| Part ofa series on |
| Women's health |
|---|
 Symbol of women's health |
Non-reproductive health |
Women's health by country |
Women's health is an example ofpopulation health, where health is defined by theWorld Health Organization (WHO) as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".[1] Often treated as simply women'sreproductive health, many groups argue for a broader definition pertaining to the overall health of women, better expressed as "The health of women". These differences are further exacerbated indeveloping countries where women, whose health includes both their risks and experiences, are further disadvantaged.
While the rates of the leading causes of death,cardiovascular disease,cancer andlung disease, are similar in women and men, women have different experiences.Lung cancer has overtaken all other types of cancer as the leading cause of cancer related death in women, followed bybreast cancer,colorectal,ovarian,uterine andcervical cancers. Whilesmoking is the major cause of lung cancer, amongst nonsmoking women the risk of developing cancer is three times greater than among nonsmoking men. Despite this, breast cancer remains the most common cancer in women in developed countries, and is one of the majorchronic diseases of women, while cervical cancer remains one of the most common cancers in developing countries, associated withhuman papilloma virus (HPV), asexually transmitted infection.HPV vaccine together withscreening offers the promise of controlling these diseases. Other important health issues for women include cardiovascular disease,depression,dementia,osteoporosis andanemia.
In 176 out of 178 countries for which records are available, there is a gender gap in favor of women inlife expectancy. InWestern Europe, this has been the case at least as far back as 1750.[2] Gender remains an importantsocial determinant of health, since women's health is influenced not just by their biology but also by conditions such aspoverty, employment, and family responsibilities. Women have long been disadvantaged in many respects such as social and economic power which restricts their access to the necessities of life includinghealth care, and the greater the level of disadvantage, such as in developing countries, the greater adverse impact on health.
Women'sreproductive and sexual health has a distinct difference compared to men's health. Even indeveloped countries,pregnancy andchildbirth are associated with substantial risks to women withmaternal mortality accounting for more than a quarter of a million deaths per year, with large gaps between the developing and developed countries.Comorbidity from other non-reproductive diseases such ascardiovascular disease contribute to both the mortality andmorbidity of pregnancy, includingpreeclampsia.Sexually transmitted infections have serious consequences for women and infants, withmother-to-child transmission leading to outcomes such asstillbirths andneonatal deaths, andpelvic inflammatory disease leading toinfertility. In addition, infertility from many other causes,birth control,unplanned pregnancy,rape and the struggle for access toabortion create other burdens for women.
Women's experience of health and disease differ from those of men, due to unique biological, social and behavioral conditions. Biological differences vary fromphenotypes to thecellular biology, and manifestunique risks for the development of ill health.[3] WHO defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".[4] Women's health is an example ofpopulation health, the health of a specific defined population.[5]
Women's health has been described as "a patchwork quilt with gaps".[6] Although many of the issues around women's health relate to theirreproductive health, includingmaternal andchild health,genital health andbreast health, and endocrine (hormonal) health, includingmenstruation,birth control andmenopause, a broader understanding of women's health to include all aspects of the health of women has been urged, replacing "Women's Health" with "The Health of Women".[7] WHO considers that an undue emphasis on reproductive health has been a major barrier to ensuring access to good quality health care for all women.[3] Conditions that affect both men and women, such ascardiovascular disease,osteoporosis, also manifest differently in women.[8] Women's health issues also include medical situations in which women face problems not directly related to their biology, such as gender-differentiated access to medical treatment and othersocioeconomic factors.[8] Women's health is of particular concern due to widespreaddiscrimination against women in the world, leaving themdisadvantaged.[3]
A number of health and medical research advocates, such as theSociety for Women's Health Research in the United States, support this broader definition, rather than merely issues specific to human female anatomy to include areas where biological sex differences between women and men exist. Women also need health care more and access the health care system more than do men. While part of this is due to their reproductive and sexual health needs, they also have more chronic non-reproductive health issues such ascardiovascular disease,cancer,mental illness,diabetes andosteoporosis.[9] Another important perspective is realising that events across the entirelife cycle (orlife-course), fromin utero to aging effect the growth, development and health of women. Thelife course perspective is one of the key strategies of the World Health Organization.[10][11][12]
Gender differences in susceptibility and symptoms of disease and response to treatment in many areas of health are particularly true when viewed from aglobal perspective.[13][14] Much of the available information comes fromdeveloped countries, yet there are marked differences between developed anddeveloping countries in terms of women's roles and health.[15] The global viewpoint is defined as the "area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide".[16][17][18] In 2015 the World Health Organization identified the top ten issues in women's health as being cancer, reproductive health, maternal health,human immunodeficiency virus (HIV), sexually transmitted infections, violence, mental health, non communicable diseases, youth and aging.[19]
Women's life expectancy is greater than that of men, and they have lower death rates throughout life, regardless of race and geographic region. Historically though, women had higher rates of mortality, primarily frommaternal deaths (death in childbirth). In industrialised countries, particularly the most advanced, the gender gap narrowed and was reversed following theIndustrial Revolution.[8] Despite these differences, in many areas of health, women experience earlier and more severe disease, and experience poorer outcomes.[20]
Despite these differences, the leading causes of death in the United States are remarkably similar for men and women, headed byheart disease, which accounts for a quarter of all deaths, followed bycancer,lung disease andstroke. While women have a lower incidence of death fromunintentional injury andsuicide, they have a higher incidence ofdementia.[8][21]
The major differences in life expectancy for women between developed and developing countries lie in the childbearing years. If a woman survives this period, the differences between the two regions become less marked, since in later lifenon-communicable diseases (NCDs) become the major causes of death in women throughout the world, with cardiovascular deaths accounting for 45% of deaths in older women, followed by cancer (15%) and lung disease (10%). These create additional burdens on the resources of developing countries. Changing lifestyles, including diet, physical activity and cultural factors that favour larger body size in women, are contributing to an increasing problem withobesity anddiabetes amongst women in these countries and increasing the risks of cardiovascular disease, kidney disease and other NCDs.[13][22] The prevalence of kidney disease is less common in women due to the estrogen-mediated protection fromferroptotic cell death.[23]
Women who are socially marginalised aremore likely to die at younger ages than women who are not.[24] Women who have substance abuse disorders, who are homeless, who are sex workers, and/or who are imprisoned have significantly shorter lives than other women.[25] At any given age, women in these overlapping, stigmatised groups are approximately 10 to 13 times more likely to die than typical women of the same age.[25]
Women's health is positioned within a wider body of knowledge cited by, amongst others, theWorld Health Organization, which places importance on gender as asocial determinant of health.[26] While women's health is affected by their biology, it is also affected by their social conditions, such aspoverty, employment, and family responsibilities, and these aspects should not be overshadowed.[27][28]
Women have traditionally been disadvantaged in terms of economic andsocial status and power, which in turn reduces their access to the necessities of life includinghealth care. Despite recent improvements in Western nations, women remain disadvantaged with respect to men.[8] The gender gap in health is even more acute indeveloping countries where women are relatively more disadvantaged. In addition to gender inequity, there remain specific disease processes uniquely associated with being a woman which create specific challenges in both prevention and health care.[20]
