Women’s health | Wikipedia audio article

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 pregnancy and
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. While the rates of the leading causes of death,
cardiovascular disease, cancer and lung disease, are similar in women and men, women have different
experiences. Lung cancer has overtaken all other types
of cancer as the leading cause of cancer death in women, followed by breast cancer, colorectal,
ovarian, uterine and cervical cancers. While smoking is the major cause of lung cancer,
amongst nonsmoking women the risk of developing cancer is three times greater than amongst
nonsmoking men. Despite this, breast cancer remains the commonest
cancer in women in developed countries, and is one of the more important chronic diseases
of women, while cervical cancer remains one of the commonest cancers in developing countries,
associated with human papilloma virus (HPV), an important sexually transmitted disease. HPV vaccine together with screening offers
the promise of controlling these diseases. Other important health issues for women include
cardiovascular disease, depression, dementia, osteoporosis and anemia. A major impediment to advancing women’s health
has been their underrepresentation in research studies, an inequity being addressed in the
United States and other western nations by the establishment of centers of excellence
in women’s health research and large scale clinical trials such as the Women’s Health
Initiative.==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 maternal and 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.A
number of health and medical research advocates, such as the Society for Women’s Health Research
in the United States, support this broader definition, rather than merely issues specific
to human female anatomy to include areas where biological sex differences between women and
men exist. Women also need health care more and access
the health care system more than do men. While part of this is due to their reproductive
and sexual health needs, they also have more chronic non-reproductive health issues such
as cardiovascular disease, cancer, mental illness, diabetes and osteoporosis. Another important perspective is realising
that events across the entire life cycle (or life-course), from in utero to aging effect
the growth, development and health of women. The life-course perspective is one of the
key strategies of the World Health Organization.===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 Organization 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.Women who are socially
marginalized are more likely to die at younger ages than women who are not. Women who have substance abuse disorders,
who are homeless, who are sex workers, and/or who are imprisoned have significantly shorter
lives than other women. At any given age, women in these overlapping,
stigmatized groups are approximately 10 to 13 times more likely to die than typical women
of the same age.==Social and cultural factors==Women’s health is positioned within a wider
body of knowledge cited by, amongst others, the World Health Organization, which places
importance on gender as a social determinant of health. While women’s health is affected by their
biology, it is also affected by their social conditions, such as poverty, employment, and
family responsibilities, and these aspects should not be overshadowed.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.Behavioral differences
also play a role, in which women display lower risk taking including consume less tobacco,
alcohol, and drugs, reducing their risk of mortality from associated diseases, including
lung cancer, tuberculosis and cirrhosis. Other risk factors that are lower for women
include motor vehicle accidents. Occupational differences have exposed women
to less industrial injuries, although this is likely to change, as is risk of injury
or death in war. Overall such injuries contributed to 3.5%
of deaths in women compared to 6.2% in the United States in 2009. Suicide rates are also less in women.The social
view of health combined with the acknowledgement that gender is a social determinant of health
inform women’s health service delivery in countries around the world. Women’s health services such as Leichhardt
Women’s Community Health Centre which was established in 1974 and was the first women’s
health centre established in Australia is an example of women’s health approach to service
delivery.Women’s health is an issue which has been taken up by many feminists, especially
where reproductive health is concerned and the international women’s movement was responsible
for much of the adoption of agendas to improve women’s health.==Biological factors==
Women and men differ in their chromosomal makeup, protein gene products, genomic imprinting,
