Background

There is growing awareness in traditional family planning (FP) and population programmes that gender is an extremely important issue because the dynamics between sexuality and gender greatly influence programme outcomes. Social norms and values shape both sexuality and gender, and those pertaining to gender in most – if not all – communities result in an imbalance of power between women and men that has a profound impact on sexual behaviours and on the reproductive and overall health of both sexes (Zeidenstein and Moore, 1996). 

For example, maternal mortality rates (MMR) in many countries have remained high despite medical interventions. According to a WHO/World Bank analysis, more than 30 percent of the overall burden of disease and disability among women - and 12 percent for men - is due to reproductive ill-health.  This differential reflects, above all, women’s lower status and their lack of autonomy.  They are frequently not allowed to make their own decisions, related either to their own reproductive health or to other areas, which influence their overall well being. 

This situation led many programmes to search for a more holistic approach to women’s - and men’s – health to change the social context  (Bongaarts and Bruce, 1995).  At the same time, the interventions must be adapted to the social context in order to be acceptable to the individual.  However, to be effective, interventions must find the right balance between adapting to the social context and effecting needed change. They must continuously challenge existing barriers. 

The Role of Knowledge in Health Improvements

In addition to lack of autonomy, lack of knowledge and awareness pertaining to reproductive health issues has a negative impact on women’s health.  Inadequate knowledge has often been documented and applies to both sexes.  However, women generally appear to be less knowledgeable on these issues than men  (among others, see Population Manager 5, 1997). 

There are many factors to consider when programmes develop health information and education.¹  As suggested, it must be adapted to the social context in order to be effective. Besides, health education messages must be in a language easily understood by the target group. The learning process should allow for interaction and open communication - as opposed to a lecture format – as well as an opportunity to clarify issues. The messages are often more effective when someone similar to the target group delivers them. For example, peer counsellors tend to be effective in youth programmes (Innovations 2, 1995).  Similarly, persons of the same gender, marital status, caste and socio-economic level have often proved to be more effective as family planning workers than persons who have less in common with clients (Bruce, 1990). 

In view of the above issues, the remaining paper describes a health education programme developed for women’s health committees established at Shamirpet Primary Health Center (PHC) near Hyderabad in the Indian state of Andhra Pradesh. There is particular emphasis on the subsequent educational activities, which evolved to raise the awareness of the village women to reproductive health issues. 

Empowering Women: Establishing Women’s Health Committees

In an effort to increase women’s “voice” and involvement in the government’s health programmes and in overall decision making at the local level, Women’s Health Committees²  (WHC) were established in 27 villages served by Shamirpet Primary Health Center (PHC)^3.  The first step was sensitization and education of the committee members. For this purpose, a health education module⁴  was developed  (Box 1).

The curriculum reflects both the needs as expressed by the community and the needs as perceived by the programme.  It encompasses general health information with an emphasis on comprehensive reproductive and child health, which are the cornerstones of the Government of India’s current  Family Health and Welfare approach (initiated in 1996). At the same time, the curriculum reflects the social context and particular problems confronting Indian women of all ages including the girl child. There is also a component to raise awareness of the law and women’s legal rights. 

Training the Women’s Health Committees

The training of the WHCs took place over a period of time. The NGO responsible for the outreach/training effort, Academy for Nursing Studies (ANS), aimed to make the training sessions interactive. Discussion and analysis of daily events frequently formed the basis for the sessions. Examples include death of a community member after an injection provided by an inadequately trained service provider in the private sector, and death during childbirth of a village woman delivering twins in a hospital. 

The WHC members were encouraged to keep a journal containing, among others, information on births and deaths in the village. In addition to helping the government ANM (auxiliary nurse midwife), keeping journals provided an opportunity for the women to practice their writing skills, and they took considerable pride in this task. 

Other activities undertaken by the WHC members as a result of the training include, among others, providing information to the community women on ORT (oral rehydration therapy), distributing ORT packets and oral contraceptives, FP motivation, and assisting community members in obtaining referral services. The members also aimed to sensitize and educate the other village women on reproductive health and important social issues in the Indian context that greatly affect their health. 

These training efforts and experiences eventually developed into “Mahila Veduka”⁵  – a celebration of woman’s life cycle. It is modified from an Indian family tradition celebrating the young pregnant woman in the family. 

“Mahila Veduka”- A Forum for Raising Awareness

The “Mahila Veduka” is celebrated in traditional village manner.  On an auspicious day, the WHC invites all the women in the village to the celebration, which is organized in a common area of the village. As representatives from the committee proceed from house to house, they apply “kumkum” on the women’s forehead (a colorful mark and religious custom).  Although the invitation is provided in traditional fashion, the WHC breaks a taboo when it brings together women of all castes. 

During the actual celebration, the WHC offers fruit, flowers and betel leaves to the women present. Sandal and turmeric pastes are prepared, and rice and coconut are arranged on a plate according to the customs in the particular village. Five women from the village are selected who symbolize the woman’s life cycle: the girl child, the adolescent girl, the pregnant or post-natal mother, the mother-in-law/mother (middle age), and the old woman.  The five women have the place of honour and represent the female community of the village. They are honoured in traditional manner and receive gifts. 

