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Sexual exploitation of children Gender-based violence is a continual threat to women and children during armed conflict. Adolescent girls are particularly vulnerable, especially in areas where the spread of AIDS/HIV has not been so high. They may not be safe even in the refugee camps to which many have fled, and rape may be used as a form of torture, or a tactical weapon, to weaken the morale of the opposition. Children can also become victims of child prostitution rackets, being taken from the scenes of fighting to brothels in other countries in exchange for food and shelter. Governments must hold those who commit rape in conflicts accountable and must reform their national laws to address the substantive nature of the abuse. Unwanted pregnancy resulting from forced impregnation should be recognised as a distinct harm, and appropriate remedies provided' (UN 1996). The main perpretators are usually the armed forces themselves, so military training must emphasise responsible behaviours towards women and children, and offenders must be prosecuted and punished. But it is also important that refugee camps should be designed so that essential facilities can be made more secure, and more women should be involved in their administration. Effective programmes must be set up to help women who have suffered traumatic experiences to regain control of their lives, and assist those who have to raise children without adequate economic and social support. Sexual exploitation and gender-based violence. In: The impact of armed conflict on children: briefing notes on the final report. New York: United Nations, 1996
Commonwealth Medical Association Workshops Following the International Conferences on Population and Development (Cairo 1994) and the Fourth World Congress on Women (Beijing 1995), the Commonwealth Medical Association has held workshops in some countries concentrating on the health of women and young people as being the groups in developing countries who are most at risk. Three of these conferences were reported in the March issue and two more are reported here.
Women's Health in Malawi The Malawi government is committed to improving women's health. However, two conditions need to be met before the necessary changes in health information and services can be introduced: 1) health professionals must be sensitised to the impor-
tance of women's health and; 2) they must be less critical and judgemental of women and respect their right to confidentiality, so that women are prepared to consult health professionals as a matter of course rather than as a last resort. A recent Medical Association of Malawi/Commonwealth Medical Association (MAM/CMA) workshop identified the problem areas as:
1. Pregnant teenagers. This is one of the most serious problems in Malawi today, babies are having babies. Teenage mothers have a higher maternal mortality rate, receive less prenatal care and have a higher rate of drop-out from school. This lack of education, with its subsequent economic implications, leads to a vicious circle of health and welfare problems. 2. HIV/AIDS and women and children. The incidence in Malawi is increasing, mainly via heterosexual sexual intercourse and transmission from mother to baby. Active educational programmes for all are an essential part of combating this problem. Women most at risk often live in rural areas where the prevention publicity messages do not reach them. Literacy rates are low, making educational pamphlets so much wastepaper, and radio messages are missed because many families cannot afford a radio. Low literacy increases the problem in another way, unemployment. Economic security for women is only available via marriage and childbearing and in a situation where a woman is expected to comply with her husband's wishes and not question his authority it can be difficult for her to put into practice whatever she may learn about safe sex. The situation is aggravated by male migrations to urban areas to seek better employment opportunities. In the towns, separated from their wives, they may frequent female sex workers, become infected and then return home to infect their wives. 3. Maternal mortality: a perpetual cloud of fear and uncertainty. In Malawi an estimated 620 women die out of every 100 000 pregnant women, an appalling statistic mainly owing to the high fertility rate and the lack of access to health services. Abortion, under pitiful conditions, is a frightening method of controlling fertility. Worldwide surveys reveal that if effective contraception was available to everyone who wished to use it, births would be reduced by 35% in Latin America, 33% in Asia and 17% in Africa. Maternal deaths would be reduced in the same proportions or, given the high mortality rate of induced abortion, by even more. The proportion of births attended by trained health-care workers has a clear relationship to the rate of maternal mortality. Studies in Ethiopia and Zimbabwe have shown that even quite simple planned prenatal and intrapartum
107
care causes an immediate drop in maternal mortality. 4. Maternal and child health. The provision of such services must be based on facts about needs and must be well planned to be effective and efficient in their costs and benefits. 5. Role of medical ethics. The need to be guided by the four principles of biomedical ethics: i. Autonomy: personal liberty of action for the individual, ii. Non-maleficience: to 'do no harm' but use abilities and skills to help the needy, iii. Beneficience: to wish good for the other, iv. Justice: that everything shall be done in fairness, and that care should be available for all. Participants in the workshop identified a broad range of medical, legal and social problems which needed to be addressed. Organisations pledged to work with the Medical Association of Malawi to ensure that an appropriate package of sexual and reproductive health measures will reach the women of Malawi. It was recognised that it was necessary to involve politicians in the cause of better health for women and it was agreed that the outcomes of the workshop would be shared with them and with the Ministries of Health, Education and Women' s Affairs. Report of a workshop in Lilongwe, Malawi. September, 1996.
