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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 2 The Context of Mortality and Morbidity THE IMPORTANCE OF CONTEXT In 1965, microbiologist Rene Dubos commented that "the prevalence and severity of microbial diseases are conditioned more by the ways of life of people than they are by the virulence of specific etiologic agents." The same can be said of the "nonmicrobial" diseases and the growing variety of environmental hazards. It is their "ways of life," then, that explain at least part of the morbidity and mortality of populations in given geographic and social settings. For women, health as a state of total well-being is "not determined solely by biological factors and reproduction, but also by effects of workload, nutrition, stress, war and migration, among others" (van der Kwaak, 1991). In this context, mortality and morbidity are indicators of what nations are prepared to do to affect the various dimensions of the human environment, their willingness to extend and improve the quality of life of their people by applying the resources required for longer and healthier survival—education, food, health care, jobs, and security —and to ensure equitable participation in the economic, political, cultural, and social processes that affect their lives (Sen, 1993; UNDP, 1993; World Bank, 1993). From this perspective, even though physical health is just one component of human development, it is an essential function of the development process (UNDP, 1991). As is the case everywhere, female health, ill-health, and mortality in Sub-Saharan Africa unfold within, and are shaped by, their sociocultural, economic, and political contexts. These are horizontal and vertical: families, communities, and networks of extended kinship are embedded in regional, national, and international hierarchies and relationships. All of these affect and are affected by one another, and all have implications for human well-being. A pivotal aspect of these horizontal and vertical dynamics is power, defined here as control or influence over, first of all, one's own life. Primary in achieving such control is access to resources—the goods, services, and information that are the intellectual, physiologic, and economic basis for healthy and productive lives. In all societies, the degree of openness or constraint of this access is affected by gender. Female morbidity and mortality are not just functions of the physical differences between males and females; whatever their evolutionary origins, they are also rooted in differences in roles and status between the sexes (Caldwell et al., 1990; Gaisie, 1990; Koblinsky et al., 1993; Mukhopadhyay and Higgins, 1988; Ubot, 1992; Vlassoff and Bonilla, 1994).
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa THE ISSUE OF HETEROGENEITY Throughout this volume, statements are made about female moridity and mortality in Sub-Saharan Africa for the purpose of comparing those indexes with the rest of the world. It cannot be emphasized enough, however, that the continent is neither homogeneous nor uniform. There are many economic, political, and sociocultural differences among East, West, central, and southern Africa; among large nations and small; highly stratified states and the more egalitarian; countries suffering wars, ethnic tensions, or other civil disturbances, and countries more serene; the economically richer and the poorer; those suffering drought and famine, and those who are not; and nations with refugees, and those without. There are also variations in religion, tribal affiliation, kinship structure, residence and household formation, language, and educational heritage. Current statistics on economic performance, population, fertility, and education also reflect the continent's heterogeneous experience and circumstance. Gross National Product (GNP) per capita in 1987 dollars ranged from $130 in Ethiopia to Gabon's $2,700; annual average change in GNP per capita since 1965 ranged from -2.7 percent in Uganda to +8.9 percent in Botswana. Land mass varies from Sudan's 967,494 square miles to Swaziland's 6,705, and national population size from 0.7 million in Swaziland to over 100 million in Nigeria. Annual population growth rates over the past 23 years range from 1.5 percent in Mauritius to 4.2 percent in Côte d'Ivoire. Although total fertility rates are uniformly high throughout Sub-Saharan Africa, there are still major differences in absolute numbers and trends among regions and individual countries, as well as within them (Blanc, 1991; Cohen, 1993). Adult literacy in Burkina Faso is 18 percent; in Botswana it is 74 percent. Secondary school enrollment ranges from 3 percent in Rwanda and Tanzania to 51 percent in Mauritius (Feachem and Jamison, 1991; UNDP, 1993; World Bank, 1993). Dealing with diversity is a fundamental difficulty for any study that pretends to deal with the continent as a whole. This report recognizes diversity as a fundamental fact and deals with it through the use of case material that illustrates commonalities or significant divergence in a given subject area. THE SOCIOECONOMICS OF LIFE AND DEATH The Variables In its 1990 Human Development Report (HDR), the United Nations Development Programme (UNDP) defined human development as the process of enlarging people's options. Of those, the most critical were the options to: (1) lead a long and healthy life; (2) acquire knowledge; and (3) have access to the resources needed for a decent standard of living. This holistic view of "human health in context" is the point of departure for this study. It was also in the 1990 Human Development Report that the UNDP introduced the "Human Development Index" (HDI) as a more realistic and informative statistical measure of human development than per capita gross national product (GNP) alone. The HDI merges national income with two social indicators—adult literacy/mean years of schooling and life expectancy at birth—to yield a composite measure that makes it possible to rank the progress of nations in relation to one another. The HDI also permits measurement of how females are doing compared with males (Anand and Sen, 1992). A great deal of analytic energy has been invested in seeking consistent patterns of causality between human mortality, and the worldwide trend of decline in that mortality, and one of the major socioeconomic factors, including income growth, education, provision of health services, ecology, and geography (cf. Feachem and Jamison, 1991). In spite of these efforts, there is still no clear picture of which of these matters most, in part because of inadequacies in the basic data and the manner of their application, and in part because of the sheer complexity in the way human health is embedded in those factors. Taking combined mortality as its lead indicator, the World Bank's World Development Report 1993 (WDR) finds four factors to be unremittingly important in mortality reduction: income growth, improvements in appropriate medical technology, basic education, and access to public health services and knowledge. These are not simple indicators, and there are important synergies among them. In all regions of the world, however, the main effect of income growth on health status lies in equity
