1. Women’s Health Chapter 9
Chapter 9: Women’s Health

2. The Importance of Women’s Health
Being born female can be:
dangerous to your health, especially in low- and middle-income countries,
discriminatory,
more likely to have unique health problems, and
related with having economic and social negative consequences as a result of morbidity, premature death and disability.
There are several key health issues related to the health of women in low- and middle-income countries, including nutrition, sex-selective abortion, discriminatory healthcare practices toward young girls, sexually transmitted infections, female genital cutting, and violence against women. Mental health issues are also very important.

3. Table 9.2: Selected Definitions on Women’s Health
This table lists some selective definitions on women’s health as it relates to our discussion on this chapter.
Data from University of Kentucky HealthCare. Glossary Index. Available at: April 15, 2007; University of New South Wales. UNSW Embryology Glossary Index

4. The Determinants of Women’s Health
Biological Determinants
Iron-deficient anemia related to menstruation or inability to consume proper amounts of iron.
Complications of pregnancy:
Eclampsia /preeclampsia, uterine prolapse, fistula, PPH.
Increased susceptibility to some infections
Conditions, such as ovarian cancer, specific to women.
Women faces a number of health related conditions that are unique to women only. Diseases like anemia, eclampsia, uterine prolapse, fistula are some examples that make women morbidity and mortality rates higher. Women are more biologically susceptible for having sexually transmitted infections and HIV than male. There are certain health conditions like uterine cancer or ovarian cancer that are very specific to women.

5. The Determinants of Women’s Health
Social Determinants
Related to gender norms and roles:
Female abortion or infanticide
Often fed less nutritious food than male children
Male dominance leads to physical and sexual abuse
Cooking with poor ventilation contributes to respiratory disease
Low social status limits access to health care
Fortunately, awareness is spreading. Video: Call to life, Pakistan and Maternal Health (5:01)
Social determinants are the most important determines in women’s health in particular in low income countries. Culture where there is different values for male and females, female suffers the disadvantage of being a female. Societies where male preference is very strong, such as India and China, families determine the sex of the child through sonogram and if the fetus is not a male child then the husband decides to abort the child for the hope of a male child in next pregnancy. Female child is often fed less food than male child. Women suffer more physical and sexual abuse because of their low social status with limitation for access to health care.

6. The Burden of Health Conditions for Females
Sex-Selective Abortion
Skewed ratios of males to females in some countries, including China, India, Taiwan, Singapore, South Korea.
Rising incomes and levels of education have led to more sex-selective abortion in these countries (Example: Punjab state, India).
Video: Female Infanticide- How can it be prevented? (3:43)
Video: The village where they kill their daughters (5:08)
Sex selective abortion phenomenon is highly prevalent in India and China. According to some studies in last 20 years in India there was close to 1 million sex selective abortion though anecdotal reports suggest a much higher number than this. The consequence of sex selective abortion is the skewed number of male female ratio. For instance it is expected that there would be about 105 females born for every 100 males. However, in China there are about 120 males born for every 100 males. Same pattern has been shown in Taiwan, Singapore, and parts of India. Though it is thought that with income and education the incidence of female infanticide should go down however, this may not be the case. As technologies like ultrasound became much more available, people in India and China misuse this technology to find out the sex of unborn child and then to kill the child.

7. The Burden of Health Conditions for Females
Female Genital Cutting
Estimated million worldwide have had some form of genital cutting performed on them.
Practice appears to be diminishing.
Can initially cause shock, infection or hemorrhaging.
Long-term problems include retention of urine, infertility, and obstructed labor.
Video: Female genital mutilation: (2:27)
Female genital cutting or mutilation is a practice existed in Africa region that has various forms. This practice is carried on girls of 4-14 years of age with razor blades, knives, or glass that are likely to be unsterilized. It has been estimated that as many as 3 million girls in Sub-Saharan Africa and in Egypt have such cutting performed on them. The practice varies from region to region, for instance in Egypt it is highly prevalent and in Niger the prevalence is low. This practice has a number of health morbidity associated with it like shock, infection, and hemorrhage. In the long run it risks problems like retention of urine, infertility, and obstructed labor.
The above is of a woman holding a poster and promoting the Saleema Campaign at a community meeting in El Khatmia Village, Gadaref State. El Khatmia is one of five villages in Gadaref that have agreed to collectively abandon FGM/C.

