adolescent girls are support, women are facing possible new occupa- exposed to the risks associated with premarital tional health hazards, and the challenge of coor- sexual intercourse, including unwanted preg- dinating employment outside the home witAi nancy, and sexually transmitted diseases, such traditional responsibilities as breastfeeding including HIV. In many countries the propor- and childcare. tion of unmarried adolescents becoming preg- nant is at an all-time high (Westoff and Ochoa Women'sBurden of Disease 1991). * Emergenceof HIV/AIDS. The rate of HIV/AIDS Becausewomen live longer than men, the common infection is accelerating rapidly among women, belief is that they are healthier. In reality, women are through exposure to infected partners. Young more likely to experience sickness and chronic poor women are at particular risk. Women fifteen to health than are men. A recent study by the Ranc twenty-five years old now account for 70 percent Corporation concluded that even though women of HIV infections among females worldwide live longer, they are more sickly and disabled than (UNDP 1993). men throughout the life cycle. The study, which

11 12 Women'sHealth and Nutrition: Making a Difference compared measures of ill health in Bangladesh, ventions, such as screening and cryotherapy for Jamaica, Malaysia,and the United States, found that preinvasive cervical cancer, are highly effective and women have more problems with physical func- relatively cheap. tioning and general health than do men. Women's health problems begin earlier in life and persist Women'sHealth and Nutrition longer into old age, with the result that women suf- throughout Life fer more from both acute and chronic nonfatal dis- eases (Strauss et al. 1992). Biological and social factors affect women'; health Data from the World Development Report 1993 throughout their lives and have cumulative effects. indicate that between the ages of fifteen and forty- That makes it important to consider the entire life four and after age sixty, men generally have higher cycle when examining the causes and consequences rates of premature death and women have higher of women's poor health. For example, girls who are rates of disability (Figure 2.1). Female disability is fed less than other household members during especially high in Asia, Sub-Saharan Africa, and the childhood may have stunted growth, leading to Middle East, much of it attributable to maternal higher risks of complications during childbirth; sex- causes, sexually transmitted diseases, and gender- ual abuse or female genital mutilation during child- based discrimination (World Bank 1993c). hood increase the likelihood of poor physical and In developing countries, one-third of the DALYs mental health in later years. While the adolescent lost by women aged fifteen to forty-four result from period overlaps with the reproductive years, it is reproductive health problems (pregnancy-related considered separately because of the long-term con- complications, sexually transmitted diseases, HIV, sequences of behaviors and health treatment initi- and genito-urinary problems), with gender vio- ated during this period (Figure 2.2). lence and rape accounting for an additional 5 per- Different health and nutrition problems affect cent (World Bank 1993c). More than one-fifth of females at different stages of the life cycle, from the DALYslost by women aged forty-five to fifty- infancy and childhood, to adolescence and the nine can be attributed to conditions that exclu- reproductive years, to the post-reproductive period sively or predominantly affect women. While the (for more detail see Annex B). For developing coun- potential gains from health interventions targeting tries as a whole, 25 percent of females are zero to women over forty-five years of age are more mod- nine years old, 21 percent are ten to nineteen years, est than those applied in earlier years, certain inter- 36 percent are twenty to forty-fiveyears, and 18 per- cent are over the age of forty-five. Figure 2.11:Burden of diseaseby region for females and malesaged 15 to 44 in 1990 Infancy and childhood DALYslost per 1,000population 160 155158 Discrimination in the care of girls can negate their innate biological advantage relative to boys. In 140 many developing countries, girls are in poorer 120 health than boys because of inadequate rutrition Asia 100 89Asla 10i1 l :t and health care. Such disparities are greatest in India 89 86 |: 011;: and China, where more girls than boys die before 80 - Latin their fifth birthday, despite girls' biological advan- Armerca 60 andthe Established tage (World Bank 1993c). Key factors that adversely 0 36 36 Caribbean market affect girls' health include: 4 n_ 121economies * Discriminatory childcare. In societies where boys 20 - 1 1 1 6 611 11 1 aremore highly valuedthan girls, boys may o0 EUL receive more preventive care and more timely F M F M F M F M F M F M F M attention when they fall ill. In some societies, Sub- Middle Former Dg efsops Saharan East socialist cDunies girls receive less food and less nutritious food Africa economies than boys (Ravindran 1986), leading to mal- of Europe nutrition and impaired physical development

F=Female M=Male * Disability O Prematuremortality and laying the groundwork for future health SourceWorld Bank 1993c. problems. An Overviewof Women'sHealth and Nutrition 13

* Sex selection.In countries where many families exposure to a variety of risks during the transition have a strong preference for sons, there is evi- from childhood to adulthood can jeopardize their dence of selective abortion of female fetuses survival and well-being. Their status within the lam- (whose sex is detected by ultrasound and amnio- ily and community is at its lowest in most countries centesis) and female infanticide (Heise et al. during this part of the life cycle. To a large extent, 1993). In Bombay,India, only one of 8,000 abor- adolescence sets the stage for health and nutritional tions performed after parents learned the sex of status in the later years, yet health policies and pro- the fetus averted the birth of a male (United grams are the least effective in addressing the needs Nations 1991b). of this age group. * Genitalmutilation. Each year an estimated two mil- * Earlychildbearing. The proportion of women giv- lion young girls, mostly between four and eight ing birth during their teenage years ranges foom years of age, are subjected to genital mutilation, 10 to 50 percent depending on the country. also known as female circumcision. Often per- While early childbearing is particularly common formed under unsterile conditions, this invasive in traditional, often rural, settings, where early procedure can lead to death, acute and chronic marriage is the norm, it is becoming increasingly disability, including recurrent urinary tract infec- prevalent among unmarried adolescents. In tions, mental trauma and painful intercourse, and some settings, a young girl may welcome an ez rly complications during childbirth (Acsadi and premarital pregnancy to demonstrate her fertil- Johnson-Acsadi 1993;WHO 1993b) (Box3.2). ity or to motivate a partner's marital commiit- ment. Premarital pregnancy can have harmful Adolescence effects on a girl's social and economic opportu- nities. In Botswana, for example, a nationial Although women ten to nineteen years old are gen- study found that one in seven women who erally free of disease, their emerging sexuality and dropped out of school did so because of preg-

Figure 2.2: Health and nutrition problems affecting women exclusively or predominantly during specific stages of the life cycle

Infancy and Childhood o0-9years) * Sex selection * Genital mutilation * Discriminatory nutrition _ health care_

Post-Reproductive Lifetime Health Years Problems (45 + years) * Cardiovascular - Gender violence diseases *Certain occupational& * Gynecological environmental health cancers hazards * Osteoporosis * Depression * Osteoarthritls * Diabetes

Reproductive Years (20-44years) * Unplanned pregnancy * STDs and AIDS * Unsafe abortion 0 Pregnancy complications * Malnutrition, especially Although the reproductive age group is iron deficiency defined as 15-44 years, the period 15-19 years is included here under adolescence 14 Women'sHealth and Nutrition:Making a Difference

nancy and, of those who left, only one in five now targeting women and young people, and returned to school (Bledsoe and Cohen 1993). In smoking is spreading most rapidly amor.g young societies where premarital sexuality is con- women. Early initiation of such behaviors sets a demned, early pregnancy carries a social stigma pattern for lifelong use and increases mrorbidity and can have particularly acute adverse conse- and mortality, including risks specific to quences. Regardless of their marital status, women's reproductive functions. teenage mothers face a high risk of serious preg- nancy-related complications and at least a 20 Reproductiveyears percent greater likelihood of maternal or infant death than women in their twenties. The risks Women's risk of premature death and disability is increase severalfold for women under age six- greatest during their reproductive years (sce Figure teen. Adolescent girls are not physically prepared 2.3 for the distribution of the disease burden in this for childbirth, since linear growth is not com- age group). Many conditions that occur in these plete until the age of eighteen and the birth canal years affect the health of women long after their does not reach mature size until about two to reproductive years are over and the health of their three years later (UN/ACC/SCN 1992a). children as well. * Unsafe abortion. Many unmarried adolescents * Unplanned pregnancy and abortion. Unplanned seek abortions-whether legal or not-to avoid pregnancy is common in every country. In most expulsion from school and social condemna- developing countries, about 20 to 30 percent of tion. Because they often seek clandestine abor- married women wish to avoid becomi ig preg- tions and delay in obtaining the procedure and nant but are not using contraception VWestoff seeking medical attention for associated prob- and Ochoa 1991). As a result, one in five births lems, adolescents have a higher rate of abortion in these countries is unwanted. Worldwide, an complications. estimated forty to sixty million women resort to - Sexually transmitted diseases, including AIDS. abortion to end unwanted pregnancy. Since the Sexually transmitted diseases, including AIDS, majority of abortions are performec. under are spreading rapidly among young women, unsafe conditions, abortion carries a high risk of mainly through prostitution and liaisons with injury and death. Unsafe abortion accounts for older men. There is evidence that adolescent girls 125,000 to 200,000 female deaths annually are biologically more vulnerable to contracting (Dixon-Mueller 1990; Rosenfield 1989; WHO these diseases than older women, and they are 1992c). The cost of treating abortior-related likely to have more difficulty negotiating safe sex complications is high-many times greater than practices with their partners. In parts of Africa, the cost of offering safe abortion service.i. HIV infection is increasing more rapidly among females than males, especially among adolescent Figure 2.3: Burden of disease in females aged 15 to 44 girls (Panos Institute 1989). On average, women in developing countries become infected five to ten years earlier than Maternalcauses STDs& AIDS men (UNDP 1993). * Undernutrition and micronutrient deficiency. Girls' nutritional needs increase in early adolescence ommunicabeand maternal berculosis because of the growth spurt associated with 7% puberty and the onset of menstruation. Injuries \.\ \ Inadequate diet during this period can jeopardize 12%

their health and physical development, with life- . . Other

long consequences. A very common condition is .A- . ommunicable iron-deficiency anemia. t5::, diseases * Increased substance abuse. Adolescents often D Cardiovascular experiment with harmful substances, including and other : disea tobacco products, alcohol, and drugs. While dis- neuro- 6' eases associated with lifestyle and behavior have psychiatric MaInt ion thernon- been less of a problem for women than for men, 12% 6% communicable 12% ~~~~~~~diseases this pattern is changing in some countries. 14% Cigarette advertising in developing countries is Source:World Bank 1993c. An Overviewof Women'sHealth and Nutrition 15

* Pregnancy-related complications. Each year, more sexually transmitted diseases, HIV/AIDS and than 150 million women become pregnant. syphilis may directly result in death. Other sex- More than fifty million of them experience acute ually transmitted diseases, however, can lead to pregnancy-related complications, and fifteen life-threatening complications such as ectopic million develop long-term disabilities (WHO pregnancy and cervical cancer. Sexually trans- 1992a). Half a million women die in pregnancy mitted diseases are also an important cause of or childbirth. The major causes of pregnancy- infertility and pain (Fortney 1993). HIV/AIDS, related deaths include hemorrhage, sepsis, which is primarily transmitted sexually, is unsafe abortion, hypertensive disorders, and spreading rapidly among women, especially in obstructed labor. Conditions such as malaria, Sub-Saharan Africa, where nearly four million viral hepatitis, diabetes, anemia, sickle cell dis- adult women are already infected (WHO 1993c). ease, tuberculosis, and rheumatic heart disease Women are at greater risk than men of contr,act- are aggravated by pregnancy (WHO 1992a). ing HIV/AIDS because they are more likely to Disabilities resulting from pregnancy include become infected each time they are exposed. genital or bladder prolapse, cervical lacerations, obstetric fistulae, anemia, and infertility. Post-reproductiveyears * Malnutrition. An estimated 450 million adult women in developing countries are stunted as a Most of the problems affecting women after the age result of childhood protein-energy malnutrition, of forty-five are chronic. In juries and infections (par- which places them at increased risk of obstructed ticularly tuberculosis) also contribute to womei's labor (World Bank 1993c). Over 50 percent of disability in their later years, as do malnutriticin, pregnant women in the developing world are anemia, and loss of visual acuity. Menopause leads anemic (WHO 1992c). About 250 million to alterations in the skeletal, cardiovascular, ner- women suffer the effects of iodine deficiency, vous, skin, genitourinary, and gastrointestinal sys- and, although the exact numbers are unknown, tems and can affect women's capacity to perform millions are probably blind due to vitamin A- everyday activities. Yet the health problems of po%;t- deficiency (Leslie 1991). The highest levels of menopausal women continue to be largely ignored. malnutrition among women are found in South Major health problems among women older than Asia (DeMaeyer and Adiels-Tegman 1985) where forty-five include: 60 percent of women of reproductive age are * Gynecologicalcancers. These may occur during the underweight, over 60 percent are anemic, and 15 reproductive years, although they are more percent are stunted (UN/ACC/SCN 1992a). prevalent after the age of forty. Cancer of tte Causes of malnutrition include inadequate food cervix and breast are the most common. supply, inequitable distribution of food within Although cervical cancer can be cured at relat- the household, improper food storage and prepa- tively low cost if detected early, 183,000 women ration, food taboos, and lack of knowledge about in developing countries die from it every year nutritious foods. Malnutrition hampers women's (Sherris et al. 1993; World Bank 1993c). Brea5t productivity, increases susceptibility to infec- cancer, which kills 158,000 women in develop- tions, and contributes to numerous debilitating ing countries each year, requires more sophisti- and fatal conditions. cated screening and treatrnent techniques * Sexually transmitted diseases, including AIDS. Most (World Bank 1993c). reproductive tract infections (RTIs) are sexually * Cardiovascular and cerebrovascujlar diseases. transmitted. RTIs are of three types: sexually Cardiovascular diseases, including ischemic transmitted diseases, infections such as candidi- heart disease, myocardial infarction, and cere- asis and bacterial vaginosis caused by over- brovascular disease (stroke), are the leading cause growth of vaginal organisms, and infections of death among adults age forty-five and older in associated with unhygienic practices. RTIs are developing countries and represent a higher pro- common in all developing countries. In Egypt, portion of the disease burden among women for example, a recent community-based study than men in this age group (World Bank 1993c). found that one half of all the women surveyed With the increasing prevalence of risk-producing had one or more RTI (Younis et al. 1993). RTIs behaviors among women (such as smoking and can cause pelvic inflammatory disease, infertil- alcohol consumption), the incidence of cardio- ity, and adverse pregnancy outcomes. Among vascular disease is expected to rise. 16 Women'sHealth and Nutrition:Making a Difference

* Diabetes. Among urban women in Asia, the Domestic violence, rape and sexual abuse are Middle East, and Latin America and the widespread in virtually all regions, classes, cul- Caribbean, where obesity and inadequate exer- tures, and age groups (Box 2.1). Sexual abuse can cise are becoming more common, the prevalence occur at anytime during the life cycle-studies of diabetes mellitus is growing. Diabetes is a suggest that an alarming proportion ofvictims of major cause of morbidity and can lead to blind- rape and incest are ten years old and younger. In ness, kidney damage, and damage of lower limbs. addition to affecting women's health-seeking * Undernutrition. In the poorer developing coun- behavior (abusive husbands often prevent tries, chronic malnutrition is common among women from seeking care), gender-based victim- women, often reflecting a lifetime of inadequate ization can lead to unwanted pregnancy, infec- intake of calories, vitamins, and minerals. In tion, miscarriage, gynecological problems, times of food shortages, elderly women are often chronic pelvic pain, injury, headaches, asthma, most adversely affected. irritable bowel syndrome, and partial or perma- * Osteoporosis.Worldwide, one in ten women over nent disability. Psychological after-effects age sixty has osteoporosis, a process of bone loss include depression, fear, anxiety, fatigue, sleep that may result in pain, disability, and increased and eating disorders, sexual dysfunction, and risk of fractures. Osteoporosis is most common post-traumatic stress disorder. Not infrequently, in women beyond reproductive age because bone loss rises sharply after menopause. Box 2.1: Gender violence through the life Insufficient calcium, inadequate exercise, smok- cycle ing, and excessive alcohol consumption are con- tributing factors. Phase Type of violencepresent * Osteoarthiritis. During and after menopause, Prebirth Battering during pregnancy (emo- women are particularly prone to the develop- tional and physical effects on the ment of osteoarthritis, a painful degenerative women; effects on birth outcome). joint disease. Typically, several joints are affected, and progression of the disease restricts Infancy Female infanticide; emoticnal and the performance of even routine activities. physical abuse. Repeated trauma to the joints has been identified as a predisposing factor, and obesity (because of Girlhood Genital mutilation; sexual abuse its effects on the weight-bearing joints) can exac- by family members and strangers; erbate the condition. forced child prostitution.

Additional Health Problems Adolescence Dating and courtship violence; economically coerced sex; sexual abuse in the workplace; rape; Some health problems that affect both men and forced prostitution; trafficking in women during the life cycle have a disproportionate women. effect on women because of cultural norms or dif- ferences in exposure or access to treatment. Three Reproductive Coerced pregnancy (for example, major types of health problems with differential mass rape in war); abuse of women impact on women are: by male partners; marital rape; * Gender-based violence. Although men are victims dowry abuse and murders; partner of street violence, brawls, homicide, and crime, homicide; psychological abuse; violence directed at women is a distinctly differ- sexual abuse in the workplace; ent phenomenon. Men tend to be attacked and rape; abuse of unmarried and killed by strangers or casual acquaintances, withidisabilities. whereas women are most at risk at home and from men whom they know. Violence against Elderly Abuse of widows; elder abuse (in women also differs in that it tends to be chronic the United States, the onlv country and prolonged rather than acute, is less likely to where data are now available, elder be reported, is often associated with sexual abuse affects mostly women). abuse, and has long-term as well as immediate physical and psychological consequences. Source:Heise 1993 An Overviewof Women'sHealth and Nutrition 17

victims of battering and sexual assault attempt aged fifteen to forty-four (World Bank 1993c). suicide (Heise, forthcoming). Factors that put women at risk of depression Recent World Bank estimates of the global bur- include their inferior status, physical or sexual den of disease indicate that in developed coun- abuse, infertility, conflicting demands posed by tries, domestic violence and rape are responsible their domestic and income-producing roles, and, for one out of five healthy days of life lost to particularly among elderly women, isolation. women of reproductive age (World Bank 1993c). * Certain occupational and environmental heailth On a per capita basis, the health burden imposed hazards. While men are exposed to many occu- by rape and domestic violence in the developed pational and environmental health hazards, and developing world is roughly equivalent, but some have particular effects on women. Because because the total disease burden is so much many women work in the home, they suffer uis- greater in the developing world, the percentage proportionately from risks in the household attributable to gender-based victimization is environment caused by inadequate water sap- smaller (roughly 5 percent). Nonetheless, on a ply, poor sanitation, and indoor air pollution. global basis, the health burden posed by gender Outside the home, women workers may face the violence among women of reproductive age is risk of sexual harassment and rape. FurtPer- comparable to that of other conditions already more, they are more likely than men to wor, in high on the world agenda. Reducing violence industries and small enterprises that are pocrly against women, therefore, would help reduce regulated, with exposure to unsafe working con- health care expenditures as well as address this ditions (with such hazards as toxic chemicals, violation of basic human rights. radiation, extreme temperatures, excessive * Depression. While neuropsychiatric problems in noise, and violence). When pregnant women general account for a similar proportion of the are exposed to many of these hazards, the health burden of death and disability among men and of their unborn children suffers as well. Heavy women aged fifteen to forty-four, depressive dis- work during pregnancy can lead to premature orders account for 5.8 percent of the burden labor and, when high energy demands are niot among women of reproductive age-twice the compensated by increased caloric intake, to low- rate among men (World Bank 1993c). Depression birth-weight babies. Most women in developing is the single most serious mental problem for countries are employed in low-wage positions women in every age group and has a significant such as food vendors, petty traders, and domes- impact on women's well-being and productivity tic workers; they cannot afford to purchzase (Paltiel 1993). Based on the harm caused by these health care or protective clothing and equip- illnesses and injuries, the World Development ment. Many women farmers, especially those in Report 1993 ranks depressive disorders and self- commercial agriculture, are regularly exposed to inflicted injuries fifth and sixth, respectively, pesticides, often without appropriate sai-e- among diseases and injuries affecting women guards. Chapter Three Health and Nutrition Interventions for Women

The health, nutrition, and behavioral factors that and reduction of gender discrimination and vio- affect the well-being and productivity of women lence. Along with the basic services outlined here, cover a wide spectrum. Under conditions of limited countries are encouraged to expand their health pol- resources, therefore, policymakers and program icy dialogue, sector work, and projects aimed at planners have to make some difficult decisions changing attitudes and practices that are detrimen- about priorities. To provide a rational basis for mak- tal to women's health. ing such choices, this chapter identifies and While the two sets of recommended interven- describes the women's health interventions that tions are beneficial to all women, strategies will need should be priorities for most developing countries. to be tailored to the economic, epidemiological, It does the same for a second set of expanded inter- demographic, and infrastructural conditions of each ventions, which can be incorporated in public country or local setting. For purposes of exposition, health and education programs as a country's recommendations for health and behavioral inter- resources permit. Interventions have been selected ventions are presented separately, though they are on the basis of their impact on female disability and often intimately related. The cultural and socioeco- death, their cost, and their feasibility in developing nomic factors that affect women's lives must also be countries (Table 3.1). Though cost-effectiveness esti- taken into account when prioritizing interventions mates are not widely available for education and and planning delivery strategies. Potentially cost- communication efforts, interventions designed to effective devices for disease prevention, such as con- alter behavior are included here because of their doms, sometimes fail in practice because social strong potential for influencing the attitudes and mores prevent women from negotiating their use. It practices of women, men, health care providers, and is also important to recognize that health and social policymakers. interventions are generally the province of different The Essential Services for women's health confer agencies, both private and government. widespread economic and social benefits of suffi- cient importance and impact to justify funding Essential Health Interventions them with public monies in all countries, if neces- sary. Many of these interventions relate to women's Essential health interventions include prevention reproductive and sexual health because unprotected and management of unwanted pregnancies, preg- sex, pregnancy, and childbearing-exacerbated by nancy services, and prevention and management of women's subordinate status-are a major cause of sexually transmitted diseases (Table 3.2). poor health among women, beginning in adoles- cence. Other interventions address unhealthy or Prevention and management of unwanted pregnancies harmful behaviors. The Expanded Services describe interventions Preventing unwanted pregnancies i.mproves that can be implemented by middle-income coun- women's health by reducing their exposure to the tries (and poorer countries to the extent that funds complications of pregnancy, childbirth, arid unsafe permit) to reap even more gains. They focus primar- abortion. In addition, the survival chances of chil- ily on expansion and improvement of the Essential dren are significantly influenced by the timing and Services, interventions for women beyond repro- spacing of births as well as by overall family size. ductive age, and behavior change interventions for Health services can best address the problem of early prevention of health and nutrition problems unwanted pregnancy by providing family planning

18 Table 3.1: Major health problems among females in developing countries and the cost-effectiveness of interventions, 1990 Age group/ Total DALYS Percent of Cost- main causes lost from total disease effectiveness Cost per WDR Women's Women's of disease all diseases burden for each of existing DALY essential Essential Expd. burden (millions) age group interventions* saved package Services Services Ages 0-4 250 Respiratoryinfections 18.5 High S20-50 0 Perinatalcauses 17.2 High o Diarrhealdisease 16.2 High $10-170 0 Childhoodcluster- 10.7 High S10-25 o Congenital problems 6.5 Not yet evaluated Malaria 4.7 High o 0 Protein-energymalnutrition 2.4 High $63 0 0 Vitamin A deficiency 2.3 High S1-4 0 0 Iodine deficiency 1.3 High S8-37 0 0 Falls 1.2 Not yet evaluated Ages 5-14 67 Intestinal helminths 12.3 High $15-30 0 Childhood cluster 8.6 High S10-25 0 Respiratoryinfections 7.9 High o Diarrhealdisease 7.1 High 0 Tuberculosis 5.7 High S3-5 0 Malaria 4.9 High S5-250 o Motor vehicle injuries 3.7 Not yet evaluated Anemias 3.0 High 0 0 Epilepsy 2.6 Not yet evaluated STDsand HIV 2.4 High S3-5 o 0 Ages 15-44 155 Maternal Causes 18.0 High $60-110 0 0 0 STDs 8.9 High S10-15 0 0 Tuberculosis 7.0 High $3-S 0 HIV 6.6 High S3-S o 0 Depressivedisorders 5.8 Moderate Self-inflictedinjuries 3.2 Not yet evaluated Respiratoryinfections 2.5 High o Anemia 2.5 High 14-13 0 0 Osteoarthritis 2.2 Not yet evaluated Motor vehicle injuries 2.1 Moderate Ages 45-59 49 Cerebrovasculardiseases 8.7 Low Tuberculosis 5.6 High S3-5 o Ischemicheart disease 4.7 Moderate Peri-,endo- and myocarditis 3.2 Not yet evaluated Periodontaldisease 3.1 Not yet evaluated Cataracts 3.1 High S20-40 Chronic obstructive pulmonary diseases 2.8 Moderate Diabetesmellitus 2.8 Moderate Osteoarthritis 2.7 Not yet evaluated Cancerof the cervix 2.6 High S150-200 o Ages 60+ 60 Cerebrovasculardiseases 16.5 Low lschemic heart disease 11.6 Moderate Chronic obstructive pulmonary diseases 8 1 Moderate Alzheimer'sdisease and other dimentias 4.8 Not yet evaluated Respiratoryinfections 4.6 High Peri-, endo- and myocarditis 3.6 Not yet evaluated Diabetesmellitus 2.4 Moderate Tuberculosis 1.9 High S3-5 0 Falls 1.8 Not yet evaluated Cataracts 1.6 High

' Interventionsof high cost-effectivenessare those that can be implemented for lessthan $100 per DALYsaved; those of moderate cost-effectiveness cost between $250 and $999per DALYsaved; and thoseof low cost-effectivenesscost more than $1,000 per DALYsaved. (Few interventions are in the range of $100 and S250 per DALYsaved). "Not yet evaluated" indicatesdiseases for which preventive and therapeutic interventions havenot been evaluated in terms of cost-effectiveness. "Vaccine-preventable diseasesof childhood. Source: World Bank 1993c

19 20 Women'sHealth and Nutrition: Making a Difference services and-where national policies permit-safe vided. Health agencies can ensure that a range of safe, services for termination of pregnancy. effective contraceptive methods are readily available and affordable by establishing a variety of service- Familyplanning services. Where fertility and mor- delivery points and encouraging commercial outlets tality rates are high, family planning alone can have to offer contraceptives at reasonable cost. Condoms, a substantial impact on maternal mortality rates. For oral contraceptives, and spermicides can be made example, in a rural subdistrict of Bangladesh, the available immediately, even in resource-poor settings, maternal mortality rate fell by a third following an since they can be provided by community-based dis- effective community-based project that raised con- tributors with appropriate training and sold through traceptive prevalence to more than 50 percent (as commercial outlets. Trained paramedical workers compared with 23 percent in the control area) (nurses and midwives) can safely provide most other (Fauveau 1991). Providing family planning services methods-including injectables, implants, IUDs, and costs, on average, only US$15 to US$150 per DALY voluntary sterilization. Where regular supply, recur- saved in low-income countries (about US$20 per rent costs, and ensuring continued availability and contraceptive user) and is one of the most cost-effec- use present obstacles (which is often the case in tive health interventions. In countries where both resource-poor settings), women may find long-acting mortality and fertility are still relatively high, the methods (IUDs and injectables) may provide an effec- cost per child-death prevented is also extremely low. tive alternative to short-term methods. In Mali, for example, it averages about US$130, or Breastfeeding also plays an importar.t role in US34to US$5 per DALYgained (World Bank 1993c). child-spacing and can complement other family To ensure effective and sustained contraceptive planning methods. During the first six months after use, programs should provide high-quality, con- giving birth, a woman who is amenorrheic (having sumer-oriented family planning services that pro- no menses) and feeding her baby only breastmilk mote informed reproductive choice. Because receives 98 percent protection against pregnancy contraceptive needs and preferences change over a (Georgetown University 1990). Infant health also woman's lifetime, a good selection of short- and long- benefits from exclusive breastfeeding for the first six term methods (including voluntary sterilization for months and breastmilk supplemented with other people who want no more children) should be pro- food for up to two years. Health workers at all levels

Table 3.2: Essential Services for women's health Essentialheolth interventions Essentialbehavior change interventions

PREVENTIONAND MANAGEMENTOF UNWANTEDPREGNANCIES PROMOTIONOF POSITIVEHEALTH PRACTICES * Family planning * Delayed childbearing among adolescents * Management of complications from unsafe abortion * Safe sex * Termination of pregnancy * Adequate nutrition

PREGNANCYSERVICES * Increased male support Prenatal care ELIMINATING HARMFULPRACTICES * Prompt detection, management and referral of * Public education and services to discourage pregnancy complications gender discrimination, domestic violence, * Tetanus toxoid immunization and rape * Iron and folate supplements * Public education to discourage female genital * Iodine supplements, where iodine deficiency mutilation disorder is endemic * Malaria prophylaxis in endemic areas Safedelivery * Hygienic routine delivery * Detection, management and referral of obstetric complications * Facility-based obstetric care Postpartumcare * Monitoring for infection and hemorrhage PREVENTIONAND MANAGEMENTOF SEXUALLYTRANSMITTED DISEASES * Condom promotion and distribution * Prenatal screening and treatment for syphilis * Symptomatic case management * Screening and treatment of commercial sex workers Health and Nutrition Interventions for Women 21

should encourage mothers to breastfeed and con- be handled safely at primary-level health centers on sume an adequate diet to meet the added nutritional an outpatient basis by trained nurses, midwives, or demands it implies. paramedics using vacuum aspiration (McLaurin et Making contraceptives widely available can al. 1991; Rosenfield 1992). Dilation and curettage greatly reduce the incidence of unsafe abortion. In requires more surgical skill and anesthetic support. Santiago, Chile, for example, deaths and hospital- Health facilities that provide abortions or treat com- ization for complications from abortion fell dramat- plications arising from unsafe abortions can realize ically after free IUD insertions were offered in 1964. substantial savings by using vacuum aspiration. In As contraceptives became increasingly available one year, a single Kenyan hospital saved an esti- throughout Chile, abortion-related deaths and com- mated US$300,000-equal to the annual salaries for plication rates plummeted (Figure 3.1). Safer abor- 200 nurses-by switching from dilation and curet- tion, although still illegal, may also have tage to vacuum aspiration to treat incomplete abor- contributed to this result. tions (Kizza and Rogo 1990). Reducing the incidence of incomplete abortions would lower hospital costs Management of complications from unsafe abortion even more. Following an abortion, women should and safe services for pregnancy ternination. Women's receive counseling, services, and referrals as needed health care can be greatly improved by timely and to ensure they have the means to prevent unwanted appropriate treatment of abortion complications, as pregnancy in the future. well as providing postcoital contraception and safe Where abortion is legal but not widely available termination of pregnancy. Complications from (as in India), programs should strive to increase unsafe abortion (hemorrhage, shock, and sepsis) are access to safe abortion by delegating responsibility, often life-threatening and costly to treat, requiring training mid-level providers, and expanding the emergency referral, two to three days of hospital reach of services. In areas where abortion is routinely care, anesthesia, antibiotics, surgery, and blood used for birth control (as in parts of Eastern Europe transfusion. Vacuum aspiration abortion, provided and Central Asia), programs need to increase the by a trained health worker early in pregnancy, for availability of contraceptives and to provide post- example, is up to a thousand times safer than the abortion family planning information and services. clandestine abortion to which women are often Offering abortion or menstrual regulation as par- of forced to resort (Johnson et al. 1992). Safe abortion more comprehensive services often increases the use is one of the most cost-effective measures for reduc- of broader reproductive health services. In rural ing maternal death and disability. Bangladesh, for example, attendance at reproduc- Abortion during the first trimester and treatment tive health clinics that offer these services has been of incomplete abortion without complications can growing by 15 percent annually (Kay et al. 1991).

Figure3.1: Ratesof contraceptive use, abortion mortality,and hospitalizationfor abortion complications, Chile,1964-78

Contraceptiveuse, Mortality from abortion Hospitalization for abortion complications (women oge 15-44) (per 100,000 live births) (per 1,000 women, age 14-44) percent

