WHERE WOMEN HAVE NO DOCTOR

Where Women
Have No Doctor

A health guide for women

A. August Burns
Ronnie Lovich
Jane Maxwell
Katharine Shapiro

Editor: Sandy Niemann
Assistant editor: Elena Metcalf

Hesperian

Berkeley, California, USA

WWW

enan.org

Hesperian Foundation and the contributors to WhereWomen Have No Doctor
do not assume liability for the use of information contained in this book. This book
should not replace properly supervised, hands-on training. If you are not sure what to
do in an emergency situation, you should try to get advice and help from people with
more experience or from local medical and health authorities.

This health guide can be improved with your help. We would like to hear about
your experiences, traditions, and practices. If you are a midwife, traditional birth
attendant, village health worker, doctor, nurse, mother, or anyone with suggestions for
ways to make this book better meet the needs of your community, please write to us.
Thank you for your help.

Copyright © 1997,2010 by Hesperian Foundation. All rights reserved.

Hesperian Foundation encourages others to copy, reproduce, or adapt to meet local needs
any or all parts of this book, including the illustrations, provided the parts reproduced are
distributed free or at cost — not for profit

Any organization or person who wishes to copy, reproduce, or adapt any or all parts of this
book for commercial purposes must obtain permission from Hesperian Foundation.

Before beginning any translation or adaptation of this book or its contents, please contact
Hesperian Foundation for suggestions about adapting the information in the book, updates
on the information provided, and to avoid the duplication of efforts. Please send Hesperian
Foundation a copy of any materials in which text or illustrations from this book have been used.

First edition: June 1997

Fourth printing: April 2010

Printed in the USA on 10% recycled paper © by Worldcolor

ISBN: 978-0-942364-25-5 paper

Library of Congress Cataloging-in-Publication Data

The Library of Congress has already cataloged the 1 0-digit ISBN as follows:

Where women have no doctor : a health guide for women / by A. August
Burns ... [et al.] ; edited by Sandy Niemann, assistant editor; Elena
Metcalf.

p. cm.

Includes bibliographical references and index.

ISBN 0-942364-25-2 (pbk. : alk. paper)

I . Women-Health and hygiene. 2. Women’s health services.

3. Community health aides. 4. Medicine, Popular I. Burns, A.

August (Arlene August), 1 952- . II. Niemann, Sandy.

RA564.85.W46 1 997 97- 1 942 1

6 1 3’.04244-dc2 1 CIP

nesperian

Hesperian Foundation

1919 Addison St., #304
Berkeley, California 94704 USA
www.hesperian.org

www.n6sp6risn.org

Credits

Project coordinator: Jane Maxwell
Art coordination:

Deborah Wolf and August Burns

Design and production:

Elena Metcalf and Jane Maxwell
Book format: Laughing Bear Associates,
Montpelier; Vermont

Cover design: Sara Boore
Cover scans and layout:

Paul Marcus and Shareen Harris

Field testing coordination:

Katharine Shapiro, Deborah Wolf,
August Burns, and ElsaAegerter

Medical editor: Melissa Smith

Additional writing:

Susan McCallister, Elena Metcalf, Sandy
Niemann, and Sarah Shannon

Additional research: Ronnie Lovich
Additional medicines research:

Todd Jailer and Brian Linde
Additional production: Lora Santiago,
Christine Sienkiewicz
Copyeditor: John Kadyk
Proofreaders: Marc Polonsky, Lorraine
Mann, and Rose Hauer
Index: Ty Koontz

Production manager: Susan McCallister

Illustrations

The artists deserve special mention. The skill and sensitivity with which they have so
gracefully illustrated this book give it a quality that we hope will allow women all over the world
to feel connected with each other. The artists are:

Namrata Bali (India)

Silvia Barandier (Brazil)
Jennifer Barrios (USA)

Sara Boore (USA)

Mariah Boyd-Boffa (USA)
Heidi Broner (USA)

May Florence Cadiente
(Philippines)

Barbara Carter (USA)

Yuni Cho (Korea)

Elizabeth Cox (Papua New
Guinea)

Christine Eber (USA)

Regina Faul-Doyle (USA)
Sandy Frank (USA)

Lianne Friesen (Canada)
JaneWambui Gikera (Kenya)
Shu Ping Guan (China)

Susie Gunn (Guatemala)

May Haddad (Lebanon)

Janie Hampton (UK)

Anna Kallis (Cyprus)

Ceylan Karasapan-Crow (USA)
Delphine Kenze (Central
African Republic)

Susan Klein (USA)

Joyce Knezevich (USA)

Gina Lee (USA)

Bekah Mandell (USA)

June Mehra (UK)

Naoko Miyamoto (Japan)
Gabriela Nunez (Peru)
Sarah Odingo (Kenya)
Rose Okong’o Olendi
(Kenya)

Rosa Oviedo (Nicaragua)
Kate Peatman (USA)

Sara Reilly-Baldeschwieler
(UK)

Diana Reiss-Koncar (USA)
Petra Rohr-Rouendaal
(Germany)

Leilani Roosman (UK)

Lucy Sargeant (USA)
Felicity Savage King (UK)
Carolyn Shapiro (USA)
Akiko Aoyagi Shurtleff
(Japan)

Pat Siddiq (Afghanistan)
Nisa Smiley (USA)

Fatima Jubran Stengel
(Palestine)

Suma (India)
DovileTomkute-
Veleckiene (Lithuania)
AndreaTriguba (USA)
AnilaVadgama (India)

Leah LihuaWang (China)
Liliana Wilson (USA)
FawziYaqub (Turkey)

Cover Photographs:

I. Mauritania by Lauren Goodsmith

2. India by Renee Burgard

3. China by Guo Hui Fen

4. Uzbekistan by GilberteVansintejan

5. Papua New Guinea by Elizabeth Cox

6. Morocco by Lauren Goodsmith

7. Democratic Republic of Congo by
GilberteVansintejan

8. Mexico by Suzanne C. Levine

ifl or

www. nespenan.org

Thanks

It is impossible to adequately thank all the people who made Where Women Have No Doctor a reality This
book started as a good idea shared by a small group of women and ended up as a remarkable international
collaboration spanning 5 continents. Now we find ourselves wanting to thank everyone who helped, but
simply listing their names does not do justice to the tremendous and generous contributions so many have
made: from the groups of women who met early on to discuss topics related to women’s health care, and
who later reviewed chapters we wrote based on what they told us; to others who sent us original materials or
reviewed (often several times) different sections of the book; to others who wrote drafts of chapters; to the
specialists in women’s health care who reviewed parts of or the entire manuscript; and to the artists — women
from 23 countries — -whose illustrations reflect just how diverse a project this was. We thank you all, for
through your combined efforts, this book now rightfully belongs to any woman who reads or uses it.

Wholehearted thanks to the following friends of Hesperian for their work on writing specific chapters, or for
contributing the time or ideas that helped complete them:

Abortion: Judith Winkler of IPAS, and Judith Tyson

Breastfeeding: Felicity Savage King, Helen Armstrong, Judy Canahuati, and Nikki Lee

Female Genital Cutting: Jane Kiragu, Leah Muuya, Joyce Ikiara, the women of MandaeleoYa Wanawake, NahidToubia

and Zeinab Eyega of Rainbo, Grace Ebun Delano, Abdel Hadi El-Tahir and Inman Abubakr Osman
Mental Health: Carlos Beristain
Pregnancy: Suellen Miller
Rape and Violence: Elizabeth Shrader Cox
Sex Workers: Eka Esu-Williams

Women with Disabilities: Judith Rogers, Pramila Balasundaram, and Msindo Mwinyipembe
For the 2006 reprint, coordination: Pam Fadem
For the 2010 reprint, coordination: Jane Maxwell

Support from Scilla Bennett, Inaki Fernandez de Retana, Shu Ping Guan, Zena Herman, Todd Jailer Susan
McCallister Kathleen Tandy, Dorothy Tegeler Kathleen Vickery, and Sarah Wallis. Advice from Maggie Bangser Alan
Berkman, Kathy DeRiemer Madelyn Hamilton, Erin Harr-Yee, Ellen Israel, Jose Jerinomo, Brian Linde, Jonathan Mermin,
Syema Muzaffar Melanie Pena, Tin Tin Sint, Melissa Smith, Susan Sykes, ElliotTrester Marco Vitoria, CurtWands-
Bourdoiseau, Beverly Win ikoff, and Susan Yanow; all were extremely helpful, as were the 4 authors.

In addition, we are deeply indebted to Deborah Bickel, Sara Boore, Heidi Broner Regina Faul-Doyle, Susan
Fawcus, Blanca Figueroa, Sadja Greenwood, May Haddad, Richard Laing, Lonny Shavelson, Richard Steen, and Deborah
Wachtel for their constant availability and selfless efforts. It’s hard to imagine what we would have done without them.

Thanks also to the following groups of women in different countries who contributed so much of their time,
hearts, and minds to review these materials and enrich the book: in Bangladesh:The Asia Foundation; in Botswana:
Thuso Rehabilitation Centre, Maun; in Brazil: the Association of Community Health Workers of Canal do Anil,
and the health educators of Itaguai; in Cyprus, Egypt, Jordan, Lebanon, Palestine, Syria, and Yemen: the many groups
of women who are members of the Arab Resource Collective; in El Salvador: the women of Morazan and
Chalatenango; in Ethiopia: the groups of women who met in Addis Ababa; in Ghana: The Association of Disabled
Women, Dorma Ahenkro, the schoolgirls of Wa, and the women of Korle Bu; in Honduras: the women of Urraco
Pueblo; in India: CHETNA, SEWA, Streehitikarini, the women of Bilaspur Madhya Pradesh, and the exiled women
ofTibet; in Kenya: MandaeleoYa Wanawake — from the districts of Machakos, Kitui, Kerugoya, and Murang’a — -the
Dagoretti Clinic Community Health Workers, the Mwakimai Self Help Group of Kisi, Crescent Medical Aid, the
women of Population and Health Services (PHS) of Nairobi, and the women ofVOWRI, Nairobi; in Mexico: the
women of Ajoya, and the community health promoters of Oaxaca; in Nigeria: the NigeriaYouth AIDS Programme;
in Papua New Guinea: the East Sepik Women and Children’s Health Project; in the Philippines: GABRIELA, HASIK,
LIKKHAN, REACHOUT and the People’s Organizations for Social Transformation; in Sierra Leone: the women of
Matatie Village; in the Solomon Islands: the women of Gizo; in Uganda: the Kyakabadiima Women’s Group, and
WARAIDS; and in Zimbabwe: the Women’s Action Group.

And heartfelt gratitude to the countless others who gave so freely of their time and talents, especially:

Hilary Abell

Rosita Arvigo

Denise Bergez

Sandra Tebben

Casmir Chipere

Jane Adair

Leonida Atieno

Stephen Bezruchka

Buffington

Lynne Coen

Niki Adams

Kathy Attawell

Pushpa Bhatt

Sharon Burnstien

Louise Cohen

Christine Adebajo

Nancy Aunapu

Amie Bishop

Mary Ann Burris

Mark Connolly

Vida Affum

Elizabeth de Avila

Edith Mukisa Bitway iki

Elizabeth Bukusi

Karen Cooke

Stella Yaa Agyeiwaa

Enoch Kafi Awity

Michael Blake

Elliot Burg

Kristin Cooney

Baldreldeen Ahmed

Marie Christine N.

