H N P D I S C U S S I O N Improving Women’s Health Issues and Interventions About this series This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent Citation and the use of material presented in this series should take into account this provisional character For free copies of papers in this series please contact the individual authors whose name appears on the paper Anne Tinker, Kathleen Finn, and Joanne Epp Enquiries about the series and submissions should be made directly to the Editor in Chief Alexander S Preker (apreker@worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256, fax 202 522-3234) For more information, see also www.worldbank.org/hnppublications THE WORLD BANK 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 477 1234 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org June 2000 P A P E R IMPROVING WOMEN’S HEALTH Issues and Interventions Anne Tinker, Kathleen Finn, and Joanne Epp June 2000 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network (HNP Discussion Paper) The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent Citation and the use of material presented in this series should take into account this provisional character For free copies of papers in this series please contact the individual authors whose name appears on the paper Enquiries about the series and submissions should be made directly to the Editor in Chief Submissions should have been previously reviewed and cleared by the sponsoring department which will bear the cost of publication No additional reviews will be undertaken after submission The sponsoring department and authors bear full responsibility for the quality of the technical contents and presentation of material in the series Since the material will be published as presented, authors should submit an electronic copy in a predefined format as well as three camera-ready hard copies (copied front to back exactly as the author would like the final publication to appear) Rough drafts that not meet minimum presentational standards may be returned to authors for more work before being accepted The Editor in Chief of the series is Alexander S Preker (apreker@worldbank.org); For information regarding this and other World Bank publications, please contact the HNP Advisory Services (healthpop@worldbank.org) at: Tel (202) 473-2256; and Fax (202) 522-3234 ISBN 1-932126-36-8 © 2000 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved CONTENTS Foreword Acknowledgments Summary of Key Issues and Interventions Introduction Determinants of Women's Health Meeting Women's Health Needs in the Developing World 12 Safe Motherhood 13 Sexually Transmitted Infections including HIV/AIDS 17 Malnutrition 19 Violence Against Women 21 Female Genital Mutilation 23 Conclusions 25 References 28 Appendix: Key Indicators of Women's Health Figures and Tables Figure 1: Determinants of women's health and nutritional status throughout the life cycle Figure 2: Health and nutrition problems affecting women exclusively or more severely than men during the life cycle in developing countries Figure 3: Burden of disease in females aged 15 to 44 in developing countries Figure 4: Intergenerational cycle ofgrowth failure Table 1: Totalfertility and access to reproductive health care among the poorest and the richest Table Essential services for women 's health FOREWORD As we assess our accomplishments since the Fourth World Conference on Women held in Beijing five years ago, I am pleased to present this World Bank update report on women's health issues and interventions The goals of improving women's health have been in place and recognized for some timefrom the first International Safe Motherhood Conference in 1987 to the International Conference for Population and Development (ICPD) in 1994, the Fourth World Conference on Women in 1995, and ICPD+5 in 1999 The Bank has been financing activities to improve women's health for almost 30 years and significant gains have been made, especially in the areas of maternal and child health and in family planning More and more, the Bank is increasing the level of policy dialogue with client countries to highlight the need to make good quality care available to women In addition to