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In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa (1996)

Chapter: 2 The Context of Mortality and Morbidity

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Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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2

The Context of Mortality and Morbidity

THE IMPORTANCE OF CONTEXT

In 1965, microbiologist Rene Dubos commented that "the prevalence and severity of microbial diseases are conditioned more by the ways of life of people than they are by the virulence of specific etiologic agents." The same can be said of the "nonmicrobial" diseases and the growing variety of environmental hazards. It is their "ways of life," then, that explain at least part of the morbidity and mortality of populations in given geographic and social settings. For women, health as a state of total well-being is "not determined solely by biological factors and reproduction, but also by effects of workload, nutrition, stress, war and migration, among others" (van der Kwaak, 1991).

In this context, mortality and morbidity are indicators of what nations are prepared to do to affect the various dimensions of the human environment, their willingness to extend and improve the quality of life of their people by applying the resources required for longer and healthier survival—education, food, health care, jobs, and security —and to ensure equitable participation in the economic, political, cultural, and social processes that affect their lives (Sen, 1993; UNDP, 1993; World Bank, 1993). From this perspective, even though physical health is just one component of human development, it is an essential function of the development process (UNDP, 1991).

As is the case everywhere, female health, ill-health, and mortality in Sub-Saharan Africa unfold within, and are shaped by, their sociocultural, economic, and political contexts. These are horizontal and vertical: families, communities, and networks of extended kinship are embedded in regional, national, and international hierarchies and relationships. All of these affect and are affected by one another, and all have implications for human well-being.

A pivotal aspect of these horizontal and vertical dynamics is power, defined here as control or influence over, first of all, one's own life. Primary in achieving such control is access to resources—the goods, services, and information that are the intellectual, physiologic, and economic basis for healthy and productive lives. In all societies, the degree of openness or constraint of this access is affected by gender. Female morbidity and mortality are not just functions of the physical differences between males and females; whatever their evolutionary origins, they are also rooted in differences in roles and status between the sexes (Caldwell et al., 1990; Gaisie, 1990; Koblinsky et al., 1993; Mukhopadhyay and Higgins, 1988; Ubot, 1992; Vlassoff and Bonilla, 1994).

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

THE ISSUE OF HETEROGENEITY

Throughout this volume, statements are made about female moridity and mortality in Sub-Saharan Africa for the purpose of comparing those indexes with the rest of the world. It cannot be emphasized enough, however, that the continent is neither homogeneous nor uniform. There are many economic, political, and sociocultural differences among East, West, central, and southern Africa; among large nations and small; highly stratified states and the more egalitarian; countries suffering wars, ethnic tensions, or other civil disturbances, and countries more serene; the economically richer and the poorer; those suffering drought and famine, and those who are not; and nations with refugees, and those without. There are also variations in religion, tribal affiliation, kinship structure, residence and household formation, language, and educational heritage.

Current statistics on economic performance, population, fertility, and education also reflect the continent's heterogeneous experience and circumstance. Gross National Product (GNP) per capita in 1987 dollars ranged from $130 in Ethiopia to Gabon's $2,700; annual average change in GNP per capita since 1965 ranged from -2.7 percent in Uganda to +8.9 percent in Botswana. Land mass varies from Sudan's 967,494 square miles to Swaziland's 6,705, and national population size from 0.7 million in Swaziland to over 100 million in Nigeria. Annual population growth rates over the past 23 years range from 1.5 percent in Mauritius to 4.2 percent in Côte d'Ivoire. Although total fertility rates are uniformly high throughout Sub-Saharan Africa, there are still major differences in absolute numbers and trends among regions and individual countries, as well as within them (Blanc, 1991; Cohen, 1993). Adult literacy in Burkina Faso is 18 percent; in Botswana it is 74 percent. Secondary school enrollment ranges from 3 percent in Rwanda and Tanzania to 51 percent in Mauritius (Feachem and Jamison, 1991; UNDP, 1993; World Bank, 1993).

Dealing with diversity is a fundamental difficulty for any study that pretends to deal with the continent as a whole. This report recognizes diversity as a fundamental fact and deals with it through the use of case material that illustrates commonalities or significant divergence in a given subject area.

THE SOCIOECONOMICS OF LIFE AND DEATH

The Variables

In its 1990 Human Development Report (HDR), the United Nations Development Programme (UNDP) defined human development as the process of enlarging people's options. Of those, the most critical were the options to: (1) lead a long and healthy life; (2) acquire knowledge; and (3) have access to the resources needed for a decent standard of living. This holistic view of "human health in context" is the point of departure for this study.

It was also in the 1990 Human Development Report that the UNDP introduced the "Human Development Index" (HDI) as a more realistic and informative statistical measure of human development than per capita gross national product (GNP) alone. The HDI merges national income with two social indicators—adult literacy/mean years of schooling and life expectancy at birth—to yield a composite measure that makes it possible to rank the progress of nations in relation to one another. The HDI also permits measurement of how females are doing compared with males (Anand and Sen, 1992).

A great deal of analytic energy has been invested in seeking consistent patterns of causality between human mortality, and the worldwide trend of decline in that mortality, and one of the major socioeconomic factors, including income growth, education, provision of health services, ecology, and geography (cf. Feachem and Jamison, 1991). In spite of these efforts, there is still no clear picture of which of these matters most, in part because of inadequacies in the basic data and the manner of their application, and in part because of the sheer complexity in the way human health is embedded in those factors. Taking combined mortality as its lead indicator, the World Bank's World Development Report 1993 (WDR) finds four factors to be unremittingly important in mortality reduction: income growth, improvements in appropriate medical technology, basic education, and access to public health services and knowledge. These are not simple indicators, and there are important synergies among them. In all regions of the world, however, the main effect of income growth on health status lies in equity

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

of income distribution and corresponding poverty reduction, as well as the extent of public investment directed toward development of human capital, both in health services and education, particularly for females.

Sub-Saharan Africa is no exception to this lack of a clear, direct association between income growth and HDI rankings. If, in frankly arbitrary fashion, we take the simple numerical midpoint (87.5) of the HDI ranking of the 173 countries, only three Sub-Saharan African countries fall into the group with the highest HDIs: Mauritius, Seychelles, and South Africa, all of which have high GNP rankings as well. A more generous cutoff adds Botswana, Congo, Gabon, Kenya, Lesotho, Madagascar, Swaziland, Zambia, and Zimbabwe, and makes the picture more complex, because all members of this group except Botswana, Gabon, and Swaziland have relatively low GNP rankings. That said, there are no dramatic exceptions at the lower HDI and GNP rankings: the very poorest countries of the Sub-Saharan have difficulty generating good HDIs. It is also the case that almost all of these lowest-ranking countries, which also have the lowest life expectancies and low health services access rates, are also the countries with low total overall adult literacy, and female literacy rates that are below 50 percent of those for males.

Nevertheless, most attempts to explain significant differentials among and within African countries in even a single phenomenon, such as infant and child mortality, founder. Part of this difficulty is generic: quantifying the contribution of admittedly crude indexes of socioeconomic development has generally found them to explain no more than half of the total variance (Blacker, 1991). Even when specific variables—for instance, maternal education—clearly and significantly correlate with mortality, the precise causal path is still unclear (Cleland and van Ginneken, 1988). The search for reasonably consistent explanations is frustrating: why, for example, if East Africa suffers the highest regional food insecurity, are the numbers of low birthweight babies and maternal mortality rates highest in West Africa?

Gender Disparities

The Human Development Report applies the HDI to data from 33 countries on separate female and male estimates of life expectancy, adult literacy and mean years of schooling, and wage rates, and calculates a Gender-Specific HDI for those countries. Computation of this HDI subset is not yet adjusted to account for the standard worldwide pattern of greater female longevity, and the report points to this area for further analytic attention. The data base also needs to be expanded to include a fuller range of countries; so far, data availability has permitted calculations in Sub-Saharan Africa only for Kenya and Swaziland.

The primary finding of this analysis is that when the HDI is adjusted for gender disparity, no country improves its HDI value. In other words, no country treats its women as well as it treats its men, although some countries do better than others.

The sources of gender bias in industrial and developing countries differ in important ways. In industrial countries, that bias is mainly in employment and wages, with women often getting less than two-thirds of the employment opportunities and about half the earnings of men. In developing countries, in addition to biases in the job market, there are great disparities in health care, nutritional support, and education. Those skews are exacerbated by poverty: the 1991 HDR notes that "Although gender discrimination is a worldwide problem, its effects are particularly harsh in the poorer countries."

