Women's health in a marginal area of Kenya

Sot. Ser. ‘Med. Vol. 23, No. I, pp. 17-29. 1986 Printed in Great Britain

._ 0377-9536;86 53.00 + 0.00 Pergamon Journals Ltd

WOMEN’S HEALTH IN A MARGINAL AREA OF KENYA*

ALXN FERGUSLIN Medical Research Centre, Department of the Kenya Medical Research Institute, P.O. Box 20752,

Nairobi, Kenya

Abstract-As eco-demographic pressure on the cultivable areas of tropical Africa increases, women, the main food producers in such areas, are experiencing serious threats to their physical health. Eco- demographic pressure may be defined as the effect of a rapidly-growing population, dependent largely on subsistence production, on the human carrying capacity of an ecological region. Continued subdivision of plots from father to sons, overgrazing, and soil erosion lower agricultural productivity and create periodic food shortages, the main burdens falling most heavily upon the poorest people. Migration to cities in search of wage employment, or to lower-potential areas in search of land are common responses.

Eco-demographic pressure in the high potential areas of Kenya has been responsible over many years for the migration of agriculturalists into marginal lands. The partial break-up of traditional modes of production and the difficulties of cultivating in a semi-arid environment greatly increase the demands on available labour, whilst levels of health are poor and health care delivery inadequate.

It is suggested that women, in particular, are subject to a high degree of stress and evidence of such stress and accompanying ill-health is presented using data from a survey conducted in Kibwezi Division of Machakos District, Kenya. Higher-than-average economic dependence on women is shown in the demographic structure. Water collection patterns show that 70% of all trips are made by women over 15 years over a median distance of 3.5 km and that 87% of women collecting water carry loads without any mechanical assistance compared with 42% of men.

Fertility levels remain high and anthropometry revealed that women in the survey were thinner and shorter than a comparable group from a more fertile part of the district. Using functional criteria, the data suggest a higher prevalence of chronic disablement amongst women, compared with men, and the disabilities mentioned tend to reflect the hard lifestyle and high fertility levels of women in Kibwezi.

Key words-women’s health, eco-demographic pressure, Kenya, migration

INTRODUCTION

Migration between rural areas is a continuing phe- nomenon in Kenya. Expansion into the former White Settler farms in the Highlands and Rift Valley was rapidly effected in the post-independence years [I] but continuing population pressure in the Highlands has intensified the migration flows towards the drier marginal areas, particularly in Eastern Province and the Rift Valley. Bernard notes that some parts of the arid and semiarid areas have population growth rates of between two and ten times the national average [2].

As Wisner [3] has suggested, marginalization can be seen both in the physical sense of a forced movement into an area where agriculture is more difficult and living conditions are harsher and in the sense of the marginalized population being able to exert less pressure for public goods and services and having less political ‘clout’.

Marginalizaton as a process of invasion of a traditional self-sufficient peasant mode of production by a capitalist market economy has been well documen- ted in East Africa [4-61 and the continuing settlement

*The data on which this paper is based was collected whilst the author was a consultant with the African Medical and Research Foundation (AMREF). Grateful thanks are expressed to AMREF for permission to use this data. The views expressed in the paper are those of the author and do not necessarily represent those of AMREF.

of low-potential land by agriculturalists originating in high- or medium-potential areas may be Seen as a continuation of the process [2,7-91.

In common with other migrational movements, migration to the marginal lands of Kenya involves changes in traditional family and kinship ties. ,Move- ment is usually made by only a section of the extended family and, often, the male head of a nuclear migrant group will remain in the new area only for as long as it takes to clear the bush and build a rudimentary house. He may then return to his original farm or to a job in the city. Wives then become the de facto heads of household. Some con- tinuity in kinship ties is often achieved by younger elements of whole communities migrating en masse to a new area. Mutual support, particularly in sharing labour, may therefore be preserved.

Despite attempts like these to preserve traditional modes of production, marginalization almost inevit- ably means coping with a more difficult life-style. Labour demands, in particular, are heavier than before and, given the reduction in family and commu- nal labour supplies, they are often unfulfilled. The recent establishment of free (and compulsory) pri- mary education in Kenya has aggravated the labour shortages substantially.

