Abstract: Health is a basic human right/women’s right. Attainment and maintenance of good health depends on women’s access to nutritious food, appropriate medicine to treat illness, clean water, safe housing, pollution-free environment and timely health services. Women’s health is determined by the forces working at homes, work-places, society and the state. To address the problems concerning women’s health, a holistic life span approach is needed. Women as human beings, home makers, workers, mothers and elderly citizens face different types of health related issues. Women’s health is determined by the material reality generated by socio-economic, cultural forces as well as gender relations based on subordination of women. Improvement in women’s health is a pre-condition for development of her family.
Keywords: reproductive heath, sex preselection, female foeticide, selective abortion, sexual violence, domestic violence, early pregnancy, contraceptive methods, reproductive health services, fertility rate, low birth rate, maternal mortality
World Health Organisation has defined health as “a state of complete physical, mental and social well-being” which is necessary for leading a productive and fruitful life. Health is a basic human right/women’s right. Attainment and maintenance of good health depends on women’s access to nutritious food, appropriate medicine to treat illnesses, clean water, safe housing, pollution-free environment and timely health services. Thus, women’s health is determined by the forces working at homes, work-places, society and the state. According to Dr. Amartya Kumar Sen, “Burden of hardship falls disproportionately on women” due to many types of inequality- mortality (due to gender bias in health care and nutrition), natality (sex selective abortion and female infanticide)), basic facility (education and skill development) special opportunity (higher education and professional training), employment (promotion) and ownership (home, land and property) (Sen 2001).
Balanced diet containing carbohydrate, protein, vitamins and minerals make a healthy body and healthy mind. Only 10% of women are fortunate to have the privilege of nutritious diet. Majority of women in our country work more than men and for longer period but eat less, the last and the leftover of poor quality food. Their energy expenditure is not compensated by intake of diet as it is inadequate and lacks in nutrition. India has the highest prevalence of iron deficiency anaemia in the world. 87% of pregnant women, about 68% in the reproductive age group and about 60-70 % of adolescent girls in our country are anaemic (Institute of Health Management 2002). This is the major reason for high level of morbidity among Indian women. The Government Organisations (GOs) and Non government Organisations (NGOs) need to make a concerted effort to provide iron rich and vitamin C rich low-cost and locally available foods to women through active nutrition education and change in dietary habits.
Women-specific common illnesses are aches/pains (back, head, stomach, uterine), weakness, fevers, respiratory problems, gastro-intestinal problems, skin, eye, ear problems and reproductive problems such as reproductive tract of infection, white discharge, endometriosis etc. CEHAT study reveals that morbidity is much higher among women than men (Sunil Nandaraj 2001) . Middle-aged women have arthritis, menopause related hot flushes and uneasiness , osteoporosis, migraine and swelling of legs.(Grewal and Purohit 1994) In both, rural as well as urban areas, proportion of physical immobility is higher among elderly women than elderly men.(Mishra 1999).
Women are the last ones to be taken to a doctor and they have the least access to rest, healthy recreation, exercise and sports. All these combined together aggravate the situation and further deteriorate women’s health.
Availability of Health Care
Women avail four types of health services. First of all, the majority of women try home remedies, failing which they approach either a homeopath, ayurvedic doctor, unani healer or the allopath. Those who can’t afford private practitioner’s fees go to a trust-run clinics/hospitals, government hospitals or Primary Health Care Centres (PHCs) or lastly the health care facilities provided by the non-government organisations. During the last decade, yoga, meditation. , (Krishnan 1998, 42) reiki, aerobics have become extremely popular among the middle and upper class educated women (IMA 1999) , while the poor women approach witch doctors (Source: Census of India, 2001).