Morbidity and Mortality

The overall patterns of mortality and morbidity in the Sub-Saharan region resemble those of other regions: the life expectancy of African females, like that of females virtually everywhere, is greater than that of males (Sai and Nassim, 1991; UNICEF, 1992), although life expectancy varies at different ages (that is, e0 is not necessarily equivalent to e15; see Brass and Jolly, 1993). And, as in nearly all developing countries, child mortality rates and the mortality risk for adult males are higher than they are for females (Murray et al., 1994), although differentials are usually small (Timaeus, 1991). In only two countries —Mali and Malawi—is there any evidence of excess female adult mortality. In the case of Mali, however, female mortality may have been overestimated because of

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

adjustments made for underreporting, and Malawi may be genuinely anomalous for reasons that are unclear (Timaeus, 1991).

Still, these global similarities do not tell the whole story: the life chances of adults in Sub-Saharan Africa are extremely heterogeneous (Timaeus, 1991), and some countries of the region have mortality levels that compare favorably with individual countries of other developing regions. At the same time, although most African countries have experienced steady declines in child mortality, aggregate mortality rates for the Sub-Sahara are still the highest in the world (Sai and Nassim, 1991). The differences in this regard between Sub-Saharan African women and the majority of their global sisters are large and absolute.

In addition, avoidable mortality is considerably higher for Sub-Saharan females overall than it is for males. Avoidable deaths are those that would not occur if the rates of a given reference population were applied in the case population (Murray et al., 1994). In the Sub-Saharan case, while the mortality risk for adult males is higher than it is for females, and much higher than it is for males in the developed world, the adult female mortality risk is so elevated, and the mortality risk among adult females in the developed world so low compared with males, that a more extreme ratio is generated. Said more simply, a Sub-Saharan female has a dramatically poorer chance of survival relative to her developed world sister than does a Sub-Saharan male compared with his developed world brother. The odds are even poorer for Sub-Saharan African mothers: their lifetime risk of maternal death is 1 in 15, compared with the 1-in-9,850 lifetime risk of maternal death in Northern Europe—that is, 657 times as great (Graham, 1991). The statement has been made that in a context of such extreme deviation, Sub-Saharan African women are "the underside of the underside" (Ramphele, 1991).

Finally, there appear to be notable gender differences within cohorts: although the infant mortality rate for boys is somewhat higher than it is for girls in every African country with available data, the picture of mortality rates among children 1 to 5 years old is much less consistent. Mortality rates among females in this age group appear to be higher in most African countries than they are for males, for reasons that are not at all clear.

Health Services Access and Utilization and Health-Seeking Behavior

In Sub-Saharan Africa, as everywhere else, access to health services is a function of costs, measured in money, time, and distance. All of these, in turn, affect utilization and interact with perceptions of care and its quality.

Access issues are particularly acute for women, whose workload, child care responsibilities, and financial situation may all constrain their ability to utilize services for themselves and for their children to a degree not experienced by men. In addition, although women may be the chief caretakers in a residential unit, they may not be the chief decision makers. Depending on family structure and residential organization, others, particularly senior males or mothers-in-law, may be the arbiters of choices about health care (Castle, 1995; Janzen, 1978). Still, Sub-Saharan African women are numerically more likely to be the principal users of health care services. This is not the case for Muslim women, whose seclusion and inability to be attended by a male health care provider put them at comparative jeopardy, to an extent that has not been systematically studied as an issue in itself.

Quality of health services affects both utilization and compliance with preventive and curative regimens (Leslie and Gupta, 1989), although the degree of importance of inadequate quality in women's underutilization of health services remains to be systematically assessed in Sub-Saharan Africa (Mensch, 1993). Nonetheless, it is only common sense to assume that suitable clinic hours and reasonable waiting times, multiple and adequate services, courtesy, efforts to diminish social and cultural distance between providers and patients, and clarity of communication would persuade more Sub-Saharan African women to utilize health services appropriately. When these features are not the rule, which is believed to be the more typical case in the region, service utilization and regimen compliance are affected negatively (Gilson, 1995; Heggenhougen, 1991; Thaddeus and Maine, 1990).

Another, more subtle factor is what might be called "medical distance" —that is, the degree to which the health care system is equipped with the appropriate knowledge and resources to deal with the specific health needs of women. There is good reason to believe that modern medical systems worldwide may not be adequately supplied with information about gender differences, at least in part because women have been largely excluded from clinical studies of the treatments prescribed for them (A. Lucas, personal communication, 1993), and in part

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

because of the general belief that, in most situations, women and men will not differ significantly in their responses to treatment.

At the heart of the matter is the absolute availability of all health-related services. People—male or female—cannot use, or decide to use, facilities that do not exist. The economic argument that demand will "make a market" and that consumers will, sooner or later, shape that market is questionable even in the developed world, where that assumption is at the heart of current debates about the relative roles of the public and private sectors in assuring the public health. If this is an arguable assumption in the developed world, then it would seem to be highly questionable in countries with large numbers of poor people, whose power to shape a market is infinitesimal.

The overall health service access figure for Sub-Saharan Africa is 60 percent; that is, just 60 percent of the region's population has access to any facility that might be described as modern. Only 41 percent of the total population of the region has access to safe water, and only 26 percent has access to sanitation; these are the lowest percentages of all the developing country regions (UNDP, 1993). In addition, although most of the developing world showed dramatic improvement between 1970 and 1990 in ratios of health care providers to population, Sub-Saharan Africa still has the fewest physicians and nursing persons of any region relative to population.

Table 2-1 displays variation in access indicators among and within individual countries. That variation is clearly wide. As of 1990, 11 countries in Sub-Saharan Africa had less than one hospital bed per 1,000 population. The physician/population ratio for the region as a whole was 1:23,540, with a range from 1:750 in South Africa to 1:72,990 in Rwanda. The regional nursing person/population ratio was 1:3,460, ranging from 1:600 in Zambia to 1:5,470 in Tanzania. At the same time, there is a relatively high ratio of nursing persons to physicians—5:1 for the region as a whole—with very few countries recording low ratios. Such ratios are viewed by Western health system analyst (cf. IOM, 1988; Reinhardt, 1991) as more favorable in achieving coverage, especially with public health measures, than are the lower nursing person-physician ratios that are so often a function of physician oversupply and can produce high costs to the society.

Finally, while 66 percent of Sub-Saharan African women are recorded as having some kind of prenatal care, only 38 percent of all births are attended by health facility personnel, the lowest such figure in all the developing regions. This cannot help but contribute substantially to Sub-Saharan Africa's maternal mortality ratio of 640 maternal deaths per 100,000 live births, the highest of all the world's regions (WHO, 1985). Community studies show that most maternal death occur outside the medical system, either at home or on the way to the hospital (Thaddeus and Maine, 1990). In response, the provision of access to high-quality emergency obstetric care is gaining recognition as the most important strategy for preventing maternal deaths in the region, in Africa, and in other developing countries where maternal mortality rates are high (Prevention of Maternal Mortality Network, 1995).

Access Bias

A severe limitation on access is urban-rural bias, which is extreme in Sub-Saharan Africa. Seventy-nine percent of the region's urban population has access to safe water; for rural areas, that figure is 28 percent. While 87 percent of the region's urban population has access to health services, over half the population in most of its countries lives more than 10 kilometers from the nearest primary care center. According to selected household surveys, of the individuals who report themselves as sick, those in urban areas obtain medical care more often than those in rural areas, and the wealthy contact a care provider more often than the poor. In Côte d'Ivoire in the mid-1980s, an urban household was nearly twice as likely to seek care as a rural household, and a family in the top income quintile within the rural population was almost twice as likely to seek care as a family in the bottom quintile (World Bank, 1993).

As for bias from other factors, there is no persuasive evidence that Sub-Saharan African females are at any significant disadvantage in being taken for clinical care in their early years. Surveys of the management of diarrheal disease, fever, and respiratory illness in infants and very young children, for example, reveal no significant differences in treatment by sex in the six African countries surveyed (Boerma et al., 1991). Nevertheless, gender bias in health services access and utilization accrues with age, as time, money, distance, and fear of stigma become matters of concern for girls and women.