110

20 10 20

16 6- zn015t_ 50 10 ~~~~~~~~~~~~0-10

6 ~~~~~~~~~~~~10 5

75 7* 74 7 1h04 3 5 70 7a t tie d l 74T 5 74 74 Year Year Year

Source:Adriasole et al. 1986. 22 Women'sHealth and Nutrition:Making a Difference

Pregnancyservices immediate attention of the health community as well as policy makers. Safe pregnancy services are designed to ensure Because most pregnancy-related complications timely detection, management, and referral of com- cannot be anticipated, all women need access to plications during pregnancy, labor, and delivery. appropriate care should complications develop. In About one in three pregnancies develop complica- Ethiopia, for example, maternity waiting homes tions requiring treatment from a trained provider, have been established near hospitals to bring and one in ten pregnancies require hospitalization. women living in remote areas to obstetric care before (A more detailed discussion of pregnancy-related the expected due date, if transport will be Jifficult services can be found in Tinker et al. 1993a). from their homes to the hospital (Brennani 1991; Becauseof their impact on the health of the child Poovan, Kifle,and Kwast 1990). as well as the mother, safe pregnancy services are Because newborns and mothers can contract highly cost-effective. Providing prenatal, delivery, tetanus from nonsterile delivery procedures, immu- and postpartum services costs less than US$2,000 nization against tetanus is especially important for per death averted, or between US$30 and US$250 women who deliver in nonmedical settings. per DALYsaved (World Bank 1993c). Immunizing pregnant women against tetanus costs In resource-poor countries, priority should be less than US$6 per DALYsaved, based on infant given to improving hygienic practices, providing deaths averted Oamison 1993). iron and folate supplementation, and strengthening The regular intake of iron and folate tablets can linkages and referral services for obstetric complica- prevent or cure anemia among pregnant and lactat- tions. In the former socialist economies of Europe ing women. Providing iron supplemental:ion for and Asia, preventive, client-centered, and updated pregnant women is highly cost-effective, at a deliv- practices are likely to have the greatest payoff. In ery cost of less than US$2to US$4per person annu- parts of Latin America where the health infrastruc- ally, or less than US$13 per DALYsaved, based on ture is relatively extensive, improving the quality of infant deaths averted (World Bank 1993c). Iron pills obstetric care and discouraging inappropriate med- should be provided routinely to pregnant women ical practices (such as excessiveuse of cesarean sec- and properly stored to protect quality. Pills ,an also tions) are likely to take priority. be made available through community-based distri- bution and commercial outlets. Health care provider Prenatalcare. Regular prenatal care is needed to training and consumer education can improve help detect and manage some pregnancy-related patient compliance. Fortification of commonly used complications (such as pre-eclampsia, infection foods (salt or sugar) with iron, iodine, and vitamin and obstructed labor) and to educate women A is even more cost-effective than supplementation. about danger signs, potential complications, and Where iodine deficiency is endemic, pioviding where to seek help. In Ethiopia and Nigeria, nurse- iodized oil to women of reproductive age is a low- midwives working with traditional birth atten- cost addition to existing maternal and child health dants referred women of short stature having their services, particularly where iodized salt is not avail- first birth to the hospital for delivery. This sub- able. However, the most effective long-term stantially reduced the number of maternal deaths approach to reducing iodine deficiency is iodlization from obstructed labor. Prenatal care is also an of salt for the whole community. Iodine supple- opportunity to provide preventive care that will mentation can reduce mental retardation ir. infants benefit the infant as well as the mother (such as and increase women's work capacity. Use of injected counseling on hygiene, breastfeeding, nutrition, or oral iodized oil every two to five years among family planning, tetanus toxoid immunization, women of reproductive age costs lessthan US$19per and iron/folate supplementation) and to treat DALYsaved, based on child-deaths averted (World existing diseases that may be aggravated by preg- Bank 1993c). nancy (such as malaria). Women who develop life- At about the fourteenth week of gestation, espe- threatening pregnancy complications must be cially in a first pregnancy, women's resistance to able to reach first-level referral centers. malaria begins to diminish. While providing bed Unfortunately, there is no established protocol for nets and antimalarial drugs to pregnant women in either the content or the timing of prenatal care. endemic areas can prevent severe illness and reduce This is an issue of concern for any maternal health the associated risk of low-birth-weight infants and safe motherhood program and deserves the (Steketee 1989), prompt diagnosis and proper treat- Healthand NutritionInterventions for Women 23 ment of malaria during pregnancy may be the most Postpartum care. Postpartum care should include cost-effective course of action. early detection and management of infection and hemorrhage, support for exclusive breastfeeding for Safe delivery. Delivery care should include safe six months, nutrition counselling and family plan- management of routine deliveries, safe-birth kits for ning services. Even among women who have deliv- traditional birth attendants, communication and ered in hospital, postpartum follow-tip is important transport to ensure timely referral and management because complications may arise after leaving inpa- of emergency complications, and essential obstetric tient care. Educating women, their families, birth functions at the first referral level. attendants, and community health workers to rec- Health agencies should be able to ensure ognize early signs of, and seek care for, infection, for hygienic routine delivery in the community by example, may be lifesaving. Antibiotic treatment is trained paramedics, particularly midwives, or tradi- sufficient to cure infection in more than 80 percent tional birth attendants. Most postpartum hemor- of cases if taken within four days of the onset of fever rhage, which is largely unpredictable, can be (Winikoff et al. 1991). prevented if skilled birth attendants effectively man- Postpartum care should respond to women's age the third stage of labor. Sepsis at delivery can be needs and preferences to ensure utilization and effec- largely prevented by minimizing vaginal examina- tiveness. In Tunisia, the innovative Sfax program tions and ensuring clean delivery practices. When delivers integrated family planning and health ser- rupture of the membranes occurs long before labor, vices to the mother and child by linking postpartum antibiotics should be provided. care with a cultural tradition. In addition to follow-up Most life-threatening complications occur dur- and counseling immediately after birth, the program ing labor and delivery, and since most of these can- provides health care services and information for the not be predicted, every woman needs access to mother and the infant on the fortieth day after birth, emergency obstetric care. Effective treatment of adayofreligiousandculturalimportanceforTunisian hemorrhage often includes rapid manual removal of mothers and children. In 1987 more than half the retained placenta, oxytocic drugs, intravenous flu- women who returned for the visit accepted a family ids, blood transfusion, and surgery. In cases of hem- planning method (Coeytaux 1989). The program has orrhage, obstructed and prolonged labor, now been adopted nationwide. hypertensive disorders such as eclampsia, and other obstetrical emergencies, the most important ele- Prevention and management of sexually transmitted ment in a woman's treatment may be transporta- diseases tion. Death from hemorrhage, for example, usually occurs within two hours of onset. When distance is At the primary health care level, efforts to control a factor, first aid at the community or health center sexually transmitted diseases should focus on pre- level may be necessary to stabilize a woman's con- venting transmission and treating infection in dition until she reaches the hospital. Advance plan- order to avert severe complications. Since the erner- ning for emergencies is therefore key to reducing gence of HIV/AIDS as a major public health prob- maternal death. lem and identification of STDs as risk factors for its Specially trained staff are needed to perform spread, primary prevention of STDs merits increas- some obstetrical procedures (cesarean section and ing attention. symphysiotomy for obstructed labor, laparotomy or Treating STDs costs only US$1 to US$55 per hysterectomy to stop persistent bleeding, treatment DALYsaved (World Bank 1993c). Preventing a single for eclampsia and sepsis, and repair of obstetric fis- STD case in a woman is estimated to be almosr 20 tulae). In Zaire, women's lives have been saved by percent more effective than preventing a single case nurses trained to perform cesarean sections (White, in a man (Over and Piot 1993). The efficiencv of Thorpe, and Maine 1987). transmission of many STDs is greater from men to Efforts must also be made to improve existing women than from women to men and the severity services. Major barriers to use of maternity care ser- of STDs (other than HIV) is generally greater in vices include long distances to health facilities, inad- women than in men. In addition, preventing and equate transportation, lack of funds to pay for curing STDs in women who are or may become preg- transport and health care fees, lack of knowledge nant reduces perinatal transmission. about the need for and benefits of formal medical The costs of treating STDs are much lower than care, and, in many settings, low quality care. the costs of treating their complications or the enor- 24 Women'sHealth and Nutrition:Making a Difference mous direct and indirect cost of widespread STD and keting project in Cameroon, an STD treatment kit is HIV infection (Piot and Rowley 1992). Although the sold in pharmacies. The kit contains antibiotics, lack of simple, inexpensive diagnostic tests for most instructions, a "partner referral" card to encourage STDs constrains control programs in areas with lim- partners to purchase the kit, STD information, and ited resources and facilities, syndromic diagnosis of condoms (FHI 1992). STDs-based on characteristic groups of symp- toms-can often be used in men, and risk-based Condom promotion and distribution. Aside from management approaches may be useful in sympto- abstinence or changes in sexual behavior, condoms matic women. are the most effective means of preventing sexual Factors such as the emergence of antimicrobial transmission of STDs, including HIV/AIDS. To pro- resistance, the prevalence rate of STDs in the popu- mote condom use, governments need tci lower lation, and the feasibility of reaching at-risk groups import duties and other fees (which typically raise (including partner notification) must be considered condom prices by 35 to 100 percent) and permit when weighing health program options. Health care condom advertising in the mass media. Subsidizing providers should concentrate on making services condom distribution and promotion is estimated to available to high frequency transmitters, particu- cost US$76 per DALYgained, taking into account the larly commercial sex workers, who contribute sub- impact of STDs, AIDS, and cervical cancer (a sec- stantially to the spread of infection. The ondary effect of some STDs) on adults and children. cost-effectiveness of interventions drops rapidly Factoring in family planning benefits reduces the when they are directed at the general population. cost per DALY gained (based on child outcomes) to Where the infection has spread beyond high-risk US$45, making condom distribution even more groups, a broader approach that includes women of cost-effective (Jamison 1993). childbearing age is important. Family planning and To date, subsidized commercial sales, commu- prenatal care services offer a valuable opportunity to nity-based distribution, and workplace programs provide STD counseling, screening, and treatment. have been effective in distributing condoms to both Because contracepting and pregnant women are high-risk groups and the, general population. A sexually active and therefore at risk, it is desirable and community-wide intervention in Zimbabwe distrib- cost-effective to offer STD counseling, diagnosis, and uted more than 5.7 million condoms and reduced treatment at clinics that also provide maternal and STD prevalence by 6 to 50 percent in different areas child health care and family planning; in addition, (World Bank 1993c). In Zaire, a 1987 mass media and clustering of services is cost-effective. Single-purpose condom marketing program was highly effective: STD programs often fail to reach women too embar- more than 80 percent of women surveyed had heard rassed to use them, and those who are asymptomatic about AIDS from the radio, and condom sales rose or who fail to recognize STD symptoms. By offering to seven times previous levels in one year 'Liskin et counseling, barrier contraceptives, and STD diagno- al. 1989). In a program in Tanzania sponsortd by the sis and treatment, family planning and maternal African Medical Research Foundation, trai!.ed peer health programs can help prevent STD transmission educators (mostly prostitutes) have been effective in and STD complications. Counseling should include distributing condoms (D'Atre 1992). the risks associated with STDs, such as effects on infant outcome and greater susceptibility to ectopic Prenatal screening and treatment for syphilis. Cost- pregnancy, as well as increased likelihood of HIV effectiveness estimates for treatment of syphilis vary infection. Health workers at all levels-including tra- greatly, depending upon its prevalence, assurnptions ditional birth attendants-should be trained to rec- about the risk of transmission, and the case-detection ognize STD symptoms and to use appropriate strategy used. In most developing countries, sero- treatment and referral protocols. Health workers logic screening for syphilis using the Rapid Plasma should also be trained to counsel on condom use, Reagin (RPR) test, which provides immediate results, identify sexual contacts, and assist in notification of and treatment with penicillin (where indicated) is a partners, when necessary. simple and inexpensive approach, with significant Drugs for treating STDs should be included on payoffs for infant outcome (Schulz et al. 1992). national essential drug lists, and the drug distribu- Accordingly, screening and treatment of syphilis dur- tion system should be streamlined. Distribution ing prenatal care is recommended. A project in should be encouraged through commercial chan- Zambia reduced the incidence of syphilis among nels and subsidized as necessary. Under a social mar- pregnant women by 60 percent within one year at a Healthand Nutrition Interventionsfor Women 25 cost of US$0.60 per prenatal screening and US$12 per tially from a countrywide strategy-involving gov- maternal syphilis case averted (Hira et al. 1990). ernment, NGOs, and even the commercial sector- The most serious consequence of gonorrhea and to inform the public and change health-related chlamydia in pregnant women is the occurrence of behavior. Such a concerted effort to foster the adop- ophthalmia neonatorum (a severe eye infection that tion of practices that improve women's health pro- can cause blindness in newborns). Routine antibi- vides a necessary framework for health service otic prophylaxis for this condition in the newborn, interventions. Supportive health policies, including which costs only $1.40 per case averted, is recom- laws, government regulations, and health care pro- mended rather than screening and treatment of all tocols, are also essential. Policymakers attempting to pregnant women (Schulz et al. 1992). address chronic health problems and new concerns would do well to consult health care workers and Symptomatic case management. Syndrome-based representatives of women's groups for their opinions treatment of gonorrhea, chlamydia, and genital on the limitations of present policy and suggestions ulcer diseases in symptomatic men is recommended. for reform. Legal initiatives and monitoring are Symptomatic women with genital ulcers or pelvic important for accelerating social changes. inflammatory disease should also be diagnosed and treated using clinical algorithms developed by Promotion of positive health practices WHO. By following the step-by-step guidelines developed by WHO, health workers can match Information, education, and communication pro- patient symptoms with those for locally prevalent grams can change the attitudes and practices of both STDs and provide treatment accordingly. Clinical men and women, health care providers, opinion and laboratory diagnosis of sexually transmitted dis- leaders, and policymakers. Through broad educa- eases is generally not feasible in low resource coun- tion programs using mass media, community meet- tries, particularly in rural areas, because of cost and ings, outreach workers, marketplace displays, and the unavailability of trained technical personnel and other communication channels, health agencies can laboratory equipment (Lande 1993; Piot and Rowley promote clinic attendance, educate consumers on 1992). healtlhy lifestyles and treatment alternatives, allay fears, refute false rumors, help shape social norms, Targeted screening and treatment of commercial sex and build a constituency for women's health and workers. When targeted to frequent transmitters of nutrition programs. Entertainment media have infection, screening and treatment can be extremely proven effective for promoting a variety of health- cost-effective. A project to diagnose and treat STDs related behaviors (including family planning, AIDS among prostitutes in Nairobi, Kenya, for example, prevention, better nutrition, and smoking cessa- reduced the mean annual incidence of gonorrhea in tion). Educational programs in clinic waiting areas this group from 2.85 cases per woman in 1986 to reduce the time needed to inform patients about 0.66 cases per woman in 1989. The project also health matters. markedly reduced the incidence of other STDs, Public education programs and counseling help including HIV; at approximately US$8-US$12 per women learn how to recognize the signs of disease case, the project prevented an estimated 6,000 to and convey information on when and where tc seek 10,000 new cases of HIV infection (Moses et al. help. Consumer education can enable women to 1991). treat minor ailments at home while urging them to Efforts are now underway to develop rapid, accu- seek timely intervention at the first sign of serious rate diagnostic methods for resource-poor settings problems. The promotion of specific household and to introduce them into STD programs through behaviors (such as handwashing and boiling water) the STD Diagnostics Initiative. Formed in 1990 by an can have a noticeable impact on the entire family's international group of STD experts, the initiative is health. Teaching women and family members to rec- working on the development of quick, inexpensive ognize the danger signs during pregnancy and to tests for chlamydia, gonorrhea, and syphilis. seek prompt medical attention can greatly reduce the incidence of maternal deaths. In Zaria, Nigeria, Essential Behavior Change Interventions a radio campaign stressing the dangers of a labor lasting more than twenty-four hours is credited with In addition to adopting the health care measures a significant decrease in the incidence of obstetric outlined above, countries can also benefit substan- fistulae (Harrison 1986). 26 Women'sHealth and Nutrition:Making a Difference

Delayed childbearing among adolescents. Favorable while campaigns promoting delayed childbearing laws and regulations have a major impact on the seem to be well received, there has been little analy- availability and accessibility of contraceptives and sis of their specific effects on behavior. abortion. Where early marriage contributes to early childbearing, governments can raise the legal age of Safe sex. Safe sex has been defined as sex that is marriage and provide encouragement and incentives safe from unwanted pregnancy, disease, or the for young women to postpone marriage and remain unwanted use of power in sexual relationships (IPPF in school. Proscriptions regardingcontraceptives and 1993). Because most people know little about sexu- medical procedures and spousal consent require- ally transmitted diseases and HIV/AIDS transmis- ments can be relaxed. Health agencies can have far sion, symptoms, and long-term risks, public more impact if they can ensure adolescents and education programs need to inform people of the unmarried women access to confidential reproduc- reasons for adopting preventive behaviors (includ- tive and sexual health information and services, pro- ing abstinence, monogamy, nonpenetrative sex, tected by law, and courteous, sensitive treatment. condom use, and other behaviors that reduce expo- Health workers need to publicize the harmful sure) and for seeking treatment when needed. effects of early childbearing and closely spaced preg- Despite some controversy, mass media campaigns nancies through a variety of channels. By advocat- have been effective in informing the public about ing postponement of the first birth until age sexually transmitted diseases and AIDS and chang- eighteen or later and at least two years spacing ing sexual behavior. Following a nine-month mass between births, health agencies can promote public media campaign in Mexico, for example, condom discussion and help to change social norms. Satisfied use rose among university students, prostitutes, and users of contraception can be used as peer motiva- other audiences (Liskin et alt 1989). tors to reinforce these messages. In general, women know less about sexually Programs need to target adolescents as a discrete transmitted diseases and AIDS than do men, leam group (Box 3.1). Messages, media use, outreach pro- grams, and service outlets need to focus on adoles- cents' preferences and appeal to them directly. Whenever possible, adolescents ,hould be involved When the GenteJoven ("Young People") program in planning, especially in the needs assessments, of the Mexican Family Planning Foundation was program design, and message testing aspects. In gen- established in 1986, Mexican schools did not pro- eral, education programs which are implemented by vide sex education. Gente Joven filled the gap by peers have been more effective than adult-directed bringing information on sexuality and family initiatives. Multiservice centers that integrate recre- planning to young people in poor urban areas. Its ation and education with health services are effec- goals are to: tive in recruiting adolescents but may be costlier per * Providea foundation to enable teenagersto mnake contraceptive user than family planning clinics or their own informed decisions, rather than simply outreach activities (Senderowitz 1994). providingcontraceptives. Gente Joven focuses on Both girls and boys need to understand the the emotional and social issues that adjles- cents experience as well as the biological and reproductive process. Schools should provide clnia aspercs o exuality. instrctionin reroducivehysioogy ad sexedu-clinical aspects of sexuality. instruction in reproductive physiology and sex edu- * Recognizethe gender differencesbetween boy.>and cation-not only information on when conception girls that influence their sexual activity and con- occurs and how to prevent it but also negotiating traceptive use. For example, a study on AkIDS skills-as part of family life education or as an inte- prevention revealed that girls are reluctant to gral part of the school curriculum, starting before bring up condom use because it might be inter- sexual activity has begun. Studies have shown that preted by boys as evidence of too much sexual access to counseling and contraceptives does not experience. Gente Joven incorporates such encourage earlier or increased sexual activity information into its program strategies. (Grunseit and Kippax 1993). * Focuson how ideas are communicated, as well as Mass media campaigns can be effective in reach- on what the message conveys. Video and radio ing adolescents. In Jamaica, the National Family are particularly effyetivntehjven because they Planning Board broadcast TV and radio spots and atinglwith eenagers. songs with the message "Before you be a mother, you got to be a woman" (Church and Geller 1989). Yet Source:Marques 1993. Healthand NutritionInterventions for Women 27

about them later, and are less likely to hear about school meals, and other supplemental feeding pro- them from the mass media (Liskin et al. 1989). grams may be helpful in improving girls' nutrition. Personal contacts with individual women or groups Even with little increase in household speading of women may be needed to convey related infor- on food, nutrition education programs can influ- mation effectively. Women can be approached at ence food selection, preparation techniques, adher- places where they usually meet, such as clinics, ence to food prescriptions, use of vitamins and other school3, market squares, and farmlands, or through supplements, and the treatment of diarrhea and grassroots organizations such as market women's other diseases that inhibit food absorption. Nutri- associations, women's media associations, women's tion education programs have been successful in a clubs, and church groups (Post 1993b). Educational variety of settings in promoting breastfeeding and programs should reach women of all ages, including appropriate weaning foods. They can also be used to women of childbearing age, young girls before they promote low-cost, nutritious foods that are readily become sexually active, and older women, who available and the cultivation of micronutrient-rich often educate and advise youth. crops in home gardens as an effective way of ensur- Counseling in negotiation skills can help ing an adequate supply of suitable foods for dietary women to persuade their partners to use condoms, improvement. A project in West Sumatra, Indonesia, and condom promotion campaigns can change for example, promoted dark green leafy vegetables men's negative image of condoms. Over the long (rich in iron and vitamin A) through the radio and term, fundamental attitudinal and behavioral other media. After the 1987-89 campaign, the pro- change is needed to make gender relations more portion of pregnant women who consumed -:hese equitable, so that women have more power to pro- vegetables daily rose from 19 to 32 percent (Favin tect themselves against unwanted pregnancy and and Griffiths 1991). A similar project in Brazil, which disease and men share responsibility for the sexual promoted a more nutritious diet for pregnant health of their partners. Outreach programs are also women along with prenatal care, reduced low birth needed to promote condom use among men. weight among infants by nearly 50 percent in one Intensified research to develop effective female-con- area (Victora et al. 1991). trolled methods of sexually transmitted disease pre- vention (such as a vaginal microbicide) is urgently Increased male support. With the support of i:heir needed. partners, women need to assume greater control over their health and well-being. In many cultures, Adequate nutrition. Health agencies can help to men are the decision-makers in such health-related inform people about women's nutritional needs at concerns as food purchases and distribution within different stages of the life cycle and serve as advo- the family, family size, birth spacing, and the use of cates for better diets for girls and women. In addi- health care. In Senegal, for example, a study seeking tion, government agencies can identify the need for to learn why so few women used maternal health programs to address contributory problems (such as services found that only 2 percent of the women poverty, women's heavy workload, high fertility, interviewed said they would decide for themselves lack of safe water supplies, and poor sanitation). to seek care in the event of pregnancy-related cam- Health workers can be trained to recognize nutri- plications. For most, the decision rested with their tional deficiencies and to counsel patients on cor- husbands (Thaddeus and Maine 1990). Men also rective measures. To be effective in countering influence women's health directly through t-ieir harmful food taboos and changing food allocation own behaviors. Education programs and services patterns within households, messages must be tai- directed to men are needed to promote contracep- lored to local conditions. tive use, safe sex, and reduction of substance abuse High priority should be given to improving nutri- and violent behavior. tional intake among young and adolescent girls in Health and other agencies need to make a con- order to prevent health problems in later life. certed effort to make men aware of women's health Adequate intake of micronutrients, especially cal- problems and encourage them to take responsibility cium and iron, is especially important. In areas where for the effects of their behavior. Reaching boys, both girls receive less or poorer quality food than boys, in and out of school, with reproductive health edu- health workers need to make an extra effort to edu- cation is important because men so often dominate cate caregivers on the long-term consequences of this the sexual relationship. School-based and rr ass practice. Special initiatives such as home visits, media programs that reach boys at a young age can 28 Women'sHealth and Nutrition:Making a Difference be particularly effective in shaping later attitudes family planning have generated useful public dis- and practices. cussion. One poster, featuring a doleful pregnant To date, few health and nutrition education pro- man asking: "Would you be more careful if it was grams have been targeted to men. Examples of male- you who got pregnant?", has been adapted for use oriented programs are found in Honduras, Kenya, in eight countries (Gallen et al. 1986). and Thailand, where breastfeeding promotion cam- paigns urge men to help their lactating wife by pro- Eliminating harmful practices viding her with extra food and liquids, assuming extra chores to enable her to rest, and encouraging In addition to educational and policy meas)ires to her to continue breastfeeding (Green 1989). In Mali, promote positive health practices, governments and the Nutrition Communication Project has mounted health agencies need to address harmful practices a multimedia campaign to persuade men to provide associated with women's subordinate status (such as women with additional and more nutritious foods discriminatory access to food and health care, geni- during pregnancy (Fishman et al. 1991). tal mutilation, and gender violence). Because these Men need to assume more responsibility for their practices arise from the general social, economic, fertility. To increase men's role in preventing and cultural environment, cooperation and coordi- unwanted pregnancy, family planning programs nation on a wide scale is needed to change them. need to reach out to men to promote the use of male By emphasizing the health aspects of h armful methods of contraception, support for their part- practices, governments can promote public aware- ner's contraceptive use, and increased spousal com- ness of their significance, prevalence, and impact. munication about family size goals, fertility Health workers can be trained to recognize and treat regulation, and disease prevention. One approach is the health conditions that result from these practices, to provide men-only hours or clinics. In five while health agencies can document them and iden- Colombian cities, PROFAMILIA, a Colombian fam- tify their causes and potential interventions fcr their ily planning association, has created men's clinics, control, as well as disseminate related information. annexed to a longstanding program directed pri- marily to women. The clinics provide family plan- Gender discrimination. Health planners, man- ning and diagnosis and treatment of urological and agers, and providers can help sensitize policyniakers, sexual problems, infertility, and sexually transmit- community leaders, and the general public about ted diseases (Rogow et al. 1990). the profound impact that gender discrimination has The imbalance in contraceptive responsibility is on the health, well-being, and productivity of particularly evident for voluntary sterilization. women-and their children. In resource-poor coun- Despite the advantages of vasectomy over female tries, public education programs on these topics can sterilization in lower health risks, cost, and recuper- be provided as part of the Essential Services for ation time, female sterilization procedures predomi- women. In informing the public, health workers nate in nearly all countries. In Latin America, women need to stress the high human costs of neglect and obtain 93 percent of the sterilization procedures mistreatment of girls and women-includirg the (PAHO 1993). Even in Thailand, where vasectomy long-term implications of inferior care for girls and has been heavily promoted, women obtain four in the deleterious effects of poor nutrition and early five sterilizations (Ross et al. 1993). The "no-scalpel" childbearing. technique of vasectomy, which has further simplified While increasing public awareness is a necessary the procedure, should be made more widely available first step, the ultimate goal is the adoption of posi- and promoted. Also, research is needed to provide a tive social norms and health behavior. Govern- wider array of male contraceptive options. ments, therefore, will need to provide active support Since women bear the major consequences of for interventions designed to change behaviors, first unplanned pregnancy, requiring men to meet their on a limited-scale and later on a national level. parental obligations might motivate them to take a Policies, cultural practices, and social norm; that more active role in preventing pregnancy. Few coun- perpetuate women's low status need to be reexam- tries have policies requiring men to take financial ined. Higher levels of education and vocational responsibility for their offspring, and there is no evi- training for women, greater participation i-i the dence about whether such policies have any impact labor force, and improved access to income, land, on sexual behavior or fertility. Proposals for initiat- and credit will also raise women's status and influ- ing campaigns to promote male responsibility for ence gender-power relations. Healthand Nutrition Interventionsfor Womei 29

Genital mutilation. Governments and NGOs, institutions, it is difficult to change without con- including professional organizations and women's fronting these underlying issues directly. That groups, should be encouraged and supported to means that the health sector must go beyond treat- work to eliminate the practice of genital mutilation. ing the consequences of violence by examining the Enactment of laws and clear policy declarations pro- roots of cultural and social legitimization of bodily hibiting female genital mutilation may help to dis- harm and male control over female behavior and courage its practice, although more broad-based encouraging other public and private institutions to efforts are needed. Widespread public education play a more active role in addressing them. programs can publicize the harmful effects of geni- In most countries, laws fail to protect the victims tal mutilation and address its cultural roots. Local of domestic violence or to punish its perpetrators. research may be needed to determine its prevalence, Many violent crimes go unreported because the vic- the cultural reasons for its perpetuation, and the tims are afraid of the perpetrator and of society's skep- harmful health, social, and economic consequences, ticism, its condemnation of victims, and ostracism. as well as to test effective approaches (Box 3.2). Where violence against women is condoned or pun- Health workers can help disseminate this informa- ished lightly, laws should be strengthened to seive as tion to the community. a deterrent. Key legal changes include removing bar- riers to prosecution (such as requiring witnesses and Domestic violence and rape. Because violence evidence of permanent injuries), eliminating prac- against women is deeply rooted in gender-based tices that are prejudicial to women (ignoring com- power relations, sexuality, self-identity, and social plaints of women who are not virgins, exonerating

Box 3.2: Eliminating female genital mutilation

Every year two million girls are subject to genital Practices Affecting the Health of Women and mutilation. Unlike male circumcision, in which the Children are working to focus attention on this foreskin is removed without damage to male organs, issue and to bring about its elimination. Since mill- female circumcision involves the cutting and tiple cultural and social factors contribute to the removal of parts or all of the external female genitals. continuation of this practice, it is best handled Practiced mainly in Eastern and Western Africa (with nationally, with involvement of local women's and an estimated prevalence of at least 50 percent in professional groups. Benin, Burkina Faso, Central African Republic, Chad, In Burkina Faso, a national committee to eradicate C6te d'lvoire, Djibouti, Ethiopia, Gambia, Guinea, female genital mutilation was established in 1990 by Guinea-Bissau, Kenya, Liberia, Mali, Nigeria, Sierra presidential decree. The committee has established Leone, Somalia, Sudan, and Togo), it is also found in provincial groups, held workshops, and developed a parts of Asia and the Middle East (such as Egypt, film and teaching materials (IAC 1993). In Kenya, India, and Yemen). Prevalence is highest in Somalia Maendeleo ya Wanawake Organization (MYWO), a and Djibouti where 98 percent of women are subject women's organization, conducted a study on female to genital mutilation, 80 percent or more of them in genital mutilation in the area. The study found that its most extreme form (Toubia 1993). approximately 90 percent of women interviewed In Genital mutilation has serious, and sometimes the study area had undergone genital mutilation. fatal, physical consequences as well as psychological Even though most circumcised women reported effects. Immediate consequences include excruciat- having experienced problems due to circumcision, ing pain, hemorrhage, tetanus, and sepsis. Long- more than 65 percent expected to have their daugh- term consequences include scarring, urinary tract ters circumcised. Additional qualitative research pro- infections, painful intercourse, obstetric fistulae, dif- vided some explanations for this practice and belief. ficulty during urination and menstruation, and Circumcision signifies a rite of passage, conferring complications in childbirth. maturity and respectability. A girl who is uncircuni- Female genital mutilation has been discussed as cised is considered unfit to become a wife and both a human rights and a health issue. In 1990, mother. Benefits such as education, gifts, celebra- the Convention of the Rights of the Child con- tions and privileges are bestowed on the circumcised demned female circumcision as torture and sexual girl. The MYWO developed a communication pro- abuse. The Forty-sixth World Health Assembly in gram to re-educate community leaders and change 1992 adopted a resolution that promotes the elim- agents, parents, elders, and youth and is currently ination of female genital mutilation and other exploring ways of eliminating the practice of female harmful traditional practices. Organizations such genital mutilation (Matovina 1992, Toubia 199.-, as the Inter-African Committee on Traditional WHO 1993b). 30 Women'sHealth and Nutrition: Making a Difference rapists who agree to marry their victims), and ensur- such as contraceptive choice for all reproductive-age ing that married women have access to family assets women. A surveillance system to assure the quality and are free to leave abusive relationships. of obstetric facilities and home-based maternal Health and family planning workers can be an health care can substantially enhance matemity care important source of support and referral for victims services. Services that might be added to the Essential of violence. They can also exacerbate the situation Services include the cost-effective management of through insensitive and judgmental behavior. chronic diseases (particularly cervical cancer) and Sympathetic treatment and providing a space to talk expanded measures to address the biological and can facilitate healing. Experience has shown that social aspects of women's health throughout the life most women will disclose abuse if questioned by a cycle. On the other hand, procedures with low cost- sympathetic health care provider. Increasingly, spe- effectiveness (such as routine ultrasound testing) and cialized counseling, legal, and support services are unnecessary surgical interventions (such as unwar- available to assist abused women who are referred ranted cesarean sections and hysterectomies) should from health care settings. Even where no special ser- be discouraged in all settings (Box 3.3). vices are available, health providers can be trained to emphasize that no one deserves to be beaten or to Expansion of Essential Services be blamed for being raped. In many countries, NGOs are raising awareness Increasedchoice of contraceptive methods. As family about the problem of violence against women. In planning programs expand to cover more clients Honduras, Jamaica, and Nicaragua, NGOs have used through a larger network of outlets, including inten- theatrical productions to generate public discussion sified outreach to adolescents, so should the range on this topic. One group has also protested against of contraceptive methods offered for delaying, spac- objectionable portrayals of women and violence in ing, and limiting pregnancies. Each method added the media (Heise et al. 1994; Popular Education attracts new users and expands the choices for cur- Research Group 1992). rent users, increasing overall contraceptive preva- lence and continuation rates and more successfully Expanded Health Interventions meeting women's differing needs. Analysis of data from seventy-two developing countries found that For developing countries with the financial resources access to a range of methods strongly affected con- and political will to go beyond the Essential Services, traceptive prevalence, while studies in Hong Kong, the Expanded Services provide a more comprehen- India, Korea, Taiwan (China), and Thailand found sive set of interventions and therefore more adequate that adding a new contraceptive method generated health services for women (Table 3.3). For lower- new adopters (Freedman and Berelson 1976). income countries that initially adopt only the Strengthening the referral system can help to Essential Services, the Expanded Services can be expand method choice by providing access to spe- incorporated incrementally, with the first priority to cialized facilities offering methods such as steriliza- expand and improve the quality of Essential Services, tion and natural faminlv planning.

Table 3.3: ExpandedServices for women's health Additionalhealth interventions Additionalbehavior change v,;terventions

EXPANSIONAND IMPROVEMENTOF ESSENTIALSERVICES INCREASEDATTENTION TO EARLY- REVENTION * Increasedchoice of contraceptivemethods * In-schooleducation about reproductivephysiclog,y, * Enhancedmaternity care sexuality,and reproductivehealth * Expandedscreening for and treatmentof sexually * Publicinformation and servicesto prevent transmitted diseases unwanted pregnancyand sexuallytransmitted * Extendednutrition assistanceto vulnerablegroups diseases * Screening,treatment, and referralfor victims of * Educationabout women'sincreased nutritional violence needs CANCERSCREENING AND TREATMENT * Educationabout smokingand substanceabuse * Forcervical cancer from agethirty-five STRATEGICEFFORTS TO REDUCEGENDER DISCRIMINATION * For breastcancer from agefifty (where resources AND VIOLENCE permit) GREATERFOCUS ON WOMENBEYOND REPRODUCTIVE AGE * Educationabout nutritional requirements * Self-helplinks with supportnetworks Health and Nutrition Interventions for Women 31

In settings with sufficient infrastructure, post- Enhanced matemity care.As the health infrastruc- coital contraception can be used to help prevent ture improves, maternity care services should be unwanted pregnancy and reduce the need for abor- upgraded to include expanded routine and referral tion, including among adolescents and rape vic- care, with increased coverage and full-service oostet- tims. The major postcoital methods are ric facilities. More detailed information on expand- combination pills containing estrogen and prog- ing maternity care services can be found in Making estin and IUDs, which have failure rates of under 2 Motherhood Safe (Tinker et al. 1993a). percent if administered within three and five days In prenatal care, increased attention needs to be of unprotected intercourse, respectively (Van Look given to the quality of care and a more compre- 1990). A new drug called RU-486, which can be pro- hensive strategy for improving women's health. vided within the first sixty-three days of pregnancy Special efforts should be made to reach marginal- and is combined with a dose of prostaglandin, ized groups, such as adolescents and the poorest shows promise as a nonsurgical method of early women. To improve the quality of care, maternal abortion. The current regimen requires medical death audits should be introduced, and efforts supervision, although alternatives are being stud- should be intensified to coordinate supervision and ied. More information on the cost of RU-486 and back-up from hospital to community level. Services on infrastructural and medical back-up require- will need to be decentralized and women redirected ments is needed before its widespread use can be to health centers for routine care, since referral sites advocated in low-income countries (Sundstrom will tend to become overwhelmed by derrand. 1993). Birthing centers located near hospitals may provide

Box 3.3: Inappropriate practices in women's health

When misapplied, some health care practices can Unwarranted cesarean sections jeopardize the health of the women they are intended to benefit, as well as squander valuable Under appropriate conditions, cesarean section can resources that could benefit larger numbers of be a life-saving procedure for the mother and infant. women. However, the incidence of cesarean sections is not always justified on medical grounds. In Brazil, for Misplaced emphasis in prenatal care example, the cesarean rate exceeds 30 percent (PAHO 1993). Cesarean rates range from 5 to 20 percent in Appropriate prenatal care with back-up for man- developed countries (Chalmers et al. 1989). Misuse of aging obstetric complications is essential for cesarean sections not only adds to health care costs maternal and child health. However, many coun- (the additional cost imposed by cesarean sections in tries emphasize the frequency of prenatal visits, Brazil in 1985 was $13.4 million) but also exposes rather than the quality of care provided. This women to far greater health risks than they face dur- emphasis on number of visits strains the resources ing vaginal deliveries. Studies in Latin America in,li- of both the individual (travel costs, waiting time) cate that the decision to perform cesarean sections is and the health system. Prenatal care is often overly based not only on maternal or fetal need, but also on dominated by an ineffective effort to predict preg- health care providers' and hospitals' economic con- nancy complications, most of which are, unfortu- siderations (PAHO 1993) and the convenience of nately, unpredictable. Because of this, access to both the provider and patient. treatment for complications must be available for all women. Misdirected screening for cervical cancer In the former Soviet republics, pregnant women are seen at least twelve times (and often over The limited cervical cancer screening conducted in twenty) during pregnancy, and prenatal visits are developing countries is generally provided through marked by numerous diagnostic and lab tests, family planning and maternal and child health clin- including routine ultrasonography. Despite these ics. Such an approach erroneously targets younger many visits, there appears to be little prenatal women rather than the women aged thirty-five counseling and education regarding nutrition and years or older who are most at risk. Screening family planning (Weinstein et al. 1993). When women from the age of thirty-five has been shown properly conducted, good quality prenatal care can to be at least 90 percent as effective as screening be provided through as few as three to six prenatal from the age of twenty-five, and to cut costs by one- visits. third (Miller 1992). 32 Women's Healthand Nutrition:Making a Difference a low-cost alternative for routine deliveries, as has made available to women with symptoms sug- been found in Mexico. gestive of STDs and to asymptomatic women, As deliveries become increasingly institutional- especially those considered at risk, who attend ized, providers need to resist the overuse or abuse of prenatal, family planning, or primary health care medical technologies and to emphasize client-ori- facilities. ented care, including preventive and promotive * Partner notification. By placing increased empha- counseling. Women should be encouraged to seek sis on notifying the partner of a person diag- the support of family members, and babies should nosed with a sexually transmitted disease, health be kept with their mothers. These "mother and baby workers can reduce the spread of such diseases, friendly" practices are now being introduced to including HIV/AIDS, and prevent reinfection countries in the former Soviet Union, replacing the after treatment of STDs. Because men more fre- common practice of separating mothers from new- quently have symptoms, they may be more borns and family members and keeping them in the likely to seek care. Furthermore, partner notifi- hospital for an unnecessarily long time for routine cation can lead to earlier treatment for women deliveries. with sexually transmitted diseases, thereby reducing the rate of serious complications, such Expanded screening for and treatment of sexually as pelvic inflammatory disease. transmitted diseases. Health agencies can increase * Reducing the transmission of HIV througl blood coverage for the screening and treatment of sexually transfusions. Pregnant women, in particular, have transmitted diseases as resources permit. Key inter- an increased exposure to blood transfusions. ventions include: Educating health care providers about possible * Expanded screening and treatment of high fre- risks and establishing guidelines for blood trans- quency transmitters. Efforts should be further fusions can reduce the number of transfusions by intensified to reach high-risk groups, which more than 50 percent at a negligible expense include, in addition to commercial sex workers, (World Bank 1993c). Where there are blood the men who hire them, truck drivers, and banks, screening of donated blood can be added migrant laborers. Projects in Peru, Tanzania, for an additional cost of about 5 percent. Where Thailand, and Zimbabwe have successfully per- such facilities are not available, rapid tests (such suaded prostitutes and their clients to use con- as the dipstick) are needed. doms more regularly. Thailand's program of 100 * HIV counseling and testing. Where HIV prevalence percent condom use in brothels now covers is high, women of reproductive age should receive sixty-six of the country's seventy-three pro- counseling and have the option of being tested for vinces (Rojanapithayakorn 1992). As part of a HIV. HIV-infected pregnant women should be social marketing project in Cameroon, prosti- provided with counseling about the risk that their tutes trained as peer educators have sold 19 per- child may be HlV-infected and informed of their cent of the condoms distributed, with the options, including abortion, and, where afford- added benefit of reducing their dependence on able, antiretroviral therapy with AZT, which may prostitution for income (USAID 1991). reduce risk of transmission to newboms by as * Detection of and treatment for genital ulcers, vaginal much as two-thirds (MMWR 1994). discharge, and pelvic inflammatory disease. Efforts should be expanded to all women of reproduc- Nutrition assistance for vulnerable groups. While tive age and should cover a broader range of the Essential Services focus on nutrition assistance reproductive tract infections, particularly vagi- for pregnant women, Expanded Services should nal discharge. While treating patients with extend this assistance to other groups at risk of mal- symptoms can help to avert serious complica- nutrition, including young and adolescent girls, and tions and the further spread of sexually trans- elderly women. Special programs for refugees and mitted diseases, the majority of women with dislocated persons may also be needed. STDs are asymptomatic. Furthermore, diagnosis Nutrition strategies fall into two major cate- of syndromes, such as abnormal vaginal dis- gories: decreasing energy loss by controlling fertil- charge, requires use of risk-based algorithms ity, preventing infections, and reducing the and/or simple diagnostic tests. Therefore, in set- physical workload; and increasing intake by tings where diagnostic facilities exist, specific improving the diet, reducing inhibitors that limit diagnosis and appropriate treatment should be the efficiency of food absorption, and providing Healthand NutritionInterventions for Wome'7 33

food and micronutrient supplements. Nutrition * Food fortification. Adding micronutrients (such as programs should assess the nutritional status of girls iron, vitamin A, and iodine) to processed foods and women at risk and provide food supplements can be a simpler and quicker means of improv- as needed, improve nutritional habits through ing nutritional status than changing diets. To be counseling and public education, identify appro- effective, fortified foods must be readily avail- priate local food sources and proper food prepara- able, widely consumed by the target population, tion and storage practices, and educate men and and relatively inexpensive (World Bank 1993c). women about improving women's dietary habits Food fortification is a cost-effective option where and food allocation within the family. In collabora- adequate infrastructure is in place. tion with other agencies, nutrition programs should promote delayed pregnancy until after the teenage Screening, treatment, and referralfor victims cf vio- years, birth-spacing intervals of at least two years, lence. Health care providers can play a key rcle in fewer pregnancies per woman, and greater use of identifying survivors of violence and referring them labor-saving technologies (Ghassemi 1990). to appropriate social and legal services. Only a few Because inadequate calcium contributes to osteo- simple questions are needed to screen for physical or porosis (bone loss), which accelerates after sexual abuse. Screening programs can be introduced menopause, calcium intake is critical, especially in prenatal clinics, emergency rooms, and other during adolescence. health facilities to assess women's risk of exposure to Governments can promote better nutrition by violence. Health facility protocols designed to iden- ensuring that low-income families have the tify victims of violence can help ensure timely i nter- means to purchase nutritious foods. Measures to vention and gather information on the severity of ensure adequate food supplies include consumer the problem. Health care providers and other pro- price supports for staple foods, transportation sys- fessionals who deal with women need to be trained tems, income transfers for vulnerable households, to recognize signs of abuse, record information on food distribution, dietary diversification, and the incidence and consequences of violence, pro- food fortification. vide sensitive counseling and treatment, collect Three major types of nutrition interventions can legal evidence for prosecution, and refer victims to be used to improve the nutritional status of women appropriate services. and girls: At least forty developing countries have N,3Os * Food supplementation. If properly targeted and that assist survivors of violence through rape crisis tailored to local market conditions, food sup- centers, centers for battered women, support groups, plementation programs can have a substantial legal aid, counseling, and other services. A few gov- impact on nutritional status (World Bank ernments-including those of Brazil, Mexico, and 1993c). In Guatemala, for instance, pregnant Papua New Guinea-also provide services to bat- women who received food supplements had tered women and rape victims. Malaysia has fonned babies with higher birth weights than women women-only teams at police stations and hospitals. who received no supplements (Villar and Rivera In Costa Rica, one NGO trains teachers, therapists, 1988). Generally, food supplementation pro- and social workers to run self-help support groups grams are costly to implement and maintain. for victims of sexual abuse (Heise et al. 1993). Nevertheless, they may be the only effective Specific violence-related services that health means of improving the nutritional status of agencies should offer are: extremely poor populations. * Postcoitalcontraception for rape victims. Offeiing * Micronutrient supplementation. Appropriate postcoital pills, IUD insertion, or abortion to micronutrient supplementation throughout the rape victims can spare them the additional life cycle-such as iron and folate pills, vitamin trauma of unwanted pregnancy. A capsules, and iodized oil-can be highly * Screeningand referral.Health workers can perfcirm effective in overcoming vitamin and mineral an important service simply by breaching the deficiencies (World Bank 1993c). Most micronu- wall of silence that surrounds abuse and putting trient programs cost less than US$50 per DALY women in contact with services designed to deal gained (McGuire etal. 1993). For more details on with violence-related problems. Screening micronutrient programs, see Enriching Lives: should be conducted privately and be as non in- Lessons from Micronutrient Programs (McGuire et vasive as possible, as part of a more general al. 1993). process of questioning about the woman's sex ual 34 Women'sHealth and Nutrition:Making a Difference

