So many like her

So many like her Throughout the world, at national, regional and inter- national levels, planners are now developing strategies for achieving Health for All by the Year 2000, so as to ensure that "every citizen can lead a socially and economically productive life" . These strategies will vary according to the different health problems and priorities of the population, and will depend on each country's natural and man-made resources, and other factors. Looking ahead to the year 2000, we can hope to hear success stories of diseases eradicat- ed, and death rates falling rapidly. But those stories alone will not mean health for all. Approximately 125 million babies are born each year- indeed it is estimated that one-third of the population in the year 2000 has yet to be born! Millions of women in developing countries are preg- nant for a significant proportion of their adult lives. In countries like India, Indo- nesia, Mexico, Brazil, Nigeria and Morocco , these women on average give birth to a live child seven or eight times, while perhaps four or five pregnancies are never completed. In many countries, one fifth of adult women are pregnant at any given time. For these women, pregnancy and childbirth may be hazardous events . Al- though death rates from maternal causes are not well calculated in many coun- tries, we do know that in some areas they are over 100 times the rates of some developed countries. In some places, the rates may be over 500 per 100,000 live births, and rates over I ,000 per I 00,000 are reported in parts of Africa . Illegally- induced abortion contributes to a large extent; in Latin America it is thought to be the cause of between one-fifth and one-half of all maternal deaths . In areas such as Africa and South Asia, about half a million women die every year from causes related to pregnancy and child- birth. That so many women are dying in In many parts of the world, as here in West Africa, women not only rear the children and do the housekeeping, but they do most of the work on the land too . ( Photo WHO/ UN/FAO/G. Tortoli ) by Vicki Hammer childbirth or from illegally-induced abortions is tragic. But it is only one part of the picture. The health problems of those surviving are tremendous, affecting all aspects Of their health, and that of their children, for a very long span of time during their lives. A rural profile To illustrate this, let's look at a wom- an in a rural village and draw a profile of what her health state might be, and how pregnancy and childbirth have affected her. She's 35 years old. When she was born, her mother was malnourished and over-worked ; she was very small and low-weight at birth ; she grew slowly. During childhood she had little good food to eat- even less than her brothers. She was malnourished or undernour- ished most of the time. She could not go to school, as her brothers could, but remained at home with her mother to help with the housework and child- minding. When she became an adolescent, her pelvic bones were misshapen, and she was shorter in stature than might have been expected. As was the tradition, she was married early, and had her first baby when she was only 14, even before she had fully developed. It was a difficult birth, but she survived. Her second preg- nancy was aborted spontaneously. It was a painful event ; she was tired and weak afterwards. Her many subsequent preg- nancies occurred often, with little time in between to recuperate- to regain her strength or to replenish her body. On one delivery, she had so much bleeding that everyone was afraid she would never recover, and she had a high fever for days . She's been anaemic ever since, a condition aggravated by the hookworm she carries . During another pregnancy, she suffered a malarial fever , and abort- ed. During later pregnancies her nutri- tional state was very poor, and her fati- gue was draining her. She had so much work- with her children, keeping up the household, fetching the water, working in the local brick factory- she began to dread the next pregnancy. When it came, she went to a woman in the village for something to end it. She was very sick, but it worked. She breastfed all of her children, but many times it was difficult and tiring. Once, in order not to lose her job at the brick factory, she bottle-fed her infant. She didn't have enough money to buy enough powder so she diluted the little she had and her eldest daughter had the job of giving the bottle to the baby. - The baby died at four months, from diarrhoea. Like her mother before her, she never went to a health centre when she was pregnant. It was too far away and too foreign. She used the same traditional birth attendant (TBA) who delivered her and who helped her sisters. The TBA, un- aware of the importance of cleanliness, used a bamboo blade to cut the umbilical cord, and her unclean hands to extract the placenta. Thus, she suffered serious infections after childbirth . Though she survived those episodes, today, at 35, she still feels dull pains and soreness in her " belly" which flare up from time to time. During her rare menstrual periods she doesn ' t experience too much pain, but she is anaemic, and sometimes there is infection because she's not able to use clean enough "protection". Also, after so many pregnancies, she probably has a partial prolapsed uterus, which often causes her strong discomfort, especially after a hard day's work carrying bricks or large urns of water. Despite all her hours of work at the factory and helping the family working in the fields, there's never been enough food around. She does all she can to pre- pare the family's meals, but her husband and children must have the most, and she will manage. She is malnourished. She is a woman who cares desperately about her family and wants to limit her pregnancies. She heard about family planning from her sisters, but was always too afraid of her husband , who would never allow it. What would people think if she had no more babies, especially af- ter her last son died? Despite these fears , she once got some contraceptive pills, yet she felt so nauseated and had so many headaches (this was surely a punishment, she thought), that she stopped . This sketchy picture of one archetypal woman's health doesn 't make too many 33 headlines, and no one takes account of her pains from the infections that persist, from the prolapsed uterus, from the anaemia and malnutrition. No one pays much attention to her fatigue. She doesn't go to the health centre to com- plain about them- after all, that's nor- mal. But the next time she aborts, or the next time she is pregnant, she may die. The next time, the dull pains from infec- tion may not subside but may become an acute case of pelvic inflammatory disease ; there will be no surgeon to save her life. How does such a woman fit into strategies for health for all? What does primary health care mean to her, or to her daughter, already pregnant for the first time? From the point of view of WHO's pro- gramme approaches, strategies for health for all will mean a new kind of health care for mothers. Maternal care within primary health care (PHC) will respond to women's total needs and problems. It can no longer be considered a special ser- vice, treating each pregnancy as if it hap- pens in isolation, divorced from the real world in which they live or unconnected with the other aspects of their health and that of their children or family. Care has to have continuity