Documento(s) 9 de 13

A gender analysis can provide a perspective on the structure of health services, their performance, and delivery. The ability of health systems to provide for, and differentiate between, gender needs is a test of their relevance and purpose. [These] perspectives are required to analyze the changes that face -- some would say threaten -- health institutions and practices in developing countries.

-- A.D. Tillett, International Development Research Centre, Regional Office for Latin America and the Caribbean, Montevideo, Uruguay

There are an extremely wide range of factors that influence whether or not a woman seeks and obtains quality care from modern health-care facilities. The obstacles that women face are much "more than a problem of distance" (Timyan et al. 1993, p. 217) and a lack of financial resources to cover the cost of care and transportation (although these are certainly important factors).

Literature in this area tends to distinguish between "access to care" and "quality of care." Quality-of-care research usually centres on the experiences of those who have managed to gain access to modern health services, but the individuals who choose not to use services, or who are unable to do so, are not addressed. However, female clients may consider access to care to be integrally linked to quality of care (Ndhlovu 1994); conversely, services considered to be of poor quality will not be used. Therefore, barriers that influence whether or not a woman is able to gain access to services will be addressed, as will factors that influence the quality of care provided to women at the point of service delivery.

Recognition of illness

Before a woman decides to seek care, she must be able to recognize the signs and symptoms that indicate the need for care (AbouZahr 1994; Manderson 1994). However, a lack of educational opportunities and poor understanding of health-related matters mean that many women are not familiar with different diseases and their presentation. For example, some women assume that "vaginal discharge is a natural part of being a woman" (Pesce 1994, p. 19) or think that back pain is normal because they have suffered from it for as long as they can remember.

How many girls and women in the world still suffer from poverty of education, information, and knowledge? This type of poverty denies women the understanding of how their bodies function, how they can protect themselves, and how to prevent diseases.

-- A. El Bindari Hammad, World Health Organization, Geneva, Switzerland

As a result of cultural restrictions and taboos, women may be unable to interpret signs of illness, particularly as they relate to the genitals. Manneschmidt (see footnote 6), for example, reported that "there is a collective denial of women's sexual issues in Nepalese society," and this has led to the absence of Nepali terms to describe aspects of the female genitals and gynecological symptoms. Manderson (1994) described how some women, who lack knowledge about the workings of their bodies, are unable to differentiate normal menstrual blood from other sources of blood (such as blood in the urine from schistosomiasis), especially in cases where genital mutilation has occurred. Manderson also explained that some women may not even notice the occurrence of minor bleeding (for example, if they urinate and bathe while clothed, as some cultural practices demand).

Competing demands

Even if a woman notices symptoms of illness, she may completely ignore these signs because of other competing demands. Women may believe that they cannot afford the "luxury" to take time out to visit a health centre or to have a period of incapacity because this would represent time and effort lost to other essential, and possibly more important, activities such as child care, food production, and paid employment (AbouZahr 1994; Bhattacharyya and Hati 1995). Temporary female workers in the Chilean fruit-picking industry, for example, said that their long working days made it impossible for them to leave their work to attend to their health problems (Berr 1994).

When women suffer from conditions such as infections of the reproductive tract or tuberculosis, they often deny their symptoms until they are too serious or too severe to ignore because of heavy competing workloads.

-- A. El Bindari Hammad, World Health Organization, Geneva, Switzerland

Because they were responsible for the well-being of their families, women living in extreme poverty in Montevideo, Uruguay, said "[they were] not able to leave their children alone" and "what should I go and seek the doctor for, I waste time" (Bonino 1994, p. 201). Women from Chad reported that they were unable to take a sick child for care because "[w]e've got other children at home waiting for us. They have to go to school and we have to go the market" (Wyss and Nandjingar 1995, p. 148).

Generally, mothers say that they are busy, that they are not able to come [to the health centre], that they have to travel or that they are traders. They also say that their business nourishes the whole family and they cannot neglect all the children just for one.

-- Kasper Wyss and Monique Nandjingar, Swiss Tropical Institute, Basel, Switzerland

The hours when health clinics are open may not be sensitive to the gender division of labour and the timing of women's work. As a result of the daytime responsibilities of women -- such as fetching water, feeding chickens, collecting the firewood, and going to the factory -- it might be easier for women to visit clinics in the evening instead of in the daytime when modern health services are usually open. Women's work patterns should therefore be considered when setting clinic hours. To increase the chances of working women receiving care, health services might also be established where women work, such as at factories (MacCormack 1992).

Other family or community members rarely assume women's essential tasks when they are ill. Women therefore continue to perform necessary activities that are difficult to defer (Watts et al. 1989; Bonilla et al. 1991). Because women do not take off enough time to care for their health, it usually takes them longer to fully recover from illness or disease. The amount of time that a woman stays in hospital (if she has to go) can be significantly shorter than the amount of time taken by a man (Bhattacharyya and Hati 1995), and a woman invariably returns to her work, both inside and outside the home, before she is fully recovered.

Women are unwilling to go to service points for their own health because their absence will disrupt household and economic activities.