Substitution of capital for labour is difficult because of the impoverishment of the migrant population. Provision of credit to marginal farmers, most of whom are squatters, exists on a small scale, but

17

18 ALAN FERGUSON

through Government agencies only. Recently, sub- In this paper it is suggested that, while health stantial amounts of foreign aid have been channelled problems affect all people in marginal areas, mar- through the Kenya Government to improve in- ginalization has a disproportionate effect on the frastructure, public services, agricultural extension health of women. The lower productivity of the land. and soil conservation in the semi-arid areas but combined with selective changes in traditional modes with variable impact. Bernard suspects that of production impact most heavily on women of “Efforts. . may require decades to show positive childbearing age and the effect on health is mea- results” and Migot-Adholla suggests that Govern- surable. ment policies, by restricting traditional responses to environmental stress, have contributed to “the deteri- oration of human conditions in these areas” [2, IO]. KIBWEZI: A MARGINAL AGRICULTUR-\L AREA

Migration to marginal areas has a detrimental effect on health. Migrants are exposed to a greater The empirical evidence is drawn from Kibwezi range of environmental diseases, particularly malaria, Division, Machakos District, an area into which against which they have no acquired immunity. Poor much recent migration has flowed from the more hygiene leads to a high prevalence of gastro-enteric productive, but overcrowded, upper areas of the disease and helminthic infections, and immunization district. Sindiga [l l] has calculated that, in 1979, the coverage and general health care are rendered more available amount of good agricultural land per per- difficult by the poor communications and dispersed son in Machakos District was 0.23 hectares, the third low density population. lowest amount of Kenya’s 42 districts. Population

Wisner [3] has indicated the connection between growth in Kibwezi between the 1969 and 1979 Cens- marginalization and poor nutritional status in a uses was 17 1% . over four times the national average. sampled gradient in Kitui and Meru Districts. Fam- Figure 1 shows the location of the study area. ilies inhabiting the more marginal areas contained Kibwezi is a dry area. Rainfall is bimodal, provid- much higher proportions of malnourished children ing two growing seasons, but is erratic in terms of compared with those living in the high-potential spatial coverage, date of onset, duration and in- zone. tensity. Fenner [ 121 notes that .‘. . on average, more

U 0 A N iI

ETHIOPIA

TANZAkIA L

I *\ INDIAN

‘\ - -

0 100 200 so0 i

‘A

KILOMETRES *\. OCEAN

:s* E

Fig. 1. Kibwezi division, Kenya

Women’s health in a marginal area of Kenya 19

0! 1967 66 69 1970 71 72 73 74 197s 76 77 70 79 1980 81 82 83 64

Fig. 2. Makindu: monthly rainfall 1967-1981, I2 month moving average.

than one-third of it falls on just four days in each year”.

Figure 2 shows a 12-month moving average of monthly rainfall at Makindu, in the north-west part of the area, between 1967 and 1984, while Fig. 3 uses the same data to show unreliability of rainfall in the two growing seasons. Two months of at least 50 mm followed by one of at least 25 mm is considered the minimum necessary, given the high evapo- transpiration rates, for a reasonable maize crop. A

series of good years in the late 1960s and late 1970s encouraged migration into Kibwezi, but intervening and recent droughts have caused much hunger and hardship. Kibwezi received famine relief after three consecutive failures of the seasonal rains, in 1983 and 1984.

The rains impart heavy seasonality to food availability. Subsistence crops are bought and sold in different quantities at different times of the year, and, in general, the seasonal variation in prices means that

1667 -

l66.-

I609- - -

IOIQ- - -

197l- - m. . . . .

1972-

l973- D B -

l674- --

1976- - -

l976- -

l977- m . . . . .

1970 -

1979- D - m.....

two- -

19.1 - -

I9.2- -

IU2- -

l664- - m . . . . .

, 1 I I r I I I I I I I I

FL6 MAR APR MAY JUNE JULY AUC SEP OCT NOV DEC (JAN)

Fig. 3. Makindu: growing season months. - Month with > 50 mm rainfall; .... . month with > 25 mm rainfall which follows at least 2 months of > SO mm.

