Scandinavian Journal of Clinical & Laboratory Investigation, 2014; 74(Suppl 244): 8-12
informa h e a lth c a re
ORIGINAL ARTICLE
G lobal w o m e n ’s h ea lth - A glob al p ersp ectiv e
NAWAL M. N O U R Global Obstetrics and Gynecology, Health Brigham and Women’s Hospital, Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, USA A bstract
The burden of disease and public health issues affecting girls and women throughout their lives is significantly greater in resource-poor settings. These women and girls suffer from high rates of maternal mortality, obstetric fistulas, female geni tal cutting, HIV/AIDS, malaria in pregnancy, and cervical cancer. Although the Millennium Development Goals (MDGs) are being met in some nations, the majority of the goals will not be reached by 2015. In addition, insufficient attention is given to non-communicable and chronic diseases such as diabetes, hypertension, hypercholesterolemia, cardiovascular diseases, stroke, obesity, and chronic respiratory diseases. A life-course approach that includes improvements in earlier-life factors such as diet and exercise is necessary to improve women’s long-term health outcomes. Innovative diagnostic tools and treatment strategies along with cost-effective health service delivery systems are needed to make a significant impact on women’s and girls’ health worldwide. K eyW ords: Global women’s health, maternal mortality, female genital cutting
Introduction Global health has been defined as the ‘area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide’ [1], Practitioners who work in global health strive to improve health, reduce disparities, and protect populations against global threats regardless of national borders [2]. Prior to ‘global health’, the term ‘international health’ was frequently used. However, this term was thought to be restrictive, as it focused mainly on infectious dis eases as well as maternal and child health. ‘Global health’ implies a more holistic approach whose pur pose is to improve health in resource-poor areas through collaborative research and clinical care. The field of global health is rapidly expanding. Academic institutions, medical schools, hospitals, and medical residency programs are adding global health to their curricula. Clinical global health fel lowships are now offered after physicians graduate from residency. Many of the fellowships include a master’s degree in public health and are designed to provide physicians with additional clinical and research training in resource-poor settings. Gradu ates expect to gain first-hand training and the expe
rience necessary to work in health care settings with limited facilities and infrastructure. These fellow ships help improve the practitioner’s ability to bring up-to-date medical knowledge to underserved areas of the world. Global women’s health focuses primarily on obstetric and gynecologic issues including family planning, pregnancy, delivery, sexually transmitted diseases, gynecologic diseases and cancers, meno pause, as well as infectious and non-communicable diseases (NCD) in resource-poor settings. Women and girls in these regions suffer from diseases and medical outcomes that may no longer exist in devel oped nations. Maternal mortality, obstetric fistulas, female genital cutting, HIV/AIDS, malaria in preg nancy, and cervical cancer are dramatically more prevalent in resource-poor settings, where many clin ical and diagnostic tools are not always available.
Maternal mortality In developed nations, when a mother dies in labor and her baby is delivered, it is considered a tragedy. An autopsy may be performed, committees evaluate whether there was any deviation from the standard
Correspondence: N. M. Nour, Global Obstetrics and Gynecology, Health Brigham and Women’s Hospital, Department of Obstetrics and Gynecology, Harvard Medical School, 75 Francis Street, Boston, MA, USA. E-mail: [email protected] ISSN 0036-5513 print/ISSN 1502-7686 online © 2014 Informa Healthcare DOI: 10.3109/00365513.2014.936673
Global women’s health
of care, and hospital guidelines and policy may change as a result of lessons learned. However, almost 800 women die per day from pregnancyrelated causes worldwide. Maternal mortality rates in developed nations (16 per 100,000 births) are much lower than in resource-poor countries, where as many as 1,000 women die per 100,000 births. Sub-Saharan Africa and South Asia bear the highest maternal mortality rates. Although these deaths are also seen as tragic, in-depth analysis of each death is rarely performed. Unfortunately, current medical knowledge, treatment, and care could prevent 99 % of these deaths, but the health systems in these regions lack the necessary infrastructure, training, and facilities [3]. In resource-poor nations, poverty significantly exacerbates already poor maternal health outcomes. Economic factors affect road conditions, hospital facilities, and the availability and quality of medical equipment and supplies. Medical factors include extremely limited access to skilled birth attendance and emergency obstetric care. Cultural attitudes towards child marriages, contraception, home births, and recognizing emergencies when they arise also affect maternal outcomes. Direct causes such as