Chapter two: an overview of women's health and nutrition.

Women's health status varies widely both within and among countries because of such factors as local disease prevalence, health-related behaviors, and women's educational attainment, exposure to health information, influence on decisionmaking, and access to health care. Poverty, environmental degradation, civil conflict, and migration also influence women's health.

Global Trends

Li the developing world, women's health status is changing in response to several emerging trends.

* More education. Girls who have attended school, especially through the secondary level, are more likely to delay marriage and childbearing, have smaller families, and use health care facilities (Schultz 1989).

* Later marriage. In most countries women are marrying later, which generally implies postponed childbearing and permits women to stay in school longer. It also implies that growing numbers of adolescent girls are exposed to the risks associated with premarital sexual intercourse, such as unwanted pregnancy and STDs, including HIV.

* Emergence of HIV/AIDS. The rate of HIV/AIDS infection is accelerating more rapidly among women than men, through exposure to infected partners. Young women are at particular risk.

* Smaller families. Women are bearing children over increasingly short periods of their lives. For the average woman in developing countries with relatively low fertility rates, such as Indonesia and Mexico, fifteen years elapse between the first and last birth--less than 20 percent of the mother's lifetime. In countries with higher fertility and lower life expectancy, such as Kenya and Senegal, the average interval is nineteen to twenty years, or about 40 percent of a woman's lifetime. Comparable intervals are eight years for women in the United States and two years for those in Japan (Freedman and Blanc 1991).

* Longer life expectancy. Life expectancy at birth has increased, primarily because of improved survival of infants and young children. As a result, health problems that emerge later in life, such as cervical cancer and cardiovascular disease, are becoming more prevalent, shifting health care concerns to those associated with chronic diseases, for which interventions tend to be less effective and more costly. Women constitute a majority of the elderly.

* Increased labor force participation. Women are entering the formal labor force in growing numbers. Along with the positive benefits of increased income and, in some settings, social support, women face new occupational health hazards and the challenge of coordinating employment outside the home with such traditional responsibilities as breastfeeding and childcare.

Women's Burden of Disease

Because women live longer than men, the common belief is that they are healthier. In reality, women are more likely to experience poor health. A recent study that compared measures of ill health in several countries concluded that even though women live longer, they are more sickly and disabled than men throughout the life cycle (Strauss and others 1992).

Data from World Development Report 1993 (World Bank 1993b) indicate that between the ages of IS and 44 and after age 60, men generally have higher rates of premature death and women have higher rates of disability. Female disability is especially high in Asia, Sub-Saharan Africa, and the Middle East, and much of it is attributable to maternal causes, STDs, and gender-based discrimination.

In developing countries, one-third of the DALYS lost by women aged 15 to 44 result from reproductive health problems, with gender violence and rape accounting for an additional 5 percent (World Bank 1993b). More than one fifth of the DALYS lost by women aged 45 to 59 can be attributed to conditions that exclusively or predominantly affect women. Although the potential gains from health interventions targeting women over 45 are more modest than those applied in earlier years, certain interventions, such as screening and cryotherapy for preinvasive cervical cancer, are highly effective and relatively cheap.

Women's Health and Nutrition throughout Life

Biological and social factors affect women's health throughout their lives and have cumulative effects. It is therefore important to consider the entire life cycle when examining the causes and consequences of women's poor health. For example, girls who are fed inadequately during childhood may have stunted growth, leading to higher risks of complications during childbirth. Similarly, sexual abuse or female genital mutilation during childhood increase the likelihood of poor physical and mental health in later years. Although the adolescent period overlaps with the reproductive years, it is considered separately here because of the long-term consequences of health problems during this period (Figure 2.1).

Different health and nutrition problems affect females at different stages of the life cycle, from infancy and childhood to adolescence and the reproductive years to the postreproductive period. For developing countries as a whole, 25 percent of females are aged 0 to 9,21 percent are 10 to 19,36 percent are 20 to 45, and 18 percent are over 45.