20 ALAN FERGLSON

MBEMBA

(MAIZE)

100 SELLERS - 359 BUYERS = 441

I60 4

140

~~~,~~~~

I I I 1 , , I 2 3 4 5 6 I 1234561 1234561

MBOSO

(BEANS)

SELLERS :330

140 BUYERS = 400

IPIGEON PEAS1 I : Jon - Fob

KIS: MARKETING OF SUBSISTENCE CROPS AND ANIMALS

,BO- SELLERS : 290 2 BUYERS = 296

160-

140-

120-

IW-

1234561

Mar - Apr,l

May - Jun.

July - Aq

SeP - act NW - Dee

480

440

360

320

240

160

1

ALL 5 CROPS

TOTAL SELLERS : 1246

TOTIL BUYERS : 1437

I‘ N

I ‘1

I I i

All month _-- s*ll*r¶

Fig. 4. KIS: Marketing of main subsistence crops. - Selling food crops; .. “. selling animals: --- buying food crops.

farmers are selling when the prices are low and of buying in food for the hungry months of the buying when they are high. year.

Figure 4 shows the buying and selling patterns of the main subsistence crops by house-holders in Kib- wezi. The data have been collected from the Kibwezi Integrated Survey (KIS) [13], described in the next section. Despite the two harvests, selling patterns show only one peak, after the long rains. Food buying peaks in the last 3 months of the year after the long dry season, when labour demands are highest and nutritional status is at its lowest. Empty stores before the January harvest probably explains the lack of a second selling peak, while the sale of animals, peaking in August. may provide much of the means

The four main subsistence crops, maize, beans, cow-peas and pigeon-peas, provide a well-balanced diet, but shortages of food are chronic and stunting is common in children. The 1982 Child Nutrition Survey [14] suggested that 23% of children in Machakos Disthct were below 90% of standard height for age and the Kibwezi Integrated Survey [ 131 showed exactly one-third of children between 2 and 6 years old to be under the 90% mark.

Lack of water is the most frequently expressed agricultural problem, followed by shortages of farm inputs-equipment, seeds, labour-and the destruc-


tion of crops by wild animals and insect pests. Although nearly all migrants are squatters, land shortage is not perceived as a problem. When questioned people usually talk about shortages in production rather than the distribution problems which, to an outside observer, are more obvious. Nearly every household has some livestock, particularly goats, the main form of liquid assets. Cotton is the main cash crop, grown by 40% of households but on a very small scale. There are some favoured areas where spring-fed irrigation produces high-grade veg- etables for urban and overseas markets, but few farmers have access to irrigation.

Off-farm employment is limited to some Govern- ment functions in Kibwezi town and Makindu, to the railway workers and to some small businesses in the market centres along the main Nairobi-Mombasa road. Population is just over 100,000, highly dispersed and with poor accessibility to the centres along the main road.

Health in Kibwezi is poor. Malaria, gastro-enteric and respiratory tract infections are the most common ailments of adults. In children, diarrhoea, measles, parasitosis and malnutrition are common and deaths from diarrhoea are frequent. In response to the difficulties of providing standard health facilities to such a dispersed population, the African Medical and Research Foundation (AIMREF) in 1978 embarked on a community-based health scheme operating from a new health centre in Kibwezi town. The most innovative element of the scheme was to motivate communities to provide men and women for training as community health workers (CHWs), with the aims of promoting health-improving practices and providing limited curative care for the most common ailments. By 1983, over 100 CHWs had been trained, each covering 40-100 households in the rural areas of the district.

The community-based health scheme in Kibwezi suffered many teething problems, not least of which was the discouraging effects of the droughts in 1980 and 1983. Amongst the first group of 37CHWs trained in 1979, only three remained active in 1983. The concept of voluntarism, common enough in more traditional activities, was a difficult concept for both the community and the CHW to accept readily and resulted in much disillusionment [15].

Impact of CHWs on maternal and child health is limited, partly because most CHWs are male-only 7 women were selected by the community for CHW training out of 44 in two Kibwezi villages in 1981 [15]. While some positive impact can be seen in promoting child health and in improving the performance of traditional birth attendants, family planning has been a non-starter with the CHW scheme. However, the scheme is still expanding and many of the earlier problems have been overcome (e.g. the high rate of attrition) and there is hope that a more positive impact over a wider area will be forthcoming.