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa of income distribution and corresponding poverty reduction, as well as the extent of public investment directed toward development of human capital, both in health services and education, particularly for females. Sub-Saharan Africa is no exception to this lack of a clear, direct association between income growth and HDI rankings. If, in frankly arbitrary fashion, we take the simple numerical midpoint (87.5) of the HDI ranking of the 173 countries, only three Sub-Saharan African countries fall into the group with the highest HDIs: Mauritius, Seychelles, and South Africa, all of which have high GNP rankings as well. A more generous cutoff adds Botswana, Congo, Gabon, Kenya, Lesotho, Madagascar, Swaziland, Zambia, and Zimbabwe, and makes the picture more complex, because all members of this group except Botswana, Gabon, and Swaziland have relatively low GNP rankings. That said, there are no dramatic exceptions at the lower HDI and GNP rankings: the very poorest countries of the Sub-Saharan have difficulty generating good HDIs. It is also the case that almost all of these lowest-ranking countries, which also have the lowest life expectancies and low health services access rates, are also the countries with low total overall adult literacy, and female literacy rates that are below 50 percent of those for males. Nevertheless, most attempts to explain significant differentials among and within African countries in even a single phenomenon, such as infant and child mortality, founder. Part of this difficulty is generic: quantifying the contribution of admittedly crude indexes of socioeconomic development has generally found them to explain no more than half of the total variance (Blacker, 1991). Even when specific variables—for instance, maternal education—clearly and significantly correlate with mortality, the precise causal path is still unclear (Cleland and van Ginneken, 1988). The search for reasonably consistent explanations is frustrating: why, for example, if East Africa suffers the highest regional food insecurity, are the numbers of low birthweight babies and maternal mortality rates highest in West Africa? Gender Disparities The Human Development Report applies the HDI to data from 33 countries on separate female and male estimates of life expectancy, adult literacy and mean years of schooling, and wage rates, and calculates a Gender-Specific HDI for those countries. Computation of this HDI subset is not yet adjusted to account for the standard worldwide pattern of greater female longevity, and the report points to this area for further analytic attention. The data base also needs to be expanded to include a fuller range of countries; so far, data availability has permitted calculations in Sub-Saharan Africa only for Kenya and Swaziland. The primary finding of this analysis is that when the HDI is adjusted for gender disparity, no country improves its HDI value. In other words, no country treats its women as well as it treats its men, although some countries do better than others. The sources of gender bias in industrial and developing countries differ in important ways. In industrial countries, that bias is mainly in employment and wages, with women often getting less than two-thirds of the employment opportunities and about half the earnings of men. In developing countries, in addition to biases in the job market, there are great disparities in health care, nutritional support, and education. Those skews are exacerbated by poverty: the 1991 HDR notes that "Although gender discrimination is a worldwide problem, its effects are particularly harsh in the poorer countries." Morbidity and Mortality The overall patterns of mortality and morbidity in the Sub-Saharan region resemble those of other regions: the life expectancy of African females, like that of females virtually everywhere, is greater than that of males (Sai and Nassim, 1991; UNICEF, 1992), although life expectancy varies at different ages (that is, e0 is not necessarily equivalent to e15; see Brass and Jolly, 1993). And, as in nearly all developing countries, child mortality rates and the mortality risk for adult males are higher than they are for females (Murray et al., 1994), although differentials are usually small (Timaeus, 1991). In only two countries —Mali and Malawi—is there any evidence of excess female adult mortality. In the case of Mali, however, female mortality may have been overestimated because of
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa adjustments made for underreporting, and Malawi may be genuinely anomalous for reasons that are unclear (Timaeus, 1991). Still, these global similarities do not tell the whole story: the life chances of adults in Sub-Saharan Africa are extremely heterogeneous (Timaeus, 1991), and some countries of the region have mortality levels that compare favorably with individual countries of other developing regions. At the same time, although most African countries have experienced steady declines in child mortality, aggregate mortality rates for the Sub-Sahara are still the highest in the world (Sai and Nassim, 1991). The differences in this regard between Sub-Saharan African women and the majority of their global sisters are large and absolute. In addition, avoidable mortality is considerably higher for Sub-Saharan females overall than it is for males. Avoidable deaths are those that would not occur if the rates of a given reference population were applied in the case population (Murray et al., 1994). In the Sub-Saharan case, while the mortality risk for adult males is higher than it is for females, and much higher than it is for males in the developed world, the adult female mortality risk is so elevated, and the mortality risk among adult females in the developed world so low compared with males, that a more extreme ratio is generated. Said more simply, a Sub-Saharan female has a dramatically poorer chance of survival relative to her developed world sister than does a Sub-Saharan male compared with his developed world brother. The odds are even poorer for Sub-Saharan African mothers: their lifetime risk of maternal death is 1 in 15, compared with the 1-in-9,850 lifetime risk of maternal death in Northern Europe—that is, 657 times as great (Graham, 1991). The statement has been made that in a context of such extreme deviation, Sub-Saharan African women are "the underside of the underside" (Ramphele, 1991). Finally, there appear to be notable gender differences within cohorts: although the infant mortality rate for boys is somewhat higher than it is for girls in every African country with available data, the picture of mortality rates among children 1 to 5 years old is much less consistent. Mortality rates among females in this age group appear to be higher in most African countries than they are for males, for reasons that are not at all clear. Health Services Access and Utilization and Health-Seeking Behavior In Sub-Saharan Africa, as everywhere else, access to health services is a function of costs, measured in money, time, and distance. All of these, in turn, affect utilization and interact with perceptions