Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 1: Women’s Health Is a Community Issue (introduction...) What Is ‘Women’s Health’? Women Are More at Risk for Disease and Poor Health Causes of Poor Health in Women Working for Change

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 1: Women’s Health Is a Community Issue

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What Is ‘Women’s Health’?

When a woman is healthy, she has the energy and strength to do her daily work, to fulfill the many roles she has in her family and community, and to build satisfying relationships with others. In other words, a woman’s health affects every area of her life. Yet for many years, ‘women’s health care’ has meant little more than maternal health services such as care during pregnancy and birth. These services are necessary, but they only address women’s needs as mothers. Except for the ability to produce babies, a woman’s health needs have been treated as no different from a man’s.

¨ Good health is more than the absence of disease. Good health means the well-being of a woman’s body, mind, and spirit.

In this book we offer a different view of women’s health. First, we believe that every woman has a right to complete health care, throughout her life. A woman’s health care should help her in all areas of life - not just in her role as a wife and mother. Second, we believe that a woman’s health is affected not just by the way her body is made, but by the social, cultural, and economic conditions in which she lives.

While men’s health is also affected by these factors, women as a group are treated differently from men. They usually have less power and fewer resources, and lower status in the family and community. This basic inequality means that:

· more women than men suffer from poverty.
· more women than men are denied the education and skills to support themselves.
· more women than men lack access to important health information and services.
· more women than men lack control over their basic health care decisions.

This larger view helps us understand the underlying (root) causes of women’s poor health. Improving women’s health includes treating their health problems, but it also requires changing the conditions of their lives so they can gain more power over their own health.

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When this happens, everyone - the woman, her family and community - benefits. A healthy woman has a chance to fulfill all of her potential. Plus, she will have healthier babies, be better able to care for her family, and can contribute more to her community. This kind of view also helps us see that a woman’s health problem is almost never her problem alone. Women’s health is a community issue.

Women Are More at Risk for Disease and Poor Health

Because a woman’s body is different from a man’s, and because of the basic inequalities between men and women, women face a greater risk of disease and poor health. Here are some of the health problems that affect women most.

Poor nutrition

Poor nutrition is the most common and disabling health problem among women in poor countries. Starting in childhood, a girl is often given less food to eat than a boy. As a result, she may grow more slowly and her bones may not develop properly (which may later cause difficulty during childbirth). The problem worsens as she becomes a young woman, because her need for good food increases as her workload increases, and as she starts her monthly bleeding, becomes pregnant, and breastfeeds.

¨ Not getting enough good food can keep a girl from growing properly, and can lead to serious health problems.

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Without enough good food, she may begin to suffer from general poor health, including exhaustion, weakness, and anemia. If a woman who is already malnourished becomes pregnant, she is more likely to have serious complications with childbirth, such as heavy bleeding, infection, or a baby that is born too small.

Reproductive health problems

Sexually transmitted diseases (STDs), including HIV/AIDS. A woman is physically more at risk for getting STDs and AIDS than a man. This is because a man’s semen stays inside her and the germs it carries can pass through the lining of the vagina into her blood. And, since a woman often has no signs of infection, she may not get treatment.

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¨ Because women must often have unsafe sex against their will, STDs are a social issue.

But the problem is really a social one. Women often have little control over decisions about sex and often cannot refuse unsafe sex. As a result, 165 million women get an STD every year, and 1.65 million became infected with HIV in 1995 alone. Without treatment, STDs can cause disabling pain, severe pelvic inflammatory disease (PID), infertility, problems during pregnancy, and an increased risk of cervical cancer. HIV/AIDS causes death.

Frequent pregnancies. In many parts of the world, a third to half of young women become mothers before they are 20 years old. Without family planning, many of these women will not have time to get strong again between births. This puts a woman at risk for poor health and complications of pregnancy and childbirth. Frequent childbirth also means she is less able to control her own life, to get an education, and to learn skills to support herself.

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Complications from pregnancy and birth. In the last 30 years, the number of infant deaths has been greatly reduced. Yet the number of women who die from pregnancy and birth has not, Every minute, one woman dies from a problem related to pregnancy. Every minute, 30 women develop a lasting health problem related to pregnancy. This means that over time, about a quarter of all women living in poor countries will be seriously affected by complications from pregnancy and birth.

¨ Every minute, one woman dies from a problem related to pregnancy.

Unsafe abortion. When a woman tries to end a pregnancy by having an unsafe abortion, she risks her life. But every day about 50,000 women and girls try to end their pregnancies in unsafe ways because they have no way to get a safe abortion. Many are left unable to have children or with lasting pain, infection, and other health problems.

¨ Every year 75,000 women die from unsafe abortions.

Female circumcision. Female circumcision, in which part or all of a girl’s outer genitals are cut off, can cause serious health problems. These include pelvic and urine system infections, sexual and emotional problems, and difficulties during childbirth. Yet despite these problems, it continues to be widely practiced. Every year about 2 million girls are circumcised, mostly in Africa, but also in the Middle East and Asia.

General medical problems

Women are more likely than men to suffer from certain health problems because of the work they do, because of poor nutrition, or from being too tired. A disease can also cause a different kind of harm to a woman than a man. For example, a woman who suffers from a disease which weakens or disfigures her may be rejected by her husband.

¨ Men and women get many of the same diseases, but women can be affected differently.

Once they are sick, women are less likely to seek and receive treatment until they are seriously ill. For example, tuberculosis (TB) is spreading among both men and women, but fewer women than men get treatment. Almost 3000 women die every day from TB - at least 1/3 of whom did not receive proper treatment or never even knew they had the disease. Other health problems that in the past affected mostly men are now risks for women, too. For example, more women are suffering from problems related to smoking cigarettes or drinking too much alcohol.

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Work hazards

Women face health risks every day from the work they do. At home, lung diseases from smoke or burns from cooking fires are so common that they are considered the main work-related health problem for women. Diseases spread through water are also common, because of the amount of time women spend washing clothes, hauling water, or standing in water while farming.

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¨ A woman faces health risks from her work inside and outside of the home. Working long hours, the ‘double work day’, can make her body too tired to fight disease.

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Millions of women who work outside the home suffer health problems due to unsafe conditions in the workplace. And when they come home from their jobs, they usually continue to work at home, so they end up with twice as much work. This leads to exhaustion and an increased risk of illness.

Mental health problems

Women and men have about the same risk of developing a mental health problem. Severe depression, however, affects many more women than men. It often affects women who are poor, who have experienced loss or violence, or whose communities have been destroyed or undergone great change. But women who suffer any kind of mental health problem are much less likely than men to get help.

¨ Problems with mental health can be as serious as other health problems.

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Violence

Violence is often overlooked as a health problem. But violence can lead to serious injuries, mental health problems, physical disabilities, and even death. Many girls are sexually abused by family members or friends. Many women are forced to have sex or are physically abused by their partners. Rope and sexual harassment are a constant threat to all women. These kinds of violence happen in almost all parts of the world, and under all social conditions.

¨ Women usually suffer violence from men they know. But most violence is not reported, and the men are not punished.

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Still, most violence against women is not reported, because the police and others often blame women rather than men for the problem. The men causing the violence are rarely punished.

Causes of Poor Health in Women

It is easy to name the direct causes of most of women’s health problems. For example, we can say that STDs are caused by different germs, poor nutrition comes from not eating enough good food, and problems during pregnancy are often caused by a lack of prenatal (before birth) care. But beneath these direct causes are 2 root causes - poverty and the low status of women - that contribute to many of women’s health problems.

LOW STATUS OF WOMEN

Status is the importance that a person has in the family and community. Status affects how a woman is treated, how she values herself, the kinds of activities she is allowed to do, and the kinds of decisions she is allowed to make. In most communities in the world, women have lower status than men. Women’s lower status leads to discrimination - that is, being treated poorly or denied something simply because they are women. Discrimination may take different forms in different communities, but it always affects a woman’s health.

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Wanting sons rather than daughters. Many families value boys more than girls because boys can contribute more to the family’s wealth, support their parents in old age, perform ceremonies after their parents die, and carry on the family name. As a result, girls are often breastfed for a shorter time, are given less food and medical care, and receive little or no education.

Lack of legal rights or power to make decisions. In many communities, a woman cannot own or inherit property, earn money, or get credit. If she gets divorced, she may not be allowed to keep her children or her belongings. Even if a woman has legal rights, her community’s traditions may allow her little control over her life. Often a woman cannot decide how the family’s money is spent or when to get health care. She cannot travel or participate in community decisions without her husband’s permission.

¨ Because so much of the work that women do is not recognized, they often lack legal protection in the workplace.

When women are denied power in these ways, they must depend on men to survive. As a result, they cannot easily demand things that contribute to good health, like family planning, safer sex, enough food, health care, and freedom from violence.

Having too many children, or having children too close together. Discrimination against women can also lead them to get pregnant more often, because bearing children may be the only way that women can gain status for themselves or their partners.

¨ Women make up half of the world’s population, but work 2 out of every 3 hours worked in the world, receive only a tenth of the world’s income, and own only a hundredth of the world’s property.

Under all these conditions, women live less healthy lives and get less health care. They also often accept their low status, because they have been raised to value themselves less than men. They may accept poor health as their lot in life and seek help only when health problems are severe or life-threatening.

The medical system does not meet women’s needs

Poverty and discrimination in the family and community not only lead to more health problems for women, they also make the medical system less likely to provide the services women need. Government policies and the global economy may add to this problem.

¨ The medical system does not provide all the services women need.

In poor countries, many people do not have access to health services of any kind. (The box below explains one reason why this problem has become worse in recent years.) And because of discrimination against women, the little money that does exist will probably not be spent on women’s health needs. So a woman may not be able to get good care even if she can afford to pay for it. Some reproductive health services may be provided, but to meet all of her health needs, she will probably have to travel to the capital city or perhaps even leave her country.

In many countries, the skills needed to care for women are considered ‘special’ and are provided only by doctors. Yet many of these services could be provided at lower cost by trained community health workers.

WHY DID MIRA DIE?

¨ There are many reasons why poor women get - and die from - diseases that can be prevented or cured.