postpartum hemorrhage, eclampsia, obstructed labor, sepsis, and unsafe abor tions are the main contributors to maternal mortal ity; others include malaria and AIDS during pregnancy [3]. Pregnant women must receive routine antenatal care, skilled care during labor, and basic emergency obstetric care. Treatments such as antibi otics, oxytocics, anticonvulsants, manual removal of retained placenta, instrumented deliveries, and post partum care significantly decrease women’s risk of death [4]. Only 46 % of women in resource-poor regions have skilled birth attendants (midwives, trained nurses, or doctors) during their delivery. Encouragingly, since 1990 maternal mortality rates have dropped by half. In 2010, 287,000 women died during pregnancy, delivery, and postpartum. Research shows that programs focused on patient and com munity education, prenatal care, emergency obstet rics, adequate transportation, and building nearby centers that perform cesarean sections were the most effective [3]. O b stetric fistula
Obstetric fistulas (OF), sometimes called the ‘near miss’ of maternal mortality, are quite rare in devel oped nations, but in resource-poor nations over 2 million women are now living with OF, and about 100,000 new cases occur every year. The highest incidence is in Africa and parts of Asia [5]. As many as 10-20 million women will experience childbirth complications resulting in vesico- or rectovaginal fistulas and subsequent infertility [6], When women experience prolonged obstructed
9
labor, the shoulders of the fetus become trapped behind the bony pelvis. The continuous pressure from the fetal head in the vagina restricts the blood supply to the vaginal and rectal tissue, producing ischemia. Eventually, without a cesarean section, this situation results in fetal demise. Days pass, the fetus becomes gelatinous and eventually is expelled. The vaginal and rectal tissue becomes necrotic and develops into a vesicovaginal fistula or a rectovag inal fistula, or both. Women are incontinent of urine and/or stool and may also develop vaginal stenosis, infertility, foot drop, and depression.They are rejected by society and are kept separate from other family members. The main contributors to OF are an immature pelvis (usually among adoles cents), first pregnancy, malnourishment, and min imal or no access to a surgical facility. According to the United Nations Population Fund, the main causes of OF are ‘the three delays’: delay in seeking medical attention, delay in reaching a medical facility, and the delay in receiving medical care upon arrival at the medical facility [7], UN organizations, hospitals, governments, and grass roots organizations have directed much attention and energy to decreasing the number of OFs. More effort must be made to keep girls in school, prevent early marriages, improve nutrition, and increasing OF awareness. In many resource-poor regions, more gynecologists are being trained in the surgical tech niques of fistula repair. Most OFs can be surgically corrected, but ensuring the success of that first sur gery is critical; if the first repair fails, the chance of any successful repair is bleak. Once the fistula is repaired, women must understand that subsequent pregnancies require a cesarean section, and they must return to a health center at the end of their pregnancies. F em ale genital cutting
Female genital cutting (FGC) is defined as ‘all pro cedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other nontherapeutic reasons’ [8]. According to the World Health Organization (WHO), more than 130 million women worldwide have undergone FGC, primarily in parts of Africa and Asia. The practice transcends religions, geography, and socioeconomic status but clearly provokes passionate controversy. The main reasons given for perpetuating FGC include improving hygiene and fertility, preserving chastity, marking a rite of passage, ensuring mar riageability, and enhancing sexual pleasure for men. The World Health Organization categorized FGC into four types. Type I involves removing part or the entire clitoris. Type II includes removing part or all of the clitoris and labia minora and/or majora. Type III (the most severe) involves removing all or part of
10
N. M. Nour
the external genitalia, including suturing the rem nant tissue over the urethra and introitus (known as infibulation); a small hole on the infibulated scar is left open for urination and menses. Type IV is the mildest and includes pricking, piercing, cutting, scraping, or burning the genitalia. Immediate impacts on health include hemorrhage, infection, sepsis, and even death. Long-term complications include dyspareunia, dysmenorrheal, vaginitis, and cystitis [9]. Labor and delivery become more difficult, and a knowledgeable person is needed to defibulate (open the scar) prior to pregnancy (to prevent dyspareunia) or delivery (to facilitate birth) [10]. Grassroots, national, and international organizations have worked to encourage abandonment of this practice. In some nations FGC has been outlawed, but enforcement is difficult. Educating and empowering girls, women, families, and religious leaders about the health and human rights issues surrounding FGC has been an effective means of stopping this practice.
