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11.2 Women

11.2 Women
Oxford Textbook of Public Health

11.2
Women

Shaoxian Wang, Lin An, and Susan D. Cochran

Introduction
Female mortality

Life expectancy at birth

Major causes of mortality by sex

Maternal mortality
Issues related to reproductive health

Anaemia

Genital mutilation

Fertility, contraception, and induced abortion

HIV/AIDS and other sexually transmitted diseases

Reproductive health services
Other health issues

Maintaining health with limited resources

Environmental and occupational health

Violence against women

Mental health
Promoting women’s health

Improving women’s reproductive health
Conclusion
Chapter References

Introduction
The field of women’s health is broader than merely issues of fertility and reproductive health, or the biological differences between women and men, because there is growing recognition that social as well as biological factors strongly influence health outcomes in women (Goldman and Hatch 2000). This is because, despite the diversity of human experience globally, in all societies the ways in which men and women are treated differ (WHO 1998a). In most societies, human activities are divided into a ‘public world of employment and politics’, assigned principally to men, and a ‘private arena of the family and household’, which is the primary responsibility of women (WHO 1998a).
Traditionally, women undertake the burden of looking after children, husbands, and other members of the family. They are also responsible for nursing infants, preparing food for young children, cooking, sewing, and maintaining the household. In many countries, they must also assist in farming and other unpaid or underpaid physical labour and increasingly take part in the broader labour market at a financial disadvantage to men. Even in developed countries, where women participate in great numbers in paid employment, they still continue to bear the major burdens of family and household demands while receiving lower wages on average (United Nations 1995). Worldwide, women work longer hours than men, and girls enter the labour market at younger ages than boys (World Bank 1994).
The social inequalities engendered by this differential treatment directly or indirectly affect women’s health and public health approaches to prevention and intervention (WHO 1995). For example, it is estimated that 70 per cent of those living in poverty worldwide are women (UNDP 1995), despite the fact that men slightly outnumber women in the world’s population (United Nations 2000). This differential risk for poverty is seen in both developing and developed regions (UNDP 1995) and contributes to the well-documented health disparities that exist between women and men.
In addition, women’s health and women’s levels of health knowledge affect the health of their own children and families, owing to their primary caretaker role within the home. For example, in developing countries the death of a mother greatly increases mortality risk and risk for termination of formal education for young children, more so than the death of a father (World Bank 1994). Thus women’s health plays a major role in the health and development of the family, the community, and ultimately the broader world. Nonetheless, in many parts of the world, men and children have priority over women for food and medical care. Women have less education and less chance to work for pay outside the family than men. When they fall ill, men and children have priority over women for the receipt of health care.
These gender biases exist not only within families but also in the broad health care sector where they influence the recommendations of health planners and providers. Thus some authors have asked: ‘Where is the M in MCH (Maternal and Child Health)?’ (Rosenfield and Main 1985). Recently, the World Health Organization (WHO) and other international agencies have called for increased attention to women’s health, especially for research and medical resources directed to address the needs of women (FWCW 1995; WHO 1995).
Female mortality
Life expectancy at birth
Worldwide, women live longer than men, although the extent of this disparity varies between regions and especially between developed and developing countries (UN 1995) (Table 1). Generally, it is rare for men to outlive women, although there are exceptions (e.g. Bangladesh), and in southern Asia, men and women have similar life expectancies (WHO 1998a). The worldwide gender gap favouring women has not always existed (WHO 1998a). Historically, maternal morbidity and nutritional deficiencies resulted in lower female than male life expectancies. But over the last century, these causes of premature mortality among women have been reduced dramatically in many parts of the world through reductions in fertility rates, later age at first pregnancy, and improvements in prenatal health care and delivery (Goldman and Hatch 2000). For example, in the United States there was a 90 per cent reduction in maternal mortality between 1950 and 1989 alone (Bird and Rieker 1999). In contrast, improvements in male longevity have been mitigated by increasing prevalence of life-threatening behaviours that men are more likely to engage in than women, such as the widespread proliferation of tobacco use (Waldron 1995).

Table 1 Gender differences in life expectancy for selected countries (1994–1997)

Reasons for the gender gap in life expectancy are not completely understood, although they are thought to be a mix of biological and social factors (UN 1995). Overall, mortality rates among infants, both male and female, are relatively higher than for other ages because infants are more vulnerable to environmental factors, especially infectious agents. As babies mature, the mortality rate decreases sharply through most of childhood. Above 55 years, the mortality rate increases more steeply. Furthermore, mortality rates in poor countries and regions are higher than in developed countries. But across strata, these effects are often more pronounced among males than females (Table 2).

