IN HER LIFETIME

Female Morbidity and Mortality in Sub-Saharan Africa

Committee to Study Female Morbidity and Mortality in Sub-Saharan Africa

Christopher P. Howson, Polly F. Harrison, Dana Hotra, and MaureenLaw, Editors

Board on International Health

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1996



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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa IN HER LIFETIME Female Morbidity and Mortality in Sub-Saharan Africa Committee to Study Female Morbidity and Mortality in Sub-Saharan Africa Christopher P. Howson, Polly F. Harrison, Dana Hotra, and MaureenLaw, Editors Board on International Health INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa NATIONAL ACADEMY PRESS 2101 Constitution Avenue., N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this the Institute acts under the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is President of the Institute of Medicine. The project was supported by funds from the Carnegie Corporation (contract nos. B-5269 and D-93065). Additional project support was provided by the Special Programme of Research, Development, and Research Training in Human Reproduction, World Health Organization (contract no. HQ/93/043301); the Kellogg Endowment Fund; and the National Research Council's NAS/NAE independent funds and IOM independent funds. Library of Congress Catalog Card Number: 95-72800 International Standard Book Number: 0-309-05430-3 Additional copies of this report are available from: National Academy Press Box 285 2101 Constitution Avenue, N.W. Washington, DC 20418 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area) Copyright 1996 by the National Academy of Sciences. All rights reserved. COVER: Oil painting by Ablade Glover. Reprinted, with permission, from the Carnegie Corporation of New York. Ablade Glover is a Ghanaian artist who has exhibited widely in the United States, Switzerland, Zimbabwe, England, Germany, and his home country. He is represented in collections in many countries. He studied art in the United Kingdom and at Kent State University and Ohio State University in the United States. Currently he is associate professor, Department of Art Education, University of Science and Technology, Kumasi, Ghana, on sabbatical in Accra, where he is directing a cooperative gallery called Artists Alliance. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa COMMITTEE TO STUDY FEMALE MORBIDITY AND MORTALITY IN SUB-SAHARAN AFRICA MAUREEN LAW (Chair), Director General, Health Sciences Division, International Development Research Centre, Ottawa, Ontario, Canada UCHE AMAZIGO, Visiting Professor, Department of Zoology, University of Nigeria, Nsukka, Enugu State JUDITH FORTNEY, Corporate Director, Scientific Affairs, and Director, Division of Reproductive Epidemiology and Sexually Transmitted Diseases, Family Health International, Research Triangle Park, North Carolina PHILIP L. GRAITCER, Associate Professor, Center for Injury Control, Rollings School of Public Health, Atlanta, Georgia FRANCOISE F. HAMERS, EIS Officer, Division of STD/HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia H. KRISTIAN HEGGENHOUGEN, Associate Professor, Department of Social Medicine, Harvard School of Medicine, Boston, Massachusetts KARUNGARI KIRAGU, Research and Evaluation Officer, Center for Communication Programs, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland JOANNE LESLIE, Adjunct Assistant Professor, University of California at Los Angeles, School of Public Health, and Co-Director, Pacific Institute for Women's Health, Los Angeles, California WALINJOM F. T. MUNA, Director, General Hospital of Yaounde, Yaounde, Republic of Cameroon JONATHAN E. MYERS, Director, Occupational Health Research Unit, Department of Community Health, School of Medicine, University of Cape Town, South Africa BENJAMIN O. OSUNTOKUN, Professor, Neurology Unit, Department of Medicine, University of Ibadan, Ibadan, Nigeria (Deceased) PATIENCE W. STEPHENS, Demographer, the World Bank, Resident Mission, Accra, Ghana JUDITH N. WASSERHEIT, Director, Division of STD/HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia BELMONT E. O. WILLIAMS, Professor, Clark Atlanta University, and Assistant Clinical Professor, Department of Obstetrics and Gynecology, More house School of Medicine, Atlanta, Georgia Project Staff CHRISTOPHER P. HOWSON, Project Director POLLY F. HARRISON, Senior Program Officer DANA HOTRA, Research Associate DELORES SUTTON, Project Assistant JAMAINE TINKER, Financial Associate CAROLINE MCEUEN, Contract Editor BERYL BENDERLY, Contract Writer

