Women’s Health: The Basis for Global Health

BY RACHEL JABER CHEHAYEB

The diversity of biological, environmental, social and governmental factors that contribute to shaping overall population health, and the extent of interconnectedness of these factors make trade-offs between interventions and decisions of resource and fund allocation exceedingly difficult. Nevertheless, women’s health perseveres as an accurate indicator of and contributor to overall health levels. Investing in women’s health, from reproductive health provision through access to family planning services to acknowledging the role of gender to reducing women’s NCD burden and gender-based violence, has huge positive externalities that are far-reaching in time horizon and scope of impact; adopting a women’s health approach to global health is a tremendously effective and sustainable manner to shape global health, with current and intergenerational benefits outweighing those of more vertical approaches.  

Family planning services through boosting reproductive health greatly shape global health. 

Family planning services(FPS), key components of reproductive health, have far-reaching impacts on several determinants of global health. One of the ways women’s health indirectly shapes global health is through contributing to economic growth. Merely meeting one third of the need for family planning in Nigeria, Kenya and Senegal could pull up income per capita by 8 to 13 percent1. Access to abortion services has comparable overall influences on the economy: the drop in overall education levels and subsequent decreased economic productivity of children post 1967 in Romania was traced back to the abortion ban1. These results are significant given the role of higher GDP per capita on increasing life expectancy and on decreasing the rate of disease and mortality1. The use of family planning services greatly suppresses the probability of delivering low birth weight babies1, hence contributing to overall improved health in the long run. These far-reaching effects are evident upon analyzing progress after twenty years of implementation of the Family Planning and Maternal Child Health (FPMCH) program in Matlab, Bangladesh. Mere access to these services caused child mortality to drop by %20 and a quantifiable increase in wealth and education levels. Families were hence able to invest in key sanitation and preventative measures, like access to clean water, leading to a reduction in neglected tropical disease incidence. Child weight, nutrition and immunization status all showed improvements2, as did the health of family members in general, including elderly living in the households. Furthermore, each prevented birth increases female labor force supply by two years, leading to more overall economic growth2. Climate change experts claim that in the long run family planning services could significantly impact the deceleration of climate change3. These factors collectively corroborate the tremendous impact of investing in women’s health on overall health. Moreover, according to WHO estimates, 100,000 maternal lives would be saved annually if women could avoid unwanted pregnancy4. Putting aside all the afore mentioned benefits of access to FPS, this mere reduction is on its own substantial given the hefty societal costs of maternal mortality.

 Current maternal health levels determine the overall health status of the next generations. 

Maternal mortality and morbidity are directly correlated to losses in social and economic development and decreases in health levels. Each maternal mortality decreases GDP per capita by $0.36, a significant drop given that a country’s economic growth contributes to 40% of reductions in infant mortality, a core health-related sustainable development goal5. GDP drops also imply a drop in healthcare spending, hence a decrease in overall healthcare services’ provision1. Aside from maternal mortality, exposure to maternal undernutrition or famine in utero has far-reaching effects on literacy, income, and even adult risk of hypertension and sub-optimal glucose tolerance later on in life. Maternal obesity was observed to increase risk of neonatal deaths in 27 separate African countries1. Lower maternal height and lower maternal weight were respectively linked to worse child health and low birth weight1, hence exhibiting the spillover effect of maternal health on the future, creating a “vicious cycle”. Aside from mothers’ physical health, mental health is also of critical importance. Postpartum and maternal depression have exorbitant consequences, from both a health and development perspective. The latest lancet series on early childhood development (ECD) stresses both the importance of nurturing care on early childhood development, and the long term consequences the proper formation of neuronal synapses and brain development have on children achieving full potential6. Besides its potentially harmful impact on ECD, a mother’s poor mental health has possibly fatal long run impacts on a child through being a risk factor for malnutrition, stunting, infectious diseases, diarrheal disease and disordered or insufficient immunization1. In the most extreme case of maternal mortality, there is an amplified risk of infant mortality, a revealing causation given that paternal mortality does not alter the risk of infant mortality1. Maternal orphans tend to have lower educational attainment and extreme economic difficulties that further fuel the cycle.  Women’s health, however, extends beyond mere maternal health and has larger health implications, particularly upon considering the rapidly growing global health burden of non-communicable diseases(NCDs). 

A women’s health focused approach is key to reducing the overall NCD burden. 