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 2-1 Health Infrastructure and Services, Sub-Saharan Africa and Selected Trends, 1970–1990

 

Population per 1,000 Doctorsa

Population per 1,000 Nursing Personsa

Nursing Person to Doctor Ratiob 1988–1992

Hospital Beds per 1,000

Populationb 1985–1990

Percent of Births Attended by Health Staff, 1988c

Percent Received Antenatal Cared

Percent Received Delivery Assistanced

Country

1970

1990

1970

1990

         

Sub-Saharan Africa

31,830

23,540

3,460

5.1

1.4

Angola

16.4

1.2

Benin

28,570

2,600

5.8

34

Botswana

15,220

5,150

1,900

52

92

77

Burkina Faso

97,120

57,320

1,680

8.2

0.3

Burundi

58,570

6,870

4.3

1.3

12

80

19

Cameroon

28,920

12,190

2,560

1,690

6.4

2.7

Central African Republic

44,740

25,930

2,460

4.5

0.9

Chad

61,900

30,030

8,010

0.9

Congo

9,510

780

Côte d'Ivoire

15,520

1,930

4.8

0.8

20

Ethiopia

86,120

32,650

2.4

0.3

58

Gabon

5,250

570

92

Ghana

12,910

22,970

690

1,670

9.1

1.5

73

82

40

Guinea-Bissau

17,500

2,820

16

Guinea

50,010

3,720

4.3

0.6

Kenya

8,000

10,130

2,520

3.2

1.7

77

50

Lesotho

30,400

3,860

28

Madagascar

10,120

8,130

240

3.5

0.9

62

Malawi

76,580

45,740

5,330

1,800

2.8

1.6

59

Mali

44,090

19,450

2,590

1,890

2.5

27

31

32

Mauritania

17,960

3,740

23

Mauritius

4,190

1,180

610

16.4

1.2

Mozambique

18,860

4,280

13.1

0.9

28

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

Namibia

4,620

Niger

60,090

34,850

5,610

650

11.3

47

Nigeria

19,830

4,240

6.0

1.4

57

31

Rwanda

59,600

72,990

5,610

4,190

1.7

1.7

Senegal

15,810

17,650

1,670

2.6

0.8

64

49

Sierra Leone

17,830

2,700

5.0

1.0

25

Somalia

7.1

0.8

South Africa

1,750

300

4.5

4.1

Sudan

14,520

990

2.7

0.9

20

71

69

Tanzania

22,600

24,880

3,310

5,470

7.3

1.1

74

Togo

28,860

1,590

6.2

1.6

81

54

Uganda

9,210

8.4

0.8

87

38

Zaire

2.1

1.6

Zambia

13,640

11,290

1,730

600

6.0

Zimbabwe

6,300

7,180

640

1,000

6.1

2.1

69

91

70

a Derived from World Health Organization data, supplemented by data obtained directly by the World Bank from national sources. Data refer to a variety of years, generally no more than two years before the year specified. Nursing persons include auxiliary nurses, as well as paraprofessional personnel such as traditional birth attendants.

b Each value refers to one particular but unspecified year within the time period denoted.

c Refers to births recorded where a recognized health service worker was in attendance. Data are from WHO, supplemented by UNICEF data, based on national sources, primarily from official community reports and records of hospitals of a wide range of size and sophistication. These figures should be used very cautiously.

d Data are from Demographic and Health Surveys, 1986–1990.

SOURCES: Blanc, 1991; World Bank, 1993.

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Health-Seeking Behavior

Throughout the world, individuals and families are adaptive, pragmatic, and pluralistic in patterning their health-seeking behavior, depending on time and circumstance (see Bastien, 1992; Cosminsky, 1983; Finkler, 1994; Heggenhougen and Sesia-Lewis, 1988; Janzen, 1978; among many examples). Sub-Saharan women resort to various home remedies, over-the-counter and prescription pharmaceuticals, and medicines purchased from traditional healers. Similarly, they seek recourse through the categories of healers, including modern allopathic medical practitioners, traditional or folk healers, and trained and untrained traditional birth attendants (TBA). These resources are used serially or concurrently in different combinations and sequences; selecting among them is a complex process based on habit, cost, perception of risk or urgency, familiarity, and ease of access. The general perspective is that traditional and modern health systems are not seen as in conflict, but rather as two different, but valid, roads to recovery. At the same time, traditional healers in Africa have only rarely ''straddled" the two systems in the same way Ayurvedic practitioners do in parts of Asia, and their patients rarely receive whatever benefits modern medicine may confer (Caldwell and Caldwell, 1993).

Although understanding this process and the behaviors associated with it would seem to be valuable to the design of preventive and curative interventions, there has been little systematic field research in the Sub-Saharan region into the ways females of different ages and educational histories manage their armamentarium of preventive and curative strategies across the spectrum of health problems and across the life span. Fortunately there is an increasing number of exceptions: the work done on mothers' management of illness in their youngest children, which offers some insight about their own health-seeking behavior; the body of behavioral and epidemiologic research that is accumulating in connection with the HIV infections and sexually transmitted diseases; data beginning to emerge from the Safe Motherhood Initiative; and the series of annual papers on gender and the tropical diseases sponsored by Canada's International Development Research Centre (IDRC). One hypothesis suggested by this still uneven body of research is that women may be most likely to attempt to access the modern medical system in connection with illness in a very young child, and least likely to do so when there is a potential for some kind of stigma—for example, for family planning services, diagnosis and treatment of either sexually transmitted diseases or tropical infectious diseases that seem to be sexually transmitted (for example, urinary schistosomiasis), or conditions that might have social repercussions if disclosed (such as leprosy).

The Dynamics of Female Education

The World Development Report is unequivocal on the centrality of education in human health, stating flatly that "Households with more education enjoy better health, both for adults and for children, [a result that] is strikingly consistent in a great number of studies, despite differences in research methods, time periods, and population samples" (World Bank, 1993).

The key link in that causal chain is women's central role in the health of their households, a centrality that prevails in virtually every society, even though patterns of decision making and external power may differ greatly. Women's own health and their efficiency in using available resources are absolutely crucial to the health of others in the family, particularly children. The weight of the literature is toward a clear association between low levels of maternal education and increased child mortality (Cleland, 1990; Elo, 1992; Harrison, 1986). This seems to be particularly true for female children, especially when they are disvalued by the larger society.

In addition, it appears that a child's health is affected much more by the mother's schooling than by the father's; furthermore, the child benefits from maternal schooling even before its birth. Data for 13 African countries between 1975 and 1985 show that an increase of just 10 percent in female literacy rates reduced child mortality by an equivalent 10 percent, whereas changes in male literacy had little influence (Hobcraft, 1993). To take a specific country case, a calculation has been made for Kenya that 2 maternal deaths and about 45 infant deaths would be averted for every 1,000 girls provided with one extra year of primary schooling (World Bank, 1993).

There is broad general agreement on the major dimensions of the advantages of female education for household health. Female education increases knowledge about the importance of health and health care. It enhances

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

the propensity and ability to get health information and act on it, as well as to seek, demand, and use health services wisely. It enhances access to income and the capacity and willingness to pay for health care, and is frequently correlated with access to such health-enhancing services as improved household water supplies. Better-educated women marry and start their families later, diminishing the risks associated with early pregnancies, and they tend to make greater use of prenatal care and delivery assistance and to produce fewer low birthweight babies (Harrison, 1986; Hobcraft, 1993; Kennedy, 1992). Children of educated mothers enjoy such health-enhancing advantages as better food and domestic hygiene and more immunization, which in different ways reduce risk of infection. Mothers with more schooling also tend to be more effective in regimen compliance, use of health technologies, and overall case management (Vlassoff and Bonilla, 1994). Female education is also clearly linked to a woman's social standing, decision making power, autonomy, and her own health status. In contrast, illiterate women do not do very well. Data from Ethiopia, for example, indicate that, regardless of whether or not abortion deaths were included in the calculation, illiterate women still suffered the most mortality (Kwast et al., 1986). While this is all very compelling, it is important to keep in mind that maternal education and most co-variates, such as child and maternal mortality, utilization of health services, and the like, are greatly confounded with income levels (Zimicki, 1989).

Table 2-2 presents data on adult literacy, mean years of schooling, and male-female primary and secondary school enrollment ratios. It also includes data on average age at first marriage and percentages of women in the labor force. The message is that Sub-Saharan Africa as a whole does not do well compared with other regions of the world; Sub-Saharan females do even less well. Although female enrollment in precollege formal education did increase substantially over the past 15 years, the percentage of female children enrolled is far less than the proportion of females in the school-age population of every country for which data are available, and the rates of growth in female enrollment are less than the rates of growth in the female primary-school-age population, suggesting that over time a growing number of girls lack access to schooling. Representation of females at higher educational levels is small to begin with, and rates of attrition are high. Part of the problem is that enrollments have been stagnating in Africa and the quality of education at all levels has been declining in the wake of the economic decline that started in the mid-1970s, and continues with the economic hardships associated with structural adjustment and other austerity programs of the 1980s (World Bank, 1989). There are other reasons as well: academic factors that do not favor girls in such subject matter areas as mathematics and sciences; cultural and societal expectations around gender roles; early marriage and pregnancy; and, for both males and females, lack of relevant or sufficiently rewarding employment in their fields of expertise (Beoku-Bettes and Ikubolajeh Logan, 1993).

Access Bias

It is crucial to note that, as in the case of health services, all difficulties and biases are multiplied for three major population categories: those who reside in isolated rural areas, where distance is the primary impediment; lower socioeconomic groups, where cost and foregone earnings are of concern; and girls. When there is substantial male emigration, leaving female heads of household with correspondingly larger responsibilities for agricultural subsistence labor, it is customary for such women to delegate at least some of their traditional responsibilities for household chores and care of younger siblings to school-age daughters. These tasks are not perceived as suitable for boys, a perception that is hardly exclusive to Sub-Saharan Africa. It is a view that is prevalent in most societies and is closely tied to cultural views about appropriate gender roles and female identity.