In low- and middle-income countries, women’s diets, often rich in staple foods, are frequently poor in vitamins and minerals, with consequences for health.[29] Low dietary diversity jeopardizes nutrient adequacy.[29]
Deeply ingrained cultural, religious, and patriarchal systems within theMENA region perpetuate gender-based power dynamics within communities and lead to discrepancies inhealthcare access. In a speech,UNFPA executive directorThoraya Ahmed Obaid outlined these difficulties and emphasized the need to change cultural and societal norms in order to improve the health of women in the area.[30]
Even after succeeding in accessing health care, women have been discriminated against,[31] a process thatIris Young has called "internal exclusion", as opposed to "external exclusion", the barriers to access. This invisibility effectively masks the grievances of groups already disadvantaged by power inequity, further entrenching injustice.[32]
Behavioral differences also play a role, in which women display lower risk taking including consume less tobacco, alcohol, and drugs, reducing their risk of mortality from associated diseases, includinglung cancer,tuberculosis andcirrhosis.[33] Other risk factors that are lower for women includemotor vehicle accidents. Occupational differences have exposed women to lessindustrial injuries, although this is likely to change, as is risk of injury or death in war. Overall such injuries contributed to 3.5% of deaths in women compared to 6.2% in the United States in 2009. Suicide rates are also less in women.[34][35]
The social view of health combined with the acknowledgement that gender is a social determinant of health inform women's health service delivery in countries around the world. Women's health services such asLeichhardt Women's Community Health Centre which was established in 1974[36] and was the first women's health centre established in Australia is an example of women's health approach to service delivery.[37]
Women's health is an issue which has been taken up by manyfeminists, especially wherereproductive health is concerned and the international women's movement was responsible for much of the adoption of agendas to improve women's health.[38]
Factors that specifically affect the health of women compared tomen are most evident in those related toreproduction, butsex differences have been identified from the molecular to the behavioral scale. Some of these differences are subtle and difficult to explain, partly due to the fact that it is difficult to separate the health effects of inherent biological factors from the effects of the surrounding environment they exist in. Women's XXsex chromosomes compliment, hormonal environment, as well as sex-specific lifestyles, metabolism, immune system function, and sensitivity to environmental factors are believed to contribute to sex differences in health at the levels of physiology, perception, and cognition. Women can have distinct responses to drugs and thresholds for diagnostic parameters.[39] All of these necessitate caution in extrapolating information derived frombiomarkers from one sex to the other.[8] Young women and adolescents are at risk from STIs, pregnancy andunsafe abortion, while older women often have few resources and are disadvantaged with respect to men, and also are at risk of dementia and abuse, and generally poor health.[19]
Women experience many unique health issues related to reproduction and sexuality and these are responsible for a third of all health problems experienced by women during their reproductive years (aged 15–44), of whichunsafe sex is a major risk factor, especially in developing countries.[19] Reproductive health includes a wide range of issues including the health and function of structures and systems involved in reproduction,pregnancy,childbirth and child rearing, includingantenatal and perinatal care.[40][41] Global women's health has a much larger focus on reproductive health than that of developed countries alone, but alsoinfectious diseases such asmalaria in pregnancy andnon-communicable diseases (NCD). Many of the issues that face women and girls in resource poor regions are relatively unknown in developed countries, such asfemale genital cutting, and further lack access to the appropriate diagnostic and clinical resources.[13]
.jpg)
Pregnancy presents substantialhealth risks, even in developed countries, and despite advances inobstetrical science and practice.[42]Maternal mortality remains a major problem inglobal health and is considered asentinel event in judging the quality of health care systems.[43]Adolescent pregnancy represents a particular problem, whether intended or unintended, and whether within marriage or a union or not. Pregnancy results in major changes in the life of a young female: physically, emotionally, socially and economically, and jeopardizes their transition into adulthood. Adolescent pregnancy, more often than not, stems from a girl's lack of choices. or abuse. Child marriage (see below) is a major contributor worldwide, since 90% of births to females aged 15–19 occur within marriage.[44]
In 2013 about 289,000 women (800 per day) in the world died due to pregnancy-related causes, with large differences between developed and developing countries.[13][45] In developed nations maternal mortality had been steadily falling[46] and on average means 16 deaths per 100,000 live births, as measured by thematernal mortality ratio (MMR).[46] By contrast rates as high as 1,000 deaths per 100,000 live births are reported in the rest of the world,[13] with the highest rates inSub-Saharan Africa andSouth Asia, which account for 86% of such deaths.[47][45] These deaths are rarely investigated, yet the World Health Organization considers that 99% of these deaths, the majority of which occur within 24 hours of childbirth, are preventable if the appropriate infrastructure, training, and facilities were in place.[48][45] In these resource-poor countries, maternal health is further eroded by poverty and adverse economic factors which impact the roads, health care facilities, equipment and supplies in addition to limited skilled personnel. Other problems include cultural attitudes towards sexuality, contraception,child marriage,home birth and the ability to recognise medical emergencies. The direct causes of these maternal deaths arehemorrhage,eclampsia,obstructed labor,sepsis and unskilledabortion. In additionmalaria andAIDS can also endanger pregnancy. In the period 2003–2009 hemorrhage was the leading cause of death, accounting for 27% of deaths in developing countries and 16% in developed countries.[49][50]
Non-reproductive health remains an important predictor of maternal health. In the United States, the leading causes of maternal death are cardiovascular disease (15% of deaths), endocrine, respiratory and gastrointestinal disorders,infection, hemorrhage andhypertensive disorders of pregnancy (Gronowski and Schindler, Table II).[8]
In 2000, theUnited Nations createdMillennium Development Goal (MDG) 5[51] to improve maternal health.[52] Target 5A sought to reduce maternal mortality by three quarters from 1990 to 2015, using twoindicators, 5.1 the MMR and 5.2 the proportion of deliveries attended by skilled health personnel (physician, nurse or midwife). Early reports indicated MDG 5 had made the least progress of all MDGs.[53][54] By the target date of 2015 the MMR had only declined by 45%, from 380 to 210, most of which occurred after 2000. However this improvement occurred across all regions, but the highest MMRs were still in Africa and Asia, although South Asia witnessed the largest fall, from 530 to 190 (64%). The smallest decline was seen in the developed countries, from 26 to 16 (37%). In terms of assisted births, this proportion had risen globally from 59 to 71%. Although the numbers were similar for both developed and developing regions, there were wide variations in the latter from 52% in South Asia to 100% inEast Asia. The risks of dying in pregnancy in developing countries remains fourteen times higher than in developed countries, but in Sub-Saharan Africa, where the MMR is highest, the risk is 175 times higher.[47] In setting the MDG targets, skilled assisted birth was considered a key strategy, but also an indicator of access to care and closely reflect mortality rates. There are also marked differences within regions with a 31% lower rate in rural areas of developing countries (56 vs. 87%), yet there is no difference in East Asia but a 52% difference inCentral Africa (32 vs. 84%).[45] With the completion of the MDG campaign in 2015, new targets are being set for 2030 under theSustainable Development Goals campaign.[55][56] Maternal health is placed under Goal 3, Health, with the target being to reduce the global maternal mortality ratio to less than 70.[57] Amongst tools being developed to meet these targets is the WHO Safe Childbirth Checklist.[58]
