DevMode
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.

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