Safe Womanhood: A Discussion Paper
Gender, Science and Development Programme
Safe Womanhood: A Discussion Paper
by Nancy Lewis, Sophia Huyer, Bonnie Kettel and Lorna Marsden
With the support of :The Ford Foundation,Canadian International Development Agency, and
the International Federation of Institutes for Advanced Study (IFIAS)
Index
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Executive Summary
1.0 Why Safe Womanhood?
Introduction to GSD's Safe Womanhood Programme
Why Safe Womanhood?
Women's health risks - Part A; Part B
2.0 Why we need a programme of research on Safe Womanhood
3.0 Principal elements of a Safe Womanhood Research Programme
Key factors to be taken into account in the design of a Safe Womanhood Research Programme
Towards a Safe Womanhood conceptual framework
Towards a series of Safe Womanhood case studies
List of acronyms
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Safe Womanhood: A Discussion Paper
Gender, Science and Development Programme
Safe Womanhood: A Discussion Paper
Executive Summary
"Safe Womanhood" is one of the initial research themes of the Gender, Science, and Development
(GSD) Programme of IFIAS. The theme and concept of "Safe Womanhood" concern expanding the
current global focus on women's health in the context of "safe motherhood" to include the
determinants of health and health risk during a woman's entire life cycle.
Chapter 1 presents the arguments that support the adoption of Safe Womanhood as an appropriate
goal for health policies directed at women. First, women face different health risks, associated not
just with biology, but with social and cultural practices as well as political and economic realities.
These gender-specific risks begin before birth with, for example, the new technologies for choosing
sex, and continue throughout life involving differential risks associated with educational
opportunities, reproductive health, marriage norms, life-style, employment, personal violence, mental
health, and aging. Second, there is very little data available about most of the health risks facing
women throughout life. Frameworks for collection of data have been male-biased, and where genderspecific data has been collected, the focus usually has been narrowly on reproductive health.
Chapter 2 describes the reasons why a research project on Safe Womanhood is needed, and the main
issues that need to be addressed. It argues that higher health care spending does not automatically
ensure increased health. A Safe Womanhood Programme could contribute to the development and
implementation of more appropriate policies by: (1) more adequately rationalising the allocation of
resources; (2) ensuring that health promotion efforts and health care systems are better targeted by
taking gender-specific risks into account; and (3) promoting the active participation of women in all
aspects of health policy, promotion and delivery.
Chapter 3 describes the main elements that should form part of a Safe Womanhood Research
Programme. These include developing a Safe Womanhood conceptual framework, preparing a set of
internationally comparative Safe Womanhood indicators beginning with existing health data, and
undertaking internationally comparable case studies. The paper concludes by setting out steps for the
phasing in of the Programme's activities.
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Safe Womanhood: A Discussion Paper
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Safe Womanhood: A Discussion Paper
Gender, Science and Development Programme
Safe Womanhood: A Discussion Paper
1.0 Why Safe Womanhood?
1.1 Introduction to GSD's Safe Womanhood Programme
The Safe Womanhood research theme was adopted at the initial meeting of the Gender, Science, and
Development Programme (GSD) out of a sense that there were specific health risks facing women
that were not being adequately addressed by national governments or international organizations.
Recognition of specific health risks for women to date largely has focused on reproductive, maternal
and child health. While the global campaign for safe motherhood has been vital in improving the
health status of the world's women, the focus on women's health needs to be expanded to include the
determinants of health and health risks during a woman's entire life cycle.
While women's health has been located in the context of the family[4] in a variety of ways in various
international agencies, Safe Womanhood crosses all the institutional settings in which women's health
may be an issue. The Safe Womanhood Research Programme aims to contribute to the development
of a concept of "Safe Womanhood" which reflects this holistic approach to women's health. In its
research it will investigate the place of women and their needs in a larger socio-economic context of
political/cultural traditions, the health policies of governments, international organizations and
funding agencies, and international science.
The overall goal is to persuade international and national policy-makers to adopt Safe Womanhood as
the goal of new health policies to address the gender-specific health risks facing women. We also
hope to ensure that such policies are implemented, leading to improved health for women throughout
the world. Achieving this goal will require:
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developing an operational definition and framework of analysis for Safe Womanhood using
both quantitative and qualitative indicators;
using these indicators, combined with existing and new data, to analyse the current gaps in
national and international health policies affecting women;
ensuring that Safe Womanhood is given high priority on the international health and
development agenda, and more specifically, to target the United Nations Fourth World
Conference on Women: Action for Equality, Development and Peace, to be held in Beijing on
2-14 September 1995 and its related NGO Forum, 30 August - 8 September 1995.
In developing the Safe Womanhood theme, the Programme will build on previous work by the World
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Health Organisation, the Ford Foundation, the International Centre for Research on Women, and
many other organizations that have been concerned with women's health issues.
The purpose of the present paper is to provide a point of departure for the Safe Womanhood
Programme. It is organized as follows:
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The rest of this Chapter presents the arguments that support the adoption of Safe Womanhood
as an appropriate goal for health policies directed at women.
Chapter 2 describes the reasons why a research project on Safe Womanhood is required, and
what the main issues are that need to be addressed.
Chapter 3 describes the main elements that should form part of a Safe Womanhood Research
Programme.
1.2 Why Safe Womanhood?
We begin with the question: "Why do we need a concept of Safe Womanhood?"
The first part of the answer, in short, is that women face different health risks than men, in a wide
variety of ways that go far beyond the obvious differences that can be attributed to sex or related
biological factors. We argue that there are important health risks related to gender. Further, by
gender, we also mean the set of attributes assigned to woman and men by history, society, culture and
politics, which vary across time and space.[5] Adopting a gender perspective, therefore, provides a
means of explaining how and why these different attributes, as well as physiological differences, lead
to different health risks for women and men. Such an understanding will increase our understanding
of human health overall.
The second part of the answer is that when we begin to look for it, we find that there are very few
data available about most of the health risks facing women. The lack of appropriate information on
women's health risks is a major barrier to effective public policy, and, we argue, leads to
inappropriate allocation of resources within the health care systems of countries throughout the world.
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Safe Womanhood: A Discussion Paper
Gender, Science and Development Programme
Safe Womanhood: A Discussion Paper
1.3 Women's health risks
This section provides an overview of women's health risks. Our emphasis is not gender-specific risks
arising from biological factors, but rather risks that arise as a result of the interaction of biophysical
and social factors. Different risks appear at various stages in a woman's life cycle, and according to
her various productive and reproductive roles. We have used these as the organizing principle for this
chapter. Our purpose in this section is not to be comprehensive, but rather to make an initial attempt
to demonstrate what can be learned by adopting a multi-disciplinary, life-cycle or life-phase approach
to health risks for women.
