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Anna Winkvist
Abstract
The importance of child care in ensuring optimal child survival, growth, and development is increasingly recognized. Unfortunately, poor health and nutrition status of the caregivers likely limit their agility to provide adequate care in many countries. Direct evidence for this has been shown in Egypt, where poor dietary intake, low haemoglobin levels, and low vitamin B6 status of the mothers were related to less time spent on care, less response to infants' vocalization, less vocalization to infants, and greater utilization of older siblings as caregivers. In Kenya, lower maternal caloric intake was associated with less physical contact with their toddlers. Indirect evidence can be inferred from a review of illnesses affecting women globally in the light of the physical and mental demands of adequate caregiving. For this purpose, ill health of women is evaluated from both epidemiological and anthropological perspectives.
Introduction
In the Western world, health is often spoken of in the sense of ill health, i.e., as a pathological condition that can be verified by clinical examination. However, health is actually a multidimensional state, and conceptualizations of health vary from country to country and even from person to person. Recognizing these multiple dimensions, WHO defines health as "a state of complete physical, mental and social well being and not merely the absence of disease and infirmity" [1]. From a cultural point of view, illness is the social recognition that a person is unable to fulfill his or her normal roles adequately, and that the situation needs to be acted upon. Thus. from this perspective health is associated with ability to carry out one's social obligations.
Recently, the role of inadequate care has received considerable attention as an underlying cause of malnutrition among children, together with inadequate household food security and inadequate access to health services [2]. Many factors contribute to a caregiver's ability to care for a young child, and health, both in the Western sense of absence of disease and in its many other dimensions, is likely one of them. How do we best support the health of the caregiver so that her or his caregiving ability is optimized? To answer this question, we need to first understand the aspects of caregiving that may be affected by poor health and nutrition status of the caregiver. Thereafter, we need to identify common health problems among primary caregivers worldwide, taking the different dimensions of health into account.
A review of these two topics is presented, followed by an evaluation of the empirical evidence for an impact of caregiver's health on caregiving capacity. Inasmuch as mothers are the primary caregivers in most societies [2, 3], the discussion mainly focuses on the health and nutrition status of adult women. However, girls in the family may also help care for younger siblings; thus, their health concerns are covered where appropriate. Finally, some activities to support good health of the caregiver are suggested.
Providing care
Longhurst [3] describes care as the provision in the household and community of resources in the form of time, attention, love, and skills to meet the physical, mental, and social needs of nutritionally vulnerable groups. In this review, the focus is on care provided for children under three years of age, with special reference to the situation in developing countries.
Care of young children can be divided into behaviours that bring the child up to a minimally healthy level or return it to a previously accepted state of health or development (compensatory care), and those that serve to enhance further growth and development (enhancement care) (M. Zeitlin et al., personal communication, 1989). Examples of caregiving behaviours include breastfeeding; providing emotional security and reducing the child's stress; providing shelter; clothing, feeding, and bathing; supervision of the child's toilet habits; preventing and attending to illness; nurturing and showing affection, interaction, and stimulation; playing and socializing; protecting from exposure to pathogens; and providing a relatively safe environment for exploration [2]. Another set of behaviours includes using resources outside the family, such as curative and preventive health clinics, prenatal care, traditional healers, or members of an extended family.
Thus, some of the caring activities require physical effort, whereas others require attention, imagination, and inspiration. Therefore, ill health leading to reduced work capacity, fatigue, apathy, or depression will likely limit caregiving ability, as will ill health leading to reduced status in the family with resulting decreased access to resources and support. These aspects of ill health among women globally are reviewed below, with an emphasis on women in developing countries. Poor mental health may also affect caring capacity, and this topic is covered elsewhere [4].
Women's health and nutrition status
What is the current health status of young and adult women in developing countries? This straightforward question, unfortunately, does not have a straightforward answer. In international health, development work has focused primarily on improving child health, and therefore only limited data on women's health and nutrition status have been collected. Difficulties in evaluating these sparse data are compounded by the lack of appropriate standards for health and nutrition status of adults in general, and of pregnant and lactating women specifically. Further, the shortcomings of health indicators used traditionally in women are only starting to be appreciated, and more informative measures have yet to be developed and put in practice. Finally, women themselves may have different views on their health status than Western medical practitioners, and it may actually be this subjective dimension that affects their ability to provide good care. Thus, women's health needs to be understood from both epidemiological and anthropological perspectives.
Epidemiological perspective
Women's health usually is equated with reproductive performance defined in terms of infant outcomes.