Paulina Abrefa Boateng

May Florence

Chris Costa

Felicia Aldrich

Bantug

Simone Bodemo

Cadiente

Elizabeth Cox

Bhim Kumari Ale

David Barabe

Nancy Bolan

Indu Capoor

Clark Craig

Jennifer Alfaro

Naomi Baumslag

Peter Boland

Ward Cates

Betty Crase

Sandra Anderson

Barbara Bayard o

Bill Bower

Mary Catlin

Mitchell Creinin

Susan Anderson

Carola Beck

Christine Bradley

Denise Caudill

Marjorie Cristol

Thomas Allen

Rayhana Begum

Paula Brentlinger

Barbara Chang

Bonnie Cummings

Adrianne Aron

Medea Benjamin

Verna Brooks

Amal Charles

George Curlin

Fred Arradondo

Marge Berer

Mary Ann Buckley

Andrew Chetley

Philip Darney

1 hlMU- S-tk or

www. nesper ian . o r

Sarah Davis
John Day

Grace Ebun Delano
David de Leeuw
Junice L. Demeterio-
Melgar

Lorraine Dennerstein
Kathy DeReimer
Maggie Diaz
Gerri Dickson
Becky Dolhinow
Efua Dorkenoo
Brendon Doyle
Sunun Duangchan
Deborah Eade
Beth Easton
Christine Eber
Tammy Edet
Lorna Edwards
Abdel Hadi El-Tahir
Erika Elvander
Li Enlin
John Ensign
Nike Esiet
Steven A. Esrey
Clive Evian
Zeinib Eyega
Melissa Farley
Betty Farrell
Anibal Faundes
Sharon Fonn
Claudia Ford
Diane Jinto Forte
Daphne Fresle
Anita Gaind
Loren Galvao
Monica Gandhi
Sabry Khaill Ghobrial
Gayle Gibbons
Marta Ginebreda
Lynn Gordon
Nora Groce
Gretchen Gross
Dora Gutierrez
Ane Haaland
Kathleen Haley

Shirley Hamber
Janie Hampton
Joanne Handfield
Barbara Harrington
Richard Harvey
Fauzia Muthoni Hassan
Elizabeth Hayes
Lori Heise
N.S. Hema
Shobha Menon-Hiatt
Hans Hogerzeil
Jane Holdsworth
Nap Hosang
Douglas Huber
Ellen Israel
Genevieve Jackson
Jodi Jacobson
Carol Jenkins
Signy Judd
Margaret Kaita
Mustapha Kamara
Tom Kelly
Mary Kenny
Joyce Kiragu
Susan Klein
Ahoua Kone
Zoe Kopp
Anna Kretsinger
Diana Kuderna
Anuradha Kumar
Dyanne Ladine
Martin Lamarque
Joellen Lambiotte
Kathleen Lankasky
Lin Lap-Chew
Hannah Larbie
BA Laris
Laura Laski
Carolyn Lee
Jessica Lee
PamTau Lee
Susan Lee
Felicia Lester
Abby Levine
Cindy Lewis
Sun U

Peter Linde
Betsy Liotus
Stephanie Lotane
Susan Lovich
Nellie Luchemo
NP Luo

Esther Galima Mabry
Martha Macintyre
Margaret Mackenzie
Rebecca Magalhaes
Monica Maher
Fardos Mohamed
Mahmoud
Lisa Maldonado
J. Regi Manimagala
Karin Manzone
Alan Margolis
Kathy Martinez
Rani Marx
Sitra Maunaguru
Danielle Mazza
Pat Mbetu

Dorothy Mbori-Ngacha
Gary Mcdonald
Sandy McGunegill
Katherine McLaughlin
Molly Melching
Tewabetch Mengistu
Tasibete Meone
Sharon Metcalf
Ann Miley
Jan Miller
Kathy Miller
Donald Minkler
Eric Mintz
Barbara Mintzes
Linda Mirabele
Nanette Miranda
David Modersbach
Rah mat Mohammad
Gail Montano
Maristela G. Monteiro
Mona Moore
David Morley
Sam Muziki
Arthur Naiman

Nancy Newton
Elizabeth Ngugi
Eunice Njovana
Folashade B. Okeshola
Peaches O’Reilly
Emma Ottolenghi
Mary Ellen Padorski
Lauri Paolinetti
Jung Eun Park
Sarah Parsons
Laddawan Passar
Palavi Patel
Jamel Patterson
Andrew Pearson
Marfa Pi cos
Gita Pillai
Linda J. Poole
Malcolm Potts
Alice Purdy
Robert Quick
Zahida Qureshi
Lisa Raffel
Rita Raj-Hashim
Narmada Ranaweera
Rebecca Ratcliff
Augusta Rengill
Dawn Roberts
Kama Rogo
Nancy Russel
Carolyn Ryan
Mira Sadgopal
Valdete Sal a
Estelle Schneider
Kimberly Schultz
Miriam N. Senkumba
Violet Senna
Shalini Shah
Nicolas Sheon
Mira Shiva
Kathy Simpson
Mohindra Singh
Elise Smith
Stephan Solter
Cathy Solter
Barbara de Souza
Judith Standly

Fatima Jubran Stengel
Kay Stone

Marianne Stone-Jimenez

Eleanor Sullivan

Susan Sykes

Michael Tan

LindaTeitjen

Judith Timyan

Susan Toft

RikkaTransgrud

NhumeyTropp

BarbaraTrott

SandyTruex

llanaTrumbull

JanisTunder

Nanette Tver

Aruna Uprety

GilberteVansintejan

Sarah Verbiest

Carol Vlassoff

BeaVuylsteke

Bela Wabi

Sandra Wald man

Martha Wambui

Judith Wasserheit

Ruth Waswa

Barbara Waxman

Jane Weaver

Vivienne Wee

Ellen Weis

Rachel West

Eve Whang

Kate White

Wil Whittington

Laura Wick

Pawana Wienrawee

Christine van Wijk

Everjoice Win

Kathryn Wirogura

Erin HarrYee

Irene Yen

Rokeya Zaman

Marcie Zellner

Kaining Zhang

Lisa Ziebel

Margot Zimmerman

The following persons and groups kindly gave us permission to use their artwork: Family Care International
for numerous drawings by Regina Faul-Doyle from their book Healthy Women, Healthy Mothers: An Information
Guide ; Macmillan Press Ltd., for Janie Hampton’s drawing on page 60 from Healthy Living, Healthy Loving] the
Environmental and Development Agency, New Town, South Africa, for the drawing on page 395 from their magazine, New
Ground ; Honto Press for Akiko Aoyagi Shurtleffs drawing on page 41 I from Gulinary Treasures of Japan; the Movimento
de MulheresTrabalhadoras Rurais do Nordeste for the drawing on page 17 from 0 Que £ Genero ?; and the Colectivo de
Mujeres de Matagalpa and the Centro de Mujeres de Masaya for the drawing on page 338 from their manual / Mas alia de
las lagrimasl. And thanks to Connexions magazine for the story on page 339.

We also thank the following foundations and individuals for their generosity in financially supporting the project: Catalyst
Foundation; Conservation, Food and Health Foundation; C.S. Fund; Domitila Barrios de Chungara Fund; Ford Foundation;
Greenville Foundation; John D. and Catherine T. MacArthur Foundation; Norwegian Agency for Development Cooperation;
David and Lucile Packard Foundation; San Carlos Foundation; Swedish International Development Cooperation Agency;
Kathryn and Robert Schauer; and Margaret Schink. Thanks also to the many individuals who made contributions to match a
Catalyst Foundation grant. Finally, a special thanks to Luella and Keith McFarland for their early support and encouragement,
and to Davida Coady for believing in this project and pushing it forward during a particularly difficult time.

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About this Book

This book was written to help women care for their own health, and to help
community health workers or others meet women’s health needs. We have tried to
include information that will be useful for those with no formal training in health care
skills, and for those who do have some training.

Although this book covers a wide range of women’s health problems, it does not
cover many problems that commonly affect both women and men, such as malaria,
parasites, intestinal problems, and other diseases. For information on these kinds of
problems, see Where There Is No Doctor or another general medical book.

Sometimes the information in this book will not be enough to enable you to solve
a health problem. When this happens, get more help. Depending on the problem, we
may suggest that you:

• see a health worker. This means that a trained health
worker should be able to help you solve the problem.

• get medical help. This means you need to go to a
clinic that has trained medical people or a doctor; or a
laboratory where basic tests are done.

• go to a hospital. This means you need to see a doctor
at a hospital that is equipped for emergencies, for
surgery, or for special tests.

If you need to get help
immediately, this picture
will also appear.

TRANSPORT!

How to Use this Book

Finding information in the book

To find a topic you want to know about, you can use either the list of Contents or
the Index.

The Contents, at the front of the book, lists the chapters in the order in which they
appear. There is also a list of contents at the beginning of every chapter Each topic on
this list appears on the numbered page listed as a large heading (words in big, dark letters).

The Index, or Yellow Pages at the back of the book, lists all the important topics
covered in the book, in the order of the alphabet (a, b, c, d...).

To find information about the medicines used in this book, look in the Green Pages

toward the back of the book. Page 485 gives more information about using medicines
and the Green Pages.

If you do not understand the meanings of some of the words used in this book, you may

find them in the List of Difficult Words that starts on page 548. The first time these
words appear in a chapter, they are printed in slanted letters, like this. You can also look
up the word in the index to see if it is explained in another part of the book.

Many chapters end with a section called ‘Working for Change’. These sections give
suggestions for working to improve women’s health in your community.

www.nesperian.org

Finding information on a page

To find information on a page, first look over the whole page. You will see that the
page is divided into 2 parts: a large, main column and a small column on the outside
of the page. The main column gives most of the information about a topic. The small
column has additional information that can help you better understand the topic.

Whenever you see a picture of a book in the small column,
this means more information about a topic can be found in
another part of the book. The words under the book say I

what the topic is. The page number on the book says where f ooc | s r j C h j n

that topic can be found. If there are several topics, the book is protein

shown once and the topics and their page numbers are listed below.

What the different things on a page mean:

Most pages have several headings. The headings in the small column give the
general topic that is being discussed on that page. The headings in the main column
give more specific topics.

page

number

general
topic -

See this page
...for more
information
about

this topic —

Get help _
right away!

chapter title

-v-

74 Pregnancy and Childbirth

Danger

Signs

during

Pregnancy

foods rich
in protein

Swelling of the hands and face or severe

HEADACHE AND BLURRED VISION (ECLAMPSIA)

Some swelling in the legs and ankles is
normal in pregnancy. But swelling of the
hands and face can be a sign of eclampsia,
especially if you also have headaches, blurred
vision, or pains in your abdomen. Eclampsia
can cause seizures ("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 yourlejt

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

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

Danger signs of eclampsia

• swollen hands and face

• dizziness

• blood pressure 140/90 or

■ severe headache

• severe pain high in

higher (see page 532)

• blurred vision

the stomach

TRANSPORT!

If a woman has any of the danger signs of eclampsia,
she needs medical help fast If she is already having seizures, see
page 87.

specific

topic

this word is
explained in the
List of Difficult
Words

very important
"" information

Medicine

Some pages also contain medicine boxes, which look like this:

These boxes tell you the amount of
medicine to give, how often to give it, and
for how long. Sometimes we recommend
medicines without putting them in a box.

In either case, look up each medicine in
the Green Pages before using it.

Medicine for Breast Infection

How much to take When and how to take

dicloxidllin^ pj^g^ 500 mg 4 times a day for 7 days.

If you cannot find this or are Take at least 30 minutes

allergic to penicillin, take: before food.

erythromycin 500 mg 4 times a day for 7 days.

Important: if a breast infection is not treated early, it will get worse. The hot and painful swelling will feel
as if it is filled with liquid (abscess). If this happens, follow the treatment described here AND see a health
worker who has been trained to drain an abscess using sterile equipment.

1 l t tl
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Contents

Thanks

How to use this book

Chapter I: Women’s Health Is a Community

What is women’s health? I

Women are more at risk for disease 2

Chapter 2: Solving Health Problems

Juanita’s story 20

What is the best treatment? 22

Chapter 3: The Medical System

The medical system 34

How to get better care 36

Chapter 5: Health Concerns of Girls

Changes in your body (puberty) 54

Changes that can lead to a better life 56

Deciding about boyfriends and sex 59

Issue I

Causes of poor health in women 6

Working for change 1 2

18

Working for change 26

To the health worker 30

32

If you need to go to the hospital 38

Working for change 40

42

47

48

52

Pressured or forced sex 62

Getting help from adults 65

Chapter 4: Understanding Our Bodies

A woman’s reproductive system 44 How a woman’s body changes

A man’s reproductive system 46 Monthly bleeding

Chapter 6: Pregnancy and Childbirth

Staying healthy during pregnancy 68

Common problems of pregnancy 69

Risks and danger signs 72

Prenatal care 76

Preparing for labor and birth 78

Giving birth 80

Chapter 7: Breastfeeding

Why breast is best 1 05

Why other feeding can be harmful I 06

HIV and breastfeeding 106

How to breastfeed 1 07

Advice for the mother 1 09

When the mother works I I I

Removing milk by hand I 1 2

66

Difficult births 88

Danger signs for the baby at birth 94

Caring for the mother and baby 95

Women with extra needs 98

To the father 1 00

Working for change 1 0 1

104

Common concerns and problems I 14

Special situations I I 8

Babies with special needs I I 8

When the mother is sick I 20

When a woman becomes pregnant I 20

Working for change I 2 1

Chapter 8: Growing Older

The end of monthly bleeding I 24

Taking care of your health I 26

Sexual relations I 28

122

Common health problems with aging I 29

Working for change I 36

Chapter 9: Women with Disabilities

Self-esteem 1 40 Personal safety

Taking care of your health 1 4 1 Working for change

Sexuality and sexual health 1 44

WWW.

