Introduction

One of the most powerful women in history, the Queen of Sheba, ruled over the region that is now Yemen. Three thousand years later the women of Yemen are not faring as well. Yemen is ranked 133 out of 169 countries on the gender-related development index [1]. Women in Yemen face numerous barriers to education, self-sufficiency, and health care. Although Yemen’s constitution shelters women by saying that “the State must protect motherhood and infancy and safeguard childhood and youth”, the Personal Status Law negates this in some respects by sanctioning discrimination against women [2]. For instance, it says that women must petition for divorce, while men can divorce at will. In addition, mothers, not fathers, lose custody of their children if they remarry. Women do not have the right to obtain a passport for themselves or their children or to travel without the permission of their husband [3]. In regard to health indices, infant and maternal mortality rates are not on track to meet the Millennium Development Goals, and multiple disparities exist among economic, rural-urban, and educational levels. Yemeni women tend to marry young and have high fertility rates. Many structural barriers to health care persist due to poor infrastructure and widespread corruption and lack of transparency in the government. One of the poorest countries in the Middle East, Yemen has a complex political, cultural and religious history which influences the current state of health for women. The purpose of this paper is to describe the primary health care issues experienced by women in Yemen, identify some of the major organizations that provide health care for women and describe a few of their projects that address women’s health, as well as discuss the primary cross-cultural issues encountered by international aid workers.

Background

Yemen is bordered by Saudi Arabia to the north, Oman to the east, the Indian Ocean to the south, and the Red Sea to the west. As the second poorest country in the Middle East and North Africa (MENA) region, Yemen has real GDP of $530 per capita [4], for unlike most of its Gulf neighbors, it does not have significant oil reserves. At least 35% of the workforce is unemployed, and most of those who are employed work in agriculture and herding, leaving 45.2% of the population living below the poverty line [5].

Although Yemen is poor in resources, it is rich in history and culture. Yemen is one of the world’s oldest centers of civilization and claims connections to famous historical figures such as Noah, the Queen of Sheba, Gilgamesh, and the prophet Mohammad. Yemen has been under the rule of ancient Minean and Sabaean kingdoms; it was part of the Roman Empire, has been under the control of the Persians and Ethiopians, as well as the Ottomans and British. In Yemen’s post-colonial history, it was divided into the People’s Republic of Southern Yemen, which was the only Marxist state in the Arab world, and North Yemen, which was a pro-Western state. The two states merged in 1990 to form the Republic of Yemen. Since unification, globalization has brought Yemen out of its previous isolationism.

Following the terrorist attack on the United States on September 11, 2001, one of the first things that most people read about Yemen in western media sources is that it is the ancestral homeland of Osama Bin Laden, and a safe haven for al-Qaida terrorists. In addition, a few years ago, Yemen gained fame for being a land where girls are married and divorced by the time they are 12 years old [6]. Yemen has made some attempts to clean up its image, including being the second MENA state to create a Ministry of Human Rights, but these efforts have been largely negated in the recent human rights abuses committed by the government against protestors during the Arab Spring revolts [7]. However, Yemen can boast that one of the 2011 Nobel Peace Prize winners was Yemeni woman Tawakkul Karman, for her “non-violent struggle for the safety of women and for women’s rights to full participation in peace-building work” [8]. Yemen has a complex political, cultural, and religious record, and this context is important for the collective history of the Yemeni people, as it influences their culture and way of life.

Religion also plays an important role in the way Yemeni approach their day to day lives. The majority of Yemenis are Muslim including Shaf’i (Sunni) and Zaydi (Shi’a), and there have been small Jewish, Christian, and Hindu minority groups [2]. Although Yemen has been influenced by the west, particularly the long term British colonization of the port of Aden, it is also strongly influenced by the more conservative Islamic sects common in Saudi Arabia. While some claim that Islam is the cause of Yemen’s problems others argue that Islam is the only hope Yemen has. Religious and political leaders believe that “Islam is not inherently an opponent or a proponent of human rights” [2]. Research has found that “Muslim reformers, mainstream clerics, and most Islamists agree that Islamic law does not deny a woman’s right to health, education, information, or freedom of movement” [2]. In any health care intervention, it is important to take into account the religious beliefs of the population and ensure that the program is appropriate in the given context, and recruit religious leaders to participate in and endorse the programs.