When women's health is conceptualized in terms of maternal outcomes, it is conceptualized narrowly in terms of maternal mortality (i.e., deaths for all women due to conditions related to pregnancy during the gestational period, labour, and birth, and the puerperium per 100,000 live births) for female life expectancy. For many countries, this may be the only health statistic on women available on a national scale. More importantly, maternal mortality rate is the public health indicator that shows the greatest disparity between developing and industrialized countries; the difference is about 200-fold [5]. In comparison, the corresponding difference in infant mortality rate is about tenfold.
Each year, around half a million women die from causes related to childbearing, and 99% of these deaths take place in developing countries. Direct causes (haemorrhage, puerperal sepsis, toxaemia, obstructed labour, and abortion) account for three fourths of these deaths [6]. These conditions are aggravated by poor nutrition status; e.g., mortality rates from haemorrhage are higher among anaemic women. The rates are also higher for teenage women or women having their first child, and for women over 35 years of age or women of high parity. Over half of the maternal deaths could likely be prevented with known technology at low cost. Maternal mortality rates are usually low where there are good family planning, prenatal care, and safe abortions, as well as good delivery facilities.
However, maternal mortality is only the tip of the iceberg. It is estimated that for each maternal death, there are over 100 acute morbidity episodes precipitated or aggravated by pregnancy, such as anaemia, hypertension, fever, and eclampsia [7]. In addition, an unknown number of women suffer from chronic morbidities as a result of childbearing, ranging from fatigue, diarrhoea, and sore back to disabling or life-threatening conditions like vesicovaginal fistula, malaria, and reactivated tuberculosis. Ironically, even though the problem is on the scale of 62 million acute morbidities annually, these other outcomes of reproduction are much less recognized and monitored than are maternal deaths. Graham and Campbell [8], referring to the negative synergism between the low priority given to women's health and its limited documentation, describe "the measurement trap" in maternal health. They identify four interrelated components of "the measurement trap": narrow conceptualization of maternal health, poor existing data sources, inappropriate outcome indicators, and limited measurement techniques. As a result, maternal health is defined as a discrete, negative state, characterized solely by physical manifestations and excluding important social and mental outcomes. The authors suggest a broader conceptualization: "Maternal health encompasses positive or negative outcomes-physical, social or mental, in a woman from any cause related to childbearing or its management" [8].
Using this framework, more informative indicators and corresponding measurement techniques can be developed. In addition to death, four other "Ds" may be monitored by appropriate measures, indexes, or proxies: discomfort, dissatisfaction, disability, and disease. For the first two, indicators of health outcomes may include stress incontinence at the end of puerperium, breast soreness preventing women from breastfeeding, and nausea during the first trimester preventing women from working adequately. Indicators of disability or disease may include reproductive tract infections as a result of intrauterine devices, reactivated tuberculosis, and anaemia. Finally, indicators of positive or optimum health may also be monitored, e.g., the proportion of women with uncomplicated deliveries or fully breastfeeding until four months postpartum [8]. Challenges in the collection of such data relate to the problems of 1) identifying pregnant women early, 2) the lack of clear definitions of many morbidities (pregnancy-induced hypertension, pre-eclampsia, eclampsia, postpartum haemorrhage, prolonged labour), and 3) the magnitude of efforts needed to gather lifetime data compared to the ease of obtaining clinical "event" data (i.e., shining the focus from pregnancies to women). However, the increased attention to women's health and intellectual developments in this area are promising and, we hope, will lead to more informative data-gathering and better-designed interventions for improving maternal health.
Still, a woman's health is far more than her reproductive health. A useful definition of women's health should encompass all aspects of women's lives, including reproductive roles (childbirth), biological reality (menstrual cycles), and the social context in which women live, work, and age [7]. The following broader definition of women's health has been suggested: "A woman's health is her total wellbeing, not determined solely by biological factors and reproduction, but also by effects of work load, nutrition, stress, war, and migration, among others" [9]. As in other sectors, women's health outside the reproductive window has been mostly overlooked in international development work. There is limited information on the health and nutrition status of young women, although some initiatives on the health of adolescent girls have been undertaken [10]. Even less is known about the health and nutritional problems of postmenopausal women. Also, the understanding of health problems of importance to non-pregnant, non-lactating adult women is equally insufficient.