Still, while evidence is anecdotal, there appear to be signs of change, at least in some parts of the region. In northern Nigeria, where seclusion has been thoroughly embedded in all parts of community and household structure for centuries, one observer noted over a decade ago that:

[Although] patterns of sexual inequality are extremely entrenched.…It is already apparent from observations over only five years that girls are being sent to school and kept there [by their parents] beyond the traditional age of marriage.… [This] could place women in line for jobs in the formal sector and lead to a whole sequence of demands and changes which are still quite remote from the perspectives of most Third World women. (Schildkrout, 1984)

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 2-2 Educational Profile of Females in Sub-Saharan Africa

Country

Adult Literacy Rate (as of age 15+)

Mean Years of Schooling (25+)

Average Age at First Marriage (females, years), 1980–1989

Enrollment Ratiosa

Women in Labor Force (percentage, total labor force), 1990–1992

 

Total 1992

F 1992

M 1992

Total 1992

F 1992

M 1992

 

Primary (gross), 1950

Secondary (gross), 1990

 

Mauritius

80

75

85

4.1

3.3

4.9

23.8

108

54

30

Seychelles

4.6

4.4

4.8

23.0

43

Botswana

75

66

85

2.5

2.5

2.6

26.4

119

45

 

S. Africa

3.9

3.7

4.1

26.1

39

Gabon

62

50

76

2.6

1.3

3.9

17.7

38

Swaziland

3.8

3.4

4.1

108

46

34

Maldives

4.5

3.9

5.1

17.9

20

Lesotho

3.5

4.1

2.8

20.5

116

31

44

Zimbabwe

69

61

76

3.1

1.8

4.5

20.4

116

46

48

Congo

59

45

72

2.1

1.1

3.1

21.9

39

Cameroon

57

45

70

1.6

0.8

2.6

18.8

95

23

30

Kenya

71

60

82

2.3

1.3

3.1

20.3

93

25

40

Namibia

1.7

126

47

24

Madagascar

81

74

90

2.2

1.7

2.6

20.3

91

18

40

Ghana

63

54

74

3.5

2.2

4.9

19.4

70

20

40

Côte d'Ivoire

56

41

69

1.9

0.9

2.9

18.9

58

14

32

Zambia

75

67

83

2.7

1.7

3.7

19.4

92

15

29

Nigeria

52

41

63

1.2

0.5

1.7

18.7

63

17

33

Zaire

74

63

86

1.6

0.8

2.4

20.1

64

15

36

Senegal

40

26

55

0.9

0.5

1.5

18.3

11

26

Liberia

42

31

53

2.1

0.8

3.3

19.4

31

Togo

45

33

59

1.6

0.8

2.4

18.5

87

12

37

Tanzania

2.0

1.3

2.8

19.1

68

4

48

Equatorial Guinea

52

38

66

0.8

0.3

1.3

36

Sudan

28

13

45

0.8

0.5

1.0

20.9

43

20

29

Burundi

52

42

63

0.4

0.3

0.7

21.7

66

4

53

Rwanda

52

39

67

1.1

0.5

1.5

21.2

70

7

54

Uganda

51

37

65

1.1

0.6

1.6

17.7

41

Angola

43

29

57

1.5

1.0

2.0

17.9

70

39

Benin

25

17

35

0.7

0.3

1.1

18.3

45

7

24

Malawi

1.7

1.1

2.4

17.8

60

3

51

Mauritania

35

22

48

0.4

0.1

0.7

19.5

43

10

22

Mozambique

34

21

46

1.6

1.2

2.2

17.6

52

6

48

C. African Republic

40

26

55

1.1

0.5

1.6

18.4

52

7

47

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

Ethiopia

1.1

0.7

1.5

18.1

30

11

41

Djibouti

0.4

0.3

0.7

31

36

Guinea-Bissau

39

25

53

0.4

0.1

0.7

18.3

42

4

42

Somalia

27

16

41

0.3

0.2

0.5

20.1

39

The Gambia

30

18

43

0.6

0.2

0.9

53

13

41

Mali

36

27

43

0.4

0.1

0.7

16.4

17

4

16

Chad

33

20

46

0.3

0.2

0.5

16.5

35

3

17

Niger

31

18

44

0.2

0.2

0.4

15.8

21

4

47

Sierra Leone

24

12

35

0.9

0.4

1.4

39

12

33

Burkina Faso

20

10

31

0.2

0.2

0.3

18.4

28

5

49

Guinea

27

15

39

0.9

0.3

1.5

16.0

24

5

30

All developing countries

69

58

79

3.9

3.0

4.9

20.8

90

34

35

Least-developed countries

46

34

58

1.6

0.9

2.2

18.7

55

12

38

Sub-Saharan Africa

1.6

1.0

2.2

19.0

60

15

37

Industrial countries

10.0

24.5

43

World

5.2

21.0

37

a The gross enrollment ratio is the number of students enrolled in a level of education, whether or not they belong in the relevant age group for that level, as a percentage of the population in the relevant age group for that level. All figures in this column are expressed in relation to the male average, which is indexed to equal 100. The smaller the figure, the bigger the gap; the closer the figure to 100, the smaller the gap.

SOURCE: UNDP, 1994.

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Access to Assets, Employment, and Income

A cursory inspection of world health suggests that the single most important factor determining survival is income (World Bank, 1994). Lower income characteristically predicts poor health status, both among and within countries. At the same time, wealth does not necessarily bring health: issues of equity and political commitment are transcendent (World Bank, 1994).

In the 1991 edition of the Human Development Report, the UNDP predicted that Africa's share of the world's poor would overtake Asia's, to rise from 30 percent to 40 percent by the year 2025. The HDR added that, while Africa had made important human development gains since independence, the world economic crisis in the early 1980s, slow economic growth on the continent during the rest of the decade, and population increases of 3.2 percent annually had combined to produce declines in per capita GNP at an average annual rate of 2.2 percent over the decade; real wages declined by 30 percent over the same period. As a result, the social gains on the continent since independence were "reordered" (Bassett and Mhloyi, 1991). An analysis of the economic experience in seven diverse African countries (Botswana, Ghana, Kenya, Nigeria, Senegal, and Uganda) concluded that their economic reversals have indeed had demographic effects and that the lives of many Africans were affected as they suffered the deaths of their children and made decisions to delay or forgo marriage and parenthood (NRC, 1993a).

To respond to the economic crises of the 1970s and 1980s, a number of the Sub-Saharan countries were required to change their economic policies and adopt macroeconomic and microeconomic reforms designed to produce price stability, sustainable monetary balance, efficient resource use, and faster economic growth. These changes generally involved cuts in public spending and liberalization of prices, areas of special relevance to the health sector. To support the reforms, the World Bank and the International Monetary Fund extended "adjustment lending" to cushion developing economies during transition to new growth paths; the effects of these "structural adjustments" have spun off a swirl of controversy and analysis (World Bank, 1993).

The UNDP view is that these economic reforms have yet to bear fruit in human development (UNDP, 1993), and the World Development Report agrees that the health costs of slow economic growth (as expressed in declining per capita incomes and increasing percentages of the population defined as living in poverty) have been high. Although, for example, child health has been improving everywhere in the developing world, gains have been much less rapid in countries with slow income growth. More severely stated, evidence suggests that the adjustment process in itself is associated with less favorable child mortality outcomes than would have been predicted by long-term trends (Cornia et al., 1987). Had economic growth in Africa been as fast in the 1980s as it was in the preceding two decades, 7 percent of total infant deaths in the region would have been averted (World Bank, 1993).

Assessing the specific effects of structural adjustment on health sector funding is more complicated. The nature and degree of impact seem to vary with the timing of the process and the ways in which spending cuts were designed. Although, in countries both with and without adjustment loans, health sector spending as a percentage of total country income declined in the early 1980s in relation to the average for the decade, it recovered in the rest of the decade much faster in countries that undertook and sustained major policy reforms (World Bank, 1993, 1994).

Whatever the long-term costs and benefits of adjustment policies, there appears to be some consensus in parts of the African policy community (SOMANET, 1992) that these policies have been more acutely problematic for the poor and for women. Cliff (1991), in her study of destabilization in Mozambique, suggests that:

Structural adjustment has an in-built gender bias against women. As Elson (1987:3) shows, "the success of the macroeconomic policy in reaching its goals may be won at the cost of a longer and harder working day for women. This cost will be invisible to the macroeconomic policymakers because it is unpaid time. But the cost will be revealed in statistics on the health and nutritional status of such women."