As non-communicable diseases continue to pose a growing global health threat, contributing 60% of deaths7, both targeting NCDs in women and targeting women’s health in general prove to be arguably the most effective approaches of dealing with these challenges. Cancer is the leading cause of death among women, leading to huge losses in disability adjusted life years and having traumatic impacts on children and families due to a mother’s prolonged suffering8. Debt accrued due to women’s cancer causes extreme financial difficulties that have negative impacts om heath8. According to the International Agency for Research on Cancer, approximately 3.3 million women died from cancer in 2008 worldwide7. Investing in women’s health and cancer treatment partially alleviates the costs of maternal mortality, psychological trauma and economics losses that reduce access to healthcare. These costs highlight the importance of focusing on women’s health: evidence suggests that increasing available studies on women’s health and NCDs and including more women in research would greatly effect health outcomes overall8. Women’s health also affects NCD incidence and progression throughout the population. As mentioned earlier, prenatal malnutrition is highly correlated to subsequent risk of hypertension. A pregnant woman’s intake of one recommended daily allowance (RDA) of multiple micronutrients would lead to lower chances of chronic disease development in her child8. Besides long term investment, educating women about NCD prevention and promoting healthy lifestyles in women causes a mirroring of induced changes and reduced NCD incidence in entire communities as a whole9. Hence, the global strategy for women’s and children’s health states stresses the importance of gender empowerment and the integration of women’s care with other services when targeting NCD reduction9. This prioritization, or even consideration, of women’s health, unfortunately, is not always the case. 

Investing in women’s health is secondary to investing in infectious disease control. 

Investing into infectious disease control, particularly into HIV/AIDs, is frequently portrayed as a more effective approach to global health promotion, with Bill Clinton, for instance, having announced that HIVAIDS programs, through strengthening infrastructure and generating positive benefits, would be ideal starting points to improving global health10. These claims have proved to be misguided, with indicators like prenatal care, maternal health and even basic vaccinations plummeting as an effect of the centralization of infectious disease programs10. In practice, vertical programs have proved to divert healthcare workers away from basic primary care provision towards infectious disease control, hence inducing neglect of other vital elements of health10.  Despite the volatility of infectious disease patterns, the health status of women continues to act as a stable measure of a well-functioning health system10. Furthermore, maternal health itself plays a role in controlling infectious disease spread.  In Kwa-Zulu Natal province in South Africa, the spread of extensively drug resistant TB was traced back to failed treatment completion due to an ailing health system that was over-focused on battling HIV10. On the other hand, targeting the improvement of women’s health is a more sustainable approach, as it encompasses the improvement of health infrastructure that would allow for improved preparedness to combat emergent infectious diseases, while also indirectly inducing a drop in the spread of sexually transmitted diseases. Poor mental health in women, for instance, has repeatedly been linked to depressed use of contraception and hence increased risk of contraction of HIV among other STDs11. In this context, a women’s health-based approach to global health has hence become the equivalent of a prevention-focused, sustainable long-term approach to global health and development, as opposed to a series of narrower short-run “symptom” targeting approaches. The above mentioned hyper-focus could also occur within the realm of women’s health, as in the case of neglect of gender-based violence. 

Violence against women is a human rights issues as opposed to a global health threat. 

Gender-based violence, that predominantly affects women, is seldom considered a public health issue12. This is noteworthy given the huge global burden of violence: data accumulated from several sources stress the contribution of violence to injury and ill-health, with one out of every five healthy days of life lost to women of reproductive age being traced back to gender-based victimization12. Female-focused violence also impedes social and economic development and hence impedes progress in health indicators. Physical violence during pregnancy has been correlated to suboptimal birth outcomes, like premature birth and low birth weight, in addition to an increased burden of mental disorders, all of which impact mother and youth12. Several costly intestinal disorders have been linked to abuse in women, with violence in general decreasing available resources due to costs of treatment12. Violence against women also significantly reduces use of contraception due to “fear of mail reprisal” thereby reducing the success of family planning services while increasing the risk of STI contraction, thereby driving progress to a standstill.12 In this case, the trauma of abuse experienced by mothers has proved to be intergenerational, deeply impacting children who witness it psychologically12. This impact of violence, alongside the impact of diseases and biological responses in general, varies with gender in nature and severity, a phenomenon that is unfortunately often disregarded.   

There is not much merit in adopting a gender-based approach to health11

The unique needs of mothers and women in general are often undermined, with common assumptions including that what benefits the child benefits the mother13, and that progression and risk of disease are rather identical among men and women. These believes divert resources away from gender-specific research that could contribute greatly to global health.  In fact, men and women exhibit distinct trajectories of illness with women, for instance, being much more likely to develop post-traumatic stress disorder as a result of child abuse11. Sharp variations in depression rates and rates of drug abuse between genders are apparent, with a large proportion of DALYs due to neuropsychiatric illness being traced back to women11. This sizeable burden stresses both the importance of emphasizing women’s health to reduce the global burden of DALYs and the importance of developing a deeper understanding of gender differences in designing specific cost-effective approaches.  Traditional association of particular diseases with gender has been contributing to differences in quality of treatment, with women receiving lower quality diagnoses and treatments for cardiovascular diseases, due to CVD being traditionally associated with men14. Gender-based interventions would surely be more effective in reducing the global burden of disease than the “one-size-fits-all” policy currently in place15. In fact, Vera- Regitz- Xshrosek claims that incorporating gender-specific analysis into medical research and the development of distinct treatment approaches could reduce treatment prices in the long run while improving overall global health across genders, with the continuation of non-gender specific therapy being the least favorable to overall health in the long run.15 