In the second phase of the programme, AMREF formally expanded its concern to health-related fac- tors, particularly water supply, and an integrated survey linking demography, agriculture, water, chronic disability, diarrhoea and nutrition was carried out. Results from the Kibwezi Integrated Survey (KIS) [I31 are used here to investigate the health

status and lifestyle of women and to attempt to show that marginalization has particularly detrimental effects on the health of women of childbearing age.

KIBWEZI INTEGRATED SURVEY

The survey was carried out in October-November 1983. A standard household questionnaire was ad- ministered in 524 households (about 3.5% of the total), randomly selected within 21 strata based on dry season water supply sites. Figure 5 shows the location of these sites and Plate 1 shows a queue for water at Mwitasyano, one of the wells developed by the community of a self-help basis. In addition to the questionnaire survey, anthropometric measures of mothers and children were taken in a sub-sample of households. Stool samples were collected from women and children to assess the prevalence of intestinal infections and blood samples were taken from a further group of women for haemoglobin assessment.

All interviews were carried out by CHWs and health centre personnel were responsible for collection and analysis of stool and blood samples, so a fair measure of community involvement was main- tained.

The results of the survey, as they apply to the health status of women, can be considered under the headings of demography, water collection, fertility and nutrition and- chronic disability.

DEMOGRAPHY

Figure 6(a) and (b) shows the population structure of the Kibwezi sample compared with that of Kenya as a whole in 1979. Comparison of the age/sex pyramid from the households sampled with that of Kenya shows three main features.

(a) There are much higher proportions of children in Kibwezi. 58% of the sampled population is under 15 years and 6% is under 1 year.

(b) There are very few old people. Only 2.8% of the sampled population is over 50, compared with 8.8% in the country as a whole suggesting the ‘pioneer’ nature of settlement in the area, but also, perhaps, comparatively low life expectancy levels in Kibwezi. Anker and Knowles estimate life expectancy at birth to be 47.0 years in Machakos in 1979 compared with 47.8 years for Kenya as a whole P61. (c) As a proportion of total population, women

aged 20-39 are more highly represented in Kibwezi, compared with Kenya as a whole, while Kibwezi has correspondingly lower proportions of males in this cohort.

Taken together, these features suggest a high de- pendency on women of child-bearing age. Some 30% of the households sampled had de facto female heads and, of these, two-thirds had husbands employed and living elsewhere and the remainder were economically independent.

Other parts of IMachakos District have higher proportions of female heads of household but in somewhat easier living conditions. The heavy in-

ALAS FERCXSOS

MUTHINGIINI

MANGELETE Kothekoni Station (13)

Fig. 3. Kibwezi integrated survey: water sources and codes.

migration to Kibwezi is reflected in the settlement characteristics of the households sampled. The median length of residence was 11 years. Only 50 persons from the 524 interviewed were living in the village in which they were born and only 20% had been born in Kibwezi Division.

Nearly all migration flows originate in-other parts of Machakos District, with just under 75% of migrants originating from within the district. Commu- nity migration is very common and the only ‘second generation’ areas are around Kibwezi and Makindu towns where commercial plantations and transport

- facilities are long-established.

The main aspects of the basic demography perti- nent to women’s health are:

(a) Despite the changing structure of households brought about by migration, crude birth rates have remained high and the proportion of children in the Kibwezi population is higher than the national average.

(b) Whilst maintaining high fertility rates, many women function as de facto heads of household and therefore have to cope with a wider range of responsibilities in difficult conditions (see, for example, the next section).

u’oms2’s i&t5 in a marginal axa 0; Ke~:;a

Plate 1. Community-built well at Mwitasyano.

(a) KENYA (1979 CENSUS)

MALE FEMALE

-T-z-l IO 5 IO

%

60t

50-59

40-49

30 - 39

20 - 29

IJ- 19

IO- 14

s-9

Under s

(b) KIBWEZI INTEGRATES SURVEY (N = 3826)

MALE FEhiALE

I3 IO 3 0 5 10

%

23

1 IS

Fig. 6. Percentage frrqilrncy distributions: demographic structure

Fig. 7. DLstnbution of wawr ax!sumption.

How these features impact on women‘s health is developed below

W,rTER COLLECTIOY