engaging clients in policy dialogue, the Bank is working in partnership with other international organizations to raise the profile of reproductive health policies The Bank has joined the World Health Organization (WHO), the United Nations Population Fund (UNFPA) and the United Nations Children's Fund (UNICEF) in 1999 to produce a joint statement expressing the agencies' commitment to reducing maternal mortality The key messages of this joint statement are: (i) policy and legislative actions are needed to reduce maternal mortality and (ii) improvement in the health sector must be accompanied by social and community interventions The health status of women has improved over the last few decades, however it remains a major development task Long standing challenges-like reducing unwanted fertility-still exist in some countries while other countries have moved on to new and different challenges This paper outlines five key areas that represent the "unfinished agenda" in women's health-areas where the Bank and other partners are beginning to develop policies and finance specific activities These areas include: safe motherhood, sexually transmitted infections (including HIV/AIDS), malnutrition, violence against women, and female genital mutilation This paper provides useful background on the determinants of women's health in these areas and points to critical policy reforms and cost-effective interventions Eduardo Doryan Vice President, Human Development Network June 2000 ACKNOWLEDGMENTS This report was finalized under the guidance of the Population and Reproductive Health Thematic Group Anne Tinker was the Task Team Leader and she prepared the overall report Kathleen Finn provided the descriptions of project activities Joanne Epp made contributions to the report and provided overall coordination for the final report Sadia Chowdhury, Michele Lioy and Jagadish Upadhyay (Bank Staff) and Mark Belsey (Consultant) provided information on the projects with which they are associated Tom Merrick, Rebeca Robboy, Homira Nassery and Subrata Dhar provided helpful comments Elfreda Vincent, Jennifer Feliciano and Nicole Mazmanian provided assistance with word processing and prepared the graphics SUMMARY OF KEY ISSUES ANDINTERVENTIONS Women's low socioeconomic status and reproductive role expose them to risks ofpoor health and premature death Yet many women's health problems can be prevented or mitigated through highly cost-effective interventions To achieve the greatest health gains at the least cost, national and donor investment strategies should give considerable emphasis to health interventions for women, particularly during their reproductive years Biological and socialfactors affect women's health throughout their lives and have cumulative effects A life cycle approach to health involves assessing critical risks and supporting key interventions that can have a positive long-term impact For example, girls who are fed inadequately during childhood may have stunted growth, leading to higher risks of complications during childbirth and low birth weight babies Complications ofpregnancy and childbirth constitute a major cause of death and disability among women of reproductive age in the developing world Of all human development indicators for adults, the maternal mortality ratio shows the largest discrepancy between developed and developing countries Improving maternal health requires increasing the proportion of deliveries attended by health providers skilled in midwifery and strengthening the referral system to effectively manage delivery complications Achieving these successful outcomes also depends on sustained high-level government commitment and behavior change at the community and household levels Unequalpower between men and women in sexual relationships expose women to involuntary sex, unwanted pregnancy, and sexually transmitted infections (including HIVA IDS) Family planning and sexual counseling can empower women and give them more control over their lives Sex education and counseling that promote mutual consent and condom use are also needed for men and boys Education of girls, access to microfinance, training, and employment opportunities for women will