Hesperian.

rg

138

146

147

Chapter 10: Staying Healthy

Cleanliness

Community sanitation

Chapter I I: Eating for Good Health

Main foods and helper foods

Eating better for less money

Harmful ideas about eating

1 50 Special needs of women,
1 5 I Working for change

I 66 Poor nutrition can cause disease

170 Ways to work

1 7 1 toward better nutrition

Chapter 12: Sexual Health

Sex and gender roles I 82 How to improve your sexual health

How gender affects sexual health I 84 Working for change

Chapter 13: Family Planning

Benefits of family planning

Choosing to use family planning

Choosing a family planning method
Barrier methods of family planning.

Hormonal methods

The IUD

1 97 Natural methods of family planning

199 Traditional and home methods

200 Permanent methods

202 Emergency methods

207 Choosing the best method

216 Working for change

Chapter 14: Infertility

What is infertility?

230

What to do for infertility

What causes infertility?

230

Losing a pregnancy

Dangers at work or at home

Living with infertility

that can hurt fertility

232

Working for change

Chapter 15: Abortion and Complications of Abortion.

Why some women have abortions 239

Safe and unsafe abortion 241

Deciding about an abortion 243

Safe methods of abortion 244

What to expect from safe abortion 248

What to expect after an abortion..

Family planning after abortion

Complications of abortion

Preventing unsafe abortion

Chapter 16: Sexually Transmitted Infections (STIs)
and Other Infections of the Genitals

Why STIs are a serious

problem for women 262

How to know if you are at risk for an STI .263
What to do if you have signs of an STI.... 263

Taking medicines to treat STIs 264

Abnormal discharge 265

Growths (warts) on the genitals 269

Sores on the genitals

Complications of STIs (PID)

Other STIs (HIV infection and

Hepatitis B)

How to feel better

Working for change

Chapter 17: HIV and AIDS

What are HIV and AIDS?

Why HIV and AIDS are different for

women

Preventing HIV

The HIV test

Living positively with HIV infection

WWW.

284 Pregnancy childbirth, breastfeeding..

Care for persons with HIV or AIDS
286 Staying healthy as long as possible....

286 Common medical problems

288 Caring for someone near death

290 Working for change

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148

.158

.163

164

.172

.176

180

.186

.194

196

.218

.222

.223

.224

.226

.227

228

.233

.234

.236

.237

238

.249

.250

.251

.259

260

.270

.274

.277

.278

.279

282

.292

.294

.296

.297

.309

.309

Chapter 18: Violence Against Women

The story of Laura and Luis 3 1 4

Why does a man hurt a woman? 3 I 6

Kinds of violence 3 1 7

Warning signs 3 I 8

The cycle of violence 3 1 9

Chapter 19: Rape and Sexual Assault

Kinds of rape and sexual assault 328

Howto avoid rape 330

Self defense for women 332

If you are sexually assaulted 333

Chapter 20: Sex Workers

Why women become sex workers 342

Health problems of sex workers 344

STIs, including HIV infection 344

Pregnancy 345

Chapter 21: Pain in the Lower Abdomen

Sudden, severe pain 354

Kinds of pain in the abdomen 354

312

Harmful effects of violence 320

Why women stay 32 1

What to do 322

Working for change 323

To the health worker 325

326

What to do if you have been raped 334

Health problems of rape 336

Working for change 338

340

Violence 345

How to protect yourself from STIs 346

Working for change 348

Negotiating condom use 348

352

Questions about pain
in the abdomen 357

Chapter 22: Abnormal Bleeding from the Vagina 358

Problems with monthly bleeding 360

Bleeding during pregnancy or after
childbirth 362

Chapter 23: Problems of the Urine System...

Infections of the urine system 366

Blood in the urine 369

Need to pass urine often 370

Bleeding after an abortion or miscarriage..363

Bleeding after sex 363

Bleeding after menopause 363

364

Leaking urine 370

When you have problems
passing urine or stool 372

Chapter 24: Cancer and Growths

Cancer 376

Problems of the cervix 377

Problems of the womb 380

Problems of the breasts 382

Chapter 25: Tuberculosis

What isTB? 388

HowTB is spread 388

How to know if a person hasTB 389

374

Problems of the ovaries 383

Other common cancers 384

When cancer cannot be cured 385

Working for change 385

386

How to treat TB 389

Preventing TB 39 I

Working for change 39 I

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Chapter 26: Work

Cooking fires and smoke 394

Lifting and carrying heavy loads 398

Work with water 40 1

Work with chemicals 402

Sitting or standing for a long time 404

Repeating the same movement 405

392

Crafts 406

Unsafe working conditions 406

Sexual harassment 407

Migration 408

Workers in the informal sector 409

Working for change 4 1 0

Chapter 27: Mental Health

Self-esteem 4 1 4

Common causes of mental health

problems in women 4 1 6

Common mental health
problems for women 4 1 9

412

Helping yourself and helping others 422

Mental illness (psychosis) 432

Ways to improve your community’s
mental health 433

Chapter 28: Alcohol and Other Drugs

Use and misuse of alcohol and drugs 436

Problems from alcohol and drugs 438

Overcoming problems with
alcohol and drugs 440

Chapter 29: Refugees and Displaced Women

Flight and arrival 448

Basic needs 448

Reproductive health 452

434

Problems from tobacco 443

Living with someone who has

a drinking or drug problem 444

Preventing drug and alcohol abuse 445

446

Mental health 454

Women as leaders 456

Chapter 30: Female Genital Cutting 458

Types of female cutting 460 What to do for health problems 46 1

Health problems from cutting 460 Working for change 466

Chapter 31: Use of Medicines in Women’s Health 468

Deciding to use medicine 470 Kinds of medicines 480

How to use medicine safely 472 Medicines that can save a woman’s life. ...484

Using the medicines in this book 473

Table of Medicines: Green pages 485

Health Care Skills

Preventing infection 525

How to take temperature, pulse,

respiration, and blood pressure 530

How to examine the abdomen 534

How to examine a woman’s genitals 535

525

Caring for burns 538

How to give fluids to treat shock 540

Howto give an injection 542

Acupressure massage 546

Vocabulary: List of difficult words 548

Where to get more information 56 1

Index: Yellow pages 565

1 l (I rfi 4 S+k «r

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Chapter 1

Women’s Health

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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 address women’s
needs only as mothers.

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.

What Is

‘Women’s

Health’!

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

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.

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.

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2 Women’s Health Is a Community Issue

Women
Are More
at Risk for
Disease and
Poor Health

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

eating for good 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.

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.

The health worker told me I
should drink more milk and eat
green leafy vegetables. But I save
all our milk for my husband and
son, and we don’t have the money
to buy vegetables.

%

A woman’s health cannot be isolated from her social status. In most of rural India, women drink
less milk than their husbands and sons and they eat only after the men have been served. This
usually leaves women with a limited diet, and it also tells about how she is valued.

— CHETNA, Ahmedabad, India

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Women Are More at Risk for Disease and Poor Health 3

Reproductive health problems

Sexually transmitted infections (STIs), including HIV. A woman
is physically more vulnerable than a man to infections like STIs
and HIV. 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.

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, millions of women get an STI every
year, and more than 17 million are already infected with HIV.
Without treatment, STIs can cause disabling pain, severe pelvic
inflammatory disease (PID), infertility, problems during pregnancy,
and an increased risk of cervical cancer. Untreated, HIV becomes
AIDS, which 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.

Complications from pregnancy and birth. In the last 40 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 or childbirth. And for every woman who dies
in childbirth, 20 more suffer from injury or infection. This
means that overtime, about a quarter of all women living in
poor countries will be seriously affected by complications from
pregnancy and birth.

Unsafe abortion. When a woman tries to end a pregnancy by
having an unsafe abortion, she risks her life. But every day about
60,000 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.

Female genital cutting. Female genital cutting, 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 3 million girls are cut, mostly in Africa, and in
some parts of the Middle East and Asia.

STIs and other
infections of the
genitals

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

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

V Every year 70,000
women die from
unsafe abortions.

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4 Women’s Health Is a Community Issue

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

TB, 387

alcohol and other
drugs, 435

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 her or makes
her look ugly may be rejected by her husband.

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 Vk 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.

work

V 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.

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

mental health

Work hazards

Women face health risks every day from their work. 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.

Millions of

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.

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Women Are More at Risk for Disease and Poor Health 5

Violence

Violence is often overlooked as a health problem. But
violence can lead to serious injuries, mental health problems,
physical disabilities, and even death. Rape and sexual harassment
are a constant threat to all women. Many girls are sexually
abused by family members or friends. Many women are
forced to have sex or are physically abused by their partners.
Increasingly violent and damaging rapes and sexual assaults have
become common practices during wartime.

Even though these kinds of violence
against women and girls happen in
almost all parts of the world, most
of it 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.

>- When women
suffer violence, it is
usually from men
they know. But most
violence against
women is not
reported, and men
are rarely punished.

violence, 3 1 3

rape and sexual
assault, 327

How women are forced into a life of poor health

Although not all women suffer
from the health problems
described above, most
will suffer from 3 of
them: poor nutrition,
pregnancies that are
too close together,
and overwork. Each of
these problems affects a
woman’s general health
and wears her body out,
making her more likely to
get sick. Pregnancy also
makes certain medical
problems — like malaria,
hepatitis, diabetes, and
anemia — worse, just as they
make pregnancy more difficult.

All these things make a woman
much more likely to suffer from
general poor health than a man.

:/Wr^
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HEALTH

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6 Women’s Health Is a Community Issue

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 STIs 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.

Poverty

Two out of three women around the world are poor. Women are not only
much more likely than men to be poor, but are most often among the poorest of
the poor.

Millions of women are caught in a cycle of poverty that begins even before
they are born. Babies born to women who did not get enough to eat during
pregnancy are likely to be small at birth and to develop slowly. In poor families,
girls are less likely than their brothers to get enough to eat, causing their growth
to be further stunted. Girls are often given little or no education, so as women
they must work at unskilled jobs and receive less wages than men (even if they
do the same kind of work). At home, their daily work is unpaid. Exhaustion,
poor nutrition, and lack of good care during pregnancy place the woman and her
children at risk for poor health.

Poverty forces her to live under conditions that can cause many physical and
mental health problems. For example, poor women often:

• live in bad housing, with little or no sanitation or

clean water. n

• do not have enough
good food, and must
spend precious time
and energy looking for
food they can afford.

• are forced to accept
dangerous work, or to
work very long hours.

• cannot use medical care,
even if it is free, because they
cannot afford time off work or away from their families.

• are so busy struggling to survive that they have little time or energy to take
care of their own needs, to plan for a better future, or to learn new skills.

• are blamed for their poverty and made to feel less important than those with
more money.

Poverty often forces women into relationships in which they must depend on
men for survival. If a woman depends on a man for her — or her children’s —
support, she may have to do things to keep him happy that are dangerous to
her health. For example, she may allow him to be violent or to have unsafe sex
because she fears losing his economic support.

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Causes of Poor Health in Women 7

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.

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.

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.

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

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.

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.

>- 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.

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8 Women’s Health Is a Community Issue

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.

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 would 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.

Debt and poor countries

Since the 1 970s, when many poor countries were pressured to borrow money from
banks in rich countries, huge debts have meant that governments are still struggling
to meet the basic needs of their people. Although there has been a lot of corruption,
many countries have started new schools, hospitals, clinics, and other projects.

