Submitted to the 32° session of the United Nations Committee for CEDAW
New York – January 10-28 2005
Luigi Toma, Emma Pizzini, Aldo Morrone
IISMAS – Istituto Internazionale Scienze Mediche Antropologiche e Sociali
on behalf of the COMITATO PER LA PROMOZIONE E PROTEZIONE DEI DIRITTI UMANI
Introduction
Gender Differences: gender differences have a more marked social impact than sexual differences (i.e. of a biological nature). Gender deals mainly with cultural issues based on the history and traditions of a given society. Men and women are different because society follows different models of behaviour based on gender. Women are systematically discriminated against in various fields, such as:
v politics (fewer women take part),
v education where the percentage of women students up to 25-30 years ago was much lower than that of male students. Nowadays society tends to determine which educational path men and women should follow. Women are encouraged to read art subjects, and men to read sciences.
v workplace: in the last ten years, the number of women in the workplace has increased, but is still much lower than that of men. The right to work is still a privilege for women university graduates and those with a diploma of higher education. Women are employed in specific fields, are more likely to be unemployed or fired. They also experience more difficulties when looking for work.
One should point out that differences exist at health level too. They are unacceptable not only in developing countries but also in those countries with a higher level of development. This paper wishes to highlight only the main and most disturbing aspects of gender differences to be found in the Italian Health Service.
Health in the Immigrant Female Population: problems connected to abortion.
In Italy the presence of foreign women, originating mainly from underdeveloped nations is now a reality especially in the big cities of the Centre and North of the country.
These numbers have been gradually increasing: from635.000 in2001 to more than one million in 2003, amounting to 48.4% of the immigrant population. In Italy, in 2003 the authorities issued 1.449.746 work permits and this number was800.080 in2001.
Family reunions, which amount to 24.3% of the total number of permits issued up to 31\12\2003, have increased the number of female immigrants, making the ratio between male and female more stable.
In Italy today, females represent 48.4% of the total immigrant population.At national level the number of non-Italian women giving birth amounts to 10.2%. This percentage is higher in the centre-north of the Country, especially in the Lombardy region, where 16.1% of all births are to non-Italian females. These women originate mainly from Eastern Europe (36%) and Africa (26%). Those from Latin America and South East Asia, represent respectively 10 and 18%. On average women in Italy and within the European Union give birth between the ages of 30 and 39 (60%), women from other areas tend to give birth at an earlier age (20 – 29 years of age).
Available data confirms that expecting immigrant females experienced more complications when giving birth and found it more difficult to receive health care whilst pregnant. According to statistics published by ISTAT (The Italian Institute for Statistics), in 1994 the mortality rate for a child born to a foreign couple was 6.6 per every thousand. When the father was Italian, the rate would drop to 4.9 per every thousand when both parents were Italian the rate would be 4.1.
Comparable results have been obtained in the Lazio region between 1992-1996, where the mortality rate was 7.4 per every 1.000 infants born to a foreign mother, compared to 3.5 when the mother was Italian. Differences were also experienced in neonatal mortality (9.3 infants dead within the first 28 days of gestation to every 1.000 born alive to immigrant women, compared to 4.3 every thousand when the mother was Italian). Data referring to postnatal mortality also show the same pattern (2.6 dead per 1.000 born alive, to an immigrant mother and 1.3 per 1.000 to an Italian mother).
Furthermore 9% of children with a birth weight of <2.500 gr. are born to mothers from developing countries. This percentage rises to 5.2% when the mother is born in the Lazio Region and to 4.4% if she originates in developed countries.
Looking at health issues relating to the immigrant female, the following transpires:
v a high rate of miscarriages;
v a lack of information, which prevents women from seeking help and assistance during pregnancy:
v the high incidence of genital female mutilation (FGM).
It is therefore necessary to give special consideration when treating the immigrant female, to differences of lifestyle and culture. This need which was highlighted in the past, has been further emphasised within the 2003-2005 Health National Plan which deals specifically with the health of the immigrant population. Within this plan, priority will be given to the welfare of and assistance to pregnant foreign women and to achieving a reduction in the number of women seeking an early termination.
One also need to look at FGM and the lack of information to second generation immigrants with one or two parents originating from those countries where FGM is usually performed.
A National Institute of Health (ISS-Istituto Superiore Sanità) survey has shown that voluntary terminations carried out by foreign (immigrant) women have increased from4.500 in1980 to20.500 in1998, with a higher percentage now made up by older women. According to available data, in 2002 the number of voluntary terminations was 130,690 (a decrease of 1.2% in comparison with 2001 [132,234 cases] and of 44.3% when compared with 1982, when the highest numbers [234,801] was recorded).
