Nursing Care of Women- More than just a Health Issue

"In our course 'Nursing Care of Women During Their Life Span' we had several objectives," says its director, Bracha Gal. "We wanted to examine the various stages in a woman's life - from adolescence to young womanhood, from pregnancy and the process of labor to preparation for parenthood, from menopause and post-menopause to old age - and to show the role of the nurse in each of these areas, one in which she is an educator as well as a caregiver, able to influence and shape attitudes.

"Equally significant, we wanted to teach the care of women from a holistic point of view, going beyond strictly medical problems and touching on forces that impinge on the lives of women, whether they be political, sociological, economic, psychological or geographic in nature."

The course, given from June 17th to August 7th, 1998, at the Dina Academic School of Nursing, adjacent to the Rabin Medical Center (formerly Beilinson Hospital) was held under the auspices of MASHAV, Israel's Foreign Ministry's Center of International Cooperation, and Kupat Holim Clalit, the major sick fund in Israel which provides health care to 80% of its population. It utilized the services of the Nursing Divisions of the Women's Medical Center, located at the Rabin Medical Center, the Community Health Services of Israel's Ministry of Health and Kupat Holim Clalit.

The course was the brain-child of Bracha Gal, Director of the Maternity Division at the Dina School of Nursing, who designed its curriculum, drawing heavily on her experience at the Women's Medical Center. It was extremely comprehensive, meticulously planned and executed. Topics covered included the female adolescent, family planning, health education and promotion, prenatal care, high-risk delivery, diabetes in pregnant women, preparation for delivery, fetal assessment and fetal monitoring, the premature infant, dysfunctional delivery, detachment and bonding, multiple pregnancies, post-partum depression, breast-feeding, early parenthood, malignant tumors in reproductive females, carcinoma of the cervix, sexually transmitted diseases, women's sexuality, contraception, menopause, the theory and philosophy of nursing and nursing ethics.

Classroom work was supplemented by visits to all the departments of the Women's Medical Center where, wide-eyed and fascinated, the participants were impressed by all the departments of this state-of-the-art facility, but especially by the delivery rooms whose high-tech system includes computerized fetal monitoring that relays data immediately to the nurse's station and the physician's office; the IVF (intra-vitro-fertilization) Unit where they saw how ovaries, eggs and embryos are removed and frozen and the ultrasound unit, specializing in early detection of anomalies, amniocentesis and pelvic tumors.

Observing these units, Elizabeth Amen Abi of Cameroon, a midwife since 1976, could not help but compare her work with that of the midwives in Israel. "Our work is much more manual and more tedious. We have no technology really, no ultrasound equipment for instance. Only recently have we begun monitoring with a foetuscope. We also don't have drips controlled by machines, but have to count the drip with our watch."

The participants were not frustrated by their exposure to this high technology. On the contrary, they were uniformly excited by what they saw. As Kokopeta Ngari of the Cook Islands, assistant director at the Nursing School of the Karotonga Hospital, said, "It was just marvelous to see the central computerized system of monitoring and to realize how quickly doctors and nurses can be alerted when something goes wrong. Similarly, although we don't have fertility clinics, it was extremely interesting to see the ones here in action and to learn about new techniques such as IVF.

"And, in spite of the fact that we don't have the same kind of advanced technology as here, there is much that I learned that I can bring back to my country, such as the idea of early detection programs. We see, for example, a lot of patients with cancer of the cervix, but generally only when the disease is in an advanced stage. Here I've learned how important it is to set up early detection programs and how much we can and should be doing to encourage women to come for examinations."

Their in-depth visits to the Women's Medical Center gave the participants a chance to observe more than just new techniques. For many it highlighted what Angela Dinu of Romania, a midwife at the Filantrophia Clinical Hospital in Bucharest, defined as the egalitarian atmosphere in the delivery room in Israel and in other aspects of patient care. "In Romania there is a barrier between doctors and nurses, a definite hierarchy - doctors, midwives and nurses - with the doctor at the head. Here the fact that everyone appreciates the work of others in the team makes for a wonderfully warm and meaningful atmosphere, one that gives the midwife more status and respect than we normally see."

Hae Won Kim of South Korea, a professor and assistant tutor (director) of the Department of Nursing, College of Medicine at Kwandong University in Kangrung City, expressed a similar view. "Although in many ways our clinical experience is similar to what I've found in Israel, we don't have the same openness and mutual respect as in Israel. Here the doctors, midwives and nurses work together without any sense of one person being more important than the other."

