Women have health needs for all the major diseases and have needs associated with membership of particular vulnerable groups, as do men. In addition women have special needs associated with their reproductive and social functions. Women are the most frequent consumers of health services, both for their own needs and in their roles as parents and carers.

This chapter looks at the health status of women in general, and explores in more detail issues which are particularly relevant to women.

2.  Health Status of Women in the South East

The death rate from circulatory disease for Irish women is 20% higher than that for European women. The average standardised death rate for Irish women from circulatory system diseases during the years 1992 to 1996 was 295 (per 100,000 female population). Women in the south east region experienced a slightly higher death rate of 306 (per 100,000 female population).

Irish women experienced a death rate approximately 13% higher from cancer than do European women on average. The average standardised death rate from all malignant neoplasms for Irish women in the years 1992 - 1996 was 179 (per 100,000 female

population). Women in the south east region experienced a slightly higher rate in the same years of 184 (per 100,000 female population). The major cancers which cause deaths in women are cancer of the breast, which causes 17% of female cancer deaths, cancer of the lung which causes 15%, cancer of the large bowel which causes 12% and cancer of the cervix which causes 2% of female cancer deaths.

Women in the South Eastern Health Board region experience similar death rates as women in the rest of the country from cancer of the large bowel and cancer of the breast. However, they experience slightly higher rates for cancer of the lung and cancer of the cervix.

Respiratory disease is an important burden of ill health and mortality in middle aged and elderly people. Women in the South Eastern Health Board area experience a significantly higher standardised death rate (114 per 100,000 female population) from respiratory disease compared to women in the rest of the country (98 per 100,000 female population).

Lifestyles, in particular smoking, is known to cause circulatory disease and respiratory disease and is the cause of 90% of lung cancer. In Ireland, according to the Happy Heart's study, 29% of adult females smoke. The counties of Carlow and Wexford within the South Eastern Health Board were surveyed as part of this study. In Carlow 39% of women smoked and in Wexford 29% of women smoked. It is clear that targeting smoking in women within the South East is a priority issue. Changing dietary habits, increasing exercise and identifying and treating high blood pressure would also improve the quality and length of life of women.

Death and injury from accidents is an important burden of ill health. In Ireland the standardised death rate for women from injuries and poisonings in the years 1992 to 1996 was 21 (per 100,000 female population). Among women in the South Eastern Health Board region this rate was also 21. Women in the south east had an excess of deaths from road traffic accidents, 8 per 100,000 versus 6 per 100,000 nationally. These are areas where preventive campaigns can be effective.

It is recommended that:

Priority be given to interventions which reduce or prevent smoking in women.

Interventions aimed at changing the other lifestyle factors which cause cardiovascular disease and cancer be especially targeted at women.

Cancer is the most common cause of death in adults under 65 years in the South Eastern Health Board region. Ireland, including the South Eastern Health Board has higher death rates from cancer than experienced in the EU on average. Irish women experience higher death rates from cancer of the trachea, bronchus & lung, colon & breast, than other European women in general. Breast cancer is the major cause of premature years of life lost by cancer in women, causing 10% of the years lost under 65 years of age in women.

3.1 Breast Screening
In order for screening services to be effective, they must reach the targeted population at the recommended intervals, achieve quality, so as to reduce factors such as false negatives and false positives, and have accessible back-up diagnostic and therapeutic services. The Eccles Street pilot project identified means of achieving this for a relatively small group of Irish females. Based on a national planned approach, breast screening is now in the process of being introduced on a wider basis. The South Eastern Health Board population will be included in the programme after it has been successfully implemented in the first phase area of the North Eastern, Midland and Eastern Health Board. In the interim, mammography screening in Waterford, Dublin & Cork is available to the population of the south east on an ad hoc basis.

It is recommended that:

The South Eastern Health Board implement the national breast screening programme when it is extended to the whole country.

Diagnostic mammography services be strengthened.

