Women and work
The women in the camp definitely do the majority of the work whether it’s cooking or actually building their hut. You can almost always find the woman outside cooking and the man inside their hut relaxing the tent. You also see women pretty much carrying entire trees on their backs for firewood. I have no idea how these women were able to do this. One of the sadder parts though was how ingrained this culture was, to the point where women didn’t even think it was odd that they were doing all the work.
Talking to women
One other pretty interesting thing that I noticed was the difference in talking to women when men were and were not around. When interviewing one woman, we were able to get loads of interesting information when there was no man around. However a few times we tried talking to women when there was a man present and either the man would answer or the woman would simply give us yes or no answers. In another interview, we asked to take a photo of the family and one man suggested that we take one of the men and one of the women and children.
There were lots of awesome GBV interventions happening in Sherkole. IRC, the partner in charge of the program, switched the name to Community Wellness to help remove the stigma associated with GBV. Unfortunately now it’s harder for refugees to know what CW is about. The Sherkole camp also had a women’s group which had lots of participation. The Bambasi camp didn’t have a women’s group setup yet, but all of the women I talked to said that they would join one if it existed which I thought was encouraging.]]>
Lesbianphobia or “Lesbianofobia” can result in a murder. Such was the case in Cordoba, Argentina Natalia “Pepa” Gaitan was assassinated by her girlfriend’s stepfather (2). Her girlfriend, Silvia, was 16 years old and was kicked out of her house by her family when she told them she was dating Pepa. Pepa then asked Silvia to move-in with her because even her extended family wasn’t comfortable with her sexual orientation. Pepa confronted Silvia’s parents and was killed by Daniel, Silvia’s stepfather. The trial took over a year to initiate and Daniel was eventually given just 14 years in prison. Pepa’s murder shows how hate crimes against women based on their sexuality still happen in liberal countries of Latin America and that they’re also forgotten or not punished sufficiently.
Discrimination based on sexual orientation ostracizes women and can take a toll on their mental well-being. They can immediately become homeless and lonely such as Pepa’s girlfriend. Studies have shown that urban and educated communities are more accepting of homosexuality. As I have stated in my other blogs, education is a powerful tool that buffers against health disparities and in this case can even prevent them.
Buenos Aires, Argentina recognizes the power of education and provided all healthcare workers with guides to stop discrimination based on gender and sexual orientation in hospitals. These workers have since gone to their homes and spread the knowledge that lead to their tolerance and acceptance. Small interventions like these initiate dialogue about something foreign and maybe even taboo as homosexuality and the knowledge gained eliminates the stigma.
The most common causes of maternal death are as follows: severe bleeding (post-partum hemorrhage), infections (sepsis), high blood pressure, obstructed labour and unsafe abortions. Most of these ailments are preventable or manageable, and certainly should not be causes of death.
Several key things are contributing to the issues listed above. Women often are slow to seek professional medical attention leading to a late diagnosis. This can be caused by a lack of financial resources, ignorance or other issues. Transportation is often a prohibiting factor as well; it can take long periods of time to transfer women to health facilities that have adequate resources to treat them. This means that emergency care is often unavailable. And even when women reach appropriate facilities the quality of is often poor
Family planning is desperately needed as well to prevent unwanted pregnancies. Not only would family planning keep women safer from complications but would allow them to have more sustainable financial situations as well.
Rwanda, Malawi, Niger and Uganda are all similar in that there is a general scarcity of resources and all receive a large amount of external aid. However progress in addressing maternal health mortality has been uneven across the four countries. Malawi and Rwanda have made much better progress. Interestingly when we look at health expenditure per capita, Uganda has actually increased the most but still had little improvement; Niger is similar.
In Rwanda, family planning, antenatal care and deliveries in health centers are all on the rise. But why? It seems to be an effective response to a public education campaign. The campaign stresses the importance of the activities listed above fore the health of the mother and her children. A system of fines has even been imposed on women who fail to attend antenatal care or deliver in health centers.
How is Rwanda addressing the problem of transferring women to appropriate health facilities? They have implemented a health insurance scheme which coves 90% of the cost of ambulance transfers. Voluntary community health workers have been issued with specifically programmed mobile phones so they can contact health facilities for referrals and advice. This efficient and cost effective system is cutting down on maternal mortalities due to transportation problems.