promote gender equality more broadly Malnutrition affects 450 million women in developing countries, especially pregnant and lactating women Iron, iodine, and vitamin A deficiency are widespread A two-pronged strategy is needed The first aims to decrease energy loss by reducing unwanted fertility, preventing infections and lessening a heavy physical workload The second focuses on increasing intake by improving diet and providing micronutrient supplements Domestic violence, rape, and sexual abuse occur in all regions, classes and age groupsaffecting about 30% of women worldwide Laws, counseling, support services, and medical care are important for prevention and management of gender-based violence Often a first step is providing a forum to raise awareness and mobilize support for action Female genital mutilation (FGM) is recognized as both a health and human rights issue-it affects two million girls each year, mainly in Africa The lesson learned from the Bank's work in combating FGM is that a broad based approach is needed, including public education and involvement of professional organizations and women's groups, as well as interaction with communities to address the cultural reasons for its perpetuation Women represent a disproportionate share of the poor and have limited access to health services Furthermore, country data show that the gap is greater between rich and poor in access to skilled delivery than access to other basic health services Efforts are needed to help govermments and non-governmental organizations expand health services to the poorest women, especially reproductive health services Communication programs are also needed to inform poor women and their families about women's health problems and the importance of seeking care Quality of care is a significant factor in a woman's decision to seek health care Even when health services are available and affordable, women may not use them if their quality is poor Promoting effective client-provider interaction is key to improving quality of health services for women This requires skilled staff, an adequate supply of drugs, and sensitivity to cultural factors Improving women's health requires a strong and sustained government commitment, a favorable policy environment, and well-targeted resources Long-term improvements in education and employment opportunities for women will have a positive impact on the health of women and their families In the short term, significant progress can be achieved by strengthening and expanding essential health services for women, improving policies, and promoting more positive attitudes and behavior towards women's health FEMALE GENITALMUTILATION Why Mum? Why did you let them this to me? Those words continue to haunt me .It 's nowfouryears after the operation and my children continue to sufferfrom its effects How long must I live with the pain that society imposed on me and my children? Gambia, Female Genital Mutilation: A Call For Global Action It is estimated that over 132 million women and girls have experienced female genital mutilation (FGM), and that some two million girls are at risk of undergoing some form of the procedure every year At least 90 percent of women have undergone the operation in Dijbouti, Egypt, Eritrea, Mali, Sierra Leone, and Somalia FGM comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other nontherapeutic reasons Genital mutilation has serious and sometimes fatal physical consequences, as well as psychological effects Complications may include hemorrhage, tetanus, and infection, as well as severe pain since the majority of procedures are performed without anesthetic Long-term consequences may include scarring, urinary tract infections, urinary incontinence, complications in childbirth, and painful intercourse Female genital mutilation has been the cause of mental and physical trauma and sometimes even death among girls and women in several African countries Traditional "elders" (male and female) carry out the procedure, most often for some remuneration The procedure is rarely carried out by anyone with health training and little attention is given to ensuring sterile conditions Because this is a very complex issue involving beliefs