Here are some common answers to this question:

A doctor may say...

Or a teacher...

Or a health worker...

All these answers are correct. Women who start having sex at a young age and are exposed to genital warts are at a greater risk for cancer of the cervix. And if the cancer is found early (usually by having a Pop test), it can almost always be cured.

Yet these answers show a very limited understanding of the problem. Each of them blames one person - either Mira or her husband - and goes no further. Mira was at greater risk of dying of cervical cancer because she was a poor woman, living in a poor country.

How poverty and the low status of women worked together to cause Mira’s death

Mira and her family were poor, so she was forced to marry and start having sex when she was very young. As a woman, she lacked power in her relationship with her husband. She had no control over when and how many children to have, or over her husband’s relationships with other women. Her family’s poverty meant that she suffered from poor nutrition her whole life, which weakened her body and left her more at risk for disease.

¨ You can explore the root causes of Mira’s death or other health problems by using the excercise called “But Why?”.

Although Mira’s community lacked health services, the nearest health center did have some women’s health services, like family planning and information about preventing HIV/AIDS. But the health workers had no information or training about other women’s health problems, even such serious ones as cancer of the cervix. They did not know how to do a pelvic exam (to look at the vagina, cervix and other reproductive parts) or a Pap test. So even if Mira had gone for medical care sooner, the health worker would not have been able to help her.

As a result, Mira had to travel a long distance at great cost to see a doctor who could tell her what was wrong. By that time it was too late.

Finally, Mira’s country was poor, with little money to spend on health care. Like the governments of many poor countries, her government chose to focus on other important health services, but not on women’s health. What money her government did spend on women’s health went to expensive hospitals in the big city instead of community health programs that women like Mira can get to. This meant that the services to find and treat cervical cancer - and many other women’s health problems - early were not available.

Poverty and the low status of women worked against Mira at all 3 levels - in her family, in her community, and in her country - to create the health problem that caused her death.

These are some of the links in the chain of causes that led to Mira’s death. They are the same links that cause many of women’s health problems.

Working for Change

IT DOES NOT HAVE TO BE THIS WAY

The way societies are organized forces most women into lives of poverty and poor health. But societies could be organized in a way that favors health instead of disease.

Since the causes of poor health exist at the family, community, and national levels, changes to improve women’s health must happen at each of these different levels.

Working for change in your family

You can improve your health by learning about women’s health problems and by making changes in your own life and in your family. Talk with your partner about what you each need to have better health, including practicing safer sex and sharing the workload fairly. You can also work to improve the health and future of your children. Here are some ideas:

¨ For other ideas of how your partner can help, see HOW MEN CAN HELP

Working for change in your community

You can improve your health and the health of other women in your community by sharing this book and by talking with them about women’s health problems.

Talking with others can be hard. Women often feel shame (for example, when talking about parts of the body) or fear about what others will think. Yet talking with others is the only way to learn more about health problems and to discover their causes. Often you will find that other women are worried about the same things, and want to discuss them.

¨ Because social conditions affect them differently, women and men may need to find different solutions for the same health problems.

Get a small group of women together to talk about health problems in your community. Try inviting women who are friends of your friends, neighbors, or women you work with. Once you have identified a health problem that many women share, it is often helpful to meet again and invite others to discuss it and learn more. When you meet, think about the root causes of the health problem, and plan the changes you can make in your families and community.

By meeting with a small group of women, you can learn more about a health problem and what can be done to solve it.

Think about involving men as well as women in discussions about women’s health. It may seem difficult to talk about women’s health problems with men, because this kind of talk is considered taboo, or ‘women’s secrets’. But since men are often in positions of power, their help can be very important. Look for men who are supportive of women, are good role models for boys, or who treat women as their equals.

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Here are some other activities that can help improve health in a community:

· Share information. Find ways to spread information about the common health problems in your community, so that everyone will know about them.

· Form support groups. Women who share common problems - such as women who have survived rape or abuse, breastfeeding mothers, women with disabilities, or sex workers - can form groups to support each other and work together to overcome their problems.

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· Work toward more independence. Projects that help women earn money and improve their working conditions also help women start to make their own decisions and gain self-esteem.

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· Develop community projects. For example, try to find ways for every family in the community to get enough to eat, or to improve community sanitation and access to clean water.

Simple and low-cost community efforts can make a difference

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When you first look at a problem, it often seems very hard to make changes. But, in fact, communities can make many improvements that do not cost too much. For example, here are some of the suggestions this book contains for preventing or helping solve women’s health problems:

· Start a community stove project. Women often suffer from lung infections, burns, and back problems. Low-cost cook stoves that are safer, use less fuel, and produce less smoke can prevent many of these problems.

· Establish an emergency transportation system. Many women die from complications of pregnancy, childbirth, and unsafe abortion. These deaths could often be prevented by reaching medical care quickly.

· Low-cost cancer screening can prevent many women from dying from cervical and breast cancer. Cancers are much easier to treat if they are found early.

· Make family planning services and good prenatal care accessible to all women. Doing so can prevent many deaths due to complications of pregnancy, childbirth and unsafe abortion.

· Train health workers to care for women’s health. They should be trained in pelvic exams, Pap tests and visual inspection, manual vacuum aspiration (MVA), breast exams, and counseling. They should also learn how to use medicines for women’s health.

Working for change in your country

You can improve your health, and the health of many other women in your country, by working together with other groups in different parts of the country. By working together, you can make important changes in the way your government treats women and women’s health. For example, community groups can pressure the government to punish men who rape or abuse women, or to make safe abortion available. Or you can get laws passed to allow women to own or inherit property - so that women are not forced to depend on men.

GAINING POWER OVER OUR OWN HEALTH

Just as ‘women’s health’ means more than maternal health, it also means more than access to health care. To be truly healthy, women need the chance to make the decisions necessary for good health. And they need access to a fair share of the resources in their communities and in the world.

By joining other women and men in the struggle for health, we can demand the chance to live healthy, full, and joyful lives - free of disease, pain, and fear.

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 2: Solving Health Problems (introduction...) Juanita’s Story (introduction...) What is the problem? Some illnesses are hard to tell apart What is causing the problem? What Is the Best Treatment? Is a treatment helpful or harmful? Risks and benefits Working for Change (introduction...) Looking for the root causes of health problems Organizing to solve community health problems To the Health Worker Helping women help themselves

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 2: Solving Health Problems

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Whenever a woman has signs of a health problem, she needs information in order to solve it. She needs to know what the problem is, its cause, what can be done to treat it, and how to prevent it from happening again.

¨ Some problems must be treated with skilled medical care. But most health problems can be treated at home or can be prevented by healthy living.

In this chapter we tell the story of one woman, Juanita, and how she solved her health problem. Although the details apply only to Juanita, the way she thinks about her problem and works to solve it can apply to all health problems. You can use this method to solve a health problem yourself or to make decisions about getting good medical care.

Juanita discovered that a lasting solution to her health problem involved looking beyond her own situation. She also had to identify the root causes of the problem in her community and country, and work to change them. Like Juanita, you and your community can use this method to identify all the causes of women’s poor health - and to plan ways to make your community a healthier place for women.

Juanita’s Story

Juanita lives in a small village in the mountains of western Honduras where she and her husband grow corn on a small plot of land. Their land does not produce enough to feed their 3 children, so several times each year Juanita’s husband, Raul, goes off to the coast with other men from the village to work on the banana plantations.

About 3 weeks after the last time her husband returned home from the coast, Juanita began to notice more discharge than usual from her vagina. Then she started having pain when passing urine. Juanita knew that something was wrong, but she had no idea what it was.

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Juanita decided to ask her friend Suyapa for help. Suyapa suggested drinking teas made from corn silk, because this had helped her when she had had pain passing urine. So Juanita tried the teas - but the pain and discharge did not go away. Suyapa then recommended the remedy her friend Mar�a del Carmen had used for pains after childbirth. The local midwife had given Mar�a a cotton cloth filled with plant medicines to wrap around her belly. When Juanita tried the remedy and it didn’t work, she thought putting the medicines inside her vagina might be better But nothing helped, and her signs kept on bothering her.

Finally Juanita decided to go to see the health worker, Don Pedro. She felt shy about having a man examine her, but by this time she was scared that something serious was wrong.

What is the problem?

Don Pedro told Juanita that in order to help hen he needed to learn as much about the illness as possible. So he asked Juanita these questions

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Some illnesses are hard to tell apart

After listening carefully to Juanita describe her pain and discharge, Don Pedro explained that signs often tell us the general kind of health problem someone has. But sometimes several different illnesses can cause the same signs. For example, a change in the amount, color, or smell of a woman’s vaginal discharge could be caused by:

· a sexually transmitted disease (STD).

· an infection of the vagina that is not an STD.

· pelvic inflammatory disease (PID), which is an infection of the womb and tubes, often caused by an STD.

· cancer of the cervix.

To get a better idea about which of these problems was causing Juanita’s signs, Don Pedro needed to know whether Juanita and her husband used condoms, and whether either of them had had other sex partners. Juanita admitted that she suspects her husband has sex with other women, since he is gone for months at a time to work. But they had never discussed it, so she did not know for sure. The last time her husband came home, however, he had complained of some pain when passing urine. He blamed it on the foods he ate at the coast.

With this added information, Don Pedro said he suspected Juanita had an STD, probably gonorrhea or chlamydia. Because it is difficult to tell these diseases apart, it is better to treat both of them.

What is causing the problem?

What Is the Best Treatment?

Is a treatment helpful or harmful?

Although Don Pedro was certain that medicines would solve the problem, Juanita wanted more information before deciding on a treatment. She knew, for example, that home remedies had often helped her mother and grandmother when they were ill. Why, then, did the remedies she had tried fail to work? Here is Don Pedro’s explanation:

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In Juanita’s case, she had used all 3 kinds of remedies:

Corn silk tea would have been very helpful if Juanita had an infection of the urine system. This is because corn silk tea makes a person pass urine more and so flushes germs out of the body. But these teas probably did not help Juanita because her infection was not in the urine system.