Improvements in maternal health, in addition to professional assistance at delivery, will require routine antenatal care, basic emergency obstetric care, including the availability ofantibiotics,oxytocics,anticonvulsants, the ability to manually remove aretained placenta, performinstrumented deliveries, andpostpartum care that is financially accessible, such as through insurance.[13][59] Research has shown the most effective programmes are those focussing on patient and community education, prenatal care, emergency obstetrics (including access tocesarean sections) and transportation.[49] As with women's health in general, solutions to maternal health require a broad view encompassing many of the other MDG goals, such as poverty and status, and given that most deaths occur in the immediate intrapartum period, it has been recommended thatintrapartum care (delivery) be a core strategy.[47] New guidelines on antenatal care were issued by WHO in November 2016.[60]
In addition to death occurring in pregnancy and childbirth, pregnancy can result in many non-fatal health problems includingobstetrical fistulae,ectopic pregnancy,preterm labor,gestational diabetes,hyperemesis gravidarum, hypertensive states includingpreeclampsia, andanemia.[42] Globally, complications of pregnancy vastly outway maternal deaths, with an estimated 9.5 million cases of pregnancy-related illness and 1.4 million near-misses (survival from severe life-threatening complications). Complications of pregnancy may be physical, mental, economic and social. It is estimated that 10–20 million women will develop physical or mental disability every year, resulting from complications of pregnancy or inadequate care.[47] Consequently, international agencies have developed standards for obstetric care.[61]
Many do not understand how past pregnancy complications impact future pregnancy birthing options. It is a common misconception that after oneCesarean Section birth, it is medically necessary for all future births. One C-section procedure does not deem parents ineligible for safe vaginal delivery.[62]
Of near miss events,obstetrical fistulae (OF), includingvesicovaginal andrectovaginal fistulae, remain one of the most serious and tragic. Although corrective surgery is possible it is often not available and OF is considered completely preventable. If repaired, subsequent pregnancies will require cesarean section.[63] While unusual in developed countries, it is estimated that up to 100,000 cases occur every year in the world, and that about 2 million women are currently living with this condition, with the highest incidence occurring in Africa and parts of Asia.[47][63][64] OF results from prolongedobstructed labor without intervention, when continued pressure from the fetus in thebirth canal restricts blood supply to the surrounding tissues, with eventualfetal death,necrosis and expulsion. The damaged pelvic organs then develop a connection (fistula) allowing urine or feces, or both, to be discharged through the vagina with associatedurinary andfecal incontinence, vaginalstenosis, nerve damage and infertility. Severe social and mental consequences are also likely to follow, with shunning of the women. Apart from lack of access to care, causes include young age, andmalnourishment.[13][65][63] TheUNFPA has made prevention of OF a priority and is the lead agency in the Campaign to End Fistula, which issues annual reports[66] and the United Nations observes May 23 as theInternational Day to End Obstetric Fistula every year.[67] Prevention includes discouraging teenage pregnancy and child marriage, adequate nutrition, and access to skilled care, including caesarean section.[13]
The ability to determine if and when to become pregnant, is vital to a woman's autonomy and well-being, and contraception can protect girls and young women from the risks of early pregnancy and older women from the increased risks of unintended pregnancy. Adequate access to contraception can limit multiple pregnancies, reduce the need for potentially unsafe abortion and reduce maternal and infant mortality and morbidity. Somebarrier forms of contraception such ascondoms, also reduce the risk of STIs and HIV infection. Access to contraception allows women to make informed choices about their reproductive and sexual health, increases empowerment, and enhances choices in education, careers and participation in public life. At the societal level, access to contraception is a key factor in controllingpopulation growth, with resultant impact on the economy, the environment and regional development.[68][69] Consequently, the United Nations considers access to contraception ahuman right that is central togender equality andwomen's empowerment that saves lives and reduces poverty,[70] and birth control has been considered amongst the 10 great public health achievements of the 20th century.[71]
To optimise women's control over pregnancy, it is essential that culturally appropriate contraceptive advice and means are widely, easily, and affordably available to anyone that issexually active, including adolescents. In many parts of the world access to contraception and family planning services is very difficult or non existent and even in developed counties cultural and religious traditions can create barriers to access. Reported usage of adequate contraception by women has risen only slightly between 1990 and 2014, with considerable regional variability. Although global usage is around 55%, it may be as low as 25% in Africa. Research shows that women in theMiddle East and North Africa use contraception at low rates. Only 14% of women who completed a survey inJordan said they usedcondoms with their spouses.[72] Worldwide 222 million women have no or limited access tocontraception. Some caution is needed in interpreting available data, sincecontraceptive prevalence is often defined as "the percentage of women currently using any method of contraception among all women of reproductive age (i.e., those aged 15 to 49 years, unless otherwise stated) who are married or in a union. The "in-union" group includes women living with their partner in the same household and who are not married according to the marriage laws or customs of a country."[73] This definition is more suited to the more restrictive concept offamily planning, but omits the contraceptive needs of all other women and girls who are or are likely to be sexually active, are at risk of pregnancy and are not married or "in-union".[74][75][68][69]
Three related targets of MDG5 were adolescent birth rate, contraceptive prevalence and unmet need for family planning (where prevalence+unmet need = total need), which were monitored by the Population Division of the UNDepartment of Economic and Social Affairs.[76] Contraceptive use was part of Goal 5B (universal access to reproductive health), as Indicator 5.3.[77] The evaluation of MDG5 in 2015 showed that amongst couples usage had increased worldwide from 55% to 64%. with one of the largest increases inSubsaharan Africa (13 to 28%). The corollary, unmet need, declined slightly worldwide (15 to 12%).[45] In 2015 these targets became part of SDG5 (gender equality and empowerment) under Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights, where Indicator 5.6.1 is the proportion of women aged 15–49 years who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care (p. 31).[78]
There remain significant barriers to accessing contraception for many women in both developing and developed regions. These include legislative, administrative, cultural, religious and economic barriers in addition to those dealing with access to and quality of health services. Much of the attention has been focused on preventing adolescent pregnancy. TheOverseas Development Institute (ODI) has identified a number of key barriers, on both thesupply anddemand side, including internalising socio-cultural values, pressure from family members, and cognitive barriers (lack of knowledge), which need addressing.[79][80] Even in developed regions many women, particularly those who aredisadvantaged, may face substantial difficulties in access that may be financial and geographic but may also face religious and political discrimination.[81] Women have also mounted campaigns against potentially dangerous forms of contraception such as defectiveintrauterine devices (IUD)s, particularly theDalkon Shield.[82]
Abortion is the intentional killing of an unborn child, as compared to spontaneous termination (miscarriage). Abortion is closely allied to contraception in terms of women's control and regulation of their reproduction, and is often subject to similar cultural, religious, legislative and economic constraints. Where access to contraception is limited, women turn to abortion. Consequently, abortion rates may be used to estimate unmet needs for contraception.[83] However the available procedures have carried great risk for women throughout most of history, and still do in the developing world, or where legal restrictions force women to seekclandestine facilities.[84][83] Access to safe legal abortion places undue burdens on lower socioeconomic groups and in jurisdictions that create significant barriers. These issues have frequently been the subject of political and feminist campaigns where differing viewpoints pit health against moral values.