Infancy and Childhood

Girls are born with certain inherent biological advantages that make them less vulnerable than boys to childhood diseases, given equal nutrition, health conditions, and health care. However, discrimination in the treatment of girls can negate their innate biological advantages. In many developing countries girls are in poorer health than boys because of inadequate nutrition and health care. Such disparities are greatest in India and China, where more girls than boys die before their fifth birthday (World Bank 1993b). In a number of other developing countries with recent national surveys, girls are also more likely to die than boys (Figure 2.2). The key factors that adversely affect girls' health include the following.

Discriminatory childcare. In societies where boys are more highly valued than girls, boys may receive more preventive care and more timely attention when they fall ill. In some societies girls receive less food and less nutritious food than boys (Ravindran 1986), leading to malnutrition and impaired physical development.

[FIGURE 2.1 OMITTED]

Sex selection. In countries where many families have a strong preference for sons, there is evidence of selective abortion of female fetuses (whose sex is detected by ultrasound and amniocentesis) and of female infanticide (Heise, Pitanguy, and Germain 1994). In Bombay, India, only one of 8,000 abortions performed after parents learned the sex of the fetus averted the birth of a male (UN 1991).

Genital mutilation. Each year an estimated 2 million young girls are subjected to genital mutilation, also known as female circumcision (see Box 3.2). Often performed under unsterile conditions, this invasive procedure can lead to death, acute pain, recurrent urinary tract infections, mental trauma, painful intercourse, and complications during childbirth (Acsadi and Johnson-Acsadi 1993; who 1993b).

[FIGURE 2.2 OMITTED]

Adolescence

Although women aged 10 to 19 are generally healthy, their emerging sexuality and exposure to a variety of risks during the transition from childhood to adulthood can jeopardize their survival and well-being. Their status within the family and community is at its lowest in most countries during this phase of the life cycle. To a large extent, adolescence sets the stage for health and nutritional status in the later years, yet health policies and programs are the least effective in addressing the needs of this age group.

Early childbearing. The proportion of women giving birth during their teenage years ranges from 10 to 50 percent. Early childbearing is particularly common in traditional, often rural, settings where early marriage is the norm, but it is becoming increasingly prevalent among unmarried adolescents. In some settings a young girl may welcome an early premarital pregnancy to demonstrate her fertility or to motivate a partner to commit to marriage. Regardless of whether or not premarital sexuality is condemned, early pregnancy can have particularly harmful effects on a girl's social and economic opportunities. In Botswana, for example, a study found that one in seven women who dropped out of school did so because of pregnancy, and of those, only one in five returned to school (Bledsoe and Cohen 1993).

Adolescent girls are not physically prepared for childbirth, since linear growth is not complete until age 18 and the birth canal does not reach mature size until two to three years later (UN ACC/SCN 1992). As a result of this and other factors, teenage mothers face a high risk of serious pregnancy-related complications. In a Nigerian study, for example, 17 percent of 14-year-olds developed hypertensive disorders of pregnancy, compared with 3 percent of women aged 20 to 34. Also in Nigeria, 33 percent of all cases of fistulae (a tearing of the walls between the vagina and bladder or rectum following prolonged labor) involve women under age 16 (who 1989).

Adolescents also face at least a 20 percent greater likelihood of maternal or infant death than women in their twenties. The risks increase several-fold for women under age 16. Despite their high risk, most unmarried adolescents lack the requisite knowledge and services to prevent pregnancy. Studies in Guatemala and Kenya found that fewer than one in ten unmarried youths could correctly identify the fertile period (CDC 1991; Ajayi and others 1991). In most developing countries a majority of young women have heard of at least one modem contraceptive method, but they generally do not have adequate knowledge about correct usage. National surveys in several African countries found that although at least one in four women aged 15 to 19 was single and sexually experienced, few were using contraception. Among those who were using contraception, large proportions were relying on ineffective traditional methods such as rhythm and withdrawal (Population Reference Bureau 1992; Yinger and others 1992).

Unsafe abortion. Many unmarried adolescents seek abortions--whether legal or not--to avoid expulsion from school and social condemnation. Because they often seek clandestine abortions and delay in obtaining the procedure and seeking attention for associated problems, adolescents have a higher rate of abortion complications. Studies of hospital records in several African countries found that between 38 and 68 percent of women seeking care for complications of abortion were under 20 years of age.

STDs, including AIDS. STDs are spreading rapidly among young women, mainly through liaisons with older men and prostitution. In Thailand, for example, an estimated 800,000 prostitutes are under age 20, one-quarter are under 14, and roughly three in ten are HIV-infected (IPPF 1992). There is evidence that adolescent girls are biologically more vulnerable to STDs than older women, and they are likely to have more difficulty negotiating safe sex practices with their partners. Li parts of Africa, hw infection is increasing more rapidly among females than males, especially among adolescent girls (Panos Institute 1989). Studies in Ethiopia and Zimbabwe reveal that while the ratio of HIV infection is equal among men and women aged 20 to 29, girls aged 15 to 19 are three to five times more likely than boys to be infected (Zewdie 1993). On average, women become infected five to ten years earlier than men (UNDP 1993).

Undernutrition and micronutrient deficiency. Girls' nutritional needs increase in early adolescence because of the growth spurt associated with puberty and the onset of menstruation. Inadequate diet during this period can jeopardize girls' health and physical development, with lifelong consequences. Iron-deficiency anemia is particularly common among adolescent girls. Skeletal growth is also delayed by malnutrition, and since a smaller pelvis can prolong labor and obstruct delivery, incomplete skeletal growth, or stunting, poses serious risks during childbirth.

Increased substance abuse. Adolescents often experiment with harmful substances, including tobacco, alcohol, and drugs. Diseases associated with lifestyle and behavior have been less of a problem for women than for men, but this is changing in some countries. Cigarette advertising is now targeting women and young people, and smoking is spreading most rapidly among young women. Early initiation of such behaviors sets a pattern for lifelong use and increases morbidity and mortality, including risks specific to women's reproductive functions. For example, women overage 30 who smoke heavily and take oral contraceptives have a higher risk of cardiovascular disease, and pregnant women who smoke have a higher risk of stillbirth, premature labor, and low-birthweight babies.

Reproductive Years

Women's risk of premature death and disability is greatest during their reproductive years. And many conditions that have their onset during this period continue to affect the health of women--and that of their children--long after their reproductive years are over.

Unplanned pregnancy and abortion. Unplanned pregnancy is common in every country. In most developing countries, about 20 to 30 percent of married women--or about 120 million women--wish to avoid becoming pregnant but are not using contraception (Westoff and Ochoa 1991). This number would increase substantially if unmarried women, women who need a better or more suitable contraceptive method, and women who use abortion services were included. One in five births in these countries is unwanted.

Worldwide, an estimated 40 million to 60 million women resort to abortion to end unwanted pregnancies. Because the majority of abortions are unsafe, the procedure carries a high risk of injury and death, accounting for 125,000 to 200,000 female deaths annually (Dixon-Mueller 1990; Rosenfield 1989; who 1992c). Abortion-related mortality is highest in countries where abortion is legally restricted, access to family planning and safe abortion services is limited, and overall maternal mortality is high. About 40 percent of the world's population lives in countries with no restrictions on abortion, 23 percent where abortion is permitted for social and medical reasons, 12 percent where abortion is permitted when the woman's life and health are at stake or there are injuries to the fetus, and 25 percent where abortion is permitted only to save the life of the woman or is not permitted at all (Henshaw 1990). The cost of treating abortion-related complications is much greater than the cost of safe abortion.