Table 2 Mortality rates by age and sex in selected countries

Evidence indicating greater biological hardiness of females compared with males can be found in several quarters. Worldwide, there is a greater likelihood that female fetuses will be successfully carried to term than male fetuses (Waldron 1986). Also, in most geographical areas, particularly when male and female infants are treated equally, females are more likely than males to survive the first year of life (UN 1995) (Table 3). In developed countries, this advantage continues into childhood, although the same is not true in many developing countries. The underlying biological basis for these differences may be due to physiological differences linked to reproduction, including a stronger and more efficient immune system and an enhanced cardiovascular system protected by oestrogen premenopausally (Bird and Reiker 1999).

Table 3 Infant and child mortality rates (1986–1993)

Social factors and the ways in which men’s and women’s lives differ also play a role. For example, men are more likely to be at risk of deaths from occupational or accidental causes than women (Waldron 1995). It has also been estimated than perhaps half of the gender-based difference in life expectancy in the United States and Sweden is a consequence of differential rates of smoking tobacco between women and men (Waldron 1986).
Major causes of mortality by sex
In most countries, there are few gender differences in the major causes of mortality (Table 4). Heart disease, cancer, cerebrovascular disease, and respiratory disease are the most common causes of death for both men and women.

Table 4 Ranking of top three causes of death and cause-specific death rates in selected countries

Maternal mortality
There are about 600 000 maternal deaths every year worldwide (WHO 1998b). Ninety-nine per cent of these occur in developing countries (Table 5). Estimates from the United Nations suggest that in developing countries one in every 48 women dies from maternal-related causes, with perhaps one in 16 women in Africa dying from these causes (Maine and McGinn 2000). In contrast, it is estimated that in northern Europe only one in 4000 women dies from maternal causes (Maine and McGinn 2000). Even within regions, women of lower socio-economic status are more at risk than women from higher socio-economic status, primarily because of limited access to health care.

