In Her Lifetime Female Morbidity and Mortality in Sub-Saharan Africa (1996) / Chapter Skim
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There are powerful reasons why this has been so; perhaps the most compelling of these has been demographic. Anxiety about population growth, and consequent concern about the high fertility rates in developing countries, drove the expansion of family planning services that began in the 1960s in much of the developing world.
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The challenge that confronts us now is how to maintain female health and well-being across that widening and ever more complex span, and adjust to the new needs that will arise. THE "LIFE SPAN" APPROACH In 1988, when the Institute of Medicine began to conceptualize this study and held the first planning meeting, its articulation of a "life cycle" approach to thinking about female health was novel and innovative.
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Subsequently, the Carnegie Corporation, the United Nations Development Programme, the World Health Organization, and the National Research Council provided additional funds in support of the study, the two committee meetings that followed, and publication of the final report. The Committee and Its Process The 14-member interdisciplinary committee appointed to conduct the study included experts in anthropology, chronic diseases, demography, epidemiology, infectious diseases, injury and violence, mental health, nutrition, obstetric health, occupational and environmental health, and sexually transmitted diseases and HIV.
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· Should the tropical infectious diseases be viewed as vector-borne or poverty-borne? More broadly, is poverty simply the largest health problem, and the problem from which all others derive?
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The committee also discussed the merits of using a measure being developed by the World Health Organization and the World Bank in their work on the global burden of disease, the disability-adjusted life year, or DALY.s The measure proved useful in Chapter 10, which examines eight tropical infectious diseases and their relative burdens; the data bases for DALY computation in these instances were reasonably robust. Definitions Sub-Saharan Africa This report considers the 39 mainland countries of the continent south of the Sahara, with the addition of the island nations, as Sub-Saharan Africa.
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Chapter 2 describes socioeconomic and sociocultural contexts and influences. Chapters 3 through 11 present the evidence on female morbidity and mortality for specific diseases and conditions: nutrition; obstetric and gynecologic health; nervous system disorders; mental health problems; selected chronic diseases; injury; occupational and environmental health; tropical infectious diseases; and sexually transmitted diseases, including HIV infection.
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; three nutrition-related conditions (anemia, iodine deficiency, and protein-energy malnutrition) ; and three conditions related to female sexual and gender identity (HIV/AIDS, the sequelae of female genital mutilation, and the entire group of sexually transmitted diseases)
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d . Ergonomic stressors Exposure to indoor air pollution Exposure to organic dusts from food processing Exposure to toxic wastes Job overload Lack of job control Othere Tropical infectious diseases (Chapter 10)
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e"Other" includes ill-fitting personal protective equipment designed for men; working under recommended exposure limits for occupational hazards designed for healthy, well-nourished men in the developed countries working an eight-hour day; exposure to malaria prophylaxis and infection not only from malaria but also from other tropical infectious diseases that pose serious risks for pregnant women or are exacerbated by pregnancy: exposure to uncontrolled chemical and ergonomic hazards that pose risks for the fetus; effects of chemicals, indoor smoke, and injury hazards that extend to infants; work-time requirements that further compromise breastfeeding and infant nutrition; and lack of sufficient "off time" to allow for appropriate rehabilitation from injury or work-related disease, thus elevating the risks from hazardous exposures or increasing female workloads. Measles is, of course, not a tropical infectious disease.
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Rheumatic heart disease, which is second only to hypertension and its complications among cardiovascular disorders resulting in hospital admissions in Sub-Saharan Africa, appears to be more common and to be associated with higher rates of morbidity and mortality in Sub-Saharan African females than in males. Cancers of the skin, and possibly those of the bladder, show a disproportionate burden in females compared with males, although the finding for bladder cancer is speculative and based on the assumption that females may be at a higher occupational risk of exposure to schistosomiasis, a risk factor for bladder cancer.
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The final conclusion has to do with the traditional biomedical position that the only interesting distinctions between male and female susceptibility to tropical infectious diseases lie in the relationship to female reproductive function. This preconception has biased biomedical research toward pregnancy and pregnancy outcomes, placental transmission, and maternally induced protection in the neonate; excluded understanding of nonreproductive effects; and limited gender-relevant research to diseases that produce these effects.