-- Trinidad S. Osteria, De La Salle University, Manila, Philippines

A woman's everyday routine is full of small waivers of herself that are acts of giving herself up to others.

-- Constanza Collazos V., Centro de Investigaciones Multidisciplinarias en Desarrollo, Cali, Colombia

Women's health is not a priority

Women in developing countries tend to place the health and well-being of their families, especially children, as a priority over their own health and, consequently, do not seek medical care for themselves. Women "give everything to [their] children" because "the children always come first" and "the only thing [they] have in life is [their] children" (Bonino 1994, p. 201). Women will ignore their own symptoms of disease and illness, but always go "to the pregnancy check-ups as a duty, because ... it is a duty to do it for the welfare of the child" (Bonino 1994, p. 202). Furthermore, male children tend to be given superior access to care compared with female children (Chatterjee 1990). In a study conducted in Bangladesh, male children less than 5 years old were brought to a treatment facility for diarrhea illness more frequently than females -- the male use rate was 66% higher than the female use rate (Chen et al. 1981).

The general low status of women, and their internalization of this status, results in the marginalization of women's physical, psychological, and emotional needs (Kwawu 1994; Manderson 1994; Bhattacharyya and Hati 1995). Women are less likely than men to consult modern health services, wait longer than men to seek treatment when ill, are reluctant to spend limited resources on their own needs, and often cope with illness by self-treatment, by consulting traditional healers, or by simply living with the condition and its resulting discomfort (Mechanic 1976; Lorber 1984; Rathgeber and Vlassoff 1993; Kwawu 1994; Iqbal 1995).

Because of their heavy household duties, women cannot afford to be sick themselves. It would be useful to discover how many ailments exist among women but never receive attention from the medical profession.

-- Dzodzi Tsikata, Institute of Statistical, Social and Economic Research, University of Ghana, Legon, Ghana

A leader of a very poor community outside of Montevideo, Uruguay, reported that, "[a] women here does not take care of herself at all. The husband or the children always come first, for the children she does have time" (Bonino 1994, p. 201). One woman from the same study reported that "I think that we give more importance to our children than to ourselves" (p. 202).

Women associate the use of a dispensary, clinic, or hospital services with the health of their children (Kwawu 1994) and generally attend health centres primarily to obtain care for their children, although they may also be suffering from a health problem. Iqbal (1995) reported that it was "observed many times that a woman who comes ... worrying about her child was herself suffering from some disease, mostly anemia and malnutrition." In an onchocerciasis hyperendemic community in Enegu State, Nigeria, women who came to the only health centre in the community were asked on three occasions their reasons for attending the clinic (Amazigo 1994). Of the 53 women (16­39 years old) asked about their reasons for attending a primary health-care program, 47 came because their children were sick, 5 women came because they were pregnant, and 1 had fever and diarrhea. Nevertheless, 20 (38%) of these women had at least one clinical manifestation of onchocerciasis.

When asked why she was not presenting her own health needs along with those of her children, a respondent observed: "The services here [at the health centre] are for our children and diseases that affect them [poliomyelitis, tetanus, tuberculosis, and measles]. I am not aware that they [the nurses] can treat filariasis. They do not remove nodules and doctors hardly come to our centre.

-- Uche Amazigo, University of Nigeria, Nsukka, Nigeria

Women need to be broadly educated about the importance of regular health care for themselves, as well as for their children. The role of self-esteem, an important factor that affects whether or not women seek care for their own health, should be considered when educational health programs are implemented (Bonino 1994). Because women tend to place great importance on their children, it may be useful to present messages that instill the notion that it is important that a woman be healthy to maintain her child's health (Iqbal 1995).

To take care of her own health, [a woman must] recognize herself as an individual, find herself worthy, strengthen her self- esteem, and [have] the power to decide about her own health.

-- Constanza Collazos V., Centro de Investigaciones Multidisciplinarias en Desarrollo, Cali, Colombia

Lack of support

Social support from others, such as relatives, friends, and neighbours can play an important role in fostering the physical and psychological health of women (Bonino 1994), and can greatly influence the health-seeking behaviour of women. Many women, particularly poor women, and those solely responsible for the care of their households, "lack the support of the family, someone to tell her to go to the doctor, to take care of herself, no one worries about her" (Bonino 1994, p. 204). Less importance may be placed on the health of female members of the household, compared with male members, and, consequently, a woman's illness may receive little attention from others (Bhattacharyya and Hati 1995). Although men are strongly pressured by other family members, particularly from mothers and wives, to seek treatment, women are unlikely to receive such encouragement (Niraula 1994) -- "a woman's role is to nurse, not to be nursed."

A study conducted in an Egyptian hamlet found that a sick person's access to care was determined by the persons's status within the family. Young women, considered to be of low-status, were likely to be treated by home remedies or traditional healers. "The women seem[ed] to need to convince the men that they [were] dangerously ill before they [were] taken to the doctor" (Lane and Meleis 1991, p. 1206). However, individuals with higher status, such as men of all ages and adult mothers of sons, were likely to be taken directly to a private medical practitioner.

[A woman] needs to be told to go for her own good and needs someone to support her at all times. What happen[ed] is that I went to the hospital by myself, I had no one to take me, so I stopped going.