Globally, there were 87 million unwanted pregnancies in 2005, of those 46 million resorted to abortion, of which 18 million were considered unsafe, resulting in 46,068,000 deaths. The majority of these deaths occurred in the developing world. The United Nations considers these avoidable with access to safe abortion and post-abortion care. While abortion rates have fallen in developed countries, but not in developing countries. Between 2010 and 2014 there were 35 abortions per 1000 women aged 15–44, a total of 56 million abortions per year.[49] The United nations has prepared recommendations for health care workers to provide more accessible and safe abortion and post-abortion care. An inherent part of post-abortion care involves provision of adequate contraception.[85]
Important sexual health issues for women includeSexually transmitted infections (STIs) and female genital cutting (FGC). STIs are a global health priority because they have serious consequences for women and infants.Mother-to-child transmission of STIs can lead tostillbirths,neonatal death,low-birth-weight andprematurity,sepsis,pneumonia,neonatal conjunctivitis, andcongenital deformities.Syphilis in pregnancy results in over 300,000 fetal and neonatal deaths per year, and 215,000 infants with an increased risk of death from prematurity, low-birth-weight or congenital disease.[86]
Diseases such aschlamydia andgonorrhoea are also important causes ofpelvic inflammatory disease (PID) and subsequentinfertility in women. Another important consequence of some STIs such asgenital herpes and syphilis increase the risk of acquiringHIV by three-fold, and can also influence its transmission progression.[87] Worldwide, women and girls are at greater risk ofHIV/AIDS. STIs are in turn associated withunsafe sexual activity that is oftenunconsensual.[86] In theMiddle East and North Africa (MENA), a large number of HIV-positive women contracted the virus from their spouses or partners.[88] In comparison to men, taboos, anddiscrimination against women living with HIV are more pervasive throughout the MENA region.[89] Women in the MENA region are more vulnerable to HIV because of gender inequity,gender-based violence, and restricted access to comprehensive healthcare systems.[89]
.jpg)
Female genital mutilation (also referred to as female genital cutting) is defined by the World Health Organization (WHO) as "all procedures that involve partial or total removal of theexternal female genitalia, or other injury to the female genital organs for non-medical reasons". It has sometimes been referred to as femalecircumcision, although this term is misleading because it implies it is analogous to the circumcision of theforeskin from the male penis.[90] Consequently, the term mutilation was adopted to emphasise the gravity of the act and its place as a violation of human rights. Subsequently, the term cutting was advanced to avoid offending cultural sensibility that would interfere with dialogue for change. To recognise these points of view some agencies use the composite female genital mutilation/cutting (FMG/C).[90]
It has affected more than 200 million women and girls who are alive today. The practice is concentrated in some 30 countries in Africa, the Middle East and Asia.[91] Female genital mutilation is still common, impacting around 50 million women and girls in the five countries ofYemen,Egypt,Sudan,Djibouti, andIraq in theMiddle East and North Africa (MENA) region, as adolescent women frequently experience a lack of bodily autonomy in the Arab world.[92] According to data, the frequency of FGM among women between the ages of 15 and 49 is high: 94% in Djibouti, 87% in Egypt and Sudan, 19% in Yemen, and 7% in Iraq.[92] FGC affects many religious faiths, nationalities, and socioeconomic classes and is highly controversial. The main arguments advanced to justify FGC are hygiene, fertility, the preservation ofchastity, an importantrite of passage, marriageability and enhanced sexual pleasure of male partners.[13] The amount of tissue removed varies considerably, leading the WHO and other bodies to classify FGC into four types. These range from the partial or total removal of theclitoris with or without theprepuce (clitoridectomy) in Type I, to the additional removal of thelabia minora, with or without excision of thelabia majora (Type II) to narrowing of the vaginal orifice (introitus) with the creation of a covering seal by suturing the remaining labial tissue over theurethra and introitus, with or without excision of the clitoris (infibulation). In this type a small opening is created to allow urine and menstrual blood to be discharged. Type 4 involves all other procedures, usually relatively minor alterations such aspiercing.[93]
While defended by those cultures in which it constitutes a tradition, FGC is opposed by many medical and cultural organizations on the grounds that it is unnecessary and harmful. Short-term health effects may include hemorrhage, infection, sepsis, and even result in death, while long term effects includedyspareunia,dysmenorrhea,vaginitis andcystitis.[94] In addition FGC leads to complications with pregnancy, labor and delivery. Reversal (defibulation) by skilled personnel may be required to open the scarred tissue.[95] Amongst those opposing the practice are localgrassroots groups, and national and international organisations including WHO, UNICEF,[96] UNFPA[97] andAmnesty International.[98] Legislative efforts to ban FGC have rarely been successful and the preferred approach is education and empowerment and the provision of information about the adverse health effects as well thehuman rights aspects.[13]
Progress has been made but girls 14 and younger represent 44 million of those who have been cut, and in some regions 50% of all girls aged 11 and younger have been cut.[99] Ending FGC has been considered one of the necessary goals in achieving the targets of the Millennium Development Goals,[98] while the United Nations has declared ending FGC a target of the Sustainable Development Goals, and for February 6 to known as the International Day of Zero Tolerance for Female Genital Mutilation, concentrating on 17 African countries and the 5 million girls between the ages of 15 and 19 that would otherwise be cut by 2030.[99][100]
In the United States, infertility affects 1.5 million couples.[101][102] The rates of infertility in theMiddle East and North Africa (MENA) are difficult to measure due to varying definitions of the condition. When infertility is defined as failure to have a successful birth, the MENA region has a very high rate at 33%. Morocco has the highest percentage of infertility among the MENA countries with an infertility rate of 56.8%. Rates of infertility, defined as failure to conceive (clinical infertility), are probably lower in the region but there is a lack of data on the exact numbers. There is a dearth of research on clinical infertility in the MENA region, with the exception ofIran, which is attributed to a societal reluctance to discuss infertility openly.[103]
Many couples seekassisted reproductive technology (ART) for infertility.[104] In the United States in 2010, 147,260in vitro fertilization (IVF) procedures were carried out, with 47,090 live births resulting.[105] In 2013 these numbers had increased to 160,521 and 53,252.[106] However, about a half of IVF pregnancies result inmultiple-birth deliveries, which in turn are associated with an increase in bothmorbidity and mortality of the mother and the infant. Causes for this include increased maternal blood pressure,premature birth andlow birth weight. In addition, more women are waiting longer to conceive and seeking ART.[106]
.jpg)
Child marriage (including union orcohabitation)[107] is defined asmarriage under the age of eighteen and is an ancient custom. In 2010 it was estimated that 67 million women, then, in their twenties had been married before they turned eighteen, and that 150 million would be in the next decade, equivalent to 15 million per year. This number had increased to 70 million by 2012. In developing countries one third of girls are married under age, and 1:9 before 15.[108] The practice is commonest in South Asia (48% of women), Africa (42%) andLatin America and theCaribbean (29%). The highest prevalence is in Western and Sub-Saharan Africa. The percentage of girls married before the age of eighteen is as high as 75% in countries such asNiger.[13][108] Approximately one in five young women in theMiddle East and North Africa were married before becoming eighteen, and one in twenty-five married before turning fifteen.[109] InEgypt, 17% of women in the 20–24 age group, 13% inMorocco, 28% inIraq, 8% inJordan, 6% inLebanon, and 3% inAlgeria were married or engaged before turning 18.[110] Most child marriage involves girls. For instance inMali the ratio of girls to boys is 72:1, while in countries such as the United States the ratio is 8:1. Marriage may occur as early as birth, with the girl being sent to her husbands home as early as age seven.[13]
There are a number of cultural factors that reinforce this practice. These include the child's financial future, herdowry, social ties and social status, prevention ofpremarital sex,extramarital pregnancy and STIs. The arguments against it include interruption of education and loss of employment prospects, and hence economic status, as well as loss of normal childhood and its emotional maturation and social isolation. Child marriage places the girl in a relationship where she is in a major imbalance of power and perpetuates the gender inequality that contributed to the practice in the first place.[111][112] Also in the case of minors, there are the issues of human rights, non-consensual sexual activity andforced marriage and a 2016 joint report of the WHO and Inter-Parliamentary Union places the two concepts together as Child, Early and Forced Marriage (CEFM), as did the 2014 Girl Summit (see below).[113] In addition the likely pregnancies at a young age are associated with higher medical risks for both mother and child, multiple pregnancies and less access to care[114][13][111] with pregnancy being amongst the leading causes of death amongst girls aged 15–19. Girls married under age are also more likely to be the victims ofdomestic violence.[108]
There has been an international effort to reduce this practice, and in many countries eighteen is the legal age of marriage. Organizations with campaigns to end child marriage include the United Nations[115] and its agencies, such as theOffice of the High Commissioner for Human Rights,[116] UNFPA,[117] UNICEF[107][111] and WHO.[113] Like many global issues affecting women's health, poverty and gender inequality areroot causes, and any campaign to change cultural attitudes has to address these.[118] Child marriage is the subject of international conventions and agreements such asThe Convention on the Elimination of All Forms of Discrimination against Women (CEDAW, 1979) (article 16)[119] and theUniversal Declaration of Human Rights[120] and in 2014 asummit conference (Girl Summit) co-hosted by UNICEF and the UK was held in London (see illustration) to address this issue together with FGM/C.[121][122] Later that same year theGeneral Assembly of theUnited Nations passed a resolution, whichinter alia[123]
Urges all States to enact, enforce and uphold laws and policies aimed at preventing and ending child, early and forced marriage and protecting those at risk, and ensure that marriage is entered into only with the informed, free and full consent of the intending spouses (5 September 2014)
Amongstnon-governmental organizations (NGOs) working to end child marriage are Girls not Brides,[124]Young Women's Christian Association (YWCA), theInternational Center for Research on Women (ICRW)[125] andHuman Rights Watch (HRW).[126] Although not explicitly included in the original Millennium Development Goals, considerable pressure was applied to include ending child marriage in the successor Sustainable Development Goals adopted in September 2015,[123] where ending this practice by 2030 is a target of SDG 5 Gender Equality (see above).[127] While some progress is being made in reducing child marriage, particularly for girls under fifteen, the prospects are daunting.[128] The indicator for this will be the percentage of women aged 20–24 who were married or in a union before the age of eighteen. Efforts to end child marriage include legislation and ensuring enforcement together with empowering women and girls.[108][111][113][112] To raise awareness, the inaugural UNInternational Day of the Girl Child[a] in 2012 was dedicated to ending child marriage.[130]
.svg)
Women's menstrual cycles, the approximately monthly cycle of changes in the reproductive system, can pose significant challenges for women in their reproductive years (the early teens to about 50 years of age). These include the physiological changes that can effect physical and mental health, symptoms ofovulation and the regular shedding of the inner lining of the uterus (endometrium) accompanied by vaginal bleeding (menses ormenstruation). The onset of menstruation (menarche) may be alarming to unprepared girls and mistaken for illness. Menstruation can place undue burdens on women in terms of their ability to participate in activities, and access to menstrual aids such astampons andsanitary pads. This is particularly acute amongst poorer socioeconomic groups where they may represent a financial burden and in developing countries where menstruation can be an impediment to a girl's education.[131] In theMiddle East and North Africa,period poverty andstigma have an influence on girls' education and general well-being. Misinformation and a lack of fundamental knowledge cause girls to miss school during their menstrual cycle and contribute to the prevailing stigma around getting your period.[132]
Equally challenging for women are the physiological and emotional changes associated with the cessation of menses (menopause or climacteric). While typically occurring gradually towards the end of the fifth decade in life marked byirregular bleeding the cessation of ovulation and menstruation is accompanied by marked changes in hormonal activity, both by theovary itself (oestrogen andprogesterone) and thepituitary gland (follicle stimulating hormone or FSH andluteinizing hormone or LH). These hormonal changes may be associated with both systemic sensations such ashot flashes and local changes to the reproductive tract such asreduced vaginal secretions and lubrication. While menopause may bring relief from symptoms of menstruation and fear of pregnancy it may also be accompanied by emotional and psychological changes associated with the symbolism of the loss of fertility and a reminder of aging and possible loss ofdesirability. While menopause generally occurs naturally as a physiological process it may occur earlier (premature menopause) as a result of disease or from medical or surgical intervention. When menopause occurs prematurely the adverse consequences may be more severe.[133][134]
Other reproductive and sexual health issues includesex education,puberty,sexuality andsexual function.[135][136] Women also experience a number of issues related to thehealth of their breasts andgenital tract, which fall into the scope ofgynaecology.[137]
Women and men have different experiences of the same illnesses, especially cardiovascular disease, cancer, depression and dementia.[138] Women are also more prone tourinary tract infections than men.[3]
Cardiovascular disease is the leading cause of death (35%) amongst women globally.[139] The onset occurs at a later age in women than in men. For instance the incidence of stroke in women under the age of 80 is less than that in men, but higher in those aged over 80. Overall the lifetime risk of stroke in women exceeds that in men.[34][35] The risk of cardiovascular disease amongst those with diabetes and amongst smokers is also higher in women than in men.[8] Many aspects of cardiovascular disease vary between women and men, including risk factors, prevalence, physiology, symptoms, response to intervention and outcome.[138] Among women in theMiddle East, cardiovascular disease-relatedmorbidity and death are increasing. At the same time, awareness and education on the disease, as well as research, are lacking in the region.[140]
