31 Women and Health

Dr. Ajeet Jaiswal

Contents

1. Introduction 
2. Understanding women’s health in the world today
3. Increasing life expectancy
4. The health transition 
5. Socioeconomic inequalities adversely affect health
6. Gender inequities affect women’s health 
7. Women amid conflicts and crisis
8. Women and the health-care system
9. Policy Implications
10. Summary

Learning objectives:

• The purpose of the module is to understand the concepts of health and women in Cross cultural perspectives.
• This module also intended to acquaint the students with some of the significant issues like health transition, socioeconomic inequalities and Gender inequities.
• Women and the health-care system and its Policy Implications are also the focus of this module.

1. Introduction:

Women are an integral part of human society. But for a woman, there couldn’t have been any man. She is the mother of mankind. Despite holding such an important and unquestionable position, role of women has been defined by men over millennia. Our Vedas tell us that women held an important place in ancient culture. No ritual was ever complete without the presence of a woman by her man’s side. All our gods are worshipped alongside their heavenly consorts. There is no dichotomy there. No one questions this. The staunchest of male chauvinist reverentially bows his head to Goddess Lakshmi, or Durga. It is not considered a sign of weakness to bow to female deities.

Women at home and society in general, are a different cup of tea. They are treated as second class citizens. How did this ‘battle of sexes’ begin? How did the men win the winning hand? I think that economics had a role to play in the scheme of things. When man took on the role of a bread earner, and woman took the natural role of a nurturer, these roles suited their intended role by the Creator. Man was physically strong, while the woman was inherently strong. Over a period of time the man started believing that his role was superior to that of the woman as without him there would be no food at the table. Woman’s role was taken as for granted. The physically feeble woman was led to believe this lie for centuries.

2. Understanding women’s health in the world today

Why focus on women and health? The response is that women and girls have particular health needs and that health systems are failing them.

What are these needs? There are conditions that only women experience and that have negative health impacts that only women suffer. Some of these conditions, such as pregnancy and childbirth, are not in themselves diseases, but normal physiological and social processes that carry health risks and require health care.

Some health challenges affect both women and men but, because they have a greater or different impact on women, they require responses that are tailored specifically to women’s needs. Other conditions affect men and women more or less equally, but women face greater difficulties in getting the health care they need. Furthermore, gender-based inequalities – as in education, income and employment – limit the ability of women to protect their health and achieve optimal health status.

Women’s health matters not only to women themselves. It is also crucial to the health of the children they will bear. This underlines an important point: paying due attention to the health of girls and women today is an investment not just for the present but also for future generations. This implies addressing the underlying social and economic determinants of women’s health – including education, which directly benefits women and is important for the survival, growth and development of their children.

Analyses of women’s health often focus on, or are limited to, specific periods of women’s lives (the reproductive ages, for instance) or specific health challenges such as the human immunodeficiency virus (HIV), maternal health, violence, or mental ill-health. The present chapter, by contrast, provides data on women’s health throughout the life course and covers the full range of causes of death and disability in the major world regions.

The chapter is based on data currently available to WHO. However, the analysis reveals serious shortcomings in the systems needed to generate timely and reliable data on the major health challenges that girls and women face, especially in low-income countries. Many of the conclusions are based on extrapolation from incomplete data. Nonetheless, the available information points clearly to challenges and health concerns that must be addressed urgently if girls and women are to realize fully their human right to health and, by extension, to their economic and social rights.

The aim of the detailed epidemiological analysis in the following section is to provide the foundation for a comprehensive understanding of the health challenges faced by girls and women around the world throughout their lives. From this overview of the burden of ill-health women face at different ages – not only deaths but also non-fatal, often chronic conditions – four main themes emerge (Figure 1). These are explored more fully later in this chapter.

First, the leading global causes of the overall burden of disease in females are lower respiratory infections, depression and diarrhoeal diseases. Box 1 explains how the burden of disease in females is calculated in disability-adjusted life years or DALYs (Box 1: Diseases that cause a large number of deaths are clear public health priorities. However, mortality statistics alone do not show the loss of health among girls and women caused by chronic diseases, injuries, sensory disorders and mental disorders. Disability-adjusted life years (DALYs) incorporate lost healthy years of life due to premature mortality and to non-fatal chronic conditions into measures of disease burden in populations,1 and give greater weight to deaths that occur at younger ages. The DALY extends the concept of potential years of life lost due to premature death to include equivalent years of healthy life lost by virtue of being in a state of poor health or disability. One DALY can be thought of as one lost year of healthy life, and the burden of disease can be thought of as a measurement of the gap between current health status and an ideal situation where

everyone lives into old age, free from disease and disability.). Neuropsychiatric conditions and sensory disorders – related, for example, to vision and hearing – are also important causes of DALYs worldwide. Infectious diseases continue to cause over half the DALYs in the African Region but have a much smaller impact in other regions (World Health Organization, 2008).