and gynecological history. Clinic staff should A program that screens all women over the age contact local women's groups to familiarize of thirty-five for cervical cancer at five-year intervals themselves with support services. Often, advo- costs an average of US$100 per DALY gained. cacy groups and crisis centers have information Increasing the screening interval reduces the cost materials that can be displayed in waiting areas. Uamison 1993). In countries where resources are Record-keeping.To interrupt the cycle of violence, more limited, feasible and cost-effective screening health care providers need to take special care to programs should treat only severe dysplasia or car- collect and document evidence of rape and cinoma in situ, and use such relatively inexpensive assault in a form that is adequate for later legal outpatient treatments as cryotherapy and loop elec- action. Such information can also be used to doc- trode excision procedures (Sherris et al. 19931). ument the extent of violence as a social problem. Breast cancer. Early detection is equally impor- Cancer screening and treatment tant for breast cancer. The inclusion of breist can- cer management in the Expanded Services will Early detection of cancers is important because treat- depend on local prevalence and resource availabil- ment is most effective in the early stages of the dis- ity. The most cost-effective method of breast cancer ease. The cost-effectiveness of cancer-screening screening is physical examination (both by the programs depends on the incidence of the disease, woman herself and by health care providers). the technical feasibility of screening and treatment Physical examination alone can detect abcut two- at early stages, and the possibility of targeting high- thirds of the cancers detected by mammcgraphy. risk groups. Where additional resources are available and breast cancer is common, mammography can be used as a Cervical cancer. Screening for cervical cancer is diagnostic tool, although this increases the cost ten- particularly cost-effective because the disease can be fold when done on an annual basis. Screen .ng pro- treated relatively easily in its early stages. The most grams that include periodic examinatio i by a common screening method is the Pap smear, but trained health worker and a mammogram once a other, more economical methods (such as visual year for women aged fifty to sixty-nine car reduce examination, either unaided or aided by low-power breast cancer mortality by 30 to 40 percent when magnification, and acetic acid treatment of the appropriate treatment is provided (Miller et al. cervix) are now being evaluated for clinical use. 1990). Treatment of breast cancer, however, requires Treatment of preinvasive cervical lesions is very suc- relatively expensive surgery, radiation thern.py, and cessful and can be conducted cost-effectively using chemotherapy and is not likely to be cost-t ffective cryotherapy and loop excision. Treatment for more in many developing country settings. advanced stages requires surgery and sometimes In countries where the incidence of breast cancer radiation, which are both far less effective and more is on the rise (due to declining fertility, dietary influ- expensive (Miller 1992). ences, and environmental carcinogens) and ade- Studies have shown that screening all women quate resources are available, breast cancer screening once in their lifetime prevents many more cases of and treatment may form a component of the cervical cancer than screening a small proportion of Expanded Services. Breast cancer screening is not women every few years. The goal should be to screen generally recommended unless resources a ^e avail- every woman thirty-five to forty years of age at least able to appropriately screen at least 70 percent of once in a lifetime. If more resources are available, the women in the target age group (Miller et al. 1990). frequency of screening could be increased to every Furthermore, cancer screening alone provides no ten years for women thirty-five to fifty-five years old. benefits; resources must also be available for the If resources increase and a high proportion of the tar- appropriate treatment. get group is being screened and resources permit, screening should be extended, first to older women Expanded Behavior Change Interventions (up to the age of sixty) and then to younger women (down to the age of twenty-five) (Miller 1992). In Most health services have paid little attentic n to the parts of Africa, incidence appears to occur earlier special health needs of school-aged girls and adoles- than in other countries, so that targeting women cents, which differ from those of young children and younger than thirty-five before targeting women adults. Adolescence, in particular, is a period of rapid over fifty-five may be more cost-effective. physical growth, physiological changes associated Health and Nutrition Interventions for Women 35

with puberty, and mental stress. Overall health and tings-regardless of age or marital status. Restricting nutritional status during these formative years car- adolescents' access to contraceptive information ries over into adulthood. It is also the time when and services has not reduced premarital sexual activ- unhealthy behaviors, such as early pregnancv, ity, but it has left adolescents without the means to smoking, and drug abuse, may begin. make responsible choices and protect themselves Health services, therefore, could realize substan- from unintended pregnancy, sexually transmitted tial benefits by intensifying programs for school-aged diseases, and HIV. girls and especially adolescents. Messages, media use, Young people and their caregivers are often outreach programs, and service outlets need to unaware of the increased need for energy-producing appeal to these young women directly by focusing on foods and micronutrients during adolescence to sup- their needs and preferences. In general, reaching port physical development and prepare young them through existing institutions, such as schools women for childbearing. Nutrition education, Dro- and networks of their peers, is more cost-effective vided through multiservice and vocational training than motivating them to come to a new site. Since centers, has been effective in improving adolescents' peer education programs have been more effective nutritional status. It is also important that young than adult-directed initiatives, youth should be people take part in food production, and that the involved in program planning and implementation. entire family learn about nutrition and supplenien- tal feeding programs (WHO 1986). Health education for early prevenition In all countries, adolescence is a period wien important lifestyle patterns are established, making For greatest benefits, health education efforts should it an important time to influence decisions about the influence behavior that affects a child at the earliest use of tobacco, alcohol, and drugs. Since smoking is possible stage of development. Nutrition programs increasing fastest among young women, public edu- should also focus on girls' nutritional requirements cation programs, school curricula, and advertising during early childhood to prevent undernutrition, regulations can place special emphasis on persujad- poor weight gain, and growth retardation. ing young women not to smoke. Mass media cam- Working through education systems, govern- paigns can counter advertising directed to young ments can provide information to girls and adoles- women that portrays smoking as glamorous and cents on general health and disease prevention, sophisticated behavior. Governments can also contraception, sexually transmitted diseases, restrict the advertising and sale of tobacco products HIV/AIDS, substance abuse, and nutritional needs. to minors, tax such products, and regulate tobac-co School curricula can also cover communication production and imports. Messages need to stress :he skills, strategies to resist peer pressure, and negotiat- hazards and disadvantages of smoking and to pro- ing techniques. A curriculum on "Life Planning," mote alternative strategies for coping with stress. which emphasizes experiential, interactive learning and puts sexuality in a broader life context, has Increased efforts to rediucegender discrimination proved successful in increasing knowledge and and violence changing attitudes (WHO 1992a). Governments can also support nonformal education programs, includ- Instead of merely treating injuries, malnutrition, ing peer education and community outreach, in and other health problems that derive from society's order to reach adolescents where they live, learn, general neglect of women, governments can mcve work, and play. vigorously to address gender discrimination and vio- With the AIDS pandemic making early sexual lence. Countries that can afford to go beyond the experimentation potentially life-threatening, it is Essential Services should define clear strategies lor particularly vital that young and adolescent girls reducing discriminatory attitudes and practices aid understand the basic facts about sexuality and repro- gender-related violence. Much more can be done, ductive health so that they can make responsible for instance, to document and publicize the effects decisions about their sexual behavior. Through edu- of gender inequity and to develop appropriate out- cational programs and counseling, health care reach programs. providers can stress the dangers of early childbear- Health agencies should concentrate on three ing and the serious consequences of sexually trans- major areas: mitted diseases. Sex education and contraceptive * Public education initiatives. Much can be accomn- services must be made available in all cultural set- plished simply by bringing to widespread pub] ic 36 Women'sHealth and Nutrition:Making a Difference

attention the damage to women's health and adequate levels of calcium. To reduce the risk of bone productivity caused by social practices that favor fracture after menopause, women should be encour- males and by violence against women. Public aged to improve their diet, exercise regulaily, stop education initiatives can work to influence the smoking, and reduce their consumption of alcohol. content of popular radio and TV programs, to Although estrogen therapy is known to retard bone educate media representatives, and to promote loss, it is not yet a cost-effective public health mea- feature and news stories and group discussions sure for developing countries (Lindsay 1993). on the subject. As women approach menopause (generally * Health care training. Regular pre- and in-service between the ages of forty-five and fifty-five), they training for health care providers is needed to need counseling about the physical and mental sensitize staff to practices that are harmful to symptoms that may develop as their estrogen lev- women, and to teach the skills needed to address els decline. For most women, these symptoms are them. Health care providers need to be aware of relatively mild and subside within two years. In possible barriers to communication with female counseling menopausal women and helpir.g them clients and of ways to elicit women's judgements to cope with hormonal changes, healsth care about their own health needs and to address providers should be instructed to be reassuring and them effectively. compassionate. * Community participation. Although health care The number of widows in both the reprcductive providers can deal with only a fraction of the and post-reproductive years is growing in c.evelop- myriad problems associated with discrimination ing countries because women tend to manTy men and violence against women, they can put who are older than they are and because of high women in touch with other agencies and orga- male mortality, especially in countries with a high nizations that can provide other kinds of assis- prevalence of AIDS. The incidence of widowhood is tance. To do this, health care providers need to also increasing in the transition economics of establish a network of relations with related ser- Eastern Europe and Central Asia, mainly due to mor- vices (including law, education, employment, tality among middle-aged men from cardiovascular credit, and community resources) and support disease, combined with rising divorce rates. With networks of professionals and community increasing widowhood and divorce, and changing activists. household composition, an increasing nuTnber of households are headed by women who may need Women beyond reproductiveage assistance to meet their domestic, childrearing and economic responsibilities. Many women now live To improve the health and productivity of women alone, which contributes to their isolation and can aged forty-five and older, as well as the associated make it difficult for them to eat properly aniJ main- costs of curative care, requires more attention to pre- tain their health. In some places, widows are subject vention through diet and exercise; avoidance of to active discrimination, exacerbated by inheritance tobacco, excessive alcohol consumption, or other laws and customs that fail to protect their rights. harmful substances, beginning early in life and con- Sustainable solutions will need to rely on efforts tinuing through and after menopause; screening for to integrate older women into the community and cervical cancer and other chronic diseases to the increase their capacity for self-help. Health care extent resources permit; and health education to providers can relieve the isolation of elderly women promote self-help. While many chronic health prob- and improve their medical and social condition by lems are not cost-effective or possible to treat, at the linking them with support networks such as day cen- least, pain relievers can be provided at low cost. ters for the elderly, peer groups, and agencies that Health care providers should advise women of all provide food and housing. For example, the Center ages of the importance of an adequate diet. of the Aged in India promotes community-based ser- Osteoporosis, for instance, which accelerates after vices such as day centers for elderly people, ol-ten run menopause, is best prevented through early intake of by the elderly themselves (Tout 1989). Chapter Four Issuesfor National Program Planning

Bringing about real change in women's health * Collaboration - collaborating with NGOs and requires strong government commitment. From private-sector providers poverty reduction to economic efficiency and inter- * Health education - promoting healthy behaviors generational benefits (described in Chapter 1), the and discouraging practices harmful to women arguments are solid for assigning a high priority to * Information and evaluation - collecting gender- women's health. A favorable policy environment specific data and monitoring progress on and adequate resources are required. Much can be women's health and nutrition. accomplished by redirecting public financing away from tertiary facilities, specialist training, and less Broadening Policy Support cost-effective curative care to the highly cost-effec- tive packages of Essential and Expanded Services Governments can use legal and regulatory mecha- (Chapter 3) and by delivering services more effi- nisms to support improvements in women's health ciently. Involving women in planning and design and nutrition that can have far-reaching effects. A makes service delivery more responsive to women's health-oriented policy agenda beneficial to women needs and improves the utilization and impact of should seek to: services. * Invest more in female education. Women who are Policymakers should also foster cooperation with better educated take better care of their own the private sector-including NGOs-to get more health and that of their children. Investing more out of a country's health care resources and to help in female education and reducing access barriers extend health care to women not reached by gov- for women can, therefore, improve both ernment programs. Some countries have established women's health and the health of their families. an office in the ministry of health to develop and All girls should be encouraged and given equal monitor a women's health policy and action plan, opportunity to attend school, including those in coordination with focal points on women in who become pregnant. other parts of government and with representatives * Strengthen legislative and other support for women's of women's groups. Finally, governments should nutrition. Four policy initiatives can make a big routinely collect and analyze gender-specific health difference in women's nutritional status: nation- data as a basis for policymaking, resource allocation, wide fortification of foods with iodine and iron; and the design and evaluation of programs. consumer food subsidies and targeted food dlis- This chapter discusses the actions that govem- tribution; dissemination of labor-saving devices ments can take immediately to improve women's for women; and better access for women to agri- health: cultural extension services and to credit for * Policy support - adopting supportive legislation, small-scale business. policies, and regulatory mechanisms * Reduce discrimination against females. Discrimina- * Financing - providing financial and other sup- tory policies affect women's health by restricting port for specific women's interventions their ability to adopt healthy behaviors and Ii m- * Service delivery - expanding coverage and iting their opportunities for economic advance- improving the quality of services ment. Examples of such policies are legicin, * Women's involvement - integrating women into ranging from employment practices that handi- the planning, implementation, and evaluation cap women, to limits on women's control over process family resources, restrictions on women's ability

37 38 Women'sHealth and Nutrition:Making a Difference

to travel or obtain credit, and laws permitting providers other than physicians. Unimpeded by early marriage for women. In most countries, for such restrictions, nurses and midwives could example, the legal age of marriage is at least two provide most of the Essential and Expanded years lower for women than for men-in most Services for women. Modifying current p.-actices Latin American countries, girls can marry at age successfully, however, will require the support of fourteen or younger. professional associations representing physi- *Abolislh practices harmfil to women's health. Policy cians and other health practitioners. interventions have the power to influence prac- * Encourage private-sector participation. (iovern- tices that harm women or are injurious to their ments can offer subsidies, tax incentives loans, health. Through legislative action, legal enforce- clinic space, equipment, free publicity, and other ment, and public education, governments can benefits to private-sector providers to encourage influence such practices as female genital muti- them to better meet women's health care needs. lation, violence against women, and the market- To ensure that private providers offer high-qual- ing of tobacco products. Governments can ban ity services, governments can establish perfor- certain practices or lend their authority to cam- mance standards and monitor indicarors of paigns to change public attitudes and behavior. service quality. Government regulation can be They can levy taxes on tobacco products and carried out, for example, through licensing other harmful substances, restrict their sale, and exams and periodic reexaminations of health regulate their advertising. By enacting and professionals; accreditation of health worker enforcing criminal penalties for violence against training programs; facility inspection; and mon- women, governments can establish a deterrent itoring cesarean sections and maternal deaths. against such crimes. * Remove legal impediments to the effective delivery of Improving the Equity and Efficiency of Health health services. Governments can change laws Financing and regulations that restrict women's access to essential health services. Examples are restric- One of the most difficult issues in health policy is tions on legal access to contraception and preg- deciding how to allocate public resources to achieve nancy termination; barriers to service use based the greatest impact on a country's overall health sta- on age, marital status, or other factors; spousal tus. The World Development Report 1993 argues that consent requirements; and import duties on con- governments can develop a national package of traceptives and drugs (Box 4.1). highly cost-effective public health interventions * Support appropriate training and delegation of and essential clinical services, which, if tbroadly responsibility. Particularly in rural areas, women's extended to the population, could substaintially access to health services c;;n he improved by reduce the national burden of disease. Any national removing legisiative and licensin-g obstacles to health package that is designed to maximize cost- allow increased responsibility for health care effectiveness and reduce the national burden of dis-

Box 4.1: Women's health ancl human rights

Increasingly, human rights safeguards in national health professionals, and women's organizaticins- constitutions and in regional and international needs to be aware of women's rights and to docu- human rights conventions are being used to pro- ment both violations and conforming practices. For mote and protect women's health. The leading inter- example, health services that require wome i to national instrument on women's equal rights is the obtain their husbands' authorization discriminate 1979 Convention on the Elimination of All Forms of against women, can limit their access to necessary Discrimination Against Women. States that ratify or health care, and relegate them to a secondary role. accede to the convention pledge to eliminate all Where such requirements exist, they should be forms of discrimination against women, including repealed. Where they have been repealed, the result- discrimination in health care and family planning. ing health benefits should be documented. States also agree to provide maternal and other Governments should develop standards to er sure essential health services to enable free and informed that laws, policies, and practices comply with :heir choice. obligations to respect and ensure human rights for Everyone concerned about women's health- women through health practices and concerns as health policymakers and managers, organizations of much as in other areas (Cook 1993). Issuesfor National Program Planning 39 ease will necessarily give considerable weight to through private providers and NGOs, for example. health interventions for women, because, as dis- Whether it provides the services itself or not, how- cussed in Chapter 3, many such interventions pro- ever, the government has a key role to play in pro- duce large health gains relative to their costs. Within viding policy direction and guidance, promoting this framework, the Essential Services for women efficient and cost-effective approaches, and facili- identified in this paper would represent a subset of tating private participation in service delivery. the national health package. Cost recovery and targeting public expenditures Selecting interventions for public finance to the poor

The criteria for the selection of and the financing In countries with severe constraints on public finds arguments for the Essential Services for women par- for health care, user fees may be unavoidable to help allel those presented in the WDR 1993 for the support the Essential Services for women and other broader national health package. The most cost- elements of the national package. Within an appro- effective interventions are selected for inclusion in priately designed price structure, user fees can the package, provided they also address a substantial encourage the efficient use of referral systems and share of disease burden in a given country. As more allow scarce public funds to go further. Overall, resources become available, permitting a more com- health system costs can be reduced, for example, by prehensive package, the next most cost-effective providing free services by paramedical health interventions are added. providers at local health centers while charging for As the WDR 1993 argued for the broader national the same services in hospitals, thereby reserving spe- health package (Box 1.1), there is a strong argument cialized care for complicated cases. Modest user fees for public funding of the subset of public health that are rolled over to improve service quality can interventions in the package of Essential Services for even increase the use of services by the poor (Litvack women because of their nature as public goods-one and Bodart 1993). User fees can also be used to fully individual can use or benefit from them without recover costs from services outside the national limiting others' consumption or benefit. The private package. Everything beyond the essential or sector will not supply public goods because it can- expanded national package is discretionary and not easily charge for them. Public information cam- could be financed from private sources (out-of- paigns about family planning are an example. Public pocket or through insurance). finance is also easily justified for some clinical ser- vices because of the large positive spillover effects- Protectingpoor women. In designing user fees, it is externalities-from treatment: a case of a sexually important to incorporate mechanisms to protect transmitted disease averted or treated, for example, the poor. There are several types of targeting mech- benefits not only the woman treated but others in anisms that can be employed. The practical use of society (including her offspring) who might later any targeting mechanism will depend on its impact have contracted the disease. Also, fairness and on demand, its administrative costs, its technical equity argue strongly for the provision of free or and managerial requirements, and the level of polit- highly subsidized Essential Services to poor women. ical support. Poor individuals, identified on the Services for more advantaged groups can be financed basis of income or nutritional status, can be pro- out-of-pocket or through insurance. vided with the Essential Services free or on a slid- Not surprisingly, there is a tradeoff between the ing scale. Vouchers can be provided, to give the population covered and the comprehensiveness of poor a broader choice of providers. Subsidized health services that are publicly-financed. As argued Essential Services can also be targeted to easily iden- in the WDR 1993, the more narrowly that interven- tifiable subgroups of the population, such as the tions can be targeted just to the poor, the more com- population of a poor neighborhood. Self-targeting prehensive the services in the package can afford to is applicable if services have characteristics that be. As national health packages become more com- imply that only the poor tend to use them (time prehensive, so too would the women's health inter- costs, fewer amenities, for example). These same ventions included in the package. characteristics, however, may also deter much of Not all the health services financed by govern- the poor population from using services. Finally, ment need to be provided by government. Govern- public expenditures can be targeted by type of ser- ments can finance maternity care for poor women vice. If STDs are more prevalent among the poor, 40 Women'sHealth and Nutrition:Making a Difference then free or highly subsidized STD services would tially life-saving procedures except in ihe pres- disproportionately benefit the poor. ence of higher-level personnel. If user fees are imposed on the poor, they would To serve the greatest number of women, all have to be very low, and demand for services should Essential Services should be made available at the be monitored to ensure that they do not restrict most peripheral level of care appropriate. Health access to care. User fees may constitute a severe care at the community level, backed up by referral impediment to low-income women with limited facilities, is especially important for women, since resources and weak claims on household resources. both normal and complicated pregnancies require a When user fees were introduced for some services at range of medical interventions. Incentives to the Ahmadu Bello University Hospital in Zaria, encourage health care providers to work ir. remote Nigeria, in 1985, the number of obstetric admissions communities can increase access to services. fell. Admissions dropped even further when addi- tional charges were levied in 1988, and maternal Designing delivery strategies to meet women's teeds mortality rose in the hospital's catchment area (Ekwempu et al. 1990). Similarly, the number of Outreach programs can extend the reach of services women attending a public outpatient clinic for STDs to girls and women and ensure that referrals to in Nairobi, Kenya, plummeted by 65 percent after higher-level centers are made as needed. Through user fees were imposed; male attendance decreased home visits to parents who neglected to take their by 40 percent (Moses et al. 1992). underweight children to a feeding center, for exam- ple, a Punjabi child health and nutrition project Strengthening Service Delivery reduced mortality rates 11 percent for girls under age five in twenty-six rural villages. Because workers Governments can influence the coverage and qual- from the center supervised the feeding, they were ity of health services through attention to the fol- able to redress a food allocation system that favors lowing areas: access to services, delivery strategies, boys (Pebley and Amin 1991). Where women's travel infrastructure, promotion of services, quality of care, is severely restricted (as in some Muslim countries), number and distribution of female health care outreach and community-based services are espe- providers, and responsibilities of non-physicians. cially important. Mobile clinics can also bring ser- vices closer to women. Increasing women's access to care Clustering services for women and children (such as family planning, postpartum care, and well- Many factors make it harder for women to get the baby care) at the same place and time often pro- health care they need. These are some of the most motes positive interactions in health benefits and common: reduces delivery costs for providers and tirne and * Adolescents' health needs are ignored and their travel costs for women (Leslie 1992). In Ethiopia, uti- sexuality is denied. lization rose substantially following the integration * Household decisionmakers may be less willing to of curative care, growth monitoring, vaccination, commit resources for the health care of females prenatal care, and family planning services (Walley than for males, and women generally have less et al. 1991). Programs also need to address con- income than men and lack control over family straints on girls and women's time. In a supplemen- resources. tal food program in India, women were found to be * Because of multiple roles in the workplace and at more likely to participate if food rations were pre- home, women often have difficulty getting away pared in advance and women could pick them up on at the times when services are offered. the way to the fields (King et al. 1986). * Cultural norms and lack of resources often make Integrating services requires some vigilance, how- it difficult for women to travel to distant sites for ever, to avoid overburdening health care providers, medical care. planners, and supervisors, or downplaying women's * Women often lack information about self-care health services. In integrated maternal and child and about when health care is needed or where health programs over the past three decades, for it is available. example, maternity care was overshadowed by child * Health providers may lack the basic training to survival strategies. Also, the more varied the range of provide the Essential Services for women and services, the greater the need for training and tech- may be prohibited from practicing certain poten- nical resources. Therefore, in developing integrated Issuesfor NationalProgram Planning 41

programs, every effort must be made to ensure atten- ity, accessibility, and efficiency of services can be tion to the full set of Essential Services and to reduce made. Instead of using overcrowded hospitals in the time spent by health care providers on less cost- urban areas for routine deliveries, for example, effective (mostly curative) services. birthing centers can be established close to hospi- In some contexts, separate services for women tals, as is now being done in Mexico City. may be appropriate. Adolescent girls, in particular, Health workers at all levels require basic equip- are not likely to use general maternal and child ment and supplies (including contraceptives, iron health services and may prefer facilities that are spe- and folate tablets, safe-birth kits, diagnostics for sex- cially designed to offer young people sympathetic, ually transmitted diseases, and antibiotics). A World nonjudgmental counseling. Women may prefer a Bank study in India found that a program to reduce separate, private setting for fertility regulation. anemia among high-risk women failed because only Because of women's limited resources and time and 12 percent of intended beneficiaries were offered varying needs, it is important that health care deliv- iron and folate tablets-and almost 80 percent of ery points be conveniently located and provide as these women dropped out because of a shortage of much choice as possible in specialized and inte- tablets (World Bank 1992c). grated services. Improving the quality of services for women Strengthening the health care delivery infrastructure Even where health services are readily available and To improve women's health, governments will often affordable, women may not use them if their qual- need to shift resources from centralized, tertiary-care ity is poor (Parker et al. 1990; Simmons et al. 1990; facilities to health services at the district level. CIAES 1991). Studies have found that quality of care Additional resources may be required to improve the is a significant factor in a woman's decision to seek infrastructure of district hospitals, health centers, prenatal care (Parker et al. 1990; Locay et al. 1990; and health posts; finance ambulances, other vehi- CIAES 1991), to give birth at a clinic instead of at cles, and communication systems for referrals; home (Sargent 1989), or to continue using contra- expand training for primary health care providers; ception (Mensch 1993). and set up reliable and efficient supply systems (Box Poor quality services generally result from a lack 4.2). Where infrastructure is weak or absent, health of infrastructure, insufficient staffing or high absen- facilities need to be strengthened and equipped for teeism, lack of female health care providers, inade- essential obstetric functions (including surgery, quate training, insensitivity to patients, shortages of anesthesia, and blood transfusion). In areas with bet- equipment and supplies, and inadequate monitoring ter infrastructure arid functional supervision and and supervision. Several factors may work to creat a support systems, further improvements in the qual- negative perception of service quality. Inconvenient

Box 4.2: A continuum of care at the district level

A minimum health delivery system to safeguard screening and treatment for STDs, and detection women's health should include community-based and referral of obstetric complications to a higher- care with a referral system, health centers, and first- level facility. Hospitals, or adequately equipped and referral facilities that can handle complicated cases. staffed health centers with twenty or more beds, At the community level, the most effective strategy should be able to provide essential obstetrical ser- is to emphasize prevention: family planning, safe vices twenty-four hours a day as well as the full pregnancy care, early detection and prompt treat- range of family planning and abortion manage- ment of sexually transmitted diseases, and coun- ment services. Transportation is often the missing seling on nutrition and breastfeeding. Local link between a medical emergency in the commu- education programs through schools and the mass nity such ns hemorrhage or obstructed labor and media are important to promote positive health life-saving skills at the referral center. In some set- practices and reduce gender discrimination and tings, a telephone or radio can link communities to violence. Local health centers, staffed by nurses or medical advice and follow-up. (A more detailed dis- midwives and (where resources allow) physicians, cussion of the continuum of care from community should provide family planning counseling and to the first-referral level, particularly for safe moth- services, maternity care, treatment of complica- erhood services, is found in MakingMotherhood Safe, tions of unsafe abortion, safe abortion services, Tinker et al. 1993a.) 42 Women'sHealth and Nutrition:Making a Difference

hours, limited services, poor treatment by staff, long vations (such as water and toilet systems and facil- waits, inadequate supplies, lack of privacy or confi- ity upgrading) to ensure privacy for women dur- dentiality, and overcrowded waiting rooms all reflect ing physical examinations and counseling. poorly on service quality and standards. There are several key initiatives governments Increasing the numberofrfemale health care providers can take to improve the quality of women's health services: Some cultures discourage women from consulting * Providercompetence. Training curricula and super- male health care providers. In Egypt, for example, visory systems should cover topics related to most trained health care workers are male, and women's particular health care needs, such as the women often avoid seeking treatment (Krieger and management of pregnancy-related complica- El-Feraly 1991). In such cases, increasing Ihe num- tions and the special needs of adolescents. ber of female health workers could improve service Health care workers may have to acquire new quality and use (Chatterjee and Lambert 1989). In technical skills, such as the use of the partograph some settings, however, similar barriers prevent in labor or manual vacuum aspiration, to man- female providers from working in remote areas. In age pregnancy complications and make appro- recognition of this problem, the Aga Khan priate referrals. Physicians, midwives, nurses, Development Network in Pakistan has trained and community-level workers need an under- women to work in their own communities as lady standing of women's health and an understand- health visitors. ing of the social, cultural, and psychological Female health care providers can play an impor- aspects of sexuality and reproduction. Greater tant role in educating women to recognize their gender awareness and good communications health and nutrition needs. In Gujarat, India, women skills are also important. health workers from the SARTHIproject offer victims - Infortned choice and counseling. For many of violence individual and community support women's health interventions, counseling as (Khanna 1992). In Longhus, China, women health well as gender sensitivity is critical. Because professionals visit pregnant women in their homes to women are often unfamiliar with preventive teach couples how to monitor delivery and i:ecognize measures and treatment alternatives, health care danger signs requiring treatment (Shen 1985). providers need to provide full information and In virtually all developing countries, trained tra- counseling on these issues to help women assess ditional birth attendants, nurse-midwives, mid- their own health care needs (Bruce 1990). A wives, and general physicians are the primary study in Rwanda showed that HIV counseling, providers of women's health services. And. in most including a thirty-five minute videotape, was developing countries, trained health care providers, associated with increased condom use and particularly midwives and physicians, are concen- reduced rates of gonorrhea and HIV infection trated in urban areas. Unsuitable accommodations among urban women (Allen et al. 1991). in rural areas, cultural restrictions on women work- * Continuity of care. Programs should include mech- ing in areas where they have no family, or the need anisms to ensure continuity of care and follow-up, to seek employment near their husbands work especially for family planning, prenatal and post- against the rural deployment of female health care partum care, and the prevention and treatment of providers. Some francophone African countries sexually transmitted diseases. Good provider- guarantee women a position near that of their hus- client relations are critical to effective follow-up, band, with the result that a disproportionate num- since patients are most apt to follow the advice of ber of midwives are assigned to urban hospitals. health care providers they know and trust. In addi- Some countries have addressed this problem by tion, procedures are necessary for recording requiring all newly qualified physicians arid nurses patient history, setting follow-up appointments, to serve in rural areas (WHO 1991c) and by encour- scheduling home visits or other outreach services, aging local communities to provide free housing for and ensuring referral to other facilities. health care providers. * Privacy. Health care providers should ensure that women can speak with them in confidence and Delegating responsibility to non-physicians that physical examinations are performed with appropriate respect for privacy. In the Philippines, Many countries have laws and practices that make it the World Bank is financing infrastructure reno- difficult for health care providers who are not physi- Issuesfor National Program Planning 43 cians-particularly midwives-to administer certain design and administration (Kardam 1991). T he essential women's health services. In many par's of active involvement of program beneficiaries also the world, midwives cannot legally use vacuum leads to increased use of services. In Peru, contra- extractors or forceps for delivery, give oxytocic drugs ceptive use jumped by more than 50 percent in the without a physician's order, or prescribe antibiotics. project zone after the women's organization Peru- Midwives need to be trained so that they are capa- Mujer engaged low-income women in the design of ble of providing independent care, particularly in educational materials on family planning (Figueroa rural areas. In Zaire, women's lives have been saved 1992). by allowing nurses, who are more readily available Bringing female health care providers into lead- than physicians during births, to perform cesarean ership positions in the health sector-not only in sections (White et al. 1987). traditional women's roles, but also in the manage- The shortage of physicians (especially women ment, decision-making, and supervision of health physicians) in some developing countries is well rec- planning, financial management, implementation, ognized, but less attention has been given to the and :esearch-will also help to shape health care shortage of trained nurses and midwives, t .ich may programs for greater impact on women's health. be worsening in some areas. A trained nurse-midwife Women need to be included in adequate numbers in must be able to give the necessary supervision, care, clinical studies and trials, so that the findings are rel- and advice to women during pregnancy, labor, and evant to women as well as men. the postpartum period, and to conduct deliveries and care for the newborn and infant (WHO 1993a). Strengthening Collaboration WHO estimates that one midwife can handle about with the Private Sector 200 deliveries a year; in a community with a crude birth rate of about 40 births per 1,000 population, To achieve widespread and efficient coverage of the therefore, one midwife would be needed for every Essential Services, govemments will have an interest 5,000 people (Kwast 1991). By these calculations, in encouraging a private sector role in financing and the number of midwives is seriously deficient in service provision. Throughout the developing many countries (Kwast 1993). All women should world, numerous NGOs, financed publicly or pji- have reasonable access-within two hours wherever vately, provide health and nutrition services to possible-to a health center with a nurse-midwife. women-often to poorer, difficult to reach groups-- Traditional birth attendants currently assist in and are actively engaged in community develop- about 60 to 80 percent of all births in developing ment. At the other end of the income range, countries (Leslie and Gupta 1989). Where reliance for-profit, private-sector providers can complement on traditional birth attendants is commonplace, government health services by providing Essentiail superimposing a system of govemment-supported Services to those who can afford them and offering prenatal and delivery care is likely to be less effective a broader array of health care options beyond the than designing services to complement and national package. strengthen existing patterns of care. A cadre of trained midwives could serve as the link between Nongovemmental organizations communities, traditional birth attendants, and the formal health care system. Governments can assist NGOs to provide women's health and nutrition services by simplifying regis- Integrating Women Into Health Planning tration procedures, providing tax incentives and and Implementation subsidies, and offering training, office space, and supplies. Involving NGOs in program planning, The best way to ensure that service delivery strate- implementation, and evaluation often benefits gov- gies are designed with women's perspectives and ernment programs as well. multiple needs in mind is to consult women about Certain characteristics of NGOs may make therm the approaches they prefer. Local women should be particularly well suited to reaching underserved oi invited to serve on committees to advise on plans, disadvantaged populations, such as refugee groups, procedures, and materials. According to outside more successfully than government services. Known experts, for example, the success of the Tamil Nadu in the community, they are able to test and adapt Integrated Nutrition Project owed much to the new approaches to health care delivery and can prominent role of local women in the project's complement and enhance government services. 44 Women'sHealth and Nutrition:Making a Difference

They can also work in areas considered too contro- women in insurance policies and by providing sub- versial for government intervention. NGOs may be sidies to ensure their provision of Essential Services especially effective in educating communities on to low-income women. Insurance schemes that women's health issues, distributing supplies, and cover prenatal and delivery care, for instance, are influencing other sectors to become involved. useful in expanding women's health care. In 1984, NGOs can be effective agents of change by chal- the Mexican Social Security Institute, financed lenging existing services and delivery mechanisms mainly by employers, spent nearly US$40 million on and by bringing pressure to bear on decision-makers family planning services in urban areas-an invest- to meet women's health needs. Many women's ment that saved some US$210 million in maternity groups, even those that are not involved in deliver- care costs, US$10 million in treatment of incomplete ing health and nutrition services, can play a key role abortions, and US$130 million in health care for in making women aware of the health services that infants (Nortman et al. 1986). are available and encouraging their use. They can To expand access to health products that require also serve as a source of information to health pro- little or no medical intervention (such as certain gram planners about women's priorities and con- contraceptives, vitamins, malaria drugs and bed- straints they face in improving their health. In nets, treatment kits for sexually transmitted dis- particular, NGOs can promote intersectoral collabo- eases, iron and folate tablets, and fortified foods), ration in efforts to improve adolescent health and to governments can encourage sales through com- reduce violence against women. mercial outlets. Small shops, pharmacies, markets, The following examples illustrate the range of and street stalls that are conveniently located are an NGO involvement in women's health activities: underused resource for bringing health care to TThe Bangladesh Women's Health Coalition, women and reducing related travel and time costs. which began as an urban clinic offering men- Pharmacies in developing countries now serve strual regulation services, provides a wide range about fifteen million contraceptive users and could of reproductive health services to approximately potentially reach eighty-five million couples who 97,000 women and children in urban and rural can afford contraceptives (Lande and Blackburn areas. Its experience demonstrates that providing 1989). integrated services and improved care, such as treating clients with respect and ensuring pri- Intensifying Public Education vacy, can increase effective use of services at low cost compared to standard family planning clin- Public education programs can be used to advocate ics (Kay et al. 1991). new policies, change perceptions about unhealthy * The National Association of Nigerian Nurses and or harmful practices, promote clinic services, and get Midwives developed a communication program feedback from patients to improve the quality of ser- to advocate the eradication of female genital vice delivery. Broad public education programs can mutilation. Nurses and midwives discussed the help reach women who do not know what services harmful effects of female genital mutilation dur- are available or where to find them. They can help ing their health education talks in clinics and overburdened health care providers educate women included it as a topic in nursing and medical about healthy behaviors, danger signs, and other school curricula. In one state the association important health topics, and they can be simplified introduced a symbolic dress to replace the tradi- to reach women with little or no education. They tional scarring used to mark the passage into can help convince women that it is worth spending womanhood (Adebajo 1990). time and money and overcoming barriers to seek . The Cairo Women's Health Book Collective has health care. They can inform family and cc,mmunity published the only book of practical health infor- members who control women's access to health care mation for women available in Arabic (Ibrahim about its potential benefits. Health education in the and Farah 1992). schools can help teach young girls and boys pre- ventive health practices, human sexuality, and pos- For-profitproviders itive gender attitudes. Finally, public education can help reshape tradi- Governments can encourage private providers to tional beliefs and customs harmful to women's expand and improve services for women's health by health. Because women's health is heavily influ- mandating the inclusion of Essential Services for enced by socioeconomic and cultural facl:ors, effec- Issuesfor NationalProgram Planning 45 tive public education programs must be designed to genital mutilation, risky sexual behavior, inade- reach far beyond the clinic walls. quate food consumption during pregnancy, unsafe delivery practices, and smoking). While some Promoting health services and healthy behaviors behaviors have been well defined through research and programmatic activities, many women's health Both women and other family decisionmakers need and nutrition issues still need to be assessed before to understand the importance of maternity care, pre- specific public education strategies and messages ventive services, and good nutrition. Information can be developed. on women's health motivates women to adopt Although women constitute the major audience healthy practices and encourages supportive behav- for health-related education, people who influerce ior from other family members. Because of this, women's behaviors (parents, husbands, in-laws, and broad public education programs are needed to pro- village leaders) should also be targeted. Husbands mote women's health services and healthy behav- have a major impact on women's workload, diet, iors. Public education programs can also help exposure to sexually transmitted diseases, and use of women locate appropriate health services and con- health services and contraception. vey information about clinic hours, costs, and Since the mass media now reach vast audiences requirements for access. In areas where husbands, in developing countries, they have enormous poten- relatives, and community members are the principal tial to communicate information along with new decisionmakers on women's access to health care, values and ideas. Mass media campaigns have been these groups should be targeted to receive messages used for family planning, nutrition, breastfeeding that promote women's health services. promotion, and AIDS prevention. Songs, radio pro- grams, and films have been especially effective in Advocacy for policy change informing adolescents about responsible sexual behavior and pregnancy. In Latin America, a study Advocacy programs are designed to increase aware- found that two popular songs promoting abstinence ness of women's health problems among policy- influenced teenage girls to discuss sexuality issues makers (political, medical, media, and religious), to with their parents and others (PCS 1992). create a policy environment favorable to health Because women have lower literacy levels than reform both within and beyond the health sector, men and may have less access to mass media, per- and to lobby for improved women's health services. sonal sources of information, such as friends, rela- For example, the national women's commission in tives, teachers, outreach workers, and leaders, Chile has adopted an extensive program to promote remain important to behavior change. Public edu- the criminalization of domestic violence, document cation programs need to ensure that mass media the dimensions of this problem, organize commu- messages are reinforced by health care providers to nity awareness campaigns, and establish crisis cen- reach women directly. ters that provide legal and psychological support (Servicio Nacional de la Mujer 1991). Meeting Information Needs

Behavior change A major constraint to improving women's health services has been a lack of information on the causes, The first step in influencing health-related behaviors severity, and distribution of women's health and is often to make women and men aware of women's nutrition problems, as well as on the relative effec- health problems and high-risk conditions. For tiveness and cost of various interventions at the example, most women are completely unaware of local level. Both donors and govemments must rec- the warning signs for complications associated with ognize that research, monitoring, and evaluation are pregnancy and so do not respond properly to them. integral to program development and service deliv- Even violence against women may be viewed as nor- ery. Inadequate information leads to ineffective pro- mal and not a cause for seeking assistance. Public grams and wasted resources. education programs can promote actions in the home or community to improve women's health Health status indicators and prevent future health problems. Public educa- tion programs can also be used to discourage unsafe Biomedical, epidemiological, and socioeconomic practices that harm women's health (such as female data are needed to assess women's health status and 46 Women'sHealth and Nutrition:Making a Difference evaluate health interventions for women. Such data verbal autopsies, and death certificate reviews are are often lacking or of poor quality. In particular, also important sources of information on women's many developing countries lack a complete and health. Qualitative research on intended beneficia- accurate vital registration system. Even where vital ries and program personnel is especially important registration systems exist, the cause of death is often in designing programs for women. Program design- incorrectly reported or omitted altogether. Maternal ers need to know whether the health problems they mortality is often underreported due to a variety of have identified are women's priority concerns; the social, religious, emotional, and practical factors, underlying causes (cultural, attitudinal, economic) such as the stigma of abortion, the desire to avoid an of health problems; and the range of acceptable, official inquiry into the cause of death, and the fail- affordable, and effective solutions. Local investiga- ure to indicate pregnancy as the precipitating cause tors, including women, should be involved in all of death (WHO 1991a). aspects of related research. Governments should insist that health and nutrition data be disaggregated by gender as well as Programdesign age group. Breaking data down into five-year or smaller age groupings provides a clearer picture of All health and nutrition projects should be designed the needs of key groups such as adolescents. in light of the culture-specific health needs of Population-based studies and data on morbidity are women (by age group), the effectiveness, cost and especially needed (ICRW 1989). Data on women's feasibility of interventions to address them, and the life circumstances and needs would promote better various factors that influence women's health. This understanding of the social, cultural, legal, eco- analysis would include, for example, women's access nomic, and psychological factors that affect to disposable income and transport, their decision- women's ability to protect their own health. making authority, cultural norms affecting travel Improved data on women's health status can con- and male/female interaction, geographic distribu- tribute to more targeted interventions and more tion of health centers and hospitals, perceptions effective program design, monitoring, and evalua- about the quality of care, and the different tasks tion (Leslie 1992). women perform. In many cases, available data are Some health problems affecting women-those insufficient to plan and manage health programs, related to abortion, adolescent pregnancy, female and agencies may need to conduct new studies to genital mutilation, and domest ic Violence-are strengthen program design. controversial and difficult to document. Even in * Knowledge, attitude, and practice surveys. Large- industrialized countries, their incidence and conse- scale surveys arid community-level studies of quences often go unreported or are misclassified.But health and nutrition behaviors have proven where health care providers are alerted to problems valuable for program design and evaluation. such as domestic violence, women do report abuse Additional studies are needed to provide insight (Heise et al. 1993). Still other problems (such as on the users' perspective and the local cultural maternal mortality) are difficult to measure because and social context; to identify individual, social, their relative infrequency makes it necessary to and economic costs associated with the preven- study large populations at substantial expense. tion and treatment of disease and injury; to Given the paucity of data on women's health, assess health care providers' understanding of health agencies should make full use of existing data women's needs; and to evaluate the efiectiveness sources, including health facility data, patient of the service delivery system. records, vital statistics registration, population-based * Operationsresearch. Operations research can be surveys, and surveillance systems. Sources outside used to test different approaches for delivering the health sector (such as police records) may be services and to identify and overcome program needed for information on violence against women obstacles. For example, WHO has supported or substance abuse. Whenever possible, programs research on interventions to reduce maternal should rely on more efficient use of available data, mortality, and the Population Council is assess- supplemented by additional research as needed. ing alternative approaches to prenatal and Women's organizations and NGOs can be especially obstetric care in several countries. helpful in disseminating research findings. * Cost-effectivenessanalysis. Research on alternative Case histories, focus group discussions, in-depth approaches can help to clarify choices regarding interviews and observation, confidential inquiries, resource allocation. Issuesfor National Program Planning 47

Field-based research can determine the most cost- complications would indicate an effective case effective combination of community-based, referral, detection, management, and referral system. and follow-up services for women in specific settings, A major constraint to effective program moni- as well as the appropriate level of care for the man- toring and evaluation is the lack of an effective man- agement of pregnancy and obstetric complications. agement information system in most developing countries. The system should integrate data collec- Program monitoring and evaluation tion and analysis into program operations and ensure that the results are provided to central and Where data are available, health status indicators- field-level managers to facilitate decision-making. changes in the prevalence of iron-deficiency anemia Limiting the number of indicators to those integral among pregnant women, for example, or in the pro- to program operations can simplify data collection portion of deaths from obstructed labor or hemor- and analysis and ensure timely feedback. rhage-can be used to measure program impact. Where monitoring systems are weak, alternative Indicators should be developed in accordance with strategies can be introduced. In areas where horne each country's resources, priorities, and needs. (A list births are common, for example, periodic house- of indicators for measuring women's health status is hold interviews may be desirable. Some aspects of provided in Annex D.) In many low-resource set- service quality can be inferred from process indica- tings, data on program impact may be difficult and tors such as the number of contraceptive methods expensive to obtain, resulting in greater reliance on available and method mix among contraceptive process indicators. Measuring program inputs and users. Additional efforts are needed to assess other outputs provides program managers with timely indicators of service quality (client waiting times, feedback on program progress and affords an oppor- travel distances, and satisfaction with services tunity to adjust interventions and treatments as received), since quality of care is a major factor indicated. For example, the proportion of pregnant affecting women's utilization of health services. women who receive iron and folate tablets and Direct observation of client-provider interactions, counseling on the danger signs of pregnancy could interviews with clients and staff, focus group dis- indicate whether prenatal care services are adequate. cussions, and sample surveys can all be used to elicit A high proportion of appropriately treated obstetric information. Chapter Five The Role of International Assistance

Sustainable improvement in the health systems of facilities, improve referral systems, and train developing countries depends foremost on a nurse-midwives. In China, the Bank funds train- nation's commitment to the health and well-being ing in maternal health care for female physicians of all its people-men and women, the poor and the and assists in making emergency obstetric ser- better-off. Foreign assistance can play a critical cat- vices more accessible to poor women. Round- alytic and supportive role, however, in improving table conferences on health in Chad, China, and women's nutrition and health by focusing policy the Philippines have highlighted safe mother- concern and ensuring adequate resources. Foreign hood and women's health, and in Benin, the assistance agencies-including the World Bank- government held central and regional work- can have an impact on women's health far beyond shops to review its maternal health and family their monetary contribution by making policymak- planning programs. ers aware of the social and economic gains to be real- * Family planning. The World Bank has supported ized from lowering rates of female death and family planning projects in a variety of settings. disability. Perhaps most important, international A Bangladesh project supports family planning agencies can help by furnishing decisionmakers and maternal and child health services provided with lessons gleaned from other countries' experi- by female outreach workers. In the Ukraine, ence and by supporting interventions that have where there are 1.5 abortions for every birth, the proven to be the most cost-effective. Bank is discussing a project with the ministry of health to strengthen maternal and child health World Bank Programs In Women's Health services and provide contraceptive supplies to and Nutrition reduce women's reliance on abortion.

