BRIEFING PAPER BPH/20
Women are subject to gender differences which have consequences on
their health status. While 'sex' refers to biological attributes of men and women, 'gender'
is understood as a social construct, referring to the distinguishing traits, attitudes,
feelings, values, behaviors and activities that society ascribes to the two sexes on a
Because of their biological attributes, women live longer than men. As
they increasingly form a larger proportion of the elderly population, they will become
progressively more susceptible to disease in the future. Women suffer from more ill-health
or are more vulnerable to certain diseases than men. This may be due to biological and/or
gender differences, in addition to many other factors about which more needs to be known.
Certain health problems are more prevalent in women; others are unique to women; still
others affect women in a different way than they do men.
In considering women's health problems, an attempt has been made to
identify those actions which will realistically achieve future progress. The issues
outlined below should not be seen as an all-inclusive list of health problems facing
women, but considered as selective pointers which reveal other health issues. They were
selected on the basis of the extent to which they:
illustrate the predominant risk factors leading to morbidity and
mortality in women of all ages;
reflect the type of health problems women face at different periods
in their lives;
||transcend national boundaries;
- are amenable to solutions using feasible, low-cost interventions;
The six issues covered are nutrition, reproductive health, the health
consequences of violence, ageing, lifestyle-related health conditions, and work
environment. Each of these issues is looked at within a lifespan
While adequate nutritional intake is important for all human beings and
closely linked to patterns of morbidity and mortality, it is particularly important for
girls and women. This is because of intergenerational and cumulative effects which
permeate different phases of a woman's life. Both protein-energy malnutrition and
micronutrient deficiencies at various stages of life contribute to morbidity and mortality
from a variety of infections and chronic diseases. Discriminatory feeding practices in
childhood sometimes lead to protein-energy malnutrition, anaemia and other micronutrient
deficiencies in young girls. Stunting caused by protein-energy malnutrition in girls is
responsible for subsequent problems in childbirth leading to increased incidence of
obstructed labour, ano- and vesiculo-vaginal fistulae, birth asphyxia and other
51% of pregnant women and 33% of women of reproductive age who are not pregnant suffer
from anaemia. In developing countries, 56% of pregnant women are anaemic. In Asia and
Africa approximately 7% of pregnant women suffer from severe anaemia (below 7gm%
adolescent girl requires, but rarely gets, 18% more iron per kg body weight than male
adolescents. Virtually all adolescent girls in developing countries suffer from
periurban and urban slums in developing countries, children are kept indoors with little
exposure to the sun. In the girl child, without other sources of vitamin D, the pelvic
bones are apt to become deformed leading to future complications such as death in
childbirth from obstructed labour.
calcium intake over the life span associated with endomitrial changes during the menopause
may lead to osteoporosis later in life.
antioxidants and unbalanced fat intake may contribute to heart conditions and cancers.
deficiency is the commonest preventable cause of mental retardation. At least 25% of
adolescent girls in developing countries are affected by iodine deficiency and this
seriously affects the next generation. It leads not only to goitre but also to brain
damage in the foetus and infant, resulting in irreversible retarded psychomotor
development. In severe cases it causes cretinism, deaf-mutism, squint, spastic diplegia
and other serious defects. It also affects a woman's reproductive function leading to
increased rates of abortion, stillbirth, congenital anomalies, low birth weight and infant
and young child mortality. Mild to moderate deficiency causes loss of 5-10 IQ points.
Nutritional equality between boys and girls, men and women, must be
addressed at both economic and cultural levels in order to deal with the technical issues
of providing more nutritious food to girls and women, in addition to the social issues
which keep girls and women in secondary place on the nutritional ladder of the family.
Indeed, women (and children) are among the first victims of malnutrition when prevailing
beliefs, customs and/or legislation keep them in a position of inferiority and as a result
some family members receive more food than others in proportion to their nutritional
requirements. Available data shows that, in some countries, a sex bias in favour of males
determines nutritional intake.