of care and its quality. Access issues are particularly acute for women, whose workload, child care responsibilities, and financial situation may all constrain their ability to utilize services for themselves and for their children to a degree not experienced by men. In addition, although women may be the chief caretakers in a residential unit, they may not be the chief decision makers. Depending on family structure and residential organization, others, particularly senior males or mothers-in-law, may be the arbiters of choices about health care (Castle, 1995; Janzen, 1978). Still, Sub-Saharan African women are numerically more likely to be the principal users of health care services. This is not the case for Muslim women, whose seclusion and inability to be attended by a male health care provider put them at comparative jeopardy, to an extent that has not been systematically studied as an issue in itself. Quality of health services affects both utilization and compliance with preventive and curative regimens (Leslie and Gupta, 1989), although the degree of importance of inadequate quality in women's underutilization of health services remains to be systematically assessed in Sub-Saharan Africa (Mensch, 1993). Nonetheless, it is only common sense to assume that suitable clinic hours and reasonable waiting times, multiple and adequate services, courtesy, efforts to diminish social and cultural distance between providers and patients, and clarity of communication would persuade more Sub-Saharan African women to utilize health services appropriately. When these features are not the rule, which is believed to be the more typical case in the region, service utilization and regimen compliance are affected negatively (Gilson, 1995; Heggenhougen, 1991; Thaddeus and Maine, 1990). Another, more subtle factor is what might be called "medical distance" —that is, the degree to which the health care system is equipped with the appropriate knowledge and resources to deal with the specific health needs of women. There is good reason to believe that modern medical systems worldwide may not be adequately supplied with information about gender differences, at least in part because women have been largely excluded from clinical studies of the treatments prescribed for them (A. Lucas, personal communication, 1993), and in part
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa because of the general belief that, in most situations, women and men will not differ significantly in their responses to treatment. At the heart of the matter is the absolute availability of all health-related services. People—male or female—cannot use, or decide to use, facilities that do not exist. The economic argument that demand will "make a market" and that consumers will, sooner or later, shape that market is questionable even in the developed world, where that assumption is at the heart of current debates about the relative roles of the public and private sectors in assuring the public health. If this is an arguable assumption in the developed world, then it would seem to be highly questionable in countries with large numbers of poor people, whose power to shape a market is infinitesimal. The overall health service access figure for Sub-Saharan Africa is 60 percent; that is, just 60 percent of the region's population has access to any facility that might be described as modern. Only 41 percent of the total population of the region has access to safe water, and only 26 percent has access to sanitation; these are the lowest percentages of all the developing country regions (UNDP, 1993). In addition, although most of the developing world showed dramatic improvement between 1970 and 1990 in ratios of health care providers to population, Sub-Saharan Africa still has the fewest physicians and nursing persons of any region relative to population. Table 2-1 displays variation in access indicators among and within individual countries. That variation is clearly wide. As of 1990, 11 countries in Sub-Saharan Africa had less than one hospital bed per 1,000 population. The physician/population ratio for the region as a whole was 1:23,540, with a range from 1:750 in South Africa to 1:72,990 in Rwanda. The regional nursing person/population ratio was 1:3,460, ranging from 1:600 in Zambia to 1:5,470 in Tanzania. At the same time, there is a relatively high ratio of nursing persons to physicians—5:1 for the region as a whole—with very few countries recording low ratios. Such ratios are viewed by Western health system analyst (cf. IOM, 1988; Reinhardt, 1991) as more favorable in achieving coverage, especially with public health measures, than are the lower nursing person-physician ratios that are so often a function of physician oversupply and can produce high costs to the society. Finally, while 66 percent of Sub-Saharan African women are recorded as having some kind of prenatal care, only 38 percent of all births are attended by health facility personnel, the lowest such figure in all the developing regions. This cannot help but contribute substantially to Sub-Saharan Africa's maternal mortality ratio of 640 maternal deaths per 100,000 live births, the highest of all the world's regions (WHO, 1985). Community studies show that most maternal death occur outside the medical system, either at home or on the way to the hospital (Thaddeus and Maine, 1990). In response, the provision of access to high-quality emergency obstetric care is gaining recognition as the most important strategy for preventing maternal deaths in the region, in Africa, and in other developing countries where maternal mortality rates are high (Prevention of Maternal Mortality Network, 1995). Access Bias A severe limitation on access is urban-rural bias, which is extreme in Sub-Saharan Africa. Seventy-nine percent of the region's urban population has access to safe water; for rural areas, that figure is 28 percent. While 87 percent of the region's urban population has access to health services, over half the population in most of its countries lives more than 10 kilometers from the nearest primary care center. According to selected household surveys, of the individuals who report themselves as sick, those in urban areas obtain medical care more often than those in rural areas, and the wealthy contact a care provider more often than the poor. In Côte d'Ivoire in the mid-1980s, an urban household was nearly twice as likely to seek care as a rural household, and a family in the top income quintile within the rural population was almost twice as likely to seek care as a family in the bottom quintile (World Bank, 1993). As for bias from other factors, there is no persuasive evidence that Sub-Saharan African females are at any significant disadvantage in being taken for clinical care in their early years. Surveys of the management of diarrheal disease, fever, and respiratory illness in infants and very young children, for example, reveal no significant differences in treatment by sex in the six African countries surveyed (Boerma et al., 1991). Nevertheless, gender bias in health services access and utilization accrues with age, as time, money, distance, and fear of stigma become matters of concern for girls and women.