Rwanda’s infrastructure is better suited to ensure that quality of care is high. Their clinics are not over run and sanity is kept as a priority. But why is Rwanda able to accomplish this and its transportation improvements? Firstly because of policy. Performance standards are being enforced, ensuring that care is professional. Second is problem solving initiatives. Rwanda has groups that are specifically targeting the key bottlenecks that are crippling the Ugandan and Niger health systems. This targeted approach allows Rwanda to improve their system while still operating at low costs.
In Niger a presidential decision abolished fees for pregnant women to receive healthcare, and while the policy was likely done with good in mind, the decision nearly led to the collapse of the health system. The appropriate research was not done and triggered a massive increase in demand. A demand so high the system could not keep up. Rwanda on the other hand has had a strong policy of encouraging citizens to subscribe to the nationwide heath insurance scheme, which has proven successful.
Overall we see with the success of Rwanda in many of these areas that the massive issues facing sub-Saharan Africa are indeed fixable problems. With specific-problem solving, policy involvement, education initiatives and cost effective solution, real change can be made to the field of maternal health, and healthcare in general.]]>
This intervention had two components: group counseling and stress management. The group counseling involved ventilation and reassurance and the stress management involved strengthening of coping skills and a relaxation technique. Each session would begin with a group song written by the local women with lyrics emphasizing that life was a cycle of joy and sorrow and sharing and problem-solving in the group could help one face it better. The women would then share or “vent.” The rest of the group would then provide reassurance and coping suggestions for the woman sharing. The session would ending with a relaxing breathing exercise.
Women in the mental health intervention group reported reduction in psychological distress and bodily aches and pains. The majority of the women said that the quality of their sleep improved, which allowed them to carryout their daily tasks without pain and fatigue. Interpersonal problems such as not having a male child and problems with in-laws, were a great source of stress for the women and they said that being able to share their problems with other women in the intervention helped them feel “unburdened” and “lighter.” The women did not have to ruminate over problems in their heads because they could share them with the group. The social support they felt from the other members of the group made gave them a sense of camaraderie in facing the challenges of their lives. The group was a mix of ages, which allowed the young women to learn from the wisdom of the older women and the younger women, who were able to more quickly learn new things could assist the older women.
Here is an example of how one woman’s sharing and the group’s feedback helped improve the woman’s life tremendously. In a group session, the woman told her story about her husband’s chronic illness and his inability to work. She had to care for her husband, in-laws and children and was not making enough money off of their land to do so. A member of the group suggested that she could start a small business to supplement the agricultural income. The woman responded that she could not because her spouse and mother-in-law were against the idea of women engaging in economic activity outside of the house. The group members solved this problem by giving her the idea her to start a small business of selling food products that she could make in the house. They then helped her market her new company. The business ended up being a complete success and even expanded to where they could hire employees.
This intervention not only increased mental health but increased economic opportunity and security for the women in the community, which will feed back positively on mental health from increased feelings of purpose and independence.
Rao, K. Community-Based Mental Health Intervention for Underprivileged Women in Rural India: An Experiential ReportInternational Journal of Family MedicineVolume 2011 (2011), Article ID 621426, 7 pagesdoi:10.1155/2011/621426
Throughout this blog I have often commented that fundamental aspects of refugee camps, like layout, are essential in consideration of the needs and needed protections for refugee women. We have already seen that the need for firewood increases women’s threat of sexual violence by taking them outside of the perimeter of the camp. This week we will briefly explore interventions through water provision, and the impact and implications for female refugees.
There are many organizations working to improve water, sanitation, and hygiene (WASH) services within camps. Though women’s safety may not be at the forefront of pushes for these interventions, the implication of their implementation on women’s health and safety is promising. One organization, Oxfam has been very active in the refugee situation and migration caused by conflict in Sudan. Oxfam has been focusing on interventions that not only provide refugees with better access to essential resources, but also curb the spread of disease. Oxfam has helped the Upper Nile River refugees to build their own water towers from scratch, providing them with a clean, convenient water source, helping about 30,00 people since 2012. The organization also constructed water wells in northern Sri Lanka, benefitting 80,000 people with a clean source of water. One resident of the camp in Sri Lanka stated:
My family and I have at last returned home to Mannar, after more than five years away. It has been very difficult for us, having to abandon our home, possessions and livelihoods. Clean water means I will no longer have to worry about my family drinking contaminated water.