-- Quoted by Maria Bonino, Universidad de la República, Montevideo, Uruguay

The true extent of some women's health problems may be completely underestimated by society. Paolisso and Leslie (1995) pointed out that, because some very serious illnesses and conditions may not be properly acknowledged by society (for example, cancer, AIDS, physical disabilities, chronic fatigue, and depression), women with such problems may not be assigned "a legitimate sick status." If a woman's illness is not identified as being authentic, it is doubtful that she will receive support from family members and the wider community to seek care.

Shame and embarrassment

Shame and embarrassment can lead to a reluctance on the part of women to share disease conditions with family members and health providers (Bhattacharyya and Hati 1995; Lule and Ssembatya 1995), and this may prevent them from reporting to health services for the diagnosis and treatment of illnesses. A reluctance to tell others is particularly acute in the case of illnesses with genital or urinary involvement (Amazigo 1994; Manderson 1994). There is considerable stigma associated with stds because these diseases are associated with sexual deviance. It is not surprising that women are very concerned about the consequences of detection and the possibility of being ostracized by their family and community (Guimarães 1994; Lule and Ssembatya 1995). Vlassoff (1994) also pointed out that women who have been victims of violence and abuse may be very unwilling to seek medical care because they are reluctant to draw attention to their situation.

Health services must be sensitive to the shame and embarrassment many women associate with illnesses. For example, if the stigma associated with stds were recognized, health services could improve the prospects that women would seek care by offering multiple services that ensure private consultations so that it is not obvious why a person is visiting the centre (World Bank 1993).

Fear of illness

In a qualitative study of women in a very poor area outside of Montevideo, Uruguay, Bonino (1994) documented many of the fears that women may have that prevent them from visiting health centres for care. Some women expressed concern that diseases would be discovered during check-ups and they said "they would rather not know [about them]." One woman was concerned that she might have "cancer of the uterus" and she would "rather not know" because her "mother-in-law died of cancer of the uterus" and her "sister-in-law left behind five children, she died of cancer of the uterus." The inclusion of blood tests in regular check-ups may lead to other concerns. According to one woman, "if they are going to do the hiv, I'm not going -- what if I've got AIDS?" (Bonino 1994, p. 202)

Apathy and depression

Women who suffer from psychological conditions, such as depression, may have a complete sense of apathy toward their own health care (Bonino 1994). Although psychological conditions often have a biological component, the particularly harsh living conditions of many women, including poverty, high stress, isolation, and an absence of social support, may work together to produce a state of depression or apathy (Bernardi and Mouriño 1991). The inability of some women to express their problems may adversely affect their psychological health. For other women, childhood experiences of violence, including rape or incest, may be factors related to their apathy or depression (Ferrando 1992). An American study (Joyce 1988) reviewed the histories of 70 women who had not had prenatal care. The study concluded that the psychosocial barriers of depression, negation, and fears were more powerful deterrents to the use of prenatal care than external barriers such as the lack of medical insurance or transport.

Access to health facilities

People should be able to receive reliable care close to where they live. However, health facilities are often poorly distributed, and health personnel and financial resources tend to be concentrated in urban hospitals (World Bank 1993; Atai-Okei 1994). Rural areas, where the vast majority of women in the developing world live, are less likely to have adequate health services.

In Kabugao, Philippines, a community in Kalinga-Apayao Province that suffers one of the highest prevalence rates of malaria in the country, the district hospital and rural clinic are reached by boat or half a day's hike through the mountain. The better-equipped provincial hospital is almost a one day journey by jeep. During the peak of the rainy season, the river becomes impossible to cross.

-- Esperanzo Espino, Department of Parasitology and Medical Entomology, Research Institute for Tropical Medicine, Manila, Philippines

Difficulties in reaching health facilities, as a result of distances, lack of transportation, or poor roads, are well-documented impediments to care (World Bank 1993; Atai-Okei 1994; Kaendi 1994; Iqbal 1995; Ren et al. 1995). In a study on malaria and visceral leishmaniasis that took place in Baringo, Kenya, during 1992­93, Kaendi (1994) found that distance was the major determining factor in the use of health care. Gender differences were reported, and 62% of the women (compared with 48% of the men) indicated that distance influenced their health-seeking behaviour. Malaria can be a serious problem where there is no health-care facility -- "many ... have died of illness before getting to hospital" (Anyangwe et al. 1994, p. 78).

In a study of 390 women who attended an antenatal clinic at Nankumba Health Centre, Mangochi District, Malawi (Lule and Ssembatya 1995), distance to the health centre was the primary reason reported by women to explain why less than one-quarter of the women delivered at a health centre, although almost 90% wanted to. The researchers reported that the number of mothers who delivered at the health centre was indirectly related to the distance in kilometres from the health centre. Of mothers who lived within 1 kilometre of the health centre, 90% delivered their babies there; whereas, only 10% of those who lived more than 20 kilometres away used the health centre. Similarly, distance from the health centre also heavily influenced the number of mothers who presented for care in their second and third stages of pregnancy.

