relationships between cultural values (including gender role behaviour), sexual norms and actual sexual behaviour, in communities where AIDs is having a serious impact.
What this kind of perspective and analysis accomplishes is the establishment of clear linkages between labour and poverty issues on the one hand, and familial roles, gender issues and demographic and health outcomes on the other.
What gender issues means here for women is that an increasing proportion of labour and marital contracts are insecure and do not offer the long-term support and resources required by them for their reproductive work of raising the next generation. This is a global:
phenomenon of serious proportions documented in both the richest and poorest nations of the world (Oppong, 1988). This approach indicates that only by more holistic and systemic, views of what is happening at the macro- and micro-levels-will, it be possible to design human centred'policies and participatory programmes, which will help to solve underlying problems and ultimately change the behavioural and demographic outcomes. \
PARENTHOOD
The unprecedented economic, ecological and political crises which are affecting all countries are afflicting the daily life of most families. In particular they are inhibiting the
ability of parents to feed, maintain, educate and care for their offsprinjg. Levels of
malnutrition are high and rising. There is widespread,evidence of attempts to prevent births through abortion and other traditional means. There is even evidence of child abandonment and street children, desperate phenomena unheard of in previous decades. For a few unfortunate children traditional systems of familial support have completely broken down.For many children fathers have proved incapable or irresponsible and mothers have been left alone caring for them, often with the help of their own mothers and other female kin.
Increasingly numbers,of such mothers alone are unable to cope.
Children are the continent's greatest resource and yet such are the current dimensions of economic crisis that many children are growing up under stark conditions of poverty and deprivation, which means they are not likely to reach their full human potential. For the
POP7APG.3/92/Inf:5
Page 21*
effects of deprivation of proteins and'stimulus, and loving care; during early childhood are by now well known and last into adulthood, i" " >*>' '■ l ' ■'" • ■ '. * Family size continues unremittingly high in most areas with.drops only slighter-not at all^and persistent averages of over six children. A widespread observation is that girls' with a little schooling, may have higher fertility than either those illiterate and subject to continuing customary constraints on sexual congress and conception, or those with higher"
levels of education who have more ready access to the modern forms of contraception. For the latter are available at least-fortthe better off in urban areas in the region.
The difficulties faced by African families in bearing and raising children to adulthood*
have been recognized for some time'. On the one hand increases in schooling and urban-ward ■ migration have-raised the costs of child maintenance and rearing, and dispersed the kin, including siblings who would normally have cared for them. Meanwhile, the urban-ward-migrations have'decreased children's'utility as farm labour and parents require cash to
support children. a;::.! . • '■ o- •■ ,- .. i
:i "Women, however, still remaiirin: subsistence, self-employment and informal sector work in which children's assistance can play a crucial part.' Indeed recent evidence on5 desertification and. pauperization has indicated that child labour'for some is becoming;
increasingly necessary'for. survival, given the labour and time intensity of mostfbrms of1
subsistence work. ■ ■- ■ .'',■-' - .'> ■■-j' * . - ;.. ;
■•-...'■ ■ f ; ':'!'• '. * ' •' •■ . r ' ■ ■ »--' ■■■ --ii .~r :.(:" >: '/t
Child labour ■
s-f. Africa is known to have the highest incidence of child labour in the world and yet it is poorly documented.26 The prognostication is that the problem is likely to persist "and-even worsen as a result of urbanization.27 j' • J ■ -■'■"-. •':■ -v ..;■.