But as the banks demand that their money be paid back, the poor countries
have been forced to change or “adjust” their economies in ways that make life
harder for poor people. These countries are forced to use much of the wealth
the people produce to pay the banks, and to change their laws to make it easier
for foreign companies to make money by using the poor countries’ resources and
labor. Basic services like water, electricity,
communications and pensions have been
sold to profit-seeking, foreign companies.

As a result, people work harder than
ever but still have trouble meeting their
basic needs. Governments now have less
money for schools, health centers,
hospitals, and programs that help
people get food and fuel at a fair
price. The health of all poor people
suffers from these changes, but the /

health of poor women and children A/1 any public health centers lack even the most

suffers most of all. basic medicines, supplies and equipment.

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Mira's Story 9

Mira’s Story

When Mira was a little girl, she dreamed of living in a big
house, with electricity and a tile floor Her husband would be
handsome and kind, and she would be able to do whatever
she wished. But Mira’s family was poor, and she was the
youngest of four daughters. Sometimes, when her father was

drinking, he would beat her mother; and weep at his misfortune
of having so many girls.

When Mira was 1 4, and old enough to be married, she cried when she
learned her dreams would never come true. It was already arranged: Mira f
would marry a man whom her father had chosen. He had some land, and /

Mira’s father thought the family would benefit from their marriage. Mira
had no choice in the matter

With the birth of Mira’s second child — a son — her husband stopped
insisting on sex so often. Mira was very glad for that. Although he did not hurt her,
he had warts all over his penis that disgusted her Over the next 20 years, she had
6 more children, including a little girl who died at age 3, and a boy who died at birth.

One day, Mira was using the latrine and she noticed a bloody discharge coming
from her vagina when it wasn’t time for her monthly bleeding. She had never had a
health exam, but now Mira asked her husband if she might see a health worker. He
replied that he didn’t trust doctors, and besides, he didn’t have the money to spend
every time she felt worried about something.

Mira was 40 when she began to suffer constant pain low in her belly. The pain
worried her, but she didn’t know who to talk to about it. Some months later, Mira
finally decided she had to go against her husband’s wishes and get medical help. She
was frightened for her life, and borrowed some money from a friend.

At the health center; Mira got some medicine for the vaginal discharge, although
the health worker did not examine her first. Mira returned home that night,
exhausted and upset that she had defied her husband and spent her friend’s savings.
As weeks passed, Mira’s health continued to worsen, and she became discouraged,
realizing that something was still wrong.

Finally, Mira became so weak that her husband believed she really was ill, and they
begged a ride to a hospital in the big city far away. After waiting several days, Mira
was seen at the hospital. Finally, she was told that she had advanced cancer of the

cervix. The doctor said they could remove her womb, but
that the cancer had already spread. The one treatment
k that might save her life was available only in another

part of the country, and was very expensive. The
doctor asked, “Why didn’t you get regular Pap
tests? If we had found this earlier, we could

have treated it easily.” But it was too late
for that. Mira went home, and in less than
2 months, she died.

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10 Women’s Health Is a Community Issue

Why did Mira die?

Here are some common answers to this question:

A doctor may say...

Mira died of
advanced cervical
cancer because
she did not get
treatment earlier.

Mira died because
she didn't know
she should have a
visual inspection
of the cervix or a
Pap test done.

Or a health worker..,

Mira died because her
husband exposed her to
genital warts and other
STIs. These put her at high
risk for developing cancer
of the cervix.

> For more
information about
cancer of the cervix,
see page 377.

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
(by having a visual inspection of the cervix or a Pap 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.

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Mira's Story | |

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.

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. 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.

>- You can explore
the root causes of
Mira’s death or other
health problems by
using the excercise
called "But Why?" on
page 26 .

that led to Mira’s death. They are the same links
that cause many of women's health problems.

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1 2 Women’s Health Is a Community Issue

Working for
Change

> For other ideas of
how your partner can
help , see page 1 4.

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:

Raising our children for a better world

How we raise our children, from the moment they are born, will determine much
of what they believe and how they act as adults.

As mothers, we teach our children every day of their lives:

• When we feed our husbands and sons first, we teach our children that girls' and
women’s hunger is less important.

• When we send only our sons to school, we teach our children that girls do not
deserve the opportunities that come from an education.

• When we teach our sons that it is manly to be violent, we raise violent men.

• When we do not speak out against violence in our neighbor’s house, we teach
our sons that it is acceptable for a man to beat his wife and children.

As mothers, we have the power to change who our children will become:

• We can teach our sons to be kind and compassionate, so they will grow up to
be kind and compassionate husbands, fathers, and brothers.

• We can teach our daughters to value themselves, so they will
expect the same from others.

We can teach our sons to share
and take pride in household
work, so their sisters, wives and
daughters do not suffer the
burden of overwork.

We can teach our daughters to be more
independent by finishing school or learning a skill.

We can teach our sons to respect all women and to
be responsible sexual partners.

We can raise our children for a better world.

Where Women Have No Doctor 20 1 0

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Working for Change | 3

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.

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. For ways to work
with a group to plan and carry out actions for change, see
pages 26 to 3 I .

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

My back hurts so much these
days from having to carry
water all the way up the hill to
my house. The health worker
says I shouldn't carry heavy
loads when Tm pregnant—
that's how Mari lost her
pregnancy. But how else would

It isn't a problem just
for women who are
pregnant! My back
is always hurting
too. I finally got my
husband to start
helping me carry
water every day.

www.n6Sp6ridn.org

I was visiting my sister
the other day, and where
she lives they got the city
to put in some water taps
close to the houses. It's
great, she doesn't have
to carry water very far at
all. Everyone loves it.

Maybe we could get enough
people together to convince
the city to do the same thing
for us. But we would need a
lot of people. And we would
need to know who to talk to,
and decide where we wanted
the water taps.

Well, we could talk
with Jose. He's
a teacher and
everyone respects
him. He could

of women, you con leorn more
about 0 health problem and
what can be done to solve it.

Where Women Have No Doctor 2010

14 Women’s Health Is a Community Issue

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.

HOW MEN CAN HELP

Any man can help improve women’s health by:

• raising his children to respect women, and treating boys and girls as equals.

• asking women what they think, and listening to them. A man can listen to his
partner's and daughters’ concerns and needs, and see if together they can find a
way to meet the needs of everyone in the family.

• talking with his partner about how many children they each want to have, and
then taking equal responsibility for family planning.

• encouraging his partner to go for regular health exams, and helping find the
money and time for her to go.

• taking turns caring for the children and doing house work.

• being faithful to his partner or, if he cannot, being honest with her and practicing
safer sex when he is not with her. If a man ever gets an STI, he should tell all of
his sexual partners right away, so everyone can get treatment.

• encouraging his partner to take a fair share of the food that there is to eat —
even if nobody is getting very much.

• encouraging all of his children to stay in school as long as they can. The longer
they can stay in school, the more choices they will have as adults, and the better
their health will be.

A man can also set a good example in his community by:

• encouraging women in his community to come to meetings, and making sure
that they have a chance to speak. Or by encouraging women to hold their
own, separate meetings, where men will not speak.

• encouraging women to become involved in planning and running community
projects.

• encouraging others to limit their use of alcohol and drugs — -these contribute
nothing to the community and waste money and energy. Try to plan
celebrations that do not involve alcohol.

• not tolerating any kind of violence against women.

• teaching children how to care for their physical, mental, and sexual health and
howto prevent common illnesses.

• working to change the image that a strong man is one who has sex with many

women. A strong man is a strong partner.

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Where Women Have No Doctor 2010

Working for Change | 5

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.

In Zimbabwe, the Musasa Project was created to help women who suffered from
violence, particularly violence in the home and sexual assault. Musasa found that
women who were beaten by their partners were not protected by the law. Many
people said that men should have power over women because that was the way it
had always been, or because it was part of their community’s beliefs. These people
also said that regular beatings reminded women of their ‘place’.

Musasa’s goal is to change this attitude
through public education and by counseling
those who have survived violence. In
this way, women, men, teachers, students,
police, and health workers are learning
that violence is an abuse of power. Musasa
plans to set up a house where women and
children can stay when they are in danger.

starting a support
group

• 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.

In a tiny Mayan village in
Guatemala, a group of women
formed a weaving group. They
sold their weavings through a
cooperative store for women’s
crafts in the capital city. The
women now earn more income
than most of the men in their
area. As a result, women have
gained new status in their families
and communities and have more
opportunities in their lives.

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Where Women Have No Doctor 2010

16 Women’s Health Is a Community Issue

community sanitation

• 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.

The Green Belt movement in Kenya has involved many women in planting and
protecting trees, which prevent soil erosion and provide fuel. The women’s success
at protecting the environment and providing fuel for their families has built their
confidence and helped them earn a living.

As one Green Belt member said, “Our forests were
running out because of our constant need for firewood.

We meet weekly to collect seeds, to do potting
and fencing, and tend the trees in
our nursery. We also talk to
groups and schools about the
environment. In this way, we
are both helping ourselves and
bettering the environment.”

Many women’s
health problems
could be
prevented or
treated early
if more health
workers were
trained to care
for women’s
health.

Simple and low-cost community efforts can make a difference

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 (see page 394).

• 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 (see page 101).

• 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 (see page 375).

• 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 howto use medicines
for women’s health.

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Working for Change | 7

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.

Many women and men are struggling to get their governments to:

• equip rural clinics and train health workers to treat common women’s health
problems. This way, rural women will not be forced to go to urban hospitals
for care.

• pay for people — especially women — from poor areas to get health training.
That way there will not be such a shortage of trained health workers.

• keep companies from damaging the environment and advertising products that
harm people’s health.

• force companies to
provide fair working
conditions and
decent wages for
women and men.

• make it easier for
people to grow
food for their
communities, not
for export.

• distribute unused
land to those who
have been forced
from their land.

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.

* I lTtA.4 Slit «r

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18 Solving Health Problems

Chapter 2

In this chapter:

Juanita’s Story 20

What is the problem? 20

Some illnesses are hard to tell apart 2 1

What is causing the problem? 2 1

What Is the Best Treatment 22

Is a treatment helpful or harmful? 22

Risks and benefits 24

Working for Change 26

Looking for the root causes of health problems 26

Organizing to solve community health problems 28

To the Health Worker 30

Helping women help themselves 30

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r

Where Women Have No Doctor 2010

19

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.

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.

>- 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.

www. nespcr121n.org

Where Women Have No Doctor 2010

)

20 Solving Health Problems

Juanita’s

Story

Step I : Start with
doubt. This means
admitting you do not
know the answer yet.

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.

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 Marfa del Carmen had used for pains
after childbirth. The local midwife had given Marfa 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 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 her; he
needed to learn as much about the illness as possible.

So he asked Juanita these questions:

Step 2: Find out as
much as possible about
the problem. Ask
questions like these:

When did you first notice
the problem?

What signs made you suspect
that something was wrong?

How often do you have these
signs? What are they like?

Have you ever had these signs
before , or has anyone in your
family or community had them
before?

Does anything make the signs
better or worse?

Where Women Have No Doctor 2010

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Juanita’s Story 21

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 infection (STI).

• an infection of the vagina that is not an STI.

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

• cancer of the cervix.

Step 3 :Think about all
the different illnesses
that could be causing
the signs.

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.

Step 4: Look for clues that
can tell you which answer
is most likely.

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

Step 5: Decide which
answer is probably
the right one.

What is causing the problem?

Infectious diseases are those that are spread from one person to another. They
can be spread through touching infected people or objects, or through the air or
water. The germs Don Pedro thinks are causing Juanita’s illness are spread through
sexual contact. But not all diseases spread from person to person.

Non-infectious diseases (not spread between people), may be caused by:

• something that goes wrong in the body, such as weak bones from aging.

• something that harms the body from the outside, such as lung problems from
breathing a lot of dust or smoke.

• something the body lacks, such as enough good food.

But illnesses rarely have just one cause. (To learn more about identifying other
causes, see page 26.) Different things contribute to whether a person is healthy
or sick, including a person’s beliefs and cultural traditions, conditions in the home
and surrounding environment, and the ways in which land, wealth and power are
distributed.

