Women's health has traditionally been equated with maternal health.
Indeed, for many years, development programs have overlooked the
health needs of women, in their emphasis on the health needs of
children. This limited definition of reproductive health has
exacerbated the existing failure to develop a holistic view of
women's health. It is no longer possi¬ble, however, to
consider maternal health in isolation from a wider context,
influenced by a variety of interacting factors related to the
environmental, social, economic, psychological, and cultural
conditions in which women live. The effects of these multiple
factors begin at birth and accumulate throughout a woman's life
cycle. All of them must be considered if the health needs of women
in particular, and the community in general, are to be addressed.
Here, I will concentrate on motherhood and health.
Sex Discrimination
The effects of sex discrimination on women's health have often been
ignored in the more extensive discussions regarding the general
links between poverty and ill health. Yet, clearly, while girls are
born with a biological advantage over boys which makes them more
resistant to infections and malnutrition, this is canceled out by
the social disadvantages suffered by women and girls. Special
emphasis on the health of women and girls is therefore needed, not
only because women contribute critically both to family and
community health and to the development of the national economy,
but because it has been so consistently neglected and/ or
mis¬understood, circumscribed as it has been by the narrow
definitions which equate women solely with motherhood and
childcare. It is with this understanding that the Women's Health
Program (WHP) of the Union of Palestinian Medical Relief Committees
(UPMRC) has attempted to address the particular health needs of
Palestinian women living in the Occupied Palestinian Territories
(OPT).
It is now a well-known fact, for example, that as women's general
eco¬nomic situation, access to economic resources, social
status and education¬al levels improve, their health tends to
improve. Thus clear correlations have been documented between
women's increased education levels and better nutrition, and
decreases in infant mortality rates and fertility rates, and an
increased ability to make decisions which benefit their health and
that of their families.
Women must have access to information on health care and family
plan¬ning in order to make effective decisions. Similarly, a
woman's work and her living conditions and the psychological
pressures which she faces affect both her physical and mental
health. Within this context, it is of par¬ticular importance
to recognize the many social values and attitudes and the various
traditional practices which may negatively affect a woman's health
and her ability to obtain adequate health care.
The General Health Situation of Women in the West Bank and the
Gaza Strip
The prolonged Israeli Occupation has resulted in poor health
conditions and a general lack of access to health services in most
geographic areas of the West Bank and Gaza Strip. Undoubtedly,
women have been most greatly affected by this situation. In
addition to the social burdens and psy¬chological pressures
which Palestinian women face, women suffer from a number of
particular illnesses. Poor nutrition, for example, is prevalent
amongst women during their reproductive years. According to UNRWA
statistics, 60 percent of all married women suffer from anemia in
the third trimester of pregnancy.
For 80 percent of the women in the Gaza Strip, the period between
births is less than two years. This makes the fertility rate in the
OPT one of the highest in the world. In the late 1980s, the average
number of children per family was between 6.1-6.9 in the West Bank
and 6.5-7.8 in the Gaza Strip.
Moreover, most women in Palestinian society marry before the age of
18, and begin reproducing at an age which puts them in a high-risk
group for pregnancy-related health problems. Many women continue to
bear children after the age of 35. These practices result in
increased morbidity and mortality rates. According to a local
study, the percentage of births in West Bank hospitals decreased
from 63.8 percent in 1987 to 55.5 per¬cent in 1991; that is,
45 percent of all births still take place in the home.l This
reflects a situation in which 71 percent of the West Bank
popula¬tion live in rural areas where ambulance services are
practically nonex¬istent. The problem is aggravated by the
fact that less than one-third of the health clinics in the West
Bank offer obstetric and gynecological ser¬vices.
The Primary Level
While working at an East Jerusalem hospital in 1982, I witnessed
one of those silent tragedies: a death from pregnancy-related
complications. Twenty-three-year old Ratiba came to give birth. She
had rheumatic heart disease. Following a complicated delivery, she
was advised to return to the hospital in six weeks to select an
appropriate birth control method. A year later, she returned to the
hospital, again in labor. She had been under enor¬mous
pressure from her husband, her mother-in-law and her community to
have more children. She died in front of me, of complications for
which nothing could be done. I felt completely helpless, and this
experience taught me that hospitals and all their high-tech
facilities cannot save women like Ratiba. Work must be done on the
community and primary health care levels,
Such a story raises two basic questions regarding women's
reproductive health. Firstly, why are some women at greater risk of
reproductive mor¬bidity? And secondly, why are so many at-risk
women not using available health services?
A number of observations help to answer these questions.2
a. Women's position in the family hierarchy, with its relative lack
of power, affects health-related behavior. For example, Palestinian
women are generally the last members of the household to eat.
Traditionally, a woman will feed her husband, then her children,
and finally herself. She is also generally the first to rise and
the last to sleep.
b. Lack of knowledge by health professionals of the life conditions
of patients. When, for example, I asked Ratiba to return in six
weeks to select a form of birth control, I did not take into
account the many social pres¬sures which would stop her from
returning.
c. Patronizing attitudes by health professionals towards women's
per¬ceptions of their health. When women complain about health
problems, our doctors, who have a very heavy patient load, often
fail to listen to women's complaints and often diagnose them as
psychosomatic.
d. Lack of awareness among women concerning their health. Women
usually go to doctors only when they are pregnant or when they are
ill. There is little awareness of the need for preventive health
care or regular checkups, such as pap smears or breast
examinations.
e. Women give lower priority to their health status. This situation
is not only linked to women's position in the family hierarchy, but
also to the fact that in our society a sick woman is not desirable.
Thus, sick women tend to minimize their symptoms and even ignore
illnesses.
f. Women's "culture of silence." We have a saying that "the best
woman is a woman without a tongue," which implies that a good woman
never complains.
Unattended Needs
A major part of our struggle as Palestinians in the West Bank and
Gaza has been to build and strengthen the national infrastructure,
the development of which has been blocked by the Israeli
Occupation, leaving many of our people's basic needs
unattended.
This is very clear in the health sector, where, for example, the
infant mortality rate in the OPT is 50 to 70 deaths per 1,000 live
births - com¬pared to 24 in Jordan and 10.3 in Israel.3 The
overall crisis in health care has particular consequences for
women's health care.
In the 1992 antenatal care statistics from Maqassed Hospital, one
of the largest hospitals in East Jerusalem, which deals
specifically with abnormal deliveries, certain facts emerge. For
example, 17 percent of its patients have had no antenatal care
whatsoever.
In terms of medical disorders during pregnancy, 52 percent of the
cases involved hypertension disorders, which reflects the general
lack of proper antenatal care during pregnancy. Similarly, there
was a high presence of anemia and rheumatic heart disease - which
can be avoided with proper primary health care.
A holistic approach to women's health implies working with women in
their communities. There is an urgent need for work at the national
level, for research into the multifaceted nature of women's health,
for a greater understanding by health-care workers of the interplay
of these factors, and finally for planning and health policy which
take these factors into account in their development of improved
health services for women.
Endnotes
1. Barghouti, Mustafa and Deibes, Ibrahim,
Research by the Health Development Information Project, 1993.
2. See Dr. Huda Zurayk's introduction to Hind A.S. Khattab's The
Silent Endurance. UNICEF and the Population Council, 1992.
3. Giacomen, Rita. Life and Health in Three Palestinian Villages
(Arabic). Nablus, 1992.