and cultural practices, communities have been reluctant to change and there have been only modest achievements FGM has been recognized as both a health and human rights issue The Declaration and Platform for Action of both the International Conference on Population and Development and the Fourth World Conference on Women, held in 1994 and 1995 respectively, call for an end to the practice of FGM Since ICPD, nearly one-third of the 28 African countries where FGM is practiced have legally banned it In 1994, Ghana became the first independent African state to pass a law against FGM Senegal and Cote d'Ivoire adopted a law against it in 1999 In Senegal, women in several villages have collectively abandoned FGM at pledging ceremonies, and a national committee has been established to educate the population on the consequences of the practice and to encourage other villages to pledge Governments and non-governmental organizations, including professional organizations and women's groups, should receive encouragement and material support to work for the elimination of genital mutilation Laws and clear policy declarations prohibiting the practice may help, but more broadly based efforts are also needed Widespread public education programs can publicize the harmful effects of genital mutilation and address its cultural roots Local research may be needed to determine the cultural reasons for its perpetuation, as well as to test effective approaches for preventing it, such as alternative rituals When researchers asked women in Egypt about the best way to abolish the practice, they 23 recommended educational campaigns directed toward parents Training for health providers on the elimination of the practice and on management of its health consequences is also needed The lesson learned from the World Bank's work in combating FGM is that legislation can only be effective when it is complemented by more broadly-based efforts These include public education programs and involvement of professional organizations and women's groups, as well as interaction with communities to address the cultural reasons for its perpetuation The Government of Guinea has passed legislation to ban FGM and imposed strict punishment on those whose practice resulted in the death of a woman or girl However, it has been difficult for the government to enforce the legislation In response, the Bank financed reproductive health project is collaborating with several NGOs to end this practice The project has implemented a public awareness campaign to educate communities about the harmful consequences of this practice NGOs, financed by World Bank grant funds, have complemented this campaign by focusing on the issues confronting those engaged in the practice-including their fear of losing status and income NGOs will coordinate with communities and assist former practitioners to find alternative employment opportunities that will benefit the entire community The Bank's assistance programs in Burkina Faso and Chad also include information, education and communication activities as well as training to reduce the practice of FGM The WorldBank's Development MarketPlaceProgramrecentlyawarded$150,000to test an approachto retrainingvillagetraditionalpractitionerswho performFGM in Kouroussa, Guinea The projectrecognizesthat performingFGM is an importantincomeearningactivity for villagewomen Theproject providesan alternativeincomesource to traditional practitionersby givingthem accessto microfinancing, trainingand marketsupportfor agricultureproducts Funds can be accessedfor vegetablefarmingand for the purchaseof equipmentfor millinglocal crops In additionto fundingfrom the Development MarketPlace, the pilot is supportedthroughfunds from a WorldBank loan to the Governmentof Guineaand microfinancefundingfrom the InternationalFinanceCorporation(IFC) 24 CONCLUSIONS Improvingwomen's healthrequiresa strong and sustainedcommitment governments by and otherstakeholders,a favorablepolicy environment, well-targetedresources Long-term and improvements educationand employment in opportunities womenwill have a positive for impacton the health of women and their families In the short term, significantprogresscan be achievedby