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 2-1 Health Infrastructure and Services, Sub-Saharan Africa and Selected Trends, 1970–1990 Population per 1,000 Doctorsa Population per 1,000 Nursing Personsa Nursing Person to Doctor Ratiob 1988–1992 Hospital Beds per 1,000 Populationb 1985–1990 Percent of Births Attended by Health Staff, 1988c Percent Received Antenatal Cared Percent Received Delivery Assistanced Country 1970 1990 1970 1990 Sub-Saharan Africa 31,830 23,540 3,460 — 5.1 1.4 — — — Angola — — — — 16.4 1.2 — — — Benin 28,570 — 2,600 — 5.8 — 34 — — Botswana 15,220 5,150 1,900 — — — 52 92 77 Burkina Faso 97,120 57,320 — 1,680 8.2 0.3 — — — Burundi 58,570 — 6,870 — 4.3 1.3 12 80 19 Cameroon 28,920 12,190 2,560 1,690 6.4 2.7 — — — Central African Republic 44,740 25,930 2,460 — 4.5 0.9 — — — Chad 61,900 30,030 8,010 — 0.9 — — — — Congo 9,510 — 780 — — — — — — Côte d'Ivoire 15,520 — 1,930 — 4.8 0.8 20 — — Ethiopia 86,120 32,650 — — 2.4 0.3 58 — — Gabon 5,250 — 570 — — — 92 — — Ghana 12,910 22,970 690 1,670 9.1 1.5 73 82 40 Guinea-Bissau 17,500 — 2,820 — — — 16 — — Guinea 50,010 — 3,720 — 4.3 0.6 — — — Kenya 8,000 10,130 2,520 — 3.2 1.7 — 77 50 Lesotho 30,400 — 3,860 — — — 28 — — Madagascar 10,120 8,130 240 — 3.5 0.9 62 — — Malawi 76,580 45,740 5,330 1,800 2.8 1.6 59 — — Mali 44,090 19,450 2,590 1,890 2.5 — 27 31 32 Mauritania 17,960 — 3,740 — — — 23 — — Mauritius 4,190 1,180 610 — 16.4 1.2 — — — Mozambique 18,860 — 4,280 — 13.1 0.9 28 — —
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Namibia — 4,620 — — — — — — — Niger 60,090 34,850 5,610 650 11.3 — 47 — — Nigeria 19,830 — 4,240 — 6.0 1.4 — 57 31 Rwanda 59,600 72,990 5,610 4,190 1.7 1.7 — — — Senegal 15,810 17,650 1,670 — 2.6 0.8 — 64 49 Sierra Leone 17,830 — 2,700 — 5.0 1.0 25 — — Somalia — — — — 7.1 0.8 — — — South Africa — 1,750 300 — 4.5 4.1 — — — Sudan 14,520 — 990 — 2.7 0.9 20 71 69 Tanzania 22,600 24,880 3,310 5,470 7.3 1.1 74 — — Togo 28,860 — 1,590 — 6.2 1.6 — 81 54 Uganda 9,210 — — — 8.4 0.8 — 87 38 Zaire — — — — 2.1 1.6 — — — Zambia 13,640 11,290 1,730 600 6.0 — — — — Zimbabwe 6,300 7,180 640 1,000 6.1 2.1 69 91 70 a Derived from World Health Organization data, supplemented by data obtained directly by the World Bank from national sources. Data refer to a variety of years, generally no more than two years before the year specified. Nursing persons include auxiliary nurses, as well as paraprofessional personnel such as traditional birth attendants. b Each value refers to one particular but unspecified year within the time period denoted. c Refers to births recorded where a recognized health service worker was in attendance. Data are from WHO, supplemented by UNICEF data, based on national sources, primarily from official community reports and records of hospitals of a wide range of size and sophistication. These figures should be used very cautiously. d Data are from Demographic and Health Surveys, 1986–1990. SOURCES: Blanc, 1991; World Bank, 1993.
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Health-Seeking Behavior Throughout the world, individuals and families are adaptive, pragmatic, and pluralistic in patterning their health-seeking behavior, depending on time and circumstance (see Bastien, 1992; Cosminsky, 1983; Finkler, 1994; Heggenhougen and Sesia-Lewis, 1988; Janzen, 1978; among many examples). Sub-Saharan women resort to various home remedies, over-the-counter and prescription pharmaceuticals, and medicines purchased from traditional healers. Similarly, they seek recourse through the categories of healers, including modern allopathic medical practitioners, traditional or folk healers, and trained and untrained traditional birth attendants (TBA). These resources are used serially or concurrently in different combinations and sequences; selecting among them is a complex process based on habit, cost, perception of risk or urgency, familiarity, and ease of access. The general perspective is that traditional and modern health systems are not seen as in conflict, but rather as two different, but valid, roads to recovery. At the same time, traditional healers in Africa have only rarely ''straddled" the two systems in the same way Ayurvedic practitioners do in parts of Asia, and their patients rarely receive whatever benefits modern medicine may confer (Caldwell and Caldwell, 1993). Although understanding this process and the behaviors associated with it would seem to be valuable to the design of preventive and curative interventions, there has been little systematic field research in the Sub-Saharan region into the ways females of different ages and educational histories manage their armamentarium of preventive and curative strategies across the spectrum of health problems and across the life span. Fortunately there is an increasing number of exceptions: the work done on mothers' management of illness in their youngest children, which offers some insight about their own health-seeking behavior; the body of behavioral and epidemiologic research that is accumulating in connection with the HIV infections and sexually transmitted diseases; data beginning to emerge from the Safe Motherhood Initiative; and the series of annual papers on gender and the tropical diseases sponsored by Canada's International Development Research Centre (IDRC). One hypothesis suggested by this still uneven body of research is that women may be most likely to attempt to access the modern medical system in connection with illness in a very young child, and least likely to do so when there is a potential for some kind of stigma—for example, for family planning services, diagnosis and treatment of either sexually transmitted diseases or tropical infectious diseases that seem to be sexually transmitted (for example, urinary schistosomiasis), or conditions that might have social repercussions if disclosed (such as leprosy). The Dynamics of Female Education The World Development Report is unequivocal on the centrality of education in human health, stating flatly that "Households with more education enjoy better health, both for adults and for children, [a result that] is strikingly consistent in a great number of studies, despite differences in research methods, time periods, and population samples" (World Bank, 1993). The key link in that causal chain is women's central role in the health of their households, a centrality that prevails in virtually every society, even though patterns of decision making and external power may differ greatly. Women's own health and their efficiency in using available resources are absolutely crucial to the health of others in the family, particularly children. The weight of the literature is toward a clear association between low levels of maternal education and increased child mortality (Cleland, 1990; Elo, 1992; Harrison, 1986). This seems to be particularly true for female children, especially when they are disvalued by the larger society. In addition, it appears that a child's health is affected much more by the mother's schooling than by the father's; furthermore, the child benefits from maternal schooling even before its birth. Data for 13 African countries between 1975 and 1985 show that an increase of just 10 percent in female literacy rates reduced child mortality by an equivalent 10 percent, whereas changes in male literacy had little influence (Hobcraft, 1993). To take a specific country case, a calculation has been made for Kenya that 2 maternal deaths and about 45 infant deaths would be averted for every 1,000 girls provided with one extra year of primary schooling (World Bank, 1993). There is broad general agreement on the major dimensions of the advantages of female education for household health. Female education increases knowledge about the importance of health and health care. It enhances