Attitude Towards Women’s Health
The segment of women in total population is note worthy. Yet the social discrimination against women results into systematic neglect of women’s health, from womb to tomb. Female infanticide and female foeticide are widely practiced in Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh, Punjab, Haryana, Himachal Pradesh and Gujarat states (Bose 2001). As per 2001 census, there were only 933 women per 1000 men and there was a deficit of 3.5 crore women in a total population of 102.70 crores. Sex-ratio is the most favourable to women is Kerala 1058. But, in Kerala also, in the 0-6 age-group , the sex ratio was 963, as per 2001 census (All India 927). The total 0-6 age-group population of Kerala was 36.5 lakhs. Out of this 18.6 lakhs were male babies and infants and 17.9 lakhs were female babies and infants. Thus, 79760 female babies and infants were less in 2001 in Kerala (61 lakhs in India). This masculinisation of sex-ratio is as a result of selective abortion of female foetuses after the use of ultra-sound techniques to determine sex of the foetus (Eapen and Kodoth 2001).
As a result of sex-determination and sex-preselection tests, sex ratio of the child population in India as a whole has declined to 927 girls for 1000 boys. Sixty lakh female infants and girls are “missing” due to sex-selective abortion of female foetuses and pre-conception rejection of daughters.
To stop female infanticide, the Tamil Nadu government introduced ‘Cradle Baby Scheme’ urging parents to leave their unwanted baby girls at cradles provided in hospitals, primary health centres and orphanages and encouraging them to take them back when they change their minds (Sreedhar 2001 10-12).
Negative attitude towards women’s health is the major reason for high levels of prenatal mortality and morbidity including low birth weight babies (Wal and Mishra 2002 254-55).
Vicious Cycles and Poor Women
The vicious cycles of poverty generates the vicious cycle of ill-health. For the mother, poverty leads to low intake of food and nutrients, which results in under-nutrition and repeated attacks from nutrition related diseases and infections, which affect them in terms of stunted development and growth. Hence they have small body size as adults, which impairs productivity; as a result of which they have low earning capacity. The end result is POVERTY. For a girl child, poverty gives only three options-child labour, child marriage and child prostitution. Poverty coupled with control over women’s sexuality, fertility and labour is manifested in neglect and discrimination of a girl child. She remains a malnourished girl. Early marriage results in early pregnancy. She becomes an impoverished mother who produces low birth weight baby (Sharma 2001 18,19). If the baby is female, she faces discrimination, repeated pregnancies/ deliveries to get son which results in maternal mortality i.e. DEATH (Arrow for change 2001). Miserable profile of reproductive health of Indian women is due to the octopus clutches of early marriage and pregnancy, high prevalence of reproductive tract infection, ignorance, high infant mortality rate, non control over fertility and sexuality, anaemia, and repeated pregnancies. As per UNICEF, in 1995, there were 453 maternal deaths per 100000 births in India. (738 in Orissa while in Kerala which had 8, is the lowest). Nutritional needs of lactating mothers demand urgent attention.
Violence and Health Issues of Women Over the Life Cycle
As unborn children, they face covert violence in terms of sex-selection and overt violence in terms of female foeticide after the use of amniocentesis, chorion villai biopsy, sonography, ultrasound, imaging techniques.(Vibhuthi Patel, 1992, 9) IVF (In Vitro Fertilization) clinics for assisted reproduction are approached by infertile couples to produce sons. Some doctors are advertising aggressively, “Invest Rs. 500 now, save Rs.50000 later i.e. if you get rid of your daughter now, you will not have to spend money on dowry.
As girls under 5 years of age, women face neglect of medical care and education, and physical violence. As adolescent and adult women in the reproductive age-group, they face early marriage, early pregnancy, sexual violence, domestic violence, dowry harassment, infertility, if they fail to produce son, then face desertion and witch hunt. The end result is a high maternal mortality. Causes of maternal deaths in our country are haemorrhage, abortion, infection, obstructed labour, eclampsia (blood pressure during pregnancy), sepsis, and anaemia.