Lack of access to water is a major problem for most people in Kibwezi. The KIS sought information on many aspects of water collection and utilization. including consumption Irv:is. time allocation, distance to SOUKZS, task aliocation and modes of col-

lection. Distances were measured b> the CHWs. using

odometers fixed to their bicycles. a more accurate method than the perceived distance often used in surveys of this nature. Figure 7 shows the frequencies of water consumption Ieveis and Fig. S the distances travelled to the water source. Consumption of water is calculated in .adult equivalents’ {AE) where a child is taken to consume three-quarters of the amount of water as an adult.

Median dry-season distaxe was 3.5 km tone-way) and the median consumption Is\-el pzr adui: equiv- alent per week was 60 litres. In both cases there is wide variation about the medians and fair!:; ske\ved distributions.

\t’ater consumption is constrained by distance from the source and by available means of transport. Consumption levels double on average during the short periods of the rain? seasons. suggesting an unfulfilled demand for water during most months of the year.

W’ater collection is traditionally a task for womT.:n and children in Akamba culture. but. given the dis:ances involved and the youthfulness of the population, it might br: imagned that this tradition wouid break down and collection Lvould be more eqcai!~ shared.

The demography of waier collection suggests that this is not the case. Figure 9(a) and ib) shows water collection by age and sex, unweighted and weighted by weekly trip frequency;.

Water collection, the most constantl>- demanding task, is still highly associated with female labour. Some 70% of all trips are made by women over 15. Women aged X-39, making up 13.29b of the sampled population. make over one-half of all water collection trips and 91” o si women in this cohort arz engaged in this task compared to 25% of men in the corresponding age grou?. Children are engaged in water coliection mainI> a: weekends, but compulsoc,

20 - 29

fj- ‘9

IO - ,‘I

5-9

?‘a

Fig. 9. Water collection: Males and females

school attendance has increased the burden on women.

When mode of transport is considered, the in- equality is increased. Table 1 shows male and female trip frequencies by walking and other means of transport.

Most men who help in water collection use bicycles. ox-carts or donkeys; women carry water on their backs. Only 50 of 794 women enumerated were privileged enough to use a bicycle to carry the typical 20-litre load. The dominance of transport technology by men has been noted recently by McCall [17]. Perhaps the situation is best summed up by the example of a household where both husband and wife made one IO-km round trip each day, each collecting 20 litres of water. The only deviation from this equal division of duties was that the wife walked while the husband took a matatu (taxi) back home.

The time and effort spent on water collection places heavy constraints on other activities. Women were asked how they thought they might utilize the extra time if water was available at their home. Most suggested that farm work: firewood collection and domestic tasks would be substituted; few women considered relaxation as a possibility, even taking account of the fact that most women spend 34 hours a day collecting water. One weary lady, however, admitted: .*. . I would just rest at home as my body is so tired”.

The physical efforts involved in water collection are heavy. On average, women are carrying 2C-25 kg loads for 3.5 km, 1.5 times per day on rough terrain and in temperatures of up to 1O’C (see Plate 2). At any given time, nearly all the women collecting water will be pregnant or breastfeeding. The effects of such a constant. heavy burden on women’s health are substantial.

FERTILITY ASD .LLTRITlOS

The age-sex pvramid discussed earlier suggested high levels of fertility, which can now be looked at in more detail, together with some of the findings from the nutrition survey. These are discussed together since, in a situation where there is a chronic food shortage, the additional nutritional demand5 of pregnant or nursing mothers often go unmet.

In Table 2. :he average number of iive births reported by the women interviewed is presented by age group and compared with figures calcuiavd from c an extensive study of maternal and child heeith in the northern part of Machakos District (the Joint Project Machakos) [18] and with fertility estimates for Kenya as a whole [19].