As examples of the inadequate information base, women's health in relation to nutrition status, work load, reproductive tract infections, AIDS, menstrual disturbances, substance abuse, and violence are reviewed. Among the 1,130 million women above 15 years of age in developing countries, a conservative estimate is that almost 500 million are stunted as a result of childhood protein-energy malnutrition (PEM), over 500 million are anaemic due to iron deficiency, about 250 million are at risk of disorders due to severe iodine deficiency, and almost 2 million are blind due to vitamin A deficiency [11-14]. For vitamin A and iodine deficiency disorders, these estimates are based on the assumption that prevalences among men and women are equal; this may not be the case if resources differ between the sexes.
Anaemia (defined as haemoglobin <12 g/dl for non-pregnant women and < 11 g/dl for pregnant women) due to iron deficiency is the most widespread nutritional problem among women, leading to reduced work capacity, increased fatigue, and loss of mental concentration. The prevalence has been estimated as 26% among adolescents, 54% to 60% among pregnant women, 41% to 47% among lactating as well as non-pregnant, non-lactating women, and 25% among postmenopausal women [11, 15]. The regions with the highest overall prevalence are South Asia, sub-Saharan Africa, and South-East Asia.
Women generally meet a smaller percentage of their current recommended daily requirements of most nutrients than men do, and increases in intake by pregnant and lactating women are usually inadequate. Studies of intrahousehold food allocations show that women receive less food than men both in absolute terms and relative to their nutritional needs [16]. Women also spend more time in total productive work (domestic and market production) than men, commonly experiencing total work days of 10 to 16 hours [16, 17]. A review of 32 studies revealed that in most countries women's average weight-for-height was below the 50th percentile for small-frame women in the United States for most countries, and that women in Africa and Asia were more deficient in fat stores than those in Latin America or the Near East [16]. In South Asia, the prevalence of PEM was significantly higher among women than men [18]. A negative effect of childhood PEM on adult working capacity, through reduced muscle mass and aerobic capacity, is well documented [19]. Clear evidence is lacking for a similar effect of current PEM on work capacity; evidence from supplementation trials is contradictory [19]. However, even if work capacity is not significantly increased, higher food intake may allow an increased energy expenditure on other activities such as child care. Also, both breastmilk volume and protein concentration are affected adversely by current low maternal weight-for-height [20].
Women in developing countries spend between 25% and 60% of their reproductive years either pregnant or lactating. Reproduction often starts early; in countries where child marriage is practiced, teenage pregnancies account for more than 10% of all births. An effect of repeated, closely spaced reproduction on women's nutrition status (so-called maternal depletion) has been suggested. However, we are not yet able to document such an effect by relating broad exposure measures such as parity and interbirth interval to outcome measures at specific stages of the reproductive cycle [21, 22]. Some researchers substitute length of depletion periods as a measure of exposure. Here, a negative effect on maternal fat stores of concurrent lactation and pregnancy has been reported among Guatemalan women [23], and of prolonged lactation among Filipino women [24]. We have suggested evaluating overall changes in women's nutrition status across one full reproductive cycle in relation to relative lengths of depletion and repletion periods during that cycle [25]. Using this framework, an effect of reproduction on maternal weight was found among marginally nourished women in Pakistan and Guatemala [26]. However, women with worst initial nutrition status instead experienced an overall weight increase concurrent with a negative trend in birth- weight of the two siblings born during the reproductive cycle. These results are consistent with findings from animal models [27]. Thus, there may be some threshold below which relatively more of the nutrients are partitioned towards the mother.
Reproductive tract infections are common among women in the developing world, causing fever and pain in the lower abdomen, fatigue, personal embarrassment, and marital stress [28]. Common infections include vaginitis, cervicitis, and pelvic inflammatory disease. Some reproductive tract infections are sexually transmitted diseases, e.g., chlamydia and gonorrhoea, but some are caused by overgrowth of normally occurring bacteria. Women are twice as likely as men to develop reproductive tract infections, because of factors like young age at coital debut, intravaginal preparations, materials used to absorb menstrual flow, and use of contraceptives. For example, users of intrauterine devices are three to five times as likely to develop pelvic inflammatory disease [28]. Women suffer more serious long-term complications than men, because lower reproductive tract infections are often asymptomatic in women and because of women's limited access to health care. However, if detected early, reproductive tract infections are relatively easily treated with antimicrobials. The prevalence of reproductive tract infections is higher in Africa, where more than 5% of women visiting antenatal, family planning, and gynecological clinics were affected, than in Asia or Latin America [28].
The current increase in sexually transmitted diseases worldwide is of great concern.
