Poverty dynamics influence the low-income status of the PM women in Ghana who participated in this research. Gender mainstreaming is needed in Ghana because women are more excluded from society than men. Women experience poverty and lack of wellbeing due to not being able to participate effectively in the Ghanaian economy. Women’s responsibilities and duties in Ghana dictate their access to economic activities. Lower productivity and an inefficient economy and allocation of resources are the outcomes of gender inequalities (Tutu, 2011). Figure 2.4 shows the typical workload of the Ghanaian woman on an everyday basis.
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Figure 2.4: The multiple roles of the Ghanaian woman (Desai and Potter, 2002)
Women’s duties focus on marital roles, childcare, farming and food production. Whilst women represent 50.1% of Ghana’s labour force, the majority are in the informal economy, in agriculture, trade and manufacturing. Women have greater poverty than men (Wrigley-Asante, 2012), due to constraints in land and labour, credit, poor service delivery, poor infrastructure access, lack of appropriate technology and few management skills (Duncan and Brants, 2004; MOFA, 2006; ADF-OSHD, 2008). Division of labour in traditional and modern wage sectors is highly gendered, few women are able to break through and take up modern jobs, leading to lower economic status (Baden et al, 1994). Lack of support services and an inability to participate in decision making at different levels also contribute to high poverty levels amongst women in Ghana (Ardayfio-Schandorf, Brown and Aglobitse 1995;
Government of Ghana 2003; Lund et al, 2008). To date, one strategy used in poverty reduction programmes in Ghana has been to increase access to credit among women, but this is challenging due to the lack of collateral amongst women to open bank accounts (Wrigley-Asante, 2012).
2.9.2 Gender governance and policy
Addressing the WASH needs of PM women has relevance to gender policy in Ghana, but PM women are not mentioned in policy documents from Ghana. The Ministry for Gender, Children and Social Protection, established in 2013, has a mandate ‘to ensure gender equality, promote
57 the welfare and protection of children, and to empower the vulnerable, excluded, the aged and persons with disabilities, for sustainable national development’ (GoG, 2014a:1). The functions of the Ministry are multiple, and certain aspects are of relevance to gender specifically, namely ‘to promote gender equity in political, social, and economic development systems and outcomes’ and to ‘safeguard the security, safety and protection of the rights of the vulnerable in society, especially the girl child and women’ (GoG, 2014a).
Ghana’s National Gender Policy (GoG, 2015: vii) has an overarching goal to ‘mainstream gender equality concerns into the national development processes by improving the social, legal, civic, political, economic and socio-cultural conditions of the people of Ghana particularly women, girls, children, the vulnerable and people with special needs; persons with disability and the marginalized’. Article 17 of the 1992 Constitution ‘prohibits discrimination of persons on the basis of gender’. Clauses 1 and 2 of Article 17 guarantee ‘gender equality and freedom of women and men, girls and boys from discrimination on the basis of social or economic status among others’ (GoG, 2015). The National Gender Policy has five commitments to achieve the goal which are relevant to PM women, namely:
1) To increase efforts to empower women and facilitate access to livelihoods, education and work, and address disparities in health, agriculture and other matters
2) To promote gender equality and adopt policy to address violence and discrimination and facilitate female empowerment
3) To increase women’s participation in leadership, governments and decision making 4) To improve women’s economic opportunities so that their basic needs are met 5) To improve gender relations to give women an improved status relative to men and in turn, improve policy to meet their needs
Policy Commitment 1, which concerns Women’s Empowerment and Livelihoods, makes specific reference to regularly reviewing programmes for women and girls, specifically mentioning WASH issues. The National Gender Policy also refers to the Maputo Plan of Action (2006), which aims to expand access to reproductive health through scaling up of midwifery services and reinforce partnerships (GoG, 2015). This highlights the need for attention to be paid to the needs of women at all life stages, despite the fact that the policy does not mention the perimenopause or menopause.
58 2.10 Women’s health and the perimenopause in Ghana
2.10.1 Older women’s health
PM women’s WASH needs relate to issues surrounding older women’s health overall. A Women’s Health and Ageing study was conducted in Accra with 1,328 older women aged over 50, which provided a picture of older women’s general health (Duda et al, 2011), and includes women of perimenopausal age. This study identified joint and back pain as the most common problem experienced among older Ghanaian women, attributed to carrying heavy loads. Risk factors for cardiovascular disease was also found through obesity, hypertension, hypercholesterolemia and diabetes. Issues were identified in the context of reproductive health. Older women had abnormalities due to female genital circumcision, fistulae, which are abnormal connections between two hollow organs, and prolapsed organs. Lesions that indicated cervical cancer were also identified within this study (Duda et al, 2011).