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Where Women Have No Doctor 2010

22 Solving Health Problems

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:

Every community has developed \
remedies for solving health
problems. Home remedies and
modern medicine can both be
helpful if practiced carefully and
correctly. But remember that
both home remedies and modern
medicines can be helpful, can be
harmless, and can also be harmful.

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.

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

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

Where Women Have No Doctor 20 1 0

What Is the Best Treatment? 23

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.

To decide if a treatment will be helpful, harmless, or harmful, learn all you can

about it first. If you are still unsure whether a treatment is harmless or harmful,

consider these things:

1. The more remedies there are for any one illness, the less likely it is that any
of them works.

2 . Foul or disgusting remedies are not likely to help — and are often harmful.

3 . Remedies that use animal or human waste do no good, and often cause
dangerous infections. Never use them.

4 . The more a remedy resembles the sickness it is said to cure, the more likely
that its benefits come only from the power of belief. For example, a red
plant will not necessarily stop bleeding.

5 . Methods that deny people food, exercise, or rest usually make them weaker,
not stronger.

6 . Methods that blame people for their problems usually add to their suffering
and pain.

too.

This helped
Maria del
Carmen, so it
may help you,

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24 Solving Health Problems

When Juanita felt satisfied that modern
medicines were the best treatment for
her health problem, Don Pedro gave
Juanita some pills called doxycycline and
ciprofloxacin and told her to come back
in a week, after she had taken them all. He
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.

Step 7: See if there is some
improvement. If there are
no results, start over again.

Step 6: Decide on the
best treatment. Always
remember to think
about possible risks and
benefits (see below).

Valeria agreed that Juanita had an STI. But because the
medicines had not helped, Valeria suspected that Juanita may
have a form of gonorrhea that is resistant to ciprofloxacin.
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 STI), and cancer.
She could also get newer, more effective medicines, if
needed.

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.

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.

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What Is the Best Treatment? 25

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:

Every treatment has risks and benefits. A risk is the chance
that something may cause harm. A benefit is the good that
something may bring. The best choice is to do something that
will cause the greatest benefit and the smallest risk.

It may help to think about scales you use to weigh food
in the market. Some things weigh more than others, and
many small things can weigh more than one big thing. The
same is true for risks and benefits. If the risks ‘weigh’ more
than the benefits, then the action is not worth doing.

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 STIs or
problems. They explained that
the medicine she had taken no longer
works in her country. They gave Juanita a
newer medicine for both her and her husband.

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26 Solving Health Problems

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:

Step 8: Look for the root
causes of the problem.

Why did Juanita get sick?

BUT WHY did she get
gonorrhea and chlamydia?

Q: BUT WHY did her husband
have gonorrhea and
chlamydia?

Q: BUT WHY did he have
sex with other people?

Q: BUT WHY was he
away from his
wife for so long?

From gonorrhea and chlamydia.

Because she was infected by her husband.

Because he had sex with other people.

A: Because men are taught that they do not

need to control their desire , and he was
away from his wife for a long time.

A: Because he does not have enough land to

feed his family and must work on the coast
for months at a time.

Q: BUT WHY does he
have so little land?

Q: Why else did

Juanita get
infected?

BUT WHY
won't
Juanita's
husband use
condoms?

Because most of the land is owned by big
landowners. (A long discussion follows
from this answer.)

Because her
husband won't use
condoms.

And so on.

Where Women Have No Doctor 2010

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Working for Change 27

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:

Step 9: It may help to
group the causes together
to think about what can
be done to address them.

This is a
nice list,
but what
can we do
about these
things?

^PHYS]CAL_^

. gonorrhea ijerms

° d co 3 - r es ista rit
germs

° Wtxoen's bodies <3 re
more susceptible
to STIs than
me its bodies,
especidy when
weakened by
many pregnancies

Political and

JXONOMlC

oiown is isolated,
50 men must
Op away -to work

o -foreign soldiers

at the coast

Spread drug'
resistant germ?
opo medicines -for

drug -resistant

gonorrhea or
laboratory for
testing in the

otovth is
isolated/ -far
a way -from

the cify

o road is in
poor Condition

^OCIaL^

c-men often
have other
sex partners

»men won't use
condoms becdost,
"it's not manly"

• lack of educatioi
about 5 T|>

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Where Women Have No Doctor 2010

28 Solving Health Problems

Organizing to solve community health problems

Step 1 0: Decide which
causes you and your
community can change.

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.

Step 1 1 : Decide what
actions can make those
changes happen.

After a lot of discussion, the women decided they would
probably not be able to change the fact that the men had
to go away for work — or even keep them from having sex
with other women. But they thought they might get their
husbands to use condoms if the men knew more about

STIs, and if condoms were not so expensive. The actions
they decided to take were:

Let's ask Don Pedro to talk
with the men about STIs ,
since they respect him and
listen to him.

Let's all meet together
to practice talking with
our husbands about
using condoms.

I'll see if the
health center
can give out
free condoms.

Other members of the group suggested these actions:

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

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

• Talk to their sons about STIs before they leave the village to
go to the coast.

Step 1 2: Make a plan for
carrying out the actions.

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?

Cause: Men do not use condoms*

Action: Help me/i I earn about tow STjs are sp read.

Wl^/^ho: Don lldro Will talk do The. men about THs and
tow condoms prevent the spread of STI s.

When: When the men return Tom the coast
What materials do we need ? Condoms.

Who is responsible? Juanita will ask Don ftdro .

How will we evaluate? If men b*jin to use condoms.

Where Women Have No Doctor 2010

When are we going to do
these things?

Who will we do them with?

• Who is responsible
for making sure
that the plan is
carried out?

* How will we
know if the plan is
working?

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Working for Change 29

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.

The Steps

Juanita’s Story

1 . Start with doubt.

1. Don Pedro did not know what caused the problem. He

needed more information.

2. Find out as much as possible

2. Don Pedro asked Juanita questions to find out what could

about the problem.

have caused the problem.

Ask questions.

3. Think about all the different

3. Don Pedro thought about all the illnesses with these

illnesses that could be causing

signs : an STI, another kind of vaginal infection, or cancer.

the signs.

4. Look for clues that can tell you

4. Don Pedro tried to find out if an STI could have caused

which answer is most likely.

Juanita's illness.

5. Decide which answer is

5. Don Pedro decided Juanita probably had an STI.

probably the right one.

6. Decide on the best treatment.

6. Don Pedro did not know which germs caused Juanita's

infection, so he chose a treatment that works for several

STIs.

1. If there are no results,

1. Juanita took the pills but did not improve and developed

start over again.

new signs. So Don Pedro asked Valeria for help.

8. Look for the root causes

8. Juanita and her friends thought about the reasons why

of the problem.

there was this kind of sickness in their community,

such as poverty, unequal land ownership, the ways that

men and women were expected to act, and lack of

information.

9. Put the causes into groups to

9. The women put the causes into physical, environmental,

think about what can be done.

social, political, and economic groups.

1 0. Decide which causes you and

10. They decided to work on the “social" causes. They think

your community can change.

they can get their partners to use condoms.

1 1. Decide what actions can

1 1. The women decided to practice how to talk to their

make those changes happen.

partners about using condoms, to see if the health

center will give out free condoms, and to ask Don Pedro

to talk with their partners about STIs.

12. Make a plan for carrying out

12. They made a plan for each action they decided to take.

the actions.

Where Women Have No Doctor 2010

30 Solving Health Problems

To the
Health
Worker

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

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.

• 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.

What we have
discussed is
private. I will not
tell anyone else.

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.

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
already knows some of the answers to her problem.

Where Women Have No Doctor 20 1 0

i Ait ~-

www.nesperian.org

To the Health Worker 3 I

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.

• 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.

Iron is found in
hemoglobin , mioglobin }
and different enzymes.
During their fertile
years women need
18 mg. daily to fill
the needs created
by menstruation ,
pregnancy , and
breastfeeding.

A/hy do so many^\
women bleed to
death during birth?

One reason is
anemia. Many women
do not eat enough
foods rich in iron ,
like meat.

But meat
costs so
much. What
other ways
can we get
enough
iron?

• 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!

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Where Women Have No Doctor 2010

32 The Medical System

Chapter 3

In this chapter:

The Medical System 34

Important health services 34

How to Get Better Care 36

Know what to expect 36

Bring a friend or family member 37

If You Need to Go to the Hospital 38

Working for Change 40

Lore

Where Women Have No Doctor 2010

www. Hesperian

33

Most areas of the world have several different kinds of health
care. For example, there are community health workers,
midwives and traditional healers, doctors and nurses. They
might work in their own homes, in clinics or health centers, or
in hospitals. 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.
Together they are called the medical system.

Most people use some combination of modern medicine and
traditional remedies to treat their health problems themselves.
This is often all they need to do. But sometimes they need to
seek care from the medical system.

Unfortunately, many women have problems getting good
health care. They may not have enough money to visit a clinic
or buy medicine. Or maybe there are no health workers in
their community. Even if women can go to a clinic, it can be difficult
to talk with health workers about their problems. Sometimes
the clinic or hospital does not offer the services they need.

This chapter gives some ideas about how women can get
better health advice and better medical care. It also suggests
ways that women can work together to change the medical
system so that it better responds to their needs.

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>* When trained
promoters give basic
health care in the
community, everyone
gets better care for
less money.

Solving Health
Problems

Where Women Have No Doctor 2010

34 The Medical System

The Medical
System

health promoters
and nurses

doctors and
nurses

InODOQO

00

OOOQQO

na

1 ao non o

00

onoooo

an,

] HOSPITAL |

FFlfl

nl

health promoter

doctors, nurses,
and specialists

Not all communities have all levels of medical services. However, whatever
the combination of services available, women ( and any other sick people)
will receive better care if there are good links between them.

Important health services

The medical system offers many different kinds of services.
Some services, like surgery, x-rays or ultrasounds (see page 37)
are usually only available in hospitals. But the following services
that women need should be offered at low cost at the
community level:

• health information so that everyone can make better
decisions about their health, treat health problems correctly,
and prevent illness.

• 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 sexually transmitted
infections (STIs), including HIV.

Tests can give more information about possible causes of
health problems. Some tests, like Pap tests for example, require
some training but no expensive equipment. These tests should
be offered at the community level. Some health centers have
laboratories with the equipment needed to get the results of
different tests. However, often a woman will need to go to a
hospital to be tested.

Other services are only available in hospitals. If a woman has
a serious illness, complications from childbirth or abortion, or if
she needs an operation, she will probably have to go to a hospital.

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Where Women Have No Doctor 2010

The Medical System 35

No matter where you go for health care, you should be treated with respect.

All people who care for your health should do their best to provide you with:

1. Access. Everyone who needs medical care should be able to have it. It
should not matter where you live, how much money you have, what your
religion is, how much status you have in the community, the color of your
skin, your political beliefs, or what health problem you have.

2. Information. You should be told about your problem and about what the
different possible treatments mean for you. The person caring for you
should make sure you understand what you need to do to get better, and
howto prevent the problem from happening again.

3. Choice. You should be able to choose whether or not you are treated,
and how. Also, you should be able to choose where to go for treatment.

4. Safety. You should be given the information you need to avoid harmful
side effects or results of treatment. You should also be told how to
prevent dangerous health problems in the future.

5. Respect. You should always be treated with respect and courtesy.

6. Privacy. Things that you say to a doctor, nurse or other health care worker
should not be overheard by others or repeated to anyone else. Exams
should be given in a way that other people cannot see your body. If there
are other people who need to be in the room, you should be told who
they are and why they are there. You have the right to tell them to leave if
you do not want them there.

7. Comfort. You should be made as comfortable as
possible during an exam. You should also have a
good place to wait and not have to wait too long.

8. Follow-up care. If you need more care, you
should be able to go back to the same
person, or be given a written record of
the care you have received to take to
a new doctor, nurse, or health worker.

Can I come back
if I don’t get
better soon?

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Where Women Have No Doctor 2010

36 The Medical System

How to
Get Better
Care

risks and benefits of
treatment

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

T here 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.

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.

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:

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.

• What will the treatment do?
Are there any dangers?

• Will I be cared? Or will the
problem come back?

• How much will the tests and
treatment cost?