In 1990, WHO estimated that more than three million women were infected with HIV (human immunodeficiency virus) [29]. Women in sub-Saharan Africa are currently most at risk and show the highest seroprevalence rates, but female risk is rapidly increasing in Asia and Latin America [30]. In many African countries, the seroprevalence rates among urban people aged 15 to 25 years are higher among women than men. Women are more likely to receive blood transfusions because of pregnancy and childbirth and therefore to become infected through this route. Further, women's position in society makes it difficult for them to adhere to preventive measures. Also, the definition of AIDS until this year was based on the symptoms that men, but not women, present, meaning that women have been diagnosed at a later stage with resulting later access to treatment and social benefits. The physical and social consequences of the AIDS epidemic are staggering, e.g., death, fatigue, and social ostracism.
Another neglected health issue that contributes to substantial morbidity among women is menstrual disturbances. For example, menstrual dysfunction and other abnormal vaginal bleeding are responsible for 350,000 hospitalizations annually in the United States, and in Niue Island, New Caledonia, half of all adult women have experienced excessive menstrual pain [7]. Still, in spite of the magnitude of clinical morbidities directly attributable to menstrual disturbances, very little research has focused on normal menstruation or the aetiology of menstrual dysfunction.
Among women in developing countries, the prevalence of cigarette smoking is about 10%, compared with 50% among men [31]. However, in some countries the prevalence among women is as high as 25% to 50%, and the numbers are increasing. Women with high rates of tobacco use tend to be young, poor, less educated, indigenous, institutionalized, or disadvantaged in other aspects [32]. Women are more likely than men to have multiple addictions and, especially among younger women, alcohol and drug abuse are increasing.
Finally, the consequences of violence against women must be recognized as a significant health problem, as it is a major cause of female morbidity and mortality worldwide. The United Nations Fund for Women (UNIFEM) emphasizes that "women cannot lend their labour or creative ideas fully if they are burdened with the physical and psychological scars of abuse" [33]. Gender-based abuse includes battering, sexual abuse of female children, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence, violence related to ex ploitation, sexual harassment at work, trafficking in women, and forced prostitution [34]. In the United States, wife abuse is the leading cause of injury among women of reproductive age, and reports from many other countries indicate that between 20% and 60% of women are battered as adults [35]. Rape and sexual abuse are far more common than earlier perceived; it is estimated that one in five American women has been the victim of a completed rape [36]. Sequelae include depression, sleep and eating disturbances, somatic health complaints, inability to concentrate, and unwillingness to breastfeed.
In sum, the large number of women dying in relation to childbearing is shocking and deserves the attention it is now receiving thanks to the Safe Motherhood Initiative. However, in sheer numbers, the problem of maternal morbidity is even more worrisome and, unfortunately, less emphasized in public health work. Acute as well as chronic morbidity episodes related to childbearing need to be recognized and prevented. In addition, health concerns of non pregnant, non-lactating women as well as women outside the reproductive window deserve attention. Malnutrition, reproductive tract infections, AIDS, menstrual disturbances, and gender-based abuse affect millions of women worldwide, draining their physical and emotional energy. Once these health issues have been defined, appropriate indicators and measurement techniques need to be developed and applied systematically. Only then will we obtain an adequate picture of health and nutritional problems affecting women globally.
Anthropological perspective
What health concerns do women recognize themselves, and what illnesses do they feel prevent them from leading full lives? Women's health concerns may differ from those diagnosed by Western health practitioners for several reasons. First, diseases become socially significant only when they are identified as illness, i.e., a malfunctioning that affects the individual and his or her role in society. Second, in many parts of the world, certain diseases are not viewed as illness because they are common to everybody (e.g., malaria in Liberia and Papua New Guinea, yaws in Liberia, goitre in Zaire, and childhood diseases in ancient Greece [37]). Third, although most people would rather be healthy than ill, few people want good health at all costs. Good health competes as a priority with all non-health priorities, and health behaviour can only be understood in the broader context of life goals. Studies in industrialized countries have compared self-reported health with medical and psychiatric morbidity, especially among the elderly [38, 39]. However, to date only a few studies have investigated health from women's own perspective in the third world.