She adds that poor urban women—and particularly female-headed households—are particularly vulnerable to the effects of adjustment. Poor urban women tend to be in low-wage, low-status jobs, with few skills that make them eligible for wage employment in the formal sector. When the formal labor market shrinks in response to adjustment,

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

females tend to be the first to be laid off and to leave school, and must then take lower-paying jobs or enter the informal labor market to patch together family subsistence.

Other costs associated with adjustment policies include increases in drug prices and the establishment of user fees for both education and health services. Analysis of clinic utilization at a referral center for sexually transmitted diseases in Kenya indicated that user fees had a dampening effect on clinic utilization, particularly for women (Moses et al., 1992). Case studies in Swaziland and Zimbabwe found that these fees led to substantial drops in clinic utilization for immunizations, preventive care, and maternal and antenatal series (Loewenson et al., 1991; Yoder, 1989). A series of 11 multidisciplinary situation analyses of facilities providing emergency obstetric care in Ghana, Nigeria, and Sierra Leone found marked declines in utilization of nonemergency services and in numbers of normal deliveries at a sample of clinics that had established or increased user fees for drugs and specific services. User fees and, somewhat ironically, lack of drugs and supplies at these facilities also contributed to unacceptably long waiting times between admission and treatment of complicated cases. At some sites, these delays were associated with increases in the numbers of maternal deaths (Ekwempu et al., 1990; Prevention of Maternal Mortality Network, 1995). At the same time, a recent and very thorough study of the Tanzanian health system suggests that user fees would not be a disincentive were the facility to provide services of reasonable quality (Gilson, 1995).

Widowhood and Its Sequelae

Another byproduct of adjustment appears to have been decreased care of the elderly, particularly widows, whose status is already fragile enough. A number of factors affect the status of women who have been widowed; these, in turn, affect their physical, economic, and mental well-being. Among these influences are household arrangements, whether or not she has children (particularly sons), age, advent of menopause, property rights, land rights, and the culturally prescribed length of mourning periods.

Legal status is crucial, particularly in connection with laws of inheritance. The tradition in patrilineal societies is for a widow to become the property of her late husband's brother or cousin (the levirate), and it is under that circumstance that she will be able to keep her children with her. Otherwise, she can only hope that the children will transfer to her some portion of their own patrilineal inheritance (Henn, 1984). Should she not acquiesce to the dictates of tradition, she may also face the possibility of ostracism by her deceased husband's family. If, as is the case in some subcultures, a widow is blamed for her husband's death, her ostracism is complete (U. Amazigo, personal communication, 1992). The levirate seems to be declining rapidly where AIDS is the probable cause of death, but the dynamics and implications of that change are unknown (Fortney, personal communication, 1994). Inheritance, however, remains a major issue in patrilineal societies, and women's rights groups are forming around attempts to understand attitudes toward traditional law, with an eye toward reform.

Economic hardship, whether or not it is related to structural adjustment programs, in combination with increased urbanization has also resulted in decreased care of the elderly. Again, widows are at particularly high-risk, because customary practices of support, either by a woman's children or by the brothers of a widow's husband, tend to attenuate in rapidly urbanizing settings; in some places, they have disappeared altogether (Adamchak et al., 1991). Widows may be utterly abandoned by their relatives and acquire a new, and detrimental, urban identity. In an urban area of Kenya, widows living alone are widely recognized as being available for any man, and the incidence of rape against widows is said to be very high (Raikes, 1989). In polygamous societies, younger widows may find refuge in remarriage, but there are accounts of older single women or elderly widows without the protection of nearby children being accused of witchcraft, murdered, and their possessions taken (P. Masanja, personal communication, 1991).

Widows may also find themselves compelled to resort to commercial sex work for economic survival. While the sample is not representative, the following figures are interesting: a study at a family planning clinic in Nairobi found a prevalence of HIV infection of 4.3 percent among married women, 8.5 percent in single women, and 11.8 percent in widowed and divorced women (D. Hunter, Department of Epidemiology, Harvard School of Public Health, personal communication, 1993). The intervening variable appears to be economic status: in general,

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

women of lower socioeconomic status, including lower-status commercial sex workers, are at higher risk of contracting sexually transmitted diseases (Brunham and Embree, 1992).

Finally, war leaves widows, and may often leave them without their children as well. In a survey of elderly women in centers for displaced persons, 64 percent in Mozambique and 74 percent in Zimbabwe were widows (Ramji, 1987). The same study found that the proportion of severe malnutrition among Mozambican women over age 45 was 21 percent, using a weight of under 40 kilograms as a cutoff point; the corresponding percentage for men in the same age group was 5 percent. This suggests that the health status of older women may be especially threatened in conditions of displacement.

POWER, CONTROL, EQUITY, AND STATUS

In an analysis of reproduction and social organization, Lesthaeghe (1989) comments on the effects of postcolonial and postindependence developmental dynamics in Sub-Saharan Africa:

The development of the migrant labor system created new roles and responsibilities for the wives of migrants and for migrant women. To a considerable extent, these have become accepted and institutionalized both culturally and legally. This and related developments, such as the spread of female education, have greatly enhanced women's status. Nevertheless, their responsibility for child-rearing, restricted access to land, exclusion from inheritance, and lack of opportunities for paid employment mean that most women, whether married or not, remain dependent on relationships with men to obtain the means of survival.

In Sub-Saharan African societies, as elsewhere in the world, women are likely to have a status subservient to that of men, with less control over family resources; minimal access to cash; and, in general, inferior social power. Some analysts claim that in several African countries, women have the status of minors and tend to be reduced to wards of their fathers or husbands (Sacks, 1982). At the same time, there is heterogeneity across Africa in the structure of family power. Circumstances range from the powerlessness described by Sacks to the greater independence found in western and middle Africa, for example. This greater autonomy can be partially credited to high levels of polygyny, which render each wife and her children a separate economic unit. This independence is compromised, however, when a wife must seek money from her husband or a child's father for such expenses as medical treatment, which then involves him in the health decision making process (Caldwell and Caldwell, 1993).

One very important source of variation is the organization of family labor. In 1982, Ifeka concluded from her ethnographic work that when gender relationships are reciprocal rather than oppositional, as she suggests they often are, the balance of power—and control—tends to be more equitable. Considered as a hypothesis, this is neither simple nor trivial and merits further inquiry in other national and subnational contexts.

Other sources of female-male power and status differential are employment, class, educational level, and the relative social position of ethnic groups. For instance, compared with the majority of their female counterparts elsewhere in Africa, market women in West Africa have considerably more access to cash income; greater control over that cash, as well as over their own freedom of movement; and, perhaps correspondingly, enhanced social status. Among the Hausa, recognition is given to women who neither remarry after divorce nor engage in prostitution, but support themselves through other income-earning activities and live with their families (Coles and Mack, 1991; Pittin, 1983). In 1980, such single urban and rural Ugandan women were described as being in the forefront of social change and, even when they were not university women, they commanded prestige and respect (Obbo, 1980).

In many African countries the processes of marrying and negotiating for the most suitable partner are real factors in social change. Education, often with considerable maneuvering to obtain it, is a factor in forming unions in which women will have greater autonomy and more equity with their spouses, particularly among the elite (Bledsoe, 1990; Obbo, 1987). Additional education, such as adult evening classes, is also seen as a means to empowerment for older women, even as they remain within their traditional roles (Osuala, 1990).

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Fostering

Older women may also achieve enhanced status through the widespread practice of child fostering, which is largely in the hands of women. Studies in Ghana found that the percentages of households with fostered-in children ranged from 17 percent for households headed by a male of working age to as high as 74 percent if the head were a woman age 60 or older (Lloyd and Brandon, 1991). The practice has a variety of social and economic functions for both the fostering-out and the fostering-in families. The foster parent benefits from the child's company and labor in furtherance of her own economic and social advancement and, more broadly, the reinforcement of the larger female social hierarchy (Castle, 1995; NRC, 1993b). "Purposive fostering" (as opposed to "crisis fostering") is intended to advance a child's short- and long-term life-chances, with schooling one of the major objectives (Goody, 1982). The picture of how well that objective is achieved is mixed. Fostered-in children, especially girls, have much lower enrollment rates than do "own children," or even their nonfostered sisters in their households of origin. In theory, girls should have more options as a consequence of fostering; in practice, this might not be the case, but there is no quantification that permits a claim in either direction. It is perhaps indicative of the benefits that can accrue to female participants in kinship fostering arrangements that they are being replicated. Informal fostering arrangements based on friendship and mutual assistance are critical for women attempting to cope with the harshness of life in urban squatter settlements.