Methods

A literature review was performed using the MESH terms “Yemen”, “women’s health”, “women”, and “health”, which returned 21 search results on PubMed, six of which had been published in the past decade. Another search with the MESH terms “Yemen”, “women’s health”, and “globalization”, found nine results, none of which were published in the past ten years or were relevant. The same searches on Google Scholar returned over 7,000 hits, only some of which had relevance to this project. In addition, published data from the World Health Organization, the World Bank, the United Nations, and the United States Agency for International Development was utilized.

The inspiration for this project came from my personal experience. I lived and worked in Sana‘a, Yemen for a year and a half from 2008 – 2010, throughout which time I visited several different women’s clinics and hospitals. During my visits, I observed doctor-patient interactions, and talked to both international and Yemeni health care workers and local women about their views on women’s health in Yemen. These experiences guided me in my research into local and international aid organizations.

The primary organizations from which information was gathered for this study were the Akhdam Clinic funded by Millennium Relief and Development Services (MRDS) [9]; Marie Stopes International (MSI) [10]; a private clinic in Sana‘a called the Women’s Health Care Center; and Yemeni and international aid workers at Deutsche Gesellschaft fur Technische Zusammenabeit (German Agency for Technical Cooperation – GTZ) [11], United States Agency for International Development (USAID), International Committee of the Red Cross (ICRC) [12], and United Nations Children’s Fund (UNICEF).

Findings

Examples

The Akhdam which literally means “servants” in Arabic, refers to the lowest class of people in Yemen, who are even more poor than the average Yemeni, and who often experience discrimination, and lack nutrition, clean water, sanitation, and health care. The Akhdam usually work as trash collectors and live in slums on the outskirts of large cities such as Sana‘a. In 2005 MRDS, in collaboration with the British Embassy, the Sana‘a Ministry of Health, and a Street Sweeper Association, started a clinic for the Akhdam people in one of the slums south of Sana‘a. The clinic is staffed by a male Dutch general practitioner, a female Yemeni general practitioner, and a male Yemeni pharmacist. They serve an average of fifteen patients per day, and more during the immunization clinics they offer once a month. Patients pay a minimum fee of one dollar for adults, fifty cents for children, and the fee is waived for infants and pregnant women. There is an onsite pharmacy, where vaccinations and contraceptives are free, and other drugs are sold at an affordable price much lower than would be offered at a regular pharmacy in town. The primary physician at the clinic is a recent graduate from Sana‘a University Medical School. She would be able to make more money working at a private clinic in Sana‘a, but she feels it is important to give back to her community and has a passion working with underprivileged patients. The primary health concerns faced by patients coming to the Akhdam Clinic are malnutrition, dehydration, hypotension caused from lack of water, family planning, and pregnancy. The primary physician generally treats patients in the clinic, but she refers complicated cases to a hospital or specialist. Sometimes women come into the clinic to have their baby, but often they will give birth at home, and will at times come get the doctor to assist with the delivery at their home.