With this background in mind, Commission members recalled that the World
Declaration and Plan of Action adopted by the International Conference on Nutrition
in Rome, December 1992, underlines as essential policy orientation that "women are
inherently entitled to adequate nutrition in their own right as individuals. They need
constantly to balance their reproductive, nurturing, educational and economic roles which
are so important to the health and nutritional well-being of the household and of the
Throughout the Plan of Action emanating from the
International Conference on Nutrition, repeated reference to women and gender equality is
made, and governments were requested to consider these seriously in their strategies and
actions to eliminate hunger and all forms of malnutrition. The Plan of Action requires,
among other things, that :
- special attention be given to the nutrition of women during pregnancy and lactation;
- the Convention on the Elimination of All Forms of Discrimination against Women be
- women's role in the community be better understood in order to ensure and promote
meaningful equality between men and women;
- equity in the allocation of food between girls and boys be promoted;
- equitable access for women and girls to economic opportunities and to education and
training opportunities be ensured;
- legal measures and social practices be adopted in order to guarantee women's equal
participation in the development process by ensuring their access and right to utilise
productive resources, markets, credit, property and other family resources;
- equal access be given to men and women to programmes of family life education,which
among other things, should enable couples to plan the spacing of their children;
- nutrition education of men and boys be enhanced, in addition to improving education of
The Global Commission of Women's Health recognised the relevance
of the above policy orientations and reiterated the importance of moving forward in their
implementation at all levels. During their discussions, a number of points were further
(1) data collected on the nutritional status of children should
be disaggregated by gender and national authorities should be encouraged to collect data
on differences in intra-household food distribution. This information would be used in the
design of appropriate programmes to meet the nutritional needs of infants and toddlers,
especially girls, pregnant and lactating women and elderly women.
(2) support should be given to projects which emphasise
income-generating activities for women, provision of training in economic skills,
increased access to markets to sell and obtain goods and services, and energy and
(3) a strong human rights agenda which concentrates on increased
democracy and more equality for women should be supported.
All of these measures would contribute to better nutritional status of
The Global Commission on Women's Health consider reproductive health as referring to all aspects of well-being
related to the reproductive system and processes within a life span perspective. It
encompasses fertility, infertility and the enjoyment of good sexual health without fear of
disease or unwanted pregnancy. The reproductive health of a woman shapes the quality of
each day in her life.
MATERNAL MORBIDITY AND MORTALITY
The medical community has known which interventions are required to
prevent maternal mortality since the 1930's, yet 20 million women have died since 1950,
and many women born in 1975 have already died in childbirth. One reason for the lack of
progress is the tendency to search for quick solutions. The tragedy of maternal death has
multiple causes and requires a comprehensive strategy comprising community
prenatal care, clean and safe delivery with trained assistance and, most critically, first
referral care for management of complications. The effects of the socially disadvantaged
position of women and girls are often cumulative, the most severe consequence being death
in childbirth. Maternal mortality rates in resource-poor countries are as high as 100
times the rates in industrialised countries.
Of the 150-200 million pregnancies which occur each year, about 23
million develop serious complications such as postpartum haemorrhage, hypertensive
disorders, eclampsia, puerperal sepsis, and abortion. Half a million of these end up with
the death of the mother. The death of the mother has dramatic consequences on the family,
especially on children. When a mother dies it doubles the death rate of her surviving sons
and quadruples that of her daughters. In high maternal mortality settings, there may be as
many as 175,000 motherless children for every million families.
Globally, 57% of couples where the wife is of reproductive age use
contraception; about 120 million women in the developing world say that they are not using
family planning even though they want to avoid becoming pregnant.
Every year over 20 million women terminate unwanted pregnancies through
unsafe abortions as a result of lack of access to relevant care and services, such as
family planning, costly contraceptive methods, lack of information and restrictive
legislative practices. Of these, many die. While some 15 million women will survive unsafe
abortions, they will experience a wide range of long-term disabilities such as obstetric
fistulae, anaemia, uterine prolapse, endometriosis, pelvic inflammatory disease, secondary
infertility, paralysis and kidney failure.