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Damage to genitourinary structure and function may result from female genital mutilation, obstructed labor, sexually transmitted disease, induced abortion, or any combination of these insults. High parity may be related to early onset of childbearing or to repeated fetal wastage, either from prior conditions or new infections.
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Urinary and fecal incontinence may proceed from newly traumatized fistulae from female genital mutilation or previous obstructed deliveries. Perinatal cardiopathies, gestational diabetes, hypertension, viral hepatitis, pneumococcal meningitis related to sickle-cell diseases, and most of the tropical infectious diseases wait in the wings to exacerbate or be exacerbated by pregnancy.
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Hypertension and stroke; diabetes; rheumatic heart disease; cardiomyopathies; chronic obstructive pulmonary disease; and cancers of the genital tract, breast, bladder, liver, and skin have all appeared in the region. Stroke is now recognized as an increasingly important cause of morbidity and mortality in Sub-Saharan African women, as is coronary artery disease, which seems to have a poorer prognosis for women than for men in the region.
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It has been possible to focus policy attention on the dilemma of female genital mutilation, with its profound biomedical implications and its equally profound cultural roots, precisely because its prevalence has been quantified to a degree that has attracted the world's attention. African women have become vigorously involved in this issue.
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and simplification of intolerance in SSA Developing means to infectious diseases, methodology for regional women than in men improve nutrition for particularly those and local use lactating mothers and producing disfigurement Chronic effects of protocols for guiding Modifications of existing pesticides and other home them toward best lactation Studies related to longitudinal surveys of chemicals on peasant practice STD/HIV control: nutrition status, farmers and others in factors determining particularly child plantation and Documentation and sexual, health-seeking, malnutrition in Sub- monocropping production practical cataloging of and reproductive Saharan Africa, so that creative approaches to behaviors data are collected/ Impact of bearing heavy better obstetric health factors determining analyzed/ reported by age weight at different ages care, treatment guidelines women's social status and gender and effects across the life and algorithms effects of female social span and life cycle with status on sexual, health Collection of nutrition regard to degenerative Prevalence and trends in seeking, and reproductive data on neglected osteoarthritis problems smoking in SSA females, behavior populations: adolescent and risk factors for girls; nonpregnant, Respiratory damage, smoking initiation among In-depth examination of nonlactating women; notably from chronic adolescent females, for social, economic, and women past reproductive bronchitis. and reduced purposes of developing mental health age lung function across the appropriate intervention determinants of violence life span programs Population-based studies of mortality, morbidity, and disability associated with induced abortion IN HER LIFETIME Development of surrogate endpoints for maternal mortality Mental health impact of psychosocial stressors related to work and environment, particularly effects of chronic fatigue
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Better description of natural history of subclinical pelvic inflammatory disease Better understanding of impact of STDs/HIV on pregnancy outcomes, and influence of pregnancy on course of STDs Prevention strategies for preventing and controlling disability from injuries of importance to SSA females, including systems of trauma care and rehabilitation techniques Studies of magnitude, determinants, and variables affecting onset, course, and outcome of post-traumatic stress disorders, in order to define effective treatment approaches Collaborative, multidisciplinary study of causes, risk factors, and reporting of violence, toward design of preventive strategies and case management Assessment of occupational exposure limits, given gender and multiplicity of other environmental stressors Operational research related to STD/HIV including but not limited to: integration of STD control with other programs characteristics of health care systems that would better serve women's needs -counseling, testing, partner notification in resource-scarce, high-risk environments program design for highrisk groups involvement of traditional practitioners development of better management algorithms for asymptomatic as well as symptomatic STD .
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24 TABLE 1-3 CODODuDd Epidemiologic Research Biomedical Research Applied/Operational Studies Ethnographic and Behavioral Research Me saw invesUg~oos of high prevalence and modality rates far rAe~c Ac~' ~ Saw ~ Development of simple, cheap treatment regimens far HIV-infected pregnant womeh to reduce perinatal transmission Development of .
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