3 Sexually transmitted diseases and AIDS. Control of World Bank lending for health, population, and sexually transmitted diseases and AIDS is an nutrition has increased five-fold over the last six important concern of the World Bank. In years. Between 1986 and 1993, the World Bank allo- Lesotho, the Bank is supporting prevention, cated nearly US$5.7 billion to more than one hun- diagnosis, and treatment services for women of dred health, population, and nutrition projects that reproductive age and research on effect ve ways have women's health components (Annex E). These to extend services to commercial sex workers. projects represent 90 percent of the Bank's projects in Brazil's Bank-assisted National AIDS/Sexually this sector since 1986. Nearly half the projects with Transmitted Disease Control Program includes women's health components are in Sub-Saharan mass media campaigns, education in the work- Africa, one-fourth in Asia, and one-fifth in Latin place, surveillance, research, and efforts to reach America (Figure 5.1). Following are the major types commercial sex workers. of activities that the Bank has supported since 1986: * Adolescent sexuality. The Bank has assisted the * Safe motherhood. More than fifty World Bank-sup- governments of Lesotho and Nigeria to develop ported projects that contain safe motherhood school-based family life education programs and components are now underway. In Indonesia, mass media campaigns to persuade adclescents the Bank is supporting the expansion of safe to delay childbearing. Indonesia's population motherhood services to the village level. In project includes clubs for young people and fam- Zimbabwe, the Bank and other assistance agen- ily planning messages on television, radio, and cies are collaborating to upgrade maternity care video aimed at youth.

48 The Roleof International Assistance 49

* Nutrition. Several nutrition projects have schools. A women in development project in the included activities to address undernutrition and Gambia includes a safe motherhood component micronutrient deficiencies in girls and women. to strengthen the community-based treatment In India, projects seek to meet the protein-energy and referral system using trained birth atten- and micronutrient needs of children and lactat- dants. The Bank-financed Human Resource ing women through supplements. In Niger, the Development Project in Senegal includes a pub- Bank is supporting the use of labor-saving lic education program aimed at men and ieli- devices to reduce energy expenditure, and in gious leaders to counter negative attitudes Malawi, an effort is underway to increase food toward family planning. In Ghana, a Bank trans- production and income generation in order to port project provides supplemental food for increase women's protein intake. women laborers. * Gynecologicalcancers. Programs in Brazil, Chile, Newer Bank projects focus more directly on Ecuador, and Venezuela include detection and women's health needs and are more comprehensive. early treatment of cervical and breast cancer. A For example, the Women's Health and Safe Bank project in Romania supports national Motherhood Project being developed in the efforts to reduce deaths from cervical and breast Philippines includes services related to maternal cancer by developing a program for the early health, family planning, sexually transmitted dis- detection of gynecological cancers at a major eases, AIDS, and cervical cancer. The project pso- teaching and research institute. vides support for NGOsworking on women's health - Gender sensitivity in diseasecontrol. In India, the issuesin the areas of communication, training, logis- World Bank has financed an innovative program tics, information systems, and partnerships with to ensure gender sensitivity in disease-control other agencies. Programs on such emerging issues as efforts. The Leprosy Elimination Program pro- violence against women are also being developed vides training for female health and public edu- Increasingly, population projects are adding cation workers on the sociocultural factors that reproductive health services to existing family plan- impede the identification and treatment of lep- ning programs. In Indonesia, the new Bank- rosy in women and on ways to promote self-care financed population project builds on tIte among women. government's successful family planning prograrn - Other sectors. Bank projects also address the with the aim of broadening community-based broader socioeconomic determinants of health services to meet women's health needs. The women's health. In Bangladesh and Burkina project includes training midwives to provide mater- Faso, World Bank-assisted education projects nal health care at the village level, providing con- include actions to improve female enrollment in traceptive information and services to adolescents, Figure5.1: World Bank-supportedpopulation, health, and nutrition projectswith women's health components, FY 1986-93 Typesof projectactivities Regionaldistribution (numberof projects) (numberof projects) Maternal healthoniy Familyastan hehplanning only Sub-SaharanAfrica MiddleEast and 14~~~~24

STDsand AIDS / .. Familyplanning 38 / and maternal SouthAsia health 15 58

Cervical cancer r Europe^; t and / \ 6 ~~~~~~~~~~~~~~~~~~~~~~~~~~CentralAsia 3 EastAsia Nutrition 10 44 Adolescent LatinAmerica sexuality and Caribbean 8 20 50 Women'sHealth and Nutrition:Making a Difference and conducting public education on reproductive issues are addressed, and community needs are health and the role of women in society. This expan- recognized. International NGOs can increase sion represents a shift from the government's earlier awareness, serve as a bridge between national orga- strategy, which was more narrowly focused on nizations and international resources, stimulate increasing contraceptive acceptability and use and- debate and action, assist in the formulation of pol- since 1986-on promoting private-sector family icy and development of programs, conduct planning services. research, and provide technical assistance. Inter- national organizations of health professionals such Partnership as physicians, nurses, and midwives can be helpful in establishing norms and standards for service Making substantial and lasting improvements in delivery and disseminating information on effec- women's health will take a multisectoral approach tive approaches and new technologies. across a broad range of issues. Assistance agencies Collaboration among assistance agencies has should coordinate their inputs to maximize each helped to advance women's health programs. For agency's strengths and capabilities. Country pro- example, the Inter-Agency Group for Safe Mother- grams could benefit from assistance agencies' com- hood supports safe motherhood programs. World parative advantage in such areas as training, Bank projects in Bangladesh, Indonesia, and technical support, institutional development, and Zimbabwe have strengthened coordination among logistics management. Within the United Nations multilateral, bilateral, and nongovemmental orga- system, WHO serves as the lead technical agency on nizations, improving the delivery of maternal health health. WHO has prepared technical guidelines on and fami;y planning services based on pilot project many topics related to women's health, such as experience. U.N.-sponsored international confer- essential obstetric services and the Mother-Baby ences on women, social development, and popula- package, and is currently developing a Healthy tion provide a forum for discussing women's health Women Counseling Guide. Many of the recom- issues at the policy level and an opportunity for mendations in this paper are derived from WHO's bringing concerns to the forefronit of the develop- work. UNDP sbpports broad poverty reduction pro- ment agenda and to the attention of a wide inter- grams, UNICEF addresses the problems of girls, and national audience. the UNFPA provides family planning and related ser- vices. In addition to being the largest single provider An Agenda for Women's Health and Nutrition of international financial assistance in the health sector, the World Bank's strengths include its ability International agencies can take six majoi steps to to conduct sector and economic analysis to examine promote improvements in women's he 1ith and issues and appropriate strategies and to engage in nutrition: policy dialogue with core ministries of government * Persuade governments to give higher priority to on resource allocation to support priority programs. women's health and nutrition Bilateral agencies are also making important * Identify an institutional base for women's health contributions to women's health. The Swedish and nutrition programs International Development Authority (SIDA), * Promote greater use of gender-based data and which gives high priority to sexual and reproductive pilot studies health, has collaborated with the World Bank and * Support cost-effective interventions for women other assistance agencies in country programs. SIDA * Increase attention to changing heallh-related has developed a strategy on sexual and reproductive behaviors health that supports the concept of essential repro- * Involve women in program planning and imple- ductive health services and encourages govemments mentation. to ensure that these services are available. Several Knowledge, policy support, and program devel- other bilateral assistance agencies have incorporated opment related to the diverse health problems reproductive health care as a priority in their assis- affecting women vary greatly among countries. For tance programs. example, strategies to address issues of new but International NGOs have national affiliates increasing concern (such as gender violence, man- with close ties to the communities they serve, agement of unsafe abortion, and sexually transmit- which often puts them in a good position to ensure ted diseases among adolescents) are relatively that information is made available, controversial untested and could benefit from external assistance The Role of Jnternational Assistance 51 to support consciousness-raising, policy analysis, ular area can be highly effective in driving new ini- and pilot programs. tiatives. Because women's health and nutrition pro- grams encompass a variety of service delivery modes Policy priorities and require collaboration with agencies outside the health sector, an institutional base can ensure pro- In many developing countries, women's health and gram direction and coherence, to see that objec-ives nutrition rank low among national priorities, even are met and that the system is operating smoothly. within the health sector. Assistance agencies can help to make the case for greater attention to Targeted research women's health, based on the multiple economic and social payoffs described in Chapter 1. Argu- Without gender disaggregated data, women's health ments for increased funding for women's health and problems can be easily overlooked. International nutrition programs should stress two key points: the agencies can support analyses that differentiate far-reaching effects of a woman's poor health and between males and females and can request that Iou- early death on her family and community as well as tine data reports include such differentiation. the national economy, and the availability of cost- Disaggregation by age group is also important for effective interventions to prevent or mitigate many program targeting. of the leading causes of death and disability among Effective program design requires research on a women. wide range of issues, including macroeconomic fac- Women represent a disproportionate share of the tors, women's socioeconomic and health status, .,nd poor and so deserve particular consideration in pro- local conditions. Assistance agencies should support grams to mitigate the adverse impact of structural studies designed to: and sectoral adjustment, particularly in the areas of * Broaden knowledge and understanding of nutrition and health. Related external assistance women's health problems in a country could take traditional forms, such as food-price sub- * Bring about policy dialogue among govemment sidies and food distribution, or more innovative agencies, program beneficiaries, and health care forms, such as social, health, nutrition, and educa- providers tion interventions designed to reach female chil- * Improve the database for the design and imple- dren, adolescents, and adults. mentation of projects For multilateral and multisectoral agencies such * Mobilize resources in support of women's health as the World Bank, policy dialogue needs to extend programs. beyond the ministry of health to include the min- Because of the influence of local social and cultural istries of finance, planning, education, and women's factors, pilot projects can be especially important for affairs, and other sectors as appropriate. For most identifying and testing approaches to improve women's health issues, policy discussion should also women's health. include key decisionmakers and influential groups In a process known as "sector work," the World outside the government, such as health profession- Bank often compiles background material to support als, women's groups, and business leaders. discussions on health policy and to assist goveni- ments in developing programs and projects. In Institutional base Brazil, for example, sector work documented tfe dimensions of women's health problems (including International assistance agencies can designate an inadequate prenatal care, high rates of unsafe abo-- individual, department, or committee to take respon- tion, and unnecessarily high rates of cesarean sec- sibility for women's health and nutrition programs tion). In India and Uganda, sector analyses helped and request that the ministries of health also estab- to identify women's health problems and con- lish an institutional base for woman's health pro- straints to women's use of health services, informa- grams. This base can serve many purposes, including tion that was used to guide health interventions to giving greater visibility to these programs, coordi- address women's needs. nating relevant activities, initiating new programs or introducing new elements to existing programs, and Support for cost-effective services promoting collaboration with other sectors. Experience with many health interventions has Foreign assistance agencies can help governments shown that an institutional base focused in a partic- match health services for women to each country'* 52 Women'sHealth and Nutrition:Making a Difference own profile of women's nutrition and health status. * Ensuring adequate representation of women in Where the health infrastructure is weak, assistance their own professional staff agencies should focus on ensuring that the Essential . Including women on project planning, monitor- Services for women are widely available. In countries ing, and evaluation teams with adequate resources and a policy environment * Encouraging national health ministries to favorable to women's health, assistance agencies can increase women's representation in high-level help to expand and improve ongoing programs, decisionmaking positions identify additional needs, and help ascertain which * Involving women's organizations and women interventions and delivery approaches are most who are experts in their field in all phases of pro- cost-effective. In most developing countries, assis- gram planning and implementation tance is needed to expand women's health and * Incorporating mechanisms for soliciting nutrition interventions on a national scale and to women's feedback on projects incorporate new components such as sexually trans- * Promoting procurement of supplies and advisory mitted disease services and education on nutrition services from women-owned businesses and and safer sex. women's cooperatives. Assistance agencies need to examine their own Assistance agencies can help to identifv areas in policies and program priorities in light of the cost- which women's inputs would be useful and facilitate effective approaches identified in the World their involvement. In addition, assistance agencies Development Report 1993. For example, few assis- can insist that collaborating agencies publicize job tance agencies support abortion management, pro- vacancies, new contracts, and other opportunities so motion of contraceptives to adolescents, and that women can compete for them. Links with cervical cancer services. The economic and social women's groups, and particularly women's income- costs for missing the opportunity to include these generation projects, should be explored. For exam- services in assistance programs are great: unsafe ple, women's groups could create clinic signs, abortion is the third largest cause of maternal mor- banners, badges, and other promotional materials. tality; pregnancies among unmarried adolescents are increasing in many developing countries; and Regional Problems and Priorities worldwide almost eight in ten new cases of cervical cancer occur in developing countries. In reorienting The following paragraphs highlight key health prob- their women's health programs, assistance agencies lems and program priorities for women in each need to incorporate a life-cycle approach and to give region of the developing world. more emphasis to early prevention and behavior change. Sub-Saharan Africa

Behavior change Sub-Saharan Africa has the world's highest fertility and maternal mortality rates. Maternal health prob- International assistance agencies can play a major lems are exacerbated by poor prenatal and delivery role in influencing health agencies to give greater care and unsafe abortion, which accounts for 20 to attention to preventive services and become more 40 percent of the maternal mortality in Africa. Africa involved in behavior change interventions outside also has one of the highest adolescent pregnancy the traditional health care delivery system. Assis- rates in the world. By age eighteen more than 40 per- tance agencies can facilitate links between health cent of women in Cote d'lvoire, Mali, and Senegal agencies and public and private institutions in other have already given birth (Population Reference fields, provide funds and technical expertise for Bureau 1992). undertaking behavior change interventions, and Sexually transmitted diseases and HIV/AIDS are support mechanisms to exchange information on a major cause of disability and death among African effective strategies. women and represent more than half of the sexu- ally transmitted disease burden among women in Women's participation developing countries. Infertility and cervical can- cer, often caused by sexually transmitted diseases, Assistance agencies can do much more to involve are common in some African countries. Female gen- women in health programs. Key areas for action ital mutilation is practiced in several countries of include: the region. The Roleof International Assistanh:e 53

Priorities for improving women's health in Africa and prompt referral of pregnancy-related complica- include: increasing access to maternity care, family tions. Intersectoral initiatives are needed to address planning, safe services for abortion management, the problems of early marriage and violence against and sexually transmitted disease services and pre- women. venting genital mutilation, HIV infection, and vio- lence against women. To deliver the necessary East and Southeast Asia clinical and preventive services-and especially to extend services to rural areas-many countries will In certain countries, such as Laos and Cambodia, need to strengthen their health care infrastructure. women's health conditions resemble those in South Special initiatives for adolescents are needed because Asia or Africa. In other parts of East and Southeast of the large numbers of young females at risk and the Asia, women are attaining levels of health, educa- great potential for improving health through the tion, and social status typical of middle-income postponement of sexual activity and childbearing, countries. In East Asia, 95 percent of women benefit safer sex practices, and good nutrition. from trained assistance during delivery, although less than half of all deliveries take place in institu- South Asia tions. There are considerable regional and urban- rural differences, however, reflecting the influence Throughout most of South Asia, women of all ages of lifestyle and economic status on disease patterns. suffer the effects of gender discrimination. For rural women, infectious diseases are a major Discrimination and neglect are estimated to cause cause of death, while urban women have h:.gher one in six deaths of female infants in Bangladesh! rates of cardiovascular and cerebrovascular diseases India, and Pakistan. In some areas, gender-specific and cervical and breast cancer. East Asia has the abuse is common, including sex selection through highest incidence of cervical cancer among the abortion, female infanticide, and injury and death developing regions. associated with wife abuse and dowry demands. Maternal morbidity and mortality rates remain Other forms of discrimination, such as giving less high in several countries in the region due to Door food to female household members, restricting their coverage of maternity care (WHO 1991). Contra- access to health services, and imposing a higher ceptive prevalence is relatively high in Indonesia, physical work burden on girls and women, are also the Republic of Korea, Malaysia, and Thailand, but common. Women's lower status is also evident in in some countries, such as the Philippines, a full lower school enrollment and retention rates. range of contraceptive methods is not available. Many women lack access to health care, espe- HIV/AIDS is growing more rapidly in Southeast Asia cially maternity care, contraceptives, and safe ser- than in any other part of the world (USAID 1991). vices for abortion management. South Asia has a Increasingly, young adolescent women are entering higher proportion of growth stunting among girls prostitution, often due to economic hardship or and anemia among pregnant women than any other force. region. Only one in three women receive prenatal Smoking and alcohol abuse among women are care or have a trained attendant at delivery. growing concerns in some parts of East Asia. as Consequently, rates of death and disability associ- multinational tobacco firms increasingly target ated with pregnancy and childbirth are high. women with sophisticated advertising. Women's Sexually transmitted diseases are widespread, and health status is also influenced by discriminatory HIV infection is on the rise. practices, such as sex selection in China and the The key component of an agenda for women's Republic of Korea and female genital mutilation in health in South Asia is to combat the effects of dis- parts of Indonesia and Malaysia. crimination by expanding access to health services, Priorities for women's health services are likely to conducting community education and outreach vary considerably throughout the region, depend- programs, increasing the proportion of trained ing on existing health infrastructure and policies In women health providers, and publicizing the impor- countries with limited services, health agencies will tance of protecting female health. Expanding and necessarily concentrate on expanding and improv- improving the quality of women's health services ing them, especially to ensure access to maternity are also important. Health programs need to give care, family planning, and safe abortion services. greater attention to the nutritional status of young Most countries in the region need to give additional girls and adolescent women, as well as to detection attention to early prevention among young and 54 Women'sHealth and Nutrition:Making a Difference adolescent girls, especially in stressing the dangers of As the proportion of older people rises, problems unprotected sex, tobacco use, and substance abuse. such as diabetes, cardiovascular and cerebrovascular Where resources permit, cancer screening and treat- diseases, and osteoporosis are becoming more sig- ment should be provided. nificant among women. Breast cancer is increasingly common, particularly in the higher-income coun- Middle East and North Africa tries. Cervical cancer is also on the rise. Women's risk of disease is raised by factors such as high rates of In the Middle East and North Africa, fertility rates are smoking, obesity, and anemia; almost one in three among the highest in the world, almost equal to women in the region is anemic (PAHO 199'.). those of Sub-Saharan Africa. High fertility and early The agenda for improving women's health in childbearing contribute to poor health among Latin America includes ensuring that low-income women. Contraceptive prevalence rates are low, and women have access to health care services, especially access to health care is poor. Cultural norms against maternity care and family planning; developing contact with men keep many women from using strategies to meet the reproductive and sexual health existing health services. Female genital mutilation is needs of adolescents; addressing the problems of practiced in some areas. Women's low status and lit- unwanted pregnancy and unsafe abortion; and pro- eracy levels, as well as lack of information and data moting healthy behaviors such as good nutrition, on women's health issues, are major obstacles to safer sex practices, and avoidance of smoking and improvements in female health. obesity. Some countries will need to give more atten- The major priority in the region is to improve tion to specific problem areas such as overuse of ter- women's access to health care by better meeting tiary health care facilities, unnecessary medical their needs for female health care providers, conve- procedures, HIV/AIDS, violence against women, and nient locations, and information on healthy behav- inadequate assistance to women beyond reproduc- iors. Better maternity care is a pressing need in most tive age, including management of cervical and countries in the region. Women could benefit sub- breast cancers. stantially from improved access to contraception and a broader choice of methods. Eastern Europe and Central Asia

Latin America and the Caribbean Women's health status in Eastern Europe and Central Asia is lower than might be expected, given In many Latin American countries, noncommuni- high levels of female education and reasonably well- cable diseases cause more deaths and disability to developed health infrastructure. Shortages of drugs women than communicable diseases and maternal and supplies are common, as are outdated health and perinatal causes combined. Nevertheless, mater- care practices that are not always cost-effective. nal mortality ratios in the region are higher than in Although almost all women receive prenatal care, other areas with comparable income levels, due in excessive emphasis is placed on diagnostic tests and large part to unsafe abortion. Fertility is moderately not enough on counselling and prevention. high in most countries. Services are often inefficient Abortion, which is legal in many countries in the and of poor quality. Tertiary and higher-level health region, is the most common method of fertility reg- facilities are overutilized for maternity care, and ulation because contraceptives are largely unavail- some countries have abnormally high rates of able. In fact, there are more abortions than live cesarean section deliveries, which adds to women's births. The needs of divorced, widowed, and elderly health risks. women require greater attention. In several coun- Unwanted pregnancy, particularly among ado- tries, women's health status is worsening, and their lescents, is an important problem. Although abor- access to such services as legal, state-subsidizei abor- tion is illegal in most countries in the region, tions is being threatened. abortion rates in some areas are among the world's Key initiatives in a women's health agenda for highest. Sexually transmitted diseases are a growing the region include making family planning infor- concern. Though the AIDS epidemic is in the early mation and services more widely available to stages, the number of cases among women is pro- reduce reliance on abortion, updating services jected to rise sharply by the year 2000 (PAHO 1993). through training to improve clinical and con- Violence against women is increasingly recognized sumer-oriented practice, ensuring that adequate as a source of poor mental and physical health. drugs and supplies are available, increasing the TheRole of International Assistance 55 emphasis on prevention (particularly avoidance of national economy, the community, individual fam- tobacco, the value of exercise, and good nutrition), ilies, and the next generation. What remains to be and addressing the needs of women beyond repro- done is to pierce the veil of indifference and inertia ductive age. that inhibits women's health and nutrition pro- grams. Assistance agencies, in partnership with local Moving from Rhetoric to Action change agents, can press for a new vision of women's health as an indispensable part of sustainable devel- The task ahead is to apply what we know about opment efforts. Given a mandate for change, agen- women's health needs to concrete actions. We know cies and individuals can advance new initiatives and that many women's health problems could be pre- support more effective allocation of existing vented or mitigated through low-cost interventions. resources. For the countless millions of women We know that these interventions can work in low- struggling to meet their family's daily needs and income settings. We know that investments in make a better life for themselves and their children, women's health have multiple payoffs for the such changes cannot come too soon. -~~~~~~~~~~~~~~~~~~~~......

*~~ ~ ~~~~~~...... Annex A. Working Papers and External Consultations

Working Papers for Women's Health and Mirai Chatterjee, Self-Employed Women's Associa- Nutrition: Making a Difference tion, India; Ayse-Akin Dervisoglu, Matemal and Child Health/Family Planning, Ministry of Health, George T.F.Acsadi and Gwendolyn Johnson-Acsadi, Turkey; Carmen Simone Grilo Diniz, Colectivo "Socioeconomic, Cultural and Legal Factors Feminista Sexualidade Saude, Brazil; Sambe Duale, Affecting Girls'and Women's Health," 1993. Academy for Educational Development, U.S.A.; Jill Gay, "Women's Access to Quality Health Services Mahmoud Fathalla, Rockefeller Foundation, Egypt; and Empowerment to Promote Their Own Anibal Faundes, Population Council, Brazil; Judith Health," 1993. Fortney, Family Health International, U.S.A.; Lori Heise with Jacqueline Pitanguy and Adrienne Malgorzata Fuszara, Center for Social-Legal Research Germain, "Violence Against Women: The Hidden on the Situation of Women, Institute of Applied Burden", World Bank Discussion Paper, 1994. Science, University of Warsaw, Poland; Kirrin Gill, Joseph Kutzin, "Obstacles to Women's Access: Issues World Bank, U.S.A.; Sandra Kabir, Bangladesh and Options for More Effective Interventions to Women's Health Coalition, Bangladesh; John Improve Women's Health," HRO Working Paper Kevany, Department of Community Health, Trinity Number 13, 1993. College, Dublin University, Ireland; Ana Langer, Kathleen Merchant, "New Directions in Policies to Instituto Nacional de Salud Publica, Mexico; Improve the Nutritional Status of Women," 1993. Florence Manguyu, Medical Women's International May T. Post, "Reproductive Tract Infections, Association, Kenya; Indra Pathmanathan, World HIV/AIDS and Women's Health," HRO Working Bank, U.S.A.; Khama Rogo, Dept. of Ob/Gynecology, Paper Number 15, 1993. University of Nairobi, Kenya; Helen Saxenian, World Judith Senderowitz, "Reassessing the Passage to Bank, U.S.A.; Jill Sheffield, Family Care Interna- Adulthood: Issues and Strategies for Young tional, U.S.A.; Ann Starrs, Family Care International, Women's Health," World Bank Discussion Paper, U.S.A.; Anne Tinker, World Bank, U.S.A.; Mariike 1994. Velzeboer, Center for Population Options, U.S.A.; Jacqueline Sherris, Elisa Wells, Vivien Davis Tsu, and Judith Wasserheit, Division of STD/HIV Prevention, Amie Bishop, "Cervical Cancer in Developing Centers for Disease Control, U.S.A. Countries: A Situation Analysis," 1993. Kajsa Sundstrom, "Abortion: A Reproductive Health March 8, 1994. Review of the final draft of Women's Issue," 1993. Health and Nutrition-Making a Difference, St. Janies Mary Eming Young, "Women's Health Beyond Hotel, London, England. Participants at this meeting Reproductive Age: The Picture in Developing included Rashim Ahluwalia, International Society of Countries", 1993. Red Cross and Red Crescent Societies, Switzerland; Berit Austveg, Ministry of Foreign Affairs, Norway; External Consultations Tim Black, Marie Stopes International, U.K.; Xavier Coll, World Bank, U.S.A.; Pat Daly, World Bank, May 17-21, 1993. Women's Health and Nutrition U.S.A.; Janet de Merode, World Bank, U.S.A.; Denys Seminar, Rockefeller Foundation Study and Conference Fairweather, International Federation of Obstetrics Center, Bellagio, Italy: Participants at this meeting and Gynocology, U.K.; Adrienne Germain, Inter- included Andrew Arkutu, Country Director, UNFPA, national Women's Health Coalition, U.S.A.; H. Tanzania; Meera Chatterjee, World Bank, India; Nardho Gunawan, Ministry of Health, Indonesia;

57 58 Women'sHealth and Nutrition:Making a Difference

Marianne Haslegrave, Commonwealth Medical Carmencita Reodica, Department of Health, Association, U.K.; Lori Heise, Pacific Institute for Philippines; Yolanda Richardson, Carnegie Corpora- Women's Health, U.S.A.; Jane Hughes, Rockefeller tion, U.S.A.; Khama Rogo, University of Nairobi, Foundation, U.S.A.; NicolasJara, Ministry of Health, Kenya; Peter Schubarth, Swiss Development Ecuador; Ilona Kickbusch, WHO Regional Office for Corporation, Switzerland; Jill Sheffield, Family Care Europe, Denmark; Christina Larsson, Swedish Inter- Intemational, U.S.A.; Prahash Shetty, London national Development Authority, Sweden; Caryn School of Hygiene and Tropical Medicine, U.K.; Levitt, Family Care International, U.S.A.; Florence Moncef Sidhom, Ministry of Public Health, Tunisia; Manguyu, Medical Women's International Associa- James Socknat, World Bank, U.S.A.; Jotna Sokhey, tion, Kenya; Elizabeth Morris-Hughes, World Bank, Ministry of Health and Family Welfare, India; Trudy U.S.A.; Alice Morton, World Bank, U.S.A.; Carol Stevens, Centre for Midwifery Practice, U.K.; Kajsa Mulholland, WHO, Switzerland; David Nabarro, Sundstrom, Swedish International Development Overseas Development Administration, U.K.; Zilda Authority, Sweden; Anne Tinker, World Bank, Arne Newmann, Ministry of Health, Brazil; U.S.A.; Nahid Toubia, Population Council, U.S.A.; Augustino Paganini, UNICEF, U.S.A.; Aagje Papineau and Felicity Zawaira, Ministry of Health, Zimbabwe. Salm, Ministry of Foreign Affairs, The Netherlands; Annex B. Life Cycle of Women's Health

This annex discusses problems of nutrition and veys, girls aged zero to four have higher mortality health that-because of differential exposure, rates than boys. In the industrialized countries of reduced accessto treatment, and culturally-imposed Norway, Switzerland, and the United States, mor- disadvantages-are disproportionately harmful to tality rates for boys are considerably higher (see women at specificstages of the life cycle. Figure B.1). In countries where girls are deemed of little eco- Infancyand Childhood nomic value, they receive little or no education and are often required to perform strenuous tasks Given equal nutrition, health conditions, and care, (including carrying firewood and water and caring girls are more likely than boys to survive childhood. for younger siblings and farm animals). One would Although boys are generally more vulnerable to expect that the combination of a heavy workload childhood diseases, unequal care can negate girls' and low status contributes to increased morbidity biological advantage. In seventeen out of twenty- among girls as compared with boys. However,while nine developing countries with recent national sur- the Demographic and Health Surveys (DHS) reveal Figure _.1:Ratio of femaleto malemortality by country ratio of female to male mortality 1.60 1.60- Ages 0-11 months Ages 1-4 years 1.40 1.40

1.20 1.20

1.00 1.00

0.80 0.80 _

0.60 . 0 0 0 0.60 - ~ Atid

*Comparativedata for Indiafor the agegroup 1 to 4 yearsis not available. Note: Tenpercent sample reported in 1990census; adjusted for under-reporting. Sources:Banister 1992 for China;Demographic and Health Survey (DHS) for Bolivia-i989, Botswana-1988,Burundi-i 987, Cameroon-1 991, Colombia-1990,Domican Republic-1991, Ecuador-1987, Egypt-1992, Ghana-1988, Guatemala-i987, Indonesia-1991, Kenya-1989, Liberia-1986, Mali-1987,Mexico-1987, Morocco-1992, Niger-1992, Nigeria-1990, Pakistan-1990-1991, Peru-1992, Senegal-1986, Sri Lanka-1987, Sudan-1990, Togo-1988,Tunisia-1988, Uganda 1988-89, Zimbabwe-1988-89; Keyfitz and Flieger 1990 forthe UnitedStates.