2.10.2 Health service provision
PM women need to access health services for support during this life stage. In Ghana, the National Health Insurance Act (NHIA) (2003) marked the emergence of the National Health Insurance Scheme (NHIS). The scheme aimed to eliminate the ‘cash and carry’ user fee system which prevented poorer and vulnerable people from accessing healthcare due to financial barriers, and to provide equitable access to healthcare for all (Mensah et al, 2010; Witter and Garshong, 2009). Despite efforts towards universal health coverage nationally, only 38% of the population were recorded as active members in 2013 (NHIA, 2013). Insurance schemes are run at a district level with finances from the central government (Williams et al, 2017).
Yet, health coverage in Ghana is inequitable. The poor, women and rural residents are consistently disproportionately uninsured for healthcare (Akazili et al, 2014; Atinga et al, 2015;
Jehu-appiah et al, 2011; Kusi et al, 2015). The study areas, La, Accra and Kotei, Kumasi, both have hospitals in their vicinity. Residents of La live near to the La General Hospital, whilst people living in Kotei are near to the Komfo Anokye Teaching Hospital on the Kwame Nkumrah University of Science and Technology campus.
2.10.3 Ghanaian perspectives on menstruation
Issues such as menstruation and the menopause are seldom discussed in the patriarchal Ghanaian society, because they are viewed as matters for women and therefore not spoken
59 about in public. The education system does not include menstruation in the curricula, and therefore the onset of menarche comes as a shock to young girls, who may only have inadequate discussion about the topic with their peers. Similarly, the symptoms of perimenopause are relatively unknown and are not discussed before women experience them. A culture of silence shrouds the perimenopause and menstruation, because women keep their experiences to themselves. Taboos around menstruation mean that women are forbidden from cooking, crossing a threshold into a house, participating in activities involving men or keep away from others, especially men, generally (Esseku, personal communication;
Bhakta et al, 2016). This research on the WASH needs of women from the onset of the perimenopause in Ghana suggests that existing taboos around the menopause and the perimenopause may be shifting, reflected through discussions of these issues through TV and radio (see Chapter 5, Section 5.4.5.1), and notably, women’s ability to open up about this topic to female researchers, as identified in this research (see Chapter 5).
2.10.4 Cultural understandings of the perimenopause
There are local cultural, traditional understandings of the perimenopause and menopause.
Field (1960) explains that in that point in time, the cessation of menstruation marks the start of a new era in Ghanaian women’s lives, and was perceived at the time as pregnancy and so women would visit a shrine in the hope of having children. Women saw the menopause as a marker of freedom to take part in rituals, visit ancestral shrines and reside in men’s houses (Nukunya, 1969). After the menopause, women could perform intimate roles such as midwifery and bathing of corpses. The rise in their status post menopause could culminate in becoming chiefs in the Mamprusi and Dagomba ethnic groups (Oppong, 1974).
2.10.5 Medical understandings of the perimenopause
Women’s experiences of the menopause have been studied in Ghana, but little literature is available on the perimenopause. Odiari and Chambers (2012) focused on the self-management of common symptoms such as hot flushes, vaginal dryness, body pains and sleep loss, and that these symptoms were perceived as part of a normal transition in life. The mean menopausal age has been identified as being 48.05 years (Kwawukume et al, 1993).
Kwawukume et al (1993) reported that menopausal aged women from within their population experienced a range of symptoms such as tiredness, sleeplessness, palpitations, weight gain,
60 hot flushes, irritability, headache, anxiety, decreased coitus, poor memory, depression and urine issues.
Setorglo et al (2012) found that night sweats were the most prevalent menopausal symptom experienced by 83.2% of the 280 women surveyed. Other WASH related symptoms amongst Ghanaian women in this study included hot flushes (76.4%), irregular periods (62.9%), incontinence (55%), joint pain (64.6%), vaginal dryness (71.4%), and loss of sleep (50.7%). This study identified that such symptoms were less prevalent as the age at menopause increased.