Pregnancy-related complications. Each year more than 150 million women become pregnant, more than 50 million experience acute pregnancy-related complications, and 15 million develop long-term disabilities (who 1992a). Half a million of these women die as a result. In developing countries more than one-fourth of all deaths of women of reproductive age are pregnancy-related, caused mainly by hemorrhage, sepsis, unsafe abortion, hypertensive disorders, and obstructed labor. While maternal mortality has fallen in parts of Latin America and in Southeast and West Asia, it remains high in Africa and South Asia. Even though the risk of dying as a result of pregnancy or childbirth has declined globally, the number of pregnancy related deaths has continued to rise as the number of women in their prime childbearing years also rises.

In addition, conditions such as malaria, viral hepatitis, diabetes, anemia, sickle cell disease, tuberculosis, and rheumatic heart disease are aggravated by pregnancy (who 1992a). Disabilities resulting from pregnancy include genital or bladder prolapse, cervical lacerations, obstetric fistulae, anemia, and infertility. In Colombia, Pakistan, the Philippines, and Syria, between 9 and 25 percent of women under age 45 suffer uterine prolapse (Omran and Standley 1976, 1981).

Malnutrition. An estimated 450 million adult women in developing countries are stunted as a result of protein-energy malnutrition during childhood (World Bank 1993b). As Figure 2.3 illustrates, more than 50 percent of pregnant women in the developing world are anemic (who 1992c). About 250 million women suffer the effects of iodine deficiency* and, although the exact numbers are unknown, millions are probably blind due to vitamin A deficiency (Leslie 1991). The highest levels of malnutrition among women are found in South Asia (DeMaeyer and Adiels-Tegman 1985), where 60 percent of women of reproductive age are underweight, more than 60 percent are anemic, and 15 percent are stunted (UN acc/SCN 1992). The causes of malnutrition include inadequate food supply, inequitable distribution of food within the household, improper food storage and preparation, taboos against eating certain foods, and lack of knowledge about nutritious foods. Malnutrition hampers women's productivity, increases their susceptibility to infections, and contributes to numerous debilitating and fatal conditions.

[FIGURE 2.3 OMITTED]

STDs, including AIDS. Most reproductive tract infections (RTIS) are sexually transmitted. RTIS are of three types: STDs, infections such as candidiasis and bacterial vaginosis caused by overgrowth of vaginal organisms, and infections associated with unhygienic practices. Women are not only more susceptible to these infections than men, but also more likely to be asymptomatic women and to experience complications from untreated RTIS. RTIS can cause pelvic inflammatory disease, infertility, adverse pregnancy outcomes, and chronic pain. Among STDs, HIV/AIDS and syphilis may directly result in death. Other STDs, however, can lead to life-threatening complications such as ectopic pregnancy and cervical cancer.

RTIS are common in all developing countries. In Egypt, for example, a recent community-based study found that over one-half of the women sampled had one or more RTIS (Younis and others 1993).

HIV/AIDS, which is primarily transmitted sexually, is spreading rapidly among women (see Figure 2.4). This is particularly true in Sub-Saharan Africa, where nearly 4 million adult women are already infected and where more than 13 million women may be infected by the year 2000 (who 1993c). Women with HIV run a high risk of passing the virus to their newborns, and they usually die while their children are still growing up. Tests of one-year-old babies of HIV-infected mothers showed that between 15 and 40 percent were also HIV-positive (who 1992b).

A number of factors place women at greater risk than men of contracting HIV/AIDS. Women are more likely to become infected each time they are exposed, because they have more mucosal surface exposed during sexual intercourse, and semen contains a much higher concentration of HIV than vaginal fluid. Women are also more likely than men to have asymptomatic untreated STDs, which increases their susceptibility to HIV infection. Furthermore, women's sex partners tend to be older than they are and thus more likely to be infected. In addition, social norms that require female passivity and economic dependence on men make it difficult for women to insist on mutual fidelity or condom use (who 1993c). Finally, women may be exposed to HIV infection when they receive blood transfusions to combat pregnancy-related anemia or hemorrhage.

Postreproductive Years

By the year 2020, one in five women in developing countries will be 50 or older. As a result of urbanization, migration, and changing family structure, women are increasingly neglected in their old age. The cumulative effects of a lifetime of nutritional deprivation, hazardous and heavy work, continuous childbearing, and low self-esteem leaves them both physically and mentally frail, while abandonment and widowhood often leave them destitute. Because of their tendency to marry men older than themselves, as well as their longer life expectancy, women are more likely than men to be widowed. With the shift away from the support of extended families, elderly women are increasingly left on their own. Loss of a partner and living alone may have important health implications.

Most of the problems affecting women after the age of 45 are chronic. Injuries and infections (particularly tuberculosis) also contribute to women's disability in their later years, as do malnutrition, anemia, and loss of visual acuity. Menopause leads to alterations in the skeletal, cardiovascular, nervous, skin, genitourinary, and gastrointestinal systems and can affect women's capacity to perform everyday activities. The health problems of postmenopausal women, however, continue to be largely ignored.

Gynecological cancers. These may occur during the reproductive years, but they are more prevalent after age 40. Cancers of the cervix and breast are the most common. Although cervical cancer can be cured at a relatively low cost if detected early, 183,000 women in developing countries die from it every year (Sherris and others 1993; World Bank 1993b). Breast cancer, which kills 158,000 women in developing countries each year, requires more sophisticated screening and treatment techniques (World Bank 1993b).

Cardiovascular and cerebrovascular diseases. Cardiovascular diseases, including ischemic heart disease, myocardial infarction, and cerebrovascular disease (stroke), are the leading cause of death among adults age 45 and older in developing countries and represent a higher proportion of the disease burden among women than men in this age group (World Bank 1993b). With the increasing prevalence among women of risk-producing behaviors (such as smoking and alcohol consumption), the incidence of cardiovascular disease is expected to rise.

Diabetes. Among urban women in Asia, the Middle East, and Latin America and the Caribbean, where obesity and inadequate exercise are becoming more common, the prevalence of diabetes mellitus is growing. Diabetes is a major cause of morbidity and can lead to blindness, kidney damage, and damage to the lower limbs.

Undernutrition. In the poorer developing countries, chronic malnutrition is common among women, often reflecting a lifetime of inadequate intake of calories, vitamins, and minerals. In times of food shortage, elderly women are often most adversely affected.

Osteoporosis. Worldwide, one in ten women over age 60 has osteoporosis, a process of bone loss that may result in pain, disability, and increased risk of fractures. Osteoporosis is most common in women beyond reproductive age because bone loss rises sharply after menopause. Insufficient calcium, inadequate exercise, smoking, and excessive consumption of alcohol are contributing factors.

Osteoarthritis. During and after menopause, women are particularly prone to the development of osteoarthritis, a painful degenerative joint disease. Typically, several joints are affected, and progression of the disease restricts the performance of even routine activities. Repeated trauma to the joints has been identified as a predisposing factor, and obesity can exacerbate the condition.

Additional Health Problems

Some health problems that affect both men and women during the life cycle have a disproportionate effect on women because of cultural norms or differences in exposure or in access to treatment. Three of the major types of health problems that have a differential impact on women are described below.

Gender-based violence. Men are often victims of street violence, brawls, homicide, and crime, but violence directed at women is a distinctly different phenomenon. Men tend to be attacked and killed by strangers or casual acquaintances, whereas women are most at risk at home and from men whom they know. Violence against women also tends to be acute, less likely to be reported, and often associated with sexual abuse.

Domestic violence, rape, and sexual abuse are widespread in virtually all regions, classes, cultures, and age groups. Reliable data on the incidence of rape are difficult to obtain, as many rapes go unreported. Among women aged 18 to 21 in five countries, however, between 8 and 18 percent of those surveyed reported that they had been raped (Heise, Pitanguy, and Germain 1994). Sexual abuse can occur at any time during the life cycle, but studies suggest that an alarming proportion of victims of rape and incest are 10 years old or younger. Other forms of violence against girls and women include female infanticide, forced prostitution, dating and courtship violence, marital rape, and abuse of widows and elderly women.