Second, in all regions and age groups, girls and women in higher income countries have lower levels of mortality and burden of disease than those who live in lower income countries. Across all ages, the highest mortality and disability rates are found in Africa.

Third, the causes of death and disability among girls and women vary throughout the life course. In childhood, most deaths and disabilities result from communicable diseases such as HIV, diarrhoeal and respiratory diseases, malaria, and maternal and perinatal conditions. At older ages, patterns of death and disability change to noncommunicable chronic diseases such as heart disease, stroke and cancers. The single exception is in Africa, where communicable diseases remain the chief causes of female deaths up to the age of 60 years.

Fourth, there are significant regional variations in the composition of the overall burden of death and disability. In Africa and South-East Asia, communicable diseases are important causes of death and disability at all ages. However, in women aged 60 years and over, in all regions, most deaths are due to non-communicable diseases.

3. Increasing life expectancy

Females generally live longer than males – on average by six to eight years. This difference is partly due to an inherent biological advantage for the female. But it also reflects behavioural differences between men and women. As newborn girls are more likely to survive to their first birthday than newborn boys are (World health statistics, 2009). This advantage continues throughout life: women tend to have lower rates of mortality at all ages, probably due to a combination of the genetic and behavioural factors regions (World Health Organization, 2008). Women’s longevity advantage becomes most apparent in old age. This may be the result of lower lifetime risk behaviours such as smoking and alcohol use. Alternatively, it may be the effect of harder-to-identify biological advantages that result in relatively lower rates of cardiovascular disease and cancer in women. The gap in life expectancy between women and men is narrowing to some extent in some developed countries. This may be due to increased smoking among women and falling rates of cardiovascular disease among men, but the question is open to debate (Glei and Horiuchi, 2007).

The female advantage in life expectancy may be a relatively recent phenomenon. Accurate historical data are hard to come by, but there is evidence that in 17th century England and Wales the life expectancy of men surpassed that of women (Wrigley et.al, 1997). Part of the explanation may lie in the low social position of women at the time, coupled with high rates of mortality that were often associated with pregnancy and childbearing. Globally, female life expectancy at birth has increased by nearly 20 years since the early 1950s when it was just 51 years (Figure 1). In 2007, female life expectancy at birth was 70 years compared with 65 years for males.

Life expectancy for women is now more than 80 years in at least 35 countries, but the picture is not uniformly positive. For instance, life expectancy at birth for women in the African Region was estimated at only 54 years in 2007 – the lowest of any region. In some African countries, particularly in East and Southern Africa, the lack of improvement in life expectancy is mainly due to HIV/AIDS and maternal mortality, but these are not the only factors at work. In a few countries, women’s life expectancy is equal to or shorter than men’s as a result of the social disadvantages that women face (World health statistics, 2009).

However, life expectancy alone tells only part of the story; the extra years of life for women are not always lived in good health. In low-income countries especially, the difference between women and men in terms of healthy life expectancy is marginal (only one year) and in several countries, healthy life expectancy for women is lower than for men (World health statistics, 2009).

4. The health transition

One of the most striking features of recent decades has been a shift in the underlying causes of death and disease around the world. This so-called “health transition” affects men, women and children in all countries and stems from changes in three interrelated and mutually reinforcing elements – demographic structures, patterns of disease and risk factors.

The demographic transition is characterized by lower mortality rates among children under five years and declining fertility rates, which result in an ageing population. The average number of children per woman has fallen globally from 4.3 during the early 1970s to 2.6 by 2005–2010 (Table 2). These declines are largely the result of increasing use of contraception.

The epidemiological transition reflects a shift in the main causes of death and disease away from infectious diseases, such as diarrhea and pneumonia (diseases traditionally associated with poorer countries), towards non-communicable diseases such as cardiovascular disease, stroke and cancers (long considered to be the burden of richer countries).

The risk transition is characterized by a reduction in risk factors for infectious diseases (undernutrition, unsafe water and poor sanitation, for example) and an increase in risk factors for chronic diseases (such as overweight, and use of alcohol and tobacco). This health transition is occurring at different rates in different countries. In many middle-income countries, including much of Latin America and China, the health transition is already quite pronounced.