1.3.1 Birth and childhood
Gender-specific risks appear even before birth. The spread of amniocentesis and ultrasound
technologies that allow parents to know the sex of their child before birth has led to the phenomenon
of selective aborting of female foetuses in several regions of the world.[6]
Some studies show that, once born, boys are taken for medical care earlier and more frequently than
girls.[7] Boys, commonly, are also better-fed than girls. This is reflected in higher malnutrition rates
among girls in many areas,[8] and in turn leads to the situation that, while rates of infectious disease
are similar for girls and boys, the episodes can be more severe for girls because of their greater
malnutrition.[9] Elsewhere it has been found that as distance to a diarrhea treatment centre increased,
the ratio of girls treated in comparison with boys decreased significantly.[10]
1.3.2 Education
Despite a general improvement in educational opportunities for children in most parts of the world,
females still obtain fewer years of schooling than males in almost all countries; this is especially a
problem in low-income countries.[11] Between 1970 and 1985, the worldwide literacy rate increased
from 56% to 60%. However, the gender gap in literacy is also increasing: the number of illiterate
women rose by 54 million between 1970 and 1985, to 597 million, compared to an increase of 4
million illiterate men over the same period, to 352 million.[12]
Lower educational attainment of girls and women increases health risks, given evidence that
education is "strongly associated" with good health, and that literacy plays an "extremely powerful
role...in determining a population's level of mortality".[13] Literacy and education can increase
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women's employment and income opportunities, while also equipping women to protect themselves
against health hazards. For example, women may be at greater risk from toxin exposure not only
because of their gender-defined responsibilities (these include spending long hours at cooking fires;
long-term exposure in fields when weeding, harvesting and processing; and increased industrial
exposure in low-level, low-paid and less-powerful positions) but also because they often lack
appropriate training or cannot read pesticide labels.[14]
On the other hand, current models of education can also increase work burdens for women in that
children are no longer available to assist them.[15] Organisations such as the Bangladesh Rural
Advancement Committee (BRAC) are pioneering new models for child education that emphasize
flexible teaching hours (i.e. hours in which children are not needed at home or in the fields), basic
numeracy and literacy, and allowances for cultural norms. BRAC has been able to increase the
number of children (especially girls) who gain access to education, without increasing the domestic
burden of their mothers.
1.3.3 Reproductive health
Reproductive health, while consisting of a set of physiological manifestations, is also related to
sociocultural and legal factors. Sexually transmitted diseases, female circumcision,[16] and the
violence experienced by women in prostitution place hundreds of millions of women at risk of severe
health complications. These complications include infection, fever, shock, hemorrhage, tetanus,
ulcers, scarring, fistula, infertility, sepsis, obstructed labour, stillbirths, and brain damage (which
affects infants lacking adequate oxygen during birth).[17]
Approximately 250 million new cases of sexually-transmitted diseases (STDs) occur each year, many
of which are associated with infertility,[18] blindness, cervical cancer and brain damage.[19] Several
STDs are associated with increased risks of HIV infection, while reproductive tract infections and
STDs are responsible for at least 750,000 female deaths each year. Almost half of these deaths are
due to cervical cancer caused by the human papillomavirus.[20] Additionally, an estimated 200,000
maternal deaths each year occur as a result of illegal or unsafe abortions.[21]
The World Health Organisation estimates that 1.5 to 3 million women will die of AIDS-related
illnesses during the 1990s in Africa alone, producing immense economic and social costs. In some
African hospitals, already over half of the admissions are AIDS-related. Additionally, despite the fact
that known HIV infection rates overall have been higher for men than women, the ratios are
converging in many countries. Studies in both Brazil and the U.S. found that survival times after
diagnosis are shorter for women than for men, probably due in part to delayed diagnosis and less
access to appropriate health services.[22] DeBruyn also suggests that women have increased risks for
exposure to HIV infection as a result of lower status and literacy levels, less access to communication
channels, poverty-induced prostitution and sexual subordination to men.
1.3.4 Marriage
Social norms and laws determine the prevalence of early marriage among women, which in turn
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affects both the number of pregnancies and the age of women at first and last pregnancies.
Disturbingly, deBruyn reports that in some areas of Africa, age at marriage is decreasing as a
response to AIDS. Behal describes women in purdah in North Indian villages as "prisoners of the
courtyard." She argues that, because of their limited mobility, "women's perceptions on issues such as
health, hygiene and how to deal with them are very low." Bhatt argues that "the expectation of life at
various ages shows that ill-health stalks the Indian woman right through her life."[23]
Several factors have been identified by researchers as key influences on maternal and child mortality,
such as low social status, lack of education, large number of children, poor nutrition, etc., but the
effects extend to the quality of life at other stages as well.
1.3.5 Migration
Global population growth as well as economic and political factors result in increasing human
migration - with accompanying implications for health. Many studies reveal that migrants, especially
women, have poorer nutritional status, greater incidence of disease, and less access to health services.
[24]
Often overlooked in discussions of migration, however, is the fact that in many areas of the world,
millions of women move at marriage to live with or near their husband's family. An example which
reflects the differential investment in girls occurs in one part of the island nation of Papua New
Guinea, where daughters are referred to as "bouncing coconuts" who leave home to live with their
husbands' families; sons are seen as "houseposts" who ensure the continuity of the community.[25]
Change in residence resulting from this tradition may lower the nutrition levels and increase the
workloads of women. It may also lower their status at home - patrilineal and exogamous marriage
customs can discourage investment in the health and education of young girls.
An important characteristic of population movement is rural-urban migration, which occurs in all
developing regions, generally by men seeking employment. This has a relatively well-studied impact
on those left in the rural area, including wives and mothers; commonly cited patterns include
increased female work loads, as well as decreased health and nutrition for women and children in
rural areas. But women also migrate, with their partners or alone. Lone female migration is
particularly prominent in Latin America. It is also estimated that more women than men reside in
Mathare, a squatter settlement of Nairobi. Over half of these women are heads of households, and
less than 10 percent work in the formal sector, compared to 20 percent of the men in that community.
[26] Crowding in substandard urban housing exacerbates the risks of poor water supply and
sanitation, infectious diseases, poverty and crime - risks to which women are more vulnerable as a
result of their lower status and productive roles.[27] Leslie notes that women's risk of violence
increases with both rural and urban migration.[28] In some cities, such as Calcutta and Bombay,
more than fifty percent of the urban population live in slum areas, with inadequate housing and a lack
of basic services.[29] Women play a vital and not well understood role in urban food supply, both for
their families and through their involvement in the informal sector. Little attention has been paid to
the mental and physical health of women in such situations,[30] or to the increasing number of older,
destitute women in Third World cities, many of whom migrate after divorce or the death of their
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husbands.[31] An important area for new research would address issues of women's immigration
from the Third to the First World, including attention to isolation, breakup of families, etc.