Escalating number of cases of domestic violence, dowry deaths and bride burning have motivated Mumbai Municipal Corporation (MMC) run K.B. Bhabha Municipal General Hospital to collaborate with an NGO, CEHAT to launch a project Dilaasa (means reassurance) to provide social and psychological support to women facing domestic violence. On March 8, 2002, the process has begun to replicate this model in all BMC run hospitals in the Greater Mumbai. Sexual harassment at work-place should be treated as an occupational health hazard as it causes damage to both the physical and mental health of women. Even women in the medical profession- right from medical students to other women health workers face this problem (Thelma Narayan 2002).
Home and Work Conditions Affecting Women’s Health
Pollution of air and water, noise pollution and chemicalisation of environment affect everybody. Scarcity of fuel-wood, fodder, water and herbs as a result of deforestation has taken heavy toll of women’s health. Rural and tribal women have to walk for miles for these basic survival needs of human beings and domestic animals. Floods create deaths, destruction and epidemics. Desertification in Western India has accentuated women’s survival struggles, as they have to depend on adhoc public works programmes. Global warming has resulted in resurgence of old epidemics such as cholera, typhoid, malaria, dengue and haemorrhagic fever. Burgeoning sex-trade has made 2 million sexworkers potential carriers of HIV, STD, AIDS. Moreover, women in prostitution may suffer from T.B., other STDs, malnutrition, malaria and skin diseases (Fernandes and Ray 1991.75). At present, there is an evidence of rising HIV rates among young married women who are infected by their husbands. Data from 7 cities in India of ante-natal clinics reveals that HIV-AIDS prevalence rates among pregnant women are 2% to 3.5 % in Mumbai and 1% in Hyderabad, Bangalore and Chennai (Khan 2001.7).
Modern lifestyle and environment have increased breast and uterine cancer among Indian women (Wal 27-30). Techniques meant for detecting cancer (e.g. self-examination of breast and pap- smere) are rarely used by women. As a result, detection of cancer and its treatment at earlier stage become impossible.
All types of fruits are cornered by liquor industry and alcoholism is aggressively promoted among the toiling poor. As a result, men don’t contribute for the daily necessity of the households. Women have to shoulder the major burden of household expenditure. Use of bio-fuels- wood, dung, crop residue resulting in indoor air-pollution takes away the lives of 5 lakh women annually (Gopalan and Shira 2000.213).
Women and Mental Health
The most neglected area concerning women has been her mental health. Stress generated due to major life events such as break-up of marriage, widowhood, illness in the family, financial hardship and abuse destroy an individual’s ability to cope with and function effectively (Nair and Nair 2002). Suppression of the extremities of an abusive relationship results in acute mental stress and trauma. In countries like India, economic dependency along with social and financial pressures trap women in abusive relationships, both physical and mental, forcing them to hide their anguish. Social workers and psychiatrists are approached by husbands to issue “mentally unfit” certificates so that they can flash them in a court of law to demand divorce. Relatives do not want to keep mentally ill women in the family. Even after their recovery, they have to languish in the mental asylum. There is a need for half-way-homes where mentally ill women can work for a few hours under the supervision of a couple of professionals and then go home in the evening. Psychotherapy, mutual and group counselling should be promoted. Shock therapy and chemical treatment should be avoided as it cabbagifies women in distress.
Health Care Facilities for Women
As women are perceived as mothers, not as individuals in their own right, they are covered under MCH (mother and child health programme). Even MCH does not cover the majority of Indian women. Only 49.2 % of total pregnant women received ante-natal check-up by health professionals. Health workers visited only 21% of pregnant women. Tetanus toxoid coverage of pregnant women was 53.8% and Anaemia prophylaxis coverage among pregnant women was 50.5% (Times of India 2002). The majority of Indian women are left with no choice but than to deliver at home (Institute of Population Studies 1995). Every 5000 population has an auxiliary nurse midwife (ANM) with responsibility to attend childbirth. Only negligible parts of home-births are attended by ANMs ( Sen and Kumar 2001.37). Institutional deliveries constituted only 22 % of total deliveries at the national level. Urban areas were better covered: 55 percent as against a very meager 18% in rural areas (Ashtekar, n.d.198).