59 60 Women'sHealth and Nutrition:Making a Difference that in most of the developing countries studied, obstructed labor, and low birthweight and poor girls have higher mortality risks than boys, there is infant viability (Ravindran 1986). no clear evidence of female disadvantage in mor- bidity and treatment. Analysis of the data (Hill and Sex selection Brown 1993) show little gender difference in nutri- tional status or in treatment for diarrheal diseases In some countries, the preference for sons is so and coughing-the only three indicators for which strong that female fetuses are aborted and newborn comparable national data are available. Unfortu- females neglected and permitted to die. In China, nately, most of the South Asian countries and China India, and the Republic of Korea, selective abortion are excluded from the analysis. Still, differences are of female fetuses detected by ultrasound and amnio- found in some countries. In Colombia, for example, centesis (and possibly also female infanticide) are a recent national survey found that 12 to 13 percent sufficiently widespread that they may be skewing more boys than girls were taken to the health center the males to females ratio (Coale 1991; Heise et al. for treatment of fever and acute respiratory infection 1994; Zeng Yi et al. 1993). Since the 1960s, the sex (Profamilia and IRD 1991). Local surveys in South ratio at birth of 106 males for every 100 females in Asia, and also in other regions, have demonstrated China has shifted to 110 males per 100 females born substantial differences in the treatment of boys and in 1991 (Zeng Yi et al. 1993). girls (Ravindran 1986). Girls in some cultures may also be subjected to Genital mutilation violence and physical abuse (including genital muti- lation, burns, beatings, and fatal injuries reported as An estimated 85 to 114 million girls and women "suicides"). Some girls are forced into early marriage worldwide have been subjected to genital mutila- or prostitution, which curtails their education and tion, also known as female circumcision. In its most can expose them to various reproductive health severe form, the clitoris and labia minora are risks. Even when girls are not physically maltreated, removed and the labia majora are sewn together, they may suffer degradation, humiliation, and feel- leaving a small hole for urine and menstrual blood ings of inferiority and worthlessness. Malnutrition, flow. The more common, lesser forms entail removal inadequate health care, and mental and physical of the clitoris and sometimes the labia minora. abuse in childhood can have lifelong conse- While mostly done between the ages of four and quences-not the least of which are the perpetua- eight, genital mutilation is sometimes done as early tion of unhealthy behaviors, including poor as infancy or as late as just prior to delivery of the nutrition and substance abuse. first child. Each year genital mutilation is performed on an Discriminatory child care estimated two million young girls in Africa and parts of the Middle East, with the stated aim of curtailing Gender differences in feeding begin in infancy, with sexuality to ensure chastity before marriage and boys in some countries being breastfed more fre- faithfulness thereafter. Women often insist that their quently and longer than girls. Son preference may daughters undergo the procedure to become socially also play a role in birth spacing: after giving birth to acceptable ("clean") and eligible for marriage. a girl, mothers wishing to try for a boy may become Usually performed without anesthesia and with pregnant sooner and thereby curtail breastfeeding unclean instruments, genital mutilation can cause sooner than if they had a boy. In some areas of the hemorrhage, tetanus, infection, injury to organs, world, girls are more likely than boys to receive sub- severe pain, mental trauma, and death. Long-term stantially less food and less nutritious food relative consequences include pain during intercourse, diffi- to their needs, and hence are at higher risk of mal- culties during childbirth, infertility, and recurrent nutrition and growth problems (Ravindran 1986). urinary tract infections. Malnutrition increases susceptibility to infec- tions and disease, stunts growth, and impedes phys- Sexual abuse iological maturity. Stunting of children before the age of three, furthermore, is largely irreversible Primarily because of the lack of data, sexual abuse (UN/ACC/SCN 1992a). For women, stunting-par- among very young girls has received little attention ticularly when combined with early pregnancy and from health professionals to date. Yet the few stud- poor weight gain in pregnancy-can lead to ies available suggest that the problem is widespread Annex B. Life Cycleof Women'sHealth 61 among diverse cultures. For example, studies in to 50 percent of young women having their first Malaysia and in Lima, Peru, found that 18 percent birth during their teenage years. Fertility rates are of the victims of sexual assault were age nine or declining worldwide, but they are falling less rapidly younger; more than 20 percent of the victims in among adolescent women. Although adolescent fer- Mexico City and the United States were age ten or tility rates vary greatly among (see Table B.2) and younger (Consumers Association of Penang 1988; within countries, early childbearing is generally Portugal 1988; COVAC 1990; Kilpatrick et al. 1992). associated with rural residence, little education, low A study in Nigeria reported that 16 percent of the income, and early age of sexual initiation (PRB 1992; female patients seeking treatment for STDs were Ross et al. 1993; UN 1989; Yinger et al. 1992). children under the age of five, and another 6 percent Early marriage generally leads to early preg- were aged six to fifteen (Kisekka and Otesanya 1988). nancy. Births to unmarried adolescents are increas- Studies in Lima, Peru, and in Costa Rica found that ing, however, due to earlier menarche, later more than 90 percent of the girls aged twelve to six- marriage, and-with urbanization and more social teen who gave birth had been raped by their father interaction outside the household-increasing or a close relative (Movimiento Manuela Ramos opportunities for sexual activity outside of marriage. [n.d]; Treguear and Carro 1991). Early sexual abuse, Media, peer pressure, and other factors have as well as sequelae such as pregnancy and STDs, have changed social mores. In some areas young women lifelong psychological and physical consequences. exchange sexual favors to meet their material netvds. In most developing countries, however, few services Despite their high risk, most unmarried adoles- are in place to provide counseling and assistance to cents lack the requisite knowledge and services to victims of sexual abuse. prevent STDs or pregnancy. Studies in Guatemala and Kenya found that fewer than one in ten unmar- Adolescence ried youths could correctly identify the fertile period (Ajayi et al. 1991; CDC 1991). In most developing Women between the ages of ten and nineteen are countries, a majority of young women have heard of generally healthy. Sexual activity-which can lead at least one modern contraceptive method but gen- to unwanted pregnancy, early childbearing, unsafe erally do not have adequate knowledge about cor- abortion, and exposure to STDs (including AIDS)- rect usage. National surveys in Botswana, Ghana, poses the greatest health risk for adolescent women. Kenya, Jamaica and Liberia found that-while at Because they are neither children nor adults, ado- least one in four women aged fifteen to nineteen was lescent girls frequently fall between the cracks of the single and sexually experienced-few were using health care and social service systems. contraception. Among those who were using con- traception, large proportions were relying on inef- Early childbearing fective traditional methods such as rhythm and withdrawal (Population Reference Bureau 1992; The timing of initiation into motherhood varies Yinger et al. 1992). Even with knowledge of contra- considerably among developing countries, with 10 ceptives, adolescents have difficulty obtaining Table B.1: Major threats to female health Reproductivehealth problems Other* Majorcauses of maternaldeath Maternalmorbidities * Nutritionaldeficiencies * hemorrhage * uterineprolapse * Chronicdiseases (cardio- and * obstructedlabor * obstetricfistulae cerebrovascular,diabetes, etc.) * infection * Urinarytract infection * hypertensivedisorders Other reproductivemorbidities * Genderviolence * unsafeabortion * femalegenital mutilation * Certainoccupational and o reproductivetract infections environmentalhealth problems Pregnancy-exacerbatedconditions (includingSTDs and AIDS) * Mentaldepression * anemia * menstrualdisorders * malaria * cancers(cervix/breast) * protein-energymalnutrition * menopausaldisorders * sicklecell disease * infertility * diabetes * osteoporosis * hepatitis * tuberculosis * heartdisease

*Theseconditions affect both sexes but havea disproportionate effect on women. 62 Women'sHealth and Nutrition: Making a Difference them, fear side effects, or avoid use because of part- vesicovaginal and rectovaginal fistulae, difficult ner opposition or religious proscription. Unmarried delivery, retardation of fetal growth, premature women often do not plan for sex, and newly mar- birth, low birth weight, and perinatal mortality ried women are encouraged to bear children early. (Koetsawang 1990; Senanayake 1990; UN 1989). Regardless of marital status, teenage childbear- In a Nigerian study, for example, 17 percent of ing-especially under age sixteen-involves serious fourteen year-olds developed hypertensive disease, health risks for the young woman and her child as compared with 3 percent of women aged twenty (including pregnancy-induced hypertension, ane- to thirty-four (WHO 1989b). In addition, younger mia, malnutrition, cephalopelvic disproportion, adolescent women may have a narrow birth canal at

Table B.2: Pregnancyrisk, contraceptive use, and birthsamong women aged 15 to 19

PregnancyRisk ContraceptiveUse (percentageof women (percentof sexuallyexperienced aged15-19) womenaged 15-19) TeenageMothers Single Percentof wome'7 Region/Country Currently and sexually Currently Never aged20 to 24 who and Dateof Survey married experienced married married had a birth byage 20 Africa Botswana,1988 6 60 17 23 55 Burundi,1987 6 2 4 - 27 Ghana,1988 21 26 5 18 51 Kenya,1989 18 26 13 14 58 Liberia,1986 32 46 2 10 64 Mali, 1987 72 1 8 - 67 Namibia,1992 7 35 21 - 63 Nigeria,1990 34 20 1 44 54 Senegal,1986 42 - 9 - 59 Togo,1988 27 37 17 45 56 Uganda,1988-89 37 22 2 8 68 Zimbabwe,1988-89 18 12 30 22 49 LatinAmerica and the Caribbean Bolivia,1989 13 13 16 - 37 Brazil,1986 13 6 48 29 31 Colombia,1986 12 7 29 - 31 CostaRica, 1990 18 11 51 - DominicanRepublic, 1992 17 6 25 - 33 Ecuador,1989 16 - 18 - ElSalvador, 1985 24 - 22 - Guatemala,1987 24 5 5 - 50 Haiti, 1989 15 8 5 - Honduras,1987 22 - 20 - Jamaica,1989 20 35 48 - Mexico,1987 18 3 30 - 35 Paraguay,1987 17 12 22 - 37 Peru,1986 12 6 23 - 27 Trinidad& Tobago,1987 20 2 43 - 30 Asia Bangladesh,1989 48 - 1S - China,1982 4 - - - India,1988 41 - - -- Indonesia,1991 18 - 29 -- 36 Korea,Republic of, 1985 1 - - - Nepal,1986 38 - 1 - Pakistan,1990-91 18 - 3 - 30 Philippines,1988 8 - - - Thailand,1987 16 - 43 - 24 Vietnam,1988 4 - 5 - MiddleEast and NorthAfrica Egypt,1992 15 - 13 - 31 Jordan, 1990-91 10 - 8 - 21 Morocco,1992 11 - 22 - 19 Tunisia,1988 4 - 11 - 13 Sources:Survey data from Demographicand HealthSurveys and Centers for DiseaseControl; PRB 1992; Ross et al. 1993;Yinger et al. 1992. AnnexB. LifeCycle of Women'sHealth 63 the time of first birth because pelvic bone growth is tions (including hemorrhage, septicemia, anemia, not completed until two or three years after growth cervical and vaginal lacerations, pelvic abscess, per- in height has stopped (Harrison et al. 1985). A nar- foration of the uterus or bowel, tetanus, and sec- row birth canal is a leading cause of difficult deliv- ondary infertility) is higher than that of older eries that prolong labor and increase the risk of women (CPO 1992). Studies of hospital records in obstetric fistulae (a tearing of the walls between the Congo, Kenya, Liberia, Mali, Nigeria, and Zaire vagina and bladder or rectum). Women with unre- found that between 38 and 68 percent of women paired fistulae constantly drip urine or feces, making seeking care for complications of abortion were them social outcasts and likely candidates for under twenty years of age. The proportion is more divorce or abandonment. In Nigeria, 33 percent of than 25 percent in Malaysia, and more than 10 per- fistulae cases involve women under age sixteen, and cent in Brazil, Chile, Guatemala, Peru, and Tha iland. in Niger, 80 percent are fifteen to nineteen years old A study in the United Kingdom showed that the risks (WHO 1989b). associated with abortion were about three times Having a very early first birth also increases a higher in girls under sixteen than in older adoles- woman's risk of dying from pregnancy-related cents (WHO 1992a). causes. According to the WHO, women aged fifteen to nineteen face a 20 to 200 percent greater risk of Sexually transmitted diseases and AIDS pregnancy-related death than older women, and the younger the adolescent, the higher the risk. In Sexually transmitted diseases (STDs) are spreading Jamaica and Nigeria, for example, women under fif- rapidly among young people. In Uganda, for exam- teen are four to eight times more likely to die during ple, youths aged fifteen to nineteen have the high- pregnancy and childbirth than those aged fifteen to est incidence of STDs in the population. Research nineteen (WHO 1989b). suggests that adolescent girls may be biologically Infants born to adolescent mothers are also more more vulnerable to STD and HIV infection than likely to die or have more severe health problems older women with mature reproductive organs. than those born to older women. In Burundi, Because of the tendency of older men to seek Ghana, Kenya, Liberia, Mali, Nigeria, Senegal, and younger partners, girls are more likely than boys to Zimbabwe, infants born to mothers aged fifteen to have STDs. nineteen face a 20 to 60 percent higher risk of dying Age disparity also implies a greater power differ- before their first birthday than those born to women ential between sexual partners, which makes it diffi- aged twenty to twenty-nine (PRB 1992). Similarly, in cult for younger women to insist on safe sexual Bangladesh, Korea, Malaysia, Pakistan, and practices. Payment of the bride price (common in Thailand, the infant-mortality risk for babies bom to marriages arranged in African and Middle Eastern teenage mothers is at least 50 percent greater than countries) encourages the marriage of young girls to that for babies born to mothers in their twenties (UN older men who can afford to pay it, but among 1989). whom the incidence of STDs is greater than in younger men. Finally, poverty forces some voung Abortion girls into commercial sex work, contributing to the rate of STDs and AIDS among them, and through Faced with an unintended pregnancy which may them, among the wives and partners of their clients lead to loss of schooling, social ostracism, and other (Havanon et al. 1993). In Thailand, where an esti- adverse consequences, many pregnant adolescents mated 800,000 prostitutes are under age twenty, one seek abortions. Where abortion is legal, roughly one- quarter are under age fourteen, and roughly three in fourth of abortions are to teenagers (Henshaw and ten are HIV-infected (IPPF 1992). Van Vort 1989; Singh and Wulf 1990). Where abor- HIV infection is also more common in young tion is illegal or restricted, teenagers often resort to people than in older adults, and this is particularly clandestine abortion and account for between one true for women. According to WHO at least half of million and 4.4 million abortions annually (CPO those infected with HIV worldwide are under the age 1992). of twenty-five (WHO 1989b), and in many parts of Because of their tendency to seek clandestine Africa, HIV infection is increasing more rapidly abortions, to delay obtaining the procedure, and to among females than among males. A study in Zaire avoid seeking medical attention for subsequent found HIV infection to be four times more prevalent problems, adolescents' rate of abortion complica- in women than in men fifteen to thirty years old 64 Women'sHealth and Nutrition:Making a Difference

(Panos Institute 1989). Where older men seek out likely to engage in experimentation and risk-taking. adolescent girls with little or no sexual experience to In middle-income countries today, adolescents are avoid HIV infection, some spread the virus to their beginning to smoke, drink alcohol, and take drugs in young partners. Studies in Ethiopia and Zimbabwe increasing numbers and at earlier ages. This early ini- reveal that, while the ratio of AIDS infection is equal tiation sets a pattern for lifelong use and increases among men and women twenty to twenty-nine morbidity and mortality in later years. Smoking years old, adolescent girls aged fifteen to nineteen increases women's risk of lung and cervical cancer are three to five times more likely than boys to be and osteoporosis. Women over age thirty whc smoke infected (Zewdie 1993). heavily and take oral contraceptives have a higher risk of cardiovascular disease. Pregnant women who Undemutrition and micronutrient deficiency smoke have a higher risk of infertility, stillbirth, pre- mature labor, and low-birth-weight babies. Although Poverty and cultural factors (such as inequitable it is still more prevalent among males than females, intrahousehold food distribution and food taboos) substance abuse is increasing among both sexes. tend to affect the nutrition of adolescent girls Furthermore male substance abuse is associated with adversely. Puberty triggers a growth rate greater than violent behavior toward women and unsafe sexual any beyond the first year of life. Although growth practices. In pregnant women, substance abuse begins slowing for girls by the age of approximately increases the chance of congenital malformations fourteen, linear growth, particularly of the long and low birth weight (Smyke 1991). bones, is not complete until the age of eighteen, and peak bone mass is not achieved until the age of Reproductive Years twenty-five (FNB/NAS/NRC 1989). Thus growth- related needs for many nutrients continue well into In developing countries, women between the ages of the early twenties and are likely to overlap with the fifteen and forty-four have higher rates of disability nutrient requirements of first pregnancy and, possi- than men, primarily because of their reproductive bly, several additional pregnancies. role. Maternal morbidity and mortality account for Girls also need more iron following menarche, 18 percent of the disability-adjusted life years particularly in developing countries where infec- (DALYs) lost by women of reproductive age, while tious diseases such as malaria, schistosomiasis, and sexually transmitted diseases and HIV account for an hookworm contribute further to anemia (Brabin and additional 16 percent. Tuberculosis, depressive dis- Brabin 1992). Anemia causes fatigue, poor appetite, orders, self-inflicted injuries (including suicide), res- poor learning capacity, and gastrointestinal and piratory infections, and anemia also cause neurological problems. While the prevalence of considerable premature death and disability (World iodine deficiency goes down in males by late ado- Bank 1993c). These conditions are largely pre- lescence or the early twenties, it remains high in ventable and could be mitigated through appropri- females-setting the stage for higher rates of iodine ate health care and the adoption of cultural p -actices deficiency among women during their reproductive favorable to women's health. years and increasing the risk of mental retardation among their offspring. Unplanned pregnancy and abortion Skeletal growth is also delayed by malnutrition. Although some catch-up on earlier growth retarda- In developing countries, one in five births is tion appears possible, it is not likely to occur with- unwanted (Westoff 1991). In countries outside out increased income or subsidized food Africa for which survey data are available, at least supplementation. Since a smaller pelvis can prolong half of all married women do not want any more labor and obstruct delivery, incomplete skeletal children (Robey et al. 1992). growth or stunting also poses serious risks during Despite their expressed desires, many women childbirth. remain at risk of an unplanned pregnancy. Surveys find that between 20 and 30 percent of the rnarried Substance abuse women of reproductive age in most developing countries-an estimated 120 million women-who During adolescence, individuals exercise increasing wish to avoid becoming pregnant are not using con- independence from their families, and are more traception (Westoff and Ochoa 1991; Robey et al. Annex B. Life Cycleof Women'sHealth 65

1992). This number would increase substantially if its high cost and need for medical supervision and unmarried women, women who need a better or follow-up, however, RU-486 is not yet appropriate more suitable contraceptive method, and women for use in developing countries. who use abortion services were included. Roughly one-fourth-an estimated forty to sixty Pregnancy-relatedcomplications million-of all pregnancies worldwide end in abor- tion (Tietze and Henshaw 1986). More than half of More than 150 million women become pregnant in these are clandestine and are performed under developing countries each year. An estimated unsafe conditions (Population Crisis Committee 500,000 of these women, however, die from preg- 1987). nancy-related causes, and more than fifty mi1lion Unsafe abortion is one of the most important experience acute pregnancy-related complications. causes of pregnancy-related morbidity and mortal- An important contributing factor to high maternal ity in many developing countries, accounting for mortality and morbidity is the inadequate coverage 125,000 to 200,000 female deaths annually. In Sub- and low quality of care provided to pregnant women Saharan Africa, abortion accounts for one in three in developing countries. Only about half the preg- pregnancy-related deaths, and one in four in South nant women in these countries receive even mini- Asia and Latin America (Dixon-Mueller 1990; La mal prenatal and delivery care (Table B.3). Guardia et al. 1990; Rosenfield 1989; WHO 1992c). While maternal mortality ratios have fallen in In most of the Central Asian Republics, where abor- parts of Latin America and in Southeast and 'Nest tion services are of poor quality and contraceptives Asia, they remain high in Africa and South ksia. are virtually unavailable, it is the second highest Even though the risk of dying as a result of preg- cause of pregnancy-related deaths. Abortion-related nancy or childbirth has declined globally, the rum- mortality is highest in countries where abortion is ber of pregnancy-related deaths has continued to legally restricted, access to family planning and safe rise as the number of women in their prime c iild- abortion services is limited, and overall maternal bearing years also rises. mortality is high. The lifetime risk of dying from pregnancy-related About 40 percent of the world's population live causes varies widely: one in every twenty-two in countries with no restrictions on abortion, 23 per- women in Africa dies of complications of pregna ncy, cent where abortion is permitted for social and med- ical reasons, 12 percent where abortion is permitted FigureB.2: Maternal mortality in Romania,196591 when the woman's life and health are at stake or maternaldeoths per 100,000 livebirths there are injuries to the fetus, and 25 percent where abortion is permitted only to save the life of the woman or not permitted at all (Henshaw 1990). The - . impact of unsafe abortion on women's health is . illustrated by Romania's experience. After Romania 140 '- ' outlawed both abortion and contraception in 1966, deaths from abortions rose dramatically. When 120 ' . these restrictions were dropped in 1990, maternal mortality fell to 40 percent of the previous year's level (see Figure B.2).0 - - At, .t Unsafe abortion can harm a woman's physical and mental health, cause infertility, and have eo ------negative social consequences. The cost of treating complications from unsafe abortions is consider- able-many times greater than that of offering safe 20 ...... ' ...... '.' abortion services. Treating abortion complications ftiornmade 1g Aborilonllgizid can consume as much as half of a hospital's budget (McLaurin et al. 1991; WHO 1990b; WHO 1990c). P .AO e le RU-486, a drug that induces abortion within the first sixty-three days of pregnancy, shows promise as Source:Adapted from Stephenson and others 1992 which used Jata a nonsurgical method of early abortion. Because of from The Ministry of Health of Romania. 66 Women'sHealth and Nutrition: Making a Difference delivery, or abortion, compared with only one in Pakistan, the Philippines, and Syria, between 9 and every 10,000 in Northern Europe (Rochat 1987). The 25 percent of women under age forty-five suffer uter- death toll is greatest in Sub-Saharan Africa and South ine prolapse (Omran and Standley 1976; Omran and Asia, where maternal mortality ratios (pregnancy- Standley 1981). The condition is associated with related deaths per 100,000 live births) are as much hard physical labor, poor maternity care, and early as 200 times higher than those in industrialized and frequent childbearing. It causes considerable countries. This is the widest disparity in human discomfort, interferes with bodily functions, and development indicators between developed and can result in a variety of complications. A recent developing countries yet reported. study in rural Egypt found that more than half of all In developing countries, more than one-fourth women of reproductive age suffered from uterine of all deaths to women of reproductive age are preg- prolapse, although many afflicted women did not nancy-related, and four in five result directly from realize that they had the condition (Zurayk 1991). obstetrical causes: hemorrhage contributes 25 per- Some illnesses (such as malaria, tuberculosis and cent; sepsis about 15 percent; unsafe abortion at viral hepatitis) can have more serious effects during least 13 percent; hypertensive disorders (eclampsia) pregnancy, because of the woman's weakened about 12 percent; and obstructed labor about 8 per- immune system and other physiological changes. cent (see Figure B.3). Additional pregnancy-related Anemia, which affects an estimated 60 to 70 percent deaths result from conditions aggravated by preg- of pregnant women in developing countries (Sloan nancy (such as malaria, viral hepatitis, diabetes, ane- and Jordan 1992), impedes the woman's ability to mia, and rheumatic heart disease (WHO 1991a). resist infection and survive hemorrhage and makes Long after delivery, many women suffer preg- women more vulnerable to complications during nancy-related disabilities (including utero-vaginal childbirth. or bladder prolapse, cervical lacerations, obstetric In some settings, the health care system may also fistulae, anemia, and infertility). In Colombia, contribute to the mother's poor health. In some

TableB.3: Globaland regionalestimates of prenatalcare, institutional deliveries anddeliveries with trainedattendant

Trainedattendant Prenatalcare* Institutionaldelivery at delivery** Country (000s) % (OOOs) % (OOOs) 46 World 90,691 64 62,453 44 86,018 60 Developed** 16,818 98 16,313 95 17,043 99 Developing 73,873 59 46,140 37 68,975 55 Africa 16,711 59 9,742 34 11,929 42 Eastern 6,538 68 2,823 30 3,346 35 Middle 1,393 43 1,400 43 1,425 44 Northern 2,450 49 1,557 31 2,643 53 Southern 1,210 89 1,149 85 1,160 86 Western 5,121 55 2,813 30 3,354 36 Asia*** 48,035 57 28,106 33 47,471 56 Eastern*** 22,407 87 12,197 48 24,352 95 South-eastern 8,828 70 4,992 39 7,336 53 Southern 14,269 35 8,484 21 12,644 31 Western 2,531 54 2,433 52 3,139 67 Latin America 8,985 72 8,192 66 9,474 75 Caribbean 747 89 613 73 754 90 Central 2,492 71 2,018 57 2,600 74 South 5,746 71 5,561 69 6,120 75 Northern America 3,774 95 3,774 95 3,956 99 Europe 6,305 99 6,048 95 6,334 99 Oceania*** 142 70 100 49 101 5) Former USSR**** 5,065 100 4,812 95 5,065 10') Estimates,using 1990 UN projectionsfor numbersof live births,were calculated for 1993 basedon studiesfor the period 1985-1993. 'Defined asone prenatalvisit anytimeduring pregnancy. -Defined asa birth attendedby trainedmedical personnel, including traditional birth attendantswho havereceived some training in modernmedical practice. **'Japan, Australiaand New Zealandhave been excludedfrom the regionalestimates, but are includedin the total for developedcountries. Figuresmay not add to totalsdue to rounding. ****Datacollected prior to recentpolitical changes. Source:WHO 1993a. Annex B. Life Cycleof Women'sHealth 67

Latin American countries, for example, unnecessary ing pregnancy, and anemia), hypertension, malaria, cesarean sections increase the risk of infection and and other infections during pregnancy. blood loss during delivery. Many hospitals also sep- arate mothers from their newborn infants, thereby Malnutrition discouraging breastfeeding. The death of a mother has profound conse- An estimated 450 million adult women in devdlop- quences for her children: fewer than 10 percent of ing countries are stunted as a result of childhood the infants who survive the death of their mother protein-energy malnutrition, and iron-deficiency live beyond their first birthday (Chen et al. 1974; anemia affects an equivalent number (World FBank Koenig et al. 1988; Strong 1992). Children under age 1993c). About 250 million women suffer the effects five are up to 50 percent more likely to die if their of iodine deficiency, and although the exact num- mother dies, and the mortality risk remains higher bers are unknown, millions are probably blind due than that faced by children under age ten with liv- to vitamin A deficiency (Leslie 1991; Tinker 1993). ing mothers (see Figure 1.2 in Chapter 1). The highest levels of malnutrition among women Even when the mother survives, pregnancy- are found in South Asia and Sub-Saharan Africa related complications can cause death and disability (UN/ACC/SCN 1992a). to her children. Each year an estimated seven mil- Some 40 percent of women aged fifteen to forty- lion infants are born dead or die within a week of nine in developing countries suffer from anemia birth because of maternal complications, poor man- (Figure B.4), compared to 26 percent of men aged fif- agement of labor and delivery, and the woman's teen to fifty-nine (WHO 1992c). Anemia in women general health status before and during pregnancy is usually caused by low iron intake combined with (WHO 1989a). Furthermore, millions of children impaired absorption and depletion of iron stores due who survive a difficult delivery suffer later from to menstruation, pregnancy, childbirth, maliria, impaired physical and mental development. Each hookworm, and other parasitic infections. Anemia year, more than two million infants die or are brain- causes extreme fatigue, seriously impedes the indi- damaged due to oxygen deficit during delivery vidual's capacity to work and learn, and reduces tol- (CAMHADD 1990). erance for hemorrhage during childbirth and In developing countries, an estimated twenty- abortion. four million low-birth-weight babies are born every Iodine deficiency, which is more prevalent year. These babies are five to thirty times more likely among women than men, can lead to goiter, anid is to die during their first week of life than babies of associated with lethargy in women and severe men- normal weight (WHO and UNICEF 1992). Key tal retardation in infants. Iodine-deficient mothers causes of underweight newborns include the have higher rates of fetal wastage, stillbirths, and mother's poor nutritional status (short stature, low low-birth-weight babies. Vitamin A deficiency, pre-pregnancy weight, inadequate weight gain dur- which is worsened by pregnancy, causes night bl ind- ness and inhibits the body's immune response Figure B.3: Medical causes of maternal deathsnesadihbtteboysmuerspseo to InFigurevel developing eic countries causes o m infection. Since Vitamin A also affects production of the body's mucosa, its deficiency thus increases risk Unsafeabortion Sepsis for some types of infection, including reproductive 13°%5 % tract infections. H, _Causes of malnutrition include inadequate tood Hypertensive Hemorrhage supply, inequitable distribution of food within the 12% 25% household, improper food storage and preparation, food taboos, lack of knowledge regarding nutrit.ous foods, and problems associated with food's biologi- cal use and absorption. Females are more likely than Obstructed males to be malnourished because of differential labormaetobmanuihdbcueodifriil 8% food allocation and a failure to recognize women's Other q :g W

Despite breastfeeding's nutritional demands on America and other regions are increasingly suffering the mother, health experts stress its many benefits from obesity-a warning that chronic diseases are for both mother and child. For the mother, breast- on the rise (UN/ACC/SCN 1992a). feeding-on-demand (including night feeds) delays the return of menses and thus prevents pregnancy Reproductive tract infections and AIDS for up to six months. Breastfeeding may also reduce the risk of breast cancer. For the child, breastfeeding Sexually transmitted diseases and other reproduc- offers optimal nutrition and protection from various tive tract infections (RTIs) have profound heall h and diseases. Experts recommend exclusive breastfeed- social consequences for women. RTIs account for ing (which consists of feeding the child on demand, more than half of all infections and parasitic diseases including night feeds) and providing the child with suffered by women ages fifteen to forty-four (Figure breastmilk only (including colostrum-the first B.5). Women are more susceptible to these infec- milk-but excluding water and prelacteal feeds) tions than men. Because RTIs are often asympto- from birth until the age of six months (PRB 1990). matic in women, they are more likely than men to Social and cultural factors have a strong impact experience complications from untreated RTls. on dietary practices. Food taboos sometimes restrict Worldwide, about 250 million new reproductive women from consuming nutritious, high-energy tract infections are sexually transmitted annually foods during pregnancy and lactation when they (WHO 1990d). RTIs that are not sexually transmit- need them most. Women's lack of control over fam- ted include infection caused by induced abortion, ily income hampers their ability to obtain nutritious improper IUD insertion, unhygienic deliverv prac- foods for themselves and their children, and preg- tices, childbirth, and such traditional practices as nant women sometimes eat less intentionally for female genital mutilation. fear of having large babies and difficult deliveries. RTIs can lead to pelvic inflammatory disease Women who are stunted from malnutrition are (PID), infertility, and adverse pregnancy outcomes at higher risk of obstructed labor, a life-threatening such as miscarriage, ectopic pregnancy, stillbirth, condition that can also lead to fistulae in the mother low birth weight, prematurity, and congenital infec- and brain damage in the infant. Poor maternal nutri- tion. PID also causes chronic pelvic pain anc recur- tion is also a leading cause of low-birth-weight rent infection. babies (WHO and UNICEF 1992). Adequate calcium According to WHO, RTIs account for roughly 40 intake to build strong bones before the age of forty, percent of infertility cases in Asia, Latin Amnerica, furthermore, is important for the prevention of and the Eastern Mediterranean region, and 35 per- osteoporosis in women's post-reproductive years. cent of cases in Africa (WHO 1987). Roughly 8 to 10 Finally, urban middle-income women in Latin percent of all couples worldwide experience some form of infertility, defined as an inability to conceive Figure B.4: Prevalenceof anemiaamong women in twelve months of unprotected intercourse, at aged 15-49, 1990 percentanemic Figure B.5:Infectious and parasiticdiseases in women 60 59 aged 15-44

50 | 1 30O 4522 42 41 40 34 30

20 1

10 Other 1696 0 Africa Asia Latin Developed TB America countries 24% Respiratory * Pregnantwomen O All women infections Source:WHO 1 992c. Source:World Bank 1 993c. Annex B. Life Cycleof Women'sHealth 69

some time during their reproductive lives (WHO users, were HIV-infected (Ford and Koetsawang 1990d). The most common cause of infertility in 1991). many developing countries is blockage in, or dam- Worldwide, about 60 percent of HIV infections age to, the fallopian tubes. Where rates of secondary result from heterosexual transmission. Women, infertility (failure to conceive again after a prior moreover, are more likely than men to contract HIV pregnancy) are high, complications due to poor infections because of: management of delivery may be the cause. In a study * Increased likelihood of infection per exposirre. of women aged fifteen to fifty in different regions of Women have a larger mucosal surface exposed Cameroon, for example, 3 to 17 percent suffered during sexual intercourse, and semen contains a from primary infertility, and 14 to 39 percent from much higher concentration of HIV than vaginal secondary infertility (Sherris and Fox 1983). For fluid. Women are also more likely than men to women, infertility can mean divorce, abandonment, have asymptomatic, untreated STDs, which and social ostracism. increase their susceptibility to HIV infection. HIV/AIDS,which is primarily transmitted sexu- * Greaterexposure and at younger ages. Women tend ally, is spreading rapidly among women (see Figure to have sex with older men, who are more likely B.6). In Sub-Saharan Africa alone, nearly four mil- to be infected. In addition, social norms that lion adult women are already infected, and accord- require female passivity and economic depen- ing to WHO nearly half of newly infected adults are dence on men make it difficult for women to women. By the year 2000, more than thirteen mil- insist on mutual fidelity or condom use (WHO lion women may be infected (WHO 1993c). AIDSis 1993c). Finally,women are exposed to HIVinfec- the leading cause of death among urban African tion when they receive blood transfusions to women aged twenty to forty (World Bank 1992c), combat pregnancy-related anemia or hemor- and in the past five years, the number of AIDScases rhage. among women in Central America has increased to Women's lower status increases their susceptibility forty times previous levels (PAHO/WHO1992a). In to both STDsand HIV/AIDS.Inadequate sex educa- Latin America and the Caribbean, AIDSis spreading tion and harmful traditional practices also ccn- among women largely because of their partners' tribute to their higher risk. Women's lower high-risk behavior. The same is true in South and economic status can lead to exchange of sexual Southeast Asia, where it is spreading rapidly among favors for economic support, which also increases prostitutes, women whose husbands are infected by their risk. prostitutes, and drug users. A recent study in Women with HIV run a high risk of passing the Thailand found that 19 percent of prostitutes in virus to their newborns and usually die while their Bangkok brothels and 46 percent of those in Chiang children are still growing up. Tested at age one, Mai, as well as more than one-third of injecting drug between 15 and 40 percent babies of HIV-infected mothers were also infected (WHO 1992b). Figure B.6:Estimated cumulative HIV infections in women by early 1994 Post-Reproductive Years EasternEurope and Australasia/ CentralAsia The health of adults over the age of fifty is often con- Sub-000' 2 EastAsia and the Pacific sidered only of concern to industrialized societies. 25,0 00 However, the majority of the world's 467 million NorthAmerica women aged fifty and older live in developing coun- >1,000,000 tries. By the year 2020 one in five women in devel- oping countries will be fifty or older. The projected .. . :: America-Latin 250 percent increase in this age group has major >1 00,000 implications for health care. Developing countries WesternEurope in transition face the dual problem of both commu- 500,000 nicable and chronic disease, with implications for orthAfrica and resource allocation, the appropriate mix of preven- MiddleEast tive and curative services,and the protection of vLl- 75,000 nerable groups. Southand South-EastAsia The vast majority of health problems among

Source:WHO 1>993c. women older than fifty are chronic (ranging from 70 Women'sHealth and Nutrition:Making a Difference chronic back pain to cancer, cardiovascular and cere- mon; in developed countries, breast, colorectal, and brovascular diseases, arthritis, and diabetes). Older lung cancers are the most prevalent (World Bank women also suffer from injuries, mental health prob- 1993c). Gynecological cancers (including breast, cer- lems, and, in low-income areas, infectious and para- vical, uterine, and ovarian) account for 27 percent of sitic disease. Loss of visual acuity and hearing, all malignancies occurring to women in developing osteoporosis, malnutrition, and anemia also con- countries. Although these cancers may begin in the tribute to substantial morbidity. Yet treatment of reproductive years, it is most common after chronic degenerative diseases in developing countries menopause. is often not available or is prohibitively expensive. In developing countries, 400,000 new cases of As a result of urbanization, migration and chang- cervical cancer are identified each year and 183,000 ing family structure, women are increasingly women die from the disease (Figure B.7) (Sherris et neglected in old age. The cumulative effects of a life- al. 1993; World Bank 1993c). The highest rates of time of nutritional deprivation, hazardous and cervical cancer are found in East and Central Africa, heavy work, continuous childbearing, and low self- the Caribbean, tropical South America, and parts of esteem leaves them both physically and mentally Asia (Meheus 1992). Women who have multiple frail, while abandonment and widowhood often partners or whose partner is promiscuous are at leave them destitute. highest risk for cervical cancer, which can usually be Because of their tendency to marry men older cured if detected early. In developed countries, wide- ti an themselves and their longer life expectancy, spread access to screening tests using cytology (Pap wornen are more likely than men to be widowed. smears) and to treatment has substantially reduced 'Af8h the shift away from tl,e support of extended disability and death due to cervical cancer. families, elderly women are increasingly left on their Each year, about 229,000 new breast can cer cases own. Loss of a partner and living alone may have are detected in developing countries, and 158,000 important health implications (including inappro- women die from the disease (World Bank 1993c). priate diet and inattention to illness) and often lead The risk of developing breast cancer is related to age to poverty, ill health, and institutionalization. at first pregnancy, menarche, and menopause, but With their increasing life expectancy, many dietary and other factors also play a role. Because the women will survive for decades after menopause. causal factors are not well known, strategies to pre- The decline in ovarian hormone levels after the ces- vent breast cancer remain unclear. Where appropri- sation of menses leads to alterations in the skeletal, ate treatment is available, however, early detection cardiovascular, nervous, skin, genitourinary, and through physical examination of the breast or mam- gastrointestinal systems. Some of the symptoms mography contribute to an improved prognosis. attributed to menopause are actually caused by Deaths attributed to lung cancer are relatively other biological changes and by psychological and low in developing countries and occur predomi- environmental forces in a woman's life. But what- nantly among men. But with women smoking more, ever the cause, millions of women develop symp- deaths from lung cancer are expected to rise. About toms around menopause that interfere with their 5 to 7 percent of women in developing countries are capacity to function at home or in the workplace currently smokers. In a handful of countries (Bolivia, (Frankenhaeuser et al. 1991). Brazil, Nepal, Papua New Guinea, Swaziland, and As women live longer, diseases related to the Turkey), more than half of all women smoke (WHO absence of ovarian steroids begin to develop. These 1992c). Smoking has deleterious effects on repro- diseases (which include osteoporosis, coronary heart ductive health (earlier menopause, cervical cancer) disease, and cerebrovascular disease) are chronic and and also contributes to the development of chronic require expensive therapy. It is important, therefore, obstructive pulmonary disease, bronchitis and car- both to teach younger women how to protect their diovascular diseases. Exposure to cooking fires and future health and to provide supportive measures second-hand smoke also contributes to lung cancer that enable post-menopausal women to continue in women. their daily activities. Cardiovascular and cerebrovasculardiseases Gynecologicalcancers In developing countries among women iixty-five Among women in developing countries, cancers of years of age and older, cardiovascular diseases, the stomach, cervix, and breast are the most com- including ischemic and hypertensive heart disease, AnnexB. LifeCycle of Women'sHealth 71

and cerebrovascular diseases, are the leading causes and Africa. In both rural and urban settings, years of of death (World Bank 1993c). In China, where these childbearing and inadequate nutrition cause diseases account for half of all deaths, women are chronic undernutrition and anemia in women, more likely to die from them than men. With the which continues into the post-reproductive period. increasing adoption of such risk-producing behav- In addition, many older women have inadequate iors as smoking and alcohol consumption, the inci- intake of protein, vitamins, and minerals, dehydra- dence of cardiovascular disease is likely to increase tion is common, and anemia (caused by a history of in developing countries. Obesity, too, may increase marginal nutrition coupled with closely spaced the risk of stroke among women and measures to pregnancies) is severe among low-income groups prevent cardiovascular diseases include control of (UN/ACC/SCN 1992a). weight and hypertension through diet and regular exercise (DiPietro et al. 1994). Osteoporosis

Diabetes Worldwide about 10 percent of women over age sixty have osteoporosis-bone loss that results in While the prevalence of diabetes appears to be low pain, disability, and increased risk of fractures. in most developing countries, it is becoming more Because bone loss rises sharply after menopause, prevalent in urban areas of Asia, the Middle East, osteoporosis is most common in older women. It Latin America, and the Caribbean. The increase in appears to be linked to decreasing hormone levels, the incidence of diabetes is associated with adoption lack of calcium in the diet during younger years, of a diet high in sugar and fat, and lack of exercise. inadequate exposure to sunlight, and inactivity. Diabetes is listed as a major factor contributing to death in thirteen of the eighteen Latin American Osteoarthritis countries and six of the ten Caribbean countries (Sennott-Miller 1989; Young 1993b). It is a major Post-menopausal women and those who have expe- risk factor for cardiovascular disease, blindness, kid- rienced repeated trauma to the joints are at particu- ney damage, and damage of lower limbs. In many larly high risk of osteoarthritis. As this degenerative countries, it is more prevalent in females than in disease progresses, it causes pain, swelling, and stiff- males Uamison 1993). Measures to prevent diabetes ness of the joints. Osteoarthritis restricts a person's include avoidance of obesity and regular exercise. ability to perform routine activities and is therefore especially debilitating to elderly women living Undernutrition alone. Treatment consists of palliative measures such as avoiding vigorous activity, weight reduction Chronic undernutrition is common among older for the overweight, and pain-relief through medi- women in Latin America, the Caribbean, South Asia, cines (Harrison and Wilson 1991).