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa the propensity and ability to get health information and act on it, as well as to seek, demand, and use health services wisely. It enhances access to income and the capacity and willingness to pay for health care, and is frequently correlated with access to such health-enhancing services as improved household water supplies. Better-educated women marry and start their families later, diminishing the risks associated with early pregnancies, and they tend to make greater use of prenatal care and delivery assistance and to produce fewer low birthweight babies (Harrison, 1986; Hobcraft, 1993; Kennedy, 1992). Children of educated mothers enjoy such health-enhancing advantages as better food and domestic hygiene and more immunization, which in different ways reduce risk of infection. Mothers with more schooling also tend to be more effective in regimen compliance, use of health technologies, and overall case management (Vlassoff and Bonilla, 1994). Female education is also clearly linked to a woman's social standing, decision making power, autonomy, and her own health status. In contrast, illiterate women do not do very well. Data from Ethiopia, for example, indicate that, regardless of whether or not abortion deaths were included in the calculation, illiterate women still suffered the most mortality (Kwast et al., 1986). While this is all very compelling, it is important to keep in mind that maternal education and most co-variates, such as child and maternal mortality, utilization of health services, and the like, are greatly confounded with income levels (Zimicki, 1989). Table 2-2 presents data on adult literacy, mean years of schooling, and male-female primary and secondary school enrollment ratios. It also includes data on average age at first marriage and percentages of women in the labor force. The message is that Sub-Saharan Africa as a whole does not do well compared with other regions of the world; Sub-Saharan females do even less well. Although female enrollment in precollege formal education did increase substantially over the past 15 years, the percentage of female children enrolled is far less than the proportion of females in the school-age population of every country for which data are available, and the rates of growth in female enrollment are less than the rates of growth in the female primary-school-age population, suggesting that over time a growing number of girls lack access to schooling. Representation of females at higher educational levels is small to begin with, and rates of attrition are high. Part of the problem is that enrollments have been stagnating in Africa and the quality of education at all levels has been declining in the wake of the economic decline that started in the mid-1970s, and continues with the economic hardships associated with structural adjustment and other austerity programs of the 1980s (World Bank, 1989). There are other reasons as well: academic factors that do not favor girls in such subject matter areas as mathematics and sciences; cultural and societal expectations around gender roles; early marriage and pregnancy; and, for both males and females, lack of relevant or sufficiently rewarding employment in their fields of expertise (Beoku-Bettes and Ikubolajeh Logan, 1993). Access Bias It is crucial to note that, as in the case of health services, all difficulties and biases are multiplied for three major population categories: those who reside in isolated rural areas, where distance is the primary impediment; lower socioeconomic groups, where cost and foregone earnings are of concern; and girls. When there is substantial male emigration, leaving female heads of household with correspondingly larger responsibilities for agricultural subsistence labor, it is customary for such women to delegate at least some of their traditional responsibilities for household chores and care of younger siblings to school-age daughters. These tasks are not perceived as suitable for boys, a perception that is hardly exclusive to Sub-Saharan Africa. It is a view that is prevalent in most societies and is closely tied to cultural views about appropriate gender roles and female identity. Still, while evidence is anecdotal, there appear to be signs of change, at least in some parts of the region. In northern Nigeria, where seclusion has been thoroughly embedded in all parts of community and household structure for centuries, one observer noted over a decade ago that: [Although] patterns of sexual inequality are extremely entrenched.…It is already apparent from observations over only five years that girls are being sent to school and kept there [by their parents] beyond the traditional age of marriage.… [This] could place women in line for jobs in the formal sector and lead to a whole sequence of demands and changes which are still quite remote from the perspectives of most Third World women. (Schildkrout, 1984)
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 2-2 Educational Profile of Females in Sub-Saharan Africa Country Adult Literacy Rate (as of age 15+) Mean Years of Schooling (25+) Average Age at First Marriage (females, years), 1980–1989 Enrollment Ratiosa Women in Labor Force (percentage, total labor force), 1990–1992 Total 1992 F 1992 M 1992 Total 1992 F 1992 M 1992 Primary (gross), 1950 Secondary (gross), 1990 Mauritius 80 75 85 4.1 3.3 4.9 23.8 108 54 30 Seychelles — — — 4.6 4.4 4.8 23.0 — — 43 Botswana 75 66 85 2.5 2.5 2.6 26.4 119 45 S. Africa — — — 3.9 3.7 4.1 26.1 — — 39 Gabon 62 50 76 2.6 1.3 3.9 17.7 — — 38 Swaziland — — — 3.8 3.4 4.1 — 108 46 34 Maldives — — — 4.5 3.9 5.1 17.9 — — 20 Lesotho — — — 3.5 4.1 2.8 20.5 116 31 44 Zimbabwe 69 61 76 3.1 1.8 4.5 20.4 116 46 48 Congo 59 45 72 2.1 1.1 3.1 21.9 — — 39 Cameroon 57 45 70 1.6 0.8 2.6 18.8 95 23 30 Kenya 71 60 82 2.3 1.3 3.1 20.3 93 25 40 Namibia — — — 1.7 — — — 126 47 24 Madagascar 81 74 90 2.2 1.7 2.6 20.3 91 18 40 Ghana 63 54 74 3.5 2.2 4.9 19.4 70 20 40 Côte d'Ivoire 56 41 69 1.9 0.9 2.9 18.9 58 14 32 Zambia 75 67 83 2.7 1.7 3.7 19.4 92 15 29 Nigeria 52 41 63 1.2 0.5 1.7 18.7 63 17 33 Zaire 74 63 86 1.6 0.8 2.4 20.1 64 15 36 Senegal 40 26 55 0.9 0.5 1.5 18.3 — 11 26 Liberia 42 31 53 2.1 0.8 3.3 19.4 — — 31 Togo 45 33 59 1.6 0.8 2.4 18.5 87 12 37 Tanzania — — — 2.0 1.3 2.8 19.1 68 4 48 Equatorial Guinea 52 38 66 0.8 0.3 1.3 — — — 36 Sudan 28 13 45 0.8 0.5 1.0 20.9 43 20 29 Burundi 52 42 63 0.4 0.3 0.7 21.7 66 4 53 Rwanda 52 39 67 1.1 0.5 1.5 21.2 70 7 54 Uganda 51 37 65 1.1 0.6 1.6 17.7 — — 41 Angola 43 29 57 1.5 1.0 2.0 17.9 70 — 39 Benin 25 17 35 0.7 0.3 1.1 18.3 45 7 24 Malawi — — — 1.7 1.1 2.4 17.8 60 3 51 Mauritania 35 22 48 0.4 0.1 0.7 19.5 43 10 22 Mozambique 34 21 46 1.6 1.2 2.2 17.6 52 6 48 C. African Republic 40 26 55 1.1 0.5 1.6 18.4 52 7 47