8. The Burden of Health Conditions for Females
Sexually Transmitted Infections
Biologically more susceptible.
Risk factors for women are young age, sex with high risk partners, and inability to use a condom.
1.9% of total DALYs lost to women aged were due to STIs.
Inappropriately and late treatment of PID, chronic pain, ovarian abscess, ectopic pregnancies, infertility, chlamydia leads to significant maternal morbidity and infant mortality & morbidity.
Biologically women are more susceptible to sexually transmitted infections (STI) because of more exposed mucosal surface. Women suffer more because most of the time STIs are asymptomatic and women are less likely to access health care because of STIs. If STIs are not treated appropriately then it could have long term effects on women health like pelvic inflammatory disease, chronic pain, ovarian abscess, ectopic pregnancies and such. If a pregnant women get STIs and not treated properly then it could lead to miscarriage, stillbirth, low birth weight babies, eye and lung damage of the babies and congenital anomalies. In recent times Chlamydia is of much more concern because it is 9 times more prevalent in women than men.

9. The Burden of Health Conditions for Females
Violence and Sexual Abuse Against Women
UNAIDS estimates 10-50% of women worldwide have been abused physically by a partner.
Can lead to injuries, unwanted pregnancy, STIs, depression, disability, and death.
Risk factors include low socioeconomic status, young age of the male partner, proximity to alcohol, and gender inequality.
Other forms of violence against women.
Violence and sexual abuse occur among women worldwide with remarkable frequency. Violence most of the time is associated with sexual abuse. Sexual abuse can include rape, sexual assault, sexual molestation, sexual harassment, and incest. Studies have indicated varied number of statistics in sexual abuse for women in the form of intimate partner violence. In addition, rape has been used as “tool of war” in a number of conflicts. Risk factors for violence against women include low socioeconomic status, young age of the male partner, proximity to alcohol, and gender inequality.

10. The Burden of Health Conditions for Women
Maternal Morbidity and Mortality
Estimates suggest that there are about 289,000 maternal deaths per year
99% of maternal deaths occur in low- and middle-income countries.
60% of all maternal deaths: India, Nigeria, Democratic Republic of the Congo, Ethiopia, Indonesia, Pakistan, Tanzania, Kenya, China, and Uganda.
20% of maternal deaths are from indirect causes, 80% are from direct causes.
Risk factors include general health and nutrition, level of education and income, ethnicity, location, age, and having a skilled birth attendant present
Video: Birth in Nepal (23:40)
Maternal deaths are the deaths that occur during pregnancy, childbirth, or until 42 days after child is born. Birth is the time that is highly risky for both mother and the child . 42% of maternal death happens during childbirth or the first day after birth. Maternal mortality ratio has been declined worldwide . Maldives is one of the countries that achieved high decline in maternal mortality ratio. The countries that comprised 50% of all maternal death are Nigeria, Pakistan, Afghanistan, Ethiopia, and the democratic republic of Congo. About 80% of maternal death cause from direct cause like hemorrhage, infection, eclampsia, and obstructed labor. Rest 20% are from indirect cause, diseases like malaria, anemia, HIV/AIDS and CVDs that complicate the pregnancy. A number of risk factors are attributable for maternal death. General health condition, nutritional status, education, income, age of the mother, geographic location, not having a skilled birth attendant all are critically related with mothers’ death.

11. The Burden of Health Conditions for Women
Unsafe Abortion
A “safe” abortion is one performed by a trained healthcare provider, with proper equipment, technique, and sanitary standards.
13% of total maternal deaths that occur annually worldwide are due to unsafe abortions.
Rates of unsafe abortion vary among regions: 60% occurs in Africa.
According to WHO, A “safe” abortion is one performed by a trained healthcare provider, with proper equipment, technique, and sanitary standards whereas unsafe is the opposite of this definition. 13% of total maternal death occurs because of unsafe abortion.

12. The Burden of Health Conditions for Women
Obstetric Fistula
Condition in which a hole opens up between bladder and vagina or rectum and vagina.
50,000 to 100,000 women each year will suffer a fistula.
Women with fistulas are often stigmatized or abandoned.
One of the four major causes of maternal mortality and morbidity.
Risk factors are those associated with an obstructed delivery.
Obstetric fistula is a condition in which a hole opens up between bladder and vagina or rectum and vagina usually happens as a result of prolonged childbirth or failed childbirth. As an outcome of this condition urine and feces leak through vagina. Women with fistula face terrible social and economic consequences as they are often stigmatized and/or abandoned.