gene expression, signaling pathways, and hormonal environment. All of these necessitate caution in extrapolating
information derived from biomarkers from one sex to the other. Women are particularly vulnerable at the two
extremes of life. Young women and adolescents are at risk from
STIs, pregnancy and unsafe abortion, while older women often have few resources and are
disadvantaged with respect to men, and also are at risk of dementia and abuse, and generally
poor health.==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 in 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.Non-reproductive health remains an important predictor of maternal
health. In the United States, the leading causes of
maternal death are cardiovascular disease (15% of deaths), endocrine, respiratory and
gastrointestinal disorders, infection, hemorrhage and hypertensive disorders of pregnancy (Gronowski
and Schindler, Table II).In 2000, the United Nations created Millennium Development Goal
(MDG) 5 to improve maternal health. Target 5A sought to reduce maternal mortality
by three quarters from 1990 to 2015, using two indicators, 5.1 the MMR and 5.2 the proportion
of deliveries attended by skilled health personnel (physician, nurse or midwife). Early reports indicated MDG 5 had made the
least progress of all MDGs. By the target date of 2015 the MMR had only
declined by 45%, from 380 to 210, most of which occurred after 2000. However this improvement occurred across all
regions, but the highest MMRs were still in Africa and Asia, although South Asia witnessed
the largest fall, from 530 to 190 (64%). The smallest decline was seen in the developed
countries, from 26 to 16 (37%). In terms of assisted births, this proportion
had risen globally from 59 to 71%. Although the numbers were similar for both
developed and developing regions, there were wide variations in the latter from 52% in
South Asia to 100% in East Asia. The risks of dying in pregnancy in developing
countries remains fourteen times higher than in developed countries, but in Sub-Saharan
Africa, where the MMR is highest, the risk is 175 times higher. In setting the MDG targets, skilled assisted
birth was considered a key strategy, but also an indicator of access to care and closely
reflect mortality rates. There are also marked differences within regions
with a 31% lower rate in rural areas of developing countries (56 vs. 87%), yet there is no difference
in East Asia but a 52% difference in Central Africa (32 vs. 84%). With the completion of the MDG campaign in
2015, new targets are being set for 2030 under the Sustainable Development Goals campaign. Maternal health is placed under Goal 3, Health,
with the target being to reduce the global maternal mortality ratio to less than 70. Amongst tools being developed to meet these
targets is the WHO Safe Childbirth Checklist.Improvements in maternal health, in addition to professional
assistance at delivery, will require routine antenatal care, basic emergency obstetric
care, including the availability of antibiotics, oxytocics, anticonvulsants, the ability to
manually remove a retained placenta, perform instrumented deliveries, and postpartum care. Research has shown the most effective programmes
are those focussing on patient and community education, prenatal care, emergency obstetrics
(including access to cesarean sections) and transportation. As with women’s health in general, solutions
to maternal health require a broad view encompassing many of the other MDG goals, such as poverty
and status, and given that most deaths occur in the immediate intrapartum period, it has
been recommended that intrapartum care (delivery) be a core strategy. New guidelines on antenatal care were issued
by WHO in November 2016.====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.=====Obstetrical fistula=====Of near miss events, obstetrical fistulae
(OF), including vesicovaginal and rectovaginal fistulae, remain one of the most serious and
tragic. Although corrective surgery is possible it
is often not available and OF is considered completely preventable. If repaired, subsequent pregnancies will require
cesarean section. While unusual in developed countries, it is
estimated that up to 100,000 cases occur every year in the world, and that about 2 million
women are currently living with this condition, with the highest incidence occurring in Africa
and parts of Asia. OF results from prolonged obstructed labor
without intervention, when continued pressure from the fetus in the birth canal restricts
blood supply to the surrounding tissues, with eventual fetal death, necrosis and expulsion. The damaged pelvic organs then develop a connection
(fistula) allowing urine or feces, or both, to be discharged through the vagina with associated
urinary and fecal incontinence, vaginal stenosis, nerve damage and infertility. Severe social and mental consequences are