Table 5 Maternal mortality rate in selected countries

Nevertheless, the causes of maternal mortality, such as haemorrhage, obstructed labour, sepsis, eclampsia, unsafe abortion, and severe anaemia, are similar in all countries and within regions, regardless of economic development (Rohde 1995). Worldwide, haemorrhage, obstructed labour, sepsis, and hypertensive disorders account for 60 per cent of maternal deaths (Maine and McGinn 2000). Unsafe abortions are blamed in approximately 13 per cent of deaths. Risk for maternal morbidity is greatest among women younger than 20 years or older than 35 years of age, but because parity is greatest among women in their twenties, this decade of life has the greatest absolute number of deaths.
Issues related to reproductive health
Health planners have typically defined women’s reproductive health issues in terms of pregnancy and childbirth, focusing their interventions on medical considerations to solve issues arising out of these events. However, women’s health has never been a simple biomedical issue. Both reproductive viability and patterns of reproduction are closely correlated with a woman’s background. Many of the risks that women in developing countries face during pregnancy are a result of a lifetime of inadequate diet, illness, heavy work, poor education, and other social practices. For example, one major cause of obstructed labour is cephalopelvic disproportion. This obstetric complication is directly related to the body configuration of the puerperant. Underdeveloped configuration is the result of chronic nutritional deficiency, infectious disease, and cultural practices such as early marriage. Reproductive health risks for women cannot be underestimated. The period during which women are subject to these additional risks is very long, often 30 years or more, representing more than half the life expectancy of women in the poorest countries.
The International Conference on Population and Development (ICPD), held in Cairo in September 1994, and the Fourth World Conference on Women (FWCW), held in Beijing in September 1995, established the goals of reproductive health and women’s reproductive rights. Both conferences noted that many women have no reproductive rights and often cannot access essential services. Many women worldwide suffer from poor physical and mental health. Hence the two conferences declared ‘women’s reproduction rights’ to be the centre of the programme of action to promote good reproductive health worldwide. ICPD’s programme of action defined reproductive health as follows (ICPD 1994):
Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.
This declaration implies that women should have both rights to safe pregnancies and healthy babies, and the freedom to decide when to have children and how often to do so. At the ICDP meeting, reproductive health was declared to include family planning, maternal and child health care, and prevention and treatment of infertility and sexually transmitted diseases, as well as improved education and social status for women. All these components were seen as essential for ensuring women’s reproductive health.
Anaemia
Worldwide, more than a third of women and approximately half of pregnant women suffer from anaemia (UN 1995). This reduces physical productivity and also increases the risk of childbirth for women and newborns. Throughout the developing world, nutritionally related iron deficiency and the exacerbation of anaemia during pregnancy is a widespread problem. It is estimated, for example, that half of women in Africa are anaemic, increasing during pregnancy to perhaps two-thirds of women (Haslegrave 1995). Even higher rates have been estimated for women in south Asia where approximately 58 per cent women in general suffer from anaemia, rising to 75 per cent of women during pregnancy (UN 1995). In developed countries, rates are lower but, even so, approximately 12 per cent of women (18 per cent of pregnant women) experience anaemia.
Genital mutilation
Female circumcision or genital mutilation refers to several patterns of ritual cutting or altering of female genitalia (Izett and Toubia 2000). This cultural practice occurs primarily in the northeastern and northern sub-Saharan parts of Africa, in some Arab countries, including Yemen, and among immigrants from these regions. It is estimated that over 80 per cent of women in Sudan, Somalia, Djibouti, Ethiopia, and Sierra Leone have undergone some form of female genital mutilation (WHO 1998e). Traditions surrounding the practice of genital mutilation vary, including the age at which it occurs, although typically girls are between 4 and 12 years of age. Female genital mutilation practices have been grouped into four major classifications (WHO 1998e): excision of the prepuce with or without partial or total excision of the clitoris, excision of the prepuce and clitoris with partial or total excision of the labia minora, excision of part or all of the external genitalia with infibulation, and other ritual practices including pricking, piercing, burning, and stretching of genitalia. It is estimated that 130 million girls and women worldwide have undergone one of these types of genital mutilation and that perhaps 2 million girls a year are at risk (UNICEF 1998).
Female genital mutilation poses a health risk for girls and women both physically and psychologically. Physically altering healthy genitalia results in impairment of normal functioning, the extent of which is dependent on the nature of the mutilation and the way in which it is performed. Most of these practices are conducted in unsanitary situations without anaesthetic. Among the immediate health consequences are pain, shock, haemorrhage, anaemia, infection, and death. Longer-term consequences include fistulae, faecal or urinary incontinence, dermoid cysts, keloidal scarring, neuromas, dyspareunia, ascending infections from the vulva, pelvic inflammatory disease, haematocolpus, and obstructed labour, depending on the pattern of genital alteration. One survey from Somalia, where most women undergo infibulation, found that 40 per cent experienced significant immediate complications and 40 per cent experienced long-term complications, excluding common difficulties with sexuality and delivery (UN 1995).
Psychological effects, too, reflect both the immediate and long-term consequences of female genital mutilation. Although less extensively documented than negative physical health outcomes, research suggests that the event is recalled as traumatic by girls and women who undergo it, with possible long-term disturbances in self-esteem and self-identity (Izett and Toubia 2000). Furthermore, chronic physical health difficulties arising from the procedure result in chronic or episodic psychological distress. Sexual responsiveness is impaired, depending upon the extent of the genital mutilation and the woman’s prior experiences with sexual arousal (Izett and Toubia 2000).
Over the last two decades efforts to abolish the practice of female genital mutilation, particularly in Africa, have included intensive community-based campaigns (WHO 1998e) and widespread educational campaigns against this traditional cultural practice but they have had less success than was hoped for (PATH 1999). More recent efforts have focused on intervention strategies that enhance women’s empowerment more generally in the hope of giving women the tools to decide if they wish to maintain or alter this cultural practice with the next generation (Izzett and Toubia 2000).
Fertility, contraception, and induced abortion
Fertility rates, or the rate of live births, has declined worldwide as a result of the development in the last 50 years of contraceptive strategies that allow people to regulate the timing and occurrence of pregnancies. For instance, in Bangladesh the total fertility rate (or the estimated number of live births that a girl will have from the age of 15 if she lives through her child-bearing years) declined from about 6.34 per woman in 1971 to 3.45 in 1995 (Jain et al. 1999). Similarly, the total fertility rate in China declined from 6.1 in 1949 to 1.5 in 1997 (State Family Planning Commission 1998). In the developed regions, where women have most ready access to contraception, total fertility rates range across countries between 1.2 and 2.2 (UN 1995). In contrast, rates range between 1.7 and 4.8 across countries in Latin America and the Caribbean, between 1.3 and 7.6 in Asia and the Pacific, and between 2.4 and 7.4 in Africa.
Despite these declines in total fertility rate, there are still millions of women with unmet contraceptive needs in developing countries (Table 6). There are more married women with an unmet contraceptive need about 31 million) in India than in any other country (Robey et al. 1996). Elsewhere, there are 5.7 million women married women with unmet contraceptive needs in Pakistan, 4.4 million in both Indonesia and Bangladesh, 3.9 million in Nigeria, 3.1 million in Mexico, 3.0 million in Brazil, and 2.5 million in the Philippines (Robey et al. 1996) . The proportion of all married women with unmet contraceptive needs in each country range from an estimated 11 per cent in Thailand and Turkey, to 36 per cent in Kenya and 37 per cent in Rwanda. On average 19 per cent of married women in developing countries, excluding China, have unmet contraceptive needs. Owing to the very strict birth control policy and widespread family planning services in China, contraceptives were available to 90 per cent of married women in 1997 (State Family Planning Commission 1998).