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Wrapping plant medicines around the belly is a harmless remedy. It will not make a health problem worse, because the medicines stay outside the body, but it will not help, either.

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Putting plant medicines into the vagina is harmful and should never be done. Plant medicines can irritate the vagina and cause dangerous infections.

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Don Pedro told Juanita that she could learn about a particular treatment and how well it works by talking to many different people who have used it. Here are some questions to ask:

· Why do you use this method?
· When do you use it?
· How do you use it?
· What happens when you use it?
· How often does it help the problem?
· Do things ever go wrong?

Think carefully about what different people say about treatments they have used. Then, when you try a remedy yourself, pay attention to what happens to your signs to see if the remedy helps you. Be careful about trying too many remedies at once.

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When Juanita felt satisfied that modern medicines were the best treatment for her health problem, Don Pedro gave Juanita some pills called doxycycline and co-trimoxazole and told her to come back in a week, after she had taken them all. He also explained that her husband, who was away again, must be treated with the medicines when he comes back, and that they must begin to practice safer sex.

When Juanita returned to see Don Pedro the next week, she told him that she had taken all the pills he gave her but her signs had not gone away. She also said her discharge was getting worse and becoming yellow in color. So Don Pedro asked Valeria, a health worker with more training, for help.

Valeria agreed that Juanita had an STD. But because the medicines had not helped, Valeria suspected that Juanita may have a form of gonorrhea that is resistant to co-trimoxazole. Valeria explained that many resistant forms of gonorrhea had come from foreign soldiers at the military base on the coast, who have been infecting the local women when they had sex. Valeria recommended that Juanita go to the city where she could get a more complete exam and be tested for gonorrhea, syphilis (another STD), and cancer. She could also get newer; more effective medicines, if needed.

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Risks and benefits

Juanita went home to think about what to do. She would have to spend most of her family’s savings to pay for a trip to the city and the medicine. Since she would be gone at least two days (the trip is almost 6 hours each way by bus and walking), and her husband was still away at the coast, she would also have to find someone to watch her children while she was gone.

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Juanita was afraid that her husband would be angry if he came back and found out that she had spent so much money to see a doctor But she was also scared that if she did not go she would get worse. Valeria told her that without treatment she could pass the infection on to a new baby if she became pregnant. With time she would probably become unable to have more children, would develop severe pain in her lower belly, and would have problems with her urine system and monthly bleeding. Her husband could also develop many serious health problems.

Juanita felt so uncertain about what to do that she went to see Valeria again. When Juanita explained her fears, Valeria suggested thinking about the problem this way:

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Juanita decided that the benefits of going for treatment weighed more than the risks.

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So Juanita went to the city for treatment, where the doctors said it was true that she had gonorrhea and probably chlamydia, but no signs of other STDs or problems. They explained that the medicine she took no longer works in her country. They gave Juanita a newer medicine for both her and her husband.

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Working for Change

When Juanita had taken the medicine and was feeling better, it was tempting to think that her health problem had been solved. But she knew this was not true. When her husband returned from the coast, she would get infected again if he did not take the medicine and use condoms. She discussed the problem with Suyapa and other women whose husbands work at the coast, and together they decided to ask Valeria for advice.

Looking for the root causes of health problems

Valeria agreed that Juanita’s health problem was not yet solved, because many of the conditions that created the problem still existed. She suggested playing a game called “But why....?” to help everyone identify all the conditions that created the problem.

Valeria gathered the women in a circle, and asked them to try and answer her questions:

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And so on.

When the women had named a long list of causes, Valeria suggested putting the causes in groups. This way it is easier to see the different kinds of conditions that cause health problems:

Physical causes: germs or parasites, or something that goes wrong in the body or that the body lacks

Environmental causes: conditions in the physical surroundings that harm the body, such as cooking smoke, lack of clean water or crowded living conditions

Social causes: the way people relate to or treat each other, including their attitudes, customs, and beliefs

Political and economic causes: causes having to do with power - who has control and how - and money, land, and resources - who has them and who does not

When the women put the causes of Juanita’s problem into these groups, they came up with the following list:

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Organizing to solve community health problems

The next step, Valeria told the women, is to look at the different causes and decide which ones you and others in the community can change. Then think about what actions must be done to make the changes happen.

Juanita and Suyapa thought they could get their husbands to use condoms if their husbands understood more about STDs, and if the condoms were not so costly. The actions they decided to take were:

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Other members of the group suggested these actions:

· Organize a community group to talk about health problems, and include STDs in the topics discussed.

· While women are washing clothes at the river, talk to them about STDs and how to prevent them.

· Talk to their sons about STDs before they leave the village to go to the coast.

The last step, said Valeria, is to make a plan to carry out each of these ideas for action. The plan, she said, should answer each of these questions:

· What are we going to do? What steps will we take?
· When are we going to do these things?
· Who are we going to do them with?
· What materials will we need?
· Who is responsible for making sure that the plan is carried out?
· How will we evaluate whether the plan is working?

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To help you use this method of solving health problems yourself, here is a chart with a list of all of the steps. On the left are the steps and on the right are the parts of Juanita’s story that go with each step. Any time you have a health problem you can use this chart to help you remember this method for thinking about and taking action to solve the problem.

To the Health Worker

Helping women help themselves

In this chapter Don Pedro and Valeria played an important role in helping the women in Juanita’s community solve a health problem. The reason that Don Pedro and Valeria were so effective was that they did not tell Juanita and her friends what to do. Rather, Don Pedro and Valeria helped the women learn how to help themselves.

You, too, can help the women in your community by following Don Pedro’s and Valeria’s example. You can:

· Share your knowledge. To help themselves, women need information. Many health problems can be prevented if people know how. But remember that you do not have to have all of the answers to help people. Many times there are no easy answers. It is fine to admit when you do not know something. The people you work with will be glad for your honesty.

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¨ Share your knowledge with other women, other health workers, and with the people who make decisions in the community.

· Treat women with respect. Each person should be treated as someone who is capable of understanding her health problems and of making good decisions about her treatment. Never blame a woman for her problem or for past decisions she has made.

· Keep health problems private. Health problems should not be discussed where others can hear Never tell anyone else about a problem someone has unless the person with the problem says it is OK.

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· Remember that listening is more important than giving advice. A woman often needs someone who will listen to her without judgment. By listening, you let her know you care and that she is important. And as she gets a chance to talk, she may find that she has some of the answers to her problem.

· Solve problems with others, not for them. Even when a woman’s problems are very large and cannot be solved completely, she usually has some choices she can make. As a health worker, you can help her realize she has choices, and help her find the information she needs to make her own decisions.

· Learn from the people you help. Learning how others solve their own problems can help you to help others better (and sometimes yourself, too).

You learn from those you help, and those you help learn from you.

· Respect your people’s traditions and ideas. Modern science does not have all the answers. And many modern medicines come from studying plant medicines and traditional ways of healing. So it is important to respect and use what is good in both methods - and to realize that both methods can cause harm when used in the wrong way.

Figure

· Find out what people really want to learn about. It is easy to fall into the trap of giving information without finding out if it will be helpful. This often happens with health workers who give prepared talks. But if you find out exactly what people want to know, they will get knowledge that is useful to them. This also helps them build on their own knowledge.

· Plan with people, not for people. When you plan your work, be sure to talk first with women and men in your community. Find out how they view the problem you are working to solve. Together, talk about what they think causes the problem and how they would like to solve it. Working together brings the best results!

Figure

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 3: The Medical System (introduction...) The Medical System Community health workers Health posts Health centers Hospitals How to Get Better Care (introduction...) Know what to expect Bring a friend or family member If You Need to Go to the Hospital Working for Change

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 3: The Medical System

Figure

Most people use some combination of modern medicine and traditional remedies to treat their health problems themselves. In many cases, this is all that they need to do. But for some health problems, a woman may need to seek medical advice.

¨ There are times when you cannot treat a health problem yourself. You may need to seek help from the medical system.

In most areas of the world, there are 4 different levels of health care: community health workers or traditional healers, health posts, health centers, and hospitals. Together, they are called the medical system. A medical system can include health workers, nurses, doctors, and others. They may be in private practice (charge money for their services), or they may be supported by the community, the government, a church, or another organization. Sometimes they are well trained and equipped - and sometimes they are not,

This chapter describes the medical system and how a woman can use it to get help for her health problems. Not every community has each of these 4 levels, and there can be many different combinations of health services that make up the medical system. But no matter what combination of health services is available, women - and all sick people - will get better care if there are good connections between the different levels of health care.

Figure

The Medical System

Community health workers

Figure

Some communities have well-trained, skilled health workers. These health workers often work out of health posts or centers, but not all do. Community health workers may or may not have formal training. But by working closely with the people in their communities, they can help prevent many common health problems, and help people treat their problems before they become more serious. A health worker can be trained to provide the same services as a health post.

¨ When health care is provided by trained health workers within the community, everyone can get better care, for less money.

Health posts

Many communities have health posts. In some places, this level of care is called a clinic or an MCH (Maternal Child Health). A health post should be able to provide:

· health information so that everyone can make better decisions about their health.

· immunizations or vaccinations that can prevent many diseases, including tetanus, measles, diphtheria, whooping cough, polio, tuberculosis, rubella, and hepatitis.

· care during pregnancy (prenatal care) that can help a woman find and treat problems affecting her or her unborn baby before they become serious.

· family planning services and supplies. Family planning can save lives by helping women control how many children they have, and the amount of time between births.

· health exams to help find and treat problems such as weak blood (anemia), high blood pressure, and sometimes sexually transmitted diseases (STDs).

Figure

Health centers

Health centers provide a middle level of care. They are usually in larger towns, so people from nearby communities as well as from the town use them. Health centers usually offer all the services a health post offers, and they may also have a few beds where sick people can stay while being cared for.

Health centers are more likely than health posts to have trained nurses and doctors. They are also more likely to be crowded, and the doctors and nurses may know less about the people they see.

Figure

Some health centers have laboratories with special equipment. This means they can do tests that give more information about the cause of a health problem. Often, however, a person must go to a hospital to have tests done.