Marie Stopes International is a non-profit international organization offering reproductive health and family planning services. They are funded by various European donors and work closely with the Yemeni government through partnerships with the Ministry of Public Health and Population (MoPHP). The staff is entirely Yemeni, except for the country representative who is British. Their primary goals are to provide women with contraceptives, to give pre- and post-natal care, and to offer safe abortions and post abortion care. Although according to Islamic law, abortion is illegal in Yemen, it is permitted to save the life of the mother, or in cases of rape or severe congenital abnormality. However, many women get suboptimal abortions by unqualified practitioners. MSI offers abortions at a reasonable cost in order to decrease the likelihood of women suffering from complications from sub-optimal abortions. In addition, MSI offers post abortive care to women who have had complications with abortions performed elsewhere. MSI has five primary clinics throughout Yemen, and has taken various mobile clinics into some of the villages. Workers in the villages provide contraceptives and educate women on how to properly use them. Village women are often ignorant of modern forms of contraceptives. For example, an international aid worker reported cases of women purchasing one package of hormonal contraceptives, and giving one pill to each of her friends, assuming that they will all be protected from pregnancy. MSI works to educate women on family planning, including spacing between childbirths, and provides them with the necessary contraceptives. MSI also reaches out to sex workers in Yemen, who are usually immigrants from Somalia or Ethiopia. Sex workers in Yemen are highly stigmatized, and often do not use condoms. This is not only a danger to the sex workers themselves, but also to the wives of the men who frequent them. MSI offers education, condoms, and STI testing to these populations. Although many of MSI’s outreach programs are fully funded at no cost to the individual, most of the treatments offered in their main clinics are pay for service. MSI offers more services with better quality care than public hospitals. While it is more expensive than public hospitals, it is more affordable than most private physicians. MSI offers treatment and medications on a sliding scale so that they can offer services to anyone who requests it.

The Women’s Health Care Center is a small private for-profit clinic in Sana‘a run by a female Yemeni physician. She has an administrative assistant, a nurse, a laboratory assistant, and a cleaning lady on her staff. The physician is an obstetrician and gynecologists trained in Yemen, India, and England. The clinic is pay for service, which means that most of the clientele is upper class, although they do treat some patients on a sliding scale or pro bono, and the physician spends one afternoon a week working at a public hospital. The most common issues treated are complications with pregnancy, including infection, previous miscarriage, and malnutrition, as well as family planning services, most common of which are oral contraceptives and IUDs. Deliveries are performed either at the clinic, at a public hospital, or at the woman’s home, and the woman and her child are sent home a few hours after delivery unless there is a complication. In addition to the clinic, the physician has a spa attached to the facility, where she and her nurse give massages, do laser hair removal, and nutritional counseling. The spa makes more money than the clinic, although the physician only works there about an hour a day. This discrepancy in funding sources for medical professionals demonstrates one of the reasons why there is such a shortage of doctors in Yemen.

Maternal and Infant Health

Maternal and infant health in Yemen is unsatisfactory according to health indices of the World Health Organization. The Millennium Development Goals (MDG) hoped to reach by 2015 list a target maternal mortality ratio of 87.8 per 100,000 live births, which would still be high compared to much of the world. However the most current data from 2005 shows an actual maternal mortality ratio of 570 per 100,000 live births [13]. Additionally the MDG target under five mortality rate is 40.6 per 1,000 live births, but the 2005 rate is 102 [14]. Yemen’s progress toward the Millenium Development Goals is far from being on target, and the MDGs will not be met without drastic transformation of Yemen’s healthcare system. Infant mortality in 2006 was 75 per 1,000 live births, and Yemen has the most under weight infants in the world, fully 32% of all infants born have a low birth weight [15]. These rates vary widely depending on wealth and whether the child is born into an urban or rural family. Rural children are 1.3 times more likely than urban children to die by the time they are five years of age, and poor children are 2.2 times more likely to die than wealthy children [13]. Quality of life continues to be precarious throughout childhood and into adulthood. Life expectancy in Yemen is 61, and healthy life expectancy is only 49 years of age [13]. Part of the reason for such high rates of infant, child, and maternal mortality is that only 20% of all births are attended by a skilled health professional (physician or midwife), and no more than 14% of pregnant women in have antenatal care consisting of at least four visits [13]. Again, these rates vary depending on wealth, education, and location of the mother. Urban mothers are 3.3 times more likely than rural mothers to have a health professional attend their delivery; wealthy women are 7.3 times more likely than poor women to have access to a health professional during childbirth, and educated women are 3.8 times more likely than uneducated women to have an attended birth [13].