Rodney (1995) reported that Grenadian women identified the lack of transportation as one of the primary barriers to services, particularly in the rural areas. They claimed there was a shortage of state-owned transportation in certain areas and that the privately owned minibuses targeted the high-density urban areas.

There are a number of major problems with the state and private community health centres [in Cambodia]. Health centres are sparsely distributed and good facilities are usually too far away. There is always a lack of transportation. Security is poor and there are safety risks associated with travelling to health centres at night. Because of the lack of infrastructure, sick people often do not arrive at health centres in time for proper treatment.

-- Neang Ren, Cambodian Midwives Association, Phnom Penh, Cambodia

In rural areas, the common mode of transportation for women is walking (or occasionally a bicycle). If an ill woman wants to visit a health centre, she may have to walk very long distances. If her child is ill, she may have to walk several kilometres with the sick child strapped on her back (Kaendi 1994). These long distances often mean that women only visit clinics when their health, or the health of their child, has reached a critical stage (Lule and Ssembatya 1995).

Clients who are farther away are less likely to have a good understanding or an exposure to the services provided by the facility. Greater familiarity can bring with it higher levels of acceptability.

-- W. Bailey, Department of Geography, University of West Indies, Jamaica

Bailey et al. (1995, p. 333) pointed out that the negative correlation between distance and the use of medical facilities is not always strictly related to the "friction of distance" -- it can also be linked women's degree of familiarity with services.

Health facilities must be made more accessible if their use in the prevention and control of disease and illness is to be encouraged (Kaendi 1994). Mobile clinics or the provision of transportation might greatly improve accessibility for women (un 1995).

Restrictions on mobility

Cultural norms that restrict the movements of women in some societies can prevent women from consulting health services (Leslie 1992; Rathgeber and Vlassoff 1993; Manderson 1994; Udipi and Varghese 1995). In rural areas of Pakistan, for example, females are not allowed to travel long distances alone. A male member of the family, even the youngest brother or son, is required to accompany a woman (Iqbal 1995). In Nigeria, "the religious practice of purdah severely restricts women's interactions with men and strangers. This limits the distance women can travel alone to seek health care" (Paolisso and Leslie 1995, p. 61). To get around this barrier to care, MacCormack (1992, p. 834) suggested that "elderly widows of secure honour and status might be trained as health workers to visit women in domestic seclusion."

When women are prevented from enjoying their legal, social, and cultural rights, they are disadvantaged with regard to access to health care.

-- Trinidad S. Osteria, De La Salle University, Manila, Philippines

A woman-centred strategy would require additional measures such as encouraging female community nurses to visit homes, especially those in communities where women are in seclusion, for case detection and management as part of the program to control malaria.

-- Uche Amazigo, Department of Zoology, University of Nigeria, Nsukka, Nigeria

Access to financial resources

Lack of access to resources to cover transport, service, and treatment costs is another barrier to care (Chiarella 1994; Bhattacharyya and Hati 1995). Women generally lack control of financial resources (often scarce) and therefore cannot, or will not, divert them for their own health. Paolisso and Leslie (1995, p. 61) state

Given the limitations on women's earnings in both formal and informal employment, and their complete exclusion from the cash economy in some cases, the extent to which poor women, particularly those who head households, can afford expenditures [associated with health care] is questionable.

Because they are financially dependent on husbands or relatives (Mwenesi 1994), women rely on male household members to pay the costs associated with health services. Men usually have the ultimate financial decision-making power about whether or not a family member can go to a health centre (Anyangwe et al. 1994; Kaendi 1994; Tsikata 1994; Vlassoff 1994).

Among the Mijikenda people, women are perceived to be the property of men because men pay a dowry to marry. Women are not expected to make any decisions without consulting their husbands. Illnesses, whatever their nature, are [perceived to be] a matter of life and death, and such matters cannot be left in the hands of women. Someone other than the mother must be involved in the health-seeking process. Mothers [also] require financial assistance to pay for either the treatment or the transport, and very few have their own money.

-- Halima Abdullah Mwenesi, Kenya Medical Research Institute, Nairobi, Kenya

Qualitative research results clearly describe the financial difficulties faced by women. A woman from Chad said: "Every time you have to pay 100 francs for this, 100 francs for that. If you multiply these 100 francs by the number of times you go to the hospital, you are not able to find the necessary money" (Wyss and Nandjingar 1995, p. 144). A similar sentiment was expressed by a woman from Kenya: "I have heard that here ... services are not free ... so if you do not have, for example, 20 shillings, [you] cannot get the services" (Ndhlovu 1994, p. 12). Another woman from Kenya complained about the cost of transportation: "She was going to take me to Kenyatta National Hospital ... but I need[ed] to find money for bus fare and I did not have this. So we did not go" (Ndhlovu 1994, p. 11).

Focus-group discussions conducted with adolescent girls in the slum revealed that they did not trust government hospital services. The general opinion was that health [care] is not affordable to the poor.