Hospitals

Hospitals are usually in large towns or cities, and can be expensive. They usually have many doctors and nurses, and special equipment for treating serious illnesses. A person with a serious illness may need to go to a special hospital that can treat certain problems. A woman might need to go to a hospital for:

· problems that cannot be treated elsewhere.
· complications of childbirth or abortion.
· emergencies such as a pregnancy in the tube.
· health problems that require an operation.

Figure

How to Get Better Care

There are many decisions to make when you have a health problem. One decision is whether to see a health worker, and what kind of health worker you think you need. If there is more than one way to treat a problem, you will need to consider the risks and benefits of each kind of treatment before you make a decision. You will be able to make the best decisions - and get the best care - if you can take an active role in working with your doctor, nurse, or health worker to solve your health problem.

Figure

Know what to expect

You will be best able to take an active role in your health if you are prepared and know what to expect when you seek medical care.

Questions about your health

It is best to learn as much as you can about your health problem before you use the medical system. Reading this book may help you understand your health problem and the possible causes. For help thinking about health problems, see “Solving Health Problems.”

The doctor, nurse, or health worker who sees you should ask about the problem you are having now and about your past health. Try to give complete information, even if you feel uncomfortable, so that the person asking the questions can learn as much as possible about your health. Always tell about any medication you are taking, including aspirin or family planning methods.

¨ It often helps to think of the questions you want to ask before you go for medical care.

You should also have a chance to ask any questions you may have. It is very important to ask as many questions as you need to make a good decision about how to solve your health problem. If these questions have not already been answered, you may want to ask:

Figure

Many doctors and nurses may not be used to giving good information, or they may be busy and not take the time to answer your questions. Be respectful, but firm! They should answer your questions until you understand. If you do not understand, it is not because you are stupid, but because they are not explaining well.

The exam

In order to know what is wrong with you and how serious your problem is, you may need an examination. Most exams include looking at, listening to, and feeling the part of your body where the problem is. For most problems you need to undress only that part of your body. If you would feel more comfortable, ask a friend or female health care worker to be in the room with you during the exam.

Figure

Tests

Tests can give more information about a health problem. Many tests are done by taking a small amount of urine, stool, or coughed-up mucus and sending it to a laboratory. Or. a needle is used to take a small amount of blood from your finger or arm. Other common tests include:

· taking some fluid from your vagina to test for sexually transmitted diseases (STDs).

· scraping cells from the opening of your womb (cervix) to test for cancer. (This is called a Pap test.)

· taking tissue from a growth to test for cancer (biopsy).

· using X-rays or ultrasound to see inside your body. X-rays may be used to find broken bones, severe lung infections, and some cancers. Try not to be X-rayed during pregnancy. Ultrasound can be used during pregnancy to see the baby inside your womb. Neither of these tests causes any pain.

ultrasound machine

¨ X-rays ore safe if they are used properly. A lead apron should be used to protect your reproductive organs.

Before you have any test, discuss the cost. Ask the doctor, nurse, or health worker to explain what he or she will learn from the test, and what would happen if the test was not done.

Bring a friend or family member

Many people feel worried about seeking medical care - even for illnesses that are not serious. And when a person is sick, it can be even harder for them to demand the care they need. If another person can go along, it can help.

If a woman is very sick, someone who can give information should go with her.

A friend can:

· watch the woman’s children.

· help think of questions to ask, remind the woman to ask them, and make sure they are answered.

· answer questions if the woman is too sick to talk.

· keep the woman company while she waits.

· stay with the woman while she is being examined, to support her and make sure the doctor acts in a respectful way.

If You Need to Go to the Hospital

If you need to have an operation or you have a serious illness, first find out if it is possible to be treated without having to stay in a hospital. If a hospital is the only place you can get the care you need, this advice may help:

· Bring someone with you who can help you get the attention you need and help you make decisions.

· Different people may examine you. Each one should write down what he or she did on a card that stays with you. This way the next person who cares for you will know what has already been done.

· Before anyone begins a test or treatment, it is very important to ask what they are going to do and why. This way you can decide if you want them to do it and help prevent mistakes.

· Try to make friends with the staff at a hospital. They can help you get better care.

· If you need to have some kind of operation, ask if it is possible to have an injection to stop pain only in the area being operated on (local anesthetic). It is safer and you will get better more quickly than if you are given medicine to make you sleep during the surgery (general anesthetic).

· Ask what medicines you are being given and why.

· Ask for a copy of your records when you leave.

Figure

After you have an operation

Before you leave the hospital, ask:

· What should I do to keep the cut clean?

· What should I do about pain?

· How long should I rest?

· When can have sex again? (If you feel too shy to ask this, perhaps the doctor or health worker can talk to your partner.)

· Do I need to see a doctor again? If so, when?

To keep your lungs healthy and prevent pneumonia, move around if you can. While in bed, take deep breaths and try ti sit up often

Eat soft, mild foods that are easy to digest.

Rest as much as you can. If you are at home, ask your family to take care of your daily chores. A few days spent taking care of yourself can help you get better faster

Watch for signs of infection: yellow discharge (pus), a bad smell, fever, hot skin near where you were cut, or more pain. See a health worker if you have any of these signs.

If your operation was in the abdomen, try not to strain the area that was cut. Press against it gently with a folded cloth, blanket, or pillow whenever you move or cough.

Working for Change

Millions of people throughout the world suffer and die from illnesses that could have been prevented or treated if they had access to good medical care. And even where health services do exist, there are many barriers that keep women, especially poor women, from using them.

But together, health workers and groups of women can change the medical system. They can make it a resource - rather than a barrier - for women as they try to solve their health problems. The medical system will not change on its own, though. It will change only when people demand it, and when they offer creative ways to bring the health care that people need within the reach of all.

A good place to begin changing the medical system is by discussing the health care problems that affect people in your community - including lack of access to good care - with other women and men.

Figure

Women can also work together to:

· help every member of the community to learn about women’s health problems. For example, you can organize a campaign to explain how important it is that women get good prenatal care. If women and their families know about women’s health needs, women will be more likely to use the health services that already exist. They will also be more likely to demand that new ones - such as better treatment and screening for cervical and breast cancer - be made available.

Figure

· see how existing health resources can be improved. For example, if there is already a community midwife, how can she get training in new skills?

· find new ways to make health care available. It is important to think about what health services you want to have, and not just what you have now. So, if there is no health worker now, how can one be trained and supported? If there is already a clinic, could it offer new services like workshops or counseling?

· share the knowledge each woman has about health care. Women already do much of the ‘health work’ in the community. For example, it is usually women who care for the sick, teach children to stay healthy prepare food, keep the home and community clean and safe, and help other women have babies. Through this work, they have learned many skills that they can use to care for each other and every member of the community.

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 4: Understanding Our Bodies (introduction...) A Woman’s Reproductive System (introduction...) The reproductive parts on the outside The breasts The reproductive parts on the inside A Man’s Reproductive System (introduction...) Having a baby - Will it be a boy or a girl? How a Woman’s Body Changes (introduction...) Hormones Monthly Bleeding (introduction...) The monthly cycle (menstrual cycle) Problems with monthly bleeding

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 4: Understanding Our Bodies

This chapter is about the parts of the body that make up a woman’s or a man’s sexual and reproductive system. This information will help you to use the rest of this book.

Figure

In many ways, a woman’s body is no different from a man’s. For example, women and men both have hearts, kidneys, lungs, and other parts that are the same. But one way they are very different is in their sexual or reproductive parts. These are the parts that allow a man and a woman to make a baby. Many of women’s health problems affect these parts of the body.

You can feel your hips bones just below your waist. They are part of the pelvis. The pelvic area is everything between the hips. This is where a woman’s reproductive parts are.

Sometimes talking about the sexual parts of our bodies can be difficult, especially if you are shy, or do not know what different parts of the body are called. In many places, the reproductive parts of the body are considered ‘private’.

¨ No one should feel ashamed of any part of his or her body.

But knowing how our bodies work means we can take better care of them. We can recognize problems and their causes and make better decisions about what to do about them. The more we know, the more we will be able to decide for ourselves if the advice that others give us is helpful or harmful.

¨ The more we know about our bodies, the more we can teach our children how to have better health.

Since different communities sometimes have their own words for parts of the body, in this book we often use medical or scientific names. This way, women from many different regions of the world will be able to understand the words.

A Woman’s Reproductive System

A woman has sexual parts both outside and inside her body. They are called the reproductive organs, or genitals. The outside parts are called the vulva. Sometimes people may use the word vagina for the whole area. But the vagina is the part that begins as an opening in the vulva and leads inside to the womb. The vagina is sometimes called the ‘birth canal’.

Figure

The drawing below shows what the vulva looks like and what the different parts are called. But every woman’s body is different. There are differences in the size, shape, and color of the parts, especially of the outer and inner folds.

The reproductive parts on the outside

Vulva: All the sexual parts you can see between your legs.

The breasts

Breasts come in all shapes and sizes. They start to grow when a girl is between 10 and 15 years old, when she changes from a girl to a woman (puberty). They make milk for babies after pregnancy. When they are touched during sexual relations, a woman’s body responds by making her vagina wet and ready for sex.

Inside the breasts:

Figure

The reproductive parts on the inside

Figure

Figure

A Man’s Reproductive System

A man’s sexual parts are easier to see than a woman’s because they are mostly outside the body. The testicles (balls) make the main hormone in a man’s body, called testosterone. When a boy goes through puberty, his body begins to make more testosterone. It causes the changes that make a boy look like a man.

Having a baby - Will it be a boy or a girl?

About half of a man’s sperm are boy sperm and half are girl sperm. Only one sperm will join with the woman’s egg. If it is a boy sperm, the baby will be a boy. If it is a girl sperm, the baby will be a girl.

Because most communities value men more than women, some families would rather have boys than girls. This is unfair because girls should be valued just as much as boys. It is also unfair because in some places a woman is blamed if she does not have any sons. But it is the man’s sperm that makes a baby either a boy or a girl!

Boy or girl? It is up to chance - much like flipping a coin.

How a Woman’s Body Changes

The Life Cycle

A woman’s body goes though many important changes during her life - at puberty, during pregnancy and breastfeeding, and when she stops being able to have a baby (menopause).