strengthening expandingessentialhealthservicesfor women,improving and policies,and promotingmore positiveattitudesand behaviortowardswomen's health, summarizedin Table In the designand implementation programs,constraintsto women's accessto care need to of be taken into account,suchas culturalrestrictionsagainstwomen's abilityto travel and limitson women's controlover familyresources Outreach,mobileclinics and communitybased servicescan be helpful Clusteringservicesfor womenand childrenat the sameplace and time often promotespositiveinteractions health benefitsand reduceswomen'stime in and travel costs, as well as costs of servicedelivery Womenshouldbe empowered make to moreinformeddecisionsand to act on them For example,public educationand counseling can increaseaccess to informationabout self-careand aboutwhen care is neededor where it is available Evenwherehealth servicesare readily availableand affordable,womenmay not use them if their qualityis poor Qualityof care is a significantfactor in a woman's decisionto seek care,to give birth at a clinicinsteadof at home, or to continueusing contraception Effectiveclient-provider interactionis increasingly recognizedas a key factor for improving qualityof services Healthprogramsachievebetter outcomeswhen clientsbelieve that their needs are beingmet and when they are treatedwith respect and technicalcompetence Qualitycan be improvedthroughadequatelytrained staff, drugs, and supplies,increasingthe numberof femalehealthproviders,establishingconvenienthours,reducingovercrowding, and ensuringprivacyand confidentiality In additionto strengthening services,countriescan take additionalsteps to meet women's healthneeds Throughlegislation,legal enforcement,and information, educationand communication, harmfulpractices suchas genderdiscrimination, domesticviolenceand FGM can be curbed Closecollaboration among government, non-governmental organizations, communities,and women's groupswill make servicesmoreresponsiveto womenand improveutilizationand impact Effortsto improvewomen's healthmust includeactivitiesorientedto men Reachingboys at a young age through school-based massmediaprogramscan be particularlyeffective and in shaping later attitudesand practices Programsdirectedto boys and men are neededto promotesafe sex, increaseawarenessof women's health and nutritionneeds, decrease genderbias, and reduceviolentbehavior The task ahead is to applywhat we know aboutwomen's healthneeds to concreteactions It is clear that many women'shealth problemscouldbe effectivelymanagedthroughlowcost interventionsin low-incomesettings The World Bank is currentlyaddressingthese 25 issues throughpolicy dialogue,lending,research and supportto severalnon-governmental organizationsthrough the Bank's small grantsfacility The problemsvary by region-as the type of approachesand specificactivities In order to ensurethat we make progressin these importantareas,the Bank has put in place a mechanismto ensurethat lessons learned are disseminated-and used-in new projects For the WorldBank,human developmentis crucial to eliminatingpovertyand women have a key role to play Investmentsin women's health and nutritionpromote equity and generatemultiplepayoffsfor families,the community,the national economy,and the next generation It is time to completethe unfinishedagendafor the womenof this generationand their daughterswho follow 26 Table Essential services for women's health Promotionof PositiveHealth Practices and Education,employmentopportunities, micro-creditto givewomen more informationand controlover decisions regardingtheir health a Counselingand public educationto promote safe sex Publiceducationand programsto ensure PregnancyRelatedServices adequatenutrition Prenatal care Strategiceffortsto increasemale * Birth planning in involvement women's health * Promptdetection,management,and referral of In-schooleducationaboutreproductive pregnancycomplications health, physiology,sexuality,reproductive * Tetanustoxoidimmunization as well as dangersof and genderrelations, * Nutritionpromotion,includingiron and folate substanceabuse and, where warranted,iodinesupplements Trainingto improvethe quality of care, and * Management treatmentof sexually includingrespectfor