Table 6 Total unmet contraceptive needs among married women of reproductive age in developing areas, 1996

No contraceptive method is perfect. Hence, women facing an unwanted pregnancy may seek to induce an abortion. Of the 40 to 60 million induced abortions performed annually worldwide, approximately 20 million are estimated as being conducted under unsafe conditions, and 95 per cent of these occur in developing countries. According to WHO (1998c), at least 80 000 women die each year from induced abortions, and many others suffer lifelong physical or mental disorders as a consequence. Complications from unsafe abortions are among the leading causes of maternal mortality (WHO 1998c). The highest abortion rate is in Europe (48 per 1000 women aged 15–44 years) and the lowest is in North America and Oceania (21 and 22 per 1000 women aged 15–44 years) (Table 7). Africa, Asia, and Latin America had similar rates (Henshaw et al. 1999).

Table 7 Estimated percentage of illegal abortions, abortion rate, and abortion ratio by region (1995)

Almost all abortions are illegal in Latin America and Africa. For example, in Chile, 80 women were recently legally prosecuted and imprisoned for having abortions. Most of these women were adolescents or young adults and single mothers; eight of the 80 women had become pregnant after being raped. A great majority of them were reported to the police by the public hospital where they sought treatment for complications from an illegal abortion (Casas-Becerra 1997). Because the illegality of the procedure is the chief cause of unsafe abortions, both the ICPD (1994) and the FWCW (1995) expressed concerns that legal structures were jeopardizing women’s health. The ICPD defined safe abortion as a component of essential reproductive health services (ICPD 1994), and asserted that, in circumstances where it is legal, abortion should be safe (ICPD 1994). The FWCW stressed the health risks of unsafe abortion and called for a review of laws that punish women who have undergone illegal abortions (FWCW 1995). Unfortunately, there are still many regions and countries where legal restrictions on abortion serve as barriers to women’s access to safe abortions (Table 8). Even in countries where abortion is legal, restrictions on ready access to the procedure, including denial of public funding for abortion and requirements that minors obtain parental consent, can make it difficult for women to obtain abortions when needed (Fried 1997).

Table 8 Legal limitations on abortion by region and countries (1997)

HIV/AIDS and other sexually transmitted diseases
In developing countries, sexually transmitted diseases are responsible for the second greatest number of disability-adjusted life years among women, second only to illnesses due to maternal causes (Padian 2000). By the end of 1999, less than two decades after AIDS was first recognized, 50 million people in the world had been infected with HIV and 14 million had died from AIDS. The number of individuals living with an HIV infection is about 34 million, with more than 95 per cent living in developing countries. UNAIDS/WHO also estimated that about 6 million people in the world were newly infected in 1998, a rate of almost 11 people per minute worldwide (UNAIDS 1999). Globally, 10 per cent of those infected were under the age of 15 years.
The number of HIV-positive women has also increased rapidly. In 1998, women accounted for 46 per cent of all infected people globally. The increasing risk for HIV is shared by women in developed and developing countries alike. For example, in France, the percentage of women among AIDS cases rose from 12 per cent in 1985 to 20 per cent by 1995. In Brazil, the figure rose from 1 per cent in 1984 to 25 per cent in 1994. Not surprisingly perhaps, the number of babies who acquire HIV from their infected mothers before or during birth or from breast feeding is also rising dramatically.
Why are women so vulnerable to HIV infection? Physiologically, compared with men, women have a larger and very thin surface area of mucosa exposed to their partner’s sexual secretion during sexual intercourse. Moreover, semen infected with HIV typically contains a higher viral concentration than a woman’s sexual secretion. Thus male-to-female transmission is more likely than female-to-male transmission. In addition, an untreated sexually transmitted disease in either of the partners enhances the risk of HIV transmission to the woman. Reproductive tract infections, most of which are sexually transmitted, are extremely common in developing countries. For example, a community-based survey in Egypt found that over half of women had one or more reproductive tract infections (World Bank 1994). Women are more likely than men to experience asymptomatic sexually transmitted diseases, and when symptoms are present women may have more difficulty attributing these to a sexually transmitted disease as opposed to common bodily changes (Padian 2000).
Another important factor is the greater social and economic vulnerability of women in comparison to men. Social inequalities between women and men serve to impair women’s abilities to individually protect themselves from HIV infection. One effect of social inequality is lack of knowledge of how to prevent infection. Millions of young girls in developing countries have been raised with little understanding of their reproductive system or the mechanics of HIV/AIDS transmission and prevention. Although human sexuality courses are sometimes taught, this occurs in later grades when girls are already less likely than boys to have remained in school. A second effect is a lack of influential power in the sexual relationship. Condom use, when condoms are available, is primarily male-controlled and the opportunity to refuse sexual encounters that women might fear are high risk is obviated by social and economic pressures. Furthermore, in many societies, sex is the ‘currency’ for girls and women who must provide sexual services in order to survive. A third effect of social inequality is less access to resources that would make it less likely for HIV to be transmitted, such as treatment for other ulcerative sexually transmitted diseases. Often women dare not seek treatment for sexually transmitted diseases without male approval.
These problems have led UNAIDS (1997) to call for the empowerment of women in order to reduce rates of HIV infection. UNAIDS has suggested six ways of achieving this.