In addition, during the years she can have a baby, her body changes every month - before, during, and after the time of her monthly bleeding. The parts of the body where many of these changes happen are the vagina, womb, ovaries, fallopian tubes, and the breasts, also called the reproductive system. Many of the changes are caused by special chemicals called hormones.

Figure

Hormones

Monthly Bleeding

About once each month during her reproductive years, a woman has a few days when a bloody fluid leaves her womb and passes through her vagina and out of her body. This is called ‘monthly bleeding’, the ‘monthly period’ or ‘menstruation’. It is a healthy process and is part of the way the body gets ready for pregnancy.

Around the world, women have many different names for their monthly bleeding.

Most women think of their monthly bleeding as a normal part of their lives. But often they do not know why it happens or why it sometimes changes.

The monthly cycle (menstrual cycle)

The monthly cycle is different for each woman. It begins on the first day of a woman’s monthly bleeding. Most women bleed every 28 days. But some bleed as often as every 20 days or as little as every 45 days.

The amount of the hormones estrogen and progesterone produced in the ovaries changes throughout the monthly cycle. During the first half of the cycle, the ovaries make mostly estrogen, which causes a thick lining of blood and tissue to grow in the womb. The body makes the lining so a baby would have a soft nest to grow in if the woman became pregnant that month.

In the middle of the cycle, when the soft lining is ready, an egg is released from one of the ovaries. This is called ovulation. The egg then travels down a tube into the womb. At this time a woman is fertile and she can become pregnant. If the woman has had sex recently, the man’s sperm may join with her egg. This is called fertilization and is the beginning of pregnancy.

During the second half of the cycle - until her next monthly bleeding starts - a woman also produces progesterone. Progesterone causes the lining of the womb to prepare for pregnancy.

¨ A woman may find that the time between each monthly bleeding changes as she grows older, after she gives birth, or because of stress.

Most months, the egg is not fertilized, so the lining inside the womb is not needed. The ovaries stop producing estrogen and progesterone, and the lining begins to break down. When the lining inside the womb leaves the body during the monthly bleeding, the egg comes out too. This is the start of a new monthly cycle. After the monthly bleeding, the ovaries start to make more estrogen again, and another lining begins to grow.

The monthly cycle

Problems with monthly bleeding

If you have problems with your monthly bleeding, try to talk with your mother, sisters or friends. You may find that they have them too and they may be able to help you.

Changes in bleeding

Sometimes the ovary does not release an egg. When this happens, the body makes less progesterone, which can cause changes in how often and how much a woman bleeds. Girls whose monthly bleeding has just begun - or women who have recently stopped breastfeeding - may only bleed every few months, or have very little bleeding, or too much bleeding. Their cycles usually become more regular with time.

Figure

Women who use hormonal family planning methods sometimes have bleeding in the middle of the month. See Hormonal Methods of Family Planning for more information about changes in bleeding caused by hormonal family planning methods.

Older women who have not yet gone through menopause may have heavier bleeding or bleed more often than when they were younger. As they get closer to menopause, they may stop having monthly bleeding for a few months and then have it again.

Pain with monthly bleeding

During monthly bleeding the womb squeezes in order to push out the lining. The squeezing can cause pain in the lower belly or lower back, sometimes called cramps. The pain may begin before bleeding starts or just after it starts.

Pressing hard on the tender place between your thumb and first finger can ease many kinds of pain. For other places where pressure can ease pain from monthly bleeding see Acupressure Massage

What to do:

· Rub your lower belly. This helps the tight muscles relax.

· Fill a plastic bottle or some other container with hot water and place it on your lower belly or lower back. Or use a thick cloth you have soaked in hot water.

· Drink tea made from raspberry leaves, ginger, or chamomile. Women in your community may know of other teas or remedies that work for this kind of pain.

· Keep doing your daily work.

· Try to exercise and walk.

· Take a mild pain medicine. Ibuprofen works very well for the pain that comes with monthly bleeding.

· If you also have heavy bleeding and nothing else works, taking a low-dose birth control pill for 6 to 12 months may help.

Pre-menstrual syndrome (PMS)

Some women and girls feel uncomfortable a few days before their monthly bleeding begins. They may have one or more of a group of signs that are known as pre-menstrual syndrome (PMS). Women who have PMS may notice:

· sore breasts
· a full feeling in the lower belly
· constipation (when you cannot pass stool)
· feeling extra tired
· sore muscles, especially in the lower back or belly
· a change in the wetness of the vagina
· oiliness or spots (pimples) on the face
· feelings that are especially strong or harder to control

Figure

Many women have at least one of these signs each month and some women may have all of them. A woman may have different signs from one month to the next. For many women, the days before their monthly bleeding starts are a time of unrest. But some women say they feel more creative and better able to get things done.

What to do:

What helps with PMS is different for each woman. To find out what will help, a woman should try different things and notice what makes her feel better. First, try following the suggestions for pain with monthly bleeding.

These ideas may also help:

· Eat less salt. Salt makes your body keep extra water inside, which makes the full feeling in your lower belly worse.

· Try to avoid caffeine (found in coffee, tea and some soft drinks like cola).

· Try eating whole grains, peanuts, fresh fish, meat and milk, or other foods that are high in protein. When your body uses these foods, it also gets rid of any extra water, so your belly feels less full and tight.

· Try plant medicines. Ask the older women in your community which ones work.

Exercise can sometimes help with the signs of PMS.

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 5: Health Concerns of Girls (introduction...) Changes in Your Body (Puberty) (introduction...) Monthly bleeding (period, menstruation) Changes that Can Lead to a Better Life Deciding about Boyfriends and Sex (introduction...) Protecting yourself if you are ready for sex Pressured or Forced Sex Pressure to have sex with a boyfriend (‘Date rape’) If someone in your family tries to have sex with you (Incest) Young girls and older men Trading girls for money or other needs If you get pregnant and did not plan to Getting Help From Adults

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 5: Health Concerns of Girls

Figure

Sometime between the ages of 10 and 15, a girl’s body begins to grow and change into an adult body. These can be exciting and difficult years. A young woman may not feel exactly like a girl or a woman - her body is somewhere in between and is doing new things she is not used to. What can make it harder is when no one talks about the changes, and so a girl may not know what to expect. This chapter describes these changes, tells how a girl can stay healthy as she grows, and gives information to help her make the right decisions for a healthy life.

Changes in Your Body (Puberty)

All girls go through changes in their bodies, but the changes happen differently for each girl. So do not worry if your body does not look exactly like your sister’s or friend’s.

Growing. Your first change will probably be that you grow fast. You may be taller than all of the boys your age for a while. You will usually stop growing 1 to 3 years after your monthly bleeding starts.

Body changes. Besides growing fast, your body will begin to change. There are natural chemicals in the body called hormones that tell your body to grow and that make these changes happen.

Figure

Inside your body. There are other changes that you cannot see. The womb (uterus), tubes, ovaries, and vagina grow and change position.

¨ Changes of puberty do not all happen at the same time or in the same order.

What you feel. As you go through these changes you become more aware of your body. You may also become more interested in boys, and in your friends. There may be times when your feelings are hard to control. In the days before monthly bleeding, it is even more common to have strong feelings of all kinds - joy, anger, and worry, for example.

Monthly bleeding (period, menstruation)

Monthly bleeding is a sign that your body can become pregnant. No girl can know exactly when she will get her first monthly bleeding. It usually happens after her breasts and the hair on her body start to grow. Several months before her first monthly bleeding, she may notice some wetness coming from the vagina. It may stain her underclothes. This is normal.

Figure

Some girls are happy when they have their first monthly bleeding, especially if they know what to expect. Girls who were never told about it often worry when the bleeding starts. It is something that happens to all women, and you can feel accepting and even proud of it. Do not let anyone make you think it is something dirty or shameful.

Caring for yourself during your monthly bleeding

Staying clean. Many girls prefer to make pads of folded cloth or wads of cotton to catch the blood as it leaves the vagina. They stay in place with a belt, pin, or underwear. The pads should be changed several times each day, and washed well with soap and water if they are to be used again.

Some women put something inside the vagina that they buy or make from cotton, cloth, or a sponge. These are called tampons. If you use tampons, be sure to change them at least twice each day. Leaving one in for more than a day may cause a serious infection.

Figure

Wash your outside genitals with water each day to remove any blood that is left. Use a mild soap if you can.

Activities. You can continue all your regular activities.

It is healthy to bathe during your monthly bleeding.

Exercise can make the pain that some girls have with monthly bleeding feel better.

Changes that Can Lead to a Better Life

The way a woman sees herself forms as she grows. It is important that a girl learns to feel good about herself when she is young, so that she will be able to develop fully and help make her community a better place. A girl is much more likely to learn this when her family and community show her that they value her.

In many places girls are raised to believe they are less important than boys. They are taught to feel shame about their bodies and about being female, and they learn to accept less education, less food, more abuse, and more work than their brothers. This not only hurts their health directly, but it makes them feel bad about themselves and less able to make the right decisions for a healthier life in the future. When girls are raised in this way, it shows that their communities do not value them as much as males.

Figure

But if a girl’s community recognizes the value of each person - whether the person is a man or a woman - she will grow up feeling she can make a better life for herself and for her family and neighbors.

A girl will feel proud if she sees that her efforts can make her community better.

The way a community treats females also affects how families treat their girl children. For example, if a community believes that girls should learn skills, a family that lives there is more likely to want their daughter to go to school for as long as she can. But in a community where women are allowed to do only ‘women’s work’ and are not allowed to participate in any public meetings, families are much less likely to believe that their daughters should be educated.

Figure

There are many ways to help girls feel better about themselves and to help their families and communities understand that girls’ lives can be different. On the next few pages are some ideas.

Ways girls can work for a better life

Find someone to talk to who you think will listen and understand - a friend, a sister, or another female relative. Talk about your fears and problems. Together, you can talk about strong women in your community, your goals, and dreams for the future.

Do things that you and your friends think are important. If you see a problem in your community, get together with your friends to do something to change it. You will all feel proud when you see that your efforts can make your community better.