Table I. Child marriage prevalence is defined as the percentage of women 20-24 years old who were married or in union before age 18 [11],
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Country
Girls married before 18 (%)
Niger Chad Central African Republic Bangladesh Guinea Mozambique Mali Burkina Faso South Sudan Malawi Madagascar Eritrea India Somalia Sierra Leone Zambia Dominican Republic Ethiopia Nepal Nicaragua
75 68 68 66 63 56 55 52 52 50 48 47 47 45 44 42 41 41 41 41
Child m arriages
Child marriage, defined as marriage under the age of 18, is an ancient custom worldwide. In 2010 it was estimated that 67 million women between the ages of 20 and 24 had been married before the age of 18. It is anticipated that 142 million girls will be married before the age of 18. Child marriages occur most frequently in South Asia, where a 2005 UNICEF study found that 48 % of women aged 15-24 were married before the age of 18; the figures were 42 % in Africa and 29 % in Latin America and the Carib bean. The majority of child marriages under the age of 18 are girls. In Mali the ratio of married girls under 18 to married boys is 72:1; in Kenya it is 21:1; and even in the United States it is 8:1. Since 1948, the United Nations and other international agencies have made efforts to stop child marriage. In many countries, the legal age of marriage is 18. Yet the percentage of girls married before age 18 in Niger is 75 %, in Chad 68 %, in Bangladesh 66 %, and in Nicaragua 41 % [11] (Table I). Some marriages even occur at birth, and the girl is sent to her husband’s home at the age of 7. These statistics indicate how loosely governments enforce these laws. Factors that perpetuate child marriages include ensuring the girl’s financial future, dowry, reinforcing social ties, and ensuring social status. Child marriage is also seen as protective against pre marital sexual activity, unintended pregnancies, and sexually transmitted diseases (STDs) - an even greater concern in this era of HIV/AIDS. While child marriage is driven by poverty, its impact on a girl’s life and health is multifaceted: less formal education, higher risk of sexually transmitted infections such as HIV and human papilloma virus (husbands have had prior sexual partners), malaria, early pregnancy, death during childbirth, and obstetric fistulas. Their
offspring are at increased risk of premature birth and neonatal, infant, and child death. Government and non-governmental policies and programs must edu cate the community, raise awareness, engage local and religious leaders, involve parents, and empower girls through education and employment in order to stop child marriages [12]. Lifespan
Once women have survived their childbearing years, the differences in women’s death rates between developed and developing nations become less extreme. In older populations, NCDs such as cardio vascular diseases, diabetes, cancers, and chronic respiratory diseases are becoming the main causes of death throughout the world, including resource-poor nations, where over 80 % of cardiovascular deaths, 90 % of respiratory deaths, and 67 % of cancers occur. The rate of obesity among women in Latin America, the Middle East, and North Africa is increasing. Health systems are not equipped to meet the chal lenges and changing needs of an older population, and the addition of NCDs to non-communicable diseases creates a ‘double burden’ on the health sys tems of developing nations [13]. There has been a change in lifestyle and diet in resource-poor regions. Diets based primarily on fresh foods and livestock now include processed foods high in sugars and unsaturated fats. Manual labor and regular daily exercise have been replaced by motorized transportation and sedentary employ ment. In addition, cultural perspectives can encour age obesity. Men may desire overweight women, who are seen as personifying wealth and fertility, while thin women can represent poverty and disease.