also likely to follow, with shunning of the women. Apart from lack of access to care, causes
include young age, and malnourishment. The UNFPA has made prevention of OF a priority
and is the lead agency in the Campaign to End Fistula, which issues annual reports and
the United Nations observes May 23 as the International Day to End Obstetric Fistula
every year. Prevention includes discouraging teenage pregnancy
and child marriage, adequate nutrition, and access to skilled care, including caesarean
section.===Sexual health=======
Contraception====The ability to determine if and when to become
pregnant, is vital to a woman’s autonomy and well being, and contraception can protect
girls and young women from the risks of early pregnancy and older women from the increased
risks of unintended pregnancy. Adequate access to contraception can limit
multiple pregnancies, reduce the need for potentially unsafe abortion and reduce maternal
and infant mortality and morbidity. Some barrier forms of contraception such as
condoms, also reduce the risk of STIs and HIV infection. Access to contraception allows women to make
informed choices about their reproductive and sexual health, increases empowerment,
and enhances choices in education, careers and participation in public life. At the societal level, access to contraception
is a key factor in controlling population growth, with resultant impact on the economy,
the environment and regional development. Consequently, the United Nations considers
access to contraception a human right that is central to gender equality and women’s
empowerment that saves lives and reduces poverty, and birth control has been considered amongst
the 10 great public health achievements of the 20th century.To optimise women’s control
over pregnancy, it is essential that culturally appropriate contraceptive advice and means
are widely, easily, and affordably available to anyone that is sexually active, including
adolescents. In many parts of the world access to contraception
and family planning services is very difficult or non existent and even in developed counties
cultural and religious traditions can create barriers to access. Reported usage of adequate contraception by
women has risen only slightly between 1990 and 2014, with considerable regional variability. Although global usage is around 55%, it may
be as low as 25% in Africa. Worldwide 222 million women have no or limited
access to contraception. Some caution is needed in interpreting available
data, since contraceptive prevalence is often defined as “the percentage of women currently
using any method of contraception among all women of reproductive age (i.e., those aged
15 to 49 years, unless otherwise stated) who are married or in a union. The “in-union” group includes women living
with their partner in the same household and who are not married according to the marriage
laws or customs of a country.” This definition is more suited to the more
restrictive concept of family planning, but omits the contraceptive needs of all other
women and girls who are or are likely to be sexually active, are at risk of pregnancy
and are not married or “in-union”.Three related targets of MDG5 were adolescent birth rate,
contraceptive prevalence and unmet need for family planning (where prevalence+unmet need
=total need), which were monitored by the Population Division of the UN Department of
Economic and Social Affairs. Contraceptive use was part of Goal 5B (universal
access to reproductive health), as Indicator 5.3. The evaluation of MDG5 in 2015 showed that
amongst couples usage had increased worldwide from 55% to 64%. with one of the largest increases in Subsaharan
Africa (13 to 28%). The corollary, unmet need, declined slightly
worldwide (15 to 12%). In 2015 these targets became part of SDG5
(gender equality and empowerment) under Target 5.6: Ensure universal access to sexual and
reproductive health and reproductive rights, where Indicator 5.6.1 is the proportion of
women aged 15–49 years who make their own informed decisions regarding sexual relations,
contraceptive use and reproductive health care (p. 31).There remain significant barriers
to accessing contraception for many women in both developing and developed regions. These include legislative, administrative,
cultural, religious and economic barriers in addition to those dealing with access to
and quality of health services. Much of the attention has been focussed on
preventing adolescent pregnancy. The Overseas Development Institute (ODI) has
identified a number of key barriers, on both the supply and demand side, including internalising
socio-cultural values, pressure from family members, and cognitive barriers (lack of knowledge),
which need addressing. Even in developed regions many women, particularly
those who are disadvantaged, may face substantial difficulties in access that may be financial