Decisions for a better future

There are important decisions that you can make with your family to create new possibilities for your future.

Figure

Education and training. Education can help you feel proud of yourself, earn a better living, and live a happier and healthier life. For many girls, education opens the door to a better future. Even if you cannot go to school, there are other ways to learn to read and develop skills. For example you can study at home, join a literacy program, or learn a trade from a skilled person (apprenticeship). When you have new skills, you have something special to give to your community, and you can support yourself and your family better. Learning new skills can help you have more choices in your life.

Figure

Waiting to get married. Talk with your family about waiting to get married until you feel ready and until you find the right partner. Many girls are able to finish school and find work before starting families. This can help you learn more about yourself and what you want. If you wait, you may even find a partner who feels the same way about life as you do.

Waiting to have children. It is easier to raise a happy and healthy child when you wait until you and your partner feel ready to start a family. If you are thinking about having a baby, these are some things to think about: Will you be able to continue your education? How will you fulfill the child’s physical needs - food, clothes, shelter, etc? Are you ready to provide the emotional support a baby needs to grow up into a healthy child? Will your partner commit himself to helping with child raising? How will your family help you?

Figure

Deciding about Boyfriends and Sex

Decisions about boys and men are difficult. Most young people begin to have loving or sexual feelings as they get older. Thinking about touching or being touched by someone in a sexual way is not unusual. (Girls may even think about another girl or woman in this way.) But people often have these feelings before they are ready to act on them.

Figure

Young women have sex for many different reasons. Some do it because they want to have a baby. Others do it because it makes them feel good or wanted. Some women feel they have very little choice because it is their duty as a wife. Some are forced to trade sex for money or for other things they need to survive, such as food, or clothes for their children, or a place to live.

¨ Only have sex when you decide that you are ready and know how to protect yourself from harm. Sex can be enjoyed by both people, but not if there is fear or shame.

Others have sex because they think it will make a man love them more. Sometimes a friend or a boyfriend can make a girl feel that she should have sex when she is not ready.

No one should have sex when she does not want to. Only have sex when you decide you are ready. Sex can be enjoyed by both people, but it is difficult to enjoy something when you feel fear or shame.

If you are ready for a sexual relationship, always protect yourself against pregnancy and disease. For more information on how, see the chapters on “Family Planning,” “Sexually Transmitted Diseases,” “AIDS,” and “Sexual Health.”

Having a relationship with no sex

Figure

Building a loving relationship takes time, caring, respect, and trust from both sides. Sex is not the only way of showing someone that you care. Having sex does not mean that you will fall in love.

You can spend personal time together without having sex. By talking and sharing experiences you can learn something more important about each other - how you view life, decisions you would make together, what kind of partner and parent you would each make, and how you feel about each other’s plans for life. Touching each other (without sexual intercourse) can be satisfying by itself, and is not dangerous as long as it does not lead you to lose control and to have sex when you are not ready.

Figure

Talk to your boyfriend. If you are sure he is right for you, but you are not sure you want to have sex, talk about ways to wait. You may find that he is not ready for sex, either. If you respect each other, you will be able to decide together

Talk to your friends. You may find that some girl friends are facing the same difficult choices. You can help each other find ways to have good relationships without sex. But think twice about advice from a friend who is already having sex. A friend may try to convince you to do something she is doing to make herself feel better about doing it. This is called ‘peer pressure’.

Protecting yourself if you are ready for sex

When you decide you are ready for a sexual relationship, you must protect yourself against pregnancy and disease. There are many ways to make sex safer. This means you have to plan before you have sex.

Talk to your boyfriend before you have sex. Let him know how important it is to protect yourself. If you find it hard to discuss, perhaps you can first pretend you are talking about another couple.

If he really cares about you, he will want to protect you. If he is pushing for sex, he may care only about himself.

Figure

Many communities have people who are trained to provide condoms and other family planning methods. Talk to them or ask a health worker where to get a method of protection. If you feel embarassed to ask, find someone you trust to help you. Some family planning clinics have special services for teenagers and may have trained teenagers as peer counselors who can give you information.

Figure

Since you cannot tell by looking if a man has a sexually transmitted disease or AIDS, sex is safer only if you use a condom every time. If a man has a discharge coming from his penis or a sore somewhere on it, he has an infection and will almost certainly give it to you!

Figure

Figure

If you had sex and notice a new discharge from your vagina, sores on your genitals, or pain in your lower belly, you could have an STD. See the chapter on “Sexually Transmitted Diseases.”

Pressured or Forced Sex

Pressure to have sex with a boyfriend (‘Date rape’)

All over the world, young girls and women are forced to have sex when they do not want to. Often it is done by boyfriends who claim to love them. In some places this is called ‘date rape’. The force is not only physical. You can feel pressure from words or feelings. He may say “please” or somehow make you feel guilty or ashamed if you do not have sex. This is still wrong.

No one should be made to have sex when they do not want to have it.

If someone has forced you to have sex when you do not want it, it is rape.

Prevention:

· If he wants to have sex and you do not, you can tell him you are flattered by his desire for you but that you are not ready. If you are afraid of being alone with the person, bring someone with you, or ask someone else to talk with him.

· Say “NO” loudly if you are pushed to have sex. Keep saying “NO” if you have to. Also say no with your body. If you say “NO,” but give in with your body, he will think that you really mean “yes.”

Figure

· Move away if you are touched in any way that you do not like. Your feelings are warning you that something worse may happen. Make a lot of noise and be ready to run if you have to.

Figure

· Do not drink alcohol or take drugs. Alcohol and drugs make you less able to use your judgement and control what happens to you.

· Go out in groups. In many places, young couples court or date in groups. You can still get to know a boy, but you are less likely to be pushed into having sex because you will not be alone.

· Go only to safe places where others can see you.

· Plan ahead. Decide how much touching will be too much for you. Do not get caught by your feelings and let things happen to you.

If someone in your family tries to have sex with you (Incest)

It is never right for someone to touch you if you do not want to be touched. Family members, such as your cousin, uncle, brother, or father should not touch your genitals or any other part of your body in a sexual way. If this happens, you need to get help. Even if the man says he will hurt you if you tell, you need to tell an adult you trust as soon as possible. Sometimes it is best to tell someone outside your family such as a woman teacher or religious leader in your community.

Figure

Young girls and older men

Some girls are attracted to older men. Going with an older man may seem very exciting, especially if he is well known or important in your community, or if he has money and can buy things. In some places a man who buys his girlfriend many presents is called a ‘Sugar Daddy’. Often a girl who goes with an older man ends up feeling she was used for sex or treated badly, especially if the man is married or has other women.

Figure

Sometimes an older man can make a young woman feel more pressured to have sex than boys her own age can, especially if he has power over her.

Figure

Trading girls for money or other needs

Figure

Sometimes a poor family will give a young daughter to an older man to pay a family debt. Or they may trade her for money or something the family needs.

Sometimes the girls are taken away to another town or city. They think they are going to work in factories, or as maids, but they are often forced to have sex for money.

Figure

If you think that you or another girl in your community is going to be sold into marriage, or sent away to work, try to get help from another adult. Perhaps an older aunt or uncle, or a woman teacher can help.

If you get pregnant and did not plan to

You may be pregnant if you had sex and your monthly bleeding is late, your breasts hurt, you pass urine often or you feel like vomiting. See a health worker or midwife as soon as you can to find out for sure if you are pregnant.

Figure

Many young girls get pregnant when they did not want to. Some of them are able to get the support they need from family and friends. For others, it is not so easy.

If you are feeling trapped by a pregnancy you did not plan and you want to end the pregnancy, please be careful in the decisions you make. All over the world, girls and women die from trying to end pregnancies in dangerous ways. There are safe ways to end a pregnancy.

Talk to someone older who you trust Your life is too valuable to lose.

Figure

Getting Help From Adults

Talking with your mother or father can be hard sometimes. Your parents may want you to live by tradition, but you feel that times are changing. You may feel that your parents do not listen or try to understand you. Or you may be afraid they will get angry.

Your family can love you without agreeing with everything you say. They may get angry because they care - not because they do not like you. Try to talk with them respectfully and help them to understand you better.

How mothers can help their daughters

You may have grown up in a time when girls were not allowed to have an education, plan their families, or make decisions about their lives. Life can be different for your daughter. If you listen to her, share your own experiences, and give her useful information, you can help her make her own good decisions. You can help her to see the good things about being a girl and a woman.

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 6: Pregnancy and Childbirth (introduction...) Staying Healthy during Pregnancy Common Problems during Pregnancy Risks and Danger Signs during Pregnancy Prenatal Care (Check-ups during Pregnancy) Preparing for Labor and Birth Giving Birth Signs that labor is near The 3 stages of labor Danger signs during labor Difficult Births Danger Signs for the Baby at Birth Caring for the Mother and Baby after Birth Women with Special Needs To the Father Working for Change

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 6: Pregnancy and Childbirth

Most women in the world today do not get prenatal care or trained help during birth. They usually have their babies at home with the help of a local midwife or a family member. This chapter has information for both the pregnant woman and her helpers, about care during pregnancy, and care both during and after the birth.

For more complete information about caring for women in pregnancy and helping them with both normal and difficult births, see the Hesperian Foundation’s A Book for Midwives (for how to order it, see the last page of this book).

Figure

Every pregnant woman needs good health, good food, and the love and support of her family and community. Many women feel very healthy during pregnancy and do not have difficult births. Most babies are born healthy.

Without water, the crops would die; and without children, life in the community could not continue.

- Mixtec saying, Mexico

At the same time, pregnancy can be one of the main dangers a woman faces in her life. About half a million women die each year from problems of pregnancy and birth (this is also called maternal mortality), mostly in poorer countries.

Most of these deaths could be prevented with basic care. This chapter has information that can help pregnant women care for themselves, or help others care for them.

HOW TO TELL IF YOU ARE PREGNANT

· You miss your monthly bleeding.
· Your breasts feel sore and grow bigger.
· You feel sick to your stomach and sometimes vomit.
· You have to pass urine more often.
· You feel tired.