1.3.6 Employment
As family structures continue to change across the globe, the proportion of female-headed households
is growing.Global estimates range from 1/3 to 1/4 of all households; estimates of 15% in Latin
America to 22% in Africa are examples of trends in the developing world. In most areas, there is a
concurrent feminization of poverty.[32] Women are joining both the formal and informal sectors of
the labour force in increasing numbers and the documentation of women's work is belatedly receiving
greater attention.[33] Estimates of female labour force participation range from 17% in West Asia
and North Africa to 40% in East Asia, while women's economic activity rates, which count "work for
pay or in anticipation of profit," are higher yet, ranging from 16% in North Africa to over 50% in
parts of Asia.[34]
As women's participation in the labour force increases, so does the phenomenon of the double or
triple workload faced by women who continue to shoulder the bulk of responsibility for work in the
household. A growing literature on time allocation quantifies the limited options women face in
attempting to meet their own or their children's health needs:
*Huffman summarizes eight studies showing that women in countries of Africa and Asia spend 8 to
12 hours per day in production activities.[35]
*Popkin and Doan review nine time allocation studies in Africa and Asia which document female-tomale work ratios of 1.20 to 1.64.[36]
The physical and mental health impacts of such burdens are more difficult to assess. Only one of the
Popkin and Doan studies cited above deals with an urban area, and very little is known about urbanrural, age or income differences in time allocation.
Gender-specific risks in non-agriculture occupational settings especially in developing countries have
received little scientific attention. The industrial sector, characterised by low income, long hours and
lack of regulation, places both women and men at risk of industrial accidents and chronic disability,
also exposing them to poor ventilation, inadequate lighting and various toxins. Because women are
often the lowest paid and least likely to have a voice, they are generally at greater risk of these health
hazards than men. Kemp notes, with respect to women's work in Indonesia:
like public health, occupational health is linked with poverty and women's status. Unlike public
health, occupational health is tied with patriarchal political control, the destruction of labour
organizations and the explicit right of men to exploit women as expressed in religious teaching and
labour laws.[37]
Women's injuries are under-reported because they are chronic (not official "time loss" industrial
injuries, such as acute injuries and trauma) and because women tend to work on a contract basis.
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Therefore, positioned in a labour market which is characterised by intense competition for work, and
lacking access to sick leave, women are unlikely to report illness. Additionally, as the majority of
workers in the informal sector, women's work in street vending, domestic work, prostitution, alcohol
brewing and waste hauling exposes them to infectious diseases, pollution, burns, and violence.[38]
Although more men are employed in the formal sector in low-income countries, occupational health
hazards often extend beyond the work site to worker families and the surrounding communities.
Workers that contract infectious diseases, such as tuberculosis, are often sent home to rural areas,
where they subsequently infect family members. For example, miners in southern Africa carry home
asbestos dust as a result of inadequate controls on worker clothing. Other occupational risks include
those of pesticides, chemical pollutants and airborne toxins, which are rarely monitored in lowincome countries.[39]
1.3.7 Food, nutrition and agriculture
Agricultural production has increased significantly in the last several decades, in both developing and
developed countries. National per capita levels of calories, protein and fat have increased in almost
all regions of the world since 1961, although the increases are often not distributed evenly.[40] At the
same time, however, malnutrition is increasing.[41] The decrease in nutritional status that may
accompany commercial agricultural production was recognized as early as the 1920s and 1930s[42]
and subsequently substantiated by documentation that persistent malnutrition or decreases in
nutritional status have accompanied agricultural development in many areas.[43]
The reasons for this are complex. Gender bias in development projects has resulted in extension and
development efforts which have consistently targeted men and excluded women from access to
credit, inputs and services,[44] so that more men are able to take advantage of opportunities to enter
commercial production or to work in urban areas. This situation has left the responsibility for
household food production to women.[45] Although women traditionally have been responsible for
much of the food production in developing regions, and as much as 80% in Africa,[46] land reform,
commercial production of cash crops and new tenure systems have expropriated their traditional
control over the land, and, in many areas, their right of cultivation.[47] Women are therefore forced
to produce the developing world's food on smaller and poorer plots of land.[48] This has obvious
effects on nutrition levels. Further, in many societies women must make do with whatever food is left
after other family members have eaten.
Increased household income does not necessarily imply an increase in nutritional status. The cash
income earned by men is often spent on consumer goods and entertainment (such as alcohol and
tobacco).[49] According to research in Latin America, Africa, the Indian subcontinent and Asia, the
proportion of income that men contribute to family welfare decreases as income increases,[50]while
the income of women tends to be spent on food, clothing, school fees and other family needs.
Women are exposed to other health risks in agricultural production. One example is exposure to
pesticides - an estimated 400,000 to 2,000,000 poisonings and 14,000 to 40,000 deaths each year are
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attributed to pesticide use.[51] Men are typically exposed to high doses when applying pesticides;
women are exposed to lower doses but for longer periods of time, while weeding, harvesting and
processing.[52] Women have often not been given the same training with regard to risks of exposure,
especially during pregnancy, and they may not be able to read precautionary material.
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Safe Womanhood: A Discussion Paper
Gender, Science and Development Programme
Safe Womanhood: A Discussion Paper
1.3.8 Water supply and sanitation
Water supply and sanitation are perhaps the most significant environmental factors affecting health.
The World Health Organisation estimates that, overall, 80% of disease in developing countries is
related to unsafe and inadequate water supply and sanitation services. It is estimated that ten to
twenty-five million people die each year from these diseases.[53] Over one billion people lack safe
drinking water and basic sanitation facilities, and in spite of the International Drinking Water Supply
and Sanitation Decade (1981-1990), the absolute number of unserved people is increasing,
particularly in rural areas.[54]
In developing countries, women are exposed to health hazards when they wash clothes, draw water
from surface sources, bathe their children, and work in flooded rice fields.[55] Because of these
responsibilities, women may face increased risk of exposure to water-based diseases such as
schistosomiasis and guinea worm and, depending on temporal and spatial activity patterns, may often
experience greater exposure to other water-related or vector-borne diseases. In general, in the tropics
and elsewhere in the developing world such hazards include: water-borne diseases, such as cholera,
typhoid, hepatitis and bacillary dysenteries; diseases related to lack of water for washing, such as
shigellosis, scabies, ascariasis and trachoma; water-based diseases, such as schistosomiasis and
guinea worm; and water-related diseases, such as malaria, dengue fever, and onchocerciasis (river
blindness).[56] In areas where women's mobility is limited by culture or religion, their risk of
exposure may conversely be less, e.g. their risk of schistosomiasis in some Islamic regions.[57]
These urgent sanitation issues complicate and are complicated by a number of the interacting factors
of a woman's life. Women's nutritional status is lowered not only by the above-mentioned diseases,
but also from the time and energy spent fetching water and fuel. Research in urban and rural East
Africa has found that in mountainous areas women spend up to 27% of their caloric intake fetching
water.[58] It is not, therefore, surprising that women make up a disproportionate amount of the 100
million people affected by nutritional deficiencies such as anemia, goitre and lack of Vitamin A.[59]
1.3.9 Fuelwood issues
While rarely considered an environmental health problem, the responsibility for fuelwood and fodder
collection also constitutes a significant health burden for women in developing countries.[60]
These activities are sometimes considered to be a major cause of desertification, but as the United
Nations Environment Programme points out, "an over-riding socio-economic issue in desertification
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is the imbalance of power and access to strategic resources among different groups in a given
society".[61] While the role of fuelwood and fodder collection in deforestation and desertification is
complex, gender bias and the denial of women's needs and interests are prominent amongst the social
factors that lead to desertification and deforestation.
