by Mridula Banyopadhyay.
The year 2000 is fast approaching and the goal of achieving ‘Health for all’ by the year 2000 is staring at us. In spite of all the programmes and policies to deliver primary health care, health for all has not been achieved in most of the developing countries of the world.
Women in the developing countries often suffer from poor health, but they are less likely than men to use health services. Women are affected by a variety of social and cultural factors which make them less likely to benefit from health care.
It is known that before birth the female foetus has a higher survival rate than the male foetus. So we would expect that this advantage would continue after birth. Yet in many developing countries, there is a wide gap between the life expectancy of men and women. In countries such as India, Nepal, Bangladesh and parts of the Middle East, men have a much higher life expectancy. In these countries many more female children die in the first few years of life. For example in India, 23% of girls but only 19% of boys die before the age of five. Although female children start out with a genetic advantage for survival, social and cultural factors mean that this advantage is soon wiped out.
Growth and work
Even from birth, boys are given preference when it comes to feeding. For example, in the Punjab, male babies are breast fed longer and given more food once weaned. Culturally, the boys and men of the family are fed first and the remaining, left-over food is for the women and girls. There is often not enough food left and it is usually of poorer nutritional quality. This poor diet affects the growth of girls, causing shorter height and smaller pelvis. This results in low birth-weight babies who are less likely to survive childhood infections, and the small pelvis causes problems during labour.
In addition to the unequal distribution of food, the hard work carried out by Indian women badly affects their health. As well as paid manual work, many women also spend hours daily carrying firewood and water. They care for the children, prepare the food and care for the home. From about seven years of age, daughters work alongside their mothers, though sons are not required to do so. These tasks are considered to be the duties of women only - even during late pregnancy. The neglect and poor nutrition of girls is a vicious cycle of poor health in the population with high mortality of infants and children.
Use of health services
There are important differences in the use of health services between males and females. Cultural tradition means that women may not travel alone. So a trip to a health centre or hospital means that male relatives must take time off work to accompany women and children. Cultural tradition means that sons inherit land and are responsible for taking care of elderly parents. Girls will need dowries and are therefore less valued. There are therefore lower rates of hospital admission for females. Treatment for females is generally only taken up during the very late stages of disease, when it is often too late for effective treatment with conditions such as pneumonia, tuberculosis and gastro-enteritis.
Maternal mortality in India is thought to be one of the highest in the world. The social, cultural and general health factors are much more important than the actual medical cause of maternal death.
There are a number of reasons why women in rural India do not seek medical care during pregnancy and birth. The distance from a health centre may be too great. It is commonly believed that childbirth is a natural process and that nothing can go wrong. Their parents received no health care and so there is no felt need. Hospitals are associated with sickness and death. The possibility of being attended to by male doctors is often unacceptable. The lack of sympathy and understanding from staff about cultural practices related to childbirth - such as certain rituals, special foods and taboos - is another reason women will not ask for medical care.
For health services to be effective, women have to use them. The use of prenatal care (to detect possible complications) and care during and after labour and delivery is particularly important in reducing maternal deaths.
Other practices have an important effect. The use of unlawful abortion and traditional practices which may be harmful, also add to the high maternal death rate in most developing countries.
Birth at home
Home deliveries are normally attended by traditional birth attendants - generally known as ‘Dais’ - who usually have little knowledge of modern ideas about health and hygiene. Kitchen knives and blades are used to cut the cord. The outer tip is burnt and a turmeric and castor oil paste applied. The knives are normally not sterilised so the risk of infection, especially from tetanus, is high. Immediately after delivery the mother and child are normally moved to one of the corners of the house away from the kitchen, away from any source of light. The mother is now ritually impure for a period of up to 40 days or more in some communities. She carries out no normal household duties and does not speak with other members of the family. Such corners are normally dark, dusty and dirty, exposing both baby and mother to many risks of infection.
There are strict traditions concerning diet before and after delivery. It is common for women to eat less food during pregnancy so that the baby will be smaller and therefore supposedly easier to deliver. After birth, cultural practices often mean that the mother has a very restricted diet lacking in vegetables and protein. For example, in rural West Bengal the mother is allowed only plain cooked rice for 21days after delivery.
Breastfeeding is continued for a long time, without the use of weaning foods and without extra nutrition for the mother. This often leads to malnutrition of both mother and child.
India’s health programs have a strong bias towards support of major hospitals in urban centres and a medical profession who generally prefer high technology, curative medicine and an urban style of life. Poor, rural women in contrast, often have no access to health care facilities and often little knowledge of health care and resources.
There is a need for a more even distribution of health facilities throughout the country which are easily accessible to people. Health staff must be trained to be tolerant and respectful of cultural beliefs and practices and courteous to patients. The high levels of infant and child mortality and maternal mortality could be largely preventable by public health measures.
But the most important factor is education for women. There is an important link between a woman’s education and her status, which enables her to make decisions about her own health and that of her family. This also gives her an opportunity for paid employment, which postpones marriage, reducing her fertility and eventually leads to lower maternal mortality.
Mridula Bandyopadhyay is at present studying for a PhD at the City Polytechnic in Hong Kong, 83 Tat Chee Avenue, Kowloon Tong, Kowloon, Hong Kong. She has worked with research and women’s development projects in India, South Korea, the Philippines and Japan.