Quality of care is essential in ensuring that women enjoy good
reproductive health throughout their lives. Such care is based on respect of women and
their particular needs, participation of women in the design and delivery of services, and
the provision of information which allows women to make informed choices about their
sexual and reproductive lives. In recognition of the need to accelerate actions in this
area, the Global Commission on Women's Health has adopted as one of its motto's, "No woman should die in childbirth".
Adolescent years are a time of profound physical and emotional
change. When adolescents are caught up in change and experimentation, their behaviour
exposes them to health risks which may have a profound effect on their health, their lives
and their prospects for the future. This is especially the case when this behaviour
results in sexually transmitted diseases or early, unwanted pregnancies.
There is a growing phenomenon of teenage pregnancies throughout the
world. Research in industrialised countries shows that these "children having
children" are physically and emotionally immature for childbearing and rearing,
have reduced educational and occupational attainment, lower income and increased welfare
dependency. Any efforts at greater empowerment of women are often frustrated early in life
as a result of adolescent motherhood.
Pregnancies that come too early, too often and too closely spaced
present a serious danger to women's health. Maternal mortality rates are higher among
teenage mothers. Their children are at increased risk of low birth weight which leads to
infant death and conditions such as cerebral palsy, autism and learning
REPRODUCTIVE TRACT INFECTIONS,
SEXUALLY TRANSMITTED DISEASES AND HIV/AIDS
Reproductive tract infections affect women in all walks of life and
they often suffer from severe forms due to lack of access to appropriate care, poor
nutrition and adverse living conditions.
The impact of sexually transmitted diseases is particularly severe for
young women, since infections have few, if any symptoms, and may go untreated until
serious problems develop. Complications include pelvic inflammatory disease, infertility,
pelvic pain, and life-threatening ectopic pregnancy.
A decade ago, women seemed to be on the periphery of the AIDS epidemic,
but today almost half of the newly infected adults are women, which is another reflection
of their social vulnerability.
Prevalence rates of sexually transmitted diseases are generally higher
among sexually active women than among sexually active men, largely because they have a
greater proportion of asymptomatic infections than men do. In one industrialised country,
6 million women, half of whom are teenagers, acquire a sexually transmitted disease.
20 million women are chronically infected with either genital herpes or human papilloma
minute of the day, every day of the year, two women become infected by HIV and every two
minutes a woman dies from AIDS.
appear to be biologically more vulnerable to HIV infection. Transmission of HIV from men
to women is as much as two to ten times more efficient than from women to men.
||By the year
2000, WHO estimates that over 13 million women will have been infected with HIV, and about
4 million of them will have died.
WHO estimates that already almost half of the newly HIV-infected adults
are women. By the year 2000, in some regions, a majority of the new infections will be in
women. As infections in women rise, so do infections in the infants born to them. To date,
these total about 1 million, of whom half a million have already developed AIDS.
In addition to being ill themselves, women are carrying the burden of
caring for children that may be infected. Eventually the children become another
statistical number in the growing problem of AIDS orphans.
One of the tragedies of health care is the persistent denial
of education to many women, and the relationship this has to diseases and health
conditions that affect them. Illiteracy in all its forms - not only the inability to read
and write, but the denial of information pertinent to an understanding by women of how
their body functions, and how they can protect themselves -is one of the most pernicious
factors leading to harmful practices perpetuated by women themselves. Some of these
health-damaging behaviours span from childhood to old age and include food taboos at
various stages in the life of a girl or a woman, harmful practices during pregnancy,
delivery and care of the new-born, introduction of harmful substances into the vagina,
female genital mutilation, and many
"Women play a central role in determining the health of family
members, and the education of women is a powerful-- if not yet fully understood-- factor
affecting child mortality, nutrition, health and school achievement."