Kinship and Residence

Power may also vary according to rules of kinship and residence. Female status is enhanced in matrilineal as opposed to patrilineal societies, and several features of matrilineality contribute to women's economic and social security (Henn, 1984; MacCormack, 1989). A woman in such a society is less likely to move away from her maternal village upon first marriage and, under certain circumstances, her husband may begin to farm there. If the marriage dissolves, a divorced woman who has moved away can reactivate land rights in her maternal village much more easily than a divorced woman in a patrilineal society. In addition, her children remain with her because they belong by right to their maternal rather than their paternal kin, and she has greater assurance of continued support from her children, irrespective of the course of her marriage (NRC, 1993b). Greater power and social status also accrue to women when they move beyond the age of childbearing; this seems to be especially true, although not exclusively so, in matrilineal groups (Ngubane, 1987).

Ironically, modernization may reverse this situation. Lesthaeghe (1989) suggests that the integration of rural and urban economies and the emergence of human capital as a movable economic asset have combined to weaken the control of lineages over economic resources and decision making. The significance of the lineage has been threatened from several directions from colonial times, and women are distinctively threatened by deterioration in the power of the matriliny:

The new family code undermines the juridical basis of the matrilineal extended family which Lemba women view as the basis of their continuing social support networks.… The government's cultural engineering project, polygyny, strong patriarchal authority, and female subordination are lauded as "authentic," "traditional" social forms, while independent women are sometimes made scapegoats for economic ills.… The cultural autonomy of the Lemba maybe undermined at the same time that their economic base can no longer support them. (Schoepf, 1987)

It is also important to inspect some of the correlates of low social status. Low female status often means that not only are families less willing to expend scarce resources on the health of their girls and women, but also that those same women may accept this perspective as appropriate. As noted in the preceding section, inequality may well be exacerbated by widowhood. Status issues also affect health care practice. In some cultural settings, women are less likely than men to become physicians, and they may be unable to work in rural areas if they are unmarried. In turn, the lack of female physicians deters many women from seeking medical care, particularly in Muslim societies.

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
HIV and AIDS

The impact of the sexually transmitted diseases, including HIV/AIDS, on female morbidity and mortality is becoming increasingly well known and is discussed at length in Chapter 11 and in the Appendix to this volume. Its interactions with female roles and status have become a growing issue as the heterosexual dimensions of the epidemic have become more apparent.

Among those dimensions, perhaps the most critical touches differential power between males and females, a differential that has several interrelated origins. One is age. Women tend to become infected with HIV-1 at earlier ages than men because of the greater biological efficiency of male-to-female transmission than the reverse, an efficiency that is enhanced if either partner has another sexually transmitted infection. Infectivity in younger women is also enhanced because their partners are generally older; they thus have a higher cumulative risk of infection than the female partners of their male contemporaries. This feature of the epidemic is being translated into more severe increases in mortality among women at younger adult ages (Gregson et al., 1994).

In an analysis of the contributions of the balance of power between women and men to HIV transmission, Mason (1994) examines each possible variable. A fundamental contributor is the imbalance in standards of sexual obligations, the "double standard." As Western as the term is thought to be, it is amazingly ubiquitous. It simply means that males are generally understood to have more sexual freedom than females, and thus more sexual partners (Mason, 1994). University women in Nairobi, interviewed in a brief informal study in 1992, reported that "women get AIDS in their own bedrooms"; in other words, they are infected by husbands who have extramarital sexual partners (Amazigo, personal communication, 1992). Several studies suggest that increasing numbers of women may be choosing not to marry, anticipating that they will have more control over their ability to demand protection from potential infection in an extramarital relationship than might be the case in a marriage (Akeroyd, 1990; Bassett and Mhloyi, 1991; Carovano, 1991; Krieger and Margo, 1991). The net result is that women are faced with almost diametrically opposed options (Bassett and Mhloyi, 1991). Whatever new status single women may have acquired in some Sub-Saharan African contexts, the dominant model for an African woman, her social insurance, is maternity. To renounce that role is a kind of social death; to contract AIDS is, of course, a biological death.

Another effect of gender inequality is to increase STD prevalence: first, because women are constrained from either asking about or controlling their husband's sexual activities; second, because women are inequitably served by appropriate health facilities, or constrained by fear of stigma or inability to pay for services; third, because they may view reproductive ill-health fatalistically as part of their natural female lot; and fourth, women's limited economic opportunities may have made some sort of exchange of sex for money a necessary option. One surprising conclusion from the analysis is that the relationship of gender inequality to the use of condoms is ambiguous to a degree that commands solid, thoughtful research involving African researchers, community women, and commercial sex workers.

Despite frequent calls for a body of national and regional information concerning patterns of sexual behavior and their determinants, there remains the dilemma of heterogeneity and the risks of undue reliance on aggregate data. There are highly significant variations in sexual behavior among different population subgroups, including differentiation by residence in urban or rural areas; educational level; use and nonuse of family planning methods; and marital status, although the last is an inadequate proxy for exposure (Rutenberg et al., 1994). One of the great challenges to research will be to locate some middle-level, cost-effective, and technically modest approaches to understanding sexual behavior patterns in some practical way in this swirl of differentiation.

SOCIAL DISRUPTION AND HEALTH STATUS

War and Civil Strife

In Angola, Burundi, Chad, Liberia, Mozambique, Somalia, South Africa, Sudan, Togo, and Zaire, civil strife and general violence have been the status quo for decades. Up to 90 percent of war-related fatalities in such

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

conflict situations have occurred among civilians (Werner, 1989), and females are at particular risk. Cliff (1991) paints a harrowing picture of the situation of women and girls in Mozambique. Because of their responsibilities for gathering firewood, hauling water, and farm work, they are in constant danger of kidnapping, repeated rape, use as forced laborers, and eventual death. UNICEF (1989) estimated that 494,000 "excess" deaths in children occurred between 1980 and 1988 in Mozambique as a result of guerrilla activities; over 1.5 million people were internally displaced, and the majority of those were female (Bread for the World, 1992; Cole et al., 1992; Forbes-Martin, 1991; Shipton, 1990).

A less obvious consequence of civil instability is the need to siphon off money for defense from other sectors, usually the social sectors, which have the potential to be especially supportive of women and children (Dodge, 1990; Gellhorn, 1984; Ityavyar and Ogba, 1989; Ogba, 1989). Mozambique's annual per capita expenditure on health in 1981 was US$4.00; by 1988, it was US$0.05. In addition, the involvement of large numbers of males in military activities drastically reduced agricultural production and, consequently, GDP. The military movements of those same males were also the major factor in increasing rates of sexually transmitted diseases, including HIV/AIDS (Bastos dos Santos et al., 1992).

Refugee Status

Both war and famine produce refugees. In 1990, one-third of the world's 16.5 million refugees were in Africa, a figure that only grows. The UNDP estimated that there were 19 million refugees worldwide by 1994 (UNDP, 1994). To this must be added the 11 million internally displaced people in Mozambique, South Africa, and Sudan, and the uncounted millions in other African countries with internal displacements of one sort or another (Bread for the World, 1992; Forbes-Martin, 1991).

Once again, females suffer greatly, and they do so in large numbers. The current estimate is that 75 percent of the world's refugees are women and girls (Overhagen, 1990, cited in Heise, 1993); in Sub-Saharan Africa, that figure surpasses 80 percent (Cole et al., 1992; Shipton, 1990). As individuals with no country, they essentially have no rights to special protection; unlike their husbands, brothers, or fathers who may be fighting in the same conflict that produced their refugee situation, women and children are not protected by the Geneva Convention.

The situation of refugee girls and women is one of extreme vulnerability. They are subject to sexual violence and the possibility of abduction at every step of their exodus, from flight, to border crossings, to life in the camps (Heise, 1993). In 1984, Aitchison reported that virtually all women from Ethiopia and Somalia entering Djibouti were raped, almost as a matter of course. Given the lack of ability to earn income in any other manner, it is not surprising that refugee women come to view prostitution as self-protection, even survival; women note bitterly that the end result is the same, and they might as well earn the money. Violence follows refugee women even after resettlement in a new country: women who are raped during their journey to freedom are, for reasons that are probably of exquisite complexity, more likely to be victims of domestic violence in their new homes (Kuoch et al., 1992).

Gender Violence

Article 2 of the 1993 United Nations declaration on violence against women defines the term "gender violence" as including, though not limited to, physical, sexual, and psychological violence occurring in the family and in the community, including battering, sexual abuse of female children, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, nonspousal violence, violence related to exploitation, sexual harassment, intimidation at work, trafficking in women, forced prostitution, and violence perpetrated or condoned by the state. The central notion is that of physical and psychological harm rather than the express intent of the perpetrator (Heise et al., 1994).