Another attempt to provide clean water to refugees comes from the International Organization for Migration. The IOM, too, is focusing on Upper Nile refugee camps, with the purpose of introducing 366 new latrines. The latrines not only provide a clean water source, but also are expected to decrease incidence of Hepatitis E cases, quickly spread through consumption of water contaminated by feces. At least 3 camps in the Upper Nile has experienced Hepatitis E breakouts or another breakout of waterborne disease; there is an obvious need for intervention.
Now, is our turn to think critically. Though these interventions were not specifically designed to decrease the travel of female refugees to access water, we can still think about the implications for women’s safety. Cleaner, more accessible water lowers the chance of women leaving the camp to retrieve essential supplies. This in turn lowers her chance of being attacked or exploited under these conditions.
What other implications for women’s health and role in refugee camps can you see being a result of providing cleaner water to refugees?
Photos of Oxfam Interventions: http://www.flickr.com/photos/oxfam/sets/72157631587477695/
One example of this occurred in 1920 when women in the US got the right to vote. Politicians now catered to their enlarged electorate population and started to incorporate issues on child heath, public schools, and there was a decline in maternal morality as a result (1). Allowing women to have a voice and be contributors will start the change needed to increase global access to health care. Women are slowly gaining traction in the public sphere, in 2011 women in Saudi Arabia were permitted the right to vote (although they have yet to vote in an election)(2). Although this is a great and progressive step I think it in an issue if women’s suffrage is still being debated rather than universally accepted. Including women politically and as community leaders is an essential step to bring women’s issues, specifically women’s health, to the forefront of discussion. I also think it is essential that female community and political leaders bring the necessary changes to their communities from the inside rather than having these changes imposed by international and foreign aid. It has been shown to change individual and community health outcomes and I think women themselves need to be involved in the discussion to be able to advocate for themselves.
For my final blog post, I would like to share the following clip:
Please watch even the first few minutes of this video before reading the rest of this post. The video, “Creating a world as it should be: the power of disabled women activists,” documents the powerful messages of 54 disabled women activists from 43 different countries. Each woman is interviewed to get her opinion on how the international and domestic communities should respond to disabled women and girls. The recurring theme that these women beautifully and loudly portray is that disabled women and girls are pitied, or “considered hopeless” by many governments and by many people, even subconsciously. These women stress the importance of independence. They want to be given the opportunity to advance in society.
They remind us that to do this, to be given the right opportunities, the rights of disabled women and girls needs to become “mainstreamed.” In other worlds, it is time that this issue becomes a priority on the international human rights agenda. Mainstreaming disability perspectives in gender-related work, gender equality and women’s empowerment work is crucial to making progress for disabled women and girls.
Ekaete Umoh, the director of the Family Centered Initiative for Challenged Persons in Nigeria, commented that, “wear everywhere, yet people do not seem to see us.” Thus far, the rights of disabled women and girls has been a “fringe” issue—an issue fought by distinct groups of people, often only those affected by disability either themselves or through family or friends. Disabled female activists like Umoh, who was interviewed in the video above, have been fighting for their rights on their own.
I want to stress the importance of intervention on the international level as initial motivation for community-based intervention. 143 countries signed the UN Convention on the Rights of Persons with Disabilities on December 13, 2006. The articles of the convention, of which Article 6 was written to specifically address the Rights of Disabled women and children, are to be used as a human rights instrument with a social dimension. The language stresses “mainstreaming” the rights of disabled persons as part of the human rights agenda. Article 1 states,” the purpose of the present Convention is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by persons with disabilities, and to promote respect for their inherent dignity.”
However, only 71 countries ratified the Convention. It is ratification of the Convention that actually ensures a nation, its governments, and successive governments fully accept the immediate legal requirements of the convention and agree to its implementation and monitoring. In many countries wherein the Convention has been ratified, Community –based rehabilitation (CBR) programs (which are oftentimes designed and co-funded by the WHO and other NGOs working within the country) have been implemented successfully. CBR programs support people with disabilities in attaining their highest possible level of health through health promotion prevention, medical care rehabilitation and assistive devices. VBR facilities advocate for services that accommodate the right of people with disabilities. And most importantly, CBR programs focus on helping disabled persons develop a high level of confidence and independence. Several beneficiaries of CBR programs have spoken to the success and important of the programs to their personal development.