Women and men have approximately equal risk of dying fromcancer, which accounts for about a quarter of all deaths, and is the second leading cause of death. However the relative incidence of different cancers varies between women and men. Globally the three most common types of cancer of women in 2020 werebreast,lung andcolorectal cancers. These three account for 44.5% of all cancer cases in women. Other types of cancers specifically affecting women includeovarian,uterine (endometrial andcervical) cancers.[141]
While cancer death rates rose rapidly during the twentieth century, the increase was less and happened later in women due to differences insmoking rates. More recently cancer death rates have started to decline as the use of tobacco becomes less common. Between 1991 and 2012, the death rate in women declined by 19% (less than in men). In the early twentieth century death from uterine (uterine body andcervix) cancers was the leading cause of cancer death in women, who had a higher cancer mortality than men. From the 1930s onwards, uterine cancer deaths declined, primarily due to lower death rates from cervical cancer following the availability of thePapanicolaou (Pap) screening test. This resulted in an overall reduction of cancer deaths in women between the 1940s and 1970s, when rising rates of lung cancer led to an overall increase. By the 1950s the decline in uterine cancer left breast cancer as the leading cause of cancer death until it was overtaken by lung cancer in the 1980s. All three cancers (lung, breast, uterus) are now declining in cancer death rates,[142] but more women die from lung cancer every year than from breast, ovarian, and uterine cancers combined. Overall about 20% of people found to have lung cancer are never smokers, yet amongst nonsmoking women the risk of developing lung cancer is three times greater than amongst men who never smoked.[138]
In addition to mortality, cancer is a cause of considerable morbidity in women. Women have a lower lifetime probability of being diagnosed with cancer (38% vs 45% for men), but are more likely to be diagnosed with cancer at an earlier age.[9]
Breast cancer is most common type of cancer among women. Globally, it accounts for 25% of all cancers.[141] It is also among the ten most commonchronic diseases of women, and a substantial contributor to loss ofquality of life.[8] In 2016, breast cancer was the most common cancer diagnosed among women in both developed and developing countries, accounting for nearly 30% of all cases, and worldwide accounts for one and a half million cases and over half a million deaths, being the fifth most common cause of cancer death overall and the second in developed regions. In theMiddle East and North Africa, there were 95,000 cases ofbreast cancer in 2019.[143] The countries with the highest age-standardized prevalence rates per 100,000 females in the region wereBahrain,Qatar, andLebanon.[143] Geographic variation in incidence is the opposite of that of cervical cancer, being highest in Northern America and lowest in Eastern and Middle Africa, but mortality rates are relatively constant, resulting in a wide variance in case mortality, ranging from 25% in developed regions to 37% in developing regions, and with 62% of deaths occurring in developing countries.[19][144]
Globally, cervical cancer is the fourth most common cancer amongst women.[141] It is particularly common in women with lowersocioeconomic status, living inlow-and middle-income countries who have reduced access to health care. Customs and cultural practices that involvechild andforced marriage, higher rates ofparity,polygamy and exposure to STIs from multiple sexual contacts of male partners further increase the chances of cervical cancer.[13] In developing countries, cervical cancer accounts for 12% of cancer cases amongst women and is the second leading cause of death, where about 85% of the global burden of over 500,000 cases and 250,000 deaths from this disease occurred in 2012. The highest incidence occurs inEastern Africa, where withMiddle Africa, cervical cancer is the commonest cancer in women. Thecase fatality rate of 52% is also higher in developing countries than in developed countries (43%), and the mortality rate varies by 18-fold between regions of the world.[145][19][144]
Cervical cancer is associated withhuman papillomavirus (HPV), which has also been implicated in cancers of thevulva,vagina,anus, andoropharynx. Almost 300 million women worldwide have been infected with HPV, one of the commonersexually transmitted infections, and 5% of the 13 million new cases of cancer in the world have been attributed to HPV.[146][87] In developed countries,screening for cervical cancer using thePap test has identifiedpre-cancerous changes in the cervix, at least in those women with access to health care. Also anHPV vaccine programme is available in 45 countries. Screening and prevention programmes have limited availability in developing countries although inexpensive low technology programmes are being developed,[147] but access to treatment is also limited.[145] If applied globally, HPV vaccination at 70% coverage could save the lives of 4 million women from cervical cancer, since most cases occur in developing countries.[8]
Ovarian cancer is the eighth most common cancer globally.[141] It is predominantly a disease of women in industrialized countries and death from ovarian cancer is more common in North America and Europe than in Africa and Asia.[148] Because it is largely asymptomatic in its earliest stages and lacks an effective screening programme, more than 50% of women have stage III or higher cancer (spread beyond the ovaries) by the time they are diagnosed, with a consequent poor prognosis.[142][8]
Almost 25% of women will experiencemental health issues over their lifetime.[149]Women are at higher risk than men fromanxiety, depression, andpsychosomatic complaints.[19] Globally, depression is the leading disease burden. In the United States, women have depression twice as often as men. The economic costs of depression in American women are estimated to be $20 billion every year. The risks of depression in women have been linked to changing hormonal environment that women experience, including puberty, menstruation, pregnancy, childbirth and the menopause.[138] Women also metabolise drugs used to treat depression differently to men.[138][150]Suicide rates are less in women than men (<1% vs. 2.4%),[34][35] but are a leading cause of death for women under the age of 60.[19] In the United Kingdom, the Women's Mental Health Taskforce was formed aiming to address differences in mental health experiences and needs between women and men.[151]
The prevalence ofAlzheimer's disease in the United States is estimated at 5.1 million, and of these two thirds are women. Furthermore, women are far more likely to be the primary caregivers of adult family members with dementia, so that they bear both the risks and burdens of this disease. The lifetime risk for a woman of developing Alzheimer's disease is twice that of men. Part of this difference may be due to life expectancy, but changing hormonal status over their lifetime may also play a par as may differences in gene expression.[138] Deaths due to dementia are higher in women than men (4.5% of deaths vs. 2.0%).[8]
Osteoporosis ranks sixth amongst chronic diseases of women in the United States, with an overallprevalence of 18%, and a much higher rate involving thefemur,neck orlumbar spine amongst women (16%) than men (4%), over the age of 50.[8][9][152] Osteoporosis is a risk factor forbone fracture and about 20% of senior citizens who sustain ahip fracture die within a year.[8][153] The gender gap is largely the result of the reduction ofestrogen levels in women following themenopause.Hormone Replacement Therapy (HRT) has been shown to reduce this risk by 25–30%,[154] and was a common reason for prescribing it during the 1980s and 1990s. However theWomen's Health Initiative (WHI) study that demonstrated that the risks of HRT outweighed the benefits[155] has since led to a decline in HRT usage.