Where Women Have No Doctor 20 1 0

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How to Get Better Care 37

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.

pelvic exam

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 infections (STIs).

• scraping cells from the opening of your womb ( cervix ) to
test for cancer. (This is called a Pap test. See page 378.)

ultrasound machine

• 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.

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.

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

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.

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.

I am her mother.

I can answer some
of your questions.

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

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Where Women Have No Doctor 2010

38 The Medical System

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.

Common operations for women

An operation is sometimes the only answer to a serious health problem.

During many operations, a doctor makes a cut in the skin in order to fix problems
inside the body or to change the way the body functions. Here are some of the
operations women commonly have:

• Emptying the womb by either scraping or suctioning (D and C, or MVA, see
page 244). Sometimes the lining of the womb must be removed — either
during or after an abortion or miscarriage, or to find the cause of abnormal
bleeding from the vagina.

• Birth by operation (cesarean section or c-section). When complications
make it dangerous for a woman or her baby to go through normal labor and
birth, a cut is made in a woman’s belly so her baby can be born. C-sections
can be necessary, but too often they are done for the benefit of the doctor,
not the woman. See the chapter on “Pregnancy.”

• Sterilization. During this operation, a woman’s fallopian tubes are cut and the
ends tied. This prevents her eggs from reaching the womb, so a man’s sperm
will not be able to make her pregnant (see page 223).

• Removing the womb (hysterectomy). A hysterectomy is a serious operation,
so it should be done only when there is no better way to solve your health
problem (see page 38 1 ). Ask if you can have your ovaries left in.

If You Need
to Go to the
Hospital

Operations are
sometimes done
when they are
not necessary , or
when a medicine
could have worked
just as well. Get
another medical
opinion if you are
not sure.

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Where Women Have No Doctor 2010

If You Need to Go to the Hospital 39

Blood transfusions

A blood transfusion may be given in an emergency, when you have lost a lot of
blood. It can save your life. But if the blood has not been tested properly, it can
carry diseases, such as hepatitis or HIV, that are spread through the blood. Avoid
blood transfusions except in cases of life or death emergencies.

If you must have an operation that you know about ahead of time, see if it is
possible to have some of your own blood taken in advance and stored at the
hospital. Then if you need it, you will get your own blood back. If you cannot have
your own blood stored, ask a friend or relative to come with you to the
hospital. Be sure she has been tested recently for hepatitis and HIV,
and that neither she nor her partner has had a new sex partner in
the last 3 months. Her blood must also be tested to make sure that
it will work in your body.

If you must receive blood from an unknown person
and the hospital does not test its blood for HIV, there
is a risk that you might become infected. After the
transfusion, protect your partner by practicing safer
sex for 3 months and then try to get tested for HIV.

For more information, see the chapters on “HIV” and
“Sexual Health.”

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 I 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?

Eat soft, mild foods that are easy to digest.

[}))

Y "

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

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.

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Where Women Have No Doctor 2010

40 The Medical System

Working
for Change

M illions 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.

I live very far away.

If there were a health
worker close by, it would
save my family the
2 weeks wages I spend
every time I have to come.

These city^\
doctors look A
down on us.

I would feel
better if
people from
the village
helped run
the clinic.

I wish they
explained what
was wrong. This
is the 4th time
this year Tve
had pain when I
passed urine. Why
does this keep
happening?

I wish they\
could give
us Pap
tests here.
Tve heard
they are
important ,
but I can't
afford to go
to the city. J

(iwishthey didn't run out of
family planning supplies. I got
pregnant last year because the
I clinic ran out , and I can't afford
to buy a lot all at once when they
V do have them.

n want there to be

separate rooms
where we could be
examined without
everyone listening.

r ; ^

| I would like the clinic
I to be open in the

evenings , after I have
( finished my work.

I don't like
having a man
examine me. I
wish there were
women health
workers.

Where Women Have No Doctor 2010

There is always
such a long wait.
If someone asked
right away what
each person
needed then the
really sick people
could be treated
sooner.

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Working for Change 4 1

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.

• 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.

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Where Women Have No Doctor 2010

42 Understanding Our Bodies

Chapter 4

In this chapter:

A Woman’s Reproductive System 44

The reproductive parts on the outside 44

The breasts 45

The reproductive parts on the inside 45

A Man’s Reproductive System 46

Having a baby — will it be a boy or a girl? 46

How a Woman’s Body Changes 47

Hormones 47

Monthly Bleeding 48

The monthly cycle (menstrual cycle) 48

Problems with monthly bleeding 50

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.

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43

Understanding Our Bodies

Every woman
changes from a
girl into a woman..

Puberty

...and then from
a woman into an
older woman.

Reproductive

years

hip bones

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.

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’.

You can feel your hip 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.

>• 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.

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.

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44 Understanding Our Bodies

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’.

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.

T HE REPRODUCTIVE PARTS ON THE OUTSIDE

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

Outer folds: The fatty lips
that close up when the legs
are together. They protect
the inner parts.

Inner folds: These
flaps of skin are soft,
without hair, and are
sensitive to touch.

During sex, the inner
lips swell and turn
darker.

Vaginal opening: The '

opening of the vagina.

Hymen: The thin piece of
skin just inside the vaginal opening.

A hymen may stretch or tear and
bleed a little because of hard work,
sports or other activities. This can also
happen when a woman has sex for
the first time. All hymens are different.
Some women do not have a hymen
at all.

Anus: The opening of
the intestine, where waste
( stool j leaves the body.
The anus connects to the
rectum (the lower part of
the intestine).

Mons: The hairy, fatty
part of the vulva.

Clitoris: The clitoris is
small and shaped like
a fower bud. It is the
part of the vulva that is
most sensitive to touch.
Rubbing it, and the area
around it, can make a
woman sexually excited
and cause climax.

Urinary opening:

The outer opening of
the urethra. The urethra
is a short tube that carries
urine from where it is
stored in the bladder to
the outside of the body.

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Where Women Have No Doctor 2010

A Woman’s Reproductive System 45

T HE 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:

Glands make the milk.

Ducts carry the milk to the nipple.

Sinuses store the milk until the baby drinks it.

The nipple is where milk comes out
' of the breast. Sometimes they stick out.
Sometimes they are fat.

The areola is the dark and bumpy skin around
the nipple. The bumps make an oil that keeps the
nipples clean and soft.

The reproductive parts on the inside

Ovaries: The ovaries
release one egg into a
woman’s fallopian tubes
each month. When a man’s
sperm joins the egg , it can
develop into a baby. A
woman has 2 ovaries, one
on each side of the
womb. Each ovary is
about the size of an
almond or grape.

Cervix: This is the
opening or ‘mouth’
of the womb, where
it opens into the
vagina. Sperm can
enter the womb
through the small
hole in the cervix, but
it protects the womb
from other things, like
a man’s penis. During
childbirth, the cervix
opens to let the baby
come out.

Fallopian tubes: The fallopian tubes connect the womb
with the ovaries. When an ovary releases an egg, it
travels through the fallopian tubes into the womb.

Womb (uterus): The
womb is a hollow muscle.
Monthly bleeding comes
from the womb. The
baby grows here during
pregnancy.

Vagina or birth
canal: The vagina
leads from the vulva
to the womb. The
vagina is made of a
special kind of skin
that stretches easily
during sex and
when giving birth.
The vagina makes
a fluid or wetness
(discharge) that
helps it keep itself
clean and prevents
infection.

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46 Understanding Our Bodies

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.

The testicles also make a
man’s sperm. A man begins
to produce sperm during
puberty, and makes more
every day of his life.

Sperm travel from the
testicles through a tube in the
penis where they mix with
a liquid produced by special

glands.

This mixture of liquid and
sperm is called semen. The
semen comes out of the penis
when a man climaxes during
sex. Each drop of semen has
thousands of sperm which are
too small to see.

Having a baby — will it be a boy or a girl?

About half of a man’s sperm will
produce a baby boy and the other half
will produce a girl. 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!

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How a Woman's Body Changes 47

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.

How a
Woman’s
Body
Changes

puberty, 54
monthly bleeding, 48
menopause, 124

Hormones

Hormones are chemicals the body makes that control how and when the body
grows. A little while before a girl’s monthly bleeding first starts, her body begins
to produce more estrogen and progesterone, the main female hormones. These
hormones cause the changes in her body known as puberty.

During the years when she can have a baby, hormones cause a woman’s body
to prepare for possible pregnancy each month. They also tell her ovaries when to
release an egg (one egg every month). So hormones determine when a woman
can get pregnant. Many family planning methods work to prevent pregnancy by
controlling the hormones in a woman’s body (see page 207). Hormones also
cause changes during pregnancy and breastfeeding. For example, hormones keep
a pregnant woman from having her monthly bleeding, and after childbirth they also
tell the breasts to make milk.

When a woman is near the end of her reproductive years, her body slowly
stops producing estrogen and progesterone. Her ovaries stop releasing eggs, her
body stops preparing for a pregnancy, and her monthly bleeding stops forever. This
is called menopause.

The amount and kind of hormones produced by a woman’s body can also affect
her moods, sexual feelings, weight, body temperature, hunger, and bone strength.

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48 Understanding Our Bodies

Monthly

Bleeding

Around the world,

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.

women have many

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.

T HE 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.

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Monthly Bleeding 49

About 1 4 days before the end 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 last 14 days 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.

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.

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

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50 Understanding Our Bodies

abnormal bleeding, 359
growing older, 1 23

Pressing hard on the
tender place between
your thumb and first
fnger can ease many
kinds of pain. For
other places where
pressure can ease pain
from monthly bleeding,
see page 546.

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.

Women who use hormonal family planning methods
sometimes have bleeding in the middle of the month. See
pages 207 to 215 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.

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 (see page 482).

• If you also have heavy bleeding and nothing else works,
taking a low-dose birth control pill for 6 to 1 2 months may
help (see page 208).

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Monthly Bleeding 5 I

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

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 (see page 50).

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.

www. nesperian . o r g

Exercise can
sometimes
help with the
signs of PMS.

Where Women Have No Doctor 2010

52 Health Concerns of Girls

Chapter 5

In this chapter:

Changes in Your Body (Puberty) 54

Monthly bleeding (period, menstruation) 55

Changes that Can Lead to a Better Life 56

Deciding about Boyfriends and Sex 59

Protecting yourself if you are ready for sex 6 1

Pressured or Forced Sex 62

Pressure to have sex with a boyfriend 62

If someone in your family tries to have sex with you 63

Young girls and older men 63

Trading girls for money or other needs 64

If you get pregnant and did not plan to 64

Getting Help from Adults 65

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53

Sometime between the ages of 1 0 and 1 5, 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.

Eating for healthy growth

One of the most important things a girl can
do to stay healthy is to eat well. Her body
needs to get enough protein, vitamins, and
minerals during her years of growth. A girl
needs at least as much food as a boy. Getting
enough to eat leads to less sickness and more
success in school, healthier pregnancies, safer
births, and a healthier old age.

Girls who get enough to
eat do better in school.

Girls also need the right kinds of food.

When a girl begins her monthly bleeding she

will lose some blood each month. To prevent weak blood (anemia), she will
need to replace the lost blood by eating foods with iron in them. Also, girls and
women both need foods with calcium to help their bones grow strong. For more
information on eating well, see page I 65.

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54 Health Concerns of Girls

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 I 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.

How a girl’s body changes in puberty

• You grow taller and rounder.

• Your face gets oily and pimples
or spots may grow.

• You sweat more.

• Hair grows under your arms
and on your genitals.

• Your breasts grow as they
become able to make milk. As
they get larger, it is common
for the nipples to hurt
sometimes. One breast may
begin to grow before the other,
but the smaller breast almost
always catches up.

• Wetness (discharge) starts to
come out of your vagina.

• Your monthly bleeding starts

(menstruation).

understanding our
bodies

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

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

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.

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Changes in Your Body (Puberty) 55

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.

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
3 times each day. Leaving one in longer may cause a serious
infection.

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.

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monthly bleeding

Where Women Have No Doctor 2010

56 Health Concerns of Girls

Changes
that Can
Lead to a
Better Life

low status of women

r he way a woman sees herself forms as she grows. It is
important that a girl learn 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 boys.