and geographic but may also face religious and political discrimination. Women have also mounted campaigns against
potentially dangerous forms of contraception such as defective intrauterine devices (IUD)s,
particularly the Dalkon Shield.====Abortion====Abortion is the intentional termination of
pregnancy, as compared to spontaneous termination (miscarriage). Abortion is closely allied to contraception
in terms of women’s control and regulation of their reproduction, and is often subject
to similar cultural, religious, legislative and economic constraints. Where access to contraception is limited,
women turn to abortion. Consequently, abortion rates may be used to
estimate unmet needs for contraception. However the available procedures have carried
great risk for women throughout most of history, and still do in the developing world, or where
legal restrictions force women to seek clandestine facilities. Access to safe legal abortion places undue
burdens on lower socioeconomic groups and in jurisdictions that create significant barriers. These issues have frequently been the subject
of political and feminist campaigns where differing viewpoints pit health against moral
values. Globally, there were 87 million unwanted pregnancies
in 2005, of those 46 million resorted to abortion, of which 18 million were considered unsafe,
resulting in 68,000 deaths. The majority of these deaths occurred in the
developing world. The United Nations considers these avoidable
with access to safe abortion and post-abortion care. While abortion rates have fallen in developed
countries, but not in developing countries. Between 2010–2014 there were 35 abortions
per 1000 women aged 15–44, a total of 56 million abortions per year. The United nations has prepared recommendations
for health care workers to provide more accessible and safe abortion and post-abortion care. An inherent part of post-abortion care involves
provision of adequate contraception.====Sexually transmitted infections====Important sexual health issues for women include
Sexually transmitted infections (STIs) and female genital cutting (FGC). STIs are a global health priority because
they have serious consequences for women and infants. Mother-to-child transmission of STIs can lead
to stillbirths, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal
conjunctivitis, and congenital deformities. Syphilis in pregnancy results in over 300,000
fetal and neonatal deaths per year, and 215,000 infants with an increased risk of death from
prematurity, low-birth-weight or congenital disease.Diseases such as chlamydia and gonorrhoea
are also important causes of pelvic inflammatory disease (PID) and subsequent infertility in
women. Another important consequence of some STIs
such as genital herpes and syphilis increase the risk of acquiring HIV by three-fold, and
can also influence its transmission progression. Worldwide, women and girls are at greater
risk of HIV/AIDS. STIs are in turn associated with unsafe sexual
activity that is often unconsensual.====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).It has affected more than 200 million
women and girls who are alive today. The practice is concentrated in some 30 countries
in Africa, the Middle East and Asia. FGC affects many religious faiths, nationalities,
and socioeconomic classes and is highly controversial. The main arguments advanced to justify FGC
are hygiene, fertility, the preservation of chastity, an important rite of passage, marriageability
and enhanced sexual pleasure of male partners. The amount of tissue removed varies considerably,
leading the WHO and other bodies to classify FGC into four types. These range from the partial or total removal
of the clitoris with or without the prepuce (clitoridectomy) in Type I, to the additional
removal of the labia minora, with or without excision of the labia majora (Type II) to
narrowing of the vaginal orifice (introitus) with the creation of a covering seal by suturing
the remaining labial tissue over the urethra and introitus, with or without excision of
the clitoris (infibulation). In this type a small opening is created to
allow urine and menstrual blood to be discharged. Type 4 involves all other procedures, usually
relatively minor alterations such as piercing.While defended by those cultures in which it constitutes
a tradition, FGC is opposed by many medical and cultural organizations on the grounds
that it is unnecessary and harmful. Short term health effects may include hemorrhage,
infection, sepsis, and even result in death, while long term effects include dyspareunia,
dysmenorrhea, vaginitis and cystitis. In addition FGC leads to complications with
pregnancy, labor and delivery. Reversal (defibulation) by skilled personnel
may be required to open the scarred tissue. Amongst those opposing the practice are local
grassroots groups, and national and international organisations including WHO, UNICEF, UNFPA