Anaemia is a major global health problem for women.[156] Women are affected more than men, in which up to 30% of women being found to be anaemic and 42% of pregnant women. Anaemia is linked to a number of adverse health outcomes including a poor pregnancy outcome and impairedcognitive function (decreased concentration and attention).[157] The main cause of anaemia isiron deficiency. In United States womeniron deficiency anaemia (IDA) affects 37% of pregnant women, but globally the prevalence is as high as 80%. Anaemia affects over one-third of the population in theMiddle East and North Africa, caused by iron deficiencies or a combination of other factors, with women making up the bulk of those affected. In Saudi Arabia, 40% of women in the 15–49 age range suffer from anaemia.[158] IDA starts in adolescence, from excessmenstrual blood loss, compounded by the increased demand for iron in growth and suboptimal dietary intake. In the adult woman, pregnancy leads to further iron depletion.[8]
Women experiencestructural andpersonal violence differently than men. The United Nations has defined violence against women as;[159]
" any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life." (United Nations, Declaration on the Elimination of Violence against Women, 1993)
Violence against women may take many forms, including physical,sexual, emotional andpsychological and may occur throughout thelife-course. Structural violence may be embedded in legislation or policy, or be systematicmisogyny by organisations against groups of women. Perpetrators of personal violence include state actors, strangers, acquaintances, relatives andintimate partners and manifests itself across a spectrum fromdiscrimination, throughharassment,sexual assault andrape, and physical harm to murder (femicide). It may also include cultural practices such as female genital cutting.[160][161]
Non-fatal violence against women has severe implications for women's physical, mental and reproductive health, and is seen as not simply isolated events but rather a systematic pattern of behaviour that both violates their rights but also limits their role in society and requires a systematic approach.[162]
The World Health Organization (WHO) estimates that 35% of women in the world have experienced physical or sexual violence over their lifetime and that the commonest situation is intimate partner violence. 30% of women in relationships report such experience, and 38% of murders of women are due to intimate partners. These figures may be as high as 70% in some regions.[163] Risk factors include low educational achievement, a parental experience of violence, childhood abuse, gender inequality and cultural attitudes that allow violence to be considered more acceptable.[164]
The COVID-19 epidemic madegender-based violence more common in Arab countries and worsened already-existing health disparities between the sexes. Yet millions of women in theMiddle East and North Africa did not receive enough attention when it came to the provision of enhanced protection from gender-based violence.[165]
Violence was declared a global health priority by the WHO at its assembly in 1996, drawing on both the United NationsDeclaration on the elimination of violence against women (1993)[159] and the recommendations of both theInternational Conference on Population and Development (Cairo, 1994) and theFourth World Conference on Women (Beijing, 1995)[166] This was followed by its 2002 World Report on Violence and Health, which focusses on intimate partner and sexual violence.[167] Meanwhile, the UN embedded these in an action plan when itsGeneral Assembly passed theMillennium Declaration in September 2000, which resolvedinter alia "to combat all forms of violence against women and to implement the Convention on the Elimination of All Forms of Discrimination against Women".[168] One of theMillennium Goals (MDG 3) was the promotion of gender equality and the empowerment of women,[169] which sought to eliminate all forms of violence against women as well as implementingCEDAW.[119] This recognised that eliminating violence, including discrimination was a prerequisite to achieving all other goals of improving women's health. However it was later criticised for not including violence as an explicit target, the "missing target".[170][100] In the evaluation of MDG 3, violence remained a major barrier to achieving the goals.[38][74] In the successor Sustainable Development Goals, which also explicitly list the related issues of discrimination, child marriage and genital cutting, one target is listed as "Eliminate all forms of violence against all women and girls in the public and private spheres" by 2030.[127][171][163]
UN Women believe that violence against women "is rooted in gender-based discrimination and social norms and gender stereotypes that perpetuate such violence", and advocate moving from supporting victims to prevention, through addressing root and structural causes. They recommend programmes that start early in life and are directed towards both genders to promote respect and equality, an area often overlooked inpublic policy. This strategy, which involves broad educational and cultural change, also involves implementing the recommendations of the 57th session of the UNCommission on the Status of Women[172] (2013).[173][174][175] To that end the 2014 UN International Day of the Girl Child was dedicated to ending the cycle of violence.[130] In 2016, the World Health Assembly also adopted a plan of action to combat violence against women, globally.[176]
Changes in the wayresearch ethics was visualised in the wake of theNuremberg Trials (1946), led to an atmosphere of protectionism of groups deemed to be vulnerable that was often legislated or regulated. This resulted in the relative underrepresentation of women inclinical trials. The position of women in research was further compromised in 1977, when in response to the tragedies resulting fromthalidomide anddiethylstilbestrol (DES), the United StatesFood and Drug Administration (FDA) prohibited women of child-bearing years from participation in early stage clinical trials. In practice this ban was often applied very widely to exclude all women.[177][178] Women, at least those in the child-bearing years, and female animals were also deemed unsuitable research subjects due to their fluctuating hormonal levels during the menstrual or other reproductive cycles. However, research has demonstrated significant biological differences between the sexes in rates of susceptibility, symptoms and response to treatment in many major areas of health, including heart disease and some cancers. These exclusions pose a threat to the application ofevidence-based medicine to women, and compromise to care offered to both women and men.[8][179]
The increasing focus onWomen's Rights in the United States during the 1980s focused attention on the fact that many drugs being prescribed for women had never actually been tested in women of child-bearing potential, and that there was a relative paucity of basic research into women's health. In response to this theNational Institutes of Health (NIH) created theOffice of Research on Women's Health (ORWH)[180] in 1990 to address these inequities. In 1993 the National Institutes of Health Revitalisation Act officially reversed US policy by requiring NIH fundedphase III clinical trials to include women.[138] This resulted in an increase in women recruited into research studies. The next phase was the specific funding of large scale epidemiology studies and clinical trials focussing on women's health such as theWomen's Health Initiative (1991), the largest disease prevention study conducted in the US. Its role was to study the major causes of death, disability and frailty in older women.[181] Despite this apparent progress, women remain underrepresented. In 2006 women accounted for less than 25% of clinical trials published in 2004,[182] A follow-up study by the same authors five years later found little evidence of improvement.[183] Another study found between 10 and 47% of women in heart disease clinical trials, despite the prevalence of heart disease in women.[184] Lung cancer is the leading cause of cancer death amongst women, but while the number of women enrolled in lung cancer studies is increasing, they are still far less likely to be enrolled than men.[138]
One of the challenges in assessing progress in this area is the number of clinical studies that either do not report the gender of the subjects or lack thestatistical power to detect gender differences.[182][185] These were still issues in 2014, and further compounded by the fact that the majority of animal studies also exclude females or fail to account for differences in sex and gender. for instance despite the higher incidence of depression amongst women, less than half of the animal studies use female animals.[138] Consequently, a number of funding agencies and scientific journals are asking researchers to explicitly address issues of sex and gender in their research.[186][187] Some countries address the underrepresentation of women in research studies by the establishment ofcenters of excellence focusing on women's health research and running large scaleclinical trials such as theWomen's Health Initiative.