The evidence of Table 2 suggests that marginalization does not act to reduce fertihrv levels despite the increased economic responsibilities of women and the heavier physical demands on them. Indeed, the evidence is that fertility levels are be- coming higher in Kibwezi and are already higher than those of the medium-potential JPM area and Kenya as a whole. Fertility levels are particularly high amongst the women under 30. The lower numbers of births reported by women of 45 and over in Kibwezi compared with the two lower cohorts may also suggest increasing fertility, although it is likely that some old women could not recall all their preg- nancies, especially if the child died soon after birth.

The existence of high levels of fertility in Kibwezi illustrates a paradox of marginal agriculture: a marginal area has a lower human carrying capacity but requires additional labour inputs, other inputs being equal, for the same agricultural output as a higher potential area.

Crude birth rates can be estimated from the numbers of children under 1 year enumerated in the sample and from the proportions of women of re- productive age who were pregnant at the time of the survey. In either case. the result is a birth rate of around 6.5%. compared with an average rate between 1975 and 19-g of 4.69% in the JPSI area 1201.

Fertility is therefore high. and possibly izsreasing. Since polygynous marriages were found in iess than 1% of households. the only real constrain: to even

*4j-l9 age group

higher rates is breastfeeding. which normally con- tinues until the child is 2 years old. The penod of post-partum infertility may thus be prolonged although its effectiveness will be grcatiy reduced as the intensity of breastfeeding declines. In the survey, over one-half the mothers had introduced vveaning food by age 4 months and 84% of mothers cited 6 months or less as the period during which breast milk alone was thought to be sufficient for the baby.

High fertility rates and long breastfeeding periods create extra nutritional demands and the heavy physical daily- labour means that the base levels of nutritional requirements are high for women. How- ever, the probability that nutritional intake is sufficient for women, especially the majority who are pregnant or lactating, is low.

An mentioned earlier. the diet is remarkably well- balanced, but there is usually an absolute shortage of all foods. This is obvious in children by the prevalence of stunting (339/o under 90% standard NCHS height for age).

The long brzastfeeding periods are indicative of a shortage of weaning foods and can be viewed as a partial transfer of the nutritional deficit from children to mothers. X marked seasonality of births in August-l 1.1 %I of all births in rhz sample population between November 1978 and October 1983 occurred in this month-tends to increase nutritional stress on nursing mothers even further. as the period of in- tensive breastfeeding then coincides with the hungry season which is also the time of peak iabour demand (October-December), The August maximum is probably related to an influx of city-based menfolk in November in response to the demand for labour. Dyson and Crook [?I] have noted this type of effect in relating birth seasonalities to the agricultural cycle.

Anthropometry reveals the extent of nutritional stress on mothers. Using Quetelet’s Index (weight divided by height squared) as a measure of total body fat [22]. Figure 10 shows that almost half of the sampled women have values of under Q = 2.0. the cut-off for ‘slight obesity’. Those in the lower quartile

P!ate 2. The road to Nooka

Women’s health in a marginal area of Kenya

Fig. 10. Quetelets Index (W/H?). N = 153 adult women in Kibwezi.

are likely to be suffering from quite severe under- nourishment.

Comparison of Quetelet Index values for the Kib- wezi sample with those found by Jansen [23] in a sample of Akamba women from the more fertile part of northern Machakos referred to above [18] shows consistent differences. Results are shown in Table 3.

larly those harbouring hookworm, indicate severe anaemia and loss of nutrients. The overall low levels may reflect presence of malaria parasites and also the relatively high proportion of pregnant women, but it is clear that intestinal parasites are associated with very low haemoglobin levels.

Kibwezi women had less body fat in each age group, the differences being statistically significant for the main childbearing group and for the entire sample. Interestingly, they were also significantly shorter than the women in the comparative group (Kibwezi: mean height = 154.8 cm, SD = 5.95, JPM Area: mean height = 156.5 cm, SD = 5.5). This may be an indication of inferior long-term nutrition levels of the poorer migrant community as well as the relatively low weights caused by the prevailing food deficit in Kibwezi.

Having previously concluded that food intake is inadequate for most women in the sample, we can now further conclude that intestinal parasitosis is an additional aggravation of widespread prevalence.

CHRONIC DISABILITY