women's privacy, transmittedinfections,malaria,and dignity,and informedchoice tuberculosis of Preventionand Management Unwanted Pregznancies Familyplanning of * Management complicationsfrom unsafe abortion * Terminationof pregnancywherenot against the law Safe Delivery Eliminationof HarmfulPractices * Laws,public education,and servicesto domestic eliminategenderdiscrimination, violence,rape, and femalegenitalmutilation Laws,public educationand policy dialogue to eliminatetraffickingof girls, and forced prostitution Laws,educationand servicesto reduce * marriageand childbearingamong adolescents Trainingand regulationto reduceoveruseor abuse of medicaltechnologies,such as unwarrantedcesareansectionsand episiotomyduring childbirth * Hygienicdeliveryby skilledattendant * Detection,management,and referral of obstetriccomplications * Facility-basedobstetriccare Postpartum care Monitoringfor infectionand hemorrhage of Preventionand Management Sexuall TransmittedInfectionsand GynecologicCancers * Condompromotionand distribution * Prenatal screeningand treatmentfor syphilis case management * Symptomatic * Screeningand treatmentof commercialsex workers * Screeningand treatmentfor cervicalcancer from age 35 and for breastcancer from age 50, as resourcespermit 27 REFERENCES Bos, E., Hon, V., Maeda, A., Chellaraj, G., and Preker, A 1999 Health, Nutrition, and Population Indicators Washington, DC: World Bank Center for International Programs June 1997 HIV/AIDS Surveillance Data Base Washington, DC: Bureau of the Census El-Zanaty, F., Hussein E., Shawky, G., Way, A., and Kishor, S 1996 Egypt Demographic and Health Survey 1995 Calverton, MD: Egyptian National Population Council and Macro International Inc Heise, L., Pitanguy, J., and Germain, A 1993 Violence Against Women: The Hidden Health Burden Discussion Paper 255 Washington, DC: World Bank Jamison, D., W.H Mosley, A.R Measham, J.L Bobadilla 1993 Disease Control Priorities in Developing Countries New York: Oxford University Press Jejeebhoy, S 1998 Implications of domestic violence for women's reproductive health: What we know and what we need to know In Kanna, J., et al (eds) Reproductive Health Research: The New Directions, Biennial Report 1996-97 WHO/HRP pp 138-149 Geneva: WHO Khan, Ayesha 1999 "Mobility of Women and Access to Health and Family Planning Services in Pakistan." Reproductive Health Matters, Vol 7, No 14, pp 39-59 Leslie, J 1991 "Women's Nutrition: The key to improving family health in developing countries?" Health Policy and Planning, 6, pp 1-19 Murray, C, and Lopez 1996 The Global Burden of Disease: A comprehensive assessment of mortality and disabilityfrom diseases, injuries and riskfactors in 1990 andprojected to 2000 Volume Geneva Narayan, Deepa 2000 Voices of the Poor: Can Anyone Hear Us? Washington, D.C: World Bank Sivard, R 1991 World Military and Social Expenditures, 14thed Washington, DC: World Priorities Inc Strauss, J., Gertler, P., Rahman, O., and Fox, K 1992 Gender and Life Cycle Differentials in the Patterns and Determinants ofAdult Health Santa Monica, CA: Rand Corporation and Ministry of Health, Government of Jamaica Swiss, S., Jennings, P.J., Aryee, G.V., Brown, G.H., Jappah-Samukai, R.M., Kamara, M.S., Schaack, R.D.D.H., and Turay-Kanneh, R.S 1998 "Violence against women during the Liberian civil conflict" JAM4, 279, 625-629 28 The Joint United Nations Programme on HIV/AIDS (UNAIDS) March 1999 Gender and HIV/AIDS Taking Stock of Research and Programs Geneva June 1999 Reducing Girls' Vulnerability to HIV/AIDS: The Thai approach Geneva June 1999 The UNAIDS Report Geneva Toubia, Nahid 1993 Female Genital Mutilation: A Call For Global Action New York: Women's Ink UNICEF Regional Office for South Asia 1997 Malnutrition in South Asia: A regional profile Kathmandu: United Nations Children's Fund United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition 1998 Challengesfor the 21s' Century A Gender Perspective on Nutrition Through the Life Cycle ACC/SCN Symposium Report Nutrition Policy Paper #17 Geneva: ACC/SCN United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition 1992 Second Report on the World Nutrition Situation Global and Regional Results, Geneva: ACS/SCN