SAFE WOMANHOOD IN A CHALLENGING WORLD

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SAFE WOMANHOOD IN A CHALLENGING WORLD

• Afaf I. Meleis, PhD, FAAN
• Professor and Margaret Bond Simon Dean
• School of Nursing
• University of Pennsylvania
• Philadelphia, PA

Global Health SeminarUniversity of North
Carolina February 3, 2006
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Is The World Unsafe?

• Violence wars, terrorism
• Infections new and reemerging
• Environment accidents, pollution, lack of caring
  and support
• Unhealthy life styles eating, sleeping,
  activity, smoking

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Is the World Unsafe for Women for other reasons?
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What Makes the World Unsafe for Women?

• Violence
• Infections
• Lifestyles cardiovascular
• Wars

I could easily discuss any of these, and I do
agree that these are compelling reasons that make
the world unsafe for women, but I believe there
are added risks for women that magnify each of
these to a higher proportion.
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What Makes the World Unsafe for Women?

• The Gender Divide
• It makes women socially, culturally, and
  biologically at higher risk for morbidity and
  mortality

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A Framework for Discussion an Unsafe World for
Women and Their Health

• The context for my comments
• Research to uncover the lived experiences of low-
  or no-income women

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Women From

• Brazil
• Columbia
• Egypt
• Kuwait
• Mexico
• USA

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We Studied(Total N of research
participants1161)

• Per diem maids in Columbia
• Per diem maids in Egypt
• Fishermens wives in Brazil
• Women in clerical jobs in Southern Brazil
• Women in clerical jobs in the USA
• Women in clerical jobs in Egypt
• Farm workers in Egypt
• Auxiliary nurses in Mexico

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The Context for My Comments

• In addition to the many years of researching
  womens situations, my practice as a nurse, my
  life experience as a woman, though privileged
  rich with educational opportunities, I will never
  claim to know through first-hand experience what
  it is like to be abused, harassed or violated, I
  can look at these experiences from an outsiders
  perspective and, somewhat, an insiders position
  and understand and relate to these experiences.

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• I am also an immigrant who lived in the center
  and on the margins, and know how different are
  the experiences and the responses at both the
  center and the margins

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The context of my comments is profoundly
influenced by my own lived personal, academic,
and clinical experiences

• A nurse
• A medical sociologist
• An immigrant
• A feminist
• A researcher

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What Makes the World Unsafe for Women?

• The burden of womens work

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Womens work is veiled, voluminous, and devalued
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In developing countries women produce 75 of food
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In sub-Saharan Africa and the Caribbean, they
provide 80 of staple food
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In Asia women carry 90 of the rice field
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An African ProverbWithout Women We Would All
Go Hungry
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Housework
At home women cook, clean, carry water, sew,
bake, and care for families
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Nationally and Internationally

• Womens work underreported and underestimated
• However, there is a beginning recognition of how
  vital women are for the hunger and economic
  crises
• Economic and labor statistics do not reflect
  womens work outside of the context of the formal
  labor force

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Womens Work

• Women are self-employed or in unpaid labor
• Much of work is not remunerated and not factored
  into economic productivity as the gross national
  product
• Women considered unproductive by economists and
  development experts

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Women create and maintain community life and
provide emotional work and labor
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• I am a poor, nonworking person. I am just a
  housewife.

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Crisis in Care-Giving

• We are facing a crisis in care-giving in health
  care systems that is impacting national and
  global health policy
• The crisis is reduced to
• Shortages and numbers of nurses
• Aging nursing population
• Immigration of nurses
• It is due to misinformed patriarchal policy
  makers that we do not yet have effective solutions

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• I grew up seeing my mother and the rest of the
  women in the family do a lot of work from sunrise
  to sunset

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Womens WorkWhen womens work is unacknowledged
and devalued

• Limited studies of employment, hazards, and
  health
• Almost non-existent studies of work, risks, and
  health

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Risks for Women

• Nature and definition of work
• Overload
• Burden of double and triple shifts

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Vicious Cycle

• Even when women try to use their culture-imposed
  types of work to earn a better living, they
  become
• Maids
• Nannies to well-to-do families in high-income
  societies.
• They are
• Exploited
• Abused
• Driven to suicide (maybe!)

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Women-Workers in Other Countries

• Domestic workers who work in other countries,
  Filipinas in Hong Kong, Indians in Saudi Arabia,
  Thai in Korea are at a higher risk because of
• Limited policies to protect them,
• Lack of access to health care,
• Demands of family in countries of origin,
• Marginalization in host family,
• Lack of support

29
Messias, D.K.H., Im, E., Page, A., Regev, H.,
Spiers, J., Yoder, L., Meleis, A.I. (1997).
Defining and redefining work Implications for
womens health. Gender and Society, 11 (3),
296-323. Messias, D.H., Regev, H., Im., E.,
Spiers, J., Van, P., Meleis, A.I., (1997).
Expanding the visibility of womens work Policy
implications. Nursing Outlook, 45,
258-264. Meleis, A.I., Lindgren, T. (2001) Show
Me a Woman Who Does Not Work! Journal of Nursing
Scholarship, Third quarter, 33 (3), 209-210.
30
Meleis, A.I. (2001). Womens Work, Health, and
Quality of Life It is Time We Redefine Womens
Work. Women and Health. 33, Numbers 1 / 2,
xvxviii (note preface to book printed as
article). Meleis, A.I., and Lindgren, T. (2002).
Man works from sun to sun, but womans work is
never done Insights on research and policy.
Health Care for Women International, 23 (6-7),
742753.
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What Makes the World Unsafe for Women

• The burden of work (producing)
• Marriage

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• It is a worldwide phenomenon that women are
  defined by marriage and are always under enormous
  pressure to be found by a husband.