New Reproductive Technologies (NRTs) and Women
NRTs perform 4 types of functions. In Vitro Fertilisation and subsequent embryo transfer, GIFT (Gamete Intra Fallopian Transfer), ZIFT and cloning assist reproduction (Registrar General 1997). Contraceptive Technologies prevent conception and birth. Amniocentesis, chorion villai Biopsy, niddling, ultrasound are used for prenatal diagnosis (Nandekar& Roy adhyaksha 1995). Feotal cells are collected by the technique of amniocentesis and CVB. Gene technologies play crucial role through genetic manipulation of animal and plant kingdoms (Patel 2000 1818,1819). Genomics is “the science of improving the human population through controlled breeding, encompasses the elimination of disease, disorder, or undesirable traits, on the one hand, and genetic enhancement on the other. It is pursued by nations through state policies and .programmes” (Gupta 2000).
It is important to examine scientific, social, juridical, ethical, economic and health consequences of the NRTs. NRTs have made women’s bodies site for scientific experimentations.
Current Use of Contraceptive Methods
Majority of population in our country (52%) is not using any contraceptive methods for birth control. Female sterilisation is most widely prevalent method of contraception (34%). Usage of Pill, Intra Uterine Device (IUD) and male sterilisation is 2% for each of the three. Condom use constitutes only 3% of the total (Lenz 2002 146-49). The rest is accounted by traditional or other method.
Contraceptives targeted at women, with serious side-effects are quinacrine, Net-en, Norplant, Depo-Provera, anti fertility vaccine and, RU 486. Side effects of long acting hormonal contraceptives are menstrual disturbance, circulatory and cardio-vascular problems, thyroid, chest-pain, giddiness, migraine, increased risk of cancer and infertility (National Family Health Survey 1998-99). Aggressively promoted HRT (Hormone Replacement Therapy) i.e. oestrogen therapy for menopausal women has generated opposition as several studies have shown that HRT has carcinogenic implications for women (Chayanila et.al 1990). The modus operandi of contraceptive research in the Asian countries is treating coloured women as raw material for experimentation for eugenics.
Women resort to abortion when faced with unwanted pregnancy due to failure of contraceptives or due to non-utilisation of contraceptive methods. As per UNICEF, 1993, about 50 lakh abortions are performed under the health services network while 45 lakh by the illegal practitioners/quacks. 10% of all maternal deaths are due to unsafe abortion, which results into haemorrhage, infection, incomplete evacuation, cervical lacerations, uterine perforations, thromboembolism and anaestheticcomplications(Sellman 2001). “A spontaneous abortion often results in severe blood loss and is therefore considered very harmful as it can cause anaemia and weakness. It is ironical however, that though spontaneous abortions are considered serious, they are so much a part of women’s lives that nothing much is done about them” (IPPF Medical Bulletin, 2001).
The focus of health programme should change from a population control approach of reducing numbers to one that is gender-sensitive and responsive to the reproductive health needs of women/ men. Women groups have raised a hue and cry against sexist, racist and class biases of the population control policy, which perceives uterus of coloured women as a danger zone. They have opposed genetic and reproductive engineering, which reduce women to reproductive organs and allow women being used as experimental subjects by science, industry and the state (Choudhary and Roy, 1997). They believe that instead of abusing reproductive biology, responsible reproduction is an answer to overpopulation and infertility. Any coercion, be it through force, incentives or disincentives in the name of population stabilisation should be rejected. Instead enabling women to have access to education, resources, employment, income, social security and safe environment at work and at home are preconditions to small family norm. Reproductive Rights of Women which guarantee women healthy life, safe motherhood, autonomy in decision-making about when, how many and at what interval to have children are a central axis around which a discourse on population policy should revolve. Several groups have prepared manuals to assist women leaders to reach out to poor, illiterate women and teach them about fertility and infertility, giving them knowledge of their anatomy, to teach women to use fertility awareness as a means of family planning and to use natural family planning as an entry point to women’s health and development (FINR RAGE 1989).