In tropical Africa, poor nutritional status is often compounded by the presence of intestinal parasites. Stool analysis showed that about one-third of both women and children had at least one parasite type present. Hookworm was the most frequently found parasite amongst the mothers and the most common helrninthic infection of children which suggests that Kibwezi tends to follow an ‘East Coast’ typology of helminth distribution rather than a ‘Kamba type’, as described by Diesfeld and Hecklau (241. The effect on women’s nutritional status was gauged by comparing haemoglobin levels for those affected and those free from parasitosis (Table 4).

The final piece of evidence presented here is derived from the preliminary assessment of the nature of chronic disability in the area. In this part of the survey, chronic disability was self-defined and no clinical verification was made. A chronically-disabled adult was defined functionally according to the response to the question “Is there anyone in the household who can never perform their normal duties because of weakness or sickness?” A positive response prompted details of the disability to be elicited and a similar question was framed with regard to children.

Haemoglobin levels are low, even for the non- infected group, but those of infected women, particu-

Using this definition, just over 20% of the households contained a person with some claimed chronic disability and several had more than one disabled member. The overall prevalence was 4% of the sampled population. Prevalence was very uneven over the age-sex Lohorts and, as Table 5 shows, the most susceptible groups, apart from old people, were women of childbearing age.

Table 3. Ouetelct’s Index: women in Kibwezi and N. Machakos

Age group n

Under 25 24

Kibwcri N. IMachakos

Q.1. Q.I. Mean SD n Mean SD

2.04 0.28 237 2.09 0.34

DiEerence of means rest

I-value

0.87 25-34 7s 2.02 0.28 57 2.12 0.28 1.99’ 35-44 36 2.00 0.30 41 2.07 0.31 0.99 45f 18 2.05 0.32 81 2.16 0.45 1.21

All groups 153 2.02 0.29 416 2.09 0.26 2.62’.

*Significant at P < 0.0s on a one-tail test. *‘Significant at P < 0.01 on a one-tail test.

28 _ ALU FERGCOON

Table 3. Hb: Infected and non-infected women

Mean Hb. SD n

Ko parasites 11.07 I .63 82 Parasites (all types) 8.55 2.2 55 Hookworm 7.4 0.97 19

From age 20 onwards, higher than expected proportions of women are chronically disabled. This is only the case for males in the over-40 age group.

The nature of chronic complaints also differs between adult males and females. Stomach complaints, often a euphemism for gynaecological problems, and general body pains, are highly associated with women. Men were more susceptible to eye problems, chronic coughs and injuries which had chronic results, while chest pains accounted for 29% of all reported disability for both males and females. Only 7 respondents out of the 154 reported chronic sufferers had not sought treatment for their problem and over one-half of the treatment-seeking trips were to facilities outside Kibwezi Division.

It is tempting to link the combination of high fertility rates, heavy physical labour and inadequate nutrition levels with these findings. While many of the symptoms reported are general and rather vague, they seem to reflect the extremely hard life led by the women of Kibwezi. Indeed, one possible reason for the higher prevalence of functionally-defined chronic disability amongst women may simply be that the physical demands made on women are that much greater and therefore even a slight physical handicap may greatly impair a woman’s ability to discharge all her duties successfully.

CONCLtiSlON

Agricultural marginalization has imposed new modes of production on the Akamba of Kibwezi which are particularly detrimental to the health of women. The evidence from the KIS suggests that women of childbearing age form a cohort which is under heavy and almost constant stress. Some traditional divisions of labour have altered, but not in a way which has allowed a more equal sharing of the additional burdens of life in a marginal area. Indeed, the local population structure, with a fairly high proportion of female heads of household, dictates that women assume more economic responsibility with fewer potential returns. Other traditional modes (e.g. water collection) have not been altered, or are changing only slowly, and are imposing heavy demands on women’s labour.

Fertility has not declined to compensate for the heavy physical outputs involved. There may, indeed, be a perceived need to have more children in order to cope with labour shortages despite the additional physical stress which frequent childbearing imposes on the women. While many men in Kibwezi under- take heavy physical labour, their burden tends to be more seasonal and is not compounded by the additional demands of motherhood.

