Women’s Health & Politics in Yemen [Archives:1998/17/Health]
This is the first of three parts of a research paper submitted at the Exeter University international conference on Yemen (1-4 April) by Ms. Ilse Worm, Berlin Free University.
Studies on women’s health in Yemen usually focuses on the medical, social and demographic aspects of health behavior and most often neglect the political dimension of health care. This paper sets women’s health in relation to the political process which took place in Yemen in the ’90s. It hereby investigates how women’s health was defined in the policy making process and how health strategies affecting women’s health were implemented.
First it presents available information on the health status and the health needs of Yemeni women as well as on the public health care services offered to women. Second, it sets the development of Yemeni health and population policies in the context of the political liberalization at the beginning of the 90s, the participation of the Islah party in the government between 1993 and 1997, the international debate on population, women and development, and the national discussions on economic reform. Third, it analyzes the main health and population policy documents issued in the 90s and demonstrates that a political consensus on the definition of women’s health and on the strategies needed to improve the health of Yemeni women could not be achieved. Finally, it examines how Mother and Child Health and Family Planning services were managed in the Ministry of Public Health between 1993 and 1997. It hereby argues that despite the ideological influence of Islah on the policy making process, the management of health care under the leadership was characterized by pragmatism and continuity.
2. Aspects of Women’s Health in Yemen
Seen in its social context, women’s health in Yemen is determined by their position in family and household, their legal status and their access to social services. The complex interplay between these factors cannot be developed here. However, the following issues should be highlighted :
Current family law still allows early marriage and, hence, encourages early pregnancies. Although, the reform of the family law endorsed in 1992 prohibited marrying girls under 15 years, it did not ensure the enforcement of this regulation. In reality, early marriage is still frequent, although it has decreased in the last two decades. This decline is mainly due to the higher educational status of Yemeni women. However, in recent years the economic crisis might also have pushed marriage age upwards.
Education also has a high impact on the fertility of Yemeni women. However, the access of Yemeni girls and women to formal and informal education, especially in rural areas, is still very low. More than 75% of Yemeni women are illiterate, in comparison to 36% men. In rural areas only approximately 15% of women can read and write and the school ratio is still very low (27.3%), while noticeably higher in cities (74.6%). (CSO 1996)
Since Yemen adopted the primary health care approach in 1978, Mother and Child Health (MCH) services were established at different levels of the health system, with a focus on infant immunization and pre-natal care. Although, some experience with outreach activities regarding immunization and health education was made, MCH services are until now overwhelmingly facility-based.
One of the main problems in the health sector lies in the severe shortage of qualified female health staff : There were only 550 qualified Yemeni midwives employed by the Ministry of Public Health in 1996, most of them working in urban areas. (CSO 1996)
Family planning (FP) services were introduced in South Yemen in the late ’70s and in North Yemen in the mid ’80s. Until the beginning of the ’90s, they were restricted to the urban areas and started to expand to the countryside since. In public health facilities, contraceptives are only provided to married women under the condition their husbands agree. They can, however, be procured from pharmacies and in private health clinics.
Despite the efforts made in the last two decades to improve health care, estimates of maternal mortality in Yemen ranges between 1,000 and 1,400 per 100,000 live births. (Babobeishi 1992: 99: UNFPA 1997: 68) This rate is one of the highest in the world and has not decreased significantly during the last decade. Direct obstetric causes, in particular, hemorrhage and obstructed labor seem to account for more than 60% of maternal deaths. (Bahobeishi 1992: 99) Indirect causes are mainly related to the high prevalence of anemia and endemic diseases among pregnant women, such as viral hepatitis or malaria. Malnutrition, early, recurrent and too late pregnancies, as well as the high number of deliveries carried out without trained attendance are the most important underlying factors leading to maternal morbidity and mortality. Although, the number of women using modern methods of contraception has risen, contraceptive prevalence was still as low as 6% in 1992 (CSO 1992) Pills and intrauterine devices are the most common methods. Lack of knowledge, fears of side effects and difficult access to family planning services are the main reasons for women not to use contraceptives. (CSO 1992a; Assa’edi 1996: 27)
Most of the recent surveys on women’s health in Yemen focus mainly on maternal health. This focus is certainly justified insofar as childbearing constitutes a recurrent event in the life of most Yemeni women. However, by restricting the focus on women’s roles as mothers, other health concerns are overlooked. Information on other reproductive health concerns affecting the life of Yemeni women, such as abortion, circumcision, reproductive tract infections, sexually transmitted diseases and HIV/AIDS is rare and, however, often not accurate.
Although abortion is prohibited by penal and civil law unless pregnancy threatens the life of the mother, it currently seems to be practiced in private and public facilities, provided the unwanted pregnancy results from a marital relationship and both wife and husband consent to it. There are, of course, no statistics on the number of women dying or suffering injuries as a result of illegal unsafe abortions. Female circumcision, consisting in the removal of the clitoral hood of newly born female children, is apparently widely spread in the Tihama, while seldomly practiced in other regions. Unlike more severe forms of female genital mutilation, it does not seem to be a great physical health concern. Data on reproductive tract infections affecting women as a result of sexually transmitted diseases or in interaction with the use of intrauterine devices are virtually non-existent. Since the establishment of the National AIDS Program in 1988, efforts were made to collect information on the prevalence of HIV infections. According to official data HIV/AIDS cases, although still very infrequent, are steadily rising and 36% of the cases known in 1997 were women.
Seen from the perspective of Yemeni women the current health system does not respond adequately to their health needs, which encompass an easy access to health services for themselves and their children, affordable medical care, as well as respect for privacy and modesty. High transport costs, the lack of female health staff and drugs in the majority of public health facilities are key determinants for the use of MCH/FP services. For these reasons and because they prefer the familiarity of a home setting, most women, despite regional differences, still deliver at home with the assistance of relatives. Even when trained midwives are available, they often lack the knowledge to handle emergency deliveries.
Furthermore, the needs of divorced or widowed women who do not receive the social support of their enlarged family are not often taken into consideration by governmental health services, which are primarily targeted to married women. The structural adjustment program implemented since 1995 will most probably, negatively affect the access of rural Yemeni women to health services, unless a structural reform of the health sector takes place. Due to high transportation and accommodation costs, health care in 1995 was for the rural population three times as expensive as for urban residents. (World Bank 1995:33) The rise of transport prices due to the removal of subsidies on diesel will certainly increase these costs. As a consequence, poor users might renounce to use preventative health care services, which in turn will primarily affect women. Furthermore, the civil service reform which foresees to freeze recruitment into government employment, if conducted without considering the need to raise the number of female health staff, might obstruct efforts to improve the quality of MCH/FP services.