T. Paul Schultz, Dept. of Economics, Yale
It is estimated that more than a thousand newborns die every day
as a complication of unsafe handling of the cord after delivery, and an equal number
suffer health risks when colostrum is purposely withheld during the first days after
Globally at least 2 million girls a year suffer genital mutilation,
approximately 6,000new cases every day - five girls every minute. An estimated 85 to
114 million girls and women in the world are genitally mutilated.
Health consequences of female genital mutilation include trauma, pain
bleeding, infections, or even death. Long-term physical complications are numerous, and
there appear to be substantial psychological effects on women's self-image and sexual
lives. For those with the severest form of female genital mutilation - infibulation - the
trauma is repeated with each childbirth. Although grossly under-reported, violence against women is now reaching
alarming proportions in developed and developing countries alike. Domestic violence and
rape have only recently been viewed as a public health problem, and yet they are a
significant cause of female morbidity and mortality. Violence against women leads to
psychological trauma, depression, substance abuse, injuries, sexually transmitted diseases
and HIV infection, suicide, and murder.
On a per capita basis the health burden of domestic violence and rape
is roughly the same for reproductive-age women in industrial and developing countries, but
because the overall health burden is greater in developing countries, the percentage
attributable to gender-based victimisation is smaller (roughly 5 percent). In some
countries, where maternal mortality and poverty-related diseases have been brought under
relative control, the healthy years of life lost to rape and domestic violence appear as a
larger percentage, accounting for 16 percent of the total burden.
Based on the limited data available, the World Bank estimates that in
industrialised countries, rape and domestic violence account for almost one in every five
healthy years of life lost to women aged 15 to 44. In these countries, abused women have
significantly worse physical and mental health when measured by standardised health status
Women who are the victims of violence rarely receive rehabilitative
care, lack insurance coverage, particularly for the mental health consequences of
violence, and do not receive any compensation which victims of other forms of
violence-causing traumas receive.
Denying women access to health care, or legislation which requires the
consent of a male partner or member of the family for services such as family planning, is
a denial of fundamental human rights and freedom of choice, and constitutes a form of
moral violence against women.
The Global Commission on Women's Health views all forms of violence
against women as a denial of a women's right to physical integrity and right to be free
from the physical and psychological effects of violence.
A number of international instruments already exist to protect women
from discrimination and violence. The International Covenant on Civil and Political
Rights protects women's right to physical integrity; the International Covenant on
Economic, Social and Cultural Rights protects women's equal right to the highest
attainable standard of physical and mental health. The Convention on the Elimination of
All Forms of Discrimination against Women protects them against discrimination. In
addition a Special Rapporteur on Violence Against Women has recently been appointed by the
Commission on Human Rights.
The health consequences of violence against women constitute a major
element of the work of the Global Commission on Women's Health, working with and
through all existing mechanisms to ensure that the health consequences of violence were
brought forcefully into the spotlight, and measures taken to eliminate all forms of
violence against women.
As life expectancy increases in most countries, it is estimated that
the number of women over the age of 65 will increase from 330 million in 1990 to 600
million in 2015. Many of these elderly women will have experienced poor nutrition,
reproductive ill-health, dangerous working conditions, violence and life-style-related
diseases, all of which exacerbate the post-menopausal phenomena of increased likelihood of
breast and cervical cancers as well as osteoporosis.
Poverty, loneliness and alienation are common. Little data exists on
the health conditions of the elderly female population except in industrialised countries
from which extrapolation is made.
Osteoporosis, a disease of calcium depletion normally occurring after
menopause, affects many women worldwide over the age of 60. The exact figures however are
unknown. In one industrialised country, osteoporosis is responsible for 1.3 million bone
fractures a year, commonly of the femur, forearm and tibia. Many of these women become
totally dependent as a result of this illness.
The market is continually creating new opportunities for lifestyles and
choices. This expansion of choices has increased the complexity of making rational and
informed decisions to protect health since behavioural and lifestyle contribute
substantially to the main causes of death worldwide, such as heart diseases, diabetes,
cancer, AIDS and suicide. Consequently, knowledge about health and a capacity for
self-care become increasingly important.