It is not easy to ascertain why women seek an early termination and current data analysis tends to confirm that there are no clear cut reasons even taking into account their age, marital status, number of children, literacy, place of residence and country of origin. The most probable hypothesis, which was first thought of in 1980s, is that women seek early termination as a last resort following the failure of contraception methods used during intercourse.
It is clear that the need for an early termination has decreased amongst women in a stable relationship, who are well educated, and have a steady job. These are women who have access to information, are better equipped to use available health services, especially family planning clinics where they can receive the most up to date information regarding the various contraceptive methods and can make more informed choices as to which suits them best.
Again data obtained from ISTAT show that in Italy, in 1988, 32.5 per 1.000 foreign women sought an early termination, as compared with 9.1 per 1.000 of the indigenous female population. These statistics refer to the 18-49 age group. When considering these numbers, it is worth remembering that most of these foreign females have a poor standard of living and often come from regions where early termination (be it legal or illegal) is more common than in Italy.
Analysis by age and citizenship shows that the highest rate of early terminations in the Italian female population occurs in the 25-34 age group, whereas immigrant females tend to seek a termination at an earlier age and again later on in life.
From 1995, ISTAT has started to collect and publish data on the number of women in Italy who seek an early termination. Since 2000 these figures have also been collected at regional level and show a constant increase of abortion carried out on foreign women, resident in this country (8.967 in1995,9.850 in1996,11.978 in1997,13.826 in1998,18.806 in1999,21.201 in2000 and25.094 in2001). This is mainly due to the increased presence of foreign migrants and contributes to the general increase in national statistics. In 2001 248.6 early terminations were carried out (for every 1.000 new born), a percentage cut of 0.8% when compared to 2000. In 2001 were carried out 9.5 early terminations per 1.000 fertile women, with a reduction of 1,8% compared to 2000.
In 2001, the number of early terminations carried out on foreign women, represented 19.1% of the national data and in some regions, such as Piemonte, Lombardia, Veneto, Liguria, Emilia Romagna, Toscana, Umbria, Marche e Lazio, the percentage of terminations relating to foreign women, reached 20%. These were mainly women who lived and resided in our country.
An accurate study of Discharges of Patients (Schede di Dimissione Ospedaliere-SDOs), shows that pregnancy and related pathologies are amongst the most common causes for hospitalisation (15.8% of all foreign women, against 2.9% at national level), as are head injuries (severe and not) [10.1% of all foreigners against 2.2% at national level) and abortions (3.8% in foreign women, 0.5% at national level). Again this would confirm that foreign\immigrant women tend to be less knowledgeable as regards contraceptives, that they live in far more precarious situations, they lack family ties, economic means, adequate housing, work, a social network, and that they are more at risk because of prostitution.
Generally better services have been provided during pregnancy, at the time of childbirth and after. For example there has been a reduction in the number of women who have the first check up during the first three months (from 25% to 16%). It also transpires that on average both Italian and foreign women have the first scan at roughly the same time. However, 4% of foreign women still fail to receive medical assistance during pregnancy and 17% face great difficulties in accessing the necessary services. Foreign women are still more likely to give birth prematurely (8.8% as opposed to 4.6 amongst the indigenous population).
As regards the levels of knowledge, these have increased since 1995-96 but are still ruefully low when compared to those of their Italian counterparts. The majority of women had no prior medical knowledge or very little indeed. We would therefore, like other contributors before, recommend that prevention, diagnosis and welfare should be redefined to better suit this section of the population.
Caesarean Deliveries
It is not possible to determine the percentage of elective primary caesarean delivery (Tces) in this country, even though national policy requires that a distinction to be made between Tces and Caesarean Deliveries (CD) during the labour. Unfortunately such data has only been collected in some of the Regions but not at national level. This binary classification does not take into account urgent cases of CD.
In Italy the percentage of CDs has increased from 11.2% in 1980 to 27.9% in 1996 and 33.2% in the year2000. Inthe last ten years, the use of CDs has constantly increased reaching extremely high levels in some of our regions. Campania (the region around Naples) for examples has since 1996 held the record for the most performed caesarean deliveries. 36.3% in 1996 and 51.4% in 2000.
In the Province of Trento, in 2001, of the 5.030 babies born the incidence of Tce was 11.8% (Total DC 26.0%, urgent DC 14.3%). In the Veneto region, in 2002, were recorded 18.3% of Tces thus showing an inverse proportion between Tces and non-Tces to those in the Trento Province (Total DC 29.4%, DC in labour 11.1%).