In addition to affecting women's health care-seeking behavior (abusive husbands often prevent women from seeking care), gender-based victimization can lead to unwanted pregnancy, infection, miscarriage, gynecological problems, depression, and many other forms of partial or permanent disability. Not infrequently, victims of battering and sexual assault attempt suicide (Heise, Pitanguy, and Germain 1994).

Of women surveyed in various countries, between 20 and 60 percent report having been beaten by their partners (World Bank 1993b). Recent estimates of the global burden of disease indicate that women of reproductive age in industrial countries lose one out of five healthy days of life because of domestic violence and rape; their counterparts in developing countries lose one out of twenty days (World Bank 1993b). The health burden of gender violence among women of reproductive age is comparable to that of other conditions already high on the world agenda. Reducing violence against women would therefore help reduce health care expenditures, as well as address this violation of basic human rights.

Depression. In general, men and women aged 15 to 44 are about equally likely to suffer neuropsychiatric problems. However, depressive disorders are responsible for 5.8 percent of all deaths and disabilities among women of reproductive age--twice the rate among men (World Bank 1993b). Suicide accounts for an additional 3 percent of deaths among women in this age group, more than are caused by either respiratory infections or motor vehicle accidents (World Bank 1993b). Depression is the single most serious mental problem for women in every age group, and it has a significant impact on women's well-being and productivity (Paltiel 1993). World Development Report 1993 (World Bank 1993b) ranks depressive disorders and self-inflicted injuries fifth and sixth, respectively, among the diseases and injuries most affecting women aged 15 to 44. Factors that put women at risk of depression include their inferior social and economic status, physical or sexual abuse, infertility, the conflicting demands of their domestic and income-producing roles, and, particularly among elderly women, isolation.

Certain occupational and environmental health hazards. While men and women alike may be exposed to many occupational and environmental health hazards, some have particular effects on women. Because many women work in the home, they suffer disproportionately from inadequate water supply, poor sanitation, and indoor air pollution. A study in India found that rural women cooking in poorly ventilated huts were exposed to 100 times the acceptable level of suspended smoke particles- --six times higher than other household members (Chatterjee 1991).

Outside the home, women workers may face the risk of sexual harassment and rape. Furthermore, they are more likely than men to work in industries and small enterprises with unsafe working conditions and poor regulation of such hazards as toxic chemicals, radiation, extreme temperatures, excessive noise, and violence. Electronic assembly workers report a loss of visual acuity, and textile workers complain of pulmonary problems, dermatitis, hand injuries, and chronic back pain (Hovell and others 1988). Exposure to toxic chemicals can cause cancer, dermatitis, miscarriage, and birth defects. Women may be particularly susceptible to some toxic chemicals for biological reasons (Rovner 1993).

Most women in developing countries are employed in low-wage positions--for example, as food vendors, petty traders, and domestic workers; they cannot afford to purchase health care or protective clothing and equipment. Many women farmers, especially those in commercial agriculture, are regularly exposed to pesticides, often without appropriate safeguards.

When pregnant women are exposed to many of these hazards, the health of their unborn children suffers as well. Heavy work during pregnancy can lead to premature labor and, when high energy demands are not compensated by increased caloric intake, to low-birthweight babies.

FIGURE 2.4 ESTIMATED CUMULATIVE HIV INFECTIONS IN WOMEN BY EARLY 1994

East Asia
and the Pacific (a)       50,000
South and
Southeast Asia       > 1,500,000
North America        > 1,000,000
Latin America        > 1,000,000
Western Europe           500,000
North Africa and
the Middle East           75,000
Eastern Europe
and Central Asia          50,000

Sub-Saharan Africa
                     > 7,500,000

a. Including Australasia.

Source: WHO 1993c.

Note: Table made from pie chart.