Table 2-3, which displays the manifestations of gender violence across the life cycle on a global basis, makes it sadly clear that there is no stage of that cycle in which the females of the world, as a group, are categorically exempt. There are three very considerable manifestations that do not seem to be part of life in Sub-Saharan Africa: there is no reliable evidence for sex-selective abortion, female infanticide, or differential access to food or medical

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 2-3 Gender Violence Throughout the Life Cycle, All Countries

In Utero

Infancy/ Early Childhood (birth through age 4)

Childhood (ages 5–14)

Adolescence (ages 15–19)

Adulthood (ages 20–44)

Postmenopause (age 45+)

Sex-selective abortion

Battering during pregnancy

Coerced pregnancy

Female infanticide

Emotional/physical abuse

Differential access to food and medical care for girl infants

Differential access to food and medical care

Child prostitution

Child marriage

Genital mutilation

Sexual abuse by family members and strangers

Sexual abuse in the workplace

Rape

Sexual harassment

Forced prostitution

Trafficking in women

Dating and courtship violence

Economically coerced sex

Partner homicide

Psychologic abuse

Sexual abuse in the workplace

Sexual harassment

Rape

Abuse of women with disabilities

Abuse by intimate male partners

Marital rape

Dowry abuse and murder

Abuse of widows

Elder abuse

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

care for female infants in the region. At the same time, other areas indicated in the table are of great concern. Table 2-4 reports on one of those areas, spousal abuse. The percentages of women who report it are terribly high, and a number of other sources indicate that it is prevalent across the entire region (Levinson, 1989). Whether alcoholism as a subset of substance abuse is a major problem in Sub-Saharan Africa is an open question (Health, 1993). If it proves to be a significant issue, it may be expected that, as elsewhere, women will suffer disproportionately, primarily because of the drain on family income that could otherwise be used for food, health services, and school fees. Substance abuse is known to be significantly correlated with accidents (Feachem et al., 1991), homicide rates, and domestic violence and spouse abuse (Malik and Sawi, 1976).

Estimates of rape incidence are highly speculative in the developing world overall, but there are some data, and they are chilling. Rates of rape in South Africa are extremely high. In 1988, although 19,308 rapes were documented in police reports, the National Institute of Crime Prevention and the Rehabilitation of Offenders estimated that only 1 in 20 rapes is reported. If that is indeed the case, the true total would be close to 386,160 (Russel, 1991; Vogelman, 1990). That is an average of one rape every minute and a half, or 34 rapes per 1,000 adult women, compared with the U.S. rate of 18 per 1,000 women (Heise, 1993).

The question of the extent of the association between rape and sexism and how that might be defined in the African context is unknown. African female voices increasingly attest to the presence of sexism (Mazrui, 1991; Ngaiza and Koda, 1991; Osaki, 1990; Weekly Review, 1991). Public reaction to the 1991 rape of 71 girls in Meru District, Kenya, was muted in ways that have been interpreted by some analysts as sexist, and the Kenyan Public Law Institute and the Women's Bureau have issued A Guide to Women of Kenya on Rape and the Legal Process (Weekly Review 1991). The entire issue of rape in Africa, its prevalence, a more precise definition of its causes and correlates, and the nature of its impact on cohorts of females is beginning to be examined. Whatever the responses to these questions, there is little doubt that rape is profoundly bad for female emotional and physical health; what is in doubt is the ability of health and social services in Sub-Saharan Africa to deal with it in an adequate fashion.

Early Marriage

The Africa-wide perception of women as primarily wives and mothers reinforces patterns of premature childbearing and high parity. Early adolescent marriage and subsequent early motherhood are all too often negative events in the health trajectory of young Sub-Saharan African women, reflected most vividly in mounting rates of abortion among adolescents. Of those women, nearly 50 percent are married by age 18, some by age 15 (UNDP, 1991). Ages at entry into a regular sexual union vary widely across the region: proportions of women who are still single between the ages 15 to 19 range from 10 to more than 90 percent, and corresponding mean ages at first union range from about 16 to more than 21 years. Links between formation of a union and motherhood in most Sub-Saharan countries are close: women are almost as likely to have their first birth before age 20 as they are to marry before age 20. That some young women are single does not mean that they are not having sexual intercourse and, in some cases, that they are not having babies. In most of the 16 countries included in the Demographic and Health Surveys (DHS), a large proportion (37–78 percent) of single women ages 15–24 have already had a sexual relationship; 26–53 percent are currently involved in a sexual relationship; and 2–42 percent have already had a child (Alan Guttmacher Institute, 1995). In general, the median age of women at first birth in Sub-Saharan Africa is approximately two years younger than it is in North Africa, Asia, or Latin America (Arnold and Blanc, 1990).

The two primary determinants of these early liaisons are the influence of Islam and the practice of polygyny, so often a feature of patrilineal societies (Lesthaeghe, 1989). In contrast, matrilineal social structure, higher levels of female education, and urbanization are three cultural factors associated with later marriage (NRC, 1993b). Polygyny ''presupposes a large age difference between spouses and … a combination of late marriage for men and early marriage for women" (NRC, 1993b). The Islamic influence is identified with a more stringent social control of women, a control more likely to be assured through early first marriages for girls (Goody, 1973, 1976; Lesthaeghe et al., 1992). Among the many consequences of early marriage is the simple actuarial probability that

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 2-4 Prevalence of Spouse Abuse, Selected Countries, Sub-Saharan Africa

Country and Author

Sample

Sample Type

Findings

Comment

Kenya (Raikes, 1990)

733 women from Kissi District

District-wide cluster

42% beaten regularly

Taken from contraceptive prevalence survey

Tanzania (Sheikh-Hashim and Gabba, 1990)

300 women from Dar es Salaam

Convenience, from 3 districts (interviews)

60% had been physically abused by a partner

 

Uganda (Wakabi and Mwesigye, 1991)

80 women (16 from each of Kampala's 5 divisions)

House-to-house written survey; 7 women refused to answer

46% of 73 women responding reported being physically abused by a partner

An additional 7 women reported beatings by family members and another 5 reported assaults or rapes by outsiders

Zambia (Phiri, 1992)

171 women ages 20–40

Convenience, women from shanty compounds, medium-and high-density suburbs of Lusaka and Kafue Rural

40% beaten by a partner; another 40% mentally abused

17% said they thought that physical abuse was a normal part of marriage

SOURCE: Heise et al., 1994.

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

women often will be widowed quite early in their lives. Because widowhood in itself is a threat to female health, as noted earlier in this chapter, the net result is usually negative.

Another negative effect of early marriage derives from the insufficient development of most adolescent bodies for the physical burdens of pregnancy. Women in early adolescence are at the highest risk of all age groups for the cephalopelvic disproportion that causes obstructed labor, the single greatest reported cause of maternal mortality (see Chapter 4).

In addition to the increase it generates in mortality risk, early childbearing also produces physiologic sequelae that contribute to higher accrued morbidity across the female life span. One very durable effect is the development of vesico-vaginal and recto-vaginal fistulae, which are ruptures in the tissue between the bladder or rectum and the vagina (Harrison, 1983). Women with unrepaired fistulae are far more likely to experience urinary or fecal incontinence, which can sometimes be ostracizing to the point of divorce. Yet repair of such tissue traumas requires a level of surgical sophistication not widely available in the region, and perhaps out of the financial reach of women in the lower socioeconomic strata.

Finally, the early onset of childbearing extends the time span of possible pregnancy and birth. A childbearing span that begins at age 15 lasts for approximately 22 years, compared with the average 7-year span in developed countries, where the range is from ages 23 through 30. In Sub-Saharan Africa, the region with the highest parity in the world, early initiation of childbearing does more than just increase the number of children a woman will conceive and bear. Grandmultiparity also increases her chances for developing the condition that has come to be called "maternal depletion syndrome." Although definition of "maternal depletion" and the mechanisms and timing of its contribution to disability are subjects of controversy (Winkvist et al., 1992), one thing that is clear is the hazardous relationship between very early childbearing and mortality: the risk of maternal mortality for women under age 20 is twice the rate for women between ages 20 and 34 (UNDP, 1991; WHO, 1992).

Traditional Medicine

There are cultural dimensions to every part of human life. While culture always matters, there are circumstances in which it quite overwhelms other fundamental dimensions of human existence such as economic dynamics, physical environment, and other seemingly more objective facts of life.

There are large areas of female life in Sub-Saharan Africa in which cultural expectations and responses dominate health status, either enhancing that status or limiting it. Much of the data that correspond to these areas are found in ethnographic accounts of relatively small human groups and are dismissed as anecdote, usually for reasons of sample size and sampling procedure. Yet it is these essentially cultural accounts that provide the clues to the thought, values, and behavior that can submerge the noblest and most "rational" attempts to enhance health status—in our case, female health status.

As everywhere, illness and disease in Sub-Saharan Africa are both cultural and biomedical constructs, so that there is a wide range in the ways illness and disease are generated, defined, explained, and managed (Dagnew, 1984; Fosu, 1981; Gaisie, 1990; Janzen, 1978; Kloos et al., 1987).