Figure B.7:Estimated number of new cervicalcancer cases per year, 1985 (thousands) Developingcountries 343.5 --- China Latin America

Africa 51.5

Developedcountries Other Asia 92.9 161.8 Source:Parkin et al. 1993. 72 Women'sHealth and Nutrition:Making a Difference

Additional Health Problems tional dowry payments. Dowry deaths usually take the form of setting the woman on fire and claiming Gender violence, mental disorders and certain occu- she died in a kitchen accident. In urban Maharastra pational and environmental hazards have a dispro- and greater Bombay, one in four deaths to women portionate impact on women. The health sector aged fifteen to twenty-four are attributed to "acci- must identify these problems as health issues, help dental burns" (Karkal 1985). to quantify their prevalence and impact, promote Reliable data on the incidence of rape are diffi- preventive measures, and provide appropriate treat- cult to obtain, as many rapes go unreported. Among ment for the medical conditions that result. women aged eighteen to twenty-one surveyed in five countries, between 8 and 18 percent reported Gender violence that they had been raped (Heise et al. 1994). Studies indicate that the majority of rape victims know their Violence against women (including physical, sexual, assailants, and that at least one-third of rapes are per- or psychological harm) is endemic in almost every petrated against girls aged fifteen and younger (Heise society and is a significant cause of female morbid- 1993). In wartime, mass rapes have been docu- ity and mortality. Violence can lead to psychologi- mented in many countries (Heise et al. 1994). cal trauma and depression, injuries, STDs, suicide, Rape and sexual assault can cause both physical and murder. Conditions resulting from rape and injury and profound emotional trauma. Studies gender violence account for about 5 percent of the show that rape victims are more likely to attempt world's total disease burden (World Bank 1993c). Yet suicide and experience major depression and other in many societies, violence against women is largely mental disorders than non-victims (Heise et al. ignored or is even condoned by community leaders 1994). Traumatic consequences-including sleep and policymakers. Laws that do not recognize gen- and eating disturbances, feelings of anger and self- der-related violence as a problem sometimes serve to blame, nightmares, inability to concentrate, and sanction it (Heise et al. 1994). sexual dysfunction-can endure for years. Rape Of women surveyed in various countries, victims also face the risk of unwanted pregnancy, between 20 and 60 percent report that they have STDs, and HIV/AIDS. In many societies, the social been beaten by their partners (World Bank 1993c). stigma of rape leads to beatings, ostracism, murder, In developing countries, gender violence is a signif- and suicide. icant cause of injury and ill health. A study in Child and adolescent sexual abuse also has Alexandria, Egypt, found that domestic violence severe, long-term psychological effects, which can accounted for 28 percent of visits to trauma units be manifested as physical complaints (such as (Graitcer 1994). In Papua New Guinea, 18 percent of chronic pelvic pain, headaches, asthma, gynecolog- urban wives reported having received hospital treat- ical problems, and gastrointestinal disorders). Early ment for injuries inflicted by their husbands, and 67 sexual victimization may also leave women with low percent of rural wives reported that they had been self-esteem and make them vulnerable to further beaten (Bradley 1988). assaults, including rape and spousal violence. Some The physical aftermath of wife-beating can studies have found a link between early sexual vic- include death, broken bones, internal injuries, mis- timization and excessive drug and alcohol use, carriage, and cuts and bruises. Battered women who unprotected sex with multiple partners, prostitu- are pregnant are twice as likely to have a miscarriage tion, and teenage pregnancy (Heise et al. 1994). and four times more likely to have a low-birth- Violence against women constitutes a significant weight baby than other women (World Bank 1993c). drain on health resources. Two studies in the United Psychological sequelae include fear, anxiety, fatigue, States found that women who had been raped or sleeping and eating disorders, and post-traumatic assaulted had higher health care costs and more stress disorder. About one in three battered women physician visits than nonvictimized women (Feletti suffers major depression-which leads some to alco- 1991; Koss et al. 1991). hol and drug abuse (Heise et al. 1994). Suicides stem- ming from marital violence have been reported in Mental disorders diverse cultures, and spousal homicide is often pre- ceded by a history of physical abuse. Overall, mental disorders are more prevalent among In India, young brides are sometimes abused and men than among women. Men are much more killed if their families fail to meet demands for addi- likely to suffer from alcohol and drug dependency AnnexB. Life Cycle of Women'sHealth 73 and epilepsy than women, but women have higher permanently disabled due to back pain, the physical rates of depressive and post-traumatic stress disor- strain of repetitive tasks coupled with fast work ders (World Bank 1993c). Studies from thirty-three speed, eye strain from close work, and deafness from countries around the world found that the preva- excessive noise. Mexico's "maquiladora" assembly lence of mental disorders among women ranged plants, which employ thousands of women, require from 6 to 35 percent, compared with 2 to 31 percent long hours of detail work in unhealthy working con- among men (Paltiel 1993). Although women are ditions, including inadequate ventilation and light- more likely to attempt suicide than men, however, ing, poor sanitation, excessive noise, unsafe more men die from suicide than women (Paltiel machinery, and exposure to toxic chemicals. 1993). Electronic assembly workers report a loss of visual Among women of reproductive age in develop- acuity, and textile workers complain of pulmonary ing countries, neuropsychiatric problems account problems, dermatitis, hand injuries, and chronic for 12 percent of the disease burden-half due to back pain (Hovell et al. 1988). Exposure to toxic depressive disorders. Suicide accounts for an addi- chemicals can cause cancer, dermatitis, miscarriage tional 3 percent of deaths among women in this age and birth defects. Women may be particularly sus- group-more than are caused either by respiratory ceptible to some toxic chemicals for biological rea- infections or motor vehicle accidents (World Bank sons (Rovner 1993). 1993c). Because of its persistence, recurrence, and Most women in developing countries are interference with well-being and performance, employed in the informal sector as food vendors, depression is the single most serious mental problem petty traders, servants, launderers, beer brewers etc. for women in every age group (Paltiel 1993). These are low-wage positions with no security or Social, cultural and biological factors that con- fringe benefits, and women workers are generally tribute to mental health problems include: sexual too poor to purchase adequate health care or invest abuse, rape, beatings, sexual harassment, fear of in protective clothing and equipment. Illiterate unwanted pregnancy, infertility, fear of STDs and domestic workers and housewives who cannot read HIV/AIDS; women's double work burden (inside and labels on toxic cleaning agents are at particular risk outside the home); low social status and gender dis- for poisoning. Women laborers and domestic work- crimination; postpartum disorders, menopause and ers also face the risk of sexual harassment, rape, and life changes associated with increasing age. accidents. Commercial sex workers face many health risks, including RTIs, STDs, HIV/AIDS, vio- Occupational and environmental health problems lence, and unplanned pregnancy. Among women farmers, the main cause of poor As part of the formal labor force, women are increas- health is heavy work and multiple responsibilities ingly exposed to unsafe conditions, (including toxic within the household. Rural women's physical eKer- chemicals, radiation, excessive noise, extreme tem- tion, low status, and lack of control over resources peratures, accidents, and violence). Women in for- affect their nutritional status, time available for mal employment work mainly in industries where leisure, health-seeking behavior, and general health working conditions are poorly regulated such as tex- status. Women employed in agribusiness and large tiles, footwear, food production, electronics, and farms are also exposed to large quantities of pesti- handicraft production. In industries where wages are cides and fertilizers, often without appropriate safe- low and employers value women for their dexterity, guards. patience and docile nature, the workforce is almost Traditional women's tasks such as tending cook- entirely female. Where the proportion of women- ing fires and carrying water and fuel, also expose headed households is high (as in most megacities in women to increased health risks and injurie;. A Latin America), women's dependence on their own study in India found that rural women cooking in earnings prevents them from negotiating for better poorly ventilated huts were exposed to a hundlred pay and working conditions. Women are also more times the acceptable level of suspended smoke par- likely than men to work in small enterprises that ticdes-six times higher than other household mem- lack the equipment and expertise to protect workers bers (Chatterjee 1991). Excessive smoke inhalation from workplace hazards. causes acute respiratory infections in infants, In workplaces with inadequate safeguards, chronic obstructive lung disease and cor pulmonale women workers are at risk of life-threatening injuries (right-sided heart failure) in adults, and such adverse and chronic diseases. They may become partially or pregnancy outcomes as low birth-weight and still- 74 Women'sHealth and Nutrition:Making a Difference births. Studies in China and India found that up to that women living in urban slums who had long- half of adult women (few of whom smoke) suffer term exposure to coal burned for heating and cook- from chronic lung and heart diseases (Smith and ing had higher rates of lung cancer than other Youcheng 1993). A study in Tienjin, China, found women (Young and Bertaud 1990). Annex C. Recommended Interventions for Women's Health and Nutrition

The following chart shows measures that commu- maintain continuum in service delivery. This sec- nity health workers, health centers and hospitals can tion also includes policy issues with direct and indi- take to improve women's health and nutrition. rect consequences for women's health. Finally. it Many of these interventions need to be reinforced at provides guidelines for messages targeted to t:he different levels of the health care system in order to community and to health personnel.

75 Annex C. Recommended Interventions for Women's Health and Nutrition Community health worker level Life Cycle Stage Services and Staff Training Supplies and Equipment Infrastructure Infancy and Outreach to provide equal access to health Weighing scales Mobile health units Childhood services to girl children with regard to: Growth and counseling cards (outreach for immunization * Immunization coverage Food supplements and other health services) * Management of diarrhea, acute respiratory Essential micronutrients (Vitamin A, Health posts infections and other childhood diseases iodine, iron) * Counseling on equal exclusive breastfeeding Vaccines for childhood diseases for female and male infants (first 6 months) * Growth monitoring and counseling on girls' nutritional requirements and consequences of poor nutrition * Targeting of food and micronutrient supplementation to reach vulnerable girl children * Recognition and reporting of female genital mutilation and other harmful differential practices towards girls Adolescence Educating the public on the nutritional needs Iron and folate tablets Youth centers of adolescent girls Food supplements Health posts * Counseling adolescents to avoid risk-taking Contraceptives (See under infrastructure for o4 behavior (smoking, alcohol, unprotected sex (See under supplies and equipment maternal care) and drug use) for maternal care) * Providing contraceptive services to sexually active adolescents * Identifying pregnant adolescents and referring them for appropriate care * Recognizing and referring STDs in adolescents Reproductive Years: Identifying pregnant women Iron and folate tablets Mobile health units for * Counseling pregnant women on appropriate Antimalarial tablets in endemic areas outreach Prenatal Care prenatal care and nutrition Blood pressure testing apparatus Health posts * Providing iron and folate tablets Maternal health cards Emergency transport * Providing tetanus-toxoid immunization Weighing scales vehicle * Monitoring nutrition and referring severely Tetanus toxoid infections Accessto radio undernourished women to the health center communication * Recognizing and referring women with danger signs in pregnancy (edema, blurred vision, bleeding) * Providing antimalarials as necessary * Counseling pregnant women on child spacing and breastfeeding * Maintaining safe birth kits * Maintaining a register on women of reproductive age Community health worker level LifeCycle Stage Servicesand Staff Training Suppliesand Equipment Infrastructure ReproductiveYears: Using hygienicpractices during delivery(safe Safebirth kits Deliveryroom for normal birth kit) deliveries Laborand Delivery Detectingand referringbirth complications Maternityhut Care (laboror rupture of membranesof more than Birthingcenter to provide 12 hours duration,prolapse of the cord, deliverylocation outside of postpartumhemorrhage) hospitalsfor normal * Monitoringmothers and newbornsafter deliveriesin urban areas delivery Emergencytransport * Counselingon earlyand exclusive vehicle(includes breastfeedingand careof newborn community-organized transport) Access to radio communication ReproductiveYears: Counselingon nutritionand personalhygiene Appropriatecontraceptive devices Mobilehealth servicesfor * Counselingon exclusivebreastfeeding and (e.g.condoms and progestin-only outreach PostpartumCare family planningmethods (e.g. progestin-only pills) * Healthposts pills) * Food supplements,micronutrient * Emergencytransport Monitoringfor postpartumcomplications supplements(vitamin A, iron, folate, vehicle (fever,bleeding, breast abscess) calcium) * Accessto radio Referringmothers with postpartum communication -a complications ReproductiveYears: * Providinginformation and serviceson a wide * Adequatesupply of appropriate * Emergencytransport range of traditionaland modern contraceptive contraceptives(eg. condomsand oral vehicle(includes UnwantedPregnancy methods contraceptives) communityorganized and Safe Abortion * Detectingincomplete abortions and referring transport) complications Accessto radio Counselingon dangersof unsafe abortion communication

ReproductiveYears: * Early detectionand referralof reproductive * Antibioticsfor treatmentof RTIs * Healthposts tract infections(RTIs) Condoms Other HealthIssues Partner notificationof personswith STDsand * Safebirth kits diagnosisand counselingof the partners Counselingon safe sexualbehavior to prevent STDs(use of condoms,reduction in number of sexualpartners) Adoptionof safebirth practicesto prevent non-sexually-transmittedRTIs Counselingon correctusage of condomsand other methodsof contran-ption CounselingHIV positive and AIDSpatients I and their families Community health worker level

Life Cycle Stage Services and Staff Training Supplies and Equipment Infrastructure

Post-reproductive Counseling older women on adequate Food supplements and coupons Home-nursing care facilities Years nutrition Blood pressure testing apparatus for aged women * Care of older women with focus on family participation, including home nursing care * Counseling on avoidance of risk factors in diseases affecting older women (smoking, alcohol, inadequate exercise) * Palliative measures and home care for terminally ill women

All ages: * Educating health workers to recognize and * Support groups to provide refer women whose injuries suggest domestic counseling to victims of Violence against or other violence domestic violence Women * Catalyzing discussion and community action (including self-help support around violence against women groups) Counseling against alcohol and drug abuse Health Center level

Life Cycle Stage Services and Staff Training Supplies and Equipment Infrastructure

Infancy and Childhood Ensuring equal access to health Weighing scales Health centers services to girl children with Growth and counseling cards regard to: Food supplements 'Immunization coverage Essential micronutrients Management of diarrhea, acute (vitamin A, iodine) respiratory infections and other Vaccines for childhood diseases childhood diseases * Counseling on equal exclusive breastfeeding of both female and male infants (first six months) * Targeting of food and micronutrient supplements to reach vulnerable girl children * Growth monitoring and counseling on nutritional requirements of the girl child and consequences of poor nutrition * Recognition and prompt reporting of female genital mutilation and other harmful differential practices towards girls

Adolescence Managing or referring problems Iron and folate tablets Youth centers specific to adolescent pregnancy Food supplements Health centers (pregnancy-induced Contraceptives (See under infrastructure for hypertension, cephalo-pelvic (See under supplies and maternal care and safe abortion) disproportion, low birth weight) equipment for maternal care and Managing or referring abortion safe abortion) complications in adolescents * Counseling on nutritional needs of adolescent girls * Counseling adolescents to avoid risk-taking behavior (unprotected sex, smoking, alcohol and drug use) and referral to de-addiction centers * Detecting and treating STDs and referring complications or sequelae - Providing contraceptive counseling to sexually active adolescents Health Center level

Life Cycle Stage Services and Staff Training Supplies and Equipment Infrastructure

Reproductive Years: Providing prenatal screening, Iron and folate tablets Health centers management and referral for Tetanus-toxoid injections Maternity waiting homes for Prenatal Care anerria, and infections including Blood pressure testing apparatus rural women who are at risk for STDs Parenteral fluids and essential complications and may need Providing tetanus-toxoid drugs (iron dextran, antibiotics, institutional care immunization antimalarials, sedatives) Emergency transport vehicle Counseling on prenatal self-care Laboratory equipment for Radio communication including nutrition, hygiene and antenatal examination (Hb danger signs in pregnancy estimation, complete blood Managing matemity waiting count, blood grouping and Rh homes typing, serological examination Referring women with high-risk for syphilis, dipsticks for urine pregnancies to the first referral examination, stool examination) ievel

Reproductive Years: Conducting routine deliveries Partogram Delivery room for normal * Managing complications Essential obstetric kit for normal deliveries Labor and Delivery Care (postpartum hemorrhage, delivery Separate labor room for eclampsia, and retained Vacuum extractor and forceps pregnant women with sepsis placenta) and prompt referral if for prolonged labor Emergency transport vehicle not responding to treatment Intravenous fluids and Radio communication x0 *Monitoring mothers and antibiotics 0 newboms after delivery Oxytocics * Counseling on early and exclusive breastfeeding and care of the newborn

Reproductive Years: * Conducting postpartumr Appropriate contraceptive * Health centers checkups for mother devices (condoms, diaphragms, Emergency transport vehicle Postpartum Care Managing and referring progestin- only pills, injectables, Radio communication postpartum complications implants, spermicides, and (puerperal sepsis, secondary lUDs) hemorrhage, thrombophlebitis) Food supplements, Vitamin A, * Providing contraceptive implants, iron, folate, calcium counseling and services (barrier Equipment for surgical methods, IUDs, injectables, contraception. implants, progestin-on!t pills, Intravenous fliciic and sterilization, and natural family antibiotics planniiig) and breastfeeding information Health Center level

Life Cycle Stage Services and Staff Training Supplies and Equipment Infrastructure

Reproductive Years: Providing clinical and Contraceptives (condoms, Emergency transport vehicle nonclinical family planning diaphragms, oral Radio communication Unwanted Pregnancy and Safe services contraceptives, IUDs, Abortion Providing safe abortion care injectables, implants, (where legal), treatment of spermicides) incomplete abortion (with Manual vacuum aspirators manual vacuum aspiration) and Antibiotics (for septic managing abortion abortions) complications (with manual Parenteral fluids (for shock) vacuum aspiration, antibiotics, Oxytocics (for hemorrhage) and fluid replacement) Training service providers to perform vacuum aspiration for first trimester abortions Providing post-abortion counseling services

_ ~ Reproductive Years: Early detection and prompt Antibiotics for treatment of RTIs Decentralized distribution of treatment of RTIs drugs (more distribution Other Health Issues Syndromic diagnosis of STDs (as Condoms warehouses) to speed delivery recommended by WHO) Laboratory equipment to test for Efficient communication Partner notification for RTIs including STDs (eg. channels and detailed reporting diagnosis, treatment and vaginal, cervical and urethral to ensure effective partner counseling of patients with swabs, testing for syphilis) notification STDs Counseling on safe sexual behavior to prevent STDs (use of condoms, reduction in number of sexual partners) Maintaining registers to assess the prevalence of STDs (including AIDS) in the area Vigilant drug supply management (against thefts, stock-outs) Counseling on dangers of drug use and sharing needles Health Center level

Life Cycle Stage Services and Staff Training Supplies and Equipment Infrastructure

Post-Reproductive Years Counseling older women on Food coupons Facilities for cryotherapy and adequate nutrition Blood pressure testing apparatus loop excision (to treat severe Educating women about risk Equipment for performing Pap dysplasia and early cervical factors particularly significant in smears cancer) older women (smoking, alcohol, Essential drugs (antidepressants, inadequate exercise) antidiabetics, antihypertensives) * Educating health workers about appropriate dosage and side effects of drugs commonly prescribed for older women (antidepressants, antid iabetics, antihypertensives) * Screening for cervical and breast 00 cancer (Pap smear, physical examination of breast) * Early detection and management of diseases of the elderly (eg. cervical cancer, hypertension, diabetes)

All ages: Training health workers on Support groups to provide gender-based violence counseling to victims of Violence Against Women * Counseling against alcohol and domestic violence drug abuse among adolescents and adults * Counseling to assuage victim's guilt and reinforce principle that no one deserves to be beaten rirst Keterral level

Life Cycle Stage Staff and Services Training Supplies and Equipment Infrastructure

Infancy and Childhood Ensuring equal access to health Antibiotics and equipment to Hospitals services to girl children with deal with serious childhood regard to: diseases * Management of severe Food and micronutrient malnutrition supplements * Management of serious childhood diseases Promoting exclusive breastfeeding for female and male infants equally (first 6 months) Recognition and management of female genital mutilation and other harmful differential practices against girls

Adolescence Managing problems specific to Iron and folate tablets Hospitals adolescent pregnancy Food supplements Infrastructure for maternal care (pregnancy induced Contraceptives and safe abortion hypertension, cephalo-pelvic Surgical and medical supplies, disproportion and low birth and equipment as recommended x0 weight) by WHO (1991a) for obstetric Treating complications of care induced abortion in adolescents (septic abortion, perforated uterus) Treating complications and sequelae of STDs in adolescents

Reproductive Years: Providing prenatal care for Essential drugs for treating Antenatal clinics women at high risk or with infections and other medical Prenatal Care medical problems problems (antibiotics, antihypertensives, anticonvu Isants) Laboratory equipment for referral examination (testing for medical problems such as hepatitis, STDs, kidney disease)

Reproductive Years: Providing surgical obstetrics and Surgical and medical supplies Facilities as recommended by anesthesia services and equipment as recommended WHO for providing surgical Labor and Delivery Care Providing medical treatment for by WHO (1991a) obstetric services pregnancy complications (such Blood bank facilitioc as sepsis, shock, and eclampsia) Ambulance Counseling on early and Radio communication exclusive breastfeeding and care of the newborn First Referral level Life Cycle Stage Staff and Services Training Supplies and Equipment Infrastructure Reproductive Years: Counseling on nutrition and Appropriate contraceptive Postpartum clinics infant care devices (equipment for surgical Family planning clinics Postpartum Care Providing family planning contraception, IUDs, progestin- counseling and services only pills, injectables, implants, Managing postpartum barrier methods) complications (puerperal sepsis, secondary hemorrhage, thrombophlebitis) Reproductive Years: Providing clinical and Adequate supply of appropriate Ambulance nonclinical contraceptive contraceptives (condoms, lUDs, Radio communication Unwanted Pregnancy and Safe services diaphragms, oral contraceptives, Facilities for surgical Abortion Providing safe abortion care injectables, implants) including interventions (hysterectomy, (where legal), treatment of equipment for surgical repair of perforated uterus) incomplete abortion (with contraception (eg. sterilization) vacuum aspiration) and Manual vacuum aspirators, managing complications of dilatation and curettage abortions (with general instruments anesthesia, antibiotics, and fluid Antibiotics (for septic abortions) replacement) Parenteral fluids (for shock) Training service providers to Oxytocics and safe blood for x0 perform first and second transfusion (for hemorrhage) 4i trimester abortions (vacuum aspiration, dilatation and vacuum aspiration and two stage evacuation) * Providing post-abortion counseling Reproductive Years: Appropriate treatment of Antibiotics for treatment of RTIs Hospitals advanced RTIs Laboratory equipment to test for Other Health Issues Recognition of and testing for RTIs (vaginal, cervical and antibiotic resistance urethral swabs, Pap smear, * Treatment of complications and culture testing for STDs, testing sequelae of RTIs for sensitivity to antibiotics in resistant infections) Screening blood for safety in use for transfusions l_l First Referral level

Life Cycle Stage Staff and Services Training Supplies and Equipment Infrastructure

Post-reproductive Years *Training health workers to *Equipment for performting Pap *Facilities for cryotherapy and prescribe appropriate drugs in smears loop excision for early cervical the correct dosage to older *Mammography (for breast cancer women cancer screening) *Surgical facilities for treating *Educating women on the side Essential drugs for treating gynecological cancers effects and dangers of diseases of the elderly overdosage Managing referral (antihypertensiveness, cases with cancers (cervical and antidiabetic) breast) and chronic diseases (hyper-tension, heart disease, diabetes)

All ages: Training health workers to *Service centers to assist women x0 recognize and report injuries and their families who have Violence Against Women suggestive of domestic violence undergone assault, sexual abuse *Counseling adolescents and and rape (eg. shelters, crisis adults about harmful effects of centers, self-support groups, alcohol and drug abuse legal assistance centers) *Collecting legal evidence of domestic violence for pr-osecution *Running treatment programs for individuals who are addicted to drugs and alcohol Policy Dialogue

Target Audience: Policymakers, program managers, community leaders, women's groups, health advocates

Life Cycle Stage Policy strategies with direct impact Policy strategies with indirect impact

Infancy and Childhood Integrate maternal and child health and Regulate use of medical tests to avoid misuse (sex nutrition programs to provide optimal services determination as a means to abort female foetuses) for both girls and boys Improve enrollment and retention rates of girls in Establish vital registration system for births schools and deaths Deter sex selection and female infanticide Provide food subsidies to vulnerable groups * Fortify foods with iodine and Vitamin A

Adolescence Assess adolescent health and nutrition needs Improve school enrollment among adolescent girls locally to determine services * Change regulations to allow pregnant girls to Improve adolescents' access to contraception continue their schooling and encourage them to and abortion complete their education Attract participation in health programs (school Broadcast information on sexual issues outreach programs, family life education, Raise and enforce the legal age of marriage multi-service centers) Prohibit prostitution among adolescents * Restrict advertising of and access to tobacco and alcohol Establish de-addiction centers especially for youth co Reproductive Years: Establish vital registration system to record Ensure that health providers are adequately deployed maternal deaths to rural areas Maternity care Fortify common foods with iron and iodine to Increase accessibility to maternal care centers by provide micronutrient supplements improving roads, transport and modes of * Target food supplements to malnourished, communication pregnant and lactating women Promote breastfeeding at the workplace Delegate responsibility for providing maternal Establish and monitor quality child care centers care to appropriate levels (management of Promote intersectoral coordination on maternal care routine deliveries to traditional birth attendants issues (education, labor) and community health workers; management Provide maternity leave and other benefits to of retained placenta and eclampsia to promote maternal and child health midwives; management of serious complications to first-referral hospitals) * Open or expand midwifery training schools

Reproductive Years: * Provide contraceptive services to men and Promote government, NGO and private sector women without restrictions based on age or cooperation and cofinanced reproductive health Unwanted Pregnancy and Safe Abortion marital status or spousal consent requirements services with NGOs and the private sector Provide safe abortion management including Legislate on a father's economic and legal post-abortion services on birth control responsibilities to his child inside and outside of * Protect women"s reproductive nghts, including marriage legal access to appropriate contraception and abortion services * Allocate public health resources to preventive health care and programs to prevent unwanted pregnancies Policy Dialogue

Target Audience: Policymakers, program managers, community leaders, women's groups, health advocates

Life Cycle Stage Policy strategies with direct impact Policy strategies with indirect impact

Reproductive Years: Develop a national notification system to assess Improve medical curricula to cover STD management the magnitude of the problem of STDs and counseling Other Health Issues Formulate a strategy based on the above Promote condom use among prostitutes and their findings to allocate resources to control clients measures and evaluate impact of STD Provide alternative employment for sex workers programs Prohibit the usage of drugs, particularly intravenous * Set national guidelines regarding integration of drugs services at and between levels (vertical service Discourage female genital mutilation delivery, integration with family planning and Provide more services through female health maternal and child health activities) providers * Target high risk groups for screening (sex Reduce/remove import duties on condoms and other x0 workers and their clients, intravenous-drug contraceptives users, migrant labor) for STDs * Improve logistics of drug supply (adequate supply, competitive prices)

Post-reproductive Years Expand surveillance data gathering to * Provide some form of health insurance for needy document the health status and needs of older older women and men women * Develop social safety nets for vulnerable groups, Introduce health counseling and screening particularly older women programs (hypertension) at the work place * Provide suitable housing (such as rooming units) to Establish day care centers and homes for aged enable elderly women to stay close to their families women, in cooperation with NGOs and * Promote interdisciplinary coordination (medical, women's organizations social and psychological services) for the care of older Encourage NGOs to initiate community women programs oriented toward inclusion of older women Promote alternative community care models (day care, short hospital stays) tailored to the needs of older women Policy Dialogue

Target Audience: Policymakers, program managers, community leaders, women's groups, health advocates

Life Cycle Stage Policy strategies with direct impact Policy strategies with indirect impact

All ages: Legislate to criminalize domestic violence and Make gender-awareness training part of the law other crimes against women school curriculum Violence Against Women Introduce reforms to facilitate prosecution of Include questions on gender violence in national gender-based crimes (rape, domestic assault) health surveys * Remove barriers that interfere with the ability Break down crime statistics by gender for both of women to escape violent relationships perpetrator and victim (barriers to divorce) Improve women's access to productive resources Train police and prosecutors about gender- (land, credit, wage employment) based violence * Introduce gender-awareness training, parenting skills, and non-violent conflict resolution into school curricula co* Work with the media to encourage positive images of equitable relationships and to remove gratuitous violence * Support NGOs that provide human rights education and legal literacy training for women Information, Education and Communication

TARGET AUDIENCE: General public, Health care providers

Life Cycle Stage Clients Health Providers

Infancy and Childhood Diseases Emphasize role of appropriate nutrition, particularly Stress importance of documenting any form of a girl's intrahousehold share of food, in her well- physical violence against girls being Warn against unethical medical tests * Build awareness of girls' nutritional requirements Encourage equal access to health care facilities for all children Imprtve enrollment and retention rates of girls in schools * Mobilize public opinion against the practice of female genital mutilation no Adolescence Highlight importance of appropriate dietary habits Promote awareness among health workers of special for girls during adolescence health needs of adolescent girls (problems of early * Educate young people about reproductive childbearing, nutritional requirements, STDs, physiology, sexuality and reproductive health contraceptive needs) Provide sex education in schools, including Ensure health information is kept confidential to information on contraception and the dangers of gain patient cooperation unsafe abortion Educate young people about the need to delay first pregnancy * Encourage peer groups to promote health education among adolescents * Highlight both short-term and long-term dangers of substance abuse * Promote development of practical skills and self- esteem among female adolescents Information, Education and Communication

TARGET AUDIENCE: General public, Health care providers

Life Cycle Stage Clients Health Providers

Maternity Care Promote early contact with health provider and Promote timely referrals for additional care antenatal care (diet, rest, regular visits) Educate traditional birth attendants and community * Educate the public to recognize danger signs in health workers about dangers of unhygienic birth pregnancy practices * Disseminate information about available pregnancy Promote the use of safe birth kits by traditional services birth attendants and community health workers * Promote hygienic birth practices Have midwives and physicians promote traditional * Develop community transportation schemes and breastfeeding intervals other means to increase women's access to Promote the use of proper family planning emergency care counseling techniques by health providers * Counsel women about alternative birth options (maternity huts, birthing centers, maternity waiting homes) * Promote exclusive breastfeeding and appropriate diet (calcium-rich foods, increased caloric consumption) for lactating mother * Disseminate information about family planning, particularly temporary methods to achieve birth spacing of at least two years Encourage male responsibility for reproduction and use of contraceptives * Educate the public to recognize symptoms of STDs * Counsel women about prevention of STDs and HIV infection

Unwanted Pregnancy and Safe Abortion Educate the public about reproductive physiology, Train traditional birth attendants and community sexuality and reproductive health health workers to recognize pregnancy early and to Include sex education in school curricula provide appropriate counseling * Provide full information on contraception, its Increase traditional birth attendants and community availability, benefits and side effects health workers' awareness of possible complications * Educate women to recognize pregnancy early and to from unsafe abortion use available services * Emphasize to traditional birth attendants, * Provide information on the legal status of abortion community health workers and nurses, signs of and where to find services incomplete abortion and importance of prompt Disseminate information on the maternal health referral. hazards connected with unsafe abortion * Train health providers to provide counseling on * Educate men about how to participate in family appropriate post-abortion contraceptive measures planning and be responsible fathers and partners Information, Education and Communication TARGETAUDIENCE: General public, Health care providers Life Cycle Stage Clients Health Providers Other Reproductive Health Issues Disseminateinformation about the modes of Promote safe birth practices among traditional birth transmission,and signs and symptoms of STDs attendants and community health workers * Disseminateinformation about the complications Train traditional birth attendants, community health and sequelae of STDs workers and community nurses to detect RTIs early, Disseminateinformation about the methods to and treat or refer patients in a timely manner prevent STD transmission (monogamy, use of Train health workers to treat women with dignity condoms) and courtesy * Encourage regular screening, and early and Educate health providers about showing cultural complete treatment for STDs sensitivitywhen dealing with sexual behavior * Provide sex education in schoolsto adolescents * Destigmatize the use of condoms * Educate the public abut the dangers of drug use and sharing of needles Promote voluntary donation of blood (as against professional donors) * Educate the public about the importance of safe birth locationand trained attendant at delivery Women's Health and Nutrition beyond Promote traditional family attitudes toward the Have community health workers and nurses stress o Reproductive Age elderly, particularly women the importance of preventive measures (healthy _ Educate women about the importance of good diet, regular exercise,regular screening) in avoiding nutrition and avoidance of risky behavior to health chronic diseases later in life Inform physicians on the effectivenessof home care Stress the importance of self-care in preventing for the elderly chronic diseases Educate health providers about the importance of Educate women about stress management,effects of providing pain relief and other palliative measures working conditions on their health, and safe and in the care of terminally ill patients (advanced effective use of over-the-counterdrugs breast cancer) Reinforcepositive health behaviors (physical activity, adequate diet) * Encourage mutual help groups to help the elderly rely on themselves and each other Reinforcethe cost-effectivenessand psychological benefits of caring for the elderly at home

Violenceagainst Women * Conduct education campaigns to make violence Make health workers aware of the prevalence of sociallyunacceptable domestic violence and its effects on women * Highlight cost of violence to society(social, health- * Stress key role that health provider plays in early care, criminal) detection, treatment and referral of victims of * Encourage men to resolve differencesnon-violently violence Mobilizepublic opinion against all forms of violence Highlight importance of accurate and complete against women documentation of the physical consequences of * Inform couples of where and how to get help for violence (rape, battery) for both health and legal problems before they escalate purposes Conduct health campaigns to discourage use of alcohol and drugs Annex D. Indicators of Women's Health and Nutrition

92 Annex D. Indicators of Women's Health & Nutrition

Using the following indicatorspolicymakers will be able to monitorboth the progress and outcome of national programs for women's health.

Life Cycle Stage Indicator Measure Interpretation Source

Infancy and Childhood Female infant mortality rate The number of female infants who High levels reflect problems related to Hospital or clinic die before the age of one per 1,000 childbirth and/or inadequate care of records, vital female infant births in a given year. female infants. registration

Female child mortality rate The number of deaths among girls This indicator is of particular significance Community survey, aged I to 4 in a given year per when compared to the rate for male hospital or clinic 1,000 female children in that age children since it is an estimate of socio- records, vital group at the mid-point of that year. economic and cultural factors that may registration overcome the biological advantage of girl children.

Immunization coverage Ratio of female infants to male A ratio of less than one (after adjusting Community survey, ratio infants covered by immunization for expected numbers in an age group) hospital or clinic %iO (for all six major childhood suggests discrimination against female records diseases as recommended by infants. WHO).

Nutrition status Percentage of girls with protein- A high percentage of girls with protein- Community survey, energy malnutrition as measured energy malnutrition suggests inadequate hospital or clinic by: access to food and/or strenuous physical records activity.

* weight for height Wasting-indicates acute malnutrition. Lfe Cycle Stage Indicator Measure Interpretation Soui,es

Infancy and Childhood Nutrition status Percentage of girls with protein- energy malnutrition as measured by:

height for age Stunting - reflects chronic malnutrition, Community survey, especially in early childhood. hospital or clinic records

weight for age This is the most common indicator for malnutrition. It is a composite of weight for height and height for age.

Adolescence Prevalence of adolescent Proportion of young women who Relevant for the identification of Surveys, hosoital pregnancies became pregnant before age 19. pregnancy complications because of the records, i:. ,Views mother's physical and psychological with key informnants immaturity. Such problems are compounded if the women is unmarried.

-9%.'o Life Cycle Stage Indicator Measure Interpretation Source

Adolescence Contraceptive usage Percentage of sexually active Indicates patterns of sexual behavior, Hospital or clinic adolescents who use family knowledge and access to contraception. records planning.

STD prevalence Percentage of adolescents who Indicates patterns of sexual behavior, Hospital or clinic contract an STD. degree of female negotiation power, use records of barrier methods, and access to health services.

Prevalence of traditional Percentage of female adolescents Suggests discrimination against females, Focus groups, practices harmful to who have been subjected to genital and deleterious social and cultural surveys adolescent girls mutilation. attitudes towards women.

Abortion prevalence Proportion of adolescents who have Indicates access of adolescents to Community survey, had an abortion. contraception, appropriate counseling and focus groups sex education.

Reproductive age group

A) Pregnancy and Matemal Mortality Ratio The annual number of maternal Often erroneously referred to as matemal Community survey, delivery care (MMRatio) deaths per 100,000 live births. mnortalityrate (WHO 1991a). It hospital records, Maternal death is defined as the represents obstetric risk. Interventions vital registration death of a woman while pregnant that improve obstetric outcomes will or within 42 days of termination of reduce the ratio. pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from incidental or accidental causes. Life Cycle Stage Indicator Measure Interpretalion Source

A) Pregnancy and Maternal mortality rate The number of maternal deaths per Includes obstetric risk and risks of Community survey, delivery care 100,000 women of reproductive age pregnancy (abortions, ectopic vital registration, (usually taken as 15 to 45 years or pregnancies). Interventions that affect hospital records 15 to 49 years). fertility and obstetric outcomes will alter the rate.

Low birth weight Percentage of infants born in a Useful as an indirect measure of matemal Community survey, particular year who weigh less than malnutrition. Low birth weight is caused hospital records 2500 grams at the time of birth. by either short duration of gestation, retarded intrauterine growth, or both. Among the major factors contributing to poor intrauterine growth are low calorie intake or weight gain during pregnancy and low pre-pregnancy weight.

Total abortion rate The number of abortions (all types), Useful as an indicator of the success of Community survey, expressed per 1,000 women of contraceptive services in meeting the hospital records, reproductive age. needs of women. However, reliable focus groups \0 information on abortions (particularly o\ unsafe abortions, which have the most serious impact on women's reproductive health) is very difficult to collect.

Total fertility rate (TFR) The number of children a woman Indicates average family size; related to Census survey, would have at the end of her the role of women and reproduction, and vital registration reproductive life if she survived to access to family planning. that age and experienced a given set of age-specific fertility rates. It is calculated by adding the age- specific rates for a given year. Survey, vital Lifetime risk of death The cumulative risk of death from Indicates risks associated with each registration (LTR) motherhood: pregnancy and number of times a woman LTR= becomes pregnant. 1 - (1 - MMRatio)n`R. Life Cycle Stage Indicator Measure Interpretalion Source

A) Pregnancy and Utilization of health Proportion of women with access Indicates availability and accessibility of Census, survey delivery care services to maternity care (within one hour health services, women's perceptions of walk or travel time). reproductive risks, cultural and social * Proportion of women who conditions, socioeconomic status. received any prenatal care from trained medical staff. * Proportion of women who received prenatal care before 20 weeks and/or after 38 weeks. * Proportion of pregnant women who received tetanus-toxoid immunization. * Proportion of pregnant women who took iron and folate supplementation. * Proportion of pregnant women who were referred and accepted referral. *Proportionof women who received '4 postnatal care from trained medical staff.

Reproductive health status * Percentage of pregnant women Indicates level of matemal nutrition (both Community survey, who are anemic (moderate = 7-11 before and during pregnancy), risks to hospital records g/dl; severe = <7g/di). mother and baby, and dietary practices. * Percentage of women gaining less than lkg per month during second and third trimester of pregnancy. Life Cycle Stage Indicator Measure Interpretation Source

A) Pregnancy and Quality of care Percentage of complications Indicates regional and national level of Observations, delivery care diagnosed during prenatal health services, health provider training, hospital records, surveillance. health worker values, government interviews with * Percentage of health facilities commitment. patients and capable of performing cesarean providers sections. * Mean waiting time at prenatal clinics. * Percentage of women who understood treatment received. * Percentage of women satisfied with treatment. * Percentage of women who delivered in an institution and who were told about family planning methods. * Ratio of midwives to population. * Prevalence of postpartum infections acquired in a hospital or co medical facility. Life Cycle Stage Indicator Measure Interpretation Source

A) Pregnancy and Quality of care Proportion of health workers able Indicates regional and national level of Observations, delivery care to perform life-saving obstetric health services, health provider training, hospital records, functions. health worker values, govemment interviews with * Knowledge, attitudes and commitment. patients and practices of health workers toward providers, maternal reproductive health. mortality * Beliefs and attitudes of health committees workers and traditional birth attendants regarding problems with birthing, pregnancy danger signs and responses.

B) Unwanted pregnancy Wantedness of pregnancy * Proportion of pregnancies not Can indicate the influence of cultural and Surveys, interviews and abortion intended. religious values, role of the woman in the with patients and * Desired family size. family and the community, and coverage providers of family planning services.

Availability of quality Percentage of women with access Reflects coverage and quality of family Surveys, interviews \x services to family planning and safe planning and abortion services. with patients and \0 abortion services. providers * Percentage of women who receive contraceptive counseling after an abortion. * Proportion of health providers skilled in providing family planning and abortion services. * Knowledge, attitudes and practices of health workers regarding contraception and abortion. LDfeCycle Stage Indicator Measure Interpresation Source

C) Other reproductive Prevalence of sexually -Percentage of women who are Suggests patterns of sexual and Community survey, health issues transmitted diseases (STDs) diagnosed as having an STD. contraceptive behavior, degree of female clinical records negotiation power, access to health services.

STD treatment Percentage of women diagnosed Indicates women's perceptions about and Hospital or clinic with an STD who completed the degree of understanding of treatment, and records prescribed treatment. adequacy of treatment in the community. * Percentage of partners of women who are diagnosed with an STD who report for testing.

STD prevention activities Percentage of population at high Indicates adequacy of education Focus groups, risk (sex workers, migrant labor) campaigns in reaching target population. interview of key who use condoms during sexual informants, survey contact.

Reproductive tract infection Proportion of total infertility cases Suggests the magnitude of complications Hospital or clinic (RTI) Proportional attributable to RTIs. and consequences from RTIs. records 0 Morbidity Rate

HIV and AIDS prevalence Percentage of population sero- Indicates the potential magnitude of the Anonymous testing I positive for HIV infection. AIDS problem in a community. of target population Life Cycle Stage Indicator Measure Interpretation Source

C) Other reproductive STD and AIDS prevention Percentage of sexually active adults Indicates the effectiveness of education Community survey health issues awareness who know how to avoid acquiring programs. STDs and WIV infection (abstinence, condoms, monogamous relationships).