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Ethiopia — — — 1.1 0.7 1.5 18.1 30 11 41 Djibouti — — — 0.4 0.3 0.7 — 31 36 — Guinea-Bissau 39 25 53 0.4 0.1 0.7 18.3 42 4 42 Somalia 27 16 41 0.3 0.2 0.5 20.1 — — 39 The Gambia 30 18 43 0.6 0.2 0.9 — 53 13 41 Mali 36 27 43 0.4 0.1 0.7 16.4 17 4 16 Chad 33 20 46 0.3 0.2 0.5 16.5 35 3 17 Niger 31 18 44 0.2 0.2 0.4 15.8 21 4 47 Sierra Leone 24 12 35 0.9 0.4 1.4 — 39 12 33 Burkina Faso 20 10 31 0.2 0.2 0.3 18.4 28 5 49 Guinea 27 15 39 0.9 0.3 1.5 16.0 24 5 30 All developing countries 69 58 79 3.9 3.0 4.9 20.8 90 34 35 Least-developed countries 46 34 58 1.6 0.9 2.2 18.7 55 12 38 Sub-Saharan Africa — — — 1.6 1.0 2.2 19.0 60 15 37 Industrial countries — — — 10.0 — — 24.5 — — 43 World — — — 5.2 — — 21.0 — — 37 a The gross enrollment ratio is the number of students enrolled in a level of education, whether or not they belong in the relevant age group for that level, as a percentage of the population in the relevant age group for that level. All figures in this column are expressed in relation to the male average, which is indexed to equal 100. The smaller the figure, the bigger the gap; the closer the figure to 100, the smaller the gap. SOURCE: UNDP, 1994.
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa care for female infants in the region. At the same time, other areas indicated in the table are of great concern. Table 2-4 reports on one of those areas, spousal abuse. The percentages of women who report it are terribly high, and a number of other sources indicate that it is prevalent across the entire region (Levinson, 1989). Whether alcoholism as a subset of substance abuse is a major problem in Sub-Saharan Africa is an open question (Health, 1993). If it proves to be a significant issue, it may be expected that, as elsewhere, women will suffer disproportionately, primarily because of the drain on family income that could otherwise be used for food, health services, and school fees. Substance abuse is known to be significantly correlated with accidents (Feachem et al., 1991), homicide rates, and domestic violence and spouse abuse (Malik and Sawi, 1976). Estimates of rape incidence are highly speculative in the developing world overall, but there are some data, and they are chilling. Rates of rape in South Africa are extremely high. In 1988, although 19,308 rapes were documented in police reports, the National Institute of Crime Prevention and the Rehabilitation of Offenders estimated that only 1 in 20 rapes is reported. If that is indeed the case, the true total would be close to 386,160 (Russel, 1991; Vogelman, 1990). That is an average of one rape every minute and a half, or 34 rapes per 1,000 adult women, compared with the U.S. rate of 18 per 1,000 women (Heise, 1993). The question of the extent of the association between rape and sexism and how that might be defined in the African context is unknown. African female voices increasingly attest to the presence of sexism (Mazrui, 1991; Ngaiza and Koda, 1991; Osaki, 1990; Weekly Review, 1991). Public reaction to the 1991 rape of 71 girls in Meru District, Kenya, was muted in ways that have been interpreted by some analysts as sexist, and the Kenyan Public Law Institute and the Women's Bureau have issued A Guide to Women of Kenya on Rape and the Legal Process (Weekly Review 1991). The entire issue of rape in Africa, its prevalence, a more precise definition of its causes and correlates, and the nature of its impact on cohorts of females is beginning to be examined. Whatever the responses to these questions, there is little doubt that rape is profoundly bad for female emotional and physical health; what is in doubt is the ability of health and social services in Sub-Saharan Africa to deal with it in an adequate fashion. Early Marriage The Africa-wide perception of women as primarily wives and mothers reinforces patterns of premature childbearing and high parity. Early adolescent marriage and subsequent early motherhood are all too often negative events in the health trajectory of young Sub-Saharan African women, reflected most vividly in mounting rates of abortion among adolescents. Of those women, nearly 50 percent are married by age 18, some by age 15 (UNDP, 1991). Ages at entry into a regular sexual union vary widely across the region: proportions of women who are still single between the ages 15 to 19 range from 10 to more than 90 percent, and corresponding mean ages at first union range from about 16 to more than 21 years. Links between formation of a union and motherhood in most Sub-Saharan countries are close: women are almost as likely to have their first birth before age 20 as they are to marry before age 20. That some young women are single does not mean that they are not having sexual intercourse and, in some cases, that they are not having babies. In most of the 16 countries included in the Demographic and Health Surveys (DHS), a large proportion (37–78 percent) of single women ages 15–24 have already had a sexual relationship; 26–53 percent are currently involved in a sexual relationship; and 2–42 percent have already had a child (Alan Guttmacher Institute, 1995). In general, the median age of women at first birth in Sub-Saharan Africa is approximately two years younger than it is in North Africa, Asia, or Latin America (Arnold and Blanc, 1990). The two primary determinants of these early liaisons are the influence of Islam and the practice of polygyny, so often a feature of patrilineal societies (Lesthaeghe, 1989). In contrast, matrilineal social structure, higher levels of female education, and urbanization are three cultural factors associated with later marriage (NRC, 1993b). Polygyny ''presupposes a large age difference between spouses and … a combination of late marriage for men and early marriage for women" (NRC, 1993b). The Islamic influence is identified with a more stringent social control of women, a control more likely to be assured through early first marriages for girls (Goody, 1973, 1976; Lesthaeghe et al., 1992). Among the many consequences of early marriage is the simple actuarial probability that
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 2-4 Prevalence of Spouse Abuse, Selected Countries, Sub-Saharan Africa Country and Author Sample Sample Type Findings Comment Kenya (Raikes, 1990) 733 women from Kissi District District-wide cluster 42% beaten regularly Taken from contraceptive prevalence survey Tanzania (Sheikh-Hashim and Gabba, 1990) 300 women from Dar es Salaam Convenience, from 3 districts (interviews) 60% had been physically abused by a partner Uganda (Wakabi and Mwesigye, 1991) 80 women (16 from each of Kampala's 5 divisions) House-to-house written survey; 7 women refused to answer 46% of 73 women responding reported being physically abused by a partner An additional 7 women reported beatings by family members and another 5 reported assaults or rapes by outsiders Zambia (Phiri, 1992) 171 women ages 20–40 Convenience, women from shanty compounds, medium-and high-density suburbs of Lusaka and Kafue Rural 40% beaten by a partner; another 40% mentally abused 17% said they thought that physical abuse was a normal part of marriage SOURCE: Heise et al., 1994.
