Women’s Health & Politics in Yemen [Archives:1998/19/Health]
This is the 3rd and last part of a research paper submitted at the Exeter University conference on Yemen (1-4 April) by Ms. Ilse Worm of Berlin Free University.
4. Women’s health in the policy making process
The policy making process which took place between 1991 and 1996 illustrates that a political consensus on the definition of women’s health and the strategies needed to improve the health status of Yemeni women could not be achieved.
4.1 Women’s health in its social context
As mentioned above, the improvement of the social, economical and health status of Yemeni women was central to the National Population Strategy endorsed by the government in 1991. In particular, it aimed at expanding the provision of educational services, especially to girls in rural areas, combat female adult illiteracy, improve women’s working conditions and social security, especially for pregnant women, widows and divorced women, as well as raising the minimum age of marriage for women (CSO 1992c: 24; 26). The Population Action Plan of 1991 called for the reform of the family and labor laws. It explicitly mentioned the need to increase the minimum legal age of marriage for women to 18 years and to ensure its enforcement (CSO 1992c:54).
In the National Health Conference of 1994 and the document issued thereafter, the limited participation of women in health, social and economic development was described as an important factor influencing negatively their health status. This limited participation was in turn related to the high rate of female illiteracy, low education and to “the wrong perceptions regarding women’s roles beyond their traditional duties at home” (Forward-looking Policies 1994: 5). However, raising the legal age of marriage was not mentioned as one possible strategy to improve women’s health.
The final draft document of the National Health Conference did not obviously completely conform to the convictions of the Ministry of Public Health leadership. Most of its form and its contents were taken over in the policy preamble to the Five Year Plan for Health Development issued in 1995. However, a thorough comparison of both documents reveals that the Five Year Plan followed a more restrictive concept of women’s health. Hence, illiteracy, low educational status and wrong perceptions regarding women’s role were still mentioned, but the passus “beyond their traditional duties at home” was omitted (Five Year Plan 1995: 14).
In the “Shari’a Guidelines for Family Planning Methods” the argument linking women’s health to an improvement of their social status was turned upside down. The authors, allegedly medical practitioners and religious scholars, argued that the heavy social problems Yemenis encountered were also resulting from the use of hormonal and mechanical contraceptives and encouraged early marriage in order to preserve the integrity (hasana) of the individual and the society (Shari’a Guidelines 1996: 2).
In contrast with this position and more in accordance with the National Population Strategy, the revised Population Plan of 1996 reaffirmed the need to improve the social, economic and political status of women. It however subordinated the achievement of equality between men and women to the principles of the Shari’a (ahkam ash-shari’a)(Population Action Plan 1996: 12). Consistently it only called for a review of the family law, but did not request to raise the minimum legal age of marriage (ibid.: 25).
4.2 Health-specific strategies to improve women’s health
The health-specific strategies which were brought forward in the Yemeni discussions on population, health and development, range from a narrow focus on facility-based maternal health services to broader concepts of reproductive health services. The National Population Strategy endorsed in 1991 aimed both at reducing maternal mortality and morbidity and at lowering fertility rates and therefore focused on the provision of maternal health services and in particular on family planning services. Hence., it was also planned to raise the contraceptive prevalence to 35% by the year 2000 (CSO 1992c: 22).
The Population Action Plan of 1991 intended to expand preventive and curative maternal health services to rural areas. The development of emergency obstetric services and the training of traditional birth attendants in local communities were foreseen. (ibid.: 32) The demand for family planning in Yemeni society was to be increased by awareness raising programs on different levels(national, regional, community) and targeted to different social groups (men, religious leaders, decision makers, women’s groups). Family Planning services were to be improved by expanding the health infrastructure, training health personnel, especially midwives, and involving the private sector (ibid,: 35).