The “Mahila Veduka” has become a forum for discussing reproductive and overall health along with the many social issues influencing them. A small number of WHC members are responsible for developing a script containing the information which is to be conveyed and for leading the discussion and experience sharing at each stage. They explain the importance of each stage of the life cycle, discuss possible problems and explore what solutions may be found at the village level to overcome the problems. The government ANM (auxiliary nurse midwife) also participates, discussing health problems and ensuring that the women know about the services available.⁶

The Social Context and Different Stages in the Woman’s Life Cycle

At the first stage, the WHC members discuss the forms of discrimination and problems the girl child in India confronts both before and after birth; how the discrimination manifests itself; and what possible efforts or actions can be taken by the women themselves to overcome the discrimination. For example, the girl may never be born because of her gender; she may be subjected to sex selection and abortion.  Other manifestations of discrimination are also discussed, for example, girls receive medical treatment less frequently than do boys when they are sick;  they are less frequently fully immunized than boys; they are more frequently underweight and malnourished than boys; they participate in household work earlier and for longer periods than boys; and more girls than boys drop out of school (ANS, 1997). 

At the particularly vulnerable stage of adolescence, the restrictions imposed on girls by both parents and society that ultimately hurt rather than protect them are discussed. Examples include early marriage followed by early childbirth. One possible action during this stage suggested at the “Mahila Veduka” is supporting each other to prevent early marriage among the daughters in the village. The WHC also spreads the message that an adolescent girls’ group has been  formed  to conduct activities to raise their awareness of reproductive health issues. 

Possible personal actions discussed at the “Mahila Veduka” to improve the quality of life as adult women include, among others, developing positive health-seeking behaviours; protecting oneself against disease including STD/HIV; discussing sexual and other problems openly; and accepting and supporting infertile women rather than ridiculing and rejecting them. 

At the stage of middle age, different common, but until recently neglected, health problems are discussed and include hormonal changes, cancer of the cervix and breast, nutritional problems and osteoporosis, uterine prolapse, aches and pains, RTIs, and diseases such as diabetes, hypertension and arthritis. The potentially positive role mothers-in-law could play is emphasized to combat traditional customs which often have a negative impact on daughters-in-law in the Indian social context. Moreover, her relative power to affect positive change in the family overall is highlighted, for example, in preventing early marriage, encouraging use of family planning, ensuring good care during pregnancy and childbirth, and so on. 

Finally, the neglect of older women is discussed while their contribution and value to the family is highlighted. The focus is on their accumulated knowledge and skills in dealing with the health problems of women and children. 

Results of the Activities

During the final evaluation of the QOC project, the activities of the WHCs were also evaluated. For example, the majority of both contraceptive users and non-users, 69 and 58 percent respectively, reported that they had noticed improvement in the services provided by the government programme (Ramana et al, 1997). When particularly asked about the WHCs, more than 50 percent of those interviewed knew about their existence although they were not always familiar with their exact activities. The respondents stated that the (existence of) WHCs had led to better availability of the HCWs, oral contraceptives and condoms. They also gave the committees credit for better antenatal care. (It should be emphasized that the establishment of the WHCs had taken place less than a year before the evaluation).

There may be other results which are more difficult to measure.  For example, being on the WHCs turned many of the women into active, involved members of their communities who experienced that their actions made a difference. Some of the women had the opportunity to practice public speaking. 

Conclusion

Along with appropriate government policies in many areas, for example, health, education, employment, and the legal system,  WHCs and programmes such as the “Mahila Veduka” are essential to sensitize and educate women on gender issues of critical importance if their social status, health and quality of life are to improve. As discussed, considerable efforts went into ensuring a participatory approach in the sensitization/educational process. The aim was to create a culturally acceptable programme in a familiar format that opens a discussion on  harmful traditions and practices and seeks solutions generated at the village level which are acceptable to the community. 

Moreover, it was considered necessary to ensure that the ownership of the efforts was in the village. The WHCs, made up by village women, manage the activities themselves – although still with some outside assistance. To change harmful traditions and underlying beliefs takes time, but the efforts must ultimately become self-sustainable. The current challenge is to strengthen the capacity of the WHCs and develop a structure which will ensure future self-sustainability. 

Academy for Nursing Studies.  Mahila Veduka: A Celebration of Women’s Life Cycle: A Technique for Gender Sensitisation for Women’s Health. Hyderabad: ANS, 1997. 

Bongaarts J and J Bruce.  “The Causes of Unmet Need for Contraception and the Social Content of Services”. Studies in Family Planning 26,2:57-75, 1995. 

Bruce J.  “Fundamental Elements of the Quality of Care: A Simple Framework”. Studies in Family Planning 21,2:61-91, 1990. 

Dohlie MB and J Satia, eds.  “Improving Quality of Care”. Population Manager 5, 1997. 

Ramana GNV et al. “India: Improving Quality of Care at Shamirpet Primary Health Center, Andhra Pradesh”. Population Manager  5:23-42. 

Satia J, S Tahir and C Andersson, eds.  Innovative Approaches to Population Programme Management. Innovations 2, 1995. 

WHO/UNICEF.  Revised 1990 Estimates of Maternal Mortality: A New Approach. WHO/FRH/MSM/96.11/UNICEF/PLN/96.1. April 1996. 

Zeidenstein S and K Moore, eds. Introduction. Learning about Sexuality: A Practical Beginning. New York: The Population Council, 1996.