Women's health in Uganda In many countries, such as Uganda, women's health is not an issue. If women survive it is by accident rather than because of any effective care programme, particularly since AIDS and related disorders have become a central feature of reproductive health. This is because of the meagre per capita health sector allocations, and because of general poverty. Health care in the private sector is very expensive, which reinforces the problem. Women have unique requirements for health care. The hazards of reproduction are exacerbated by violence, rape, female genital mutilation, lack of power over their lives, overwork and underfeeding. In all areas men are deemed to be 'more important'. Statistical data on women's health in Uganda is limited, but it is acknowledged that much work is needed to improve health-care opportunities for women. Women are crucial to social and economic development and their health will affect the health of future generations. Women play a crucial role in the agrarian economy, tilling the land, planting and har-
108
Midwifery
vesting crops and caring for the whole family. They form 65% of the total labour force and their well-being is, therefore, vital to the economy. In Uganda women's development is impeded by poverty. The general population is poor, but women bear the brunt of this because of their nurturing role in society. Women work on average 14-18 hours a day and sleep only 4-6 hours. More is expected of them than of their male counterparts and they are constantly under stress. Despite this, women are still regarded as belonging to the 'weaker sex' and are treated as second class citizens with fewer educational and employment opportunities. A woman has no human rights. Examples are quoted of women who have been tortured and beaten because they have failed to deliver vaginally. If a woman fails to deliver vaginally it is considered to be because bad spirits are around and something must be done to appease them. This appeasement is more important than obtaining appropriate medical care for the woman concerned. Given the very strong 'boy preference' it is fortunate that there is no pre-natal sex selection, but the importance of producing sons leads to women producing more children than is economically viable or physiologically safe. There is an inevitable increase in morbidity and mortality. In some work places it is a crime to get pregnant or to breast feed, although the men who decree this have wives at home who they expect to do just that. These double standards lead to many problems including concealment of pregnancy, increased abortion rates and low levels of breast feeding. Traditional beliefs hamper women's development and opportunities. Women belong to their families who have often paid an expensive bride price and value must be obtained from the investment. In spite of the prevalence of HIV/AIDS, wife sharing and widow inheritance is still practised. In Uganda maternal mortality ranges between 500-1120 per 100000 live births. Infant mortality is officially 97 per 1000 with high perinatal mortalities contributing 45-50% of this figure. Contraceptive usage is a mere 15%, and only 33% of deliveries are assisted by trained personnel. The situation is desperate and the Ministry of Health programme on Safe Motherhood recognises the need for change. Political support is needed to increase budget allocation for health services, especially for emergency
obstetric care. Delivery personnel must be adequately educated and trained, and health units must be appropriately equipped to handle emergencies. Transport and communications are areas which need attention and funding. In rural areas, where bridges are regularly washed away, referral of women with problems is impossible because they are unable to travel to hospitals with more facilities. Women need adequate nutrition, antenatal care, maternal care, transport and communications, well trained health workers, well-equipped health centres, the support of their husbands and families, and a knowledge of their own worth. Even the basic infrastructure is hostile to women's development. Inadequate support in terms of water and sanitation facilities affect poor women in particular. Women have most frequent contact with water, which increases their exposure to water-borne diseases. Women can be forced to spend more than 25% of their calorific intake fetching water. The resulting comprised nutritional status can lead to deficiencies such as anaemia and lack of vitamin A, and the physical strain of carrying water can lead to many physical problems. The proposed changes challenge the existing social order and, therefore, assume a political status which requires long-term political commitment. Women's organisations are central to strategies for empowermerit, and can assist women to learn ways to change and improve their status. Women's health problems have much to do with their lack of control over social resources and societal arrangements which do not favour women. Women's empowerment and social change are the key measures needed to promote women' s health. Report of a workshop, Kampala. September 1996
Dates for your diary Advance notice The International Confederation of Midwives 25th Triennial Congress will be hosted by the Integrated Midwives Association of the Philippines Inc at the Philippine International Convention Center, Manila from May 22 to 27, 1999. The theme will be Midwifery and Safe Motherhood: beyond the Year 2000. For further details please contact: The Secretariat, 25th ICM
Triennial Congress, Integrated Midwives Association of the Philippines Inc, Pinaglabanan corner Ejercito Streets, San Juan, Metro Manila, PO Box no SJPO 175346. Fax: +63 2 70 53 35. Johns Hopkins Sixth Annual multi-disciplinary update on Obstetric Anaesthesia, 23-24 Aug 1997, Renaissance Harborplace Hotel, Baltimore, Maryland, USA. For further information contact: Office of Continuing Medical Education, Johns Hopkins Medical Institutions, Turner 20, 720 Rutland Avenue, Baltimore, MD 21205-2195, USA. Tel: (410) 955-2959; Fax: (410) 955-0807; e-maih cmenet@ som.adm.jhu.edu; web-site: http://ww2. med.jhu.edu/cme.
