harmonizing approaches to women’s health in africa khama rogo md phd

Harmonizing Approaches Harmonizing Approaches to Women’s Health in to Women’s Health in

AfricaAfrica

Khama Rogo MD PhD Khama Rogo MD PhD

Life Expectancy

35

40

45

50

55

60

65

50 55 60 65 70 75 80 85 90 95 00

South-Africa

Botswana

Uganda

Zambia

Zimbabwe

Life Expectancy in Africa

Women’s Health: A broader developmental issue

Women’s right to the enjoyment of highest standards of health throughout the life cycle ….is essential to leading productive and fulfilling life, and the right to control all aspects of their health is basic to their

empowerment

economic rationale – poverty alleviation health rationale – family and children human rights rationale – choice and inequities

Care giver

Worker Mother

Leader

Wife

Provider

G5: Maternal MortalityG5: Maternal Mortality

G4: Child MortalityG4: Child Mortality

G2: EducationG2: Education

G7: EnvironmentG7: EnvironmentG3: GenderG3: Gender

G6: HIV/AIDSG6: HIV/AIDS

G8: PartnershipsG8: Partnerships

G1: Poverty/HungerG1: Poverty/Hunger

Responsibility Starts Early…

Girl and Sibling

Responsibility starts early -Continues throughout life

Girl – caring for siblings, housework… pupil Adolescent – cook, carrier of water and firewood;

early marriage; early motherhood Adult – providing for children, husband, in-laws,

own family; worker,farmer, trader, leader, Old age – widowed; family headship, community

leadership

Demographically, Slightly more women than men

Population Growth

• 693 Million in 2002

• 1.1 Billion by 2025

• 1.7 Billion by 2050

Doubling of population in

20 years

Economic Rationale

Dependency ratio9:1

Dependency ratio9:1

Dependence on women higher

• Biological burden – pregnancy, delivery, lactation

• Physical burden – the porter, long hours; long miles

• Psychological burden - work/life balance;insecurity; cultural transition

Heavy Burden on Women

Heavy burden Vulnerability and ill health

0-9 years0-9 years

10-19 years10-19 years

15-49 years15-49 years

45+ years45+ years

Life – Cycle approach to Women’s Health

6.7

5.8

6.7

6.0

2.7

2.5

2.5

1.6

5.4

3.0

2.74.6

0 1 2 3 4 5 6 7 8

Latin America

Asia

Sub-Saharan Africa

Developingcountries

Developedcountries

WorldEarly 1960s

2002

High Fertility Still Highly Valued

Very little change in Africa in 40 years

Contraceptive Prevalence Rate among Married Women (%)

13

43

5962

0

10

20

30

40

50

60

70

Sub-Saharan

Africa

North Africa Asia (exc luding

China)

Latin America

Family Planning Low

NO family planning, NO rest for womankind

National Contraceptive Prevalence Rates

Most < 10%Only 4 > 30%

Most < 10%Only 4 > 30%

0

10

20

30

40

50

60

Chad

1996

/97*

*

Niger 1

998

Nigeria

199

9

Camer

oon

1998

Ghana

199

8

Guine

a 19

99

Zambia

199

6

Burkin

a Fa

so 1

998/

99

Benin

200

1

Mal

i 200

1

Cote

d'Ivo

ire 1

998/

99

Tanza

nia

1999

Togo

1998

Seneg

al 1

997

Liber

ia 19

86

Ethiop

ia 2

000*

*

Zimba

bwe

1999

Ugand

a 20

00/0

1

Kenya

199

8**

Mal

awi 2

000*

*

Use Unmet Need

Unmet Need for Family Planning

20-35% unmet need20-35% unmet need

%

Higher premium on child, not mother

Mother and ChildX

• 1:8 of girls born in Angola or Mozambique will die in pregnancy (risk is 1000X higher than Western Europe)

• For each maternal death 30 to 40 suffer life-long debilitating injuries (e.g. incontinence of stool/urine)

• Adolescents form up to 30% of maternity population.

High risk pregnancies are the African Woman’s fate

Every minute, a woman dies in pregnancy

The 3 Delays

I. Delay in the homePoor knowledge

II. Delay in transportationto health facility

III. Delay in accessingappropriate service at health facility

What Kills African Women in Pregnancy?

Sepsis15%

Eclampsia6%

Obstructed labour13%

Other causes8%

Haemorrhage

25%

Abortion33%

(>50%)

Pregnancies ……Too Early …Too Frequent …Too Late

Maternal Deaths

Wide sub-regional differences

Western Africa

1340Eastern Africa

1340

North Africa

460

Central Africa

1020

Southern Africa

360

Deaths per 100,000 births

PAC

EQUITY FOR WOMEN

PRIMARY HEALTH CARE

Basic Maternity Care

PILLARS OF SAFE

MOTHERHOODF

amil

yP

lan

nin

g

Ess

enti

alO

bst

etri

c C

are

Safe Delivery

ANC

77.1

216.5

119.4

96.1

233.8

318.2

192.4

131.8

147.4

102.1

166.5

107.3 111.5

188.6

273.8

140.2 142.5151.5

0

50

100

150

200

250

300

350

Ethiopia 2000* Ghana '93,'98 Kenya '93,'98 Malawi '93,'00 Niger '92,'98 Nigeria '90,'99 Senegal'92/93,'99