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa women often will be widowed quite early in their lives. Because widowhood in itself is a threat to female health, as noted earlier in this chapter, the net result is usually negative. Another negative effect of early marriage derives from the insufficient development of most adolescent bodies for the physical burdens of pregnancy. Women in early adolescence are at the highest risk of all age groups for the cephalopelvic disproportion that causes obstructed labor, the single greatest reported cause of maternal mortality (see Chapter 4). In addition to the increase it generates in mortality risk, early childbearing also produces physiologic sequelae that contribute to higher accrued morbidity across the female life span. One very durable effect is the development of vesico-vaginal and recto-vaginal fistulae, which are ruptures in the tissue between the bladder or rectum and the vagina (Harrison, 1983). Women with unrepaired fistulae are far more likely to experience urinary or fecal incontinence, which can sometimes be ostracizing to the point of divorce. Yet repair of such tissue traumas requires a level of surgical sophistication not widely available in the region, and perhaps out of the financial reach of women in the lower socioeconomic strata. Finally, the early onset of childbearing extends the time span of possible pregnancy and birth. A childbearing span that begins at age 15 lasts for approximately 22 years, compared with the average 7-year span in developed countries, where the range is from ages 23 through 30. In Sub-Saharan Africa, the region with the highest parity in the world, early initiation of childbearing does more than just increase the number of children a woman will conceive and bear. Grandmultiparity also increases her chances for developing the condition that has come to be called "maternal depletion syndrome." Although definition of "maternal depletion" and the mechanisms and timing of its contribution to disability are subjects of controversy (Winkvist et al., 1992), one thing that is clear is the hazardous relationship between very early childbearing and mortality: the risk of maternal mortality for women under age 20 is twice the rate for women between ages 20 and 34 (UNDP, 1991; WHO, 1992). Traditional Medicine There are cultural dimensions to every part of human life. While culture always matters, there are circumstances in which it quite overwhelms other fundamental dimensions of human existence such as economic dynamics, physical environment, and other seemingly more objective facts of life. There are large areas of female life in Sub-Saharan Africa in which cultural expectations and responses dominate health status, either enhancing that status or limiting it. Much of the data that correspond to these areas are found in ethnographic accounts of relatively small human groups and are dismissed as anecdote, usually for reasons of sample size and sampling procedure. Yet it is these essentially cultural accounts that provide the clues to the thought, values, and behavior that can submerge the noblest and most "rational" attempts to enhance health status—in our case, female health status. As everywhere, illness and disease in Sub-Saharan Africa are both cultural and biomedical constructs, so that there is a wide range in the ways illness and disease are generated, defined, explained, and managed (Dagnew, 1984; Fosu, 1981; Gaisie, 1990; Janzen, 1978; Kloos et al., 1987). The National Traditional Healers Association of Zimbabwe has defined 'traditional medicine' as follows: The sum total of all the knowledge and practice, whether explicable or not,used in diagnosis, treatment, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing. Traditional medicine might also be considered as a solid amalgamation of dynamic medical know-how and ancestral experience. (Chavundaka, 1984) What this definition does not address explicitly is the very fundamental matter of etiology—that is, the cultural explanations of why disease befalls humankind. Traditional medicine is built on a deeply rooted structure of belief and theory about the origins of illness and the maintenance of health, a structure that takes into account both spiritual and physical causation. One of these beliefs is the almost fatalistic view that physical suffering is intrinsic to the female condition. Another widely distributed explanatory structure is the set of beliefs around humoral balance in the human body and the importance of equilibrium between conditions typically described as "hot" and "cold" (Logan, 1977). Even when the definitions of these states of being and the strategies for dealing
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa with them vary—as they often do, from society to society—the concept of mental and physical balance is found in virtually every region of the world. Although the idea of balance is a reasonable medical and societal premise for healthy lives and is the basis for a large number of beneficial traditional health interventions, it is often ignored by Western medical practice. Throughout Sub-Saharan Africa, traditional medicine is a lively and pervasive component of everyday life, and an estimated 90 percent of the population rely on traditional healers as primary health care providers (WHO, 1982). This may be because of the heritage of respect this category of health practitioner has acquired across the generations, the very positive nature of many of the health interventions such healers provide or reinforce, because such practitioners constitute the only accessible resource, or some combination of all of these factors. Traditional Practices Within the system that is traditional medicine are sets of what we chose to call "traditional practices," which are employed in the maintenance or restoration of what is culturally defined as "health." Some of these are tightly integrated into aspects of Sub-Saharan culture and society and may reinforce them across the life span. In childhood and adolescence, the most notable practices are early marriage and female genital mutilation; in adulthood, they include traditional practices linked to pregnancy, birth, and the postpartum period; and, in later years, they involve practices associated with widowhood. The degree to which these practices affect female health, either positively or negatively, is almost completely unquantified. Analysis has been based largely on the amassing of anecdote, a very few in-depth studies, and extrapolations from experience elsewhere. This base of information, although incomplete, suggests that certain traditional practices in the Sub-Saharan region are strongly supportive of female health. The positive view of breastfeeding is a good example; the prescription for an ample