In the early stages of the health transition, women and children face high levels of mortality, often linked to nutritional deficiencies, unsafe water and sanitation, smoke from solid fuels used for cooking and heating, and lack of care during childhood, pregnancy and childbearing. These traditional risks not only exact a direct toll on the health of women and children but also have an adverse impact on the health of the next generation. Women with poor nutrition, infectious diseases and inadequate access to care tend to have infants with low birth weight whose chances of health and survival are compromised (Berkman DS et al., 2002,; Mendez and Adair, 1999). Public health interventions have long focused on combating these problems through improved nutrition, cleaner household environments, and better health care. However, new or previously unrecognized health challenges continue to emerge – including overweight and obesity, lack of exercise, use of tobacco and alcohol, violence against women, and environmental risks such as poor urban air quality and adverse climate change. The impact of these emerging risks varies at different levels of socioeconomic development. Urban air pollution, for example, is often a greater risk to health in middle-income countries compared with high-income countries because the latter have made greater progress in environmental and public health policies.

The risk transition reflects differences in the patterns of behaviour of men and women. For example, in many settings, use of tobacco and alcohol was traditionally higher among men than women. More recently, however, smoking rates among females have started to approach those of males; the health consequences (e.g. increased rates of cardiovascular diseases and cancers) will emerge in the future. In low-income and middle-income countries, alcohol use is generally higher among men. However, in many higher income countries, male and female patterns of alcohol use are beginning to converge.

5. Socioeconomic inequalities adversely affect health

Socioeconomic status is a major determinant of health for both sexes. As a general rule, women in high-income countries live longer and are less likely to suffer from ill-health than women in low-income countries. In high-income countries, death rates among children and younger women are very low and most deaths occur after the age of 60 years (Figure 2). In low-income countries the picture is quite different. The population is younger and death rates at young ages are higher, with most deaths occurring among girls, adolescents and younger adult women.

In high-income countries, non-communicable diseases, such as heart disease, stroke, dementias and cancers, predominate in the 10 leading causes of death, accounting for more than four in every 10 female deaths. By contrast, in low-income countries, maternal and perinatal conditions and communicable diseases (e.g. lower respiratory infections, diarrhoeal diseases and HIV/AIDS) are prominent and account for over 38% of total female deaths (Table 3).

Poverty and low socioeconomic status are associated with worse health outcomes. Data from 66 developing countries show that child mortality rates among the poorest 20% of households are almost double those in the richest 20% (World health statistics, 2009). In both high-income and low-income countries, levels of maternal mortality may be up to three times higher among disadvantaged ethnic groups than among other women (Australia’s health, 2008; Anachebe, 2006). There are similar differentials in terms of use of health-care services. For instance, women in the poorest households are least likely to have a skilled birth attendant with them during childbirth.

6. Gender inequities affect women’s health

The adverse impact on health of low socioeconomic status is compounded for women by gender inequities. In many countries and societies, women and girls are treated as socially inferior. Behavioural and other social norms, codes of conduct and laws perpetuate the subjugation of females and condone violence against them. Unequal power relations and gendered norms and values translate into differential access to and control over health resources, both within families and beyond. Gender inequalities in the allocation of resources, such as income, education, health care, nutrition and political voice, are strongly associated with poor health and reduced well-being. Thus, across a range of health problems, girls and women face differential exposures and vulnerabilities that are often poorly recognized (World health statistics, 2009).

7. Women amid conflicts and crisis

Women face particular problems in disasters and emergencies. Available data suggest that there is a pattern of gender differentiation at all stages of a disaster: exposure to risk, risk perception, preparedness, response, physical impact, psychological impact, recovery and reconstruction Gender and health in disasters. Geneva, World Health Organization, 2002). Studies of several recent disasters in South-East Asia found that more women than men died as a result of the disaster. In situations of conflict and crisis, women are often at greater risk of sexual coercion and rape (Cottingham et.al, 2008 ). In the midst of natural disasters and armed conflicts, access to health services may be even more restricted than normal, contributing to physical and mental health problems that include unwanted pregnancy, and maternal and perinatal mortality. Even when health care is available, women may be unable to access it because of cultural restrictions or their household responsibilities (Garcia and Reis, 2005).

8. Women and the health-care system

The socioeconomic and gender-based inequalities that women face are played out in their access to and use of health-care services. As already noted, the poorest women are generally least likely to use health-care services. The reasons are complex: services may be unavailable or inaccessible, or women may be unable to find affordable transport. Socio-cultural norms also often limit women’s mobility and interaction with male health providers.

The way that socioeconomic inequality plays out in different settings is important for determining the most effective policy and programme responses. In some settings, barriers to access to health care affect all households except the wealthiest (Figure 3).

In Chad and Nepal, for instance, only the wealthiest households use a skilled birth attendant at delivery. In India, Indonesia and Pakistan, while access to health services is better across all income groups, the wealthiest benefit most and poorer households are left behind. In Colombia and Gabon, the use of skilled birth personnel is relatively high across most income groups but not in the poorest group. These different patterns of inequality imply the need for different programmatic interventions that range from targeting the poorest to strengthening the whole health system, to a combination of both strategies (The world health report, 2003).

It is a paradox that health services are so often inaccessible to women or unresponsive to their needs given that health systems are so highly dependent on women. Women are the main providers of care within the family and constitute the backbone both of the formal health workforce and of informal health-care provision. Women predominate in the formal health workforce in many countries. The available data are of variable quality and derive from different sources but they indicate overall that women make up over 50% of formal health-care workers in many countries (George, 2007; Gender and health workforce statistics, World Health Organization, 2008).

Women tend to be concentrated in occupations that may be considered to have lower status – such as nursing, midwifery, and community health services – and are a minority among the highly trained professionals (Gender and health workforce statistics, World Health Organization, 2008). Typically, more than 70% of doctors are male while more than 70% of nurses are female – a marked gender imbalance. In many countries, female health-service providers are particularly scarce in rural areas, a situation that may arise in part because it is unsafe for females to live alone in some isolated areas. The picture may well be different if traditional birth attendants and village volunteers were included in the calculations as these are the domains of women in many countries. However, this information is rarely routinely available. Moreover, there are some notable exceptions. For example, Ethiopia and Pakistan are among the countries that have sought actively to recruit and train female health workers in rural areas.

Female health workers face several work-related health problems. Because there are more women in the health-care workforce and because female health-care workers are often working with sharps, women account for about two-thirds of all global hepatitis B and C infections and HIV infections due to needlestick injuries (Pruss-Ustun et al, 2003). Women are also prone to musculoskeletal injuries (caused by lifting) and burnout (Pruss-Ustun et al, 2003; Aiken et al., 2002; Josephson et al., 1997; Mayhew, 2003; Seifert and Dagenais, 1998; Pechter et al., 1997). Female health workers are exposed to hazardous drugs that are mutagenic and possibly carcinogenic, and to chemical hazards such as disinfectants and sterilants which cause asthma, (Pechter et al., 1997). as well as to adverse reproductive outcomes such as spontaneous abortion and congenital malformations. Female community health workers may also be subjected to violence (Gender and health workforce statistics, World Health Organization, 2008).

9. Policy Implications

Despite huge advances in health in recent years, women in many parts of the world still face health problems that should have been tackled many years ago. Elsewhere, women have benefited from progress only to find themselves confronting new problems, many of them chronic and emerging at older ages. These problems can be improved by health promotion and health-care interventions earlier in life.

Women and men share the same right to the enjoyment of the highest attainable standard of physical and mental health (Report of the Fourth World Conference on Women, 1995). However, women are disadvantaged due to social, cultural, political and economic factors that directly influence their health and impede their access to health-related information and care. Strategies to improve women’s health must take full account of the underlying determinants of health – particularly gender inequality – and must address the specific socioeconomic and cultural barriers that hamper women in protecting and improving their health. These strategies must be placed in the broader context of revitalized primary health care, which addresses both priority health needs and the underlying determinants of health (The world health report, 2008). Primary health care can make a difference through policy action to strengthen leadership, build responsive health services, achieve universal coverage and leverage change in public policy.

10. Summary

• Women are an integral part of human society
• Our Vedas tell us that women held an important place in ancient culture
• Women at home and society in general, are a different cup of tea.
• Some health challenges affect both women and men
• Women’s health matters not only to women themselves. It is also crucial to the health of the children they will bear.
• Females generally live longer than males
• The female advantage in life expectancy may be a relatively recent phenomenon
• One of the most striking features of recent decades has been a shift in the underlying causes of death and disease around the world.
• The risk transition reflects differences in the patterns of behaviour of men and women.
• Socioeconomic status is a major determinant of health for both sexes
• Poverty and low socioeconomic status are associated with worse health outcomes.
• The adverse impact on health of low socioeconomic status is compounded for women by gender inequities
• Women face particular problems in disasters and emergencies.
• The socioeconomic and gender-based inequalities that women face are played out in their access to and use of health-care services
• Female health workers face several work-related health problems.
• Despite huge advances in health in recent years, women in many parts of the world still face health problems that should have been tackled many years ago.
• Women and men share the same right to the enjoyment of the highest attainable standard of physical and mental health
• This module has summarized some of the health challenges faced by women across their lives and has given an overview of some of the underlying determinants of women’s health.
• It is clear that women around the world face health challenges at every stage of their lives from early childhood to old age, and whether at home, at work or in wider society.