3.2  Cervical Screening
Cancer of the cervix accounts for approximately 2% of cancer deaths among Irish women. The risk factors for the disease are multifactorial. Cervical smears screen for the precursor of cervical cancer, which is asymptomatic, rather than the disease itself. Treatment of this precursor stage is almost completely successful in preventing cervical cancer, whereas treatment of cancer of the cervix only has an overall five year survival of 57%. At present cervical screening for cervical cancer is not effective as it is neither structured nor co-ordinated. Smear taking is done on an ad hoc basis. As for breast screening, a national pilot project is underway to identify the most effective means of providing an effective cervical screening service, which will then be spread on a planned basis nation-wide. In the interim, ad hoc screening will continue to be available to the residents of the South Eastern Health Board.

It is recommended that:

Anti-D blood products are given to mothers who are rhesus negative to prevent rhesus haemolytic disease among babies/foetuses who are rhesus positive. In the late 1970s and early 1990s anti-D manufactured by the Blood Transfusion Service Board (BTSB) became infected with Hepatitis C viruses 1b and 3, respectively.

In 1994, screening for Hepatitis C antibodies was offered to anti-D recipients in a nation-wide programme. Positive antibody tests suggest at least previous infection. Additional tests are then done to test for the actual virus (viraemia and viral load). Approximately 65,000 people were tested. To date in Ireland, 1,016 rhesus negative women have tested positive for Hepatitis C antibodies (i.e. previous exposure), of whom approximately 500 have tested positive for the actual Hepatitis C virus (HCV). The approximate figures for the South Eastern Health Board are 150 patients with antibodies of whom 75 patients have detectable levels of the virus. In addition, country-wide, approximately 300 blood transfusion and other blood product recipients, both men and women, have been diagnosed positive for HCV antibodies of whom approximately 50 live in the South Eastern Health Board area.

There are also a small number of patients who have contracted Hepatitis C after haemodialysis or organ transplantation. By far the largest group of HCV antibody positive and viraemic patients in Ireland are to be found in the injecting drug addict community (5,000 - 10,000) mainly based in Dublin. HCV is not spread easily by close physical contact among families or by sexual intercourse.

A comprehensive health care package for those infected by blood products supplied by the BTSB was put in place by agreement with representative groups and Department of Health in 1994. The Health Amendment Act, 1996 which came into effect in September of that year gave statutory entitlement to a range of primary health care services free of charge to persons who have contracted Hepatitis C from BTSB supplied products. Each Health Board appointed a liaison officer to ensure the smooth delivery of services and to serve as a contact point for affected individuals/organisations. In addition to the liaison officer, in the SEHB specialist medical needs are provided and co-ordinated through the Consultant Hepatologist at St. Luke's Hospital Kilkenny, two Hepatitis Nurse Counsellors and a Hepatology Secretary. Future plans include the provision of an outpatient hepatitis clinic at Waterford Regional Hospital, St. Joseph's Hospital, Clonmel and Wexford General Hospital serviced by the above staff from St. Luke's Hospital, Kilkenny. To facilitate the provision of integrated care in 1998 the Department of Health established a pilot project in the SEHB, co-ordinated by the SEHB G.P. Vocational Training Scheme and the Primary Care Unit SEHB, to facilitate and to enhance the education and training of GPs in Hepatitis C and related viral hepatitides. If successful the new programme may be devolved on a national basis.

Future strategies for the control of Hepatitis C will include public health measures, educational programmes targeted to high risk groups, screening of blood/tissue banks, interferon treatment combined with other specific antiviral agents and ultimately vaccination.

It is recommended that:

5.2  Service Developments
Progress has been made in the community care programme on public health nurse training and information dissemination to clients. This needs to be continued.

The Primary Care Unit developed a scheme to encourage general practitioners to employ family planning trained doctors to provide gender choice in the provision of family planning and vasectomy services in general practice. Health Board clinics have not yet been established.