-- S.A. Udipi and M.A. Varghese, sndt Women's University, Bombay, India

As transitional economies, such as those in Cambodia, China, Laos, Mongolia, and Viet Nam, move from centrally planned economies under socialist governments to market economies, user fees are increasingly being introduced and more and more men and women are having to pay for essential health services. Zhang (1994), from the Department of Public Health, Kunming Medical College, China, reported that economic reforms and the introduction of user fees have made services less accessible for some women. A number of disadvantaged women from very poor households who used to enjoy free services may now be unable to see a rural doctor when necessary. Because employment opportunities are not equally available to women and men, women are more disadvantaged by having to pay for health services.

Their treatment-seeking behaviour had more to do with their lack of financial resources than with their lack of will or knowledge to seek treatment.

-- Stella Anyangwe, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon

Sex and maturity of the health worker

In many poor countries, the primary health-care worker is male. The lack of female health-care providers is another deterrent that prevents women from reporting to health services, particularly for illnesses involving the genitals and those causing physical deformities. When female clients do see male providers, shyness and reservation, especially concerning sexual health matters, can make it nearly impossible to establish a good client­provider relationship (Iqbal 1995; Manneschmidt, see footnote 6).

Cultural dictates may simply not allow women to be seen by male providers. In some Middle Eastern countries, for example, most physicians are men; however, there is a strong cultural belief that women should not be seen after puberty by men who are not part of their family (World Bank 1993). In Bangladesh, ideologies of purity and shame are so important to the status of women that Muslim female patients cannot speak directly to their doctors; instead, husbands or fathers explain the women's health concerns to the doctor on their behalf (Rozario 1995). A female care provider is preferred to a male for obstetrical and gynaecological care in Pakistan, even if the female has fewer qualifications. A male provider can be seen in the case of minor problems not related to reproductive health (Iqbal 1995).

Lack of female doctors in private clinics and government hospitals was another problem. Two-thirds of the girls [in a predominantly Muslim slum community outside Bombay] never went to a male doctor unless absolutely necessary. Their mothers would get prescriptions and medicines on their behalf by describing the symptoms to the doctors.

-- S.A. Udipi and M.A. Varghese, sndt Women's University, Bombay, India

The Muslim religious practice of purdah prevents male doctors in Bangladesh from being present during the delivery of a child. Despite grave danger to the health of a woman during labour, mothers will forbid their daughters from going to urban hospitals for delivery, "where violation of purdah [is] inevitable" (Islam 1989, p. 234).

Male doctors also refuse to see female clients under certain circumstances. In Central Nepal, women have problems obtaining care from male providers when they are menstruating because they are believed to be polluted and untouchable at this time (Niraula 1994). Likewise, in Bangladesh, because "[c]hildbirth pollution is the most severe pollution of all ... and delivering the baby, cutting the cord and cleaning up the blood are considered to be the most disgusting of tasks" (Jeffery et al. 1988, p. 106), some male doctors prefer to not handle deliveries and leave these tasks to female traditional birth attendants (Rozario 1995).

In a qualitative study of barriers that prevent women from using formal health services in Bolivia, the women interviewed said that "it should be women who attend to us" (Chiarella 1994, p. 214). More than half of the women interviewed in a study conducted in Kenya also said they would prefer a woman because "she is my kind" and because it would be easier to share problems with a woman (Ndhlovu 1994). Unfortunately, security concerns, constraints on the mobility of women, and the importance of women living with their families frequently prevent the recruitment of female health workers.

In addition to the sex of the provider, a recent study conducted in Kenya found that the age and maturity of the provider was also important to women. Women may be discouraged from seeking services because the "providers are younger than themselves and they have no wish to show their nakedness to young providers" (Ndhlovu 1994, p. 19). Women preferred "mature women who are married and have had babies" because they were believed to be able to understand and sympathize better with "women problems."

Adolescent females and women [are unwilling] to undress for the predominantly male health workers. In Nigeria, women are unwilling to have, as women in northern Nigeria put it, "strange men gazing at their nakedness."

-- Uche Amazigo, University of Nigeria, Nsukka, Nigeria

Culturally sensitive services

Health care for women must be culturally acceptable, otherwise women may underutilize existing health services. Two studies, one from Bolivia, and one from China, explored the reluctance of indigenous women to use formal western-based health services because aspects of the services contradicted cultural beliefs and practices (Chiarella 1994; Zhang 1994).

Chiarella (1994) used qualitative research techniques to explore some of the reasons why indigenous women in the rural area of Cochabamba, Bolivia, did not use the formal health-care system although there was an appropriate supply of services and health programs. The area is comprised of numerous migratory peoples descended from different ethnic groups, which include Quechua, Aymara, and Oriental.

Women of the Tropical Chapare, Bolivia, [rarely] used western- based health services because procedures contradicted with [cultural] beliefs of what constituted desired practices. In some cases, the traditional and western-based health systems complemented each other. In other cases, the systems were very different and in opposition, and this led to the underutilization of services.