postpartum rest period for new mothers is another. Still others remain to be identified and more systematically characterized so that they can be maintained as valued components of national and local systems of medical care or, in the cases of traditional practices that are injurious to female well-being, discouraged. Food Prescriptions and Proscriptions Cultural prescriptions and proscriptions of certain foods have the potential to influence female nutritional status, particularly in areas where high levels of malnutrition, iron-deficiency anemia, chronic malaria, goiter, and helminthic infestations have been documented. The ethnographic record in Sub-Saharan Africa reflects patterns of food prescriptions and proscriptions, particularly for pregnant women, that are not unlike such prescriptions and proscriptions elsewhere in the world, where they fall into three categories of concern: (1) possible harm to the fetus; (2) a precipitated miscarriage; or (3) a difficult delivery, including concerns about an overly large fetus. At the same time, researchers do not yet have a good grasp of the volume, duration, and quality of either the positive or the deleterious effects of these traditional practices. This is partly because it is difficult to separate the effects of traditional dietary practices from the effects of overall food shortages, and partly because the monitoring and logging of actual food intake in largely illiterate human groups is difficult and costly. While these restrictions cause no harm in areas of considerable dietary diversity and affordable dietary substitutes, food proscriptions in food-deficient circumstances may affect dietary quality for pregnant women and their imminent offspring. For women of already poor nutritional or health status, any resulting undernutrition could not be helpful. One aspect of prenatal nutritional intake that appears to reach beyond anecdotal levels toward real potential significance is the concern for keeping fetal size down. In Ethiopia, traditional birth attendants (TBA) advise pregnant women to restrict their intake of foods, including milk and vegetables, that are believed to increase the weight of both mother and baby (UNDP, 1991). Whether the intake of nonprescribed foods is adequate is unknown. It may be that nothing detrimental is happening, but since rates of low birthweight are so high in the region, some inquiry would be useful.
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Pregnancy, Labor, and Delivery Maternal mortality rates are high in Sub-Saharan Africa, and at least some of that mortality and related morbidity can be attributed to traditional practices that need to be categorized as harmful. A recent study in Nigeria concluded that 4 percent of reported maternal deaths were attributable to such practices (WHO, 1991) and noted that, because such a large proportion of births and deaths in Sub-Saharan Africa occur outside hospital, the 4 percent figure may be a significant undercount. At the same time, the accuracy of cause-of-death attributions are so highly questionable in general that it might be more useful —and culturally neutral—to look initially in some systematic way at the practices themselves and ask whether they are, in themselves, appropriate even for populations of women in optimum health. A crucial function in the childbearing sequence and in the perpetuation of traditional practices is the role of the TBA, trained or untrained. Because that is so directly an obstetric topic, it is addressed as such in Chapter 4. Female Genital Mutilation The term "female circumcision," until recently in general use, has been largely replaced by the more collective term "female genital mutilation" (FGM). FGM comprises a variety of operations that, in their most prevalent forms, go beyond circumcision of the clitoris to excision of most of the external female genitalia (Gordon, 1991). Whatever terminology is employed, the topic is highly charged and highly complex. Not only are these traditional procedures of considerable biomedical importance (see Chapter 4), but they also exemplify the profound integration between what is medical and what is cultural, and between what is modern and what is traditional. As preface to any scrutiny of the biomedical aspects and effects of these practices, it is important to look at what is known about their prevalence and to place them in the context to which they are so intimately and, in some cases, precisely tied. FGM is practiced extensively throughout Sub-Saharan Africa, in Oman, South Yemen, the United Arab Emirates, Malaysia, India, and Pakistan, as well as in large immigrant communities in Europe, the United Kingdom, and the United States. Somewhere in the range of 84 to 94 million girls and women in the world today have undergone some form of genital excision (Cutner, 1985; Lightfoot-Klein, 1989; Rushwan, 1990). Kouba and Muasher (1985) estimated that 5.5 million children or adolescents are operated on annually, primarily in Africa. One source (Hosken, 1992) calculates that the practice is found in at least 20 Sub-Saharan countries, and that the percentage of women who have undergone the procedure ranges from nearly 100 percent of women in Somalia and Djibouti to under 5 percent in Uganda and Zaire. It is vital to recognize that there are differences in the extent of the practice among and within the Sub-Saharan countries. For example, approximately 70 percent of women in Burkina Faso have been genitally excised; the percentage in neighboring Ghana is around 30 percent (Hosken, 1992). There is also variation within countries: in northern Sudan, for example, 89 percent of ever-married women ages 15–49 are infibulated, while the procedure is rare in southern Sudan (Kheir et al., 1991). (The types of FGM are described from a biomedical perspective in Chapter 4.) CONCLUSIONS The purpose of this report, as stated in its opening chapter, is to assemble as much as possible of what is known about the biomedical dimensions of female morbidity and mortality in Sub-Saharan Africa. This has not been done before in a systematic way, and the committee believes that just as it is perilous to limit thinking about human health to biology alone, it is similarly perilous to focus on larger environments without understanding the biologic organisms with which they interact. It is surely true that there is no pharmaceutical remedy for inequitable economic and educational opportunity or for the easy victimization of females. It is equally true, however, that biomedical understanding can produce at least some of the solutions to human health problems that will persist in even the most equitable societal settings for a very long time.
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Representative terms from entire chapter: