WOMENAID INTERNATIONAL

WOMEN'S HEALTH PROBLEMS

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 differential basis.

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 perspective. 

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 conditions.

Globally, 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% haemoglobin).

The 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 iron-deficiency.

In the 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.

Lack of calcium intake over the life span associated with endomitrial changes during the menopause may lead to osteoporosis later in life.

Lack of antioxidants and unbalanced fat intake may contribute to heart conditions and cancers.

Iodine 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 entire community".

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 strictly applied;
  • 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 women.

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 emphasised:

(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 labour-saving measures.

(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 women.

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 mobilisation, 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".

EARLY PREGNANCY

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 disabilities

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.

More than 20 million women are chronically infected with either genital herpes or human papilloma virus infections.

Every minute of the day, every day of the year, two women become infected by HIV and every two minutes a woman dies from AIDS.

Women 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.

HARMFUL PRACTICES

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 more.

"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 University, USA

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 birth.

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 questionnaires.

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 illusion.

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 fulfil.

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 health conditions.

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 needed.

Published by WomenAid International

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