Women's Health

Women's health refers to the health of women, which differs from that of men in many unique ways. Women's health is an example of population health, where health is defined by the World Health Organization as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". Often treated as simply women's reproductive 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 in developing countries where women, whose health includes both their risks and experiences, are further disadvantaged.

Although women in industrialised countries have narrowed the gender gap in life expectancy and now live longer than men, in many areas of health they experience earlier and more severe disease with poorer outcomes. Gender remains an important social determinant of health, since women's health is influenced not just by their biology but also by conditions such as poverty, 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 including health care, and the greater the level of disadvantage, such as in developing countries, the greater adverse impact on health.

Women's reproductive and sexual health has a distinct difference compared to men's health. Even in developed countries pregnancyand childbirth are associated with substantial risks to women with maternal 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 disease such as cardiovascular disease contribute to both the mortality and morbidity of pregnancy, including preeclampsia. Sexually transmitted infections have serious consequences for women and infants, with mother-to-child transmission leading to outcomes such as stillbirths and neonatal deaths, and pelvic inflammatory disease leading to infertility. In addition infertility from many other causes, birth control, unplanned pregnancy, unconsensual sexual activity and the struggle for access to abortion create other burdens for women.

Definitions and scope:

Women's experience of health and disease differ from those of men, due to unique biological, social and behavioural conditions. Biological differences vary all the way from phenotype to the cellular, and manifest unique risks for the development of ill health.The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".Women's health is an example of population health, the health of a specific defined population.

Women's health has been described as "a patchwork quilt with gaps".Although many of the issues around women's health relate to their reproductive health, including maternaland child health, genital health and breast health, and endocrine (hormonal) health, including menstruation, birth control and menopause, 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". The 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. Conditions that affect both men and women, such as cardiovascular disease, osteoporosis, also manifest differently in women.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 other socioeconomic factors.Women's health is of particular concern due to widespread discrimination against women in the world, leaving them disadvantaged.

Global perspective:

Gender differences in susceptibility and symptoms of disease and response to treatment in many areas of health are particularly true when viewed from a global perspective.Much of the available information comes from developed countries, yet there are marked differences between developed and developing countries in terms of women's roles and health.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". In 2015 the World Health Organisation 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.

Life expectancy:

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 from maternal deaths (death in childbirth). In industrialised countries, particularly the most advanced, the gender gap narrowed and was reversed following the industrial revolution. Despite these differences, in many areas of health, women experience earlier and more severe disease, and experience poorer outcomes.

Despite these differences, the leading causes of death in the United States are remarkably similar for men and women, headed by heart disease, which accounts for a quarter of all deaths, followed by cancer, lung disease and stroke. While women have a lower incidence of death from unintentional injury (see below) and suicide, they have a higher incidence of dementia (Gronowski and Schindler, Table I).

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 life non-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 with obesity and diabetes amongst women in these countries and increasing the risks of cardiovascular disease and other NCDs.

Social and cultural factors:

Women's health is positioned within a wider body of knowledge cited by, amongst others, the World Health Organisation, which places importance on gender as a social determinant of health. Women's health is affected not just by their biology, but also by their social conditions, such as poverty, employment, and family responsibilities.

Women have traditionally been disadvantaged in terms of economic and social status and power, which in turn reduces their access to the necessities of life including health care. Despite recent improvements in western nations, women remain disadvantaged with respect to men.The gender gap in health is even more acute in developing 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.

Even after succeeding in accessing health care, women have been discriminated against, a process that Iris 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.

                                                   Women demonstrate for abortion rights, Dublin, 2012

Reproductive and sexual health:

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 which unsafe sex is a major risk factor, especially in developing countries.Reproductive health includes a wide range of issues including the health and function of structures and systems involved reproduction, pregnancy, childbirth and child rearing, including antenatal and perinatal care.Global women's health has a much larger focus on reproductive health than that of developed countries alone, but also infectious diseases such as malaria in pregnancy and non-communicable diseases (NCD). Many of the issues that face women and girls in resource poor regions are relatively unknown in developed countries, such as female genital cutting, and further lack access to the appropriate diagnostic and clinical resources.

Maternal health:

Pregnancy presents substantial health risks, even in developed countries, and despite advances in obstetrical science and practice.Maternal mortality remains a major problem in global health and is considered a sentinel event in judging the quality of health care systems.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 a girl's life, physically, emotionally, socially and economically and jeopardises

her 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 girls aged 15–19 occur within marriage.

                                                                                                        Maternal death:

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.Maternal mortality in western nations had been steadily falling, and forms the subject of annual reports and reviews.Yet, between 1987 and 2011, maternal mortality in the United States rose from 7.2 to 17.8 deaths per 100,000 live births, this is reflected in the Maternal Mortality Ratio (MMR).By contrast rates as high as 1,000 per birth are reported in the rest of the world,with the highest rates in Sub-Saharan Africa and South Asia, which account for 86% of such deaths.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. 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 are hemorrhage, eclampsia, obstructed labor, sepsis and unskilled abortion. In addition malaria and AIDS complicate 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.

Complications of pregnancy:

In addition to death occurring in pregnancy and childbirth, pregnancy can result in many non-fatal health problems including obstetrical fistulae, ectopic pregnancy, preterm labor, gestational diabetes, hyperemesis gravidarum, hypertensive states including preeclampsia, and anemia.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.Consequently, international agencies have developed standards for obstetric care.

Female genital mutilation:

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 the external female genitalia, or other injury to the female genital organs for non-medical reasons". It has sometimes been referred to as female circumcision, although this term is misleading because it implies it is analogous to the circumcision of the foreskin from the male penis.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).

Child marriage:

Child marriage (including union or cohabitation)is defined as marriage 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. The practice is commonest in South Asia (48% of women), Africa (42%) and Latin America and the Caribbean (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 as Niger (Nour, Table I).Most child marriage involves girls. For instance in Mali 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.

Other issues:
Other reproductive and sexual health issues include sex education, puberty, sexuality and sexual function. Women also experience a number of issues related to the health of their breasts and genital tract, which fall into the scope of gynaecology.

Women in health research:

Changes in the way research ethics was visualised in the wake of the Nuremberg 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 in clinical trials. The position of women in research was further compromised in 1977, when in response to the tragedies resulting from thalidomide and diethylstilbestrol (DES), the United States Food 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. Women, at least those in the child bearing years, were also deemed unsuitable research subjects due to their fluctuating hormonal levels during the menstrual cycle. 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 of evidence-based medicine to women, and compromise to care offered to both women and men.

Women's Health Initiative logo

Goals and challenges:

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 gender in research studies needs to be balanced appropriately to allow analysis that will detect interactions between gender and other factors. Gronowski and Schindler suggest that scientific journals make documentation of gender a requirement when reporting the results of animal studies, and that funding agencies require justification from investigators for any gender 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 in clinical research. However, there has been progress in terms of large scale studies such as the WHI, and in 2006 the Society for Women's Health Research founded the Organization for the Study of Sex Differences (OSSD) and the journal Biology of Sex Differences to further the study of sex differences.

Research findings can take some time before becoming routinely implemented into clinical 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 gender differences in drug metabolism into account.

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