But if a girl's community recognizes the value of each
person — whether the person is male or female — she will grow
up feeling she can make a better life for herself and for her
family and neighbors.

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.

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.

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Changes that Can Lead to a Better Life 57

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.

Try to plan your future. The first thing you
can do to plan for your future is to set
goals. A goal is something you would
like to happen. For most girls this
is not easy. Many feel their lives
are controlled by their families
or the traditions of their
communities. But you can
start to help yourself by
knowing what you want.

Next, try to talk to
a woman or man
who works at
something you
would like to
do. It could be
someone you
admire,
or a
leader

in your

community. Ask
if you can spend time
with that person to learn
more about their work.

Sometimes girls feel frustrated because their dreams and hopes for their future
may conflict with the beliefs in their community and family about what a woman
should do. It is important to explain your dreams and hopes carefully to adults and
to listen to their concerns also. See page 65 for ideas about how to communicate
with your family.

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58 Health Concerns of Girls

Decisions for a better future

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

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 better support yourself and your family.
Learning new skills can help you have more choices in your life.

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?

Parents and girls can work together to organize ways for girls to learn about how
the body works, sexuality and prevention of early pregnancy. This can be done at
home, and programs can be held in schools, community meeting places, or places
of worship.

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Deciding about Boyfriends and Sex 59

Most young people 0r

begin to have loving or f%

sexual feelings as they /kw

get older. Thinking about Syj

touching or being touched in

by someone in a sexual ft j

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

Young women have sex for many c
reasons. Some do it because they wj
have a baby. Others do it because it
them feel good or wanted. Some wc
feel they have very little choice because

it is their duty as a wife or girlfriend. Some 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.

Others have sex because they think it will make someone
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, or have not given consent.

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 Infections,” “HIV,” and “Sexual Health.”

Deciding
about
Boyfriends
and Sex

V Only hove 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.

Health risks of early pregnancy

Most girls' bodies are not ready for a safe and healthy birth. Young women
are more likely to develop eclampsia (which causes seizures, “fits”) during
pregnancy. Because their bodies may still be too small for a baby to come out,
mothers under age 1 7 are more likely to have long, difficult labors, and blocked
births. Without medical help, a woman with any of these problems can die.
Blocked births can also damage the vagina, causing urine and stool to leak (see
page 370). Babies born to girls younger than 17 are more likely to be born too
small or too soon. If you are already pregnant, try to see a trained midwife or
health worker as soon as possible to find out how to have the safest birth. For
more information, see page 72.

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60 Health Concerns of Girls

What girls should know about having sex

You can get pregnant the first time you have sex.

You can get pregnant any time you have sex without a
family planning method (even if it is only once).

You can get pregnant even if the man thinks he did not let
his seed (sperm) come out.

You can get an STI or HIV if you do not use a condom
when you have sex with an infected person. And you
cannot tell by looking at a person if he is infected.

It is easier for a girl to get a sexually transmitted infection
(STI) or HIV from a boy or man than it is for her to give
these diseases to him. This is because of the way sex
works — because she is the ‘receiver’. It is also harder to
know if a girl has an infection, because it is inside her body.

Always use a condom for protection against STIs and HIV. But the most
certain way to avoid pregnancy, STIs, and HIV is to not have sex.

pressure to have sex

Having a relationship with no sex

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.

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’.

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Deciding about Boyfriends and Sex £ I

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

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.

Since you cannot tell by looking
if a man has a sexually transmitted
infection or HIV, 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!

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 STI. See the chapter on
“Sexually Transmitted Infections.”

family planning

safer sex

STIs

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62 Health Concerns of Girls

Pressured
or Forced
Sex

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

rape

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 may not only be physical.

You can feel pressure from words or feelings. He
may threaten you or 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.

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.”

• 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.

• 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.

atAi&til-

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Where Women Have No Doctor 2010

Pressured or Forced Sex 63

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.

rape

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.

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.

Don’t let Mr. Chifeve push you into it,
Tarisai. Remember Alice? He got her
pregnant and she had to leave school. I
will help you tell Mama and Baba.

In many communities, more young women and girls are getting infected with
HIV than any other group of people. There is more risk for girls who have sex
with older men, because older men have usually had more chances to become
infected with HIV. But it can happen with a man of any age.

www.n6Sp6riRn.org

Where Women Have No Doctor 20 1 0

64 Health Concerns of Girls

sex workers

Trading girls for money or other needs

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.

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.

safe abortion

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.

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

Talk to someone older who you trust.

Your life is too valuable to lose.

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.

Where Women Have No Doctor 20 1 0

nespenan.org

Getting Help from Adults 65

r alking 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.

Ideas for better communication

• Choose a good time to talk, when your
parents are not busy, tired, or worried
about something else.

• Share your concerns, worries and goals
with them. Ask what they would do in

• Give them something to read or show
them a picture to get them started talking.
You can read a part of this book together
if it is related to your problem.

• If you get angry, try not to shout. You can make your parents angry and they
may think you do not respect them.

• If you have tried these things and you still cannot talk to your parents, find
another older person you can talk to. It could be a teacher, the mother of a
friend, an aunt, an older sister; grandmother, someone in your place of worship,
or a health worker.

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.

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Getting
Help From
Adults

Where Women Have No Doctor 2010

66 Pregnancy and Childbirth

Chapter 6

In this chapter:

Staying Healthy during Pregnancy 68

Common Problems during Pregnancy 69

Risks and Danger Signs during Pregnancy 72

Prenatal Care (Check-ups during Pregnancy) 76

Preparing for Labor and Birth 78

Giving Birth 80

Signs that labor is near 80

The 3 stages of labor 80

Danger signs during labor 85

Difficult Births 88

Danger Signs for the Baby at Birth 94

Caring for the Mother and Baby after Birth 95

Women with Extra Needs 98

To the Father 1 00

Working for Change 1 0 1

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 Hesperian’s A Book for
Midwives (for how to order it, see the last page of this book).

Where Women Have No Doctor 20 1 0

1 ^iiObU<ytiL

www.nesperian.orc

67

Pregnancy

and

Childbirth

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.

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

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

— Mixtec saying,
Mexico

• 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 wi
probably be born any time in the 2 weeks before
or after this date.

o

o

o

o

o

o

o

o

o

o

Many women know
when their baby will
be born by counting
the passing of
1 0 moons.

WWW.

Where Women Have No Doctor 2010

68 Pregnancy and Childbirth

Staying

Healthy

during

Pregnancy

eating for good health

prenatal care

>- Read about the
‘Danger signs during
pregnancy’, starting
on page 73, to learn
when it is important
to see a health
worker,

STIs

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

If you 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 so your baby will not suffer from mental slowness.

• Sleep and rest more. If you work

standing up, try to sit or lie down Do your
several times during the day. daily work...

• 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 (see page 161).

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

• Practice squeezing exercises, so your vagina will be stronger
after the birth (see page 371).

• 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
infection (STI) or other infection.

• Get tested for HIV. Prevent HIV infection during pregnancy
by using condoms when you have sexual intercourse.

• 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.

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Common Problems during Pregnancy 69

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)

Common

Problems

during

Pregnancy

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.

To help with morning sickness...

...try eating a biscuit, a tortilla, a piece of
bread, a chapati, or a little rice or porridge
when you wake up in the morning.

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 (see page 298).

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).

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.

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infections of the
genitals

Where Women Have No Doctor 2010

70 Pregnancy and Childbirth

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.

•t.

• 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.

What to do:

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

If you have

hemorrhoids, sitting in
cool water can help
with 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.

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Common Problems during Pregnancy 71

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.

What to do:

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

foods with calcium

If your foot or leg cramps:

Push
down on
your heel.

...and
f point
your toe
upward...

...then
gently
stroke your
leg to help
it relax.

DO NOT
point your
toe down.

It can make
the cramps
worse.

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.

lifting and carrying
heavy loads

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. See
page 74.

swelling of the hands
and face

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72 Pregnancy and Childbirth

Risks and

Danger

Signs

during

Pregnancy

health center

m

a

hospital

ill

i I

fill

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

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 birth, and they may need more
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. For more on anemia, see the next page.

• 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, seizures,
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 1 7 are more likely to have
eclampsia (which causes seizures), long, difficult labors, babies
born too early (premature), and blocked births, which may
damage the bladder, vagina, and womb (see page 370).

• Mothers who had problems with past pregnancies — such
as seizures, 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 (see page 145.)

• Women with HIV can take medicines to prevent passing
HIV to their babies (see page 520).

Other women who should try to give birth
at a health center or hospital

Some women — who have none of the extra risks listed above — are still likely to
have dangerous births. These women should also try to give birth at a health center
or hospital:

• A woman with a baby in the wrong position for birth at the end of pregnancy

(see page 75) can have a long, difficult labor. The mother, the baby, or both may die,

• Women carrying twins often have one baby in the wrong position for birth. Also,
these mothers are more likely to bleed after birth.

• Women who have their genitals cut can have severe tearing of the genitals during
the birth (see page 464). This can cause great pain, heavy blood loss, and infection.

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Risks and Danger Signs during Pregnancy 73

Danger signs during pregnancy

In addition to the problems just listed, these danger signs may occur during
pregnancy. A woman with any of these signs may be in serious danger and should
see a health worker. See the next few pages for more about them.

• feeling very weak • bleeding from • swelling of hands and face,

or tired the vagina or bad headache and blurred

• pain in the belly • fever eyesight

Feeling very weak or tired (anemia)

If you feel very weak or tired, you could be anemic
(see page 1 72). Women who are very anemic are much
more likely to have heavy bleeding after the baby is born.

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 I 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

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.

Signs of tubal pregnancy (ectopic pregnancy):

• missed monthly bleeding, and

• pain in the lower abdomen on one side, or

• slight bleeding from the vagina, or

• feeling dizzy, weak, or faint

What to do:

Go to the nearest hospital.

2. Strong pain that comes and goes (cramping) in the first

6 months could mean you are losing the pregnancy (having
a miscarriage ). See page 234.

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 (see page 75).

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foods rich in iron

tubal pregnancy

V Strong pain in
the abdomen does
not always mean
something is wrong
with a pregnancy. For
information about
other possible causes ,
see pages 353 to
357.

TRANSPORT!

Where Women Have No Doctor 2010

74 Pregnancy and Childbirth

miscarriage

TRANSPORT!

Bleeding from the vagina

1. Bleeding early in pregnancy. Light bleeding from the vagina
for a few days 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 (see page 73). If the bleeding gets
heavier and stronger than a normal monthly bleeding, you
are probably losing the pregnancy (having a miscarriage).

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.

166

foods rich in protein

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 (eclampsia)

Some swelling in the legs and ankles is normal in pregnancy.
But swelling of the hands and face can be a sign of eclampsia,
especially if you also have headaches, blurred vision, or pains in
your abdomen. Eclampsia can cause seizures, 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.

Danger signs of eclampsia

• swollen hands and face

• dizziness

• blood pressure 140/90 or

• severe headache

• severe pain high in

higher (see page 532)

• blurred vision

the stomach

TRANSPORT!

IMPORTANT

If a woman has any. of the danger signs of eclampsia ,
she needs medical help fast If she is already having seizures, see page 87.

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Where Women Have No Doctor 2010

Risks and Danger Signs during Pregnancy 75

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.

(Turn the page to learn howto check the baby’s position.)

>■ If the baby's head
is down , the birth is
more likely to go well.

Positions that cause difficult or dangerous births

Baby with buttocks
first (breech)

If the baby's head

is up, the birth may
be more difficult.

It may be safer for
the mother to give
birth in a hospital.

Baby lying sideways

If the baby is lying
sideways , the mother
should give birth in a
hospital. She and the
baby are in danger. A
baby that stays sideways
cannot be born without
an operation.

During the last month of
pregnancy, it may be possible
to change the baby’s position
by lying in this position for
1 0 minutes, 2 times a day:

Lie on the foor 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, see page 90.

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.

TRANSPORT!

If labor starts too early (before the 8th or 9th month)

Some babies born too early might not live. A woman may be able to slow or
stop labor by lying in bed with her hips raised, and resting until the labor stops (see
the picture above). If she can go to a hospital, they may be able to stop the labor.
Even if they cannot stop the labor, they can sometimes keep the baby alive. (Also
see page 94 for how to care for a baby born too early.)