1.
Combat ignorance: improve the access of girls to formal schooling and ensure they have information about their own bodies, education about AIDS and the other sexually transmitted diseases, and the skill to say no to unwanted or unsafe sex.

2.
Provide HIV prevention services to women: ensure that girls and women have access to appropriate health care and HIV/AIDS prevention services at places and times that are convenient for them and expand voluntary HIV testing and counselling services.

3.
Develop female-controlled HIV infection prevention methods: encourage the development of methods that are under the direct control of women that they can use in the absence of male approval or co-operation. Although the male condom currently is the only barrier method easily available for HIV prevention, UNAIDS is facilitating the development of and access to several such methods, including the female condom and vaginal microbicides—virus-killing creams or foams that women can insert vaginally before sexual intercourse.

4.
Build safe norms: recognizing the power of social norms to protect individuals from pressure to engage in unwanted or unsafe behaviours, UNAIDS calls for support for women’s groups and organizations to question traditional sexual norms and behaviours which have caused women to be infected with AIDS. This includes educating boys and men to respect girls and women, to be responsible in sexual behaviours, and to share responsibility for protecting themselves, their sexual partners, and their children from HIV and other sexually transmitted diseases.

5.
Reinforce women’s economic independence: economic independence allows women the option of risking disapproval in sexual negotiations. UNAIDS suggests building more opportunities for training and educational classes for women, setting up credit programmes and co-operatives, and include HIV/AIDS prevention activities in these programmes. For example, UNAIDS has supported Zambian women fish traders to form a co-operative which was given interest-free loans by UNAIDS. With such credit co-operatives, the fish-traders are able to resist the need to barter sexual favours with fish wholesalers or truck drivers who control their access to fish markets and to transportation.

6.
Reduce women’s vulnerability through changing social policies: current social policies from the community level up to the national level serve to maintain social inequalities. Social policies structured to protect women’s rights and fundamental freedoms and to improve their economic independence and legal status will reduce women’s vulnerability to HIV infection through altering behavioural risk patterns.
Reproductive health services
The 1994 ICPD in Cairo marked the historical turning point for women’s reproductive health. Before the ICPD, many family planning programmes emphasized only demographic targets for family planning, neglecting the social and psychological components of the field of reproductive health services. In particular, women’s concerns were overlooked. The programme of action from the ICPD declares:
All countries should strive to make accessible through the primary health care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015. Reproductive health care in the context of primary health care should include: family-planning counseling, information, education, communication and services; education and services for prenatal care, safe delivery, and postnatal care, especially breast-feeding and infant and women’s health care; prevention and appropriate treatment of infertility; abortion as specified in paragraph 8.25, including prevention of abortion and the management of the consequences of abortion; treatment of reproductive tract infections, sexually transmitted diseases and other reproductive health conditions; and information, education and counseling, as appropriate, on human sexuality, reproductive health and responsible parenthood. Referral for family-planning services and further diagnosis and treatment for complications of pregnancy, delivery and abortion, infertility, reproductive tract infections, breast cancer and cancers of the reproductive system, sexually transmitted disease, including HIV/AIDS should always be available, as required. Active discouragement of harmful practices such as female genital mutilation, should also be an integral component of primary health care, including reproductive health care programs.
This meeting reframed the goals of reproductive health services. Formerly, family planning programmes aimed solely at demographic targets, but now these programmes focus also on the needs and desires of individuals. In addition, ICPD’s call for comprehensive reproductive health services specifically includes the involvement of women to serve women’s needs and safeguard women’s rights.
For example, Bangladesh was one of the first countries to adopt the Programme of Action drafted at the 1994 ICPD in Cairo (Hardee et al. 1999). Although Bangladesh is one of the poorest countries in the world, where both the literacy level and social status of women are very low, it increased contraceptive use by women from 3 per cent in the 1970s to 45 per cent in recent years. Its main intervention was to train 28 000 ‘on-the-spot’ women workers who deliver oral contraceptives and contraceptive injections house by house (Schuler et al. 1995). Furthermore, the quality of reproductive health services in various departments was improved. For example, in one project in 1996, Bangladesh undertook a collaborative project with the Asia Foundation, the University of North Carolina, and USAID to train 20 county family planning officers in administration management. The objective was to enhance implementation of family planning programmes. Training included increasing levels of knowledge, skill, and competence among workers in the fields of family planning, statistics, epidemiology, demography, management, coalition building among persons and organizations, and professional standards and behaviour. Measured outcomes of this project found that the contraceptive prevalence rate increased in all the 19 counties served by an average of 5.47 per cent (Jain et al. 1999).
Other health issues
Maintaining health with limited resources
Overall life expectancy in most parts of the world is increasing, particularly in northern Africa, parts of Asia, and Central America (UN 1995). There are exceptions. For example, countries in Eastern Europe have experienced little gain in longevity and some in sub-Saharan Africa actually have suffered a decline in life expectancy due to increasing mortality from AIDS (UN 1995). One consequence of increasing longevity worldwide is that an increasing proportion of the world’s population is older than in the past. Furthermore, because of the gender gap, with increasing age a greater and greater proportion of these individuals are women. For example, in the United States, 60 per cent of individuals over 65 years of age and 70 per cent over 85 years of age are women (Leveille and Furalnik 2000). For women, this represents more years at risk for experiencing age-related morbidity and decreasing likelihood of assistance from a spousal partner (UN 1995). Table 9 presents data from a survey in China demonstrating age-related increases in problems in one’s ability to live independently. The table shows that, although ageing is not invariantly linked to disability, this becomes increasingly likely as one lives longer and women are more likely to experience this than men.

