BMJ No 7116 Volume 315
Education and debate Saturday 1 November 1997
Women's health
Women's health is a global issue
Naomi Craft
This is the first of three articles explaining the impact of women's health on the international community
All over the world, women live longer than men.(1) The largest differences are in eastern Europe, the Baltic states, and central Asia. In the Russian Federation women live 12 years longer than men; in most developing countries the differences are smaller, with women outliving men by only 3 years in Africa.
In developing countries, life expectancy for both sexes has increased from 40 to 63 years since 1960, and in countries with high incomes it is now at least 75 years.(2) Only in Uganda and Zambia has life expectancy dropped - from 48 to 43 for women and from 46 to 43 for men - due to the impact of AIDS.(1)
Although women are living longer, they do not necessarily live better, healthier lives. In developing countries, communicable diseases, together with illnesses relating to childbirth, account for most morbidity in women (fig 1). In the developed world too, women are sicker than men, according to their own assessments of their physical and psychological wellbeing.(3)
Lesley Doyal, professor of health and social care at the University of Bristol, explains that "While women risk contracting the same endemic diseases as men, both biological and social factors may increase exposure or worsen the effects." (3)
Global influences on women's health
Some things affect women more often than men, regardless of where they live. These include poverty, changing demography (birth rates and an aging population), gender, violence against women, and lack of research about women.
Summary points |
Poverty
Over 70% of the 1.3 billion people living in poverty are
women.(4) The link between poverty and ill health is well
established.(5) The social causation hypothesis relates
health to structural factors such as working environment or behavioural
factors such as diet.(6) To reduce poverty and therefore
improve health, the World Bank has encouraged governments to invest in
policies which support economic opportunities for
women.(1)
Changing demography
The total birth rate has fallen by 40% in the past 30 years and
the percentage of contraceptive users has increased from around 14% in
1960-5 to an estimated 57% of women of reproductive age in
1994.(7) Where there is a choice, women delay childbirth.
Research in Britain has shown that at least one woman in five now in
their 20s and 30s will have no children.(8) The feminist
writer Joan Smith notes that "in the past, without reliable methods
of contraception, women had little choice. For centuries, people mixed
up the fact that nearly all women had children with the assumption that
they all passionately wanted to do it. Take away the element of
biological inevitability and what happens? A substantial minority turn
out to have other things on their mind, whether it's a career or a
life based around lovers and close friends." (9)
 Fig 1 - Burden of disease in adult men and women aged 15-44 years in the developing world, 1990. Adapted from World Development Report 1993, p28(2) |
Research by the Special Programme of Research, Development and Research
Training in Human Reproduction based at the World Health Organisation
shows that millions of women say that they want no more children in the
near future or have reached their desired family size, but these women
are not using any contraception. This may be due to lack of access to
family planning services or because healthcare planners have not taken
into account women's needs and perspectives.
The proportion of elderly people in the population is increasing worldwide. There are at least 302 million women in the world who are over the age of 60, in comparison to 247 million men. |
Older women's health needs are different from those of men, particularly as many of these elderly women will have experienced poor nutrition and reproductive ill health. Because women tend to marry older men, many of these women will be widows, and this increases the risk of poverty, ill health, and isolation.