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76 Pregnancy and Childbirth

Prenatal

Care

(Check-ups

during

Pregnancy)

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

P renatal 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. 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.

A midwife 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. 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
and birth defects.

• 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 (see page 161).

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

• give tests for HIV (see page 288) and syphilis, along with
other sexually transmitted infections (see page 261).

• give medicines to prevent a woman’s HIV from spreading to
her baby.

A birth attendant

Check the eyelids
and finger nails for
signs of anemia
(see page 1 72).

What to expect at a prenatal check-up

or midwife should do these things at a prenatal check-up:

• Check the growth of the baby in the
womb. Normally the womb will grow
2 fingers each month. At 4 Vi months
it is usually at the level of the navel. If
the womb seems too small or too big
or grows too fast, it may mean there is
Check the hands a problem,

and face for swelling
(see page 74).

Check weight,
urine, and
blood pressure
(see page 532).

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Prenatal Care (Check-ups during Pregnancy) 77

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.

Checking the baby’s position

During pregnancy, it is common for a baby to change position several times in
the womb. By the end of the pregnancy, the baby should be lying in the womb
with its head down. This is the best position for birth. To make sure the baby is
head down, feel for the head like this:

(

With the thumb
and 2 fingers,
push in here, __
just above the
pubic bone.

Have the mother
breathe out all
the way. Using
both hands, feel
the baby.

The baby’s bottom is
larger and wider...

...and its head is
harder and
more round.

2 . Push gently from side to side,
first with one hand, then with the
other. At the same time, feel what
happens to the baby’s body with
the other hand as you push.

If the baby’s
buttocks are pushed
gently sideways, the
baby’s whole body
will also move.

But if the head
is pushed gently
sideways, it will bend
at the neck and the
back will not move.

With the
other hand,
feel the top of
the womb.

So bottom up
feels larger
high up...

...and
bottom
down feels
larger low
down.

3 . Just before birth, a baby will move
lower in the womb to get ready for
birth. So, late in pregnancy, you may
not be able to feel the baby’s head
move.

If the baby is still high
in the womb, you can
move the head a little.

But if it has already
moved lower, you
cannot move it.

A woman’s first baby
sometimes moves lower about 2 weeks before
labor begins. Second or later babies often do
not do this until labor starts.

1 Ai ?T «-

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Where Women Have No Doctor 2010

78 Pregnancy and Childbirth

Preparing
for Labor
and Birth

>- 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.

Things to have ready before birth

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

alcohol

clean string

new razor blade

clean cloths

two bowls, one for
washing, one for
holding the afterbirth

These are some additional supplies a midwife or birth attendant may have:

i TL^=j)

flashlight

sterile
gloves or
plastic
bags

m

several
injections of
ergonovine,
ergometrine,
or oxytocin

HIV medicines
for mother and
baby if mother
has HIV

blunt-tipped scissors for
cutting the cord before the
baby is born all the way

sterile syringe
and needles

sterile needle and gut
thread for sewing tears
in the birth opening

tetracycline or
erythromycin ointment
for the baby’s eyes

suction bulb for
sucking mucus out
of the baby’s nose
and mouth

This is also the time to:

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

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clean the
birth place

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Preparing for Labor and Birth 79

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, reassure the mother
so that she will not be afraid. Remember that most babies are
born without problems. Stay calm and cheerful, and let her
know that you trust her ability to give birth.

• 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’ (see page 73). 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’ (page 85). Take the
woman to a hospital if she has any of these signs.

• Treat her with kindness and respect.

IMPORTANT

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

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.

preventing infection

>- For safe childbirth
practice the 3 cleans:

I. Clean hands

2 . Clean place to
give birth

3 . Clean tool to
cut the cord

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Where Women Have No Doctor 20 1 0

80 Pregnancy and Childbirth

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
1 0 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.

The 3 stages of labor

Every birth has these 3 parts.

Stage I 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 1 0 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 I, and
should not take more than about 2 hours.

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

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.rdllticAi&.it'l-

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r

The 3 stages of labor 8 1

Stage I: 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

1 0 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 1 0 minutes or faster for more than 1 2 hours and the
baby is not ready to be born, see Too long labor', page 86.

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’, page 85. If the waters are green
or brown, see ‘Green or brown waters’, page 86.

3. Is the baby in a head-down position? Feel the mother's
abdomen (see page 77). If the baby is sideways or breech,
you must take her to a health center or hospital.

too long labor, 86

waters break and
labor does not start, 85

green or brown
waters, 86

checking the baby’s
position, 77

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 (see page 82).

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

During labor, let the woman choose the most comfortable positions. For many
years, doctors and some midwives asked women to lie on their backs, but this
is often a difficult position for going through labor and giving birth. Encourage a
woman in labor to try different positions. Most women find it easier to push the
baby out when they are kneeling, squatting or sitting propped up.

Where Women Flave No Doctor 20 1 0

82 Pregnancy and Childbirth

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:

too-long labor

• 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,’ page 86.

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.

Vj|l/

Now push hard.

Now do not push hard.

The head usually comes

...then the baby turns so

out face down...

the shoulders can be born.

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.

nespenan.org

Where Women Have No Doctor 2010

The 3 stages of labor 83

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
(see page 86).

• 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.

To cut the cord:

I.

2 .

When the cord stops pulsing, put 2 clean ties around it, using square knots.
Put one tie about 2 finger widths from the baby and put the other one
about 2 more finger widths farther from the baby.

The first loop of
a square knot...

...the second loop of
a square knot.

Cut the cord between
these 2 ties with a new
razor blade. If you
must use something
else to cut the cord,
make sure it has been
boiled for 20 minutes.

Tie the cord in 2
places before cutting.
The chance of a
baby getting tetanus
is greater when the
cord is cut far from
its body.

IMPORTANT

To avoid tetanus and other infections , the cord and anything that touches
it must be very clean. Never put dirt or animal dung on the cord stump.

Care of the eyes

Gonorrhea can cause blindness.
Since many women do not know
they are infected, put \%
tetracycline, erythromycin, or
chloramphenicol eye ointment
in each of the baby’s eyes
within an hour of birth.

!(jf)rlU S+k *r

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

problems in
newborn babies

WWW.

Where Women Have No Doctor 2010

84 Pregnancy and Childbirth

Rolling the nipples
con help the womb
contract and stop
bleeding.

Stage 3: The placenta comes out

When the baby is wrapped and at the mother's breast, it is
time for the placenta to come out.

Watch the vagina to see when the cord gets longer. This
means the placenta is separating from the womb. Also watch
to make sure there is no heavy bleeding. When the cord
lengthens, tell the mother to push out the placenta. Do not
pull on the cord.

If the placenta does not come out right away and there is
no bleeding, it is OK to wait up to I hour.

To help the placenta come out:

• Have the mother squat and push. If she cannot push, have
her blow into a bottle, sneeze, or cough.

• Ask the mother to pass urine.

• Encourage the baby to nurse, or have someone roll the
mother’s nipples. This will help make her womb contract.

• If nothing else works, give her an injection of 10 milligrams
of oxytocin in her buttock or thigh.

• If the mother starts to bleed, see page 92.

>■ When the placenta
is out, put it in a bowl
and check it to make
sure it is all there.

too much bleeding

Check the placenta

Usually the placenta comes
out whole, but sometimes a
piece gets left inside. This
could cause bleeding or
infection later To see if
everything has come
out, check the top and
bottom of the placenta,
and the membranes from
the bag of waters.

If the mother is bleeding, or there seems to be a piece of
the placenta or membranes missing, follow the instructions on
page 92 for too much bleeding.

Danger signs during labor 85

Danger signs during

LABOR

• waters break but

• bleeding before the

• green or brown waters

labor does not start

baby is born

• fever

• baby lying sideways

• too long labor

• convulsions or “fits”

Waters break but labor does not start

Most women will give birth within 24 hours after their
waters break. If labor has not started after 1 2 hours, the
woman and her baby could get a serious infection.

What to do:

• The mother must not put anything in her vagina. She
should not have sex. This could cause an infection.

• If she has a fever or there is a bad smell in the vagina, an
infection is starting. She needs intravenous (IV) antibiotics.
Even if labor starts, the woman and her baby could die.

Go to a health center or hospital.

• Try to get labor started. The woman should swallow
2 tablespoons of castor oil, roll her nipples, or have
someone suck them for a while every few hours until labor
starts. There may also be special local teas that women use
to start labor. If labor still does not start after a few more
hours, she should go to a health center or hospital.

DANGER!! Do

not use injections
to start labor.

They can cause
contractions that
are so strong that
they can kill the
woman or the baby.

TRANSPORT!

A

OIL

&

Baby lying sideways (transverse)

If labor has started and the baby’s arm comes out
first, it almost always means the baby is sideways.
Check the baby’s position (see pages 75 and 77).

A baby lying sideways cannot be born without an
operation. Do not try to change the position of the
baby once labor has started. This can tear the womb
or separate the placenta from the womb wall.

What to do:

Take the mother to the hospital.

Bleeding before the baby is born

Some light, pink-colored fluid, or mucus and brown blood
during labor is normal. But if the mother is bleeding bright red
blood, it could mean that the placenta is separating from the
womb wall or is covering the opening of the womb. This is
very dangerous.

What to do:

Take the mother to the hospital right away. If possible, start
an IV and give her IV fluids.

I I if (I r ~-

TRANSPORT!

WWW.

Where Women Have No Doctor 20 1 0

86 Pregnancy and Childbirth

should not see the
sun rise twice.

— Proverb from Niger

TRANSPORT!

TRANSPORT!

>- A woman who
is only a little warm
may just need to
drink more fluids.

TRANSPORT!

Too-long labor

If the mother has been in good strong labor for more than
1 2 hours, or she has been pushing for more than 2 hours without
any signs that the baby will be born soon, there may be a problem.

What to do:

If her contractions are not coming every 2 or 3 minutes
and lasting for a full minute, she may not be in good labor
yet. Encourage her to sleep. If she cannot sleep, ask her to
roll her nipples and walk between contractions to help labor
get stronger. Encourage her to drink and eat light foods. Fruit
juices or tea with sugar can give her energy.

If the mother has been in labor for more than I 2 hours, or
has been pushing for more than I hour; take her to a health
center or hospital. She may need medicines to help her labor
or an operation for the baby to be born.

Green or brown waters

Brown or green waters can mean that the baby is in trouble.

What to do:

If it is still early in labor or if the mother has not started
pushing, it is best for this baby to be born in a hospital.

If the mother is in Stage 2 of labor and the baby is
going to be born soon, have the mother push as hard
as she can and get the baby out quickly. As soon as
the baby’s head is born, wipe its mouth and nose with
a clean cloth or use a suction bulb to suck the
mucus out. Keep the baby’s head lower than its
body to help the mucus come out. If the baby
has difficulty breathing, take it to a hospital.

Fever

Fever is usually a sign of infection.

What to do:

Touch the woman's forehead with the back of one of your
hands, and touch your own forehead with your other hand.

(See page 530 for taking temperature with a thermometer if you
have one.) If she feels a little warmer than you, she may just
need fluids. Give her plenty of water, tea, juice, or soda pop.
Remind her to pass urine every few hours.

If she feels very hot to touch and she has chills, take her to a
health center or hospital. She needs antibiotics right away. Give
ampicillin, 500 mg by mouth every 6 hours, or inject 1 .2 million
Units of procaine penicillin into her buttock or thigh, every 12
hours until you can get to a hospital.

Where Women Have No Doctor 20 1 0

www. nesperia.n.orc

Danger signs during labor 87

Seizures (“fits”), or very swollen hands and face
(eclampsia)

If the mother starts to have a seizure (“fit”):

• Put something under
…[truncated]

Summary: Where Women  Have No Doctor    A health guide for women    A. August Burns  Ronnie Lovich  Jane Maxwell  Katharine Shapiro   Editor: Sandy Niemann  Assistant editor: Elena Metcalf    Hesperian   Berkeley, California, USA      WWW     enan.org    Hesperian Foundation and the contributors to WhereWomen Have No Doctor  do not assume liability for the use of information contained in this book. This book  should not replace properly supervised, hands-on training. If you are not sure what to  do in…

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