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Dedication The Committee to Study Female Morbidity and Mortality in Sub-Saharan Africa dedicates this report to Patricia Rosenfield and Rosalee Karefa-Smart of The Carnegie Corporation. Their vision, hard work, and strong commitment to the life span perspective and female health made this project possible.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Acknowledgments Although this book is cited as a report of the Committee to Study Female Morbidity and Mortality in Sub-Saharan Africa, the committee chair and Institute of Medicine wish to acknowledge the following committee members, IOM staff, and outside experts as primary authors: Chapter 1 (Beryl Benderly, consultant science writer; Polly Harrison; Christopher Howson); Chapter 2 (Kristian Heggenhougen; Polly Harrison; Dana Hotra); Chapter 3 (Joanne Leslie; Bibi Essama, University of California at Los Angeles); Chapter 4 (Judith Fortney; Karungari Kiragu); Chapter 5 (Benjamin Osuntokun); Chapter 6 (John Orley and Giovanni de Girolamo, World Health Organization); Chapter 7 (Walinjom Muna); Chapter 8 (Philip Graitcer); Chapter 9 (Jonathan Myers); Chapter 10 (Uche Amazigo); Chapter 11 (Judith Wasserheit; Francoise Hamers); and Appendix A (Christine Costello, National Academy of Sciences; Douglas Ewbank, University of Pennsylvania; Christopher Howson; Patience Stephens). For their part, the committee gratefully acknowledges the valuable contributions of the following people to their report: F. C. Okafor, Maureen Obi, and N. Ivoke, University of Nigeria, for their help with Chapter 10; Richard Rothenberg and Sevgi Aral, Centers for Disease Control and Prevention, for their insightful comments and suggestions regarding Chapter 11; and Susan Scrimshaw, University of Illinois at Chicago, for her sage editorial advice on the report as a whole. The committee owes a special debt of gratitude to Caroline McEuen, contract editor, for her substantive and creative editing of the final document. The committee also thanks those individuals whose vision and hard work contributed to the early development of this project in 1986, including Polly Harrison, Jill Gay, April Powers, and Belkis Giorgis, Institute of Medicine; Susan Scrimshaw, University of Illinois at Chicago; Judith Bruce, the Population Council; Elayne Clift, Academy for Educational Development; Carol Corillon, National Academy of Sciences; Joan Dunlop, International Women's Health Coalition; Patrice Engle, Institute of Nutrition of Central America and Panama; Ruth Bamela Engo-Tjega, Labor Ministry-Cameroon; Benjamin Gyepi-Garbah, Barbara Hertz, and Althea Hill, the World Bank; Don Hopkins, the Carter Center; Sandra Huffman, Center to Prevent Childhood Malnutrition; Angela Kamara, Columbia University; Marjorie Koblinsky, the Ford Foundation; Michael Latham, Cornell University; Haydee Lopez, Chilean Medical Association; Cathie Lyons, The United Methodist Church; Ken McIntosh, Harvard Medical School; Henry Mosely, The Johns Hopkins University; Isabel Nieves, the Institute of Nutrition of Central America and Panama; Judy Norsigian and Norma Svenson, Boston Women's Health Book Collective; Adhiambo Odaga, Oxford University; Chloe O'Gara, U.S. Agency for International Development; Freda Paltiel, Canadian Ministry of Health; Barbara Pillsbury, University of California at Los Angeles; Barry Popkin, University of North Carolina; Eva Rathgeber, International Development Research Centre; Allan

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Rosenfield, Columbia University; Nawal El Saadawi and Irene Santiago, Oxfam; Judith Timyan, International Center for Research on Women; and Ann Tinker, the World Bank. The committee also thanks the many people who provided information, critical analysis, advice, and informal review in the last two years of the project, including Margaret R. Becklake, McGill University; Mark Belsey, World Health Organization; Ronald Blanton, Case Western Reserve University; Barry Bloom, Albert Einstein College of Medicine; Lita Curtis, Institute of Medicine; Aleya El-Bindari Hammad, World Health Organization; Lori Heise, Pacific Institute for Women's Health; Kenneth Hill, Johns Hopkins School of Hygiene and Public Health; King Holmes, University of Washington; Niki Jazdowska; Eileen Kennedy, International Food Policy Research Institute; Mere Kisekka, Ahmadu Bello University, Nigeria; Claude Lenfant, National Heart, Lung, and Blood Institute; Adetokunbo Lucas, Harvard School of Public Health; Deborah Maine, Columbia School of Public Health; Violaine Mitchell, Institute of Medicine; Jane Mutambirwa, University of Zimbabwe; Elena Nightingale, Carnegie Corporation of New York; Obioma Nnaemeka, University of Minnesota; Frederick Robbins, Case Western Reserve University; Jeanne Stellman, International Labor Organization; and Tomris Turmen and Carol Vlassoff, World Health Organization. The committee would also like to thank individuals within the Institute of Medicine whose support was instrumental to the project. These include Christopher P. Howson, Study Director; Polly F. Harrison, Senior Program Officer; Dana Hotra, Research Associate, and Dee Sutton, Project Assistant, who typed volumes, arranged travel, and organized and assisted at meetings. Others within the Institute of Medicine and National Academy of Sciences who were instrumental in seeing the project to completion were Kenneth I. Shine, IOM President, who provided invaluable editorial advice at a key juncture in report preparation; Enriqueta C. Bond and Karen Hein, IOM Executive Officers; Susan M. Wyatt and Jamaine Tinker, Financial Associates; Mary Pat Nowack, Contract Specialist; Sharon Scott-Brown, Administrative Assistant; Michael Edington, Editor; and Betsy Turvene, Consultant. The committee is especially grateful to Claudia Carl, Administrative Associate, for her expert help in coordinating the outside review of this manuscript. In particular, the committee would like to thank Timothy Rothermel of the United Nations Development Programme, and Paul Van Look, Einar Roed, and Guiseppe Benagiano of the Human Reproduction Programme, World Health Organization, for their help in securing additional funds for this project. Finally, it is with great sadness that committee and staff note the death of Benjamin O. Osuntokun, Professor of Neurology, University of Ibadan, Nigeria, on 23 September 1995. His expertise, hard work, and graciousness as a physician and member of this committee were key to the success of this project. We will miss you, Ben.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Contents  1   SUMMARY   1      Preamble   1      The "Life Span" Approach   2      The Study Process   3      Conclusions and Research Needs   6  2   THE CONTEXT OF MORTALITY AND MORBIDITY   25      The Importance of Context   25      The Issue of Heterogeneity   26      The Socioeconomics of Life and Death   26      Power, Control, Equity, and Status   38      Social Disruption and Health Status   40      Conclusions   47  3   NUTRITIONAL STATUS   54      Women's Roles and Female Nutritional Status in Sub-Saharan Africa   55      Extent of Malnutrition Among Females in Sub-Saharan Africa   59      Functional Consequences of Female Nutritional Status: Taking a Life Span Perspective   68      Conclusions   74      Research Needs   75  4   OBSTETRIC MORBIDITY AND MORTALITY   80      Gender Burden   80      The Life Span: An Approach to Maternal Morbidity and Mortality   81      The Magnitude of Pregnancy-Related Mortality and Morbidity   83      The Nature of Maternal Mortality as a Public Health Problem   91      The Multiple Causality of Maternal Death   95      Maternal Health and Family Planning   107      Menopause   113