Table 9 Results from a survey of people aged 60 years and older assessing ability to function independently (China, 1994)

In both developed and developing countries, health status among older women is much worse than among older men. For example, in a 1993 household interview survey (Feng 1999) on the functional health status of rural elders aged 60 or over conducted in Henan Province, China, several indicators demonstrated that a greater proportion of women’s later years are impaired by disabilities in comparison to men. As shown in Fig. 1, whether one measures activities of daily living, instrumental activities of daily living, or gross physical function, the number of years living with a disability are greater among women than men in all age groups above 60 years of age. The prevalence rate of disabilities in activities of daily living, instrumental activities of daily living, and gross physical function were 10.2 per cent, 30.3 per cent, and 33.5 per cent, respectively. Thus women in the older age groups experience greater rates of morbidity than men.

Fig. 1 Life expectancy, both years of disability and disability-free years, by age and sex estimated from a household survey in China in 1993.

In most societies, women with physical disabilities face additional challenges in maintaining a healthy quality of life in the context of social inequalities resulting both from gender and physical disability. The Center for Research on Women with Disabilities (Nosek et al. 1997) in the United States conducted a nationwide survey concerning the impact of physical disabilities on women. They found that women with physical disabilities, in contrast with those without, have limited opportunities to establish relationships, lower likelihood of having children, and suffer more physical, social, and emotional abuse. This abuse can include withholding of necessary equipment (wheelchair, braces), medication, transportation, or essential assistance in daily living, such as dressing or getting out of bed. Another observation from the study was that women with disabilities seldom obtained information about sexuality and reproductive health tailored to their needs. A common misperception was that disabled women were not sexually active, even if they were. These women also are more likely to suffer from chronic diseases that have an earlier age of onset when compared with women who are not disabled (Table 10).

Table 10 Survey estimating prevalence of chronic diseases in women with physical disabilities (United States)

Environmental and occupational health
Conceptualizing environmental and occupational health risks for women is complicated by both social and biological factors. The diversity of women’s roles and their increasing participation in the broader labour market results in exposures that occur both in the household and the external workplace. The importance of workplace hazards for women is often overlooked despite the fact that toxins do exist in the home, women’s occupations can and do bring them into contact with harmful chemicals and risk of physical injury, and many tools and machines are designed for larger and stronger average physiques (Silbergeld 2000a). For example, indoor cooking, an activity commonly undertaken by women in developing countries, represents a serious environmental hazard resulting in morbidity arising from acute and chronic exposure to smoke and toxic gases (World Bank 1994).
In addition, dietary, biological, and immunological differences between women and men may result in differential patterns of exposures and dissimilar responses to similar environmental exposures (Blair et al. 1999; Silbergeld 2000b). Men and women differ in their rates of contact with environmental toxins, the extent to which these substances are absorbed into or excreted from the body, and the rate at which they are metabolized. Levels of circulating hormones also influence the process. Within women, these rates are also altered by the biological changes associated with pregnancy, lactation, and menopause, leading to interactions between lifestage and the effects of toxins.
Despite these differences between women and men, very little research has focused on environmental and occupational health issues among women (Blair et al. 1999; Lindbohm 1999). The reasons for this are varied (Silbergeld 2000b). Many animal studies are limited to male animals. Most studies of environmental risks in humans have drawn respondents, primarily male, from occupational settings where there are intense and more easily measured exposures to toxins of interest. Furthermore, when surveys of women’s health are conducted, such as the Women’s Health Initiative in the United States, a large longitudinal cohort study of postmenopausal women, occupational experiences are not measured in sufficient detail. Nevertheless, the effects of toxins on some outcomes, such as gynaecological cancers, can only be studied in women and there are increasing concerns that results from studies using only male subjects do not generalize well to understanding health effects in women (Blair et al. 1999).
Violence against women
The effects of violence against women is another emerging area in women’s health because of both directly attributable health consequences and the ways in which male violence against women expresses and reinforces the social inequalities that are known to impair women’s health (WHO 1997). Worldwide, violence is often employed as a means by which control can be exerted over other human beings. Three current themes in today’s worldwide patterns of violence are the greater importance of low-intensity conflicts in impoverished countries where civilian populations, including women, experience the brunt of the conflict, the high prevalence of deadly weapons, such as land mines, and the terrorization of the civilian population as a method of warfare (Desjarlais et al. 1995). Such violence impacts on both men and women, but women are also at risk for other forms of violence from intimate partners and members of their own family. Furthermore, social and community responses to the gender-based violence against women differs from violence where men are both perpetrators and victims (Miller and Downs 2000).
Gender-based violence against women is of many types including rape and sexual assault, physical battering, psychological abuse, forced abortions, female infanticide, and ‘dowry death’ (Desjarlais et al. 1995). Worldwide it is estimated that approximately 25 to 50 per cent of women, depending on the study, report being a victim of physical abuse from men (Heise et al. 1995) and 60 per cent of murders of women are linked to domestic violence (WHO 1997). Estimates of recent or lifetime prevalence of being sexually coerced by an intimate male sex partner vary worldwide from 6 per cent of women surveyed in London who reported forced sex in the past 12 months to more than half of women surveyed in a study from Turkey reporting on their lifetime experiences (WHO 2000). The World Bank estimates that a substantial portion of total morbidity among women is due to the effects of rape or domestic violence, accounting for 5 per cent of women’s disease burden in developing countries and 19 per cent in developed countries (WHO 1998a).
Mental health
Among the 10 leading causes of disability worldwide in 1990, five were mental disorders (Murray and Lopez 1996). Between the ages of 15 and 54 years, there is little difference between women and men in rates of psychiatric disorders (Kessler et al. 1994; World Bank 1994), although the relative frequency of different disorders varies (Table 11). Women are more likely than men to experience depression and anxiety disorders, while men are more likely than women to evidence substance use disorders (Kessler et al. 1994; World Bank 1994; Desjarlais et al. 1995). The prevalence of major depression among women is 1.5 to 3 times higher than among men depending on the study and the time frame of reference (Kessler 2000). Although men are more likely than women to commit suicide, the female death rate from suicide is increasing, especially among women of child-bearing age. For example, suicides are the leading cause of death in women of child-bearing age in China (J. Yang, unpublished work, Beijing Medical University, 1999).