-- Giovanna Chiarella, Health Research, Advice and Education Center, Cochabamba, Bolivia

The researchers discovered that there were many differences between the traditional and western systems in their practices and beliefs related to prenatal care, labour, and delivery. Indigenous women were reluctant to attend hospitals for deliveries because of drawbacks inherent in the modern health-care system. Indigenous women preferred to deliver their babies at home because they could take "maté" tea to help in labour, they could be attended by their relatives and husband, they could walk around, they could be wrapped up warmly and wear their own clothes, they were not shaved or cut, and they were able to deliver vertically, squatting on their haunches. At the western-based hospital, however, nothing could be consumed, they were attended by strangers, they could not walk around during labour, they were undressed and given a hospital gown, the hospital was cold, an episiotomy was mandatory, and they had to deliver horizontally in the gynecological position. Women also said that hospital practices were unacceptable because they were unable to swaddle themselves so that the magre would not rise (the magre is a mythical organ that is believed to form behind the naval during pregnancy and which might rise and cause death by asphyxiation).

The traditional system also has different notions about the importance of the placenta. Among these indigenous people in Bolivia, the placenta is viewed as a continuance of life. Once the placenta is expelled, it is supposed to be washed and buried in a shady spot. In the case of a boy, the placenta should be buried in a coca patch, and in the case of a girl, it should be buried in the kitchen. If this rite is not adhered to, it is believed that a number of problems could arise. For example, the child may become sick and die or may turn out to be irresponsible or alcoholic, and the mother may also become ill (Chiarella 1994). Women said that it was important to follow this ritual with the placenta because it made them feel secure. This detailed ritual with the placenta is in sharp contrast to the western system in which the placenta is merely discarded. Women in rural villages in Yunnan, China, were also reluctant to have a hospital delivery, primarily because they were afraid of losing the placenta (Zhang 1995).

According to the traditional culture and religion, the placenta is thought to be the protective saint of the fetus, and it must be buried in a safe place to ensure the healthy development of the newborn. Not surprisingly, many women risk deliveries at home to ensure that they will be able to obtain the placenta for proper burial. Some scholars have suggested that hospital delivery would be more acceptable to women in these areas if return of the placenta were guaranteed.

-- Kaining Zhang, Kunming Medical College, Kunming, China

Medical and hospital practices should ensure that they are culturally acceptable to the people who are intended to use them. Health services should adapt their working methods to accommodate traditional practices that are not detrimental to women's health (Turmen and AbouZahr 1994). Because of the importance placed on the placenta in some cultures, a ceremony for couples to welcome the placenta from the hospital to their home could be encouraged (Zhang 1994).

Although cultural norms and values must be respected, at some point it may be necessary for the health sector to challenge beliefs and practices that are harmful to women's health. In rural Myanmar, for example, qualitative research discovered that some traditional customs surrounding pregnancy and prenatal care were perfectly healthy; whereas others were potentially harmful to women (Win May et al. 1995). Healthy cultural practices during pregnancy, such as not lifting heavy loads, eating plenty of fruit and vegetables, and not avoiding any foods during pregnancy, should be encouraged by health providers. Other beliefs, such as the perception that edema is a normal phenomenon and that prenatal care is unnecessary if the mother is healthy, could be detrimental to pregnant women and should be discouraged.

Health personnel [in rural Myanmar] should educate pregnant mothers to be more aware of edema as a danger sign and to value and to use antenatal health-care services regularly. In this way, maternal mortality and morbidity could be reduced, and the health of the mother and child improved.

-- Daw Win May, Institute of Nursing, Yangon, Myanmar

Poor quality of care

Women's decisions to seek care are influenced by their judgements about the nature and quality of health services. If women lack confidence in the available services, they generally do not use them. Women are often reluctant to use local health services because they believe, often correctly, that these services are poor. As a result, tertiary-level facilities are often seriously overcrowded because women consider them to be more effective and seek them out, despite the distances (AbouZahr 1994).

Many women have had poor personal experiences with health services, and their health is compromised by their reluctance to return to such services. According to one woman: "They treated me so bad, so bad, that I didn't say anything, I came back home and never went back" (Bonino 1994, p. 203). Another woman in the same study said: "The students were there, they undressed me, they all touched me. I am scared to go back" (p. 202). Women may not go for check-ups because the doctor "checks them up, and puts his finger in [the vagina]" (p. 202).

Women's health-seeking behaviour is also influenced by negative stories relayed to them by relatives and neighbours about the care they received: "My sister told me that they were going to cut me up from top to bottom -- and so I never went" (Bonino 1994, p. 202). A study conducted in Malawi found that a significant percentage of women delivered their children at home because of negative past experiences or because others told them that midwives and staff had poor attitudes or were very unkind to women during labour (Lule and Ssembatya 1995). Women with positive attitudes to the staff at the health centre were almost three times more likely to deliver their children with the assistance of a trained person compared with those with negative attitudes. Some women said older female relatives advised them not to go to health centres or traditional birth attendants for delivery. Certain sources of information, such as friends and relatives, can be particularly credible to women who were making health-related decisions.

Judith Bruce (1990) of the Population Council in New York identified a number of quality of care elements that are important to women. These included the opportunity to make an informed choice, the provision of high-quality information, technical competence, good interpersonal relations,²¹follow-up and continuity mechanisms, and the appropriate constellation of services. However, results from numerous research studies have indicated that women in developing countries often receive very poor quality of care (WHO 1995). Haaland (1994), for example, reports that

Rural women in Africa often have many complaints about the care they receive from health workers in their communities. They frequently accuse them of being impatient, rude, and careless. They also complain that health-care workers charge exorbitant prices for medicines and services. As a result of these problems, rural women to a large extent care for their health problems at home.