Nurse Education Tomorrow: Eighth Annual Participate Conference for Education in Health Care, 2-4 Sep 1997, University of Durham, England, UK. For further information contact: NET Conference Administration, Suffolk Educational and Training Services Ltd, Suffolk College, Rope Walk, Ipswich, Suffolk IP4 1LT, UK. Tel: +44 1473 296642; Fax: +44 1473 216416. Sharing visions for global midwifery: Midwifery Today International Conference, 6-10 Nov 1997, London, England, UK. Fee: (full subscriber - whole conference) £240AJS$375 up to 16 Jun 1997, then it increases; (non-subscriber whole conference) £275/US$425 upwards as above; rates for part or whole days also available. For further information contact: Midwifery Today, PO Box 2672-597, Eugene, OR 97402, USA. Tel +1 541 344 7438 or +1 800 743 0974; Fax +1 541 344 1422; E-mail: Midwifery@ aol.com. ICM Europe - German-speaking Region Workshop, 8-9 Nov 1997, Institute for Further Medical Education, Prague, Czechoslovakia. For further information contact: Bund Deutsche Hebammen e.V., Steinh~iuser Strage 22,76135 Karlsruhe, Germany. ICM Europe - French-speaking Regional Workshop, 2-4 December 1998, Montpelier, France. For further information contact: Ruth Brauen, Av de Chailly 67, 1012 Lausanne, Switzerland. VIII. Deutsehen Hebammenkongress, 11-13 May 1998, Bremen, Germany. For further information contact: Isolde Brandst~idter, Christmannsweg 33, 79206 Breisach, Germany.
Sexual exploitation of children Gender-based violence is a continual threat to women and children during armed conflict. Adolescent girls are particularly vulnerable, especially in areas where the spread of AIDS/HIV has not been so high. They may not be safe even in the refugee camps to which many have fled, and rape may be used as a form of torture, or a tactical weapon, to weaken the morale of the opposition. Children can also become victims of child prostitution rackets, being taken from the scenes of fighting to brothels in other countries in exchange for food and shelter. Governments must hold those who commit rape in conflicts accountable and must reform their national laws to address the substantive nature of the abuse. Unwanted pregnancy resulting from forced impregnation should be recognised as a distinct harm, and appropriate remedies provided' (UN 1996). The main perpretators are usually the armed forces themselves, so military training must emphasise responsible behaviours towards women and children, and offenders must be prosecuted and punished. But it is also important that refugee camps should be designed so that essential facilities can be made more secure, and more women should be involved in their administration. Effective programmes must be set up to help women who have suffered traumatic experiences to regain control of their lives, and assist those who have to raise children without adequate economic and social support. Sexual exploitation and gender-based violence. In: The impact of armed conflict on children: briefing notes on the final report. New York: United Nations, 1996
Commonwealth Medical Association Workshops Following the International Conferences on Population and Development (Cairo 1994) and the Fourth World Congress on Women (Beijing 1995), the Commonwealth Medical Association has held workshops in some countries concentrating on the health of women and young people as being the groups in developing countries who are most at risk. Three of these conferences were reported in the March issue and two more are reported here.