The authors of “Forward-looking Policies” identified maternal health as a priority issue. They advocated the expansion and improvement of MCH/FP services, hereby mentioning the development of emergency delivery services and outreach services(Forward-looking Policies 1994: 20). They foresaw the establishment of nursing schools in the governorate hospitals in order to train female nurses and midwives (ibid.: 28). Malnutrition was to be addressed by establishing a national nutrition program specifically targeting mothers and children (ibid,: 19). The authors reaffirmed the importance of family planning by referring to the National Population Strategy and called for discouraging pregnancies among teenagers and mothers above thirty-five years of age. In accordance with Arabic and Islamic values, awareness raising programs regarding reproductive norms were to be linked to concerted efforts to improve women’s status. (ibid.: 20-21) Finally, sexually transmitted diseases and AIDS were considered for the first time as an issue for health policy and the development of a prevention program, including health education and control of blood transfusions was recommended.(ibid.: 18).
In the political preamble to the Five Year Health Plan Family Planning improving women’s health was not mentioned as a major component of a strategy. The authors called for discouraging early (not teenagers) pregnancies, but omitted late pregnancies over an age of thirty-five. They did not recommend raising awareness regarding reproductive norms in general, but only in relation to pregnancy and delivery and did not link these strategies to efforts to improve women’s status. Finally, a passus which was not included in the “Forward-looking Policies” was added, which recommended to reduce risks related to the frequent pregnancies by providing family planning services which did not contradict the policy of the Ministry of Public Health (Five Year Plan 1995: 32-33).
In the Five Year Plan itself, the improvement of women’s health was mainly restricted to the expansion of facility-based maternal health services. Hence, reducing the total fertility rate, or increasing the contraceptive prevalence rate was not part of its objectives. The overall strategy adopted to improve maternal health was to expand and strengthen MCH/FP services in public health facilities, by focusing on nutrition, antenatal and delivery care. The main target groups were pregnant women and children. The main implementation mechanisms referred to were the training of health personnel and health education (ibid., 117-121, 125-132, 198-201). Among the factors contributing to the spread of sexually transmitted diseases and AIDS, the lack of awareness about the disease and prevention methods, the geographical location of Yemen next to the Horn of Africa, Yemeni migrants in Arab and other foreign countries, uncontrolled blood transfusions, as well as high dowry prices, which – as it was assumed – leading young men to unhealthy sexual practices outside marriage, were mentioned. The measures to be taken included establishing a control system for blood transfusions, raising public awareness and targeting health education to groups at risk, training health staff and regulating the work of the National AIDS Committee through a specific law (ibid., 149-153).
The authors of the “Shari’a Guidelines for Family Planing Methods” further restricted the provision and use of family planning services. In general, they strongly recommended that modern contraceptive methods should not be provided to women before their third child was born, except in cases when pregnancy threatened the mother’s health. Hence, families were to be made aware of the risks of early pregnancies below 18 years and in case of early marriage, modern contraceptives could be used. Instead of discouraging pregnancies over 35 years, pregnant women below 18 and above 39 were to receive intensive health care. The authors upheld that the permission of the husband, besides the agreement of the wife, was an essential condition for the provision of family planning services. Contraceptives should not be provided, under any circumstances, to unmarried women. They further asserted that abortion was legally forbidden except in case the mother’s life was endangered by pregnancy. Finally, the use of pills inducing abortion immediately after conception were to be allowed in emergency situations, such as rape (Shari’a Guidelines 1996: 2-3) .
In contrast to this restrictive view, the expansion of primary health care including reproductive health services was considered a priority by the Population Action Plan of 1996. Although, the nature and range of these services were not clearly defined, youth was included as a target group for health education related to safe pregnancies and the prevention of sexually transmitted diseases. Furthermore, the importance of providing accessible, integrated and low-cost family planning services and to improve their quality was stressed. Contraceptive methods were described as a way to prevent unwanted pregnancies and abortions as well as a protection against sexually transmitted diseases and AIDS (Population Action Plan 1996, 4-7).