Deforestation affects not only climate and soil fertility - factors which affect nutrition levels - but also
forces women to use increasing amounts of time and energy to obtain the necessary fuel for
household consumption. Studies in several African and Asian countries found that women spend 4 to
6 hours each day collecting fuelwood. In regions of Sudan, it now takes four times as long as it did
ten years ago to gather fuelwood. In many areas women must carry loads as heavy as 35 kilograms as
far as 10 kilometres.[62] The years spent carrying heavy loads lead to acute and chronic injuries,
including miscarriages, stillbirths, uterine disorders, and back pain.[63]
The health effects of carrying heavy loads for long distances extend beyond the immediate physical
consequences. The responses of women to the increasing scarcity of fuelwood have major effects on
their own and their families' health. They may be forced to purchase fuel, thus decreasing
expenditures on other necessities. In some areas of the world, daughters are taken from school to help
collect fuel and fodder.[64] Women are forced to use cattle dung and straw for fuel which would
otherwise be used for fertilizer or animal feed, with accompanying detrimental effects on food
production. The smoke of these materials is frequently more polluting, so that respiratory disease is
increased in women and children who spend time in the home.[65] Burns are also a serious health
problem.[66]
Deforestation also leads to water shortages (through loss of ground water) which are exacerbated by
leaching of pesticides and fertilizers into water sources. Shortages of water suitable for domestic use
in many areas of Africa and South Asia have reached a critical level.
Family diets change significantly when adequate fuel is unavailable. More raw foods and fewer
legumes (which require longer cooking time) are eaten, and more leftovers are served cold. This can
lead to increased gastrointestinal infections. The percentage of snack or "fast" foods which are
incorporated into the daily diet, and which are generally less nutritious, increases. Dankelman and
Davidson go so far as to observe that a "close statistical association exists between per capita
consumption of food and that of fuel.[67]"
1.3.10 Violence against women
Violence and exploitation of women includes spouse abuse, rape, prostitution, female circumcision
and armed conflicts. Domestic violence occurs within the social reproductive sphere and is a serious
problem in all parts of the world. The scant data available to document violence against women
suggests it is pervasive but drastically under-reported. In the U.S. each year, over one million women
seek medical care for injuries caused by marital violence. A study in a Bangkok slum found that half
of the women there are regularly beaten. Another study of 153 Kuwaiti women found that one-third
had been assaulted.[68] Leslie[69] notes that in Bangladesh half of all murders are committed by
husbands against wives; in Bogota, 1/5 of bodily injury is due to marital violence, and women make
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up 94% of all hospital patients. In Pakistan, by Islamic ordinance, rape victims can be charged with
adultery. Kelkar[70] describes the situation in India: in the three years prior to 1991 there were
11,259 dowry-related murders. Further, the numbers are escalating, although the situation appears to
be worse in northern India than in the south. Kelkar also suggests that incidences of rape appear to be
increasing. According to a study in 1982, 42.5% of these rapes committed in rural and tribal areas are
committed by policemen, army personnel and forest guards. Dalit (oppressed castes) and adivasi
(indigenous) women are particularly vulnerable. These examples show the wide range of cultural,
caste (in India), historical and economic factors which must be taken into consideration in addressing
issues of violence against women.
One of the functions of violence against women, according to Kelkar, is that it keeps them powerless.
With this understanding, it becomes clear that the term encompasses much more than physical harm.
Exploitation, discrimination and intimidation are also violations of women - such a definition leads
one to understand more clearly some of the contextual and societal issues of violence. For example,
the state often plays an important role in furthering violence against women by legitimizing the
patriarchal patterns of family structures. This is true also outside India; observers in the U.S., for
example, acknowledge the persistent reluctance of authorities to intervene in domestic violence, the
effects of which, both physical and psychological, can lead to increased depression and suicide rates.
Other issues of violence against women include the increased risk, both inside and outside the home,
associated with urban migration.[71] Female circumcision - often actually female genital mutiliation can also be termed a violence issue, most often perpetuated by women fearful for their daughters'
future marriage prospects. The socialisation of young women into second- or third-class status is also
an important violence issue.[72]
1.3.11 Women's mental health
It is much more difficult to measure mental than physical health. In both high- and low-income
countries, women appear to experience greater incidence of depression than men. However, in lowincome countries, men receive more treatment for mental illness than women; in high-income
countries men receive more treatment from specialists. Known causes of depression of particular
relevance to women include single parenthood, infertility,[73] abuse, resettlement, poverty and
abandonment.[74]
Suicide rates and substance abuse are other indicators of mental health. In most countries, women
unsuccessfully attempt suicide more often, while men are more frequently successful in committing
suicide. However, in many countries the suicide rate is significantly higher or increasing at a faster
rate for women than for men.[75] The rates of women's tobacco and alcohol abuse in low-income
countries are also increasing, despite the fact that substance abuse has typically been associated with
high-income countries and with men generally.[76]
1.3.12 Aging
In both high and low-income regions, the absolute and relative numbers of elderly are increasing. In
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developing countries, the percentage of people over 60 years of age, at 6% in 1980, is expected to
increase to ten percent by 2020, while the number of older women in developing regions has doubled
in the last 25 years. The major causes of death among older people in developing regions include
cardiovascular and cerebrovascular diseases, infectious diseases, and cancer. Although information is
scarce, it is believed that over half of the elderly in developing countries may be disabled.[77]
The World Health Organisation notes that "women are more likely to suffer from chronic, but not
fatal conditions, whereas men tend to suffer from acute and fatal illnesses. In other words, older men
have shorter life expectancy but relatively more years of life free from functional disability.[78]"
Although elderly women and men tend to die from the same diseases, older women are more likely to
suffer debilitating conditions such as osteoporosis, arthritis, diabetes and hypertension. Older women
may also experience more mental health problems.[79] A study in the U.S. found that "dementia was
the most important serious illness that developed in men and women after the age 75, ahead of heart
attacks, strokes and cancer...All dementias were three times as likely among elderly women as among
men in the study." Women are also more likely to experience age-related hearing and vision loss.[80]
The health and quality of life for the elderly are affected by urbanization, increased female labour
force participation, changing family structures, high unemployment and lack of social security. These
factors also contribute to a lack of inadequate care and resources for the elderly worldwide.[81] These
factors and the duty of elder care within the extended family put burdens on women - many of whom
are grandmothers themselves - who must care for both children and elderly kin.
1.3.13 Access to appropriate health care services
Women face two issues relating to appropriate health care services: restricted access and
inappropriate or unnecessary care. Despite the common assumption that women receive health care
more often than men, some evidence suggests that in adulthood, females are less likely to receive
adequate care.[82] For example, although roughly equal numbers of women and men in Africa suffer
from AIDS-related illnesses, men occupy many more AIDS hospital beds.[83] It appears that hospital
occupancy rates are higher, in general, for men than for women, in spite of women's reproductive role.