In research conducted among low-income women in an urban slum area in Lahore, Pakistan, as well as in a traditional village outside of the city, women's own perceptions of health and health concerns were explored through repeated, in-depth interviews [40]. The results were highly similar in both areas. Women with no formal education and who were ranked the poorest within the study sample described a woman of good health as someone who is neither too thin nor too fat, strong, and courageous and therefore does not visit the doctor unnecessarily, and who works hard and efficiently. For example, one woman explained that a woman who can work hard along with bearing children is a healthy woman, and another woman emphasized that a healthy woman is thin enough that she can fit in small spaces, sit on the floor, and easily do all her household work. In contrast, women with a few years of education and who were ranked at higher socio-economic status emphasized mental health. Typical comments were that a healthy woman has good control over her mind and thoughts, does not worry over all problems in life or get angry easily, and never gives up her courage and hope. Common worries mentioned were death or illness of a child, birth of a girl, infertility, the future fate of daughters, difficult pregnancy, and financial hardships. Finally, women who had 10 or more years of education and were ranked as being of the highest socio-economic status underscored cleanliness and good social behaviour as signs of good health.
Headache, backache, and general aches and pains were described as common female health concerns by these Pakistani women. Headaches were regarded as more common among women than among men because of women's responsibility for, and worry over, all household work and child care. Many women added white vaginal discharge or simply gynecological problems as common and disturbing female health problems. A few women also mentioned high or low blood pressure as well as diabetes. The kinds of health problems that the women acknowledged suffering from themselves included these illnesses. In addition, fatigue, prolapsed uterus, and scars from repeated episiotomies were added here. Finally, the majority of these women felt that women of poor health were less respected in their marital family than healthy ones, leading to poor support as well as poor access to resources.
A study in Baluchistan, Pakistan, also found general aches and pains, general weakness, and gynecological problems to be most commonly reported by the women themselves [41].
Del Vecchio Good [42] reported that among Iranian women, commonly discussed female health problems were heart distress, heart palpitations, weak nerves, anaemia, and aches and pains. She emphasized how beliefs stemming from classical Galenic-lslamic medical theories influenced these women's beliefs about health. The function of heart and blood are central here, and adequacy of blood is associated with strength and vigour. Sensations of weakness are often expressed in terms of blood deficiency. Inasmuch as women lose blood during menstruation, childbirth, miscarriages, and abortions, they frequently complain of blood deficiency. Further, anxiety and emotional distress in response to life stresses are discussed in terms of heart distress. Women, because of stress in their daily lives, are believed to be more prone to heart distress, weak nerves, and blood deficiency. Thus, heart distress is associated with being female. Finally, special attention is also given to the polluting dimension of menstrual blood. Women who are not pregnant should menstruate regularly. A reduction in menstrual flow not caused by pregnancy or nursing is seen as a sign of loss of youth, fertility, and physical attractiveness to their husbands. Also, if the menstrual blood circulates in the body instead of being discharged, it can cause aches and pains, especially in joints and head, according to the Iranian women.
Many Pakistani mothers believe that breastmilk becomes unsuitable for the child if the mother is ill or weak. Pakistani unlicensed practitioners support this view, arguing that mothers should not breastfeed if they are suffering from chronic diseases (such as diabetes, cancer, or tuberculosis), weakness and anaemia, or breast abscess or cracked nipples, as this would cause infection of the milk [43]. Further, some women in Pakistan hold that a mother should not breastfeed while having white vaginal discharge [40]. This belief was also found in South India, where white vaginal discharge was associated with loss of vitality (dhatu), which in turn was believed to affect the quality of milk [44].
A broad initiative on women's health has recently been carried out in India. Here, workshops on ethnographic methods for investigating illnesses regarded as important by the women themselves were held for organizations and individuals involved in health programmes for poor women [45]. The research initiated thereafter revealed reproductive morbidity to be a significant problem; this morbidity is often neglected because of socio-cultural factors as well as women's poor access to health care [46]. Among reproductive morbidities, white vaginal discharge was the most commonly reported illness. Many times the women used euphemisms for this condition, e.g., weakness or backache, because of the perceived shameful nature of the ailment. The sense that these illnesses were part of womanhood was expressed by many women. From the research it was possible to construct an ethnomedical model of causes and sequelae of women's illnesses. Common perceived causes were consumption of "hot" foods and having extramarital sex, and common sequelae were weakness and backache.
In summary, these anthropological studies reveal that stress is seen as a major health problem by many women in developing countries. Gynecological problems (especially white vaginal discharge), weakness, and general aches and pains may also be important concerns of many women. Good health is viewed by some women as the ability to cope with stress, and by others as the ability to work hard and efficiently. However, more studies in other societies are needed. Still, programmes aimed at improving women's health need to pay more attention to stress and gynecological problems and to be implemented with greater sensitivity to women's own conceptualization of good health.