Women commonly complain that they are not provided with sufficient information. For example, women in rural Bolivia said they were dissatisfied because they were "poked everywhere" and the doctors "looked at us all over," but the doctors did not provide any explanations to the women (Chiarella 1994, p. 213). In a study conducted in Barbados and Grenada (Rodney 1995), health professionals felt that women did not need, or would not understand, their conditions, and therefore they neglected to communicate relevant, user-friendly, and sensitive information to them. When information is provided, health-education messages may not be provided in a way that is useful or easily understood by rural women -- for example, written messages are of little use to women with low literacy levels.

Discussions from behind the screen were heard clearly by all strangers in the room, as was information relevant to the care of breasts and nipples, to personal hygiene, and to vaginal discharges and sexual activities.

-- Ra'eda Al-Qutob, United Nations Fund for Population Activities (UNFPA)/WHO, Amman, Jordan, and Salah Mawajdeh, Jordan University of Science and Technology, Irbid, Jordan

It is generally believed that female clients place great emphasis on interpersonal relationships. Research findings, however, have highlighted a general lack of sensitivity on the part of providers in their dealings with clients. For example, women who received family-planning services in Kenya complained of long waiting times and said that they were not properly welcomed or made to feel comfortable by providers (Ndhlovu 1994). Mawajdeh et al. (1995) reported that many women in their study of the quality of prenatal care in Irbid, Jordan, were annoyed by the lack of auditory and visual privacy.

The doctor should not scold one for taking the child [who is] dirty because if she goes for an emergency, she's not going to be thinking that she should wash him beforehand.

-- Quoted by Maria Bonino, Faculty of Medicine, Universidad de la República, Montevideo, Uruguay

Women have also reported being harshly judged or scolded by health professionals because their lifestyle and behaviours were deemed to be inappropriate. One woman reported that her "sister was three months pregnant and when the doctor went out to call her she was smoking and she got scolded. And right then and there she did not go in" (Bonino 1994, pp. 202­203). Some women said they felt concerned about their level of cleanliness and type of dress, and they believed that it would be too much effort to "get ready" to go to the clinic. Women have been verbally abused by nurses and told that their clothes smelled (Bello 1995). Nomadic women in Illorin, Nigeria, reported that staff at the health facility (who were from another tribe) insulted them and told them that they behaved like the cows they herded (Bello 1995, p. 30). A woman in Iqbal's (1995) study reported that "they insulted me, and it couldn't go on like this; so I decided to stay at home."

Poor and otherwise marginalized women often feel they are treated differently than middle-class and paying clients. At a hospital in Bangladesh, Rozario (1995, p. 104) was told that "if a patient's guardians pay a large sum of money to the doctors and the nurses, they usually keep an eye on the patient. Otherwise, there is no guarantee that the patient is going to be attended to when needed. Mawajdeh et al. (1995) found that women who looked better received better communication and information from the clinic. A lower caste woman from a hill village in central Nepal (quoted in Niraula 1994, p. 157) reported the follwing:

There is differential treatment in the health centre. If someone higher-caste and influential goes for treatment, he or she not only receives most of the time of the health post staff, but also receives free medicine. As for us, the poor, they direct us to buy from the shop .... When a family planning or health worker comes to the village, he never comes directly to us. He or she finds difficulty even to speak to us.

In many cases, there is a gulf between the worldview of the female client and that of the provider. The vast differences between clients and providers may act as a barrier to seeking care, and, if care is sought, may dramatically affect communication, understanding, and trust between the client and the provider.²²

In a recent study of client-provider interactions, Simmons and Elias (1994, p. 4) state:

Clients often experience providers as powerful individuals, who by social background and training are far removed from their own daily realities and concerns. Clients and providers bring very different expectations to their encounters, and these differences in perspective and power profoundly affect the nature of the interaction.

For example, one researcher described the difficulties in communication that developed between a client and provider at a regional hospital in the Eastern Province of South Africa²² -- the client was from a poor, rural, Xhosa family living in a remote area with little infrastructure. She spoke only Xhosa and adhered to a traditional way of life. In contrast, the medical practitioners consulted were white, male, English-speaking South Africans trained in medical schools and working in a regional hospital.

Women living in rural areas are disadvantaged. The viewpoints of urban-educated health workers and physicians, with their theories on anatomy and physiology and disease and treatment, are often very different than the viewpoints of rural women. This gap can present a barrier to the use of health services.

-- S.A. Udipi and M.A. Varghese, sndt Women's University, Bombay, India

Likewise, in central Nepal, where the service provider is usually a high-caste, educated, urban male and the patient is a lower-caste illiterate, poor, rural female, the status differences between the service providers and users "creates communication gaps and shadows the objectivity of the service" (Niraula 1994, p. 163).