It is important also to take into account the social context in which
such individual "choices" are made. The effects of social status and social
conditioning, of economic and social policies, and of the behaviour of large and powerful
corporations deserve scrutiny. Smoking, for example, is often viewed simply as an
individual act predisposing one to specific disease, but tobacco is an addictive substance
and the addition is normally acquired during early adolescence. Furthermore, the sharp
difference in smoking behaviour among population groups point to the importance of social
influences. It may be more appropriate to consider smoking as an individual response to a
social environment than to see it as a voluntary lifestyle choice.
The "choice" of practising unsafe sex, putting the individual
at risk of HIV and other sexually transmitted diseases, is also questionable, especially
where women are concerned. Most of the HIV-positive women in the world have acquired the
infection in their homes. In many societies, it is considered acceptable for men to engage
in extra-marital sex, while women are expected to remain monogamous. In these situations
women are usually able to do little to control their husband's infidelity and appeals to
women to practice safer sex have little value. Even if condoms were readily available and
affordable (which is not the case), they have little ability to negotiate their use.
Unless the conditions of the relative powerlessness of women in sexual relationships, and
the underlying problems of poverty which drive some women to trade sex for the means to
support themselves and their children, are addressed, individual choice remains an
With the above in mind, the need to develop strategies to promote
healthy behaviour throughout the life span was stressed since women are concerned in a
special way for a number of reasons:
decisions concerning their own health have intergenerational effects;
they are invariably the ones who make decisions on health behaviour
and seek health services for the family;
they are increasingly subject to the health risks inherent in the new
environment of sedentary occupations, excessive consumption and stressful lifestyles.
As industrialisation and urbanisation evolve, lifestyles change and
health-damaging behaviour related to this change increases.
While men have higher mortality rates from suicide, women predominate
for suicide attempts. The typical suicide attempt is made by a single woman under the age
of 25, often as young as 15.
In both developing and developed countries, females are the currently
targeted new "market" for advertisers of tobacco and alcohol products, further
predisposing them to immediate and long-term health consequences of addiction.
When women migrate, their vulnerability to sexually transmitted
diseases and HIV infection increase. High unemployment and lack of community and family
support may result in women engaging in some kind of sexual barter.
Both men and women are exposed to health risks related to the work
environment. However, women's health is affected in specific ways primarily owing to the
gender differences which play a major part in defining the roles and functions women
Lack of education has been a major factor in limiting the work options
available to women working outside the domestic sphere. These women are still concentrated
in low-skilled and low-paid occupations which often present high health risks. Repetitive
tasks (assembly lines), tasks requiring precise work for long periods (electronics
assembly), or processing of agricultural or horticultural products (fruit and flower
packing) have been shown to have consequences on the reproductive tract, skin, and the
musculo-skeletal and nervous system.
Certain health conditions, such as chronic bronchitis and back pain,
are particularly linked heating homes, the carrying of heavy loads of fuelwood, and the
use of household chemicals.
Toxicological effects on the foetus have also been shown. Given the
shortage of accessible safe drinking water in many countries, women are often forced to
carry heavy loads of water for household use long distances, also contributing to these
In a recent study a significant and positive correlation was found
between heavy use of pesticide and prevalence rates of deformity of limbs, dysfunctions of
joints, amputations and visual deformities. Other studies have shown that pesticide use
may contribute to cancer.
Not enough is known about the impact of women's work on their health
status. Nor is enough known about the impact of women's health status on their work. It is
for this reason that the Commission agreed to include the work environment as a vital
issue area having a broad impact on women's health. Gaps in knowledge will have to be
filled through undertaking country studies on the health consequences of women's work and
cross-country studies in areas which are common throughout the world such as the health
impacts of pesticide use in agricultural activities.
It was emphasised that women's health security will be enhanced when
their economic activities are linked to the improvement of health status and provision of
health services and care. Legislative measures to protect and promote women's physical and
mental health in the work-place is an additional area where study and advocacy efforts are
Published by WomenAid International