One such success story comes from Muhammad Akra, a man from Sindh Province, Pakistan. He became deaf as a teenager due to an illness. Akra described visiting the doctor as a dependent before entering a CBR program and becoming confident and independent: “Being deaf I was always unaware of what they were talking about. If I asked the doctor a question he usually replied that he had told my family everything. And if I asked my family a question they always said “don’t worry, nothing special” or “we will tell you later.” Nobody really told me anything – I just had to take the tablets. No-one used sign language and nobody had the time or willingness to communicate with me using pen and paper. Over time I began to lose my confidence and became very dependent on others. After joining a CBR Programme I slowly gained confidence and developed the courage to face the challenges myself. I started refusing to take a family member with me to the doctor. This forced the doctor to communicate with me directly in writing. Some doctors still ask me to bring someone with me on my next visit but I always tell them that I am an adult. I feel good as I have developed self-confidence and have also helped to raise the profile of disability by educating medical professionals.”
There needs to be an increase in the number of countries that not only sign, but RATIFY the Convention on the Rights of Persons with Disabilities. Ratifying such an international convention is the first step in enhancing the importance of the rights of disabled women and girls on the national level. I hope to see an increase in ratification and, along with it, the implementation of more international CBR programs on the domestic level.
“Community Based Rehabilitation Guidelines.” World Health Organization. 2010.
“Convention on the Rights of Persons with Disabilities.” The United Nations Enable: Development and Human Rights for All. http://www.un.org/disabilities/default.asp?navid=14&pid=150.
Jolly, Debbie. “The UN Convention on the rights of Persons with Disabilities.” The European Network on Independent Living, 2010. <http://whqlibdoc.who.int/publications/2010/9789241548052_health_eng.pdf>.]]>
In recent decades, there has been significant progress toward the goal of universal primary education as a civil or human right. More children enrolling in and completing primary education has increased demand for secondary education, but it is very difficult for children to remain in school, especially in developing countries and particularly for girls. Money and home responsibilities are major barriers. MacArthur’s investment in secondary education strengthens other Foundation initiatives such as reducing maternal mortality and promote young women’s reproductive health. It creates possibilities for girls who have suffered human rights violations in conflict-ridden zones such as northern Uganda to be reintegrated into society. Secondary education also expands opportunities for female entrants into higher education in places like Nigeria, where MacArthur has worked for over ten years with some of the country’s leading universities. The MacArthur Foundation has a lot of funds to distribute worldwide, but its choice to invest in women’s health and education is especially important.
In my last blog post I want to look towards the future and bring the conversation about maternal mortality full circle. In my first post I introduced the United Nations Millennium Development Goal (MDG) to improve maternal health. This ambitious goal includes two targets. First, reduce the maternal mortality ratio by three quarters from 1990 to 2015 and second, by 2015 achieve universal access to reproductive health (1). I highlighted the country Laos who announced in 2009 that the country would not be able to reach the MDG target. With only two years left before 2015, where does the rest of the world stand? What is our progress and where are we heading?
At the 2013 Global MDG Conference a week ago, Helen Clark the Administrator of the UN Development Program acknowledged maternal mortality reduction and universal access to reproductive health as areas where too little progress has been made in terms of the goals and targets that were set in 2000 (2). Of the 189 nations that made this promise to women by signing the United Nations Millennium Development Goals, 181 were analyzed in a study published by The Lancet in 2010. The analysis concluded only 23 countries were on track to achieve the 75% decrease in the maternal mortality ratio by 2015 (3). This predicted outcome is disheartening and on an artificial level appears that little headway has been made for women’s reproductive health.
A closer analysis of the data shows gradual process. The global maternal death rate estimated in 2008 was 342,900 compared to 526,300 in 1980 and experts in the field agree that the maternal death rate is a third less than in the past three decades, still short of the MDG goal, but nonetheless is progress (4). The Lancet study notes global progress in the reduction seen in the maternal mortality rate is not surprising because four crucial drivers of maternal mortality are improving worldwide (3).
An eminent supporter of women and children’s health, The Bill & Melinda Gates foundation in September 2011 announced the investment of $35 million in funding for innovative ideas in family health. The objective of the grants is to engage the world’s scientists and entrepreneurs in creating revolutionary breakthroughs for health challenges facing women and children (5). Melinda Gates recognized for her philanthropic focus in women and children’s health voiced her frustration this past January about the quality of data surrounding global health issues. She argues measurement is crucial in identifying appropriate interventions to improve maternal mortality and is necessary to set clear goals and track progress in order to make substantial improvements in the field (4). Looking towards the future and facing the prospect of poor outcomes for the MDG maternal health goal we need to develop tools that allow us to accurately track the maternal mortality rate, its causes per community, and rate the efficacy of the interventions we champion.