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MARRIAGE A Risk Factor

• Women are violated and killed because marriage
  brings
• Bridal burning in India
• Abuse and battering by
• husband and in-laws
• Burden of caring for
• in-laws

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CHILD LABOR
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CHILD LABOR
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What Makes the World Unsafe for Women

• The burden of work (producing)
• Marriage
• Violence

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What Makes the World Unsafe for Women

• Laws that condone and support domestic violence
  under the pretence that this is a family matter
• Social pressure that forbids women from
  disclosing/reporting violence

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• Disclosing rape is
• not accepted
• It is newsworthy
• when a father
• allows a daughter
• to disclose being
• raped

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Laws that violate women ? stoning for having a
baby out of wedlock
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Let us look at what happened in the Soviet Union -

• Some may say changes in political regimes may
  bring more safety for women. . .

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Issues Uzbek Women Face

• Domestic Violence police underreporting, failure
  of state and families to correct the problem
• Limited knowledge of the options available to
  women facing domestic violence
• Forensic evidence centers are few and located in
  big cities, far from reach of rural women
• Victims often hesitate to report violence to the
  police out of fear to shame the family and of
  futility of their attempts as well as economic
  impact of police fines and jail time on the
  family budget

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Issues Uzbek Women Face

• Families often do not support the victims
• Beating is always a womans fault. Men never
  beat for nothing
• Rape of married women
• Limited access to higher education
• Stigmatization of divorced women
• Polygamy
• Poverty and limited employment opportunities due
  to gender discrimination

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Issues Facing Ukrainian Women

• Domestic violence
• Medical service to women, especially pregnant, is
  often inadequate
• High rates of infant mortality, miscarriages, and
  STDs
• High cost of contraceptives and lack of basic
  knowledge of family planning leading to high
  abortion rates

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Issues Facing Ukrainian Women

• Gender-based employment discrimination that is
  also based on age and appearance
• Marital status-based employment discrimination
• Women trafficking into forced labor and sex
  industry

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Examples from Eastern Europe

• Since the fall of the Soviet Union
• Laws do not prohibit discrimination against women
• Higher HIV infection rate for women
• Prostitution to support drug habits or to feed
  family
• Police detain prostitutes but rape them in lieu
  of money or release

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Violence

• Wars
• Terrorism
• For women these mean
• Rape
• Trafficking
• Sex industry
• Infections
• Burden of more work
• Loss of work as men come back from war
• Religious revival

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Rape Violence and Children
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How about Afghanistan and Iraq post-war
liberation?
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Publications on the Issue
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• In times of economic turmoil, women suffer the
  most for their families
• Women are fired first
• When rations are given, usually to men, women may
  be forced to prostitute themselves to feed their
  families

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There are hidden consequences of 9/11
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Domestic violence is a taboo exacerbated by
terrorism
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Different Types of Violence

• Young women and girls are two and a half times
  more likely to be infected by HIV/AIDS than their
  male counterparts.
• In Sub-Saharan Africa, women ages 15-24 account
  for 75 of all young people infected with
  HIV/AIDS.
• In South and Southeast Asia, 30 of all those
  infected with HIV are women, and this percentage
  is rising rapidly.
• Peter Bell, CARE 2005

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What Makes the World Unsafe for Women

• The burden of work (producing)
• Marriage
• Violence
• Pregnancy, birthing, motherhood (reproducing)

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Reproductive Roles as Risks

• 1 in 7 women in parts of Africa will die in child
  birth. (In Sweden 1 in 6000)
• In Iraq, a woman is 3.5 times more likely to see
  her child die in 1st year than in Sweden
• 200 million women become pregnant around the
  world, one third is unintended and unwanted
• Nigerian women face 1 in 13 lifetime risk of
  maternal mortality
• Women living in Sub-Saharan Africa face the
  greatest risk of mortality due to unsafe abortion
• Gender-based violence is associated with higher
  mortality rates

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• A son gave her security in the marriage, and was
  going to be a man, a breadwinner

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With increasing technology to determine the sex
of a baby

• Women who choose to give birth to a daughter
  suffer prejudice

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Another Kind of Violence Associated with
Reproductive Function

• Female vaginal mutilation/female
  circumcision/female purification
• Different types posing different risks
• Increased risk of infections
• Increased risks to reproductive system
• Increased risks for psycho trauma