Women's Commission for Refugee and Children 1999 Sexual Violence in the Kosovo Crisis: A synopsis for UNCHR guidelines for prevention and response New York: Women's Commission for Refugee Women and Children World Bank 1993 World Development Report 1993: Investing in Health New York: Oxford University Press 1994 A New Agenda for Women's Health and Nutrition Development in Practice Washington, D.C 1994 Population and Development: Implications for the World Bank Washington, D.C 1995 Investing in People: The World Bank in Action Washington, D.C 1995 Working with NGOs Operations Policy Department Washington, D.C 1996 Improving Women's Health in India Washington, D.C 1998 Improving Women's Health in Pakistan Washington, D.C 1999 Intensifying Action Against HIV/AIDS in Africa: Responding to a development crisis Washington, D.C 29 1999 Population and the World Bank Adapting to Change Washington, D.C 1999 Safe Motherhood and The World Bank: Lessons from IO Years of Experience Washington, D.C * 2000 Advancing Gender Equality: WorldBankActions Since Beiiing Washington, D.C - 2000 World Development Indicators Washington, D.C World Health Organization (WHO) 1992 Women 's Health: Across Age and Frontier Geneva - 1997 Female Genital Mutilation Joint statement WHO/UNICEF/UNFPA Geneva - 1998 Maternal Health Around the World Wall Chart - 1998 Female Genital Mutilation: An Overview Geneva 1999 Reduction of Maternal Mortality, Joint statement WHO/UNFPA/UNICEF/World Bank 30 WORLD BANKPROJECT INFORMATION SOURCES Argentina AIDS and STD Control Project Status Report April 19, 2000 Bangladesh Personal communication with Dr Sadia Chowdhury, April 2000, and "Today" feature article World Bank Supportfor Nutrition in Bangladesh April 19, 2000 Chad Personal communication with Michele Lioy, April 2000, and World Bank Findings #150 January 2000 CHAD: The Safe Motherhood Project, Strengthening the Health System China Personal communication with Jagadish Upadhyay, and Study on Functional Coordination, February 1998 Guinea Email communication with Tshiya Subayi, April 2000 Indonesia Patricia Daly and Fadia Saadah June 1999 Indonesia: Facing the Challenge to Reduce Maternal Mortality World Bank East Asia and Pacific Watching Brief Kenya Sexually Transmitted Diseases Control Project Status Report October 29, 1999 Korea Personal communication with Eun Jeong Kim, April 2000 Vietnam Dr Vu Manh Loi et al 1999 Vietnam: Gender-based Violence A study commissioned by the World Bank prepared by The Institute of Sociology 31 APPENDIX: KEY INDICATORS WOMEN's HEALTH OF Country Total fertility rate births per woman 1998 Albania 2.5 Algeria Angola Argentina 2.6 97 38 b Armnenia 1.3 95 35 b Azerbaijan Bangladesh 2.0 3.1 99 37 440 b c Belarus 1.3 22 d Benin Bolivia Bosnia and Herzegovina Prevalence of anemia % of pregnant women 1985-99a 77 92 500 390 10 330 160 c c b d c 99 15 d 99 3.5 51 77 42 6.7 29 Brazil Bulgaria Burkina Faso Burundi 6.2 4.5 Cameroon Central African Republic Chad Chile China Colombia 5.0 4.8 6.4 2.2 1.9 2.7 Congo, Dem Rep 6.7 -Cambodia 49 1.1 6.3 -Botswana Illiteracy rate % of females 15 + 1998 5.7 4.1 1.6 4.2 2.3 Congo, Rep Contraceptive Births attended Maternal prevalence by skilled mortality rate health ratio per % of women staff 100,000 aged 15-49 % of total live births 1990-98a 1996-98a 1990-98a~ 6.0 16 49 77 12 2.6 5.0 Croatia 1.5 Cuba Czech Republic Dominican Republic Ecuador Egypt, Arab Rep El Salvador Eritrea Estonia Ethiopia 1.5 1.2 2.9 2.9 3.2 3.3 5.7 1.2 6.4 Gabon 5.1 Gambia, The Georgia 5.6 1.3 42 24 19 14 55 46 15 99 85 72 85 26 36 53 41 54 33 68 63 80 430 1,100 830 23 65 80 c c c b c b 44 67 37 13 52 24 44 100 32 33 68 69 25 53 29 c c 27 _ 27 34 b 64 b d 47 23 17 11 58 25 62 160 170 c c 17 24 14 1,000 50 c d 42 80 22 16 87 29 600 99 100 96 64 46 87 21 100 77 22 12 69 64 57 48 60 71 I . 