Health workers who are from the same community as the people being served may have better success and provide better care than those from outside the community because they share a common cultural background and common experiences (Bonino 1994; Lange et al. 1994). Likewise, those who totally immerse themselves in a community may gain the trust and respect of the people being served -- crucial elements to good health care. For example, a woman, when discussing a family doctor who had been working for years in her area, reported that, "with him it's different, he explains everything and you understand it all; it's as if he was one of us, as if he belonged here" (Bonino 1994, p. 203).

Good interpersonal care requires sufficient time on the part of the provider. Many physicians, however, reportedly do not provide enough time to let women talk about how or what they feel (AbouZahr 1994; Vlassoff 1994). Women should have the opportunity to discuss various psychosocial factors related to their health and well-being. In this way, they can learn about the relationship between the illness and disease and their lives as women, workers, mothers, and wives (Gupte 1994). However, doctors are often "too busy and therefore in too much of a hurry to finish each case and go to the next" (Ndhlovu 1994, p. 14).

School curricula, including medical and health education curricula, must address gender issues and the specific health needs of women. The basic training and refresher training courses of all health providers need reorientation to place health in the context of unequal gender status, and to provide women's perspectives on their needs and experiences.

-- Boungnong Boupha, Lao Women's Union, Laos (see Boupha 1995)

Women are frustrated and discouraged when they travel great distances to the health centre by foot only to discover that the health worker is not there or that there is only one person available who has to treat many, and is therefore unable to provide adequate service and attention to individual clients (Chiarella 1994). Time of access for clients at some health facilities may be limited to only a fraction of the official 8 hours. Because health-care providers often receive little compensation for their work in public clinics, they may spend part of the working day at a private clinic to make extra money.

Providers in developing countries usually face numerous constraints that affect the quality of care they are able to provide. They tend to be overworked and underpaid, and health centres are invariably understaffed and underfinanced. As a result, they complain of having neither the time nor the energy to provide long explanations and high-quality care to their clients (Vlassoff 1994).

Health systems face other problems such as inadequate facilities, deficient professional training, poor renumeration for health professionals, and lack of social commitment.

-- Constanza Collazos V., Centro de Investigaciones Multidisciplinarias en Desarrollo, Cali, Colombia

Ensuring the availability of essential supplies, equipment, and medication is a necessary requirement for good quality health care. However, there are often serious deficiencies in this domain (AbouZahr 1994; Atai-Okei 1994; Lwihula 1994; Ren et al. 1995). Researchers from Africa, Asia, and Latin America have reported problems with condom availability, particularly in remote areas. A lack of gloves, disinfectant, and clean water has been reported in some family-planning services in Kenya: "cases have been cited ... where clients were seen crying because an IUD could not be removed because there was either no water or sterilizing lotion" (Ndhlovu 1994, p. 24).

The lack of integration of health services is another key factor that influences women's health-seeking behaviour and the quality of care received. In many countries, different types of health services (such as prenatal care, family planning, immunizations) are not integrated, and they may even be offered on different days (World Bank 1993). Women are therefore forced to return repeatedly to a clinic to receive care for their various health needs as well as the needs of their children. Given the heavy workloads and limited personal time available to women, strategies aimed at combining several health services at convenient times to meet women's needs should to be fully explored (World Bank 1993; Manderson 1994). When women present their children for care, it is an ideal opportunity to provide women themselves with other health services. Women would be more inclined to seek care for themselves when they present for care for their children rather than to arrange separate visits. The integration of efforts to prevent and treat stds and HIV with general health-care services may also increase the chance that women will receive care for these stigmatizing diseases.

Further away from the city, as one approaches the periphery, the facilities and support services dwindle. Communication becomes difficult and most things have to be done manually. This results in the feeling of being overburdened, which causes health workers' positive attitudes to slacken. Services become superficial.

-- Daisy Tin Tin Saw, Cambodian Child Health Project, World Vision International, Phnom Penh, Cambodia

Preference for traditional practices

The numerous barriers that prevent women from gaining access to health services, in addition to the poor quality of care sometimes delivered, may make traditional systems of medicine look more attractive than formal health services. Prohibitive costs associated with health services and the lack of time to travel to centres are two reasons why women prefer local traditional healers.

As a woman from the Benighat area of central Nepal (quoted in Niraula 1994, p. 163) said:

Whenever I have [a headache], I visit the dhami dai (shaman brother). He chants some mantra touching my head three times and I feel much better after some time. Dhami dai is just across the house and I do not pay him anything for his services. If I go to the health post, it takes time and money. Where on earth am I going to get that much money for my illness? I get satisfaction from the services from him.

Rural women in Bangladesh reportedly preferred traditional birth attendants (dai) over doctors for the delivery of their children because they do not have to be concerned about their modesty in front of the female village dai who are from the area and familiar to them. Secondly, doctors are expensive, but "[a] dai is merely given a sari, if anything, and maybe a meal of chicken curry" (Rozario 1995). Traditional healers are also preferred by some women because they provide meaningful explanations of illness, in comparison with the limited information provided by modern health providers (Vlassoff 1994).

²¹ Which would involve such qualities as privacy, respectful and responsive behaviour, being treated as an equal, and adequate time with the provider.

²² See Vincent, P.S., "The snake that broke Sitandile's neck." Unpublished paper submitted to the 1994-95 TDR/IDRC competition.

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