HOW TO KNOW WHEN THE BABY IS DUE

Add 9 months plus 7 days to the date when your last normal monthly bleeding began. Your baby will probably be born any time in the 2 weeks before or after this date.

Many women know when their baby will be born by counting the passing of 10 moons.

Staying Healthy during Pregnancy

If you can take good care of yourself while pregnant, you are more likely to have a safe pregnancy and birth and a healthy baby.

· Try to eat enough nutritious foods. Good nutrition gives strength, prevents infection, builds a healthy baby, and helps prevent too much bleeding during birth. Remember that you are feeding both yourself and your baby. Use iodized salt to make sure your baby will not suffer from mental slowness.

· Sleep and rest whenever you can. If you work standing up, try to sit or lie down several times during the day.

Figure

Do your daily work...

... but rest whenever you can

· Go for prenatal (before-birth) check-ups to make sure there are no problems, and to find problems before they become serious. If you have never had a tetanus immunization, get one as soon as you can. Get at least 2 before the end of the pregnancy.

Figure

¨ Read about the ‘Danger signs during pregnancy’, to learn when it is important to see a health worker.

· Keep clean. Bathe or wash regularly and clean your teeth every day.

· Practice squeezing exercises, so your vagina will be stronger after the birth.

· Try to get daily exercise. If you sit down at work, try to walk a little every day. But try not to tire yourself.

· Get treatment if you think you have a sexually transmitted disease (STD) or other infection.

Figure

· Avoid taking modern or plant medicines, unless a health worker who knows you are pregnant says it is OK.

· Do not drink alcohol or smoke or chew tobacco during pregnancy. They are bad for the mother and can harm the developing baby.

· Avoid pesticides, herbicides, or factory chemicals. They can harm the developing baby. Do not touch or work near them, or breathe in their fumes. Never store food or water in their containers.

· Stay away from a child with a rash all over its body. It may be caused by German Measles, which can harm the baby.

¨ If there is malaria where you live, sleep under a bed net to avoid being bitten by mosquitos.

Common Problems during Pregnancy

When you are pregnant your body changes and you may have some of the following common problems. But remember, most of these problems are normal in pregnancy.

SICK STOMACH (NAUSEA)

Although it is often called ‘morning sickness’, during pregnancy you may feel sick to your stomach at any time during the day or even all day long. It usually goes away by the end of the 3rd or 4th month.

What to do:

· Drink a cup of ginger or cinnamon tea 2 or 3 times a day, before meals.

· Eat small meals often, and avoid foods that are oily or hard to digest.

· Lick a lemon.

· Ask the midwives in your community for good local plant medicines or remedies.

IMPORTANT
See a health worker if you vomit so much that you cannot keep any food down, or if you are losing weight. Also watch for signs of dehydration.

HEARTBURN OR INDIGESTION

Heartburn causes a burning feeling in the throat and chest. It is most common in later pregnancy, after eating or when lying down.

What to do:

· Eat several small meals instead of one large meal.
· Avoid spicy or oily foods.
· Drink plenty of water and other clear liquids.
· Try not to lie down right after eating.
· Sleep with your head higher than your stomach.
· Take a cup of milk or yogurt, some bicarbonate of soda in a glass of water, or calcium carbonate (antacid).

Figure

DISCHARGE FROM THE VAGINA

During pregnancy, it is normal to have more white discharge than usual from the vagina. But if the discharge itches, burns, or has a bad smell, you may have an infection of the genitals, which should be treated. If the discharge is bloody or has mucus in it, or if there is a lot and it looks like water, see a health worker. You may be starting labor too early.

Figure

SWOLLEN VEINS (VARICOSE VEINS)

Blue swollen veins in the legs and around the vagina are called varicose veins. They are caused by the weight of the growing baby. They can become quite large and painful.

What to do:

· Try not to stand up for too long. If you have to stand, walk in place or move your feet and legs. When you are sitting down, put your feet up as often as possible.

· Be sure to walk every day. If you have a disability and cannot walk, ask someone in your family to help move and exercise your legs.

· If the problem is severe, wrap your legs with cloths. Begin wrapping at the ankles and work up to just below the knee. The bandage should be tighter around the ankle and looser further up the leg. Take off the bandages at night.

Women with swollen veins should try to put their feet up when they can, and wrap their legs if the swelling is very bad.

CONSTIPATION (DIFFICULTY PASSING STOOL)

Pregnancy makes the bowels work more slowly. This can make the stool harder, so it is more difficult to pass.

What to do (these things also help prevent constipation):

· Drink at least 8 glasses of liquid every day.

· Get regular exercise.

· If you are taking iron tablets, try taking only one a day with fruit or vegetable juice. Or skip a few days.

· Eat plenty of fruits, vegetables, and foods with fiber - like whole grains and cassava (manioc) root.

· Do not take laxatives. They only solve the problem for a short while and then you need to take more.

PILES (HEMORRHOIDS)

Hemorrhoids are swollen veins around the anus. They often itch, burn, or bleed. Constipation makes them worse.

If you have hemorrhoids, sitting in cool water can help with the pain.

What to do:

· Sit in a basin or pan of cool water to relieve the pain.

· Follow the advice above for preventing constipation.

· Soak some clean cloth in witch hazel (a liquid plant medicine) if you can find it, and put it on the painful area.

· Kneel with your buttocks in the air. This can help relieve the pain.

Figure

LEG CRAMPS

Pregnant women often get foot or leg cramps - especially at night, or when they stretch or point their toes down. Leg cramps may be caused by not enough calcium in the diet.

Figure

What to do:

· Eat plenty of foods that contain calcium, such as milk, cheese, sesame seeds, and green leafy vegetables.

· If your foot or leg cramps:

Figure

LOW-BACK PAIN

Low-back pain is caused by the weight of the growing baby.

What to do:

· Ask someone to rub or massage your back.
· Ask your family for help with some of the heavy work.
· Take care to stand and sit with your back straight.
· Sleep on your side with a pillow or rolled up cloth between your knees.
· Do the ‘angry cat’ exercise for a few minutes, 2 times each day, and whenever your back hurts.

Figure

Angry cat exercise

SWELLING OF THE FEET AND LEGS

Some swelling of the feet is normal during pregnancy - especially for women who must stand all day.

What to do:

· Put your feet up as often as you can during the day.

· When resting, lie on your left side.

· If your feet are very swollen, or they are swollen already when you wake up in the morning, or your hands and face also swell, these are signs of danger during pregnancy.

Figure

Risks and Danger Signs during Pregnancy

WOMEN WHO HAVE EXTRA RISKS

Women with any of the following problems can have more dangerous pregnancies and births. They should plan to go to a health center or hospital for the birth. If possible, they should try to get prenatal care during pregnancy.

· Weak blood (anemia) makes a woman more likely to bleed heavily (hemorrhage) during birth, become ill after childbirth, or even die.

· Sugar sickness (diabetes) often causes very serious problems for the mother and the baby. The baby can die before birth or sometimes grows very large and gets stuck in the pelvis.

· High blood pressure can lead to severe headaches, fits, and even death.

· Older mothers who have had many babies often have long, difficult labors, and heavy bleeding after the birth.

· Mothers under the age of 17 are more likely to have toxemia (which causes fits), long, difficult labors, babies born too early (premature), and blocked births, which may damage the bladder, vagina, and womb.

· Mothers who had problems with past pregnancies - such as fits, birth by operation, heavy bleeding, a too-early or too-small baby, or a baby born dead - are more likely to have problems in another pregnancy or birth.

· Women with disabilities, especially women with a loss of feeling in the body or difficulty walking, can have problems during both pregnancy and birth.

A woman who is likely to have a dangerous birth should plan to have her baby in a health center or hospital.

Feeling very weak or tired (anemia)

If you feel very weak or tired, you could be anemic. Women who are very anemic are much more likely to have heavy bleeding after the baby is born.

Figure

What to do:

· Eat foods rich in iron - meat, fish, chicken, eggs, beans, peas, and leafy green vegetables.

· Take 325 mg of iron 2 times a day, and 1 mg of folic acid once a day, until the baby is born. If you take iron tablets with fruits like oranges, mangoes, or papayas, your body uses the iron better.

Figure

Pain in the lower belly (abdomen)

1. Strong, constant pain in the first 3 months may be caused by a pregnancy that is growing outside the womb in the tube, (a tubal pregnancy). As the tube stretches, it causes pain. If the pregnancy grows large enough, the tube will burst and bleed. This is very dangerous. You will bleed inside your abdomen and may die.

Figure

Signs of tubal pregnancy:

· missed monthly bleeding, and
· pain in the lower abdomen on one side, and
· slight bleeding from the vagina
· feeling dizzy, weak, or faint

Figure

What to do:

Go to the nearest hospital.

¨ Strong pain in the abdomen does not always mean something is wrong with a pregnancy. For information about other possible causes, see Pain in the Lower Abdomen.

2. Strong pain that comes and goes (cramping) in the first 6 months could mean you are losing the pregnancy (having a miscarriage).

3. Strong, constant pain in late pregnancy. This could mean the afterbirth (placenta) is coming off the wall of the womb. This is very dangerous. You could die if you do not get help. Go to the nearest hospital.

4. Pain that comes and goes in the 7th or 8th month could mean you are going into labor too early.

Bleeding from the vagina

1. Bleeding early in pregnancy. Light bleeding from the vagina during the first 3 months of pregnancy can be normal. But if you have pain with the light bleeding, it could mean a pregnancy is developing outside the womb, which is very dangerous. If the bleeding gets heavier and stronger than a normal monthly bleeding, you are probably losing the pregnancy (having a miscarriage).

Figure

2. Bleeding later in pregnancy. Bleeding after the first 3 months can mean there is something wrong with the afterbirth (placenta). Both you and the baby are in danger.

What to do:

· Go to the nearest hospital.
· On the way, lie down with your feet up.
· Do not put anything in your vagina.

Fever

High fever, especially along with shivering, body aches and severe headache, can be caused by malaria. Treatment for malaria depends on where you live. See Where There Is No Doctor for more information.