Women's Health in Malawi The Malawi government is committed to improving women's health. However, two conditions need to be met before the necessary changes in health information and services can be introduced: 1) health professionals must be sensitised to the impor-
tance of women's health and; 2) they must be less critical and judgemental of women and respect their right to confidentiality, so that women are prepared to consult health professionals as a matter of course rather than as a last resort. A recent Medical Association of Malawi/Commonwealth Medical Association (MAM/CMA) workshop identified the problem areas as:
1. Pregnant teenagers. This is one of the most serious problems in Malawi today, babies are having babies. Teenage mothers have a higher maternal mortality rate, receive less prenatal care and have a higher rate of drop-out from school. This lack of education, with its subsequent economic implications, leads to a vicious circle of health and welfare problems. 2. HIV/AIDS and women and children. The incidence in Malawi is increasing, mainly via heterosexual sexual intercourse and transmission from mother to baby. Active educational programmes for all are an essential part of combating this problem. Women most at risk often live in rural areas where the prevention publicity messages do not reach them. Literacy rates are low, making educational pamphlets so much wastepaper, and radio messages are missed because many families cannot afford a radio. Low literacy increases the problem in another way, unemployment. Economic security for women is only available via marriage and childbearing and in a situation where a woman is expected to comply with her husband's wishes and not question his authority it can be difficult for her to put into practice whatever she may learn about safe sex. The situation is aggravated by male migrations to urban areas to seek better employment opportunities. In the towns, separated from their wives, they may frequent female sex workers, become infected and then return home to infect their wives. 3. Maternal mortality: a perpetual cloud of fear and uncertainty. In Malawi an estimated 620 women die out of every 100 000 pregnant women, an appalling statistic mainly owing to the high fertility rate and the lack of access to health services. Abortion, under pitiful conditions, is a frightening method of controlling fertility. Worldwide surveys reveal that if effective contraception was available to everyone who wished to use it, births would be reduced by 35% in Latin America, 33% in Asia and 17% in Africa. Maternal deaths would be reduced in the same proportions or, given the high mortality rate of induced abortion, by even more. The proportion of births attended by trained health-care workers has a clear relationship to the rate of maternal mortality. Studies in Ethiopia and Zimbabwe have shown that even quite simple planned prenatal and intrapartum
107
care causes an immediate drop in maternal mortality. 4. Maternal and child health. The provision of such services must be based on facts about needs and must be well planned to be effective and efficient in their costs and benefits. 5. Role of medical ethics. The need to be guided by the four principles of biomedical ethics: i. Autonomy: personal liberty of action for the individual, ii. Non-maleficience: to 'do no harm' but use abilities and skills to help the needy, iii. Beneficience: to wish good for the other, iv. Justice: that everything shall be done in fairness, and that care should be available for all. Participants in the workshop identified a broad range of medical, legal and social problems which needed to be addressed. Organisations pledged to work with the Medical Association of Malawi to ensure that an appropriate package of sexual and reproductive health measures will reach the women of Malawi. It was recognised that it was necessary to involve politicians in the cause of better health for women and it was agreed that the outcomes of the workshop would be shared with them and with the Ministries of Health, Education and Women' s Affairs. Report of a workshop in Lilongwe, Malawi. September, 1996.
Women's health in Uganda In many countries, such as Uganda, women's health is not an issue. If women survive it is by accident rather than because of any effective care programme, particularly since AIDS and related disorders have become a central feature of reproductive health. This is because of the meagre per capita health sector allocations, and because of general poverty. Health care in the private sector is very expensive, which reinforces the problem. Women have unique requirements for health care. The hazards of reproduction are exacerbated by violence, rape, female genital mutilation, lack of power over their lives, overwork and underfeeding. In all areas men are deemed to be 'more important'. Statistical data on women's health in Uganda is limited, but it is acknowledged that much work is needed to improve health-care opportunities for women. Women are crucial to social and economic development and their health will affect the health of future generations. Women play a crucial role in the agrarian economy, tilling the land, planting and har-
108
Midwifery