13. Differences Between the Health of Men and Women
Greater focus has recently been put on the extent to which gender discrimination affects women’s health.
19 conditions disproportionately affect women- some are specific to women, some are related to women’s higher life expectancy, some are a result of gender discrimination.
For last couple of decades women health gained special attention especially in reproductive health because “women are child bearer”. More recently focus has been shifted towards the inequality women faces that disproportionately affect women health.
Source: Women and Health Initiative, Harvard School Of Public Health

14. The Cost and Consequences of Women’s Health Problems
Violence, STIs, and fistula tend to isolate women socially.
When a woman dies in childbirth, her family is typically left without a primary caregiver.
Substantial economic costs from women’s health issues.
The social cost of women health problems is huge. When women die of childbirth it put the health of the young child or other children in the family in danger. Fistula, violence, STIs tend to isolate women socially. Studies have examined that the economic costs of women health issues ranges from 1.6% to 2% of country’s GDP.

15. Addressing Future Challenges
Female Genital Cutting
Efforts that promote change need to be specifically tailored to local practices and beliefs.
Promote female empowerment, education, and control over economic resources.
Since 1997,WHO has been trying to raise global concern to stop the practice. In 2008, they passed a resolution on the elimination of FGC.
Read the story of Sudan: Religious leader speaks out against female genital mutilation/cutting
Female genital cutting (FCG) is a social norm. A practice very widely spread among different ethnicities of Africa. Efforts that promote change need to be specifically tailored to local practices and beliefs. For some cultures FCG is a prerequisite for marriage and if people start to abandon the practice then they risk marriage for their girls. One way to reduce the incidence of FCG could be to promote female empowerment, education, and control over economic resources which could lead to elimination of this harmful cultural practice.

16. Addressing Future Challenges
Violence Against Women
Protecting women through legislation.
Shelters for abused women.
Ensuring police, judges, and healthcare workers are trained to deal with violence against women in effective ways.
Video: Bangladesh Ministry of Women and Children Affairs Communications Campaign on Violence Against Women (6:57)
There is very little evidence on what will work to reduce the violence against women in a cost effective way. Studies have shown that in high income countries legislation to protect women against violence had positive impact. Shelters for abused women can also help to reduce the violence against women. Ensuring police, judges, and healthcare workers trained to deal with violence against women in effective ways have proven to be useful.

17. These are some suggested measures to reduce intimate partner violence.

18. Addressing Future Challenges
Sexually Transmitted Infections
Surveillance of STIs.
Program of health education.
Appropriately trained health workers to provide proper treatment.
The importance to reduce STIs is enormous because STIs increases the chances of HIV/AIDS. The goals of any program to reduce the incidence of STIs should integrate the goals of reducing the infection, reduce the complications of infections, and reduce the spread of infection to the newborn. To do it more cost effective way it is better to prevent the disease before happening. Some of the educational message that could be disseminated into the community are ,to aware the girls about the danger of having sexual relations at early age, to be able to refuse the unwanted sex, have relations with fewer partners, using condoms, and to diagnose and treat STIs as early as possible.

19. Addressing Future Challenges
Maternal Mortality
Provide hygienic and appropriate post-abortion care at the lowest level of the health system possible
Provide effective family planning methods
Births attended by a skilled healthcare provider
Enhance emergency obstetric care
Reduce unsafe abortion and thereby reduce mortality
Family planning saves lives. Because pregnancy and abortion are such important risks for disability, illness, and death, one way to avoid these problems is to reduce unwanted pregnancy through the promotion and widespread availability of family planning. In low- and middle-income countries where abortion is legally restricted, most of the disability, morbidity, and mortality associated with abortion is the result of unsafe abortion. If abortions are legal in a country, they need to be conducted in a safe manner. In countries in which abortion is not legal, services must be available for post-abortion care, since abortions will still be conducted, but often in unsafe ways.

20. Towards a better future…
Video: Pakistan Maternal/Child Health music video (5:32)
This music video positions pregnancy as a very special stage in the life of a woman and highlights the important but often neglected fact that the health and wellbeing of mother and child is a joint responsibility of husband and family members. The video was a finalist in the 2010 New York Festivals International TV Awards.