Gender
Gender describes those characteristics of men and women which are
socially constructed, in contrast to sex, which is biologically
determined. As Rebecca Cook, professor in law and medicine at the
University of Toronto, explains: "Leadership through success in
battle is male gendered, whereas caring for the dependent young, sick,
and elderly is female gendered. It is obvious that women can be
political and industrial leaders, and that men can be caregivers, but
it has been considered exceptional for people to assume a gender role
at variance with their sex." (10)
For women, gender differences may mean inequality and discrimination. "Not all women are worse off than men," says Professor Lesley Doyal, "but in most societies the male is valued more highly than the female." (3)
| Violence against women
The 1993 World Development Report estimates that 5-16% of the healthy years of life lost to women of reproductive age can be linked to victimisation based on gender, rape, and domestic violence.(2) Women refugees are at particular risk of sexual abuse and violence - the refugee population has grown from 2.5 million in 1970 to over 18 million in 1995.(11) There is not much reliable, population based data but it is clear that violence can result in long term mental, physical, and sexual health problems.(12) |  Fig 2 - Brick making generates income for women in Uganda |
Lack of research about women
Research on populations tends to be undifferentiated by sex and
has excluded proper studies of women.(14-16) The grounds for
excluding women are that the menstrual cycle introduces a potentially
confounding variable in analysis of data that can be overcome only by
larger subject pools and more complex data gathering and analysis. A
further protective reason has been that experimental use of treatments
might expose fetuses to unknown risk, and excluding women who might be
pregnant involves intrusive questioning or testing.(17)
Bernadine Healy from the National Institutes of Health in the United States summarises the task: "It is now time for a general awakening - women have unique medical problems." (18) Some diseases are unique to women; others, such as coronary heart disease, may have different effects in women.
Health of women in the developing world
Issues affecting women in the developing world may also be applied to women living in socioeconomically deprived areas in the developed world. Important among these are education, lack of autonomy, legal status, preference for sons, traditional practices, lack of access to health care, work and environmental health hazards, and unequal human rights.
| The Girl Child Project(20) The Girl Child Project was established by the Family Planning Association of Pakistan to raise awareness among young girls and their families of unfair and unnecessary discrimination against girls. "People here don't educate their girls because to them girls are not theirs," points out 16 year old Nacema Ansari from Ratta Amral, Rawalpindi. "Girls are seen as belonging to their future in-laws' families and any investment in their future is futile. They go to their husbands' homes at a young age, usually anywhere from 13 to 17. The rest of their lives are spent looking after in-laws, and bearing and bringing up children to prolong and strengthen their husband's family line." In the project girls are given information on health, hygiene, nutrition, education, first aid, food preservation, and women's rights. Girls have been taught how to conduct adult literacy training, grow trees, and promote environmental cleanliness. Shabnam Naheed, 16, who lives in Baldia, said, "In my own family, my mother used to give meat to my brothers first and then to us girls. I learnt during the workshops that this was not right. So I went home and told my mother that even the Prophet Muhammad had said to treat girls equally. Now we all eat well." |
 Fig 3 - There is a trend towards educating and empowering women - classroom in Brunei |
Education
Globally, more than 960 million adults are illiterate, two thirds of whom are women.(19) Households with more education enjoy better health, both for adults and for children.(1) Women with even a few years of schooling have more self confidence; they assume responsibility, communicate more with their husbands, and may have a higher status in the family, giving them more say in health decisions.(2) |
Lack of autonomy
Women can know how to care for minor illnesses and recognise
serious illness but can lack the autonomy to decide when to go for
treatment for themselves or for a child. For example, well informed
women in India find it hard to take their own decisions about family
planning, as Dr Sundari Ravindran from the Centre for Development
Studies in India describes: "When husbands disapprove of their wives
practising contraception, it is an exceptionally brave woman who defies
the authority of their husband." (13)
Legal status
Laws and customs about land ownership, inheritance, marriage, or
divorce in many countries discriminate against women, often
contributing to their poverty and poor health. For instance, in Lesotho
only widows and women who are legally determined to be household heads
may apply for credit in their name. Wives, even if they are de facto
heads of households, are barred from applying for
credit.(21) In Kenya, rights to inherit from their fathers
belong only to sons.(8)
Preference for sons
In regions where sons are highly valued, girls may be given
inferior nutrition and health care from birth and weaned early to allow
the mother to conceive a boy as soon as possible.(22) In
extreme cases this preference may lead to prenatal sex selection in
favour of boys, or to infanticide.(11)
Traditional practices
Traditional practices such as female genital mutilation may harm
women, and dowry and bride price may lead to physical abuse,
intimidation, or even death. Many cultures place high value on having
children at a young age, perhaps even before girls have reached
physical maturity. In Nepal, one third of girls are married by the age
of 15(23); in India, southeast Asia, and subSaharan Africa,
one third to one half are married during adolescent years, typically to
men a decade older.