Cervical cancer screening Percentage of women over 35 years Indicates degree of coverage of Hospital, clinic or who have had at least one Pap vulnerable group. program records, smear. surveys

Breast cancer screening Percentage of women over 50 years Indicates degree of coverage of Hospital, clinic or who have had a physical breast vulnerable group. program records, examination by trained medical surveys staff.

Violence against women Prevalence of gender- -Percentage of women who have Indicates magnitude of the problem. Community based related violence in the been beaten by an intimate male surveys community partner. -Percentage of women presenting to Indicates magnitude of the problem. Hospital or clinic health facilities with trauma records attributable to domestic violence. -Percentage of reported rape cases Indicates level of state effort to address Police and judicial that are prosecuted; percentage of the problem. records rape prosecutions that result in conviction. Annex E. World Bank Population, Health, and Nutrition Projects with Women's Health and Nutrition Components (FY 1986-93)

102 Annex E. World Bank Population, Health, and Nutrition Projects with Women's Health and Nutrition Components (FY 1986-93)

Conponents

Bank Total IBRD/ Financing Family Maternal Cervical Adolescent AIDSI Project Country Project Title FY IDA US$ Planning Health Cancer Fertility STDs Nutrition Cost Africa $1162.3m

Cote D'lvoire Health and Demographic Project 86 IBRD $ 22.2m $ 29.7m

Ghana Health and Education Rehabilitation 86 IDA $ 15.0m * $ 16.0m Project

Niger Health Project 86 IDA $ 27.8m $ 1.7m *AIDS $ 29.3m

Rwanda Family Health Project 86 IDA S 10.8m $ 1.2m $ 14.5m

Sierra Leone Health and Population Sector Support 86 IDA S 5.3m $ .lm * * $ 5.7m oi Project

Gambia National Health Development Project 87 IDA S 5.6m $ 0.6m *AIDS $ 20.8m

Guinea-Bissau Population, Health and Nutrition 87 IDA $ 4.2m * $ 4.4m Project

Malawi Second Family Health Project 87 IDA $ l .Om $ 4.8m $ 24.9m

Zimbabwe Family Health Project 87 1BRD $ lO.Om $ 2.Dm *AIDS $ 52.6m

Burundi Population and Health Project 88 IDA $ 14.Om $ 4.4m $ 18.7m

Ethiopia Family Health Project 88 IDA $ 33.Om $ 3.3m = $ 43.9m

Guinea Health Services Development Project 88 IDA $ 19.7m *AIDS $ 22.5m

Kenya Third Population Project 88 IDA $ 12.2m $22.2m _ $ 28.3m

Uganda First Health Project 88 IDA $ 42.5m * AIDS $ 65.5m

Benin Health Services Development Project 89 IDA $ 18.6m $ 0.3m * *AIDS = 32.0m Components

Bank Total IBRDI Financing Family Maternal Cervical Adolescent AIDS! Project Cowitry Project Title FY IDA US$ Planning Health Cancer Fertility STDs Nutrition Cost

Guinea-Bissau Social and Infrastructure Relief 89 IDA $ 5.Om *AIDS $ 17.0m Project I I_I

Mozambique Health and Nutrition Project 89 IDA $ 27.0m * $ 42.5m

Nigeria Imo Abia Health and Population 89 IBRD $ 27.6m $ 0.1m * *AIDS $ 36.8m Project

Zaire National AIDS Control Project 89 IDA $ 8.1m *AIDS $ 21.9m

Caweroon Social Dim. of Adj./ Human 90 IEBRD $ 21.5m * *AIDS $ 94.3m Resources Project

Chad Social Development Action Program 90 IDA $ 13.4m

Gambia Women In Development Project 90 IDA $ 7.0m *$ 15.1m

Kenya Fourth Population Project 90 IDA $ 35.0m $35.0m $ 41.3m

Lesotho Second Population, Health and 90 IDA $ 12.1m $ 1.2m * * *AIDS $ 22.1m Nutrition Project

Nigeria National Essential Drugs Project 90 IBRD S 68.1m

Tanzania Health and Nutrition Project 90 IDA $ 47.6m $ 9.5m *AIDS $ 70.0m

Ghana Health and Population II Project 91 IDA S 27.0m $ 4.9m . $ 34.4m

Kenya Health Rehabilitation Project 91 IDA $ 31.0m *AIDS

Madagascar Health Sector Improvement Project 91 IDA $ 31.0m $ 4.4m *AIDS $ 42.5m

Malawi Population. Health and Nutrition 91 IDA S 55.5m $ 5.8m * *AIDS * $ 74.3m Sector Credit

Mali Second Health, Population and Rural 91 IDA $ 26.6m * * *AIDS $ 61.4m Water Supply Project F

Nigeria HSalth System Fund Project 91 RD* * * $ 94.5m Components

Bank Total IBRDI Financing Family Maternal Cervical Adolescent AIDSI Project Cowutry Project Title FY IDA US$ Planning Health Cancer Fertility STDs Nutrition Cost

Nigeria National Population Project 91 IDA $ 78.5m $78.5m * $ 93.6m

Rwanda First Population Project 91 IDA $ 19.6m $19.6m

Senegal Human Resources Development 91 IDA S 35.0m $14.8m *AIDS $ 52.8m Project

Togo Population and Health Sector Adj. 91 IDA $ 14.2m $ 4.3m * *AIDS * Project

Zaire Social Sector Project 91 IDA $ 30.4m * * $ 37.0m

Zimbabwe Second Family Health Project 91 IBRD $ 25.0m c17.7m *AIDS $116.9m cofin.

Equatorial Guinea Health Improvement Project 92 IDA $ 5.5m S 0.2m *AIDS $ 6.Om $ 24.4m U'i Mauritania Health and Population Project 92 IDA $ 15.7m $ 6.9m

Niger Population Project 92 IDA $ 17.6m $11.6m *AIDS $ 24.1m

Rwanda Food Security and Social Action 92 IDA $ 19.1m * * * $ 46.1m Project

Sao Tome and Health and Education Project 92 IDA $ 11.4m . Principe . _

Angola First Health Project 93 IDA $ 19.9m $ 0.6m *AIDS $ 22.2m

Burundi Social Action Project 93 IDA $ 10.4m $ 0.5m $ 15.7m

Guinea Bissau Social Sector Project 93 IDA $ 8.8m $ O.9m *AIDS $ 9.7m

Madagascar Food Security and Nutrition 93 IDA $ 21.3m * $ 32.4m Zimbabwe AIDS Control Project 93 IDA $ 64.5m * $ 87.3m Components Bank [ Total IBRDI Financing Fatnily Malernal Cervical Adolescent AIDSI Project Country Project Title FY IDA US$ Planning Health Cancer Fertility STDs Nutrition Cost

East Asia $ 618m

China Rural Health and Preventive 86 [BRD S 15.0m * $177.4m Medicine Project

Indonesia Second Nutri'on and Community 86 [BRD 5 33.4m $ 57.7m Health Project

China Integrated Regional Health 89 IDA $ 52.Om _ $113.Om Development Project

Indonesia Third Health Project 89 IBRD $ 43.5m *AIDS $104.5m

Philippines Health Development Project 89 IBRD $ 70.1m * * $108.4m

China Infectious and Endemic Disease 91 IDA $129.6m * * *AIDS $113.Om Control Project

4 Indonesia Fifth Population Project 91 [BRD $10 .Om $104.Om * $148.4m

Indonesia Community Health and Nutrition 93 IBRD $ 93.5m $ 9.4m $164.1m Project

Papua New Population and Family Planning 93 IBRD $ 6.9m $ 6.9m *AIDS $ 32.7m Guinea Project

Philippines Urban Health and NutHition Project 93 IDA $ 70.0m $ 17.5m $ 82.2m

South Asia $ 1888.5m

Bangladesh Third Popilation and Family Health 86 IDA $ 78.Om $ 78.0m * $213.8m Project I_I_I_I_L

India West Bengal - Fourth Population 86 IDA $ 51.0m $ 51.0m * $ 89.9m Project

India Fifth (Bombay and Madras) 88 IDA $ 57.0m 1$ 57.Om *S 78.2 Population Project S l lI Components

Bank Total IBRDI Financing Family Maternal Cervical Adolescent AIDS/ Project Country Project Title FY IDA US$ Planning Health Cancer Fertility STDs Nutrition Cost

Sri Lanka Health and Family Planning Project 88 IDA $ 17.5m S 5.3m * $ 21.3m

India Sixth Population Project 89 IDA $113.3m $231.0m

India Population Training (Pop VII) 90 IDA $ 86.7m $ 86.7m $141.5m Project

India Second Tamil Nadu Integrated 90 IDA/ $ 95.8m $139.1m Nutrition Project IBRD

Bangladesh Fourth Population and Health Project 91 IDA $180.Om $ 61.5m $601.4m

India Integrated Child Development 91 IDA/ $ 96.0m * * * $157.5m Services Project IBRD $ 10.0m

Pakistan Family Health Project 91 IDA $ 45.Om $ 13.5m $ 62.9m 0 Sri Lanka Poverty Alleviation Project 91 IDA $ 57.5m $ 85.Om

India Child Survival and Safe Motherhood 92 IDA $214.5m $ O.lm $329.6m Project

India Family Welfare (Urban Slums) 92 IDA $ 79.Om * * $ 96.6m Project

India National AIDS Control Project 92 IDA $ 84.0m *AIDS $ 99.6m

India Social Safety Nets Project 93 IDA $296.2m $ 40.Om $906.3m

India Second Integrated Child 93 IDA $194.Om $248.8m Development Services Project

India National Leprosy Elimination Project 93 IDA $ 85m $138.3m

Pakistan Family Health Project 93 IDA $ 48.Om $ 12.Om = $114.Om

Latin America & $1095.5m Caribbean Northeast Basic Health Services 86 IBRD $ 59.5m * * $129.7m Brazii ProjeCL I I I I I I I I Components

Bank Total IBRD/ Financing Family Maternal Cervical Adolescent AIDSI Project Country Project Title FY IDA US$ Planning Health Cancer Fertility STDs Nutrition Cost

Colombia Health Services Integration Project 86 IBRD $ 36.5m = $ 75.8m

Jamaica Population and Health Project 87 IBRD $ 10.0m $ 6.8m * $ 12.4m

Brazil Northeast Endemic Disease Control 88 3IBRD $ l0.Om *AIDS $ 89.5m

Mexico Water and WID Project 89 IBRD $ 20.Om _ * $ 67.8m

Bolivia Integrated Health Development 90 IDA $ 20.0m * * $ 38.6m Project

Bolivia Social Investment Fund Project 90 IDA $ 20.Om $ 95.6m

Brazil Second Northeast Basic Health 90 IBRD $267.Om $ 13.4m * * *STDs * $610.6m Services Project o Colombia Child Community Care and Nutrition 90 IBRD S 24.0m $ 40.2m co Project

Haiti Health and Population Project 90 IDA $ 28.2m $ 1.6m * *AIDS $ 33.7m

Jamaica Social Sectors Development Project 90 IBRD S 30.Om $ 67.Om

Mexico Basic Health Care Project 91 IBRD SlSO.Om $ 3.5m * * $249.8m

Venezuela Social Development Project 91 IBRD $100.Om $ 5.0m * * *STDs * $320.9m

Ecuador Second Social Development Project 92 IBRD $ 70.0m $102.2m

Guyana Health, Nutrition, Water and 92 IDA S 10.3m * $ 11.7m Sanitation Project

Colombia Municipal Health Project 93 IBRD $ 50.0m $ 5.Omr $ 83.1m

Guatemala Social Investnent Fund Project 93 IBRD $ 20.Om $ 0.6m * $ 80.Om

Honduras Nutrition and Health Project 93 IDA $ 25.0m $ 0.1m *AIDS * $ 54.2m

Chile Health Sector Reform Project 93 IBRD $ 90.Omr $298.8m

Nicaragua Social Investment Fund Project 93 IDA $ 25.0m * $ 68.Om Components

Bank Total IBRDI Financing Family Maternal Cervical Adolescent AIDSI Project Country Project Title FY IDA US$ Planning Health Cancer Fertility STDs Nutrition Cost

Middle East & $ 561.3m North Africa

Oman Health Project 87 IBRD $ 13.3m $ 30.6m

Turkey Health Project 89 IBRD $ 75.Om $146.7m

Republic of Health Sector Development Project 90 IDA $ 15.0m $ 1.5m * $ 19.1m Yemen

Morocco Health Sector Investment Project 90 IBRD $104.Om * * $171.3m

Egypt Social Fund Project 91 IDA $140.0m = _572.7m

Tunisia Population and Family Health Project 91 IBRD $ 26.Om $ 26.0m $ 63.2m o Iran Health and Family Planning Project 93 IBRD $141.4m $ 59.5m $294.Om

Jordan Health Management Project 93 IBRD $ 20.Om $ 2.Om $ 30.0m

Republic of Fifth Family Health Project 93 IDA $ 26.6m $ 10.7m $ 30.2m Yemen

Europe and $ 371m Central Asia

Poland Health Services Development Project 92 IBRD $130.Om $ 6.5m $130.Om

Romania Health Services Rehabilitation 92 IBRD $150.0m $ 14.4m * *AIDS $207.5m Project I

Hungary Health Services and Management 93 IBRD $91.Om * $132.6m Project

* Component addressed by project Annex F. Glossary

Acquired immunodeficiency syndrome (AIDS)- Chlamydia-a bacterial infection that is transmit- a chronic viral infection that produces severe, life- ted sexually or to infants during childbirth. It is threatening defects in the immune system, leaving often asymptomatic; some women have vaginal dis- the body vulnerable to other infections and cancers. charge, pain on urination, spotting, and lower AIDS is a fatal disease and is spread through sexual abdominal pain. If untreated, chlamydia can cause contact with an infected person, parenteral exposure pelvic inflammatory disease and premature delivery. to infected blood by transfusion or needle sharing, Infected infants can develop respiratory and eye and perinatal transmission. AIDS has not been infections. shown to be transmitted by respiratory droplet spread, by vectors such as mosquitoes, or by casual, Cytology-the microscopic analysis of human cells, nonsexual cc ntact. collected through procedures such as smears, scrap- ing and aspiration. Cytological examination enables Amniocentesis-a procedure in which amniotic the identification of conditions such as infections fluid is withdrawn transabdominally from the uterus and cancers. of a pregnant woman. The fluid is analyzed to iden- tify genetic defects or to determine the sex of the Dilatation and curettage-a surgical procedure in fetus. which the lining of the uterus is scraped and its con- tents are removed. Anemia-a condition characterized by a reduced number of red blood corpuscles or hemoglobin in Disability-adjusted life year (DALY)-A measure of the bloodstream, which occurs when the equilib- the loss of healthy life, known as the burden of dis- rium between blood loss and blood production are ease. It has two components: (1) losses from prema- disturbed. The patient initially suffers from fatigue ture death, defined as the difference between the and weakness, but if severe, anemia has serious actual age at death and life expectancy at that age in health consequences. Moderate anemia is defined as a low-mortality population; and (2) loss of healthy 7-11 grams per dl hemoglobin; severe anemia is less life resulting from disability. than 7 g/dl. Ectopic pregnancy-a life-threatening condition in Cardiovascular diseases-diseases of the heart and which the fertilized egg develops outside the uterus, blood vessels. often in the Fallopian tube.

Cesarean section-a surgical procedure used to Genital mutilation-Also known as femaale cir- deliver a baby by cutting through the woman's cumcision, genital mutilation entails removal of abdominal wall and uterus. Indications for surgery the woman's external sexual organs (the degree of include obstructed labor and fetal distress. mutilation varies), rendering intercourse and child- birth painful and potentially hazardous. It has Child mortality rate-the number of deaths among no health benefits and causes permanent sexual children from age one through four in a given year dysfunction. per 1,000 children in that age group at the mid-point of that year. Sometimes child mortality is used to Genital ulcers-skin eruptions located orn or near refer to deaths among all children under age five. the vagina or anus, mainly caused by chancroid,

110 AnnexF Glossary 111 syphilis, and herpes, which are mainly transmitted around the age of S0. It may be accompanied by sexually and can be treated with antibiotics. physical and psychological symptoms related to hor- Chancroid ulcers are painful and cause bleeding, monal and other changes occurring at this period. vaginal discharge, and swollen lymph nodes in the groin. Syphilis lesions are usually painless, but can Menstrual regulation-a procedure for inducing lead to serious illness, including neurological and menstruation using a hand-held syringe to empty cardiovascular infections. Herpes lesions may have the uterus up to 49 days after a previous period. no symptoms or may be extremely painful; compli- cations include neurological and genital infections. Obstetric fistulae-a rupture that results in an abnor- mal passage linking two areas such as the vagina, rec- Gonorrhea-a bacterial infection that is transmit- tum, bladder, and abdominal cavity. Obstetric fistulae ted sexually or to infants during childbirth. It is com- are caused by difficult labor, unsafe abortion, and tra- monly asymptomatic in women, although some ditional practices such as genital mutilation. women may have vaginal discharge and burning uri- nation. If untreated, it can cause pelvic inflamma- Osteoporosis-a bone disorder characterized by a tory disease with subsequent risk of infertility or reduction in bone density and increased porosity ectopic pregnancy. Among newborns, it causes an and brittleness, leading to increased susceptibility to eye infection that can lead to blindness if untreated. fractures. Post-menopausal osteoporosis occurs n women within fifteen to twenty years after Human immunodeficiency virus-the virus that menopause. causes acquired immunodeficiency syndrome (AIDS). Pap smear-a test in which cells taken from tlie Infant mortality rate-the number of infants who cervix are examined for uterine cancer. Pap is a short- die below the age of one year per 1,000 births in a ened version of Papanicolaou, the test's inventor. given year. Partograph-a graphic record of cervical dilation Life expectancy-the average number of additional used to monitor a woman in labor. years that a person can expect to live if current mor- tality trends were to continue. Life expectancy at Pelvic inflammatory disease-a severe infection (if birth is the most common measure used to assess the upper reproductive tract, which can lead to infer- trends and compare subgroups. tility and ectopic pregnancy.

Malnutrition-a disorder of nutrition that includes Perinatal mortality rate-the number of fetal both under- and over- nutrition. It may be caused by deaths after twenty-eight weeks of pregnancy plus an unbalanced/insufficient diet or by defective the number of deaths to infants under seven days of assimilation and utilization of foods. age per 1,000 live births.

Maternal mortality rate-the number of deaths of Reproductive tract infection-a general term fo- women due to pregnancy and childbirth complica- various types of infections affecting the reproductive tions per 100,000 women aged fifteen to forty-five organs, including vaginal and cervical infections. or fifteen to forty-nine years. This rate measures a genital ulcer disease, and pelvic inflammatory dis. woman's lifetime risk of dying associated with repro- ease. Major sources of RTIs include sexual transmis. duction; it is influenced by the likelihood of becom- sion and unhygienic practices during abortion, ing pregnant and by the risk of dying in childbirth. delivery, IUD insertion, and genital mutilation.

Maternal mortality ratio-the annual number of Sexually transmitted diseases (STDs)-an deaths to women due to pregnancy and childbirth umbrella term for various infections that are trans- complications per 100,000 live births. This ratio mitted through sex, including chancroid, chiamy- measures a woman's chance of dying once pregnant, dia, genital herpes, gonorrhea, human known as obstetric risk. papillomavirus, syphilis, and trichomoniasis.

Menopause-the permanent cessation of menstrua- Syphilis-a sexually transmitted infection that pro- tion in the human female, which normally occurs duces genital lesions, which can increase the risk of 112 Women'sHealth and Nutrition:Making a Difference contracting HIV. Infection during pregnancy can (echoes of) pulses of ultrasonic waves directed into cause miscarriage, stillbirth, and congenital defects. the tissues. Ultrasonography is often used to identify If left untreated, syphilis can cause neurological fetal and abdominal abnormalities. complications. Uterine prolapse-a sinking of the uterus into or Total fertility rate-the average number of children extending outside the vagina, usually resulting from that would be born to a woman during her lifetime injuries during childbirth or advanced age. if she were to pass through her childbearing years conforming to the age-specific fertility rates of a Vacuum aspiration-a method of pregnancy ter- given year. mination in which the contents of the uterus are removed by suction, using either a hand-held Ultrasonography-the visualization of deep struc- syringe or electric pump. tures of the body by recording the reflections of Bibliography

Acsadi, George T.F., and Gwendolyn Johnson- paper presented at the World Bank Conference on Acsadi. 1993. "Socio-economic, Cultural, and Public Expenditures and the Poor: Incidence arid Legal Factors Affecting Girls' and Women's Targeting," June 17-19, Washington, D.C. Health." World Bank Women's Health and Askew, I., and A.R. Khan. 1990. "Community Nutrition Work Program Working Paper Series. Participation in National Family Planning Pro- World Bank, Population, Health and Nutrition grams: Some Organizational Issues." Studies in Department, Washington, D.C. Family Planning 21:127-42. Adebajo, Christine, Carol Kazi, Elisabeth Crane, and Askew, Ian, Placid Tapsoba, Youssouf Ouedraogo, Ian Todreas. 1990. "Community Mobilization: Claire Viadro, Didier Bakouan, and Pascaline Steps Toward Eradicating Female Circumcision and Sebgo. 1993. "Quality of Care in Family Planning Other Harmful Traditional Practices in Nigeria." Programmes: A Rapid Assessment in Burkina Paper presented at the 118th Annual Meeting of Faso." Health Policy and Planning 8(1):19-32. the American Public Health Association, New York, Banister, Judith. 1992. "China: Recent Mortality N.Y., September 30-October 4, 1990. Levels and Trends." Paper presented at the Annual Adriasole, G. et al. 1986. Actualizaci6n del Documento Meeting of the Population Association of America, "Evaluacion de 10 Aos de Planlficaci6n Familiar en Denver, May 1992. U.S. Bureau of the Census, Chile." Santiago: Asociacion Chilefia de Pro- Suitland, Md. tecci6n de la Familia (ACPF), 1970; and ACPF, Barnum, Howard and Joseph Kutzin. 1993. Public Memoria, APROFA, 1986. Hospitals in Developing Countries: ResourceUse, Cosi, Agyemang, Nelson Godfried. 1992. "Issues for Financing. Baltimore and London: Johns Hopkins Young Ghanaians." The Health Exchange August University Press for the World Bank. /September 1992. Behrman,Jere R. 1990. TheAction of Human Resource.; Ajayi, Ayo A., Leah T. Marangu, Janice Miller and and Poverty on One Another: What we Have Yet to John M. Paxman. 1991. "Adolescent Sexuality and Leam. World Bank, Washington, D.C. Fertility in Kenya: A Survey of Knowledge, Bhatia, S., A.S. Faruque, and J. Chakraborty. 1980 Perceptions and Practices." Studies in Family "Assessing Menstrual Regulation Performed b) Planning 22(4):205-216. Paramedics in Rural Bangladesh." Studies in Family' Allen, Susan, Christina Lindan, Antoine Serufilira, Planning 11:213-218. Philippe Van de Perre, Amy Chen Rundle, Francois Blaney, Carol Lynn. 1993. "Steps to Improve Nsengumuremyi, Michel Carael, Joan Schwalbe, Quality: Measure It, Monitor It." Network (Family and Stephen Hulley. 1991. "Human Immuno- Health International) 14: (1): 9-11. deficiency Virus Infection in Urban Rwanda: Bledsoe, Caroline H., and Barney Cohen, eds. 1993. Demographic and Behavioral Correlates in a Rep- Social Dynamics of Adolescent Fertility in Sub- resentative Sampling of Childbearing Women." Saharan Africa. Washington, D.C.: National Joumal of the American Medical Association Academy Press. 266(12):1657-63. Boohene, E., J. Tsodzai, K. Hardee-Cleaveland, S. Weir, Amazigo, Uche. 1993. "Vector-Borne Infectious and B.Janowitz. 1991. "Fertility and Contraceptive Diseases." In Women's Health in Africa. Use Among Young Adults in Harare, Zimbabwe." Washington, D.C.: National Academy Press. Family Planning Perspectives24(1):4-11. Appleton, Simon, and Paul Collier. 1993. "On Brabin, Loretta, and Bernard J. Brabin. 1992. "The Gender Targeting of Public Transfers." Discussion Cost of Successful Adolescent Growth and

113 114 Women'sHealth and Nutrition:Making a Difference

Development in Girls in Relation to Iron and Stable Populations. 2nd ed. New York: Academic Vitamin A Status." American Joumal of Clinical Press. Nutrition 55(5):955-8 Cochrane, Susan and Frederick Sai. 1993. "Excess Bradley, Christine. 1988. "How Can We Help Rural Fertility." In Dean T. Jamison, W. Henry Mosely, Beaten Wives? Some Suggestions from Papua New Anthony R. Measham, and Jose-Luis Bobadilla, Guinea." Paper presented at the International eds., Disease Control Priorities in Developing Welsh Women's Aid Conference, Cardiff, Wales, Countries. New York: Oxford University Press. Pp. U.K. 333-362. Brennan, Maureen. 1992. "Training Traditional Coeytaux, Francine. 1989. "Celebrating Mother and Birth Attendants." Postgraduate Doctor Africa Child on the Fortieth Day: The Sfax, Tunisia 11(1):16. Postpartum Program." Quality/Calidad/Qz,alitiNo. Bruce, Judith. 1990. "Fundamental Elements of 1. New York: Population Council. Quality of Care: A Simple Framework." Studies in Commonwealth Association for Mental Hlandicap Family Planning 22 (November-December): 343- and Development Disabilities (CAMHADD). 1990. 347. "CAMHADD Global Workshop 'Towards Global Center for Population Options (CPO). 1992. Strategy on Prevention and Management: of Birth Adolescents and Unsafe Abortion in Developing Asphyxia through Maternal and Newborn Care at Countries. Washington, D.C.: CPO. Primary Health Care Level in Developing Centers for Disease Control (CDC). 1991. 1987 Countries.' New Delhi (India), 28 January-3 Guatemala Demographic and Health Survey: Further February 1990." Newsletter 10:4. Analysis of Data, B. Young Adult Module. Atlanta, Consumers Association of Penang. 1988 Rape in GA: CDC. Malaysia. Penang, Malaysia. Centers for Disease Control (CDC). 199. Cook, Rebecca J. 1993. Human Rights in Relation to "Zidovudine for the Prevention of HIV Transmis- Women's Health. Geneva: World Health sion from Mother to Infant." Morbidity and Organization. Mortality Weekly Report (MMWR) 43(16):285-287. COVAC. 1990. "Evaluacion de Proyecto para Chalmers, Ian, Murray Enkin, and Marc Kierse. Educacion, Capacitacion, y Atencion a Mujeres y 1989. Effective Care in Pregnancy and Childbirth. Menores de Edad en Materia de Violencia Sexual, New York: Oxford University Press. Enero a Diciembre 1990." Mexico City: Asociacion Chatterjee, Meera. 1991. "Indian Women: Their Mexicana Contra la Violencia a las Muje res. Health and Productivity." World Bank Discussion D'Artre, A. (AIDSTECH).1992. ISTDInterventions in Paper 109. Washington, D.C. Tanzania and Ghana]. Personal communication Chatterjee, Meera, and Julian Lambert. 1989. cited in "Controlling Sexually Trainsmitted "Women and Nutrition: Reflections from India and Diseases." Population Reports. Series l,, No. 9. Pakistan." Food and Nutrition Bulletin 11(4):13-28. September 15, 1992, p.v-9. Chen, Lincoln et al. 1974. "Maternal Mortality in Das Gupta, Monica. 1987. "Selective Discri mination Rural Bangladesh." Studies in Family Planning against Female Children in Rural Punjab, India." 17(5):243-251. Population and Development Review 13:1 Church, Cathleen A., and Judith Geller. 1989. (March):77-100. "Lights! Camera! Action! Promoting Family De Maeyer, E.M. and M. Adiels-Tegman. 1985. "The Planning with TV, Video, and Film." Population Prevalence of Anemia in the World." World Health Reports Series J, No. 28. December 1989. Statistics Quarterly 38(3):302-316. CIAES (Center for Health Research, Consultation DiPietro, Loretta, Adrian M. Ostfeld, and Gary L. and Education). 1991. "Qualitative Research on Rosner. 1994. "Adiposity and Stroke among Older Knowledge, Attitudes and Practices Related to Adults of Low Socioeconomic Status: The Chicago Women's Reproductive Health." Working Paper Stroke Study." American Joumal of Public Health no. 9, July. Mother Care, Arlington, Va. 84(1):14-19. Coale, Ansley. 1991. "Excess Female Mortality and Dixon-Mueller, Ruth. 1990. "Abortion IPolicy and the Balance of the Sexes in the Population: An Women's Health in Developing Countries." Estimate of the Number of 'Missing Females."' International Journal of Health Services 20:297-314. Population and Development Review 17(3):517-523. Dixon-Mueller, Ruth, and Judith Wasserheit. 1991. Coale, Ansley and Paul Demeny with Barbara The Culture of Silence: Reproductive Tract Infections Vaughan. 1983. Regional Model Life Tables and Arnong Women in the Third World. New York: Bibliography 115

International Women's Health Coalition. Fortney, Judith. 1993. "Best Practices for Women's Edgerton, V.R., G.W. Gardner, Y. Ohira, K.A. Health and Nutrition." Family Hea lth Gunarwardena, B. Senewiratne. 1979. "Iron International, Research Triangle Park, N.C. Deficiency Anaemia and its Effect on Worker Frankenhaeuser, Marianne, Ulf Lundberg, and Productivity and Activity Patterns." In British Margaret Chesney. 1991. Women, Work and Hea.'th: Medical Journal 2:1546-1549. Stress and Opportunities. New York: Plenum Pre's. Ekwempu, C.C., D. Maine, M.B. Olorukoba, B. Essien Freedman, Ronald, and Bernard Berelson. 1976. and M. N. Kisseka. 1990. "Structural Adjustment "The Record of Family Planning Programs." and Health in Africa." Letter. Lancet July 7, Studies in Family Planning 7(11):3-40. 1990:56-57. Freedman, Ronald, and Ann K. Blanc. 1991. Ettling, M.B., K. Thimasarn, S. Krachaiklin, and P. "Fertility Transition: An Update." Pp. 5-24 in Bualombai. 1989. "Evaluation of Malaria Clinics Institute for Resource Development/Macro in Maesot, Thailand: Use of Serology to Assess International, Proceedingsor the Demographic and Coverage." Transactions of the Royal Society of Health Surveys World Conference, Washingtotn,D.C., Tropical Medicine and Hygiene. 83:325-330. 1991. Vol. 1. Columbia, MD. Family Health International (FHI). 1992. Gallen, Moira E., Laurie Liskin, and Neeraj Kaik. "Cameroon Launches Social Marketing of 1986. "Men-New Focus for Family Planning Antibiotics." Network 12(4):14-15. Programs." Population Reports Series J, No. :,3. Fauveau, Vincent. 1991. "Matlab Maternity Care November-December 1986. Program." Review paper prepared for the World Gay, Jill. 1993. "Women's Access to Quality Health Bank Department of Population and Human Services and Empowerment to Promote their Own Resources, Washington, D.C. Health." Women's Health and Nutrition Work Favin, M., and M. Griffiths. 1991. "Social Marketing Program Working Paper Series. World Bank, of Micronutrients in Developing Countries." Department of Population, Health and Nutrition, Manoff Group, Inc., Washington, D.C. Washington, D.C. Feletti, V.J. 1991. "Long-term Medical Consequences Georgetown University School of Medicine. 1990. of Incest, Rape and Molestation." Southern Medical Guidelines for Breastfeeding in Family Planning and Journal 84:328-331. Child Survival Programs. Washington, D.C.: Figueroa, Blanca. 1992. "Adding Color to Life: Georgetown University/Institute for International Illustrated Health Materials for Women in Peru," Studies in Natural Family Planning. in "By and For Women: Involving Women in the Gertler, Paul and Jacques van der Gaag. 1990. Tne Development of Reproductive Health Care Willingness toPayforMedical Care. Baltimore:Johns Materials." Quality/Calidad/Qualite No. 4. New Hopkins University Press for the World Bank. York: Population Council. Ghassemi, Hossein. 1990. "Women, Food and Fishman, Claudia, D. Toure, and Peter Gottert. 1991. Nutrition: Issues in Need of a Global Focus." In "Nutrition Promotion in Mali: Highlights from a Women and Nutrition. UN/ACC/SCN Symposium Rural Integrated Nutrition Communication Report, Nutrition Policy Discussion Paper No. 6l. Program." Paper presented at the Sixth Inter- Geneva: United Nations Administrative Corm- national Conference of International Nutrition mittee on Coordination/Subcommittee on Nutri- Planners Forum, September 4-6, 1991, Paris. tion, p. 145-65. Academy for Educational Development, Graitcer, Philip L. 1994. [In juries from domestic vio- Washington, D.C. lence in Egypt] Personal communication cited in FNB/NAS/NRC. 1989. "Osteoporosis." In Diet and Heise et al. 1994. Health: Implications for Reducing Chronic Disease Green, Cynthia P. 1989. Media Promotion of Breasi- Risk. Washington, D.C.: National Academy Press feeding: A Decade's Experience. Washington, D.C.: Foner, N. 1989. "Older Women in Nonindustrial Academy for Educational Development. Cultures: Consequences of Power and Privilege." Grunseit, A. and S. Kippax. 1993. Effects of Sex In Women in Later Years: Ethnic and Cultural Education on Young People's Sexual Behavio,. Perspectives.Binghamton, N.Y: Haworth Press. Geneva: World Health Organization. Ford, Nicholas, and Supom Koetsawang. 1991. "The Harrison, K.A., A.F. Fleming, N.D. Briggs, and C.E. Socio-Cultural Context of the Transmission of HIV Rossiter. 1985. "Growth During Pregnancy ix in Thailand." SocialScience andMedicine 33(4):405- Nigerian Teenage Primigravidae." British Joumal o,r 414. Obstetrics and Gynecology 5 (Supplement):32-39. 116 Women's Healthand Nutrition:Making a Difference

Harrison, Pinseley Randolph, and Jean B. Wilson. Inter-African Committee on Traditional Tractices 1991. Harrison's PrinciplesofInternal Medicine. 12th Affecting the Health of Women and Children edition. New York: McGraw-Hill Health Profession (IAC). 1993. "Profile of a National Committee: Division. Burkina Faso." 1AC Newsletter 15(December Havanon, Napapom, Anthony Bennett, and John 1993):13. Knodel. 1993. "Sexual Networking in Provincial International Center for Research on Women Thailand." Studies in Family Planning 24:(1):1-17. (ICRW). 1989. Strengthening Women: Health Heise, Lori. 1993. "Violence Against Women: The Research Priorities for Women in Developing Missing Agenda." In Marge Koblinsky, Judith Countries. Washington, D.C.: ICRW. Timyan, andJill Gay, eds., The HealthofWomen: A International Planned Parenthood Federation Global Perspective. Boulder, CO: Westview Press, (IPPF). 1992. "Adolescent Prostitutes in Thailand." pp. 171-195. Open File. February 1992, p. 9. Heise, Lori, Jacqueline Pitanguy, and Adrienne . 1993. "Sexual Health Program: Program Germain. 1994. "Violence Against Women: The Description." London: IPPF, p. 3. Hidden Health Burden." World Bank Discussion Jacobson, Jodi L. 1993. "Women's Health: The Price Paper. World Bank, Population, Health and of Poverty." In Marge Koblinsky, Judith Timyan, Nutrition Department, Washington, D.C. and Jill Gay, eds., The Health of Women: .4 Global Henshaw, Stanley K. 1990. "Induced Abortion: A Perspective. Boulder, CO: Westview Press, pp. 3- World Review, 1990. " Family Planning Perspectives 31. 22:76-89. Jamison, Dean T. 1993. "Disease Control Priorities in Henshaw, Stanley K., and Jennifer Van Vort. 1989. Developing Countries: An Overview." In Dean T. "Teenage Abortion, Birth and Pregnancy Statistics: Jamison, W. Henry Mosley, Anthony R. Measham, An Update." Family Planning Perspectives 21(2):85- and Jose-Luis Bobadilla, eds., Disease Control 88. Prioritiesin Developing Countries. New York: Oxford Herz, Barbara, and Anthony Measham. 1987. The University Press, pp. 3-34. Safe Motherhood Initiative. World Bank, Population, Jamison, Dean T., W. Henry Mosley, Anthony R. Health and Nutrition Department, Washington, Measham, and Jose-Luis Bobadilla, eds. 1993. D.C. Disease Control Priorities in Developing Countries. Herz, Barbara, K. Subbarao, Masoma Habid and New York: Oxford University Press. Laura Raney. 1991. "Letting Girls Learn: Promising John Short and Associates, Inc. USA). 1987. Approaches in Primary and Secondary "Technical Information on Population for the Education." World Bank Discussion Paper No. 133. Private Sector: Peru Trip Report, January 11-18, Washington, D.C.: World Bank. 1987. JSA, Columbia, MD. Hill, Ken, and Lecia Brown. 1993. "Gender Johnson, Brooke R., Janie Benson, and Beth Leibson Differences in Child Health: Evidence from Hawkins. 1992. "Reducing Resource and Reducing Demographic and Health Surveys." World Bank, Quality of Care with MVA." IPAS Advances in Population, Health and Nutrition Department, Abortion Care 2(2):1-5. Carrboro, N.C. Washington, D.C. Kardam, Nuket. 1991. Bringing Women In: Women's Hira, S.K., G.J. Bhat, D.M. Chikamata, B. Nkowane, Issues in International Development Programs. G. Tembo, P.L. Perine, and A. Meheus. 1990. Boulder, Co.: Lynne Reinner Publishers. "Syphilis Intervention in Pregnancy: Zambian Karkal, Malini. 1985. "How the Other Half Dies in Demonstration Project." Genitourinary Medicine Bombay." Economic and Political Weekly, p. 1424. 66:159-64. Katz, Elizabeth G. 1993. "Women's Health and Hovell, M.F. et al. 1988. "Occupational Health Risks Nutrition." World Bank, Education and Social for Mexican Women: The Case of the Maquiladora Policy Department, Washington, D.C. along the Mexican-United States Border." Inter- Kaufman, Joan, Zhang Zhirong, Qiao Xin jian, and national Joumal of Health Services 18(4):617-627. Zhang Yang. 1992. "The Quality of Family Ibrahim, Barbara and Nadia Farah. 1992. "Women's Planning Services in Rural China." Studies in Lives and Health: The Cairo Women's Health Book Family Planning 23(2):73-84. Collective," in "By and For Women: Involving Kay, Bonnie, Adrienne Germain, anc. Maggie Women in the Development of Reproductive Bangser. 1991. "The Bangladesh Women's Health Health Care Materials." Quality/Calidad/Qualite Coalition." Quality/Calidad/Qualite. No. 3. New No. 4. New York: Population Council. York: The Population Council. Bibliography 117