The course had another significant component to it, one that went beyond the technical material that was presented. "By focusing on women," explains Gal, "I want to give the field of women's health the importance and recognition it deserves and often does not receive. By so doing, I hope to advance the status of women in other spheres too." To this end, the group met with two of Israel's leading activists and lobbyists for women's rights - Naomi Chazan, a member of Israel's Knesset (its Parliament), and Marcia Friedman, a former member of the Knesset. Both women explained the gains women in Israel have made, as well as the areas in which much still needs to be done - such as that of domestic abuse.

One of the highlights of the course was the day spent at a shelter for battered women where its director, Ruth Resnick, a longtime advocate of the right of women to take control of their lives, gave a seminar, explaining in detail the problems of the battered woman and its sociological and psychological implications and consequences.

For many of the participants the concept of shelters was a new one. As Abi said, "I am most impressed by the way Israel is trying to fight violence in the home. In my country, Cameroon, we treat it only at the social welfare level, i.e., by women reporting the situation to the social welfare authorities, but this is far from a solution since there is very little that these social workers can do except, in extreme cases, suggest divorce. Here in Israel we saw how the subject is taken much more seriously than we do and should. Recently, however, we have had some lawyers going around telling women about their rights, but we need to expand this activity."

Similarly impressed by her visit to the shelter was Ingrid Garcia of Guatemala, head nurse at a government health clinic in San Jose, Pinula. "It was very thrilling to see how Israel is raising the consciousness of its society to the problem of the battered woman. In my country we have a very 'macho' society and there is much prejudice and discrimination towards women - with fewer opportunities for study and less chance to go out to work since our women tend to have large families. Women in the villages, for example, average over eight children, while in the cities, however, where women are better-educated, the rate is lower - usually only three children per family." Garcia credits her government for making an effort to promote smaller families.

"Our problems, however, are most acute in the villages which are not easily accessible. In the cities we do have a fairly well-developed system of health, education and services. We go into the schools, for example, and instruct the pupils about good hygiene, sex education and the use of the condom. We have also recently instituted a new program of giving people vaccines, such as for hepatitis. But it is in our villages," she repeated, "where there are serious problems, such as a high incidence of TB and other respiratory disease due to poor hygiene and poor sanitation."

For Garcia, as for many of the participants, their visit to a Bedouin village was an eye-opening experience. "There, right in the desert, the Bedouin, still somewhat nomadic, have access to a modern health clinic, a model of what we could do for our remote villagers." Dinu echoed a similar view. "We too have the problem of providing care for our outlying rural villages. A health unit, as the one we saw set up for the Bedouins, could serve as a model for us too, providing care for people never before exposed to modern health practices."

When designing the course, Gal was aware that the program would be intense. With a BA and MA in nursing from Tel Aviv University, where she is now completing requirements for her doctorate, she is, however, no novice to the world of education. "As a student, as well as an educator, I believe in the ability of individuals to learn and absorb material, even that which is new and difficult."

Gal had over 90 applicants for her course, choosing a third of that number. "All were women in influential and responsible positions who would be able to transmit back to others the material and ideas presented here. In 'teaching the teachers' I knew that some of the applicants were not instructors or teachers per se, but all were experienced nurses, responsible for guiding and influencing their younger colleagues." Angela Dinu is such a case. "With all the lecturers constantly urging us to become actively involved in the teaching process, encouraging feedback and dialogue, I, myself, acquired valuable insights on how to transmit material."

Since Gal is a strong believer in active, not passive learning, an important component of the course was a final paper presented at the conclusion of the studies. Having alerted the participants to bring with them statistics from their own country, she then paired the students off, each from a different country, and asked them to prepare a paper comparing the similarities and differences in the birth customs of their respective countries.

Gal designed the project with three objectives in mind. "First, we realize that participants learn as much from each other as they do from us - and we wanted to give a structure to this exchange of information. Second, their exposure to multicultural customs helps them highlight and identify their own problems. Third, we gave them some valuable technical skills, such as how to use a library - a first-time experience for some of them. Assisted by the director of our library, they were shown how to prepare pre-research abstracts. Some classes in the use of the computer were also given."