Scientifically accurate books for sex-education and fertility awareness are now available (Samooh 1995). Sex education for women becomes meaningful only when it is linked with for assertiveness training. Girls and women who are unable to handle gender-based power relations end up as victims even after receiving thorough physiological, anatomical, scientific and medical details of sex-education (Nandekar and Rajadhyalsha, 1999).
Women, Health and Law
Medical Termination of Pregnancy (MTP) Act (1972) stipulates that only trained doctors are eligible to conduct abortion in registered clinics. Prenatal Diagnostic Techniques Act (1994) prevents the use of ante natal sex determination tests for selective abortion of female foetuses. CEHAT has filed a petition in the Supreme Court of India for effective implementation of the Act as well as to expand the scope of the Act to cover sex-preselection (preconception) techniques in its purview.
Women’s groups in Delhi and Hyderabad have jointly filed a petition in the Supreme Court of India against human trials of injectible contraceptives (Sabala and Krant 1995). The Lawyers Collective HIV/AIDS Unit helps many infected women who are abandoned by their families after the death of AIDS afflicted spouse, denied rights to marital home and custody of their children (Streevani 1991-94).
For sensitive handling of medico legal dimensions of sexual violence, rape, molestation, assault, dying declaration of the women victims of poisoning, burns and attempted suicide, the doctors, nurses, other health care workers and special executive magistrates need to be trained, as evidences of medical examination play important role during the court proceedings and the final judgement. Women’s organisations have prepared an exhaustive code of conduct for the doctors, police, lawyers, special executive magistrates and social workers for recording of dying declaration (Lawyers Collective 2001). Medical kit for examination of victims of sexual violence has been prepared by CEHAT (Sakhya 2002). There is a need for medical kit for examination of women under-trials whose death occurs in police custody or jail to ascertain the nature of torture (D’Souza 1997).
There is a need to situate women’s health in the overall macro parameters (Lingam 1998). Gender divide in the access of health care and health cost is so sharp that women have to access informal providers and informal care. Gender audit in health should be done on the basis of identifying issues for reorientation at each stage of women’s life cycle and focussing on the problems of each age group of women. Dr. Veena Shatrughna states, “While writing a book on Women and Health, we found that almost every illness could be ripped apart from the point of view of being woman. The medical system is premised on the assumption that there is a family which is caring. Women really struggle to fit into this framework. Women never have that kind of support . Every illness has specific implications and consequences of being women. Looking at gender is seeing how women negotiate in this hostile environment” (Shatugna 2001).
To address the problems concerning women’s health, a holistic life span approach is needed (Gupta 2001 11-12). Women as growing human beings, home-makers, workers, mothers and elderly citizens face different types of health related issues. Women’s health is determined by the material reality generated by socio-economic, cultural forces as well as gender relations based on subordination of women. It is important to make men aware about women specific health needs. Improvement in women’s health is a precondition for development of her family. For an effective public education on the abovementioned issues, charismatic personalities should teach the “Women and Health” module. How to engender medical education? This question needs to be addressed. There is also, a need for gender sensitive books for the health practitioners.
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VIBHUTI PATE. Is co-ordinator of Sophia Centre for Women’s Studies and Development, which is the first of its kind in the Bombay University. She was reader at the Research Centre for women’s Studies at SNDT Women’s University(1988 – 1992). She is a founder member and a trustee of the Centre for Enquiry into Health and Allied Themes (CEMAT). She has taken Ph.D in Labour Economics from Bombay University. She was a visiting fellow at the Development studies Institute at the London School of Economics and Political Science. She is on the governing board of Vikas Adhyayan Kendra. Author of four books- two of them text books. She has written extensively in national and international journals on issues related to women, social movements, economics and health. She is a well known women’s rights activist and played important role in campaigns for improving women’s status and for changing laws related to women.