There have been some improvements in the provision of female sterilisation services. In 1995, 171 women were provided with this service in the region, and in 1997 this had increased to 251. However, the average waiting time for surgery is 1.5 years, the service is not available in each hospital in the region and 32% of women have to travel outside the SEHB region to receive the service.

5.3  Service Review
The implementation of the recommendations approved by the health board should now be reviewed, and the provision of an equitable and comprehensive family planning service throughout the region evaluated.

It is recommended that:

6.1   Introduction
Teenage pregnancy was identified as an important public health issue in the 1996 Report of the Director of Public Health. In this report the issue is further explored and the progress made to date on the subject is outlined.

The objective of highlighting this issue is its importance for the health of young women and their children. The data and research evidence presented is the factual position relating to current behaviour. The Health Board does not advocate a moral philosophy on this subject,

but confines its role to the duty of improving health and social gain, particularly prevention, reducing the rate of abortion and support to families.

Pregnancy for a teenager is not always an unplanned or an unhappy event. Where the pregnancy is unplanned, in most cases the young mother will cherish their child when it is born.

However, for many of those for whom the pregnancy is unplanned, the pregnancy constitutes a major crisis in their lives. It may force them down a path in life which they may not have chosen had they not become pregnant and where their educational, employment and social opportunities are limited as a result of having to care for their child.

The number of births to very young teenagers (i.e. aged less than 15 years) is small and has remained constant over this time.

Figure 5.1  Birth Rate for 15-19 year old women in Ireland (1970-1996) per 1,000 female population 15-19 years

What has changed in this time is that teenagers are less likely to be married, as the average age at marriage has increased, or to get married when they become pregnant, or less likely to allow their child to be adopted. Instead they are more likely to choose to rear their baby themselves, sometimes with the help of their parents or their partner.

In the South East 98% of births to teenagers in 1996 were to single women.

Table 5.1 Live births to women aged < 20 years and abortions in 15-19 year olds per 1,000 Female Population 15-19 years, 1994

There has been little research in Ireland on teenagers' attitudes to sexuality, contraceptives and pregnancy and no research has tried to describe the whole spectrum of attitudes and experiences which surround the complex issue of teenage pregnancy.

The study described the problems single women with crisis pregnancies had when it came to counselling and information about the options available to them i.e. marriage, lone parenthood, adoption and abortion. Some women, because they did not know with whom they could consult when they were considering abortion as an option, contacted English clinics themselves and did not, therefore, have any opportunity to discuss their decisions until they had travelled to England.

The findings showed that there was a lack of information available to women about the option of adoption and the availability of the services that facilitate adoption, including residential homes.

For women who choose to rear their child themselves, the support of their partner and of their parents was very important to them. Parents, with emotional, financial and practical support, were particularly helpful in a women's adjustment to maternity and motherhood.

Women were aware of and encountered the stigma attached to their non-marital status. They described the impact that the pregnancy had on their social life, that it set them apart from their friends and left them marginalised socially.

6.4  Evidence of effective interventions to reduce teenage pregnancy and to support pregnant teenagers, teenage mothers and their children.

Strategies to prevent teenage pregnancy have been tried in many countries. These are based on one, or a combination of, (a) education-based approaches, (b) provision of contraceptive services and (c) improving life options or job prospects for young people.

The SEHB hosted a seminar on the subject of 'Teenage Pregnancy in the South East' in May 1998 which invited service providers from the health, educational, social service, local authority, youth and community group sectors, as well as some young people themselves, to work together at integrating services, identifying the gaps and developing responses to the service needs.

Some of the ideas generated included:

á developing a directory of preventive, counselling and support services at local level, which would provide details of the services available in the area and the contact person in each service. This would be made available to all the local service providers, which includes the schools and youth services, to those to whom young people would turn for help and to the young people themselves;

á providing a link person in each area between the schools and the health services, so that the schools could avail of, if and when they required it as part of the Relationship and Sexuality Education (RSE) programme, a speaker from the health services who would talk to pupils, teachers or parents on agreed topics;

• standardisation of services and of practice in each local area;
• training for parents in discussing relationship and sexuality issues with their children;
• providing support for parents of teenage parents;
• developing support groups for young fathers;
• improving access for teenagers to contraceptive and counselling services;
• developing support services which encourage pregnant teenagers and young mothers to continue their education;
• providing child care facilities for any initiatives.