A new tool created by The United Nations Children’s Fund to help policymakers and community health workers understand high rates of maternal mortality is called the Maternal and Perinatal Death Inquiry and Response (MAPEDIR). Rather than recording a maternal death and as a statistic, MAPEDIR aims to sensitize communities to the health issues that lead to birth complications, provide an investigative report into maternal deaths by interviewing family members to determine biological and social causes, and analyzing the data to develop high impact social interventions (6). It is the hope that MAPEDIR will improve the data we have to access maternal mortality.
There are numerous organizations worldwide on the local, national, and global scale that focus their efforts on improving women and children’s health and in solidarity aim to reduce the maternal mortality ratio. Throughout my posts I have highlighted interventions that utilize design to increase access to emergency care, harness technology to improve health, and health policies enacted to save women the horrible fate of maternal death.
Although we have come a long way in reducing maternal mortality compared to where we were decades ago, there is still a lot to be done in order to prevent the needless deaths of women and ensure all women their right to reproductive care, autonomy over their bodies, and personal vitality.
Philippine reproductive health bill and abortion
As I mentioned a few weeks ago, the recently enacted Responsible Parenthood and Reproductive Health Act of 2012 was a very divisive piece of legislation that faced strong opposition from the Catholic Church. In another blog post, I discussed the issue of abortion in the Philippines, and how it is criminalized and stigmatized within society. While the reproductive health bill aims to improve reproductive health and increase access to contraception among the nation’s poorest, there are still several issues that detract from improving reproductive health throughout the country. One issue is that the law continues to criminalize abortion, which is a major setback to women’s reproductive health.[i] Also, despite the health bill’s requirement for schools to provide sex education, schools can opt out of sex education because of religious grounds.i After looking into the bill further, I also found out that the bill’s supposed ‘universal access’ to contraception is limited to only 5 million households that are identified as ‘poor’ by the government.i
These setbacks are unfortunate, as they will likely hinder the potential to significantly improve reproductive health particularly for the nation’s poorest. As the Catholic Church continues to have a strong influence on Philippine health policy, I don’t see the nation’s stance on abortion changing anytime soon. While I applaud the nation’s policymakers for recognize the importance of improving reproductive health, I hope the Philippines can implement the positive aspects of the bill and make tangible gains in increasing access to reproductive health services for impoverished women.
Improving access to maternal health care in rural communities
In my past blog posts, I have also discussed geography and low resources as barriers to health care for women living in isolated, rural parts of the Philippines. I want to discuss another project aimed at improving maternal health care by improving the local health system in its provision of maternal and child health services. “Project for Cordillera – wide strengthening of the local health system for effective and efficient delivery of maternal and child health services” is a joint program started by the Philippine Department of Health and the Japan International Cooperation Agency with the aim to reduce maternal and neonatal death. [ii] The project started two years ago as a pilot program in the provinces of Abra and Apayao, and during this pilot, the project trained 100 health professionals and supplied basic emergency obstetric care equipment to eight hospitals and nine rural health centers.ii This year, the project aims to upgrade community health centers to be adequate birthing centers by supplying additional equipment, training more health care providers, and increasing education to pregnant women on maternal health and giving birth.ii By improving the local maternal health system in underserved communities, the project aims to encourage women to give birth in community health centers, where the availability of more equipment and trained health care providers (as opposed to giving birth in a home) may help reduce the risk of maternal mortality.ii As the pilot program has just taken off, I hope that this project can be implemented on a larger scale to help bridge the gap between the demand for more maternal health services and the nation’s available resources and health care providers.
In summary, I think I have learned a lot about the complex issues involving reproductive and maternal health in the Philippines, from abortion to cervical cancer to contraception. I have also learned so much about the complicated relationship between society, government, and religion in this nation. While the Philippines has a long way to go in improving maternal and reproductive health especially among the nation’s poorest, the positive interventions I researched help me remain hopeful that the country is headed in the right direction.
[i] Pastrana, Dante. Philippine reproductive health bill continues to illegalize abortion. World Socialist Web Site. http://www.wsws.org/en/articles/2013/02/22/phil-f22.html
[ii] Bitog, Rubyloida. Groups urge pregnant women to give birth in health centers. Sun Star Baguio. http://www.sunstar.com.ph/baguio/local-news/2013/03/07/groups-urge-pregnant-women-give-birth-health-centers-271615