[84] We suggest that this is an area where a relatively simple initial indicator of this might be
identified, concerning for example, information on allocation by gender of hospital beds or wards. A
complete assessment of the situation would necessitate not only understanding patterns of morbidity
and mortality by sex, but also the context in which the allocation of beds is made.
Paolisso and Leslie summarize some of the typical constraints on women's access to formal health
services in low-income countries: women almost always have less disposable income and time for
health care; additionally, in many regions, cultural norms prevent women from using public
transportation or visiting male health care providers, while inadequate privacy can prevent women
from using health facilities.[85] Obviously great regional and individual differences in these patterns
exist which warrant investigation, especially those linking utilization to outcome.
In many cases where women do have access to medical care, the benefits of that care can be
questioned. The allocation of resources for women's health over the life cycle needs to be reassessed.
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Cervical cancer has become the fastest increasing cancer for women in low-income countries,
especially for women beyond menopause. According to Paolisso and Leslie, the widespread
implementation of a very simple health procedure could change this: "even a single screening in a
woman's lifetime can reduce the death rate from cervical cancer by about 50%."[86] The problem for
some higher-income women is that of unnecessary or inappropriate care, a health issue which has
only relatively recently received notice. Unnecessary or premature Caesarian sections have been
common in North America, and the efficacy of hysterectomies has only recently received widespread
attention in view of their immense hormonal and chemical impacts. In Brazil, women seeking to
circumvent laws against sterilization undergo Caesarian sections in order to obtain tubal ligations.
[87] Yet many poor Brazilian women are forcibly sterilised, often without their knowledge.
The use of inappropriate and sometimes dangerous pharmaceuticals is another risk which affects
women differently from men, a result both of advertising strategies and of the preconceptions of
health care personnel.[88] Arminee Kazanjian has suggested an assessment framework for
technology decisions in health care which is based on principles of justice and equitable access to
health care. Such decisions would be made in a social context, and ranked according to contribution
to society along policy dimensions such as population risk; impacts on population using generic
measures such as function and psychological status; fiscal and economic implications; social
ramifications and legal and ethical implications; as well as technology assessment evidence.[89]
1.3.14 Summary
As demonstrated above, gender-specific health risks for women occur and vary throughout the life
cycle and as a reflection of the cultural, social, political and economic contexts and institutions of
their lives. There are differences in anatomy, physiology, genetics, age, social status, income,
activities, and environment.[90] This analysis is only the beginning of the development of a
comprehensive understanding of the differential health risks for women and men and girls and boys
in various parts of the world - an understanding which goes beyond measurement of mortality and
morbidity outcomes, and includes the daily physical, mental, social and economic costs for the
individual and society. The pressing need for a comprehensive understanding of the differential
health risks facing women is one of the main reasons why we need a conceptual and operational
definition of Safe Womanhood.
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Safe Womanhood: A Discussion Paper
2.0 Why we need a programme of research on Safe
Womanhood
So far, we have demonstrated that a new concept of Safe Womanhood is necessary to focus
appropriate attention on the gender-specific health risks affecting women throughout their life cycle,
and to serve as the organizing principle for gathering the data required to make appropriate policy
choices relating to women's health. This chapter deals with the question of why we need a specific
programme of research on Safe Womanhood, and what that programme of research should consist of.
2.1 Overall context for health policy
Health policy is currently dominated by three major issues:
1. First, almost every health care system in the world is under financial pressure, because of a
combination of rising costs for technology-intensive treatments, and attempts by government to ration
health care spending in the face of budget deficits and other priorities.
2. Partly as a result of financial pressure, there is increasing recognition of the fact that spending on
health care does not necessarily improve population health outcomes. This has led and will continue
to lead to more interest by policy-makers in the determinants of health, and in the ounces of
prevention that are worth more than pounds of cure.
3. The focus on prevention will lead to more widespread interest in the various models of communitybased approaches that have proven to be the most effective in improving the health status of
populations.
The following paragraphs elaborate on these three major points.
Prior to the World Health Organisation's Alma Ata Conference of 1978 in what is now Kazahkstan,
low-income countries focused on the construction of high-technology, Western-style medical
systems, while actively discouraging traditional medical practices. Alma Ata marked a watershed:
policy makers acknowledged that a centralized approach to health promotion was too expensive and,
furthermore, did not provide adequate health services to the majority of populations. Leaders instead
committed themselves to "accessible, affordable and socially relevant" health care using community
participation and appropriate technology.[101]
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This commitment and the reiteration of the definition of health as "the physical, mental and social
well being of the individual" generated the comprehensive primary health care (CPHC) approach
which encompassed not only health services but also the social, economic and political determinants
of health.[102] The goal of the World Health Organization to achieve health for all by the year 2000,
however, proved unreachable and led to reformulation of a second approach - selective primary
health care (SPHC) - which had more achievable or at least more measurable objectives, and
consisted largely of vertical programmes (selective, disease-based programmes for the eradication of
a single disease, such as smallpox).[103]
It can still be argued, however, that research and policy lacunae concerning adult health in general
(particularly in the developing world) have caused recent programmes and interventions in the
developing world to neglect the health of women and men,[104] as indicated in the following
selection of statistics:
●
●
●
twenty-seven percent of all deaths in developing countries occur between the ages of 15 and
59; 72% of these are avoidable and one half of life-years lost occur during adulthood;
the average probability of dying between the ages of 15 and 60 in developing countries is 25%
for men and 22% for women; respective figures for the developed world are 12% and 5%;
currently, half of adult deaths around the world are associated with cancer, cardiovascular
disease or injury, while adult morbidity is characterized by longer episodes and greater
disability than in the past: lower mortality rates and longer life expectancy do not necessarily
reflect lower morbidity rates or increased quality of life.[105]
In addition to the above data, ongoing demographic and health transitions suggest that key concerns
continue to shift for both women and men. Rapid declines in mortality due to innovations in curative
services and improved sanitation, coupled with lagging declines in fertility rates, have led to
tremendous population growth, mostly in developing countries: the world's population more than
doubled between 1950 and 1990, from 2.5 billion to 5.3 billion.[106] At the same time, the global
population is aging, and the health of and health care for the elderly (defined for international
purposes as those over 60) need to be addressed.[107] Longer life expectancies, aging populations
and increased risk exposures have increased the prominence of noncommunicable, chronic and
degenerative diseases as the ultimate causes of death, as compared to infectious and parasitic diseases,
[108] although the latter continue to affect quality of life to a great degree.