Uganda '95,'00 Zimbabwe'94,'99

De

ath

s p

er

1,0

00

liv

e b

irth

s

Child Mortality

Under 5’s: Little Improvement in the 1990s

0

20

40

60

80

100

120

140

160

180

200

Mal

i 20

01

Ethio

pia 2

000*

Mal

awi 2

000*

Burki

na Fas

o 199

9

Guinea

199

9

Togo 1

998

Tanza

nia 1

999

Uganda

2000

/01

Camer

oon 1

998

Ghana

1998

Niger

ia 1

999

Kenya

199

8

Seneg

al 1

997

Dea

ths

per

1,0

00 i

nfa

nts

un

der

ag

e o

ne

Infant Deaths

Two times higher mortality for Infants born at intervals less than two years

< 2 years

> 2 years

HIV Prevalence Rates

M-F ratio is 1:6 in adolescents

M-F ratio is 1:6 in adolescents

600 - 1199

Over 1200

Less than 600

Maternal Mortality Ratio(per 100,000)

130-149

Over 150

Less than 129

Under 5 Mortality(per 1000)

Adult HIV Prevalence 2002

3% - 9.9%

10% - 14.9%

1% - 2.9%

Over 15%

Under 5 Mortality, Maternal Mortality and

Adult HIV Prevalence

No African country is spared

Education Health Recreation Employment

Adolescents & Youth

• Low school enrolment• High early dropout• Early child bearing• Early marriage• Harmful traditions• High unemployment• Drugs• War and displacement

Dreams DeferredDreams Deferred

Age at Marriage: Selected Countries

Median Age at First Marriage, Women 20 to 24 at Time of Survey

16 16

17 17 17

18 18

Niger 1998

Chad1996/1997

Guinea 1999

Mali 2001

Mozambique1997

Burkina Faso1998/1999

Uganda2000/2001

Source: ORC Macro, Demographic and Health Surveys.

Years

Unintended Births to African Teens

19

32

34

36

41

48

Tanzania 1999

Uganda 2000/2001

Malawi 2000

Ethiopia 2000

Zimbabwe 1999

Kenya 1998

Births to 15-to-19-Year-Olds Who Said Births Were Unintended

Source: ORC Macro, Demographic and Health Surveys.

Percent (%)

Teenage Childbearing by Education

13

17

45

46

47

56

59

6

5

11

17

16

21

17

Cambodia 2000

Egypt 2000

Haiti 2000

Nicaragua 2001

Mali 2001

Bangladesh 1999/2000

Uganda 2000/2001

No education At least some secondary education

15-to-19-Year-Olds Who Are Mothers or Are Pregnant With First Child

Source: ORC Macro, Demographic and Health Surveys.

Percent (%)

Female Genital Mutilation

Practiced in 28 countries.

Female Genital Cutting, by Age

Female Genital Cutting, by Age

Prevalence Among Younger and Older Women

71

43

97 94

32

94 90

1622

74

53

98 97

48

92 91

22 25

BurkinaFaso

CentralAfrican

Republic

Egypt Eritrea Kenya Mali Sudan Tanzania Yemen

Ages 20-24 Ages 45-49

Source: Special tabulations of Demographic and Health Survey data for 1989-2000 by Principia International, Inc., and published data from ORC Macro.

Percent (%)

• Low female education – lack of information

• Lack of control of resources • Harmful cultures and traditions• Disempowering male attitudes • Poor governance/insecurity• Transitional societies• Inadequate health care/prevention

Women’s Health in Africa: Confounding Factors

Emerging Issues

• Increase in women headed households

• Needs of poor urban women

• Needs of professional women

• Conflict and displacement

• Gender based violence

• Migration of both males and females

Multi-Sectoral Approaches

Improving Women’s Health: Opportunities

•Changing societal orientations in Africa

•The African Woman, ever innovative

•African and international agreements/covenants: ICPD, WSSD, CEDAW

•MDGs – Super Eight

•NEPAD

•AU and the peace dividends – Angola, Mozambique, Rwanda, Sierra Leone, DRC, Liberia, Sudan, Somalia

Investments: Where/How

• Health Sector: Prevention & Access to services, Emerging issues

• Economics: Micro-finance

• Education: EFA plus

• Governance: Security & Legislation

• Socio-cultural: Male attitude

Leadership - Information

Improving Other Areas of Investment

• Water

• Energy

• Environment

Community Participation – NGOs

Working at all levels

Lack of incomeLack of Decision MakingGender Based V iolence

Lack of access to basic amenities

IndividualFam ily level

CulturalReligiousConflict

New challenges

HouseholdCom m unity level

Resource allocationPolicy and Legislation

Tools/Technologies

NationalInternational Level

W omen's Health

Focus on Integration

Call for Effective Leadership

1. Stronger political commitment

2. Additional and better use of resources: inter-sectoral linkages

3. Seeing beyond vertical programs: commendable but not adequate

4. Intensive and outcome oriented professional action

We can do more outside the health sector

Africa 2015No Improvement to Women’s health….

…NO MDGs

““Educate a Educate a woman and you woman and you

educate a educate a nation….” nation….” Aggrey of Aggrey of AchimotaAchimota

““Invest in Invest in women’s health women’s health todaytoday and you and you

will have a will have a healthy healthy

nation…”nation…”

Sector Specific MDG Targets

Goal 1: Reducing Malnutrition

Targets: 50% reduction in hunger between 1990 and 2015

Goal 4: Child Mortality

Targets: 2/3 reduction in child mortality between 1990 and 2015

Goal 5: Maternal Mortality

Target: ¾ reduction in maternal mortality between 1990 and 2015

Goal 6: Communicable Diseases

Target: halt and reverse HIV/AIDS, malaria, other diseases by 2015

Accelerating health programs could save 20m children in the next 10 yrs

2.0

4.0

6.0

8.0

10.0

12.0

2000 2005 2010 2015

An

nu

al n

um

ber

of

chil

d d

eath

s (m

illi

on

)

Current trendTo reach MDG goalAccelerated program in 60 countries

Tools for Community Approaches

"Will the legacy of our generation

be more than a series of

broken promises?"

Nelson Mandela, 2001