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa      Conclusions   114      Research Needs   116  5   NERVOUS SYSTEM DISORDERS   123      Life Span Perspective   123      Toxic and Nutritional Disorders of the Nervous System   123      Headache Syndromes   126      Cerebrovascular Diseases and Use of Oral Contraceptives   127      Other Neurological Disorders   128      Conclusions   129      Research Needs   129  6   MENTAL HEALTH PROBLEMS   136      Mental Health and Mental Illness in Africa: General Issues   136      Gender Differences in the Rate, Course, and Outcomes of Mental Disorders: Global Issues   138      The Epidemiologic Evidence in Africa   139      Gender Differences in Africa for all Psychological Disorders   139      Affective and Neurotic Disorders   140      Schizophrenia   142      Psychological Disorders in General Medical Settings   144      Psychological Disorders in Pregnancy and the Puerperium   147      Conclusions   148      Research Needs   149  7   CARDIOVASCULAR DISEASES, CANCERS, AND CHRONIC OBSTRUCTIVE PULMONARY DISEASES   152      Cardiovascular Diseases   153      Cancers   159      Chronic Obstructive Pulmonary Diseases   162      Conclusions   163      Research Needs   164  8   INJURY   169      Definitions   170      Injuries Worldwide   170      Injuries in the Developing World   171      Injury Patterns in Developing Countries   171      Life Span Approach   173      Violence Against Females—A Growing Public Health Problem   177      Conclusions   179      Research Needs   180  9   OCCUPATIONAL AND ENVIRONMENTAL HEALTH   183      Women's Work in Sub-Saharan Africa   183      Women and Work in Historical Context   185      Problems of Definition   186      The Nature of Occupational and Environmental Health Problems   188      Life Span Approach   189      Nature of the Evidence   191      Conclusions   195      Research Needs   197

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa  10   TROPICAL INFECTIOUS DISEASES   200      Malaria   205      Schistosomiasis (Bilharziasis)   212      African Trypanosomiasis   216      Trachoma   219      Dracunculiasis (Guinea Worm)   220      Onchocerciasis and Lymphatic Filariasis   225      Leishmaniasis and Leprosy   228      Conclusions   230      Research Needs   231  11   SEXUALLY TRANSMITTED DISEASES AND HIV INFECTION   242      Overview   243      Magnitude of the Problem   252      Societal Determinants of STDs and HIV Infection   259      Conclusions   260      Research Needs   261      Appendix   273  APPENDIX A:   DEMOGRAPHIC OVERVIEW AND STATE OF THE DATA   283      Data on Female Mortality and Morbidity Across the Life Span   283      Conclusions   294      Research Needs   295     INDEX   299

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa NOTE: This map, which has been prepared solely for the convenience of readers, does not purport to express political boundaries or relationships. The scale is a composite of several forms of projection. SOURCE: Reprinted, with permission, from National Research Council, Social Dynamics of Adolescent Fertility in Sub-Saharan Africa. Copyright 1993 by the National Academy of Sciences.