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• Another kind of violence is preventing women from
  having safe abortions

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What Makes the World Unsafe for Women

• Burden of Womens work (producing)
• Marriage
• Violence
• Pregnancy, birthing, motherhood (reproducing)
• Resources

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Health Care is a Major Problem

• Distance
• Transportation
• Length of wait
• Availability of personnel
• Cost of medicine
• Cost of transportation
• Many responsibilities

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Their Health Care

• A source of overload
• Fragmented
• Inaccessible economically
• Relied more on illness care

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What Makes the World Unsafe for Women

• Burden of Womens work (producing)
• Marriage
• Violence
• Pregnancy, birthing, motherhood (reproducing)
• Resources
• Theoretical and conceptual frameworks

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Theoretical/Conceptual Frameworks

• Biomedical Model
• Reproductive Maternal Model
• Morality Model

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Theoretical/Conceptual Frameworks

• Biomedical Model
• Disease focus
• Gender is not front and center
• Sociopolitical/cultural context minimized
• Fosters dependency
• Reproductive and Maternal Model
• Focus on pregnancy and birthing
• Lacks context of womens life
• Attention is on reproductive years

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Theoretical/Conceptual Frameworks

• Morality Model
• Adherence to moral standards buys care
• Commercial sex workers stigmatized
• Preservation of virginity is paramount
• Ritual killing goes unpunished
• Bride burning ignored
• Trafficked women stereotyped

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What Makes the World Unsafe for Women

• Burden of Womens work (producing)
• Marriage
• Violence
• Pregnancy, birthing, motherhood (reproducing)
• Resources
• Theoretical and conceptual framework
• Policies

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An Example of Policy that Makes the World Unsafe

• . . . any organization receiving
• USAID assistance must declare
• that it does not promote,
• support, or advocate the
• legalization of prostitution.
• U.S. Senate

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Reaction by Governments

• The Government of Brazil rejected 40M from USAID
  because the United States wanted to impose
  controls on countries that receive the funds.

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• Our feeling was that the manner in which the
  USAID funds were consigned would bring harm to
  our program from the point of view of its
  scientific credibility, its ethical values, and
  its social commitment. We must remain faithful
  to the established principles of the scientific
  method and not allow the theological beliefs and
  dogma to interfere.

Pedro Chequer, DirectorBrazilian AIDS Program
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Themes in the Lives of Women

• Exploitation
• Overload
• Worry
• Social insecurity
• Economic insecurity
• Inaccessible health care
• Inaccessible education

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Marginalization

• Intermediacy
• Differentiation
• Power
• Secrecy
• Reflectiveness
• Voice
• Liminality

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• The single best predictor of perceived wellbeing
  was role integration, balance between stressors,
  and satisfaction in all combined roles.

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Level of Education(2005 Carnegie Challenge)

• Gain of 4 years of education fertility drops by
  one birth (Klasen 1999)
• One additional year of education decreases infant
  mortality rate by 5-10 (Schultz 1993)
• Primary and secondary education protects women
  and their children against HIV/AIDS and violence
  (Herz and Sperling 2004)
• Womens education increases ability to resist
  violence in India (Sen, Amartya 2000)

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Level of Education(2005 Carnegie Challenge)

• Educated women are less likely to be circumcised
  and oppose it more often for their daughters and
  granddaughters in Africa (ORC Macro International
  1995)
• Mothers education associated with less intent to
  circumcise daughters, less risks and greater use
  of medical personnel (when circumcized), in Egypt
  (Malhotra and others 2003)

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• Lack of education makes the world unsafe for women

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Coping Strategies and Resources

• Turning to self
• Problem solving
• Reaching out

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Womens Health as a Foreign Policy

• Change conceptual framework
• Develop explicit policies
• Redefine work

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Change Conceptual Framework

• Stereotyping, morality, reproductive, stigma, and
  exploitive
• Vulnerable, gendered, equity and empowering

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What Will Make the World Safe for Women?

• Womens health on the agenda
• Equity
• Opportunities
• Paradigm change - gender

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Explicit Policies

• Develop health programs that acknowledge womens
  perspectives, experiences, and context
• The daily situations of women, need to be
  described and integrated in health programs
• Identifying women who are most vulnerable to
  risks
• Provide resources and structure to support and
  protect women

86
Messias, D.K.H., Regev, H., Im, E., Spiers, J.,
Van, P. Meleis, A.I. (1997). Expanding the
Visibility of Womens Work Policy Implications.
Nursing Outlook, 45, 258-264. Messias, D.K. H.,
Im., E., Page, A., Regev, H., Spiers, J., Yoder,
L., Meleis, A.I., (1997). Defining and
Redefining Work Implications for Womens Health.
Gender and Society, 11(3) 296-323.
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Work Redefined

• Energy expenditures
• Activity
• Space
• Time
• Resources
• Results
• Values
• Meanings

Messias et al. 1997Meleis et al. 2001
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Keeping Womens Health as a Top Priority on
National and International Agenda

• Education
• Development
• Research
• Services

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Women in a Safe World