The seminar supported the RSE programme which is being introduced into schools by the Department of Education and Science. It charted a way forward in the integration and development of services in the region.

The Regional Co-ordinator for Child Care Services in the Health Board has since undertaken to set up a core group in each county to look at the issues involved and to invite anyone working with young people in the area to work with them in addressing the issues which arose from the seminar.

Funding has been obtained from the Health Research Board to undertake a project, in conjunction with the Department of General Practice in University College in Cork, on teenagers' attitudes to pregnancy prevention and teenage pregnancy.

It is recommended that:

The Health Board continue to support schools as they introduce the RSE programme.

The Health Board review the comprehensiveness and accessibility of contraceptive and counselling services available to teenagers in the region.

The Regional Advisory Committee on Women's Health include recommendations in the Women's Health Plan about further service developments in contraceptive and counselling services.

Support be given from health service personnel to the county-based working groups on teenage pregnancy.

Research be conducted on teenagers' attitude to and knowledge of contraception and contraception services, pregnancy prevention, pregnancy and the reasons for decisions in relation to unplanned pregnancy, the services and supports that they need and how to improve access to the services.

7 Folic Acid

In Ireland each year approximately seven or eight babies are born with neural tube defects (Spinabifida or Hydrocephalus). The link between neural tube defects and inadequate intakes of folic acid have been known for some years. Taking folic acid before conception and in early pregnancy is known to prevent about 50% of neural tube defects. The current number of babies being born with neural tube defects could be reduced to 3 or 4 per year if women took adequate levels of folic acid prior to conception and in early pregnancy.

In view of this apparent poor compliance and in consideration of measures taken in other countries to achieve a more acceptable level of folic acid intake, i.e. food fortification, the South Eastern Health Board as part of a wider Irish study in 1997, examined women's behaviour in terms of folic acid intake, their knowledge of why they took it during pregnancy and their source of information. A total of 300 women, post delivery, participated in the study in the South Eastern Health Board. The preliminary results show that 60% of women had not planned their pregnancy and less than 25% of women took folic acid in the three months leading up to becoming pregnant. Overall knowledge of the benefits of folic acid in preventing neural tube defects was high. The challenge remains in empowering women to plan pregnancies and consume folic acid prior to becoming pregnant, either through food fortification or oral dosage.

It is recommended that:

Information relating to the SEHB:

Intention to breast or bottle feed is recorded on the birth notification form completed within 36 hours of birth by the midwife. Based on data from the Child Health System of the 5,707 live births during 1997, an average of 33% of mothers intended to breast feed their babies (i.e. 27% in Carlow, 37% in Kilkenny, 30% in South Tipperary, 34% in Waterford, and 35% in Wexford). Clearly the results fall short of the target of a breast-feeding initiation rate of 35% by 1996 in some counties (Table 5.2).

Table 5.2  Breast Feeding intention (36 hour Birth Notification Form) by place of Birth 1997 (for SEHB births)

As part of the 1997 Folic Acid study mentioned in section 5.7, post partum mothers were asked how they intended to feed their babies and for how long, if their intended method was breast feeding. The results of this, will help in identifying areas which need further attention.

Breast feeding is a particular item in the community care service plan for 1998. As part of an overall response to the national strategy, data on the four month breast-feeding rate is being gathered by the PHNs. However, it is evident from the "intention to breast feed" rates in Table 5.2, that to achieve real changes, the ante-natal and indeed pre-conception periods are of immense importance.

It is recommended that:

The breast feeding policy of the health board should specifically target the peri-conceptual and ante-natal periods and should be a feature of hospital and community service plans.