throughout the whole cycle of growth, development and repro- duction , and must ensure that families have contact with PHC workers on a reg- ular basis. It will mean a health care for mothers and children very different from the old-style basic health services, when the maternal and child health (MCH) clinic m(ght only open its doors in the morning (when women are working the hardest), and then only a few times a week. MCH care in primary health care encompasses all levels of activities-in the family, the home, the community and the health facility. It is not a service delivered to mothers and children, and delivered by health professionals only. Left: Work which in some countries would be regarded as heavy manual labour and there- fore reserved for m en, is often cheerfully undertaken by women- like these building workers in India. If in addition to this work a woman must also care for a growing family and look after her husband and her home, she will begin to dread the next pregnancy. Facing page: Again in India , a traditional midwife examines a mother-to-be. Many countries now train their traditional birth attendants in the use of hygienic procedures and techniques to prevent infection. Such women can then play a positive role in reducing the mortality and morbidity within their community. (Photos WHO/ILO and WHO/A.S. Kochar) The fact is that women have always been the main health care providers throughout the world; what they do in the home for themselves and the family constitutes the bulk of MCH care activi- ties. Primary health care, however, does not mean merely giving recognition to this fact ; it means that support is given through intensive education and infor- mation to families-women , men and children- about healthy practices, mak- ing the technical knowledge available that was previously kept "behind closed doors". Women are not passive targets ; nor are they just mother-carers in the home. The participation of women and wom- en's organizations as partners in commu- nity health actions is crucial. In India and Bangladesh, the community-based, women-to-women networks are seen as effective ways to provide family planning information , supplies and follow-up sup- port. Mothers ' clubs in Korea are active family planning and MCH care " provid- ers". Women from the National Union of Women in Mali , from the women 's organizations in Samoa, and so on, are part of the communities' cadres of primary health care workers. MCH care will not require intricate fetal monitoring machines and wires; it will not include potent drugs to induce labour, or anaesthesia during normal deliveries. MCH care will include those tools and actions which aim to prevent problems, which are suited to people's culture and life-style ; and which can ef- fect appropriate treatment when needed . Many methods of MCH care rely on the sound practices of tradition . Perhaps ironically, scientific research has only recently begun to "prove" their effective- ness . For example, recent research in ob- stetrics now concludes that the sitting or squatting position for delivery that is common to many traditional societies is better than the lying-down position- a position encouraged by male obstetri- cians since childbirth became. a medical specialty in the 18th century. In 1979, during a symposium on "Recent Prog- · ress in Perinatal Medicine", there was agreement that women who were either walking or sitting at the beginning of labour, and in a sitting position for deliv- ery, had a considerably shortened labour period in comparison to those women who remained lying down. Also, the research showed that babies born of women who had been in a sitting posi- tion had better oxygen levels. Techniques for monitoring pregnancy are promoted through health educa- tion- techniques which can best be done by women or families themselves. In China, in a recent Shanghai programme, fathers and mothers were taught how to keep a check on the progress of the preg- nancy through regular physical measure- ments of the height of the uterus, listen- ing to the fetal heart beat, and counting the number of kicks of the fetus at regu- lar times during the day. Village health workers in Malaysia and local midwives in Turkey are being trained to identify risks, so that those women with potential problems can receive the special care they may need. In many countries, tradi- tional birth attendants are being trained in techniques to prevent infections (such as using clean instruments), how to avoid excessive bleeding, and how to observe hygienic procedures. Other technologies such as immuniza- tions and family planning are preventive, future-oriented actions which can have a great impact on reducing mortality and morbidity among women and children. MCH care in primary health care is not limited to actions of the health system. Educational and literary programmes, for instance, have been important health vehicles. Improving women's nutrition before and during pregnancy and while breastfeeding requires action in all spheres, including the agricultural, in- dustrial , educational and other sectors. Several programmes in countries such as Botswana, Kenya and Ghana have shown that with support from agricul- tural extension workers and credit facili- ties, women's groups have been able to improve their food production, with pos- itive effects on their personal income and on their nutritional status. Improving maternal nutrition , howev- er, involves more than increasing food intake. Energy expenditure is also part of nutrition and is especially important dur- ing the last three months of pregnancy. The workload of women, particularly in developing countries, leaves little time for rest at such times. While maternity leave has been instituted in most devel- oped countries, in most developing coun- tries legislation and resources are lack- ing ; and the feasibility of applying this type of measure for most of the women who need it is questionable. In this issue we ·have looked at just a few aspects of health in just a few regions of the world. The scale of operations which will slowly but surely carry the Member States of the World Health Organization for- ward towards the goal of Health for all can hardly be expressed in a sin- gle issue of World Health. In the months to come, we will return again to other aspects of public health, including the role of research and its application in pro- motion of primary health care, and further examples of how health ser- vices can be successfully provided to millions who at present have ac , cess to no care of any kind . Since 1981. is the International Year of Disabled Persons, we shall also return to the subject of preventing disabling diseases and injuries, and of rehabilitating those who already suffer from physical and mental handicaps. Educational programmes are needed to change attitudes about women's workloads (including household work, h~alth care and childrearing) so as to bring a better balance and sharing of re- sponsibilities and tasks between women and men . New ways to support commu- nity networks for the day care of children should be found. These, as well as other community-based social measures that are appropriate to local situations, have to be promoted as part of M CH care to support women and to ensure that they, together with men , " lead a socially and economically productive life" in the year 2000. Such measures will represent an investment in both the present and future generations. • 35