In the Region of Emilia-Romagna, the regional model requires the identification of non urgent DCs outside labour, urgent DCs outside labour, and DCs whilst in labour. Using this differentiation, it has been possible in 2003 to determine quite precisely the percentage of Tces (18.6%). (Total DCs 31%, DCs whilst in labour 10.3%, DCs outside labour – urgent 1.8%.)
SDOs have helped to highlight the limitations of current guidelines for DCs and the lack of agreement in diagnostic definitions. The frequency of DC could be better described when using Robson’s classification, where deliveries are divided in 10 clear sections, defined by: parity, number of foetuses, obstetric anamnesis, period of gestation, labour and birth.
These sections are mutually exclusive, totally inclusive, easy to create and use.
In Italy, a study carried out in Emilia-Romagna in 2003, on the incidence of Tces has shown that differing schooling levels do not seems to influence the mothers’ choice.
There has only been one paper investigating women’s preferences with regard to childbirth. In1999 astudy showed that of all women interviewed after undergoing a natural childbirth, 89.9% said they would make the same choice, second time round. The interviews were carried out with 1986 new mothers in 23 university hospitals throughout the country. 77% of those women who delivered by caesarean said, next time round they would rather have a natural birth.
Conclusion
Health taken in its widest context, is now universally recognised as one of the most fundamental and important of human rights and as such it needs to be addressed.
In Italy, as well as in other countries, women live longer than men, but the state of their health appears to be worse, not only in subjective terms but also because of the social disadvantages caused by their heavier workload and by the lack of economic and cultural resources. Theright to lifeis a fundamental one and it implies not only the right to procreation, but also the right to protection. In order to comply, women all over the world must have access to those services that can facilitate child bearing and delivery.
In order that the National Health System (NHS) can find effective solutions for the improvement of the health of all women it is necessary to realize a new perspective that is characterized by “multi-causality” and “multi-sectoriality” of the health care interventions, that will have to consider disease, disability and quality of life as the result of the interaction between human biology, life-style, environmental and cultural factors. This innovative approach will be able to come true only through common actions and single planning coordinated and carried out by structures of the NHS. These include the human resources for health (HRH), that can be defined as the complex of all individuals engaged in promoting, protecting or improving the health of the women as well as the public health. HRH issues are strongly linked to non-health policies and should be dealt with in the context of development and macroeconomic policies. But actions and plans must be financed by public agencies (Ministry of Health, and different domains of health systems such as Administrations of Regions, Provinces and Municipalities, Ministry of Justice, of the Interior, of Labour and Social Security and Ministry of Education) and by private institutions (Foundations, NGO, ONLUS, private for-profit and not-for-profit systems and other private social institutions). It is also acknowledged that health workforce development should be considered in a broad perspective, taking into account the influences of globalisation, national and sub-national political, socio-demographic, economic, geographical and cultural factors. A systematic development of such interdisciplinary activities, with the supervision of international organs of surveillance could supply, within the next 5-7 years, useful indications on the effectiveness of interdisciplinary methods of prevention, diagnoses and treatment, and obtain immediately enjoyable, extensible and reproducible results on all the national territory.
It is well know that poverty in Italy as in Europe and in the world, is multidimensional and is linked not only to material deprivation but also to low educational achievement, poor health, vulnerability and exposure to environmental and occupational risks, as o voicelessness and powerlessness. “Disease weighs heavily on economic development. … But economic development requires more than just healthy individuals. […] Economic development is a multisectoral process, and the strategy for economic development must build on a broad range of social investments as well as strategies to encourage private-sector business investments.”
Therefore, it can be firmly stated that:
“the Health Care Services can widely contribute to economic development”(Erio Ziglio, Rogerio Barbosa, Yves Charpak, Steve Turner HEALTH SYSTEMS CONFRONT POVERTY Public Health Case Studies n.1,WHO European Office for Investment for Health and Development, Geneva 2004).
The scientific confirmation of such important conclusion comes to us proposed also by the WHO that, in a document recently published introduces some examples on how the Health Systems of the European Region, that comprises 52 States and a total of over 900 million inhabitants, can contribute to reduce the poverty and to improve the public health. Although the same document acknowledges that it is difficult to recommend similar policies and methods for the whole European Region, we believe that some of the examples described in this study can be repeated easily in other situations in the same Country. In fact, the reproducibility of innovative models of social-health care inside the same Country is based necessarily on the common legislation and in the totality of practices, social values and expectations substantially shared by the national community.