Childbirth in Yemen is viewed as a strictly female occasion. In the conservative Muslim context of Yemen where strict gender separation exists, men are not allowed in the birthing room, and women are unlikely to feel comfortable with a male physician assisting in the delivery. The overwhelming majority of physicians are men, and with the shortage of physicians in Yemen, especially in rural areas, most women are unable to seek medical care during the seemingly every day ritual of childbirth. The Ministry of Health has recruited women from many of the villages and trained them as midwives, but as many things in Yemen, the selection of women is based on patronage rather than ability, and many of these women are under trained or lack the personal motivation to actually practice midwifery. The scarcity of antenatal care and competent assistance in childbirth, in addition to high rates of poverty and malnutrition leads to significant negative effects on healthcare for women and children.

Fertility

Yemen has one of the fastest growing populations in the world, with a 3.5% population growth in 2006 [4]. The current population of around 21 million is expected to double in the next twenty years to over 40 million. Adolescents (ages 15-24) are currently 18% of the population [16], and since this age group has the highest fertility rates, this will exacerbate population growth. Yemen is already a poor country, with few natural resources, a high unemployment rate, and an alarming decrease in food and water security. In fact, Sana’a is expected to be the first capital in the world to run out of water, due to depletion of aquifers and lack of any lakes or rivers. A growing population will only intensify these problems.

Yemen’s high fertility rate not only exacerbates the problem of over population, it can also be detrimental to both maternal and infant health. The average woman in Yemen has six children in her lifetime, and 83% of these births are to adolescent women [13]. Yemeni women typically begin bearing children at an early age. The median age at which women have their first child is 19.5, with half of Yemeni women having their first baby before the age of 20 [16]. A significant difference exists in childbearing contingent on whether the woman lives in an urban or a rural setting, and her level of education. In rural areas, 17% of teenage girls (ages 15-19) have started childbearing, compared with 14% in urban areas. The contrast related to education is even more pronounced, with 20.4% of illiterate teens having started childbearing, opposed to only 12.2% of adolescents who are in school [16]. Some research shows that modernization lead to socioeconomic development, which allows for more opportunities for social mobility, and this in turn leads to increased contraceptive use and decreased fertility rates [17]. Using this framework, the most effective way to reduce fertility in Yemen may be to increase women’s access to education, health care, and economic opportunities.

High fertility rates are closely linked to the rarity of modern contraceptive use among Yemeni women. However, the percentage of women using contraceptives has increased dramatically in the past several years. From the early 1990s to 2003, contraceptive use increased from 7% to 23% [13]. Even with this increase, 36% of women have an unmet need for family planning [16]. Women in Yemen often do not have access to, information about, or permission to use contraceptives. Research has found that the primary reason women state for not using contraceptives is their husband’s disapproval [18]. Additionally, only about half of Yemeni women have knowledge about modern methods of contraception [16]. Knowledge and use of contraception varies significantly by age. 8.6% of married teens (ages 15-19) are using any form of contraception, with only 2.7% using a modern method, whereas 18.7% of married young adults (ages 20-24) are using any form of contraception, with 6.1 using a modern method [16]. This shows that as age increases, women are more likely to know about and use some sort of birth control. However, as many girls in Yemen marry when they are young, it is important to ensure that they have this knowledge as well. The most common method of contraception in Yemen is prolonged breast feeding, followed by hormonal pills [16]. Abortion is illegal unless it is to save the life of the mother, the mother is a victim of rape, or the fetus has a congenital abnormality. Even in these cases, the procedure requires the consent of the husband. Although abortion is illegal according to Islamic statutes, many private doctors perform abortions. Unfortunately, procedures are often substandard and have poor outcomes because the technique is not taught in medical schools and is not routinely performed. Contraceptive use is higher in urban areas than rural, in educated women versus uneducated, and in the wealthy compared to the poor [17]. This fact again demonstrates the importance of providing women with education and economic opportunities in order to increase their exposure to family planning.