and Amnesty International. Legislative efforts to ban FGC have rarely
been successful and the preferred approach is education and empowerment and the provision
of information about the adverse health effects as well the human rights aspects.Progress
has been made but girls 14 and younger represent 44 million of those who have been cut, and
in some regions 50% of all girls aged 11 and younger have been cut. Ending FGC has been considered one of the
necessary goals in achieving the targets of the Millennium Development Goals, while the
United Nations has declared ending FGC a target of the Sustainable Development Goals, and
for February 6 to known as the International Day of Zero Tolerance for Female Genital Mutilation,
concentrating on 17 African countries and the 5 million girls between the ages of 15
and 19 that would otherwise be cut by 2030.===Infertility===In the United States, infertility affects
1.5 million couples. Many couples seek assisted reproductive technology
(ART) for infertility. In the United States in 2010, 147,260 in vitro
fertilization (IVF) procedures were carried out, with 47,090 live births resulting. In 2013 these numbers had increased to 160,521
and 53,252. However, about a half of IVF pregnancies result
in multiple-birth deliveries, which in turn are associated with an increase in both morbidity
and mortality of the mother and the infant. Causes for this include increased maternal
blood pressure, premature birth and low birth weight. In addition, more women are waiting longer
to conceive and seeking ART.===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.There are a number of cultural
factors that reinforce this practice. These include the child’s financial future,
her dowry, social ties and social status, prevention of premarital sex, extramarital
pregnancy and STIs. The arguments against it include interruption
of education and loss of employment prospects, and hence economic status, as well as loss
of normal childhood and its emotional maturation and social isolation. Child marriage places the girl in a relationship
where she is in a major imbalance of power and perpetuates the gender inequality that
contributed to the practice in the first place. Also in the case of minors, there are the
issues of human rights, non-consensual sexual activity and forced marriage and a 2016 joint
report of the WHO and Inter-Parliamentary Union places the two concepts together as
Child, Early and Forced Marriage (CEFM), as did the 2014 Girl Summit (see below). In addition the likely pregnancies at a young
age are associated with higher medical risks for both mother and child, multiple pregnancies
and less access to care with pregnancy being amongst the leading causes of death amongst
girls aged 15–19. Girls married under age are also more likely
to be the victims of domestic violence.There has been an international effort to reduce
this practice, and in many countries eighteen is the legal age of marriage. Organizations with campaigns to end child
marriage include the United Nations and its agencies, such as the Office of the High Commissioner
for Human Rights, UNFPA, UNICEF and WHO. Like many global issues affecting women’s
health, poverty and gender inequality are root causes, and any campaign to change cultural
attitudes has to address these. Child marriage is the subject of international
conventions and agreements such as The Convention on the Elimination of All Forms of Discrimination
against Women (CEDAW, 1979) (article 16) and the Universal Declaration of Human Rights
and in 2014 a summit conference (Girl Summit) co-hosted by UNICEF and the UK was held in
London (see illustration) to address this issue together with FGM/C. Later that same
year the General Assembly of the United Nations passed a resolution, which inter alia
Urges all States to enact, enforce and uphold laws and policies aimed at preventing and
ending child, early and forced marriage and protecting those at risk, and ensure that
marriage is entered into only with the informed, free and full consent of the intending spouses
(5 September 2014) Amongst non-governmental organizations (NGOs)
working to end child marriage are Girls not Brides, Young Women’s Christian Association
(YWCA), the International Center for Research on Women (ICRW) and Human Rights Watch (HRW). Although not explicitly included in the original
Millennium Development Goals, considerable pressure was applied to include ending child
marriage in the successor Sustainable Development Goals adopted in September 2015, where ending
this practice by 2030 is a target of SDG 5 Gender Equality (see above). While some progress is being made in reducing
child marriage, particularly for girls under fifteen, the prospects are daunting. The indicator for this will be the percentage