Table 11 Gender differences in patterns of mental health disorders worldwide: relative contributions to disability-adjusted life years lost due to mental disorders

Surveys worldwide also document that women experience greater levels of depressive distress than men, sometimes reported as problems with ‘nerves’, ‘heart distress’, or intrusion of unwanted ‘spirits’ (Desjarlais et al. 1995). The reasons for this difference are generally attributed to the greater likelihood that women are impoverished in comparison with men, experience greater role strain and exhaustion, are more likely to experience abuse, particularly from intimate partners and family members, and have less of control over necessary resources (World Bank 1994; Desjarlais et al. 1995; Seaman and Wood 2000).
Promoting women’s health
Two of the most important tenets of contemporary thinking about successful health development are that communities or constituencies must participate in decision-making, and that the non-health sector must work together with the health sector to achieve effective and sustained change. In promoting women’s reproductive health and health in general, it is apparent that efforts to empower women are critical, because through empowerment women can participate in making the changes around them that are essential for their health. Without empowerment, they lack the tools and the freedom to create needed change. In developed countries, such as the United States and Australia, recognition of this need resulted in widespread social movements to alter the methods of health education and services delivery for women (Broom 1998; Seaman and Wood 2000). In developing countries, different models have been tried to create change. Two examples from China are described below.
Improving women’s reproductive health
The Ford Foundation and Yunnan Province in China carried out a collaborative project on women’s reproductive health and development beginning in 1991 (Wang and Li 1994). The major strategies adopted by the project are detailed below (Li and Wang 1998).
Empowerment of women
To motivate women to express their wishes and needs, the programme planners employed focus group discussions and photo novellas to encourage women to express their needs. The rural women identified two themes that were their most urgent needs. One stressed that their labour was too heavy and very hard. They said: ‘Who has time to think about their health and suffering? We will be thankful if we will be given a little time to rest.’ They wished to lighten the intensity of their labour. Another theme was that village women badly needed nurseries and kindergartens to provide care for their children. The village women had to do endless farm work and household duties. If there were no grandmothers to look after the young at home, mothers had to bring their babies to the field with them. When children reached the age of 2 or 3 years, they were frequently left at home unattended. Furthermore, these toddlers sometimes had to look after their younger brother or sister, and to perform other duties such as feeding the chickens.
Co-ordination of multiple sectors
Poverty and the overall low level of economic development made it unlikely that any intervention in the health sector alone will address the multiple causes of ill health among poor rural women. Women’s health, and that of their families and communities, can be improved only if health interventions are integrated with efforts to improve women’s educational and employment opportunities, to reduce gender bias in the distribution of nutritional, health, and other resources, to alleviate heavy workloads and the burdens of poverty, and to combat women’s powerlessness so that they would have more effective control over their own lives. However, efforts to encourage co-ordination across domains of interest such as health care, education, and community resources, often devolve into conflicts surrounding competition for scarce resources. In this instance, the project worked specifically on evolving more synergistic relationships that could provide benefits for all.
Collaboration between multiple disciplines
The programme in Yunnan province involved collaboration between biomedical workers, sociologists, anthropologists, and others. Every one of the team members contributed their professional skill.
The programme developed over 40 projects ranging from midwifery training to the construction of water reservoirs to supply portable water to villages to promote pig raising and increase personal income. These experiences in Yunnan province demonstrated that empowerment for women to achieve better health outcomes requires co-ordination of various sectors and collaboration of diverse disciplines to promote women’s reproductive health. Focusing only on reproductive issues would not have solved the health problems these women faced.
Decreasing maternal mortality rate
A second example of promoting women’s health come from attempts to decrease the maternal mortality rate. Two methods of reducing the maternal mortality rate are to provide adequate antenatal care as well as performing clean and safe deliveries. Adequate antenatal care in the absence of safe childbirth is not sufficient because most obstetric complications occur abruptly and unexpectedly. If not treated in time, most women will die. Some authors assert that obstetric complications need to be treated at health organizations where blood transfusion, Caesarean section, placenta removal, and induced labour facilities are available (Rohde 1995). Some experts have called on the developed countries to assist developing countries in upgrading their emergency obstetric care facilities to ensure safe childbirth for women (Nowark 1995).
Although China is considered a developing country, in 1995 the maternal mortality rate was 61.9 per 100 000 live births, the lowest maternal mortality rate among the countries that have similar levels of economic development. The reason for this is that China started to organize primary health services in 1949. Gradually, a three-tier health system was established (Taylor et al. 1985). The three-tier health system covers even the remote areas in the country. As of 1998, every township had a health centre (a small hospital), and more than 90 per cent of the villages had a health post (Table 12). The three-tier health system is a guarantee of ‘Health for All’ (including reducing safe childbirth) at the functional level.