Cultural norms and attitudes toward marriage and gender roles influence women’s health. The minimum legal age for marriage in Yemen is 15, but many girls are still married before this age, especially in rural areas. The average marrying age for a woman in Yemen is 16.5, and most of these girls are married to men much older than themselves [16]. In Yemen, almost 50% of marriages are consanguineous [16]; marriage among first cousins is especially common. Polygamy is legal and practiced in Yemen, although most men cannot afford to have more than one wife, since Islamic law requires that each of the wives, up to four, must be well cared for and treated equally. Polygamy is more common in villages and among the wealthy. These marriage practices are largely cultural and economic. In Yemeni society, great emphasis is placed on a woman’s role as wife and mother. From an early age, girls are trained to be an obedient wife, to perform domestic tasks, and in the rural areas to work in agriculture. The majority of adolescent girls do not go to school because they are needed at home. Socialization of women in the culturally defined role of a wife most often excludes any reproductive health education, and once a couple marries, social pressures affirm the urgency to produce offspring. Half of all women have their first child before the age of 20 [16]. Most women enter marriage and childbearing with no formal education of how their bodies should respond to sexual activity, pregnancy, and the birthing process.

Yemeni social structure maintains a distinct split between the public and private spheres. Women are in charge of the house, and are rarely involved in the public sphere. This means that any decision made outside the home needs the permission of the man of the house. If the woman is single, her father or eldest brother is the primary authority; if she is married, it is her husband. Only 2.4% of women make health decisions on their own, while 36% of women’s health care decisions are made solely by their husbands. The remaining women make their decisions jointly with their husband or another family member [16].

Health Care System

According to the Yemeni constitution, health care is guaranteed to everyone, but due to financial restraints, lack of health care providers, inefficiency, and pervasive corruption, universal access to healthcare is far from the actual case. The Yemeni government spends only 5.6% of its total budget on health, which amounts to less than $20 per person per year [13]. Yemenis depend on personal finances in order to pay for health care, with 95.2% of health care expenditures being out of pocket [13]. In addition to health care being underfunded, the need for more health care professionals is critical. There are 3 physicians, 7 nursing and midwife personnel, 3 community and traditional health workers, and 1 pharmaceutical personnel per 10,000 people in Yemen [13].

Yemen’s Ministry of Public Health and Population (MoPHP) oversees the country’s health at the central level. MoPHP provides immunization campaigns, and is in charge of maternal and child health and family planning. They also have programs to fight infectious diseases such as tuberculosis, malaria, and HIV/AIDS. In recent years, Yemen has attempted to decentralize their health care, encouraging greater emphasis on govornate and district public health systems. Most of Yemen’s health care is concentrated in the large cities, with rural areas being critically under served.

One of the main problems affecting Yemen’s public health system is corruption. Transparency International ranked Yemen 103 out of 159 countries in terms of corruption. In 2008, USAID published an assessment of Yemen’s MoPHP in which they found that most of the jobs in the Ministry were patronage based, there were few if any clear job descriptions, and many of the workers were unqualified. Of the 600 MoPHP staff, 18% were university graduates, 52% had a certificate, and many had not completed high school. While some employees were qualified and worked hard, efficiency suffered because of low operational budgets and salaries, and no protocol for performance based promotions or demotions. Although Yemen has laws laying out standards for medical equipment, staff, and facilities, they are not regulated or enforced. Equipment obtainment is poorly planned an often inefficient. For example, an expensive x-ray machine will be purchased for a clinic without basic laboratory facilities, and equipment is often faulty or parts for repairs are unavailable. Pharmaceuticals are ordered in bulk by the government, and theoretically, hormonal contraceptives should be available free of charge to anyone who wants them. However, in reality, drugs are often filtered off, and physicians working at public hospitals will take the drugs and sell them in their private clinics, saying to patients at the hospital that they have run out. With the low pay and minimal accountability, these practices are not uncommon. Additionally, health and management information systems are weak and unreliable, only covering approximately 20% of health care facilities [4]. As a result, continuity of care is almost non-existent, public health data is difficult to obtain, and health care providers face little accountability for their patients’ outcomes.