of women aged 20–24 who were married or in a union before the age of eighteen. Efforts to end child marriage include legislation
and ensuring enforcement together with empowering women and girls. To raise awareness, the inaugural UN International
Day of the Girl Child in 2012 was dedicated to ending child marriage.===Menstrual cycle===Women’s menstrual cycles, the approximately
monthly cycle of changes in the reproductive system, can pose significant challenges for
women in their reproductive years (the early teens to about 50 years of age). These include the physiological changes that
can effect physical and mental health, symptoms of ovulation and the regular shedding of the
inner lining of the uterus (endometrium) accompanied by vaginal bleeding (menses or menstruation). The onset of menstruation (menarche) may be
alarming to unprepared girls and mistaken for illness. Menstruation can place undue burdens on women
in terms of their ability to participate in activities, and access to menstrual aids such
as tampons and “sanitary pads”. This is particularly acute amongst poorer
socioeconomic groups where they may represent a financial burden and in developing countries
where menstruation can be an impediment to a girl’s education.Equally challenging for
women are the physiological and emotional changes associated with the cessation of menses
(menopause or climacteric). While typically occurring gradually towards
the end of the fifth decade in life marked by irregular bleeding the cessation of ovulation
and menstruation is accompanied by marked changes in hormonal activity, both by the
ovary itself (oestrogen and progesterone) and the pituitary gland (follicle stimulating
hormone or FSH and luteinizing hormone or LH). These hormonal changes may be associated with
both systemic sensations such as hot flashes and local changes to the reproductive tract
such as reduced vaginal secretions and lubrication. While menopause may bring relief from symptoms
of menstruation and fear of pregnancy it may also be accompanied by emotional and psychological
changes associated with the symbolism of the loss of fertility and a reminder of aging
and possible loss of desirability. While menopause generally occurs naturally
as a physiological process it may occur earlier (premature menopause) as a result of disease
or from medical or surgical intervention. When menopause occurs prematurely the adverse
consequences may be more severe.===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.==Non-reproductive health==
Women and men have different experiences of the same illnesses, especially cardiovascular
disease, cancer, depression and dementia, and are more prone to urinary tract infections
than men.===Cardiovascular disease===
Cardiovascular disease is the leading cause of death (30%) amongst women in the United
States, and the leading cause of chronic disease amongst them, affecting nearly 40% (Gronowski
and Schindler, Tables I and IV). The onset occurs at a later age in women than
in men. For instance the incidence of stroke in women
under the age of 80 is less than that in men, but higher in those aged over 80. Overall the lifetime risk of stroke in women
exceeds that in men. The risk of cardiovascular disease amongst
those with diabetes and amongst smokers is also higher in women than in men. Many aspects of cardiovascular disease vary
between women and men, including risk factors, prevalence, physiology, symptoms, response
to intervention and outcome.===Cancer===
Women and men have approximately equal risk of dying from cancer, which accounts for about
a quarter of all deaths, and is the second leading cause of death. However the relative incidence of different
cancers varies between women and men. In the United States the three commonest types
of cancer of women in 2012 were lung, breast and colorectal cancers. In addition other important cancers in women,
in order of importance, are ovarian, uterine (including endometrial and cervical cancers
(Gronowski and Schindler, Table III). Similar figures were reported in 2016. While cancer death rates rose rapidly during
the twentieth century, the increase was less and later in women due to differences in smoking
rates. More recently cancer death rates have started
to decline as the use of tobacco becomes less common. Between 1991 and 2012, the death rate in women
declined by 19% (less than in men). In the early twentieth century death from
uterine (uterine body and cervix) cancers was the leading cause of cancer death in women,
who had a higher cancer mortality than men. From the 1930s onwards, uterine cancer deaths
declined, primarily due to lower death rates from cervical cancer following the availability
of the Papanicolaou (Pap) screening test. This resulted in an overall reduction of cancer
deaths in women between the 1940s and 1970s, when rising rates of lung cancer led to an
overall increase. By the 1950s the decline in uterine cancer