Table 12 The three-tier health system in China

Because the rural areas enjoy governmental priority for improving health, the township health centres and village’s health posts have been provided with essential equipment and personnel allowing in some instances blood transfusions and Caesarean sections, if needed. The existing gap in obstetric care between urban and rural areas is decreasing. By the end of 1997, about 93 per cent of deliveries in China were attended by trained health care workers (WHO 1998c).
In addition to addressing needs for safe childbirth, China also provides extensive family planning services. Indirectly, this also lowers the maternal mortality rate by allowing women to delay first pregnancy to older ages and to have fewer children. All contraceptives are provided free of charge and unmet contraceptive needs are rare. Countrywide, government agencies at all levels, from central to local, emphasize family planning. Nevertheless, the maternal mortality rate in rural areas is still higher than urban areas. Thus more needs to be done (Table 13).

Table 13 Maternal mortality rate in China (per 100 000 live births): national surveillance results

Conclusion
One of the more interesting global facts about health is that women live longer than men, but experience greater morbidity (Goldman and Hatch 2000). This pattern of gender-associated differences in morbidity and mortality is a modern experience reflecting the gain in life expectancy for women from reducing the risks of childbirth and possibly the increasing mortality risks for men from tobacco use and other health risk related behaviours (Waldron 1995). Furthermore, public health interventions currently available and cost-effective in reducing human disability offer the potential for greater gains in reducing morbidity among women than men (World Bank 1994).
Over the last decade, it has become increasingly clear that further improvements in women’s health, and collaterally in the health of their children and families, are dependent on successfully addressing the ill health effects generated by social inequality (ICPD 1994; World Bank 1994; FWCW 1995). Although women, unlike men, experience health risk associated with reproduction and child rearing, much of this additional risk is generated by women’s lower social, educational, cultural, and economic status. Furthermore, women face additional threats to their health, such as relative lack of access to health care, greater risk of suffering, violence, and coercive, high-risk sexual encounters, that are not linked to reproduction but do stem directly from social inequalities.
Understanding women’s health calls for an awareness of the biological differences between men and women, a focus on health matters specific to women’s reproductive role, and an appreciation for the deleterious effects of social inequities. Improving the health of women will ultimately depend on the recognition of their rights to social, educational, cultural, and economic equality. A first step in achieving this goal is the empowerment of women in addressing their own health issues.
Evidence that this comprehensive view of women’s health is taking hold can be seen in grassroots-level organization, national-level interventions, and international health efforts taking place worldwide (FWCW 1995; WHO 1995, 1998; Broom 1998a; UN 2000). Nevertheless these efforts, to date, have not remedied the problem. Tackling the complex issues raised by the field of women’s health requires collaboration across many sectors in society, not just the health sector. The challenge for public health is to involve all parties in negotiation. This includes, in particular, the women themselves because interventions designed without the participation of women are likely to be ill informed, inefficient, or poorly accepted.
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