Anthropometry suggests that the majority of women in Kibwezi are undernourished and this con- dition is exacerbated by the widespread prevalence of intestinal parasitosis, normally considered to be less of a problem in Kibwezi than malaria, gastro-enteric infections and bilharzia. The cumulative nature of these problems is clear: a heavier workload imposes higher nutritional demands which are augmented by high fertility rates and long breastfeeding periods. Seasonal shortages of food are normal and famine is common. The high nutritional demands go unmet and predispose women to a range of debilitating diseases. In many cases prolonged exposure to such stress leads to chronic disability and the burden on

the more healthy women is concomitantly increased. Much planning effort has been directed to Kenya’s

arid and semi-arid lands in recent years, but raptdly increasing population threatens to swamp these efforts and destroy the fragile eco-demographic bal- ance.

Health planning in particular faces a familiar di- lemma: how to improve peoples’ health without concomitantly encouraging more and more settlement of marginal areas. In this respect, the identification of women of childhearing age as a prime target group may go some way to providing a solution. Unfortunately, family planning pro- grammes are unpopular and unsuccessful (particularly amongst Akamba men), but health im- provements may be attained indirectly by attacking some of the features which make women’s lifestyles so arduous. Reversal of the discrimination against women farmers by providing more credit and extension services to women’s groups, of which there are many in Kibwezi, is one possibility. It is clear, too, that any improvement in water supplies particularly benefits women and, since men tend to monopolize technical innovations in water transport, the burden may be subtly shifted to men by promoting improved carrying methods by bicycle, ox-cart or hand carts.

Efforts to dampen the seasonal variations in food availability by community-based grain stores is an- other possibility which would be particularly helpful to women.

Ace

Table 5. Chronx disability: prevalence by age and sex

51ale Female

96 Sample % Disabled % Sample % Disabled

Under 5 I 13.4 5-9 9.7

IO-IJ 7.3 15-19 1.6 X-29 4.5 30-39 4.5 40--19 3.1 50-59 1.8 6Oi 1.0

3.9 3.9 4.5 3.2 4.5 4.5 -7 ::9 7.1

10.6 2.6 9.9 5.8 6.9 1.5 1.9 I .9 73 9.7 5.9 12.3 3.0 IO.4 I .o 6.5 0.6 5.2


Combined with more conventional health- promotive measures at the community level (e.g. MCH-FP information, nutrition education) such ac- II.

tions provide the means of alleviating at least some of the stress borne by women in the marginal agricul-

12.

tural areas of Kenya. Meanwhile, the monitoring of morbidity and mortality amongst different cohorts is

13.

a necessary action in evaluation and monitoring of 14. the impact of such interventions.

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AMREF-YAfrican Medical and Research Foundation). Kibweri Integrated Sumey. AMREF. Nairobi. 1985. Republic of Kenya. Third Child .Vutrition Suney 198-? Central Bureau of Statistics, Ministry of Finance and Planning, Nairobi. 1983. Ferguson A. C. Kibwezi rural health scheme 1978-83, review and assessment. AIMREF. Nairobi, 1983. Anker R. and Knowles J. C. An empirical analysis of mortality differentials in Kenya at the macro and micro levels. Econ. Dec. Cult. Change 29, 165-185. 1980. McCall M. Accessibility and mobility in peasant agriculture in tropical Africa. Paper given at the Institute of British Geographers Annual Conference, Leeds, 1985. Ginneken J. K. van and Muller A. S. (Eds) Muternaf and Child Health in Rural Kenya: An Epidemiological Study. Croom Helm, London, 198-t. Republic of Kenya. Kenya Fertility Surce! 1977-78. First Report. Central Bureau of Statistics. Xfinistry of Economic Planning and Development, Nairobi, 1980. Ginneken J. K. van et al. Population growth. fertility, mortality and migration. In .Cfaternai and Child Health in Rural Kenya: An Epidemiological Studs (Edited by Ginneken J. K. van and Muller A. S.), pp. 59-70. Croom Helm, London, 1984. Dyson T. and Crook N. Seasonal patterns in births and deaths. In Seasonal Dimensions IO Rural PorertF (Edited by Chambers R., Longhurst R. and Pacey A.), pp. 135-162. Frances Pinter, London, 1981. Florey C. The use and interpretation of the ponderal index and other weight/height indices in epidemiological studies. J. chron. Dis. 23, 93, 1970. Jansen A. A. J. Weight, height, weight-for-height and Quetelet’s Index of Akamba schoolchildren and adults. E. Afr. med. J. 61, 272-282, 1984. Diesfeld H. and Hecklau H. K. Kenya: A Geomedical Monograph. Springer, Heidelberg, 1978.

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Women's health in a marginal area of Kenya