The experience of a number of developing countries has shown-that it is possible to bring about significant reductions in the incidence of child labour and to extend protection ^ to. working.children, even at-low levels of per capita'income and development (ILO, 1991a:12). Moreover; poverty can be * no excuse for the-abuse of human rights"
(ILO, 1983:20). Many countries have demonstrated it is feasible to ban child labour before the completion/of primaryeducation or before 12 or 13 years of age.- This would have a significant impact on the incidence of child labour and provide protection for the youngest and most vulnerable. /Although the struggle against child labour cannot be won only through legislative.action,»it.certainly cannot be fought without it (ILO, 1991:58).28 * ' >
-'- . A significant point in the context of this discussion' is that^a vicious cycle is created supporting high fertility when subsistence, unmechanized work requires mothers to rely on help for family survival from the labour.of their children, i - *v - »
-*-*, * ■ . ■ ' ■ ' * '■»>•■_
Maternal costs and control
When babies are born, mothers pay with their life and health. Maternal malnutrition, including chronic iron deficiency, anaemia, infant low birth weights and death are recognized
to form a terrible souice.of suffering for many women. '■ Iron deficiency is a serious problem
affecting at least half.of. all women of"reproductive age; more than 60 per cent of pregnant women and about half of children under 12 years. . ' ■• * *POP/PAC.3/92/Inf.5 Page 22
In 12 out of 29 countries for which data area available, the maternal mortality rate is higher than 500 for every 100,000 live births. Moreover, it has been estimated that each year about 150,000 mothers in Africa die and roughly the same number suffer permanent disability because of complications from pregnancy and childbirth; At the same time the infant mortality rate for most of the sub-Saharan African region ranges from 100 to 170 for every 1,000 live births. Rates of disability and death are particularly high among teenage1
mothers. . . .■
If maternal mortality is to be reduced, comprehensive systems of health-care must take into account both preventive and curative medicine. Attention will also have to be paid to family planning and prenatal care, as well as a system of access to immediate referral and emergency care, especially during the critical time of labour and delivery (Winicoff et al., 1991). Fortunately, many countries are adopting Safe Motherhood Strategies and this is a set of programmes for which needed technical assistance has been forthcoming. There is still far to go. But strategies for Health for All by the Year 2000 give high priority to prevention
of maternal mortality and Safe Motherhood Initiatives. - j
A decade ago and then more recently, first the World Fertility Surveys and then the Demographic and Health Surveys have shown that a large number of women say they want no more births, but they are not systematically taking any effective action to prevent such an occurrence for-a variety of reasons, including lack of availability and costs of contraceptives. Prolonged breast-feeding is still a widely used mechanism for spacing births.
It is estimated that 90 per cent of mothers are still breast-feeding their infants at six months of age.
For the many women who have little or no access to means of birth postponement, other than post-partum sexual abstinence, which remains important, frequent and prolonged breast-feeding is the only means not only to feed their, babies, but to space the next birth through post-partum amenorrhoea and suppressed ovulation. In fact it has been calculated that in many countries more births are still averted by this means than by any other single family planning method (WHO, 1990a). Even though lactational amenorrhoea is not completely reliable to protect against pregnancy for the individual mother, the effectiveness of breast-feeding as a birth spacing mechanism has important health policy implications.29
There is, however, accumulating evidence of the erosion of the intensity and duration of nursing practices, especially among mothers where work separates them from their children (Ofosu, in press). There is evidence that among the educated, urban,dwellers and women in formal sector employment, breast-feeding duration and intensity .tends to be truncated thus the effects on ovulation are diminished. This is a topic on which there is surprisingly little ethnographic evidence and yet it is a topic of tremendous importance for child survival and development, and birth spacing. There is thus a need for studies of women's working conditions and child feeding and care practices in different types of environments (Oppong, 1991). This would inter alia demonstrate the relevance and effectiveness of such maternity protection as exists, and also highlight types of support required, such as child care facilities, which are now in demand by working women in both
rural and urban areas. . . •'.'...'
Certainly the kinds of work that women do profoundly affect the survival, development and opportunities available to their children. On the debit side, differences in child mortality have been found according to insecurity of mother's employment (Turshen, 1991). Moreover, examples abound of employed mothers having to leave their infants with older children or alone, even babies have to be left behind.
POP/APC.3/92/Inf.5 Page 23 Parents face the terrible prospect of losing one in five or more of the children borne to them1. Levels of infant and child mortality were, observed to be declining three or more decades ago, but more recently harsh economic programmes have been associated with evidence of new increases in infant mortality. Differences are apparent not only between countries, but between different ethnic groups and localities. Rates for the regionremain
among the highest in the world. -•...-,, . ;
;r-' * , ', ■ ■ '** •
In a third or more of child deaths, malnutrition is implicated - the inability of mothers and others who. may be helping them to provide adequate food. This failure' is partially linked to too closely spaced births and too high parities. Mother's resources are under too great a strain. The strain is greatest in cases where traditional mechanisms for control and support have broken down, and modern mechanisms of control and assistance, have not been
put into; place. . ■< :■ s ' . ■ , - _:■*..