24 97 45 11 -3 50 46 45 _ Costa Rica C6te d'Ivoire 60 46 24 _ _ _ _ _ _ 80 70 _ b 70 _ _ _ _ _ _ 73 _ _ _ Total fertility rate births per woman Contraceptive Births attended Maternal prevalence by skilled mortality rate health ratio per % of women staff 100,000 aged 15-49 % of total live births Country 1998 1990-98 a Ghana 4.8 20 44 Guatemala 4.4 32 29 Guinea Guinea-Bissau Haiti Honduras Hungary India Indonesia Iran, Islamic Rep 5.4 5.6 4.3 4.2 1.3 3.2 2.7 2.7 31 25 21 47 96 35 36 74 Iraq 4.6 Jamaica Jordan Kazakhstan Kenya Korea, Dem Rep Korea, Rep Kyrgyz Republic Lao PDR 2.6 4.1 2.0 4.6 2.0 1.6 2.8 5.5 1996-98a 18 50 73 41 57 73 54 65 50 59 39 92 97 190 c 910 d 220 15 410 450 37 41 70 590 110 20 65 650 b e c d d b b 100 45 d 100 c 89 50 94 100 95 57 55 98 75 18 11 490 620 39 c d b c c b 580 c - 45 100 98 98 30 60 25 1.1 2.4 4.6 3.7 1.4 1.8 5.7 6.4 3.1 Mali 6.5 24 Mauritania 5.4 40 75 97 50 68 48 42 150 230 Moldova Mongolia Morocco Mozambique Myanmar Namibia Nepal Nicaragua Niger Nigeria 23 45 19 22 2.0 _ _2.8 65 1.7 2.5 3.0 5.2 3.1 4.8 4.4 3.7 7.3 5.3 74 99 31 44 57 68 65 15 31 59 29 29 60 33 64 45 40 40 74 64 14 83 54 27 88 64 17 57 20 33 57 40 50 27 35 71 10 17 62 49 70'~ 21 35 42 56 18 58 24 69 69 b 29 20 c 41 11 d d c 20 45 45 58 58 16 65 36 41 55 49 66 73 21 20 78 31 93 48 230 230 540 150 590 27 55 56 c c c b c I .1 Lebanon Lesotho Libya Lithuania Macedonia, FYR Madagascar Malawi Malaysia Mexico d d c c c 1998 Illiteracy Rate % of Females 15 + 1985-99a 1990-98a Latvia Mauritius Prevalence of anemia % of pregnant women Country Total fertility rate birthsper woman 1998 Oman Pakistan 4.6 4.9 Panama 2.6 Papua New Guinea Paraguay Peru Philippines 4.2 3.9 3.1 3.6 Poland Puerto Rico 1.4 1.9 Romania Russian Federation 1.3 1.2 Rwanda Saudi Arabia Contraceptive Births attended prevalence by skilled rate health % of women staff aged 15-49 % of total 1990-98a 1996-98" Maternal mortality radio per 100,000 live births 1990-98a 18 26 59 64 47 19 84 24 85 53 61 56 53 Prevalence of anemia % of pregnant women 1985-99" b d 190 270 170 c c c d 78 98 90 57 34 99 99 41 50 6.1 5.7 21 26 90 Senegal 5.5 13 Sierra Leone 6.0 Slovak Republic South Africa 1.4 2.8 SriLanka 2.1 Sudan Syrian Arab Republic Tajikistan Tanzania Thailand Togo Trinidad Tobago and Tunisia 4.6 3.9 3.4 5.4 1.9 5.1 1.8 2.2 Turkey 2.4 Turkmenistan Uganda 2.9 6.5 Ukraine 1.3 Uruguay Uzbekistan Venezuela, RB Vietnam West Bank and Gaza Yemen, Rep Yugoslavia, FR Zambia Zimbabwe 2.4 2.8 2.9 2.3 5.9 6.3 1.7 5.5 3.7 c 60 76 96 38 15 56 75 42 21 26 37 110 510 74 16 39 12 57 42 b c c c 50 59 57 48 b 38 36 62 42 74 25 30 46 20 17 9 53 70 36 b c b 25 96 98 97 79 31 30 d 45 16 d 65 530 44 480 44 53 48 43 69 67 92 38 78 50 98 81 18 72 24 36 60 10 40 d b 560 100 82 43 71 25 69 54 47 Illiteracy rate % of females 15 + 1998 21 21 65 160 b b c c 350 10 650 400 c d c d I 29 52 43 99 47 69 26 48 34 34 77 31 17 Notes for Table a Data are for most recentyear available Maternalmortalityratios are currentlybeing updatedby WHO and UNICEF b Officialestimate c Estimatebased on surveydata d Estimateby the World Health Organizationand Eurostat e Estimateby UNICEF Source: World Bank 2000 WorldDevelopmentIndicators 35 H N P D I S C U S S I O N P A P E R Improving Women’s Health Issues and Interventions About this series Anne Tinker, Kathleen Finn and Joanne Epp This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent Citation and the use of material presented in this series should take into account this provisional character For free copies of papers in this series please contact the individual authors whose name appears on the paper Enquiries about the series and submissions should be made directly to the Editor in Chief Alexander S Preker (apreker@worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256, fax 202 522-3234) For more information, see also www.worldbank.org/hnppublications THE WORLD BANK 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 477 1234 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org ISBN 1-932126-36-8 June 2000 ... strengthening and expanding essential health services for women, improving policies, and promoting more positive attitudes and behavior towards women''s health WOMEN''S HEALTH: ISSUESAND INTERVENTIONS IMPROVING. .. IMPROVING WOMEN’S HEALTH Issues and Interventions Anne Tinker, Kathleen Finn, and Joanne Epp June 2000 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, ... I O N P A P E R Improving Women’s Health Issues and Interventions About this series Anne Tinker, Kathleen Finn and Joanne Epp This series is produced by the Health, Nutrition, and Population