The National Traditional Healers Association of Zimbabwe has defined 'traditional medicine' as follows:

The sum total of all the knowledge and practice, whether explicable or not,used in diagnosis, treatment, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing. Traditional medicine might also be considered as a solid amalgamation of dynamic medical know-how and ancestral experience. (Chavundaka, 1984)

What this definition does not address explicitly is the very fundamental matter of etiology—that is, the cultural explanations of why disease befalls humankind. Traditional medicine is built on a deeply rooted structure of belief and theory about the origins of illness and the maintenance of health, a structure that takes into account both spiritual and physical causation. One of these beliefs is the almost fatalistic view that physical suffering is intrinsic to the female condition. Another widely distributed explanatory structure is the set of beliefs around humoral balance in the human body and the importance of equilibrium between conditions typically described as "hot" and "cold" (Logan, 1977). Even when the definitions of these states of being and the strategies for dealing

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

with them vary—as they often do, from society to society—the concept of mental and physical balance is found in virtually every region of the world. Although the idea of balance is a reasonable medical and societal premise for healthy lives and is the basis for a large number of beneficial traditional health interventions, it is often ignored by Western medical practice.

Throughout Sub-Saharan Africa, traditional medicine is a lively and pervasive component of everyday life, and an estimated 90 percent of the population rely on traditional healers as primary health care providers (WHO, 1982). This may be because of the heritage of respect this category of health practitioner has acquired across the generations, the very positive nature of many of the health interventions such healers provide or reinforce, because such practitioners constitute the only accessible resource, or some combination of all of these factors.

Traditional Practices

Within the system that is traditional medicine are sets of what we chose to call "traditional practices," which are employed in the maintenance or restoration of what is culturally defined as "health." Some of these are tightly integrated into aspects of Sub-Saharan culture and society and may reinforce them across the life span. In childhood and adolescence, the most notable practices are early marriage and female genital mutilation; in adulthood, they include traditional practices linked to pregnancy, birth, and the postpartum period; and, in later years, they involve practices associated with widowhood.

The degree to which these practices affect female health, either positively or negatively, is almost completely unquantified. Analysis has been based largely on the amassing of anecdote, a very few in-depth studies, and extrapolations from experience elsewhere. This base of information, although incomplete, suggests that certain traditional practices in the Sub-Saharan region are strongly supportive of female health. The positive view of breastfeeding is a good example; the prescription for an ample postpartum rest period for new mothers is another. Still others remain to be identified and more systematically characterized so that they can be maintained as valued components of national and local systems of medical care or, in the cases of traditional practices that are injurious to female well-being, discouraged.

Food Prescriptions and Proscriptions

Cultural prescriptions and proscriptions of certain foods have the potential to influence female nutritional status, particularly in areas where high levels of malnutrition, iron-deficiency anemia, chronic malaria, goiter, and helminthic infestations have been documented. The ethnographic record in Sub-Saharan Africa reflects patterns of food prescriptions and proscriptions, particularly for pregnant women, that are not unlike such prescriptions and proscriptions elsewhere in the world, where they fall into three categories of concern: (1) possible harm to the fetus; (2) a precipitated miscarriage; or (3) a difficult delivery, including concerns about an overly large fetus.

At the same time, researchers do not yet have a good grasp of the volume, duration, and quality of either the positive or the deleterious effects of these traditional practices. This is partly because it is difficult to separate the effects of traditional dietary practices from the effects of overall food shortages, and partly because the monitoring and logging of actual food intake in largely illiterate human groups is difficult and costly. While these restrictions cause no harm in areas of considerable dietary diversity and affordable dietary substitutes, food proscriptions in food-deficient circumstances may affect dietary quality for pregnant women and their imminent offspring. For women of already poor nutritional or health status, any resulting undernutrition could not be helpful.

One aspect of prenatal nutritional intake that appears to reach beyond anecdotal levels toward real potential significance is the concern for keeping fetal size down. In Ethiopia, traditional birth attendants (TBA) advise pregnant women to restrict their intake of foods, including milk and vegetables, that are believed to increase the weight of both mother and baby (UNDP, 1991). Whether the intake of nonprescribed foods is adequate is unknown. It may be that nothing detrimental is happening, but since rates of low birthweight are so high in the region, some inquiry would be useful.

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Pregnancy, Labor, and Delivery

Maternal mortality rates are high in Sub-Saharan Africa, and at least some of that mortality and related morbidity can be attributed to traditional practices that need to be categorized as harmful. A recent study in Nigeria concluded that 4 percent of reported maternal deaths were attributable to such practices (WHO, 1991) and noted that, because such a large proportion of births and deaths in Sub-Saharan Africa occur outside hospital, the 4 percent figure may be a significant undercount. At the same time, the accuracy of cause-of-death attributions are so highly questionable in general that it might be more useful —and culturally neutral—to look initially in some systematic way at the practices themselves and ask whether they are, in themselves, appropriate even for populations of women in optimum health.

A crucial function in the childbearing sequence and in the perpetuation of traditional practices is the role of the TBA, trained or untrained. Because that is so directly an obstetric topic, it is addressed as such in Chapter 4.

Female Genital Mutilation

The term "female circumcision," until recently in general use, has been largely replaced by the more collective term "female genital mutilation" (FGM). FGM comprises a variety of operations that, in their most prevalent forms, go beyond circumcision of the clitoris to excision of most of the external female genitalia (Gordon, 1991).

Whatever terminology is employed, the topic is highly charged and highly complex. Not only are these traditional procedures of considerable biomedical importance (see Chapter 4), but they also exemplify the profound integration between what is medical and what is cultural, and between what is modern and what is traditional.

As preface to any scrutiny of the biomedical aspects and effects of these practices, it is important to look at what is known about their prevalence and to place them in the context to which they are so intimately and, in some cases, precisely tied. FGM is practiced extensively throughout Sub-Saharan Africa, in Oman, South Yemen, the United Arab Emirates, Malaysia, India, and Pakistan, as well as in large immigrant communities in Europe, the United Kingdom, and the United States. Somewhere in the range of 84 to 94 million girls and women in the world today have undergone some form of genital excision (Cutner, 1985; Lightfoot-Klein, 1989; Rushwan, 1990). Kouba and Muasher (1985) estimated that 5.5 million children or adolescents are operated on annually, primarily in Africa. One source (Hosken, 1992) calculates that the practice is found in at least 20 Sub-Saharan countries, and that the percentage of women who have undergone the procedure ranges from nearly 100 percent of women in Somalia and Djibouti to under 5 percent in Uganda and Zaire.

It is vital to recognize that there are differences in the extent of the practice among and within the Sub-Saharan countries. For example, approximately 70 percent of women in Burkina Faso have been genitally excised; the percentage in neighboring Ghana is around 30 percent (Hosken, 1992). There is also variation within countries: in northern Sudan, for example, 89 percent of ever-married women ages 15–49 are infibulated, while the procedure is rare in southern Sudan (Kheir et al., 1991). (The types of FGM are described from a biomedical perspective in Chapter 4.)

CONCLUSIONS

The purpose of this report, as stated in its opening chapter, is to assemble as much as possible of what is known about the biomedical dimensions of female morbidity and mortality in Sub-Saharan Africa. This has not been done before in a systematic way, and the committee believes that just as it is perilous to limit thinking about human health to biology alone, it is similarly perilous to focus on larger environments without understanding the biologic organisms with which they interact. It is surely true that there is no pharmaceutical remedy for inequitable economic and educational opportunity or for the easy victimization of females. It is equally true, however, that biomedical understanding can produce at least some of the solutions to human health problems that will persist in even the most equitable societal settings for a very long time.

Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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Page 38
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 39
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 40
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 41
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 42
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 43
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 44
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 45
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 46
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 47
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 48
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 49
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 50
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 51
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Page 52
Suggested Citation:"2 The Context of Mortality and Morbidity." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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The relative lack of information on determinants of disease, disability, and death at major stages of a woman's lifespan and the excess morbidity and premature mortality that this engenders has important adverse social and economic ramifications, not only for Sub-Saharan Africa, but also for other regions of the world as well. Women bear much of the weight of world production in both traditional and modern industries. In Sub-Saharan Africa, for example, women contribute approximately 60 to 80 percent of agricultural labor. Worldwide, it is estimated that women are the sole supporters in 18 to 30 percent of all families, and that their financial contribution in the remainder of families is substantial and often crucial.

This book provides a solid documentary base that can be used to develop an agenda to guide research and health policy formulation on female health—both for Sub-Saharan Africa and for other regions of the developing world. This book could also help facilitate ongoing, collaboration between African researchers on women's health and their U.S. colleagues. Chapters cover such topics as demographics, nutritional status, obstetric morbidity and mortality, mental health problems, and sexually transmitted diseases, including HIV.

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