■ - , i
The State.of the World Children (UNICEF, 1992) recently stressed the importance for child survival and well-being of maintaining a balance between births, and maternal resources available for care, through responsible planning of births: The report .emphasized that the alternative practical methods available for ensuring responsible parenthood are so many and diverse that they cater to. the needs, of different cultural and religious.groups. ,
A major finding of demographers and health specialists, of the past decade has been the fact that there are potentially huge gains to be made from more adequate spacing and timing of births in terms of human lives, and well-being of mothers and children. Not only does such spacing and timing avert deaths and physical suffering, but it can help to avert the stresses and conflicts suffered by mothers, unable--to cope with the responsibilities which child care and maintenance involve and the conflicts experienced,: as they try to combine their heavy schedules of work with child nursing and; care. . ,. . ,,
Over the past decade and more, it has become.potentially much easier for women and men to control the timing and'Spacing of births, as knowledge of human reproductive physiology has become more widespread and as access to contraception has become increasingly available in rural as well as urban areas: not only within the context of maternal and child health services, and primary health care programmes, but also as a result of marketing strategies and campaigns by non-govemmental as well as governmental agencies concerned to promote access to family planning. Reliance upon traditional methods of long-term abstinence remains, however, widespread and acceptance and availability of modern forms of contraception remains uneven, and often methods are not known or unavailable in the rural areas. . • * ' ■ . . ■ ■ . -;
.;. •. Withregard to modern means of birth timing, the majority of countries in the region have the lowest contraceptive prevalence found in the world (less than 20,per cent). There is by now substantial evidence that demand is growing for child spacing methods, other than traditional, sexual abstinence of the mother.1 This evidence is partly provided .by the fact that a quarter to half of maternity related deaths are associated with abortion. Recent analysis of the data from the Demographic and Health Surveys has shown that in sub-Saharan Africa in all countries except Kenya the demand for family planning for spacing purposes still exceeds that for limiting births, the main need is for methods to-delay the next birth. In Ghana and Kenya unmet need increased during the eighties and the data show the need for family planning can often increase more rapidly than its availability. Unmet need was found in both rural and urban areas (Westoff and Ochoa, 1991). . ■ . ■:. .
POP/PAC.3/92/Inf.5 Page 24
Meanwhile, contraceptive use is increasing where it is available, so that it has been estimated the present level of contraceptive prevalence rate could be increased to 25 per cent compared to the present rate of 1 to 10 in most countries (World Bank, 1989:71). Changes are seen most clearly in reproductive behaviour when both education and community based family planning services reach women. In the recent past women's own organizations have
increasingly become involved in this aspect of family welfare provision. The potential of
women's income-earning groups in this regard is quite significant (Evans, 1992). This is an aspect of the empowerment of women to promote family survival and welfare, which will need to be expanded and supported for the rest of the decade and beyond.'. In much of the study of birth in the past decade and more, the emphasis has been upon the propensity and ability of women to control their reproductive behaviour and outcomes. The reminder has recently been given, however, that the socio-political context of procreation is often ignored in research designs, project development and in policy pronouncements (Postel, 1992). For not only is a considerable proportion of births unplanned or undesired by the women who undergo labour, but a not insignificant percentage
is the result of sexual violence and rape (ibid.). For in situations of crisis, war and growing
populations of refugees, such as are now rising, evidence of such, non-traditional behaviour patterns is mounting, as is evidence of sexual harassment in places of education, training and work, resulting in impairment of women's reproductive health if not their deaths.-Furthermore, sympathetic recorders of women's lot have noted how they may easily become the scapegoats for fertility, which is too high and family planning programmes which fail and for malnutrition of children and poor feeding practices, when the fact is that they have no knowledge, resources, or food available to take any individual action. Clearly solutions for widespread problems need more than individual approaches. Fortunately, socio political action is being taken by a variety of women's organizations, trade unions, .cooperatives and others, including programmes of education and primary health care.
Furthermore, it is well documented that when women are well educated survival of mothers and their children are more assured (Caldwell, 1990).
Fostering
Ethnographers have long described the ready delegation of child care to older siblings and non-parental kin, and the importance of this practice for women's ability to remain heavily involved in productive activities throughout the reproductive span (e.g. Goody, 1978). As demographers have more recently provided statistical evidence -fostering still remains an important mechanism whereby children can be placed with parental, figures best situated either to take advantage of their labour or to look after them (Page, 1989). Patterns of fostering have been shown to vary according to female occupational status (e.g. We"ry, 1987). There is also considerable transfer of children between rural and urban areas - to
attend school, to be cared for by grandmothers, etc. Patterns also vary according to conjugal
status. '
Whereas in an earlier era, studies of fostering showed no noticeable ill effects upon the individuals concerned, there is now mounting evidence that such children may have
higher rates of malnutrition, deprivation, even mortality.30 •
It is often children of mothers alone of teenagers, divorcees, unmarried mothers -who are sent to grandmothers.31 Often the latter are ill-equipped to care for them.