There is substantial debate concerning both the efficiency and efficacy of the various approaches to
health promotion which have arisen since Alma Ata, and while there is little doubt that the lives of
women would be greatly improved by the implementation of comprehensive primary health care, the
harsh reality is that as the capacities of national governments and international donors are
increasingly strained,[109]primary health care becomes a victim of the global recession. Yet while
maternal health initiatives are likely to be effective in decreasing morbidity and mortality for
otherwise healthy women, the broad range of factors which affect health (declining fertility rates,
aging populations and rapidly changing social systems) indicate, as we have demonstrated, that an
expanded approach to health will be necessary to decrease morbidity and mortality rates and improve
the quality of life for women as well as men at all stages of the life cycle. In the challenging set of
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circumstances of this century, the development and use of a framework to understand and analyse
"Safe Womanhood" therefore becomes increasingly important.
The mounting burden of foreign debt, recession and economic restructuring in much of the
developing world[110]necessitates higher success rates for health and development programmes.
Worldwide there is increased recognition that higher health care spending does not ensure increased
health. In fact, it has been shown that in the cases where it detracts from spending in other public
service sectors, increased investment in formal health systems and technology may have little effect.
There is concern, for example, that health care spending in the United States has "surpassed an
optimum threshold and become a drag on the nation's economy,"[111] with all the effects on quality
of life that are entailed.
2.2 Potential contribution of a Safe Womanhood Research Programme
In this context, a Safe Womanhood Research Programme could make a major contribution to the
development and implementation of appropriate policies, in three major respects:
2.2.1. Resource allocation
As noted in this paper, there is evidence that in many countries, women have less access to health
care resources than men. Put positively, as policy-makers address issues of resource allocation in
future, there is an opportunity to rationalize the allocation of resources in a way that recognizes the
differential health risks facing women and men. This is only possible, however, if there is a much
better information base on gender-specific health risks.
2.2.2. Appropriate initiatives to improve health outcomes
As more and more jurisdictions recognize the importance of taking a more holistic approach to health
policy that stresses prevention in addition to cure, it is essential to understand which preventative
policies would be generally effective in the population as a whole, and which policies have to be
specifically targeted to minimize gender-specific health risks. In this context, it is useful to stress that
a holistic approach to health requires a multi- or trans-disciplinary approach.
2.2.3. Women's participation in health systems
As jurisdictions search for new models for the delivery of holistic health services, consideration will
have to be given to the roles of women and men, in terms of both the current differentiation of gender
roles in the family and society and the changes that many people hope to see in those roles in future.
To cite but one example, given the crucial importance of early child development and the special
responsibilities for child-rearing that women continue to have in most of the world, it is thus clearly
essential, in a preventive, community-based approach to health, that women be active in all aspects of
health services policy and delivery.
The rationale for a Safe Womanhood Research Programme at this time is therefore to catalyze the
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research necessary to ensure that as policy-makers restructure health policies and systems in the
coming years in response to a variety of pressures, they have access to sound research on genderspecific health risks affecting women, and on policies and health service delivery approaches that
have been or could be effective in addressing those risks.
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Gender, Science and Development Programme
Safe Womanhood: A Discussion Paper
3.0 Principal elements of a Safe Womanhood Research
Programme
This chapter describes the major elements of a Safe Womanhood Research Programme, beginning
with a summary of some of the important factors to be included in the design of a research
programme, moving on to a discussion of a conceptual framework for Safe Womanhood, and
followed by a discussion of Safe Womanhood indicators, some potential case studies, and the
remaining activities that would be included in the first major phase of the research programme. We
believe a programme of this magnitude is necessary to deal with this subject in a way which creates
the possibility of having a long-term impact on global health policies and programmes affecting
women. Such a programme would coincide with the priorities identified at a 1991 meeting of the U.S.
National Center for International Health (NCIH):
1) compilation of gender-specific data;
2) an end to gender discrimination in health policy and action;
3) life cycle approach to women's health;
4) support for women's empowerment as personal and family health decision makers.
3.1 Key factors to be taken into account in the design of a Safe
Womanhood Research Programme
Any effective research programme dealing with Safe Womanhood would need to take into account
the following factors:
* Building on previous work;
* Enhancing health research capacity in developing countries;
* Participation of women at all levels;
* Community involvement;
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* Trans-disciplinary approach.
These factors are elaborated on below.
3.1.1 Building on previous work
The realization that more data is needed pertaining to gender-specific health risks is not new. Since
the 1970s and the United Nations Decade for Women, the need for better information on women has
received considerable attention from policy makers and researchers. The United Nations has issued a
number of publications which outline the use of social indicators to assess the situation of women.
[112] These documents, based on expert group meetings of researchers, producers and users of
statistics, argue that there is need for better statistics and indicators on women and women's health:
1) to accurately portray the situation of women and the differences in life circumstances for women
and men;
2) to identify problems and needs of population sub-groups;
3) to plan programmes that address those problems and needs;
4) to monitor and evaluate the effectiveness and differential impacts of policies and programmes;
5) to analyze the underlying determinants of gender differentials; and
6) to show trends in these differences over time.[113]
In spite of efforts to develop better statistics regarding the situation of women, analysts in the 1980s
observed that current statistical methods neglect low-income groups, particularly women, and
continue to underreport women's morbidity and mortality, as well as their economic contributions.
[114] The situation remains true in the 1990s. A substantial list has been generated of both general
health concerns and specific conditions that are neglected by a narrow focus on maternal and
reproductive health. Recently, the International Center for Research on Women has produced several
monographs on this subject[115] in which it identifies several heretofore neglected health concerns
for women:
* chronic conditions, such as cancer and cardiovascular diseases;
* sexually transmitted diseases and reproductive tract infections;
* female circumcision;
* domestic violence;
* nutritional deficiencies;
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* mental health and substance abuse;
* the health needs of older women; and
* occupational health.
The Pan American Health Organization's Regional Program on Women, Health and Development as
well as the Asia and Pacific Development Centre have identified a similar set of health concerns.
[116] The technical discussions at the 1992 World Health Organisation World Health Assembly
concerning Women, Health and Development resulted in the passing of a resolution calling for the
establishment of a Global Commission on Women's Health. Its purpose is in part to ensure that
women's health concerns are included in the United Nations Population Conference (1994) and the
United Nations Conference on Women (1995). The book Women's Health Across Age and Frontier
resulted from this meeting. [117]
Other initiatives in this area include the 1991 meeting of the National Center for International Health,
an International Conference on Women's Health.[118] A special issue of the IDS Bulletin appeared in
early 1992, entitled "Gender and Primary Health Care: Some Forward Looking Strategies". The
subject was also addressed in a recent issue of Social Science and Medicine on gender and health. In
it, Richters suggests that a narrow focus on maternal health
reproduces the belief that biological processes associated with reproduction represent the most
significant risk to women's health in developing countries and distracts the attention from other
significant health risks such as poverty, discrimination, humiliation, physical and symbolic violence,
sexual harassment and poor working conditions.[119]
3.1.2. Enhancing research capacity in developing countries
The building of indigenous capacity with respect to both research and policy formulation in the Third
World has been identified as central to the goal of improving health globally.[120] Several parallel
tensions exist. Frenk has identified the tension between "relevance" - investigation driven by needs of
decision makers - and "excellence" - research which adheres to the norms of scientific inquiry. He
suggests a new organizational response which reconciles proximity to decision making with
academic quality, using the example of WHO's decision-linked research.[121] In order to effectively
build research capacity, method must be grounded in theory, and indigenous researchers must be
trained in interpretation and analysis, not only data collection.[122] Women must be equally
represented in this effort.
3.1.3. Participation of women at all levels
Effective approaches to Safe Womanhood will require women's participation in a wide variety of
ways. A broader conceptualisation of women's health should, by definition, incorporate women's own
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perceptions and understanding of their health needs and the constraints they face in meeting these
needs. Effective women's health policy also demands recognition of women's overall roles and
responsibilities, including their involvements as producers, labourers, caregivers and environmental
managers, on one hand. On the other, they are also researchers, policy makers, and providers of
health services, whose perspective and influence can and does mobilize broader approaches to
women's and men's health.
3.1.4. Community involvement
A related and crucial concern is the involvement of local communities, NGOs and government
officials and their knowledge base. Important questions arise, however, in terms of the definition of
community. In this context the definition of community should be understood not only in
geographical terms. An understanding of the gender and other roles which are played out within a
community is a necessary aspect of effective health systems, so that involvement of communities
from the beginning, while difficult in presenting a particular set of methodological challenges, is
nevertheless essential.
3.1.5. Trans-disciplinary approach
As we have shown, the complex issues surrounding human health now demand an interdisciplinary or transdisciplinary - approach. We propose that Safe Womanhood efforts draw upon biomedicine,
epidemiology and social science to move well beyond selective, disease-based orientations into new
theoretical orientations and methodological approaches. The challenge is to create a new, perhaps
radical, conceptual framework that is part of an interactive process, with input not only from research
scientists based in the North but also from researchers, policy makers and communities where the
greatest health challenges remain, in the South.
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Safe Womanhood: A Discussion Paper
3.2 Towards a Safe Womanhood conceptual framework
Developing an operational definition of Safe Womanhood requires a new paradigm for health and
health science. This presents a major challenge and one that to be successful will necessitate major
intellectual effort, institutional commitment, political will and national and international attention.
The Commission on Health Research for Development has outlined some of the challenges
highlighting the concept of essential national health research.[123] Several large research and training
projects,[124] whose goals have included the building of indigenous capacity in the developing
world, are examples of a shift to a new vision. Safe Womanhood must be central to this new vision.
Biomedical researchers often note the crucial role of social, economic and political forces in
determining health. However, they typically characterise these forces as determinants beyond the
influence of health policy.[125] A preliminary step in addressing the critical influence of social
variables on health is understanding their impacts. Frameworks of analysis from the social sciences, e.
g. human ecology,[126]and political economy[127] can incorporate the study and definition of links
between the micro levels (of individuals, households and communities) and macro levels (of national
and international forces).[128] Pelto, in an analysis of these impacts, calls for new theory and
methods, but also outlines several techniques within a human ecology framework that can be used to
make these linkages, including disaggregation of national statistics, nested sampling, and
organizational analysis.[129]
Within the social sciences there is an increasing awareness that understanding the dynamics of what
is occurring in communities necessitates an approach that does not stop at the door step: elements of
intrahousehold dynamics are also an important part of health.[130] Manderson and Aaby survey the
increasing use of rapid assessment procedures in health research, noting the use of a growing list of
qualitative and quantitative techniques which rapidly generate biomedical and social science
information. They emphasize the need to develop more rigorous sampling practices within rapid
assessments.[131] Investigation of the intrahousehold allocation of resources is key,[132] keeping in
mind differences according to gender, but also those between women within the household.[133]
These examples serve to illustrate some of the many approaches that should be explored to better
understand women's health. Although researchers and policy makers alike might prefer a simple
cookbook approach to improving women's health, the complexity of the relationships between
biomedical and social variables suggests this is unlikely. However, a diverse array of successful
methods and techniques is already being used to address community development concerns within
the natural resource and health fields. Attempts to actively integrate biomedical and social science
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approaches with these methods are likely to produce additional fruitful developments: improved
health outcomes as well as theoretical and methodological advances.
We do not underestimate the difficulties of this synthesis, especially when combined with efforts that
both recognize the value of comparative approaches and that also seriously address the need to build
research capacity within the developing world, but it is essential if the challenges are to be met.
3.3 Towards a set of Safe Womanhood indicators
A key ingredient in a long-term effort to improve women's health is a set of quantitative "outcome"
indicators of Safe Womanhood. These are necessary for several reasons:
* As a means of focusing the attention of decision-makers;
* As a means of evaluating the results, over time, of Safe Womanhood initiatives;
* To assist in identifying resource allocation priorities.
There are two alternative approaches. One is to focus on developing a comprehensive framework of
Safe Womanhood indicators covering the entire life cycle as discussed in this paper. While one might
develop a comprehensive framework of Safe Womanhood indicators covering the entire life cyle
"from scratch", it makes more sense to develop a set of internationally-comparative indicators based
on existing health data, and expand the set to include a full range of Safe Womanhood indicators as
additional data becomes available. We recommend the latter approach.
Therefore, we would propose to concentrate the initial efforts of the Safe Womanhood Programme on
establishing a method for analyzing women's health issues through the development of an
international comparative method for the analysis of existing health data (World Health Organisation,
UNFPA, national governments, etc.). This approach would build on existing U.N. and national data
within a broader vision which incorporates the multiple factors affecting health. In this way a core
framework of globally relevant indicators can be constructed that will allow regional and crossnational analysis, complemented by additional locally identified indicators.
Policy indicators for national and international levels could then be arrived at and made accessible to
policy makers. For example, the number of deaths of women from smoking-related diseases is rising
dramatically, especially in the developing world, but data relating to this is uneven or missing in
many cases. Policy initiatives cannot therefore be sufficiently refined to have the most efficient
impact.
There has been considerable discussion concerning the value of broad international comparisons of
health indicators. The problems with aggregate indicators based on uneven data are well known.
However, their utility in understanding changes in the cause of adult death has been illustrated.[134]
The indicators used and methods developed must be sufficiently flexible to be applied at various
geographic levels of analysis. They must also be sufficiently flexible to include local perceptions of
health and disease. We anticipate that a core set of indicators would be expanded according to the
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unique sets of circumstances extant in different regions; they would hence have locally applied value
with respect to both policy and programme formulation and evaluation.
A great deal of the data to be incorporated into an evolving Safe Womanhood framework may
already exist, some of it not having been considered as measures of health status according to
traditionally-held definitions. Obviously, sources of great potential include vital statistics and health
surveillance data. While data on health service utilization must be used with caution, because at best
it provides information only on illnesses for which individuals seek treatment, it is an important and
available source of information which is often under-utilized.
As we have shown, a Safe Womanhood framework must be flexible enough to incorporate measures
not typically related directly to health status. To date, many sets of quality of life indicators have been
proposed or are in use. Composite indicators (e.g. Quality of Life (QLI), Human Development Index
(HDI)) are particularly problematic, and we are not proposing a single Safe Womanhood "index".
Instead, a key set of indicators (that will be modified over time) should be identified. Mortality data,
which is most easily collected and recorded, will be a starting point, but in itself it reveals only a
narrow slice of the risks to women's health and even less about how to ameliorate them.
Understanding gender differences in levels of health and utilization of health care will necessitate the
utilization of methodologies being developed by economists, sociologists, nutritionists and others, in
order to understand resource allocation within families. There is much that can be learned in looking
at how morbidity relates to available measures of mortality differently for women and for men. The
lack of unambiguous data on female morbidity and mortality makes it difficult to identify and assess
the factors, environmental or otherwise, that do affect women's health. Alanagh Raikes, writing about
women's health in East Africa, suggests that one useful starting point for an improved understanding
of factors relevant to women's health would be to analyse existing morbidity data by geographical
region and gender specificity. However, as Raikes points out, morbidity data is often not good
enough to allow for this breakdown. Not only are the data lacking in gender specificity, but their
overall accuracy is often grossly inadequate as well.[135]
Therefore, included in the methodological challenges that must be addressed will be the identification
of useful measures of morbidity as well as methods to relate utilization data to actual health status.
One obstacle to the compilation of data is the fact that in many low-income countries, even
information regarding cause of death is incomplete and often inaccurate. Although the use of
mortality data by cause introduces a degree of subjectivity and uncertainty, it provides considerably
more information about health and disease in populations. Some, but not all, morbidity is captured in
mortality data, and is extremely difficult to measure adequately even in the developed world.[136]
Methodologies will first need to be developed to identify the kind of morbidity data which will be
most useful and also to explore how it relates to more available mortality data.
The acknowledgement that conventional economic indicators are not adequate measures of
development has led to an increasing focus on generating quality of life indicators within the
international research community. Since the 1985 UN meeting on Women in Nairobi, quality of life
indicators for women have received special attention (e.g. United Nations Department of
International Economic and Social Affairs; Population Crisis Committee; and the Population
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Council); typically these include measures related to health status. Furthermore, in national vital
statistics, in mortality by cause and morbidity reporting, and from surveys and in-depth research in
selected areas, considerable additional information is available. Surprisingly perhaps, with respect to
women's health this interest is only beginning to be translated into action in the international arena.
How do we define women's health? How do we measure it? How do we improve it? Sociocultural
norms, household economics and community development have been identified as key components
of the health transition[137] - how can we measure these? What can they tell us about women's
health?
Where they are available, it is interesting to see what commonly used statistical indicators of
women's well being actually measure.The World's Women, which was compiled from a variety of UN
sources, provides measures of life expectancy, maternal mortality, infant mortality, male and female
child mortality, fertility, contraceptive use, availability of trained birth attendants, and smoking rates.
Domestic violence is reported in a section separate from health. Such indicators tell us very little
about women's non-reproductive well being.
Identifying appropriate quantitative indicators of women's well being is not an easy task. As Payne
suggests:
at the centre...lies the fundamental problem of what is meant by health, how this varies...and how to
reconcile the divide between positive concepts of health as more than an absence of illness, and the
necessity of relying on the only regularly-produced statistics which measure rates of death and
sickness rather than health.[138]
How can "positive concepts of health" be identified and measured as indicators of women's well
being?[139] The NCIH guidelines suggest some qualitative indicators of women's well being. Among
these would be the proportion of decision making roles in health assessment, promotion and
expenditure by women.
The challenge is not to stretch women's extraordinary coping skills past the limits of their mental and
physical health. Instead, "we need more and better studies on the...effects of women's help-giving...as
others rely on their strengths...to the detriment of their own well being, including burnout, a form of
physical and emotional exhaustion."[140] From this point of view, the amount of leisure time
available to women, both in number of hours and in comparison with men, is also a potentially
important qualitative indicator of their well being.
While much undifferentiated (or gender-blind) data exists, new conceptual frameworks and new
methodologies are needed to advance the cause of women's health. The availability of existing data
must be assessed and methodologies "revisioned" to allow a synthesis of biomedical, epidemiological
and social sciences approaches, moving towards what Rosenfeld has described as a transdisciplinary
theoretical framework.[141]
Although she was speaking specifically of population and family planning, the comments of Nafis
Sadik, Executive Director of the United Nations Population Fund, are equally relevant for women's
health in its broader definition:
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Safe Womanhood: A Discussion Paper
Progress has been made...However, much more needs to be done. Increased efforts are required to
ensure that the collection, analysis and dissemination of data are disaggregated by gender. Accurate
indicators of the actual situation of women in specific areas are urgently needed. Only with this type
of information can policies and programmes that are intended to improve women's situation and
increase their participation in development efforts be planned, and progress measured.[142]
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Safe Womanhood: A Discussion Paper
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3.4 Towards a series of Safe Womanhood case studies
In parallel with efforts to develop internationally comparable Safe Womanhood indicators, we
propose a set of Safe Womanhood case studies, to be undertaken in a number of locations around the
world. The case studies would serve several important purposes:
*To explore the "life cycle" data that could be collected to expand Safe Womanhood indicators
beyond an initial set, which will be built primarily on existing health data;
*To examine specific initiatives to improve women's health in a regional and community context, to
identify specific examples of initiatives that have been successful in improving women's health, and
to analyse the implications for policy;
*To explore and further develop the Safe Womanhood conceptual framework.
Regional and area-integrated studies of life cycle health would be based primarily on existing health
care facilities and systems in developing countries. There are, however, areas such as Sioux Lookout
in Canada in which a great deal of mortality and morbidity data for indigenous communities has been
generated, but which needs further analysis in order to be useful for policy. In short, a key outcome of
anticipated studies will be data analysis in forms useful for policy and decision making.
Based on the results of this first wave of studies, the usefulness of the first set of indicators would be
assessed and revised as appropriate, and the quantity and quality of data currently available would be
identified. Recommendations would then be developed regarding additional data collection projects
and/or the development of a programme for assisting national and international statistical agencies to
amend their approaches to the gathering and interpretation of health data.
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Safe Womanhood: A Discussion Paper
List of Acronyms
APDC Asia and Pacific Development Centre
BRAC Bangladesh Rural Advancement Committee
FAO Food and Agriculture Organisation
GSD Gender, Science and Development Programme
ICRW International Center for Research on Women
IDS Institute for Development Studies, University of Sussex
IFIAS International Federation of Institutes for Advanced Study
IFPRI International Food Policy Research Institute
ILO International Labour Organisation
NCIH National Center for International Health
NGO Nongovernmental organisation
PAHO Pan American Health Organization
STD Sexually-transmitted disease
UNDP United Nations Development Programme
UNEP United Nations Environment Programme
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
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Safe Womanhood: a Discussion Paper
UNIFEM United Nations Fund for the Development of Women
USAID US Agency for International Development
WHO World Health Organisation
WINAP Women's Information Network for Asia and the Pacific
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