A related issue is the inclusion of pregnant women in clinical studies. Since other illnesses can exist concurrently with pregnancy, information is needed on the response to and efficacy of interventions during pregnancy, but ethical issues relative to the fetus, make this more complex. This gender bias is partly offset by the initiation of large scale epidemiology studies of women, such as theNurses' Health Study (1976),[188]Women's Health Initiative[189] andBlack Women's Health Study.[190][8]
Women have also been the subject of neglect in health care research, such as the situation revealed in theCartwright Inquiry inNew Zealand (1988), in which research by two feminist journalists[191] revealed that women withcervical abnormalities were not receiving treatment, as part of an experiment. The women were not told of the abnormalities and several later died.[192]
The Women's Health Care Market is today a major pharmaceutical industry, projected to double in size within the five years from 2019 to 2024 and reach USD 17.8 billion. The by far most valued company worldwide whose leading products are in Women's Health isBayer (Germany) with the focus area of Contraception.[193]
In addition to addressinggender inequity in research, a number of countries have made women's health the subject of national initiatives. For instance in 1991 in the United States, theDepartment of Health and Human Services established anOffice on Women's Health (OWH) with the goal of improving the health of women in America, through coordinating the women's health agenda throughout the department, and other agencies. In the twenty first century the Office has focussed on underserviced women.[194][195] Also, in 1994 theCenters for Disease Control and Prevention (CDC) established its own Office of Women's Health (OWH), which was formally authorised by the 2010Affordable Health Care Act (ACA).[196][197]
Internationally, manyUnited Nations agencies such as theWorld Health Organization (WHO),United Nations Population Fund (UNFPA)[198] andUNICEF[199] maintain specific programs on women's health, or maternal, sexual and reproductive health.[3][200] In addition the United Nations global goals address many issues related to women's health, both directly and indirectly. These include the 2000Millennium Development Goals (MDG)[168][51] and their successor, theSustainable Development Goals adopted in September 2015,[55] following the report on progress towards the MDGs (The Millennium Development Goals Report 2015).[201][74] For instance the eight MDG goals, eradicating extreme poverty and hunger, achieving universal primary education, promoting gender equality and empowering women, reducing child mortality rates, improving maternal health, combating HIV/AIDS malaria and other diseases, ensuring environmental sustainability, and developing a global partnership for development, all impact on women's health,[51][13] as do all seventeen SDG goals,[55] in addition to the specific SDG5: Achieve gender equality and empower all women and girls.[127][202]
Research is a priority in terms of improving women's health. Research needs include diseases unique to women, more serious in women and those that differ in risk factors between women and men. The balance of sex and/or gender in research studies needs to be balanced appropriately to allow analysis that will detect interactions between sex and/or gender and other factors.[8] Gronowski and Schindler suggest thatscientific journals make documentation of sex a requirement when reporting the results of animal studies, and thatfunding agencies require justification from investigators for any sex inequity in their grant proposals, giving preference to those that are inclusive. They also suggest it is the role of health organisations to encourage women to enroll inclinical research. However, there has been progress in terms of large scale studies such as the WHI, and in 2006 theSociety for Women's Health Research founded the Organization for the Study of Sex Differences and the journalBiology of Sex Differences to further the study ofsex differences.[8]
Research findings can take some time before becoming routinely implemented intoclinical practice. Clinical medicine needs to incorporate the information already available from research studies as to the different ways in which diseases affect women and men. Many"normal" laboratory values have not been properly established for the female population separately, and similarly the "normal" criteria for growth and development. Drug dosing needs to take sex differences in drug metabolism into account.[8]
Globally, women's access to health care remains a challenge, both in developing and developed countries. In the United States, before the Affordable Health Care Act came into effect, 25% of women of child-bearing age lackedhealth insurance.[203] In the absence of adequate insurance, women are likely to avoid important steps to self care such as routine physical examination, screening and prevention testing, and prenatal care. The situation is aggravated by the fact that women living below thepoverty line are at greater risk ofunplanned pregnancy, unplanned delivery and electiveabortion. Added to the financial burden in this group are poor educational achievement, lack of transportation, inflexible work schedules and difficulty obtaining child care, all of which function to create barriers to accessing health care. These problems are much worse in developing countries. Under 50% of childbirths in these countries are assisted by healthcare providers (e.g.midwives, nurses, doctors) which accounts for higher rates of maternal death, up to 1:1,000 live births. This is despite the WHO setting standards, such as a minimum of four antenatal visits.[204] A lack of healthcare providers, facilities, and resources such asformularies all contribute to high levels of morbidity amongst women from avoidable conditions such asobstetrical fistulae, sexually transmitted infections and cervical cancer.[8]
These challenges are included in the goals of the Office of Research on Women's Health, in the United States, as is the goal of facilitating women's access to careers inbiomedicine. The ORWH believes that one of the best ways to advance research in women's health is to increase the proportion of women involved in healthcare and health research, as well as assuming leadership in government,centres of higher learning, and in theprivate sector.[181] This goal acknowledges theglass ceiling that women face in careers in science and in obtaining resources fromgrant funding to salaries and laboratory space.[205] TheNational Science Foundation in the United States states that women only gain half of thedoctorates awarded in science and engineering, fill only 21% of full-time professor positions in science and 5% of those in engineering, while earning only 82% of the remuneration their male colleagues make. These figures are even lower in Europe.[205]
{{cite journal}}: CS1 maint: numeric names: authors list (link){{cite book}}: CS1 maint: location missing publisher (link)
Media related toWomen's health at Wikimedia Commons
| |||||||||||||||||
| Sexual health |
| ||||||||||||||||
| Non-reproductive health |
| ||||||||||||||||
| Sociocultural factors | |||||||||||||||||
| Politics, research and advocacy |
| ||||||||||||||||
| Women's health by country | |||||||||||||||||