In conclusion, women’s health is at the heart of global health, with current status of women’s health being a rather accurate mirror of both current and future global health levels, and a reflection of the quality of existing health infrastructure and services. This importance of women’s health merits a channeling of investments and global efforts towards improving not only reproductive and maternal health but also the health of women outside the realm of motherhood, coupled with a need for increased research into gender-based health differences. The impact of gender-based violence on overall health is simple proof of the hefty cost of neglecting a contributing factor to women’s health. A women’s health-focused approach to health is hence both sustainable and all- inclusive, equating women’s health to global health.   

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References :

  1. Violence against women: The hidden health burden Lori L Heise with Jacqueline        Pitanguy and Adrienne Germain, 1994. Reproductive Health Matters. 1994;2(4):126. doi:10.1016/0968-8080(94)90061-2.
  2. Joshi S, Schultz TP. Family Planning and Women’s and Children’s Health: Long-Term Consequences of an Outreach Program in Matlab, Bangladesh. Demography. 2012;50(1):149-180. doi:10.1007/s13524-012-0172-2.
  3. Guillebaud J. Voluntary family planning to minimise and mitigate climate change. Bmj. 2016:i2102. doi:10.1136/bmj.i2102.
  4. FPP Newsletter October 2014 (PDF). Human Rights Documents online. doi:10.1163/2210-7975_hrd-5540-2014005.
  5. Kirigia JM, Oluwole D, Mwabu GM, Gatwiri D, Kainyu LH. Effects of maternal mortality on gross domestic product (GDP) in the WHO African region. African journal of health sciences. https://www.ncbi.nlm.nih.gov/pubmed/17348747. Accessed May 9, 2017.
  6. 2016 Lancet Early Childhood Development Series. http://www.bing.com/cr?IG=22410C4CBA8B475CAA246ED6F78FCA3C&CID=19E699F100F363EE21AD938C01636287&rd=1&h=ya3SQ-QX_06BA15Tt4-ejFe9ZY7L2f5R351G8D2gdXI&v=1&r=http%3a%2f%2fwww.thelancet.com%2fseries%2fECD2016&p=DevEx,5034.1. Accessed May 9, 2017.
  7. The global impact of non-communicable diseases on macro … http://www.bing.com/cr?IG=585642F19FF44CECAA39CDC80EA28843&CID=2A425A08CE80636206995075CF106263&rd=1&h=g2ggFNaNopar4JvJJmxYrUyNxPMxIyMPwuECwSgQ9Wo&v=1&r=http%3a%2f%2feuropepmc.org%2farticles%2fPMC4457808&p=DevEx,5071.1. Accessed May 9, 2017.
  8. User S. Women’s Cancer Needs to Be a Global Priority: Why a Multi-sector Commitment Is Needed to Reduce the Burden of Women’s Cancers – The Center for Global Health and Diplomacy (GHD). http://www.cghd.org/index.php/global-health-challenges/non-communicable-diseases-ncds/cancer/21-womens-cancer-needs-to-be-a-global-priority-why-a-multi-sector-commitment-is-needed-to-reduce-the-burden-of-womens-cancers. Published May 9, 2017. Accessed May 9, 2017.
  9. 18 2012 S. Women Play Important Role In Fighting NCDs. The Henry J. Kaiser Family Foundation. http://kff.org/news-summary/women-play-important-role-in-fighting-ncds/. Published April 20, 2013. Accessed May 9, 2017.
  10. Garrett L. The Challenge of Global Health. Foreign Affairs, Vol 86, No 1 (Jan – Feb, 2007), pp 14-38. http://www.jstor.org/stable/20032209.
  11. Jenkins JH, Good M-JD. Women and global mental health: vulnerability and empowerment. Essentials of Global Mental Health.:264-281. doi:10.1017/cbo9781139136341.031.
  12. Violence against women: The hidden health burden Lori L Heise with Jacqueline Pitanguy and Adrienne Germain, 1994. Reproductive Health Matters. 1994;2(4):126. doi:10.1016/0968-8080(94)90061-2.
  13. Crawford J. Maternal Mortality—A Neglected Tragedy. The Lancet. 1985;326(8451):395. doi:10.1016/s0140-6736(85)92541-3.MinMC
  14. Maas AHEM, Appelman YEA. Gender differences in coronary heart disease. Netherlands Heart Journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018605/. Published December 2010. Accessed May 9, 2017.
  15. Regitz-Zagrosek V. Why Do We Need Gender Medicine? Sex and Gender Aspects in Clinical Medicine. 2011:1-4. doi:10.1007/978-0-85729-832-4_1. H? 

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