Education

Studies reveal that girls who have access to education are more likely to use contraceptives, less likely to have high fertility rates, and more likely to be economically stable [17]. Access to education differs greatly between girls and boys in Yemen, although the gap has decreased in recent years. The percentage of males without education in 1992 was 12.7%, compared to 67.6% of females. In 1997, this improved somewhat, to 5.9% of boys who had received no education, and 54.3% of girls. The difference between girls and boys who have obtained secondary education is also drastic, with 68% of boys having completed high school, and only 21.1% of girls [16]. Differences in educational obtainment between girls and boys are largely based on cultural and economic factors. Girls are often needed at home to help with housework and take care of younger siblings, and when they are married at a young age, they often stop going to school. Boys in Yemeni society, however, have fewer responsibilities at home and are more likely to continue their education.

In addition to overall education, the issue of reproductive and sexual education needs to be addressed. The Yemeni government has identified the need for increased reproductive and sexual education for young people. The National Council for Childhood and Motherhood and the Ministry of Youth are attempting to raise awareness about reproductive health issues among youth. However, like many programs in Yemen, it is under-funded and largely ineffective. Reproductive health and sexual education in schools is implemented by National Population Council and is funded by Yemeni NGOs such as the Yemeni Association of Family Planning, and international NGOs such as the European Project on IEC, the UN, and the WHO. However these projects are mostly small scale, and are not integrated into the school curriculum. In fact, the topic of reproductive health is not a part of school curriculum, nor does it receive comprehensive coverage in medical schools or health institutions. Few reproductive health resources are available in Arabic. Even the medical school textbooks are in English. It is imperative that reproductive and sexual education needs to become part of required school curriculum, but alone is not sufficient, since many girls and boys do not attend school.

Effect of Globalization

Yemen is an interesting case study for the topic of globalization, because the country has had a variety of external influences throughout history, but has been relatively isolated from the West until the 1960’s, and many parts still have minimal exposure to Western culture. In addition, Yemen has not only been influenced from western globalization, but even more from globalization within the Arab world. Saudi Arabia exerts a strong cultural, political, and religious influence on Yemen, which may explain the apparent paradox of urban women often being more religiously conservative than rural women.

Another example of globalization is the influence of the Dawudi Buhra sect of Shia Islam, which although originated in Yemen, is now based in India. In the Haraz mountains, Buhra religious leaders have established programs to decrease the farming and consumption of qat, a mild amphetamine that is almost ubiquitous among Yemenis. They also work to offer education to children, including girls, as well as working to ensure water availability.

Globalization from the West also exists, but to a lesser extent. Many international aid organizations funded by western countries are active in Yemen. Unfortunately, with the growing violence and political instability in the country several aid organizations have withdrawn or heavily reduced their activities in the country. Since many of the health interventions targeting women, children, and rural communities are funded by international aid agencies, the current political situation has an adverse effect on the most vulnerable populations in Yemen.

Discussion and Recommendations

Improving the health of women in Yemen will require a multifaceted approach. Any interventions must take into account cultural and religious norms, as well as shortcomings in the health care system and persistent lack of funding. The first issue to focus on is education, since it affects all other aspects of women’s wellbeing. When girls have access to education, it is more likely they will have greater autonomy over their life experiences, social mobility and reproductive health. Second, reproductive health and sexual education needs to become integrated into the school curriculum for both boys and girls. Adolescents will benefit from understanding the risks of early childbearing, the positive effects of family planning, and options for contraception. Besides educating the public, more health professionals need to be recruited, and reproductive health and sexual education should be a required part of all training curriculum. To further extend these services, more community health workers should be recruited and trained. Incentives should be offered to health care professionals willing to work in the villages. Since young marriage is common in Yemen, culturally appropriate premarital counseling, including information on sexual and reproductive health should be offered to all new couples. To be effective, these changes need to take place with the support of the government, religious leaders, and the public. Religious leaders should be recruited to emphasize the importance of sexual and reproductive health education and to help design materials that reflect Islamic principles and still protect women’s health. Furthermore, all the organizations working to improve the health status of women need to collaborate so that they offer the most efficient services to the greatest number of people. Despite all the obstacles that Yemen faces, women’s health can still be a priority. Yemen has an abundant network of human resources that can be utilized to educate and empower women and ultimately improve their health and quality of life.