left breast cancer as the leading cause of cancer death till it was overtaken by lung
cancer in the 1980s. All three cancers (lung, breast, uterus) are
now declining in cancer death rates (Siegel et al. Figure 8), but more women die from lung cancer
every year than from breast, ovarian, and uterine cancers combined. Overall about 20% of people found to have
lung cancer are never smokers, yet amongst nonsmoking women the risk of developing lung
cancer is three times greater than amongst men who never smoked.In addition to mortality,
cancer is a cause of considerable morbidity in women. Women have a lower lifetime probability of
being diagnosed with cancer (38% vs 45% for men), but are more likely to be diagnosed
with cancer at an earlier age.====Breast cancer====Breast cancer is the second most common cancer
in the world and the most common among women. It is also among the ten most common chronic
diseases of women, and a substantial contributor to loss of quality of life (Gronowski and
Schindler, Table IV). Globally, it accounts for 25% of all cancers. In 2016, breast cancer is the most common
cancer diagnosed among women in both developed and developing countries, accounting for nearly
30% of all cases, and worldwide accounts for one and a half million cases and over half
a million deaths, being the fifth most common cause of cancer death overall and the second
in developed regions. Geographic variation in incidence is the opposite
of that of cervical cancer, being highest in Northern America and lowest in Eastern
and Middle Africa, but mortality rates are relatively constant, resulting in a wide variance
in case mortality, ranging from 25% in developed regions to 37% in developing regions, and
with 62% of deaths occurring in developing countries.====Cervical cancer====Globally, cervical cancer is the fourth commonest
cancer amongst women, particularly those of lower socioeconomic status. Women in this group have reduced access to
health care, high rates of child and forced marriage, parity, polygamy and exposure to
STIs from multiple sexual contacts of male partners. All of these factors place them at higher
risk. In developing countries, cervical cancer accounts
for 12% of cancer cases amongst women and is the second leading cause of death, where
about 85% of the global burden of over 500,000 cases and 250,000 deaths from this disease
occurred in 2012. The highest incidence occurs in Eastern Africa,
where with Middle Africa, cervical cancer is the commonest cancer in women. The case fatality rate of 52% is also higher
in developing countries than in developed countries (43%), and the mortality rate varies
by 18-fold between regions of the world.Cervical cancer is associated with human papillomavirus
(HPV), which has also been implicated in cancers of the vulva, vagina, anus, and oropharynx. Almost 300 million women worldwide have been
infected with HPV, one of the commoner sexually transmitted infections, and 5% of the 13 million
new cases of cancer in the world have been attributed to HPV. In developed countries, screening for cervical
cancer using the Pap test has identified pre-cancerous changes in the cervix, at least in those women
with access to health care. Also an HPV vaccine programme is available
in 45 countries. Screening and prevention programmes have limited
availability in developing countries although inexpensive low technology programmes are
being developed, but access to treatment is also limited. If applied globally, HPV vaccination at 70%
coverage could save the lives of 4 million women from cervical cancer, since most cases
occur in developing countries.====Ovarian cancer====By contrast, ovarian cancer, the leading cause
of reproductive organ cancer deaths, and the fifth commonest cause of cancer deaths in
women in the United States, lacks an effective screening programme, and is predominantly
a disease of women in industrialised countries. Because it is largely asymptomatic in its
earliest stages, more than 50% of women have stage III or higher cancer (spread beyond
the ovaries) by the time they are diagnosed, with a consequent poor prognosis.===Mental health===
Almost 25% of women will experience mental health issues over their lifetime. Women are at higher risk than men from anxiety,
depression, and psychosomatic complaints. Globally, depression is the leading disease
burden. In the United States, women have depression
twice as often as men. The economic costs of depression in American
women are estimated to be $20 billion every year. The risks of depression in women have been
linked to changing hormonal environment that women experience, including puberty, menstruation,
pregnancy, childbirth and the menopause. Women also metabolise drugs used to treat
depression differently to men. Suicide rates are less in women than men (

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