Lack of access to health care
In the developing world, women use health services less than
men.(11) This may be because facilities do not exist or
because the costs of services are prohibitive. Often health services
are insensitive to the cultural needs of women: in many Middle Eastern
countries, for example, most doctors are men, despite a strong belief
that women should not be seen after puberty by men who are not
relatives.(2)
In some places, services are narrowly centred around women in their
reproductive roles.(13) Individual health services such as
prenatal care and immunisations may be offered on different days,
meaning that women have repeatedly to return with their
children.
Work and environmental health hazards
Outside the home, women tend to work in the informal sector or in
smaller, less regulated enterprises than men. Poor conditions
predispose these women to health risks ranging from exposure to
carcinogenic chemicals or excessive noise, heat, and humidity, to
physical strain, eye strain, and allergic reactions.(11)
In the home, in most cultures women are responsible for maintaining
the household, including caring for children and elderly and sick
people. Every day a woman may need to walk up to 10 kilometres for
water or fuel, carrying loads of 20 kg or more on her
head.(11)
Unequal human rights
Women in many societies have little or no access to education and
may be subject to laws, practices, stereotypes, and prejudices that are
harmful to them. As human rights lawyer Rebecca Cook notes, "The poor
state of women's health in many regions of the world, including within
deprived socioeconomic populations in developed countries, can be seen
as one result of women's inability to protect their own interests."
(10)
|
Inalienable human rights The human rights of women and of the girl-child are an inalienable, integral, and indivisible part of universal human rights. The full and equal participation of women in political, civil, economic, social, and cultural life, at the national, regional and international levels, and the eradication of all forms of discrimination on grounds of sex are priority objectives of the international community. - Vienna Declaration and Programme of Action adopted by the World Conference on Human Rights, Vienna, 25 June 1993 |
Health of women in the developed world
Many women, particularly in the developed world, are challenging the traditional view that a woman's place is in the home, but in western Europe women are still outnumbered by men in higher education (93 women per 100 men).(1)
| This is in spite of the fact that
in the developed regions outside western Europe, in Latin America and
the Caribbean, and in western Asia, the population has more women than
men.(1) At the end of 1994, 10 women headed governments, and
the number of countries with no women ministers fell from 93 to 59
between 1987 and 1994.(1) Women rarely represent more than
1-2% of senior management positions in business.(1) Changes in central and eastern Europe and the former USSR have had an adverse effect on health. Maternal and infant mortality have risen, and morbidity from circulatory diseases in women has increased. Women have more mental health problems and there is more violence against women, often linked with alcohol intake by men. In areas where the birth rate has fallen women are less exposed to the hazards of childbearing. The rapid changes in women's economic roles, however, may raise issues about how women are to cope with their dual roles and increased workload. |  Fig 4 - Women's economic roles have changed rapidly, but traditional practices carry on - spinning wool in Ethiopia |
| Provision of public handpumps in Imo State, Nigeria, reduced the median time that each household spent on water collection in the dry season from six hours a day to 45 minutes.(2) |
Conclusion
As far back as the first general assembly of the United Nations in 1945, female delegates demanded special attention for women's issues. During the United Nations Decade for Women (1976-85) many organisations began to appreciate the link between women's status, fecundity, and development and started implementing small scale community projects for women's development. Many of these addressed the need for income generation and new skills. There is now a trend towards educating and empowering women and encouraging women to get involved in developing strategies for change. Projects also aim to encourage both women and men to challenge gender stereotypes.
Many employers continue to underinvest in women. The World Bank believes that markets fail to capture the benefit to society of investing in women and girls. It argues that public policy can reduce gender inequalities - for example, by modifying laws to ensure equal opportunities. It recommends that governments should redirect public money to investments offering the highest social returns and target those interventions which correct for gender inequalities.(2)
Gower Place Practice,
London WC1E 6BN
Naomi
Craft
freelance medical journalist
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