Swelling of the hands and face or severe headache and blurred vision (toxemia)

Figure

Some swelling in the legs and ankles is normal in pregnancy. But swelling of the hands and face can be a sign of toxemia, especially if you also have headaches, blurred vision, or pains in your abdomen. Toxemia can cause fits, and both you and the baby can die.

What to do:

· Find someone who can check your blood pressure. Go to a health center or hospital if necessary.

· Rest as often as possible, lying down on your left side.

· Try to eat more foods with a lot of protein every day.

· Plan to have the birth in a health center or hospital.

Figure

IMPORTANT
If a woman has any of the danger signs of toxemia, she needs medical help fast If she is already having fits.

BABY IN THE WRONG POSITION WHEN LABOR STARTS

If the baby is buttocks first (breech) when labor starts, the birth can be more difficult. If the baby is lying sideways when labor starts, the baby cannot be born without an operation.

¨ If the baby’s head is down, the birth is more likely to go well.

During the last month of pregnancy, it may be possible to change the baby’s position by lying in this position for 10 minutes, 2 times a day:

Lie on the floor with pillows under the hips. Try to get the hips higher than the head.

Do this exercise every day with an empty stomach, until the baby changes to a head-down position and then stop. The baby’s position should be checked each week.

· If labor starts and the baby is still sideways, the mother must go to a health center or hospital where the baby’s position can be changed, or where she can have an operation. Without medical help, the mother and her baby will almost certainly die.

· If labor starts and the baby is still buttocks first.

IMPORTANT
DO NOT try to change the baby’s position by hand yourself unless you have been trained to do it and have done it before successfully. You can tear the womb and harm both the mother and the baby.

Prenatal Care (Check-ups during Pregnancy)

Prenatal check-ups are important to find and take care of problems early - before they become dangerous. Good prenatal care is not difficult to give and does not require very expensive equipment. Many birth attendants, midwives and health centers, as well as hospitals, can give this care. It can save many lives.

If you are pregnant, try to have at least 3 check-ups:

1. As soon as you think you are pregnant.
2. Around the 6th month of pregnancy.
3. A month before the baby is due.

¨ Prenatal check-ups can help you decide the best place to have your baby: at home, or at a health center or hospital.

A midwife, birth attendant, or health worker will ask about past pregnancies and births, including any problems, such as a lot of bleeding or babies that died. This information can help you both prepare for similar problems in this pregnancy and birth. A midwife may also be able to:

· make sure a woman is eating well enough and suggest ways for her to eat better food, if necessary.

· give iron and folic acid tablets, which help prevent anemia.

· examine the mother, to make sure she is healthy and that the baby is growing well.

· give vaccinations to prevent tetanus, a disease that can kill both mothers and babies.

· give medicine to prevent malaria if it is common in the area

· give tests for HIV and syphilis, along with other sexually transmitted diseases.

To check whether the baby is healthy, a midwife may listen for the baby’s heartbeat. It may be possible to hear it by putting one ear against the woman’s abdomen, but often you cannot tell the baby’s heartbeat apart from the mother’s. It is easier with a fetoscope. Another sign the baby is healthy is if the mother feels the baby move every day, and if she has felt it move on the day of the check-up.

fetoscope

Preparing for Labor and Birth

THINGS TO HAVE READY BEFORE BIRTH

A pregnant woman should have these things ready by the seventh month of pregnancy:

Figure

¨ If you do not have a new razor blade, you can use rust-free scissors or a knife if you boil them for 20 minutes just before cutting the cord.

This is also the time to:

· plan transportation in case you need to go to the hospital.

Figure

· clean the birth place.

Figure

HELPING A WOMAN GIVE BIRTH

If you are pregnant, read this information to know what to expect during labor and after the baby is born. It will also make you better able to help other women during birth.

If you are helping a woman give birth, you can make a big difference in helping her have a safe and healthy birth. Remember that most babies are born without problems.

Stay calm and cheerful. Reassure the mother so that she will not be afraid. Let her know that you trust her ability to give birth.

Figure

DO

· Keep your nails clean and cut short.

· Wash your hands with soap and clean water. Let them dry in the air.

· Know which women have extra risks and learn the ‘Danger Signs during Pregnancy’. Make sure the mother gives birth in a health center or hospital if she has any of these risks or danger signs.

· Learn the ‘Danger Signs during Labor’. Take the woman to a hospital if she has any of these signs.

· Treat her with kindness and respect.

¨ For safe childbirth practice the 3 cleans:

1. Clean hands

Figure

2. Clean place to give birth

Figure

3. Clean tool to cut the cord

Figure

IMPORTANT
Protect yourself from HIV and hepatitis by wearing clean gloves during a birth. If you do not have gloves, use washed plastic bags.

Figure

DO NOT

· Do not put your fingers or anything else in the woman’s vagina. Checking how much the womb has opened does not help the baby to be born, and may cause a dangerous infection.

· Do not give any medicine to speed up labor or to make labor stronger. These medicines can kill the mother and the baby. (Medicines that cause the womb to contract should only be used to stop bleeding after the baby is born.)

· Do not tell her to push before she is ready. When it is time for the baby to be born, she will feel like she has to pass stool and will start pushing on her own.

· Do not push on the outside of her womb to make the baby come out faster This can tear her womb or cause the placenta to separate from the womb too soon. Both the mother and the baby can die.

Giving Birth

Signs that labor is near

These 3 signs show that labor is starting or will start soon. They may not all happen, and they can happen in any order.

1. Clear or pink-colored mucus comes out of the vagina. During pregnancy, the opening to the womb (cervix) is plugged with thick mucus. This protects the baby and womb from infection. When the cervix starts to open, it releases this plug of mucus and also a little blood.

2. Clear water comes out of the vagina. The bag of waters can break just before labor begins, or at any time during labor.

3. Pains (contractions) begin. At first contractions may come 10 or 20 minutes apart or more. Real labor does not begin until contractions become regular (have about the same amount of time between each one).

When any one of these signs occurs, it is time to get ready for the birth. Here is a list of things you can do:

· Let your midwife know that labor is starting.

· Make sure that the supplies for the birth are ready.

· Wash yourself, especially your genitals.

· Continue to eat small meals and drink whenever you are thirsty.

· Rest while you can.

Figure

The 3 stages of labor

Every birth has these 3 parts.

Stage 1 begins when contractions start to open the cervix and ends when the cervix is fully open. When it is the mother’s first birth, this stage usually lasts 10 to 20 hours or more. In later births, it often lasts from 7 to 10 hours. It can vary a lot.

Stage 2 begins when the cervix is open and ends when the baby is born. This stage is usually easier than Stage 1, and should not take more than about 2 hours.

Stage 3 begins when the baby is born and ends when the placenta comes out.

Stage 1: The cervix opens

To make sure that labor is going well, check:

1. How long has the woman been having contractions and how often do they come? At first, they may come every 10 or 20 minutes and last for a minute or less. After some time they will come more quickly - about every 2 to 5 minutes - and each one will last longer, about a minute and a half, until the baby is born. If she has had a contraction every 10 minutes or faster for more than 1 day and 1 night (24 hours) and the baby is not ready to be born, see ‘Too long labor’.

2. Have her waters broken? If they have, ask when. If it has been more than a day, see ‘Waters break and labor does not start in a few hours’. If the waters are green or brown, see ‘Green or brown waters’.

3. Is the baby in a head-down position? Feel the mother’s abdomen. If the baby is sideways or breech, you must take her to a health center or hospital.

Figure

You can also help the mother by reassuring her that she is doing well and by encouraging her to:

· stay active.
· eat light foods, not heavy or oily foods.
· drink as much sweet liquid and warm tea as she wants.
· pass urine often.
· take deep, slow breaths during contractions, and to breathe normally between them.
· not push until she feels a strong need to push.

Walking helps the womb open. It can also make the pain less and help the mother feel calmer.

Stage 2: Pushing the baby out

Signs that it is time to push (this means the cervix is fully open):

· The mother feels a strong need to push. It may feel like needing to pass stool.

· During contractions, you can see the mother’s bottom bulging and you may see the baby’s head at the opening of the vagina. At first, the baby’s head moves back inside between contractions.

What to do:

· Stay with the mother all the time and reassure her that she and the baby are doing well.

· Each contraction will come with a very strong urge to push. When the mother feels like pushing, have her take a deep breath and push as if she were passing stool, but with all her strength. Many women find it helpful to moan or groan in a deep voice with the pushes.

· Make sure that everything is going well and is ready for the birth. If the woman has been pushing for more than 2 hours, see Too-long labor,’.

Figure

Birth of the head

When the baby’s head stays at the opening of the vagina, even between contractions, it is time for the head to be born:

1. Tell the mother not to push hard, but to give little grunts or little pushes.

2. Allow the head to come out slowly, between contractions. This will help to prevent the mother’s skin from tearing.

3. After the head is born, wipe the baby’s mouth and nose with a clean cloth.

Figure

Figure

Birth of the shoulders

To help the shoulders come out:

1. Gently hold the baby’s head and guide it toward the mother’s back (away from her abdomen). This lets the front shoulder be born first Never pull or twist the head.

2. The rest of the baby will then come out easily. Be ready! Hold the baby so it does not fall.

Care of the baby at birth

A healthy baby will start breathing, move its arms and legs, and start crying right away. To care for the baby:

· Wipe its mouth and nose with a clean cloth. To help the mucus drain, keep the baby’s head lower than its body. If there is a lot of fluid or mucus, remove it with a suction bulb.

· Give the baby to the mother right away. Put a clean cloth around both of them. Do this as soon as possible so the baby stays warm.

· Put the baby to the mother’s breast immediately. When the baby sucks, the mother’s womb tightens and stops the bleeding. This will also help the placenta come out more quickly.

· Tie and cut the cord only when it turns white and stops pulsing. To prevent tetanus, a serious disease that kills many babies, cut the cord close to the baby’s body.

Figure

Care of the eyes

To prevent infection from gonorrhea, put 1% tetracycline, erythromycin, or chloramphenicol eye ointment in each eye within an hour of birth.

Pull down the lower lid to put a little bit of ointment inside. Putting ointment outside the eye does no good.