vesting crops and caring for the whole family. They form 65% of the total labour force and their well-being is, therefore, vital to the economy. In Uganda women's development is impeded by poverty. The general population is poor, but women bear the brunt of this because of their nurturing role in society. Women work on average 14-18 hours a day and sleep only 4-6 hours. More is expected of them than of their male counterparts and they are constantly under stress. Despite this, women are still regarded as belonging to the 'weaker sex' and are treated as second class citizens with fewer educational and employment opportunities. A woman has no human rights. Examples are quoted of women who have been tortured and beaten because they have failed to deliver vaginally. If a woman fails to deliver vaginally it is considered to be because bad spirits are around and something must be done to appease them. This appeasement is more important than obtaining appropriate medical care for the woman concerned. Given the very strong 'boy preference' it is fortunate that there is no pre-natal sex selection, but the importance of producing sons leads to women producing more children than is economically viable or physiologically safe. There is an inevitable increase in morbidity and mortality. In some work places it is a crime to get pregnant or to breast feed, although the men who decree this have wives at home who they expect to do just that. These double standards lead to many problems including concealment of pregnancy, increased abortion rates and low levels of breast feeding. Traditional beliefs hamper women's development and opportunities. Women belong to their families who have often paid an expensive bride price and value must be obtained from the investment. In spite of the prevalence of HIV/AIDS, wife sharing and widow inheritance is still practised. In Uganda maternal mortality ranges between 500-1120 per 100000 live births. Infant mortality is officially 97 per 1000 with high perinatal mortalities contributing 45-50% of this figure. Contraceptive usage is a mere 15%, and only 33% of deliveries are assisted by trained personnel. The situation is desperate and the Ministry of Health programme on Safe Motherhood recognises the need for change. Political support is needed to increase budget allocation for health services, especially for emergency
obstetric care. Delivery personnel must be adequately educated and trained, and health units must be appropriately equipped to handle emergencies. Transport and communications are areas which need attention and funding. In rural areas, where bridges are regularly washed away, referral of women with problems is impossible because they are unable to travel to hospitals with more facilities. Women need adequate nutrition, antenatal care, maternal care, transport and communications, well trained health workers, well-equipped health centres, the support of their husbands and families, and a knowledge of their own worth. Even the basic infrastructure is hostile to women's development. Inadequate support in terms of water and sanitation facilities affect poor women in particular. Women have most frequent contact with water, which increases their exposure to water-borne diseases. Women can be forced to spend more than 25% of their calorific intake fetching water. The resulting comprised nutritional status can lead to deficiencies such as anaemia and lack of vitamin A, and the physical strain of carrying water can lead to many physical problems. The proposed changes challenge the existing social order and, therefore, assume a political status which requires long-term political commitment. Women's organisations are central to strategies for empowermerit, and can assist women to learn ways to change and improve their status. Women's health problems have much to do with their lack of control over social resources and societal arrangements which do not favour women. Women's empowerment and social change are the key measures needed to promote women' s health. Report of a workshop, Kampala. September 1996
Dates for your diary Advance notice The International Confederation of Midwives 25th Triennial Congress will be hosted by the Integrated Midwives Association of the Philippines Inc at the Philippine International Convention Center, Manila from May 22 to 27, 1999. The theme will be Midwifery and Safe Motherhood: beyond the Year 2000. For further details please contact: The Secretariat, 25th ICM
Triennial Congress, Integrated Midwives Association of the Philippines Inc, Pinaglabanan corner Ejercito Streets, San Juan, Metro Manila, PO Box no SJPO 175346. Fax: +63 2 70 53 35. Johns Hopkins Sixth Annual multi-disciplinary update on Obstetric Anaesthesia, 23-24 Aug 1997, Renaissance Harborplace Hotel, Baltimore, Maryland, USA. For further information contact: Office of Continuing Medical Education, Johns Hopkins Medical Institutions, Turner 20, 720 Rutland Avenue, Baltimore, MD 21205-2195, USA. Tel: (410) 955-2959; Fax: (410) 955-0807; e-maih cmenet@ som.adm.jhu.edu; web-site: http://ww2. med.jhu.edu/cme.
Nurse Education Tomorrow: Eighth Annual Participate Conference for Education in Health Care, 2-4 Sep 1997, University of Durham, England, UK. For further information contact: NET Conference Administration, Suffolk Educational and Training Services Ltd, Suffolk College, Rope Walk, Ipswich, Suffolk IP4 1LT, UK. Tel: +44 1473 296642; Fax: +44 1473 216416. Sharing visions for global midwifery: Midwifery Today International Conference, 6-10 Nov 1997, London, England, UK. Fee: (full subscriber - whole conference) £240AJS$375 up to 16 Jun 1997, then it increases; (non-subscriber whole conference) £275/US$425 upwards as above; rates for part or whole days also available. For further information contact: Midwifery Today, PO Box 2672-597, Eugene, OR 97402, USA. Tel +1 541 344 7438 or +1 800 743 0974; Fax +1 541 344 1422; E-mail: Midwifery@ aol.com. ICM Europe - German-speaking Region Workshop, 8-9 Nov 1997, Institute for Further Medical Education, Prague, Czechoslovakia. For further information contact: Bund Deutsche Hebammen e.V., Steinh~iuser Strage 22,76135 Karlsruhe, Germany. ICM Europe - French-speaking Regional Workshop, 2-4 December 1998, Montpelier, France. For further information contact: Ruth Brauen, Av de Chailly 67, 1012 Lausanne, Switzerland. VIII. Deutsehen Hebammenkongress, 11-13 May 1998, Bremen, Germany. For further information contact: Isolde Brandst~idter, Christmannsweg 33, 79206 Breisach, Germany.