Kennedy, Kathy I., Roberto Rivera, and Alan S. Kristof, Nicholas D. 1993. "Peasants of Chiina McNeilly. 1989. "Consensus Statement on the Use Discover New Way to Weed Out Girls." New York of Breastfeeding as a Family Planning Method." Times, July 21, 1993, p. A-1. Contraception 39(5):477-496. Kutzin, Joseph. 1993. "Cost-Effectiveness Issues in Keyfitz, N. and V. Flieger. 1990. World Population, Women's Health." World Bank, Population, Growth and Aging. Demographic Trends in tihe Late Health and Nutrition Department, April 20, 1'993, Twentieth Centurvy.Chicago: University of Chicago Washington, D.C. Press. Kutzin, Joseph. 1993. "Obstacles to Women's Ac ess: Khanna, Renu. 1992. (Social Action for Rural and Issues and Options to More Effective Interventions Tribal Inhabitants of India (SARTHI) Project, to Improve Women's Health." Human Resources Baroda, Gujurat State, India.] Personal communi- Development and Operations Policy Worbing cation cited in Heise et al. 1994. Paper, HROWP 13. World Bank, Washington, I).C. Kilpatrick, D.G., C.N. Edmunds, and A.K. Seymour. Kwast, Barbara. 1991. "Shortage of Midwives: The 1992. Rape in America: A Report to the Nation. Effect on Family Planning." IPPF Medical BuAl?tin Arlington, VA:The National Victim Center. 25(3):1-3. King, J. et al. 1986. Programme Review of CARE MCH Kwast, Barbara. 1993. "Safe Motherhood - The First CD and SNP Title II Programme in India: Evaluation Decade." Paper presented at the 23rd Report. New Delhi: U.S. Agency for International International Congress of the International Development. Confederation of Midwives, Vancouver, Canada, Kirschstein, Ruth L. 1991. "Research on Women's May 9-14, 1993. Health." American Joumal of Public Health Labbok, M.H. 1986. "Literacy, Parity, Family 81(3):291-293. Planning, and Maternal Mortality in the Third Kirumira, E., A. Katahoire, A. Aboda, and Karin World." Lancet ll(October 11, 1986):865-866. Edstrom. 1993. "Study on Sexual and Reproduc- LaGuardia, K.K., M.V. Rotholz, and P. Belfort. 1990. tive Health in Uganda Women." Kampala, "A 10-Year Review of Maternal Mortality in a Uganda: Child Health and Development Center, Municipal Hospital in Rio de Janeiro: A Cause 'or Makerere University. Concern." Obstetrics and Gynecology 75:27-32. Kisekka, Mere, and B. Otesanya. 1988. "Sexually Lande, Robert. 1993. "Controlling Sexually Transmitted Disease as a Gender Issue: Examples Transmitted Diseases." PopiulationReports Series L, from Nigeria and Uganda." Paper presented at the No. 9 (June 1993). AFARD/AAWORDThird General Assembly, Dakar, Lande, Robert E. and Richard Blackburn. 1989. Senegal, August 1988. "Pharmacists and Family Planning." Population Kizza, A.P., and K.O. Rogo. 1990. "Assessment of the Reports Series J, No. 37. Manual Vacuum Aspiration (MVA) Equipment in Lande, Robert E. and Judith S. Geller. 1991. "Paying the Management of Incomplete Abortion." East for Family Planning." Population Reports Series J, African Medical Journal 67:812-22. No. 39. Koenig, M.A. et al. 1988. "Maternal Mortality in Lema, V.M. 1990. "The Determinants of Sexuali-y Matlab, Bangladesh: 1976-85." Studies in Family Among Adolescent School Girls in Kenya." East Planning 19(2):69-80. Africa Medical Joirnal 67(3):191-200. Koetsawang, Suporn. 1990. "Adolescent Leslie, Joanne. 1991. "Women's Nutrition: The K(y Reproductive Health." In Helen M. Wallace and to Improving Family Health in Developing Kanti Giri, eds., Healtht Care of Women and Chzildren Countries?" Health Policy and Planning 6(1):1-19. in Developing Countries. Oakland: Third Party . 1992. "Women's Lives and Women's Health: Publishing Co. Using Social Science Research to Promote Better Koss, M., P. Koss, andJ. Woodruff. 1991. "Deleterious Health for Women." Journal of Woman 's Healthi 1 :,. Effects of Criminal Victimization on Women's Leslie, Joanne, and Geeta Rao Gupta. 198'. Health and Medical Utilization." Archives of "Utilization of Formal Services for Maternal Internal Medicine 151:342-347. Nutrition and Health Care." International Center Krieger, Laurie, and Mohamed ElFeraly. 1991. "Male for Research on Women, Washington, D.C. Doctor, Female Patient: Access to Health Care in Leslie, Joanne, Margaret Lycette, and Mayra Buvinic. Egypt." Paper presented at the Annual Meeting of 1988. "Weathering Economic Crises: The Crucial the National Council for International Health, Role of Women in Health." In David E. Bell and Washington, D.C., June 23-26, 1991. Michael R. Reich, eds., Healthi, Nutrition, an,l 118 Women'sHealth and Nutrition:Making a Difference

Economic Crises: Approaches to Policy in the Third Macro International. 1992. "Adolescents in Sub- World. Dover, England: Auburn House Publishing Saharan Africa." Columbia, MD: IRD/Macro Company, pp. 307-348 International, Demographic and Health Surveys. Levin, H. Poltitt, R. Galloway and J. McGuire. Macro International. 1993. "Indonesia Moves "Micronutrient Deficiency Disorders." In Dean T. Toward Privatization of Family Planning Services." Jamison, W. Henry Mosely, Anthony R. Measham, Demographic and Health Surveys Newsletter 6(1):5. and Jose-Luis Bobadilla, eds., Disease Control Manderson, Lenore, Jennifer Jenkins, and Marcel Priorities in Developing Countries. New York: Oxford Tanner. 1993. "Women and Tropical Diseases: University Press, pp. 421-454. Introduction." Social Science Medicine 37(4):441- Levin, L. et al. 1979. Self-Care: Lay Initiatives in 443. Health. New York: Prodist. Marques, Magaly. 1993. "Gente Jover /Young Li, Ruowei, Xuecun Chen, Huaicheng Yan, Paul People: A Dialogue on Sexuality with Adolescents Deurenberg, Lars Garby, and Joseph Hautvast. in Mexico." Quality/Calidad/Qualite' No. S. New 1994. "Functional Consequences of Iron York: Population Council. Supplementation in Iron-Deficient Female Cotton Matovina, Michael. 1992. "Female Genital Mill Workers in Beijing, China." In American Mutilation." Information Sheet. World Bank, Journal of Clinical Nutrition 59(4):908-913 Africa Technical Department, Gender team, Lindsay, Robert. 1993. "Prevention and Treatment of Washington, D.C. Osteoporosis." Lancet Vol. 341 (March 27, 1993): Meheus, Andre. 1992. "Women's Health: Impor- 801-805. tance of Reproductive Tract Infections, Pelvic Liskin, Laurie, E. Benoit, and Richard Blackburn. Inflammatory Disease and Cervical Cancer." In 1992. "Vasectomy: New Opportunities." Popula- Adrienne Germain, King K. Holmes, Peter Piot, tion Reports Series D, No. 5. and Judith N. Wasserheit, eds., Reproductive Tract Liskin, Laurie, Cathleen Church, Phyllis T. Piotrow, Infections. New York: Plenum Press, pp. 61. 78-91. and John A. Harris. 1989. "AIDS Education-A Mensch, Barbara. 1993. "Quality of Care: A Beginning." Population Reports Series L, No. 8. Neglected Dimension." In Marge Koblinsky, Litvack,JennyI.,andClaudeBodart. 1993. "UserFees Judith Timyan, and Jill Gay, eds., The Health of Plus Quality Equals Improved Access to Health Women: A Global Perspective. Boulder, Col.: Care: Results of a Field Experiment in Cameroon." Westview Press. Social Science and Medicine 37(3):369-383. Merchant, Kathleen. 1993. "New Directions in Locay, Luis, W. Sanderson, and Ethel Carillo Weeks. Policies to Improve the Nutritional Status of 1990. "Prenatal Care in Peru." International Women." Women's Health and Nutrition Work Center for Research on Women, Washington, D.C. Program Working Paper Series. World Bank, Lopez, Alan D. 1993. "Causes of Death in Industrial Population, Health and Nutrition Department, and Developing Countries: Estimates for 1985- Washington, D.C. 90." In Dean T. Jamison, W. Henry Mosely, Miller, A.B. 1992. "Cervical Cancer Screening Pro- Anthony R. Measham, and Jose-Luis Bobadilla, grammes: Managerial Guidelines." Geneva: World eds., Disease Control Priorities in Developing Health Organization. Countries. New York: Oxford University Press. Miller, Anthony B., J. Chamberlain, N.E. Day, M. McGuire, J.S., and B.M. Popkin. 1990. Helping Hakama, and P.C. Prorok. 1990. "Report of a Work- Women Improve Nutrition in the Developing World: shop of the UICC Project on Evaluation of Screen- Beating the Zero Sum Game. World Bank Technical ing for Cancer." International Journal of Cancer Paper 114. Washington D.C.: World Bank. 46:761-769. McGuire, Judith, Rae Galloway, and The Manoff Mora, Germaine, Claudio Betts, Jill Gay, Karen Group. 1993. Enriching Lives: Lessons from Hardee, Virginia Chambers and Laurie Fox 1993. Micronutrient Programs. [Draft No. 5. July 6, 19931. "Quality of Care in Women's Reproductive I Iealth: World Bank, Population, Health and Nutrition A Framework for Latin America and the Department, Washington, D.C. Caribbean." Pan American Health Organization McLaurin, Kate E., Charlotte E. Hord, and Merrill (PAHO). October 11, 1993. Wolf. 1991. "Health Systems' Role in Abortion Moses, S., F. Manji, J.E. Bradley, N.J.D. Nage.kerke, Care: The Need for a Proactive Approach." Pp. 1- M.A. Malisa, and F.A. Plummer. 1992. "Impact of 34 in Issues in Abortion Care 1. Carrboro, NC: User Fees on Attendance at a Referral Centre for International Projects Assistance Services. Sexually Transmitted Diseases in Kenya." Lancet Bibliography 119

340:463-66. Paltiel, Freda L. 1993. "Women's Mental Health: A Moses, S., F. Plummer, E. Ngugi, N. Nagelkerke, A. Global Perspective." In Marge Koblinsky, Judith Anzala, and J. Ndinya-Achola. 1991. "Controlling Timyan, and Jill Gay, eds., The Health of Women. A HIV in Africa: Effectiveness and Cost of an Inter- Global Perspective. Boulder, Col.: Westview Press, vention in a High-Frequency STD Transmitter pp. 197-216. Core Group." AIDS 5(4):407-11. Pan American Health Organization (PAHO). 199.'a. MotherCare. 1991. "Is Perinatal Mortality a Useful Acquired Immunodeficiency Syndrome (AIDS) in the Indicator of Maternal Mortality?" MotherCare Americas. Doc. PAHO/WHO/CE 109/12. 16 April Matters 2(1):9. 1992. Movimiento Manuela Ramos. n.d. "Rape: Can I . 1992b. Reproductive Health in the Americas. Have This Child?" Lima, Peru. Washington, D.C.: PAHO/WHO. Murray, Christopher. forthcoming. "Quantifying . 1993. Gender, Women and Health in thie the Burden of Disability: The Technical Basis for Americas. Scientific Publication No. 541. Disability Adjusted Life Years." Bulletin ofthe World Washington D.C.: PAHO/WHO. Health Organization. Panos Institute. 1989. AIDS and Children: A Family Murray, Christopher, and Alan Lopez. forthcoming. Disease. London: Panos Institute. "Quantifying the Burden of Disability: Data, Parker, Laurie, Geeta Rao Gupta, Kathleen Kurz, and Methods, and Results." Bulletin of the World Health Kathleen Merchant. 1990. "Better Health lor Organization. Women: Research Results from the Maternal Murray, Christopher, Alan Lopez, and Dean T. Health Care Program." International Center for Jamison. forthcoming. "Global Burden of Disease Research on Women, Washington, D.C. in 1990: Summary Results, Sensitivity Analysis Parkin, D.M., E. Laara, and C.S. Muir. 1988. and Future Directions." Bulletin of the World Health "Estimates of the Worldwide Frequency of Sixteen Organization. Major Cancers in 1980." International Journal of Mwabu, Germano, Martha Ainsworth, and Andrew Cancer 41(2):184-197. Nyamete. 1993. "Quality of Medical Care and Parkin, D.M., P. Pisani, and J. Ferlay. 1993. Choice of Medical Treatment in Kenya: An "Estimates of the Worldwide Incidence of Empirical Analysis." Technical Working Paper No. Eighteen Major Cancers in 1985." Internationial 9. The World Bank, Africa Technical Department, Joumal of Cancer 54:594-606. Human Resources and Poverty Division, Pebley, Anne, and Sajeda Amin. 1991. "The Impact Washington, D.C. of a Public-Health Intervention on Sex Differei- Nortman, D.L., J. Halvas, and A. Rabago. 1986. "A tials in Childhood Mortality in Rural Punjab, Cost-Benefit Analysis of the Mexican Social India." Health Transition Review 1(2):143-69. Security Administration's Family Planning Piot, Peter and Jane Rowley. 1992. "Economic Program." Studies in Family Planning 17(1):1-6. Impact of Reproductive Tract Infections ar d Omran, A.R., and C.C. Standley. 1976. "Family Resources for Their Control." In Adrienne Formation and Maternal Health." In Family Germain, King K. Holmes, Peter Piot, and Judilh Formation Pattems and Health. Geneva: World N. Wasserheit, eds., Reproductive Tract Infections: Health Organization, pp. 335-372. Global Impact and Priorities for WVomen'sReproduc- . 1981. "Family Formation and Maternal tive Health. New York: Plenum Publishing Ccir- Health." In Further Studies on Family Formation poration, pp. 227-249. Patterns and Health. Geneva: World Health Organi- Piotrow, Phyllis et al. 1990. "Mass Media Fami.y zation, pp. 271-302. Planning Promotion in Three Nigerian Cities." Over, Mead, M. Ainsworth, Mujinja, Koda, Semali, Studies in Family Planning 21(5):265-274. Lwihula, and Gupta. forthcoming. Coping with Poovan, P., F. Kifle, and B. Kwast. 1990. "A Maternily Crisis: The Impact of AIDS on Households in Sub- Waiting Home Reduces Obstetric Catastrophes" Saharan Africa. World Bank, Washington, D.C. World Health Forum 11:440-45. Over, Mead, and Peter Piot. 1993. "HIV Infection Popular Education Research Group. 1992. Womcn and Sexually Transmitted Diseases." In Dean T. Educating to End Violence Against Women. Toronto: Jamison, W. Henry Mosely, Anthony Measham Popular Education Research Group. and Jose-Louis Bobadilla, eds., Disease Control Population Communication Services (PCS). 1992. Prioritiesin Developing Countries. New York: Oxford Media and Behavior Change. Baltimore: Johns University Press, pp. 455-528. Hopkins University Press, PCS. 120 Women's Healthand Nutrition:Making a Difference

Population Crisis Committee. 1987. "Access to Birth Renteln, Alison Dundes. 1992. "Sex Selection and Control: A World Assessment." Population Briefing Reproductive Freedom." Women's Studie.: Inter- Paper No. 1. Washington, D.C.: Population Crisis national Forum 15(3):405-426. Committee. Robey, Bryant et at. 1992. "The Reprodluctive Population Reference Bureau (PRB). 1990. Breast- Revolution: New Survey Findings." Pollulation feeding: Promoting a Natural Resource.Washington, Reports Series M, No. 11. D.C.: PRB. Rochat, R.W. 1987. "Table 2: Estimated L.fetime Population Reference Bureau (PRB). 1992. Adolescent Chance of Dying from Pregnancy-related Causes, Women in Sub-Saharan Africa. Washington, D.C.: by Region, 1975-84." In Anne Starrs, ed., Preventing PRB. the Tragedy of Maternal Deaths: A Report on the Portugal, Ana Maria. 1988. "Cronica de una Viola- Intermational Safe Motherhood Conference, Nairobi, cion Provocada?" Revista Mujer/Fempress "Contra- February 1987. World Bank, Population, Health violencia." Santiago, Chile: FEMPRESS-ILET. and Nutrition Department, Washington, D.C., p. Post, May T.H. 1993a. "Reproductive Tract Infec- 13. tions. World Bank, Working Paper for Population, Rogo, K.O. 1991. "Induced Abortion in Sub-Saharan Health and Nutrition Department. Washington, Africa." Kenyatta National Hospital, Nairobi, D.C. Kenya. Post, May T.H. 1993b. "Reproductive Tract Rogow, D., J. Bruce, and A. Leonard. 1990. Infections, HIV/AIDS and Women's Health." "Man/Hombre/Homme: Meeting Male Repro- Human Resources Department and Operations ductive Health Care Needs in Latin America." Policy Working Paper, HROWP 15. World Bank. Qiuality/Calidad/Qualite No. 2. New York: f'opula- Washington, D.C. tion Council. Post, May T.H. 1993c. "Women and HIV/AIDS." Rojanapithayakorn, Wiwat. 1992. "100 I'ercent World Bank, Working Paper for Population, Condom Use Seeks to Slow HIV Spread." Network Health and Nutrition Department. Washington, 13:4 (May 1992). Durham, N.C.: Family Health D.C. International. Potter, Linda et al. 1987. "Oral Contraceptive Rosenfield, A. 1989. "Maternal Mortality in Compliance in Rural Colombia: Daily Use, Developing Countries: An Ongoing But Neglected Personal and Provider Characteristics." Paper pre- 'Epidemic'." Journal of the American Medical sented at the Annual Meeting of the American Association 262:376-379. Public Health Association, New Orleans, LA, Rosenhouse, Sandra. 1989. Identifing the Ploor:Is October 19-22, 1987. Headship a Useful Concept? World Bank, Profamilia and Institute for Resource Development Washington, D.C. (IRD). 1991. Encuesta de Prevalencia, Demografia y Ross, John A., W. Parker Mauldin, Steven R. Green, Salud, 1990. Bogota, Colombia: Asociacion Pro- and E. Romana Cooke. 1992. Family Planning and Bienestar de la Familia Colombiana and Chiild Survival Programs as Assessed in 1991. New Columbia, Md.: IRD/Macro International, Inc. York: Columbia University, Center for Population Raikes, Alanagh. 1990. Pregnancy,Birthing and Family and Family Health. Planning in Kenya: Changing PatternsofBeliavior: A Ross, John A., W. Parker Mauldin, and Vincent C. Health Utilization Study in Kissi District. Miller. 1993. Family Planning and Population: A Copenhagen: Center for Development Research. Cotnpendium of International Statistics. New York: Ras-Work, Berhane. 1989. "Female Circumcision." Population Council. In Elton Kessel, and Asghari Awan, eds., Maternal Rovner, Sandy. 1993. "Many Toxins Target Women and Child Care in Developing Countries: Assessment, Specifically." Washington Post Health Magazine Promotion, Implementation. Switzerland: Ott Verlag June 29, 1993, p. 5. Thun. Royston, Erika, and Sue Armstrong, eds. 1989. Rathgeber, Eva M., and Carol Vlassoff. 1993. Preventing Maternal Deaths. Geneva: World Hlealth "Gender and Tropical Diseases: A New Research Organization. Focus." Social Science Medicine 37(4):513-520. Ruzicka, L.T., and P. Kane. 1986. "Nutritional Ravindran, Sundari. 1986. "Health Implications of Deficiencies as a Factor in Differential Infant and Sex Discrimination in Childhood." Child Mortality: The Experience of the Countries WHO/UNICEF/FHE 86.2. Geneva: World Health on the Indian Sub-Continent." In Hlarald Organization and UNICEF Hansluwka, Alan D. Lopez, Y. Porapakkhani, and Bibliography 121

P.Prasartkul, eds., New Developments in the Analysis Series. World Bank, Population, Health and Nu:ri- of Mortality and Causes of Death. Bangkok: World tion Department, Washington, D.C. Health Organization, pp. 257-294. Simmons, Ruth, Michael Koenig, and Zahidul Sargent, Carolyn. 1989. Maternity, Medicine and Huque. 1990. "Maternal-Child Health and Family Power: Reproductive Decisions in Urban Benin. Planning: User Perspectives and Service Con- Berkeley: University of California Press. straints in Rural Bangladesh." Studies in Family Saxenian, Helen. 1993. "Women's Health Issues in Planning 21(4):187-96. July/August. the World Development Report 1993: Investing in Singh, Susheela, and Deirdre Wulf. 1990. Today's Health." World Bank, Population, Health and Adolescents, Tomorrow's Parents: A Portrait of rhe Nutrition Department, Washington, D.C., May Americas. New York: Alan Guttmacher Institute. 1993. Singh, V., A. Sehgal, and U.K. Luthra. 1992. "Screen- Schulz, K.F., J.M. Schulte, and S.M. Berman. 1992. ing for Cervical Cancer by Direct Inspection." "Maternal Health and Child Survival: Oppor- British Medical Journal 304 (February 29, tunities to Protect Both Women and Children 1992):534-535. from the Adverse Consequences of Reproductive Sinnathuray, T.A. et al. 1980. "Pattern of Acute Pelvic Tract Infections." In Adrienne Germain, King K. Inflammatory Disease in Abortion-related Holmes, Peter Piot, and Judith N. Wasserheit, eds., Admissions." American Joumal of Obstetrics apid Reproductive Tract Infections: Global Impact and Gynecology 137 (7 Pt.2):868-871. Priorities for Women's Reproductive Health. New Sloan, N.L., and E.A. Jordan. 1992. "The Prevalence York: Plenum Publishing Corporation. of Maternal Anemia in Developing Countries." Schultz, T. Paul. 1989. "Returns to Women's Educa- Working Paper 7b. Arlington, VA: John Snow tion." WPS 001. World Bank, Population and Inc./The Mother Care Project. Human Resources Department, Washington, D.C. Smith, Kirk R., and Liu Youcheng. 1993. "Indoor Air Senanayake, Pramilla. 1990. "Adolescent Fertility." Pollution in Developing Countries." In Jonathan In Helen M. Wallace and Kanti Giri, eds., Health Samet, ed., The Epidemiology of Lung Cancer. N .w Care of Women and Children in DevelopingCountries. York: Marcel Dekker. Oakland: Third Party Publishing Co. Smyke, Patricia. 1991. Women and Health. London: Senderowitz, Judith. 1994. "Reassessing the Passage Zed Books Ltd. to Adulthood: Issues and Strategies for Young Somali Women's Democratic Organization/Italiatn Women's Health." World Bank Discussion Paper. Association for Women in Development. 1990. World Bank, Population, Health and Nutrition "Information Campaign to Eradicate Female Department, Washington, D.C. Circumcision." Senderoi' itz, Judith, and John Paxman. 1985. Stansfield, Sally K., Gordon S. Smith, and William P. "Adolescent Fertility." Population Bulletin 40(2). McGreevey. 1993 "Injury." In Dean T. Jamison, W. Sennott-Miller, L. 1989. "The Health and Socio- Henry Mosely, Anthony R. Measham, and Jose- economic Situation of Midlife and Older Women Luis Bobadilla, eds., Disease Control Priorities in in Latin America and the Caribbean." In Mid-Life Developing Countries. New York: Oxford University and Older Women in Latin America and the Press. Caribbean. Washington, D.C.: Pan American Starrs, Ann. 1993. Report on Women's Health and Health Organization and American Association of Nutrition Seminar Sponsored by the World Bank, Retired Persons. Rockefeller Foundation Study and Conference Centcr, ServicioNacional de Ia Mujer. 1991. PerfildelaMujer: Bellagio, Italy, 17-21 May 1993. New York: Family Argumentos Para un Cambio. Santiago, Chile. Care International. Shen, Li. 1985. "Home Prenatal Care in the Longua Steketee, Richard. 1989. "Recent Findings in Peri- Commune." In Women in China. Beijing. Quoted natal Malaria." Working paper for the XIX Inter- in APWRCN 1990. national Congress of Pediatrics, July 23-28, Paris, Sherris, J. D., and Fox, G. 1983. "Infertility and France. Sexually Transmitted Diseases: A Public Health Stephenson, Marcia, Marsden Wagner, Mihaela Challenge." Population Reports Series L, No. 4. Badea, and Florina Servanescu. 1992. "Commein- Sherris, Jacqueline D., Elisa S. Wells, Vivien Davis Tsu, tary: The Public Health Consequences of and Amie Bishop. 1993. "Cervical Cancer in Devel- Restricted Induced Abortion-Lessons from oping Countries: A Situation Analysis." Women's Romania." American Journal of Public Health Health and Nutrition Work Program Working Paper 82(10):1328-31. 122 Women'sHealth and Nutrition:Making a Difference

Stewart, Lindsay (International Planned Parenthood United Nations (U.N.). 1989. Adolescent Reproluctive Federation/Western Hemisphere Region). 1993. Behaviour. Vol. II. Evidence from Developing (Services for Adolescents in Colombia) Personal Countries. ST/ESA/SER.A/109/Add.1. New York: communication, January 1993. U.N. Strauss, John, Paul Gertler, Omar Rahman, and - . 199 la. Concise Report on the World Population Kristin Fox. 1992. "Gender and Life-Cycle Situation in 1991. ST/ESA/SER.A/124. New York: Differentials in the Patterns and Determinants of U.N. Adult Health." Santa Monica, CA: Rand . 1991b. The World's Women 1970-1990: Trends Corporation and the Ministry of Health, and Statistics. New York: U.N. Government of Jamaica. . 1993. World Population Prospects: The 1992 Strong, Michael A. 1992. "The Health of Adults in Revision. ST/ESA/SER.A/135. New York: U.N. the Developing World: The View from United Nations Administrative Committee on Bangladesh." Health Transition Review 2(2):215- Coordination/Subcommittee on Nutrition 224. (UN/ACC/SCN). 1990. Women and Nutrition. Sundstrom, Kajsa. 1993. "Abortion: A Reproductive UN/ACC/SCN Symposium Report, Nutrition Health Issue." World Bank Women's Health and Policy Discussion Paper No. 6. Geneva: Nutrition Work Program Working Paper Series. UN/ACC/SCN. World Bank, Population, Health and Nutrition United Nations Administrative Committee on Department, Washington, D.C. Coordination/Subcommittee on Nutrition Thaddeus, Sereen, and Deborah Maine. 1990. Too (UN/ACC/SCN). 1992a. Second Report on thu World Far to Walk: Maternal Mortality in Context. New Nutrition Situation. Vol. I: Global and Regional York: Center for Population and Family Health, Results. Geneva: UN/ACC/SCN. School of Public Health, Faculty of Medicine, United Nations Administrative Committee on Columbia University. Coordination/Subcommittee on Nutrition Tietze, C. and S. Henshaw. 1986. Induced Abortion: A (UN/ACC/SCN). 1992b. Second Report on tht World World Review, 1986. Sixth edition. New York: Alan Nutrition Situation. Vol. II: Country Trends, Afethods Guttmacher Institute. and Statistics. Geneva: UN/ACC/SCN. Timyan, Judith, Susan Brechin, Diana Measham, United Nations Development Program (UNDP). and Bisi Ogunleye. 1993. "Access to Care: More 1990. Human Development Report 1990. New York than a Problem of Distance." In Marge Koblinsky, and Oxford, U.K.: Oxford University Press. Judith Timyan, and Jill Gay, eds., The Health of . 1993. Young Women: Silence, Susceptibi,'ityand Women: A Global Perspective. Boulder, Col.: the HIV Epidemic. New York: UNDP HIV and Westview Press. Development Program. Tinker, Anne. 1993. "Women, Health, and United Nations Population Fund (UNFPA). 1993. Development." Paper presented at the Bellagio The State of World Population 1993. New York: Conference on Women's Health and Nutrition, UNFPA. May 1993, World Bank, Population, Health and United States Agency for International Develop- Nutrition Department. ment (USAID). 1991. HIV Infection and AIDS: A Tinker, Anne, Marjorie A. Koblinsky, and others. Report to Congress on the USAID Program for Preven- 1993a. Making Motherhood Safe. World Bank, tion andControlofHIVlnfection. Washington, D.C.: Population, Health and Nutrition Department, USAID. Washington, D.C. Van Look, Paul FA. 1990. "Postcoital Contra- Tinker, Anne, et al. 1993b. Women's Reproductive ception." Outlook 8:3 (September 1990):2-6. Health in the CentralAsian Republics. EC3HR, World Victora, Cesar, Fernando Barros, Juraci Cesar, Bank, Population, Health and Nutrition Depart- Bernardo Horta, and Silvia Moreira Lima. 1991. "A ment, Washington, D.C. Pastoral da Crianca e a Saude Materno-Infaritil em Toubia, Nahid. 1993. Female Genital Mutilation: A Dois Municipios do Maranhao." UNICEF, lirasilia, Call for Global Action. New York: Women, Ink. Brazil. Tout, A. 1989. Aging in Developing Countries. New Villar, J. and J. Rivera. 1988. "Nutritional Supple- York: Oxford University Press. mentation During Two Consecutive Pregnancies Treguear, Tatiana L., and Carmen Carro. 1991. Ninas and the Interim Lactation Period: Effect on Birth Madres: Recuento de una Experiencia. San Jose, Costa Weight." Pediatrics 81(1)51-57. Rica: PROCAL. Vlassof, Carol. and E. Bonilla. 1992. "Gender Differ- Bibliography 123

ences in the Determinants and Consequences of . 1992c. WID Fact Sheet: Women and AIDS in Tropical Diseases: What Do We Know?" Geneva: Sub-Saharan Affica. World Bank, Women in Devel- World Health Organization Special Programme for opment Unit, Africa Technical Department, Research and Training in Tropical Diseases. Washington, D.C. Walley, John, Bekele Tefera, and Mary Anne . 1992d. World Development Report 1992. New McDonald. 1991. "Integrating Health Services: the York: Oxford University Press. Experience of NGOs in Ethiopia." Health Policy and . 1993a. "Better Health in Africa." World Bank Planning 6(4):327-35. Africa Technical Department. Unpublished, Walsh, J., Feifer, C. Measham, A and Gertler, P. Washington, D.C. "Maternal and Perinatal Health." In Dean T. . 1993b. Effective Family Planning Prograrns. Jamison, W. Henry Mosely, Anthony R. Measham, World Bank, Washington, D.C. and Jose-Luis Bobadilla, eds., Disease Control . 1993c. World Development Report 1993: Prioritiesin Developing Countries. New York: Oxford Investing in Health. New York: Oxford University University Press, pp. 363-390. Press. Wasserheit, Judith, and King Holmes. 1992. In . 1994. Enhancing Women's Participation in Adrienne Germain, King K. Holmes, Peter Piot, Economic Development. World Bank, Washington, and Judith N. Wasserheit, eds., Reproductive Tract D.C. Infections: Global Impact and Priorities for Women's World Health Organization. 1984. Biomass Fltel ReproductiveHealth. New York: Plenum Publishing Combustion and Health. Geneva: WHO. Corporation. . 1986. Young Peoples' Health: A Challenge for Weinstein, Judith, Elizabeth Oliveras, and Noel Society. Geneva: WHO. Maclntosh. 1993. "Women's Reproductive Health . 1987. "Infections, Pregnancies and Infer- in the Central Asian Republics." World Bank, tility: Perspectives on Prevention." Fertility and Population, Health and Nutrition Department, Sterility 47:964-68. Washington, D.C. . 1988. Consultation on Maternal and Perinatal Westoff, Charles F. 1991. "Reproductive Preferences: Infections. WHO/MCH/91.10. Geneva: WHO. A Comparative View." DHS Comparative Studies . 1989a. "Maternal and Child Health: No. 3. Columbia, MD: Macro Systems/institute for Regional Estimates of Perinatal Mortality." Weekly Resource Development. EpidemiologicalRecord. Geneva: WHO. Westoff, Charles F., and Luis Hernando Ochoa. 1991. . 1989b. "Youth and Reproductive Health." "Unmet Need and the Demand for Family Plan- The HealthofYouth: Facts forAction.No. 6. Geneva: ning." DHS Comparative Studies No. 5. Columbia, WHO. MD: Macro Systems/Institute for Resource - . 1990a. The Health or Youth. [Final reporl]. Development. Geneva: WHO. White, S.M., R.G. Thorpe, and D. Maine. 1987. . 1990b. "Measuring Reproductive Morbidity. "Emergency Obstetric Surgery Performed by Report of a Technical Working Group, Geneva, 30 Nurses in Zaire." Lancet 2:612-13. August-i September 1989." Unpublished Winikoff, Beverly, Charles Carignan, Elizabeth (WHO/MCH/90.4). Geneva: WHO. Bernardik, and Patricia Semeraro. 1991. "Medical . 1990c. "Maternal Health and Safe Mothe-- Services to Save Mothers' Lives: Feasible hood Programme, Progress Report: 1987-1990." Approaches to Reducing Maternal Mortality." (WHO/MCH/90.11). Geneva: WHO Division of Working Paper No. 4. New York: Population Family Health. Council. . 1990d. "Prevention and Management cf World Bank. 1991. World Development Report 1991: Infertility." Progress. No. 15. Geneva: WHO The Challenge of Development. New York: Oxford Special Programme of Research, Development and University Press. Research Training in Human Reproduction. .1992a. India: Study of Women's Health. Report - . 1990e. "Sexually Transmitted Infections 11098-IN South World Bank Asia Country Increasing by 250 Million Annually." PressRelease Department ll, Population and Human Resources Geneva: WHO, December 20, 1990. Operations Division, Washington, D.C. . 1991a. Maternal Mortality: A Global Fact Book. - . 1992b. Senegal: Women in Development Geneva: WHO. CountryAssessmentand Strategy. AF5PH. Report No. . 1991b. Midwifery Education: Action for Safe 10903-SE. Motherhood. WHO/MCH/91.3. Geneva: WHO 124 Women'sHealth and Nutrition: Making a Difference

Maternal and Child Health Division, Division of Young, Mary Eming. 1993a. "Health of Women in Family Health. Industrial Workforce in Developing Countries: A . 1991c. "Trained Women Health Providers: Case of Textile and Electronics Industries." World Their Types, Number and Deployment in Bank, Population Health and Nutrition Depart- Developing Countries." ment, Washington, D.C. . 1992a. Approaches to Adolescent Health and Young, Mary Eming. 1993b. "Women's Health Development: A Compendium of Projects and Beyond Reproductive Age: The Picture in Devel- Programmes. Geneva: WHO. oping Countries." World Bank Women's Health . 1992b. Global Programme on AIDS: 1991 and Nutrition Work Program Working Paper Progress Report. Geneva, WHO. Series. World Bank, Population, Health and Nutri- . 1992c. Women's Health: Across Age and tion Department, Washington, D.C. Frontier.Geneva, WHO. Young, M., and A. Bertaud. 1990. "A New Perspective - 1993a. Coverage of Maternity Care:A Tabula- in Health Planning: A Case of Tianjin." Health tion ofAvailable Information. WHO/FHE/MSM/93.7 Policy 14:139-149. Geneva: WHO Division of Family Health. Younis, N.H., Khattab, H. Zurayk et al. 1993. "A .1993b. Global Health News and Review. Vol. 1, Community Study of Gynecological and Related No. 2. Morbidities in Rural Egypt." Studies in Family - 1993c. "13 Million HIV Positive Women by Planning 24(3). 2000." Press Release WHO/69, 7 September 1993. Zeng Yi et al. 1993. "Causes and Implications of the Geneva: WHO. Recent Increase in the Reported Sex Ratio at Birth - forthcoming. "Mother and Baby Package." in China." Population andDevelopmentReview 19:2 Geneva: WHO Maternal Health and Safe Mother- (June 1993):283-3-2. hood Program. Zewdie, Debrework. 1993. "Men, Women and World Health Organization and UNICEF 1992. "Low AIDS." Paper presented at the XlIlth International Birth Weight: A Tabulation of Available Infor- Conference on AIDS in Africa, Marrakech, mation." WHO/MCH/92.2. Geneva: WHO Mater- Morocco, December 12-16, 1993. AIDS Control nal Health and Safe Motherhood Programme. and Prevention Project, Arlington, VA. Yinger, Nancy et al. 1992. Adolescent Sexual Activity Zurayk, Huda, ed. 1991. "Study on Reproductive and Childbearing in Latin America and the Morbidity in Rural Giza: Description of Study and Caribbean: Risks and Consequences. Washington, Results of First Phase of Analysis." Population D.C.: Population Reference Bureau. Council, Cairo, Egypt. Distributors of World Bank Publicatdons

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Recent World Bank Discussion Papers (continued) No. 228 PortfolioInvestment in DevelopingCountries. Edited by Stijn Claessensand Sudarshan Gooptu

No. 229 An Assessmentof VulnlerableGroups in Mongolia:Strategiesfor Social Policy Platning. Caroline Harper

No. 230 Raisingthe Productivityof Women Fanmersin Sub-SaharanAfrica. Katnne Saito

No. 231 AgriculturalExtension in Africa. Aruna Bagchee

No. 232 TelecommunicationsSector Reform in Asia: Towarda New Pragmatism.Peter L. Smith and Gregory Staple

No. 233 Land Reformand FarnnRestructuring in Russia.Karen Brooks and Zvi Lennan

No. 234 PopulationGrowth, Shifting Cultivation, and UnsustainableAgricultural Development: A Case Study in Aladagascar. Andrew Keck, Narendra P. Sharma, and Gershon Feder

No. 235 7ite Designand Administrationof IntergovernmentalTransfers: Fiscal Decentralization it LatinAmerica. Donald R. Winkler

No. 236 Publicand PrivateAgricultural Extension: Beyond Traditional Frontiers. Dina L. Umali and Lisa Schwartz

No. 237 IndonesianExperience with FinancialSector Reform. Donald P. Hanna

No. 238 PesticidePolicies in DevelopingCountries: Do They EncourageExcessive Use?Jumanah Farah

No. 239 IntergovertimentFiscal Relations in Indonesia: Issues and Refonn Options.Anwar Shah and Zia Qureshi

No. 240 ManagingRedundaticy in OverexploitedFisheries. Joshua John

No. 241 InstitutionalChange and the PublicSector in TransitionalEconomies. Salvatore Schiavo-Campo

No. 242 AfricaCan Compete!:Export Opportinitiesand ChallengesforGannents and Home Productsinn the U.S. Market. Tyler Biggs, Gail R. Moody, Jan-Hendrik van Leeuwen, and E. Diane White

No. 243 LiberalizinigTrade it Services.Bemard Hoekman and Pierre Sauve

No. 244 Women in HigherEducation: Progress, Constraints, and PromisingItitiatives. K. Subbarao, Laura Raney, Halil Dundar, andJennifer Haworth

No. 245 "hat We Kriowabout Acquisition of Adult Literacy:Is ThereHope? Helen Abadzi

No. 246 Exploiting ItnfonnationTechnologyfor Development: A Case Study of India. Nagy Hanna

No. 247 Improvingthe Transferand Use of AgriculturalInformation: A Cuide to IniformationTechnology. Willem Zijp

No. 248 Outreachand Sustainabilityof Six Rural FinanceInstitutions in Sub-SaharanAfiica. Marc Gurgand, Glenn Pederson, andJacob Yaron

No. 249 Populationand IncomeChange: Recent Evidence. Allen C. Kelley and Robert M. Schmidt

No. 250 Submissionand Evaluationof ProposalsforPrivate Powser Generation Projects in DevelopingCountries. Edited by Peter A. Cordukes

No. 251 Supply and Demandfor Financeof Small Enterprisesin Ghana. Emest Aryectey, Amoah Baah-Nvakoh, Tamara Duggleby, Hemamala Hettige, and William F. Steel

No. 252 Projectizingthe GovernanceApproach to Civil ServiceRefonn: An EnvironmentAssessmentfor Preparing a Sectoral Adjustment Loanin The Gambia.Roger F. Pinto

No. 253 Small FirmsImnformally Finan ced: Studiesfrom Bangladesh. Edited by Reazul Islam,J. D. Von Pischke, and J. M. de Waard

No. 254 IndicatorsforM'Ionitoring Poverty Reduction. Soniya Carvalho and Howard White

No. 255 ViolenceAgainst Women: The HiddenHealth Burden.Lorn L. Heisc, Jacqueline Pitanguy, and Adrienne Germain The World Bank Headquarters European Office Tokyo Office U 1818 H Street, N-W. 66, avenue d'l6na Kokusai Building Washington, D.C. 20433, U.S.A. 75116 Paris, France 1-1 Marunouchi 3-chome Chiyoda-ku, Tokyo 100,Japan Telephone: (202) 477-1234 Telephone: (1) 40.69.30.00 Facsimde: (202) 477-6391 Facsimile:(1) 40.69.30.66 Telephone: (3) 3214-5001 Telex: MCI 64145WORLDBANK Telex: 640651 Facsimile:(3) 3214-3657 MCI 248423 WORLDBANK Telex: 26838 Cable Address: INTBAIRAD WASH INGTONIDC

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