While doing their research, participants learned how to identify the reasons for the similarities and differences, zooming in on the political, economic, geographic and sociological issues that gave concrete meaning to the underpinning of the course - its focus and emphasis on seeing women from a holistic point of view, on seeing how different factors interlock to shape attitudes and customs.

For her paper, Abi was paired with a participant from Poland. "We both noted the changes taking place in our respective countries. I, for example, reported how birth customs in Cameroon have changed quite dramatically. Not too long ago pregnant girls were helped and looked after by their grandmothers in their homes, with no proper prenatal care and delivered at home by traditional midwives. Today, most women deliver their babies in hospital.

"However, since we have no system of national insurance, people have to pay for all medical services, including medications. The result: women who haven't the money for a hospital delivery still give birth at home, but bring their children to hospital for the vaccinations which the State pays for."

Abi found the idea of socialized medicine "very impressive" and its lack "one of my country's most serious problems. Still," she added, "our health situation has improved. If 30 to 35 years ago, women didn't understand the importance of immunization, today they do, thanks in large part to the work of various women's organizations which give lectures on the benefits to which people are entitled."

Abi is an ardent community activist. She is president of her country's Midwives' Association and a vice-president of Cameroon's Women's Association, as well as a member of other women's groups. "Through these organizations, we are informing women of their rights - and not only in the health field. As a result, there has been a slow but dramatic increase in the status and position of women in Cameroon. If once the status of women was low, today we now have women in our Parliament, some even heading ministries and others heading large organizations. Our women are also better-educated than in the past, with many going abroad to international conferences where they bring back ideas they try to sell to our Parliament."

A contrasting picture was painted by Kim who was paired with a woman from Vietnam "where our situations are quite similar. In both countries the status of women is an issue that has yet to be properly addressed. In South Korea, however, our nurses are relatively powerful and the Korean Nursing Association is working to reduce the gender gap - the inequalities in salary and job opportunities. Nevertheless old customs die hard. Even highly educated women, for example, still want only sons since ours is such a male-dominated society - and men are seen as more important than women."

Combining the statistical material she had brought with her, coupled with psychological insights gained at the course, Kim feels that South Korean women have a long way to go in order to know, utilize and appreciate their strengths. "Most are still bound by conventional and traditional ways of thinking which see women mainly as homemakers. The result: the majority of our nurses are single, with 80% doing just the three-year nursing program for RNs and only 20% taking and completing the four-year academic university course.

There was much positive feedback from course participants. Dinu, for example, who was paired with a woman from Thailand, found it "very exciting to learn about other countries and their different cultures. In Romania," she said, "the position and status of women is quite good. We get the same salaries as men and have the same opportunities for higher education. Many women have doctorates, especially in the sciences - from biology to genetics. In Thailand, however, the position of women is different. In many ways they are quite subordinate to men since, by tradition, they must obey their husbands."

Dinu felt that she had learned a great deal at the course. As a member of the Romanian Midwives Association, she is involved in developing programs for women, as well as for youngsters in high schools "where we regularly go to give information about family planning, sex education and sexually transmitted diseases." Her stay in Israel reinforced her conviction "that we are moving in the right direction." She also reported on a new program, still in its planning stage, where - aware that many women have no time to come to programs and lectures - talks will now be given in private homes, gathering three to four women at a time to discuss a variety of topics - from sexuality to early detection of cancer.

To reinforce the multicultural focus of the course, Israeli midwives at the hospital adopted the participants and hosted them for several weekends. "We wanted," says Gal, "to give our students the feeling of what life in Israel is like, not only by touring historical, archeological and religious sites which, of course, we did, but also by allowing them to experience first-hand what life in an Israeli home is like."

This home hospitality facet of the program was enthusiastically received. "The students were fascinated by these visits," says Gal simply. "Many found it unbelievable how we live so matter-of-factly in a country which, before coming here, they had seen only in stereotyped terms as a place fraught with violence, terrorist acts and military engagements." As Ngari said, "I thought that there was a lot of war in Israel but there isn't. Here I feel very safe. And add to this the thrill of being in the Holy Land and this has definitely been an experience I'll never forget."

Gal admits that she had great expectations from the course "which," she says with justifiable pride, "were met most successfully. Our participants were extremely motivated to learn: they were a serious and dedicated group who invested as much in themselves as we did in them."