Global women’s health Cervical cancer, now rare in W estern nations, is the second leading killer am ong w om en in lowand m iddle-resource settings [14]. A pproxim ately 260,000 w om en die annually from such cancers, 85 % in resource-poor nations. N o t surprisingly, w om en w ith low socioeconom ic status have poor access to health care, b u t custom s and cultural practices p u t girls and w om en at fu rth e r risk when they enforce child m arriages, high parity, and polygam y and condone m ultiple sexual partners am ong husbands. Because of poor infrastructure for screening and prevention, cervical cancer is d etected too late for treatm en t to be effective. A ffordable H PV vaccines are being p roduced and being m ade available to developing nations. H PV testing is now widely available in W estern nations b u t n o t yet affordable in developing nations. In addition, a new H PV test is being designed for areas w ithout electricity. It is accurate, reliable, and affordable and will soon be available in C hina and In d ia [14]. L ow -technology m ethods such as ‘screen and tre a t’ have been prom ising, w ith a sen sitivity o f 77 % and specificity of 86 %, and health providers are easily trained [15]. However, w om en diagnosed w ith cervical cancer have little hope for survival, since it m ay be too advanced for surgery to be an option, and radiation m achines are n o t available in m any o f these nations. O utreach p ro gram s educating w om en and their com m unities on prevention and treatm en t of cervical cancer is n ec essary; governm ents m ust m ake a significant invest m ent in vaccines, H PV screening, and cervical cancer treatm ent. T he M illen n iu m D evelop m en t G oals In 2000, the U n ited N ations established eight M il lennium D evelopm ent Goals (M D G ): eradicating extrem e poverty and hunger, achieving universal prim ary education, prom oting gender equality and em powering wom en, reducing child m ortality rates, im proving m aternal health, com bating HIV/AIDS m alaria and other diseases, ensuring environm ental sustainability, and developing a global partnership for developm ent [16]. T he 2015 deadline for the M D G has encouraged nations to focus on these eight goals. T h e m ost relevant parts of the M D G for w om en’s health are the third, fifth, and sixth goals. M D G 3 specifically stipulates elim inating gender disparity in prim ary and secondary educa tion, preferably by 2005 and at all levels by 2015. A lthough the world has achieved equality in p ri m ary education betw een girls and boys, only two of the 130 countries have achieved it at all levels of education [17]. M D G 5 stipulates reducing the m aternal m ortality ratio by three quarters. Overall, m aternal m ortality has dropped by 47 %, and E ast ern and S outhern Asia and N o rth e rn Africa have reduced m aternal m ortality by two thirds. A ntenatal
11
care delivered in countries has increased from 64 % in 1990 to 81 % in 2011. A lthough 50 million babies worldwide are still delivered w ithout skilled birth attendants each year, the rural-urban gap of skilled care is narrow ing [18]. M D G 6 targets halting and then reversing the spread of H IV /A IDs, m alaria, and other m ajor diseases. N ew H IV infections are declining, m ore people are living longer with HIV due to fewer A ID s-related deaths, and access to treatm ent has increased. By 2011, 11 countries achieved universal access to antiretroviral therapy and 8 m illion people are receiving A R T (nearly a six-fold increase from 1.4 m illion in 2010). T he incidence of m alaria has decreased by 17 % since 2000, and m alaria-specific m ortality rates have decreased by 25 %. Since 2000, 1.1 million deaths have been averted [19]. C onclusion T h e M D G s has clearly m ade an im pact on the health o f w om en and girls globally. T hese en co u r aging im provem ents over the last decade are due to collaborative efforts betw een governm ents, in tern atio n al organizations and non-governm ental organizations. Investing in girls’ and w om en’s h ealth and education n o t only benefits the whole fam ily b u t also the com m unity. K eeping girls in school and p o stponing child m arriages n o t only delays pregnancy b u t it decreases the risk of S T D s, m atern al m ortality, and OF. R aising awareness regarding fam ily planning, antenatal services, S T D prevention, and the harm ful effects of F G C are all necessary to advance the status of girls and w om en. W ith an aging population, atten tio n m u st also be focused on N C D s. It is critical to have a co n tin u ed com m itm ent and collaboration in order to im prove health service delivery to girls and w om en worldw ide. Q uestions and answ ers Questions to D r Gronowski and D r N our: Q (Beastall UK): Are you aware of efforts in different parts of the world to prioritize w om en’s health? A (Gronowski): I know m ost about those pro grams in the US and there certainly are long-term research studies as well as the W omen’s H ealth Initia tive. T here are also organizations which are focused on w om en’s health. Certainly W H O and C D C have wom en’s health initiatives bu t I don’t know what is happening in specific countries. I would be surprised if initiatives have not started in other countries in the developed world. Q (Beastall): It is difficult to get funding in devel oped countries since it is a case of recognizing its priority and reallocating funding for it and I think that is m ore difficult in the developing countries.
12
N. M. Nour
The question is where does the funding come from? A (Nour): Usually the funds are coming mainly from international organizations such as WHO and from western countries but their interest is variable depending on what is the topic of interest at a par ticular time. Funding goes in cycles; when there is a lack of interest, the funding stops though the prob lem is still there. Comments (Coustan): I would like to point out that the specialty of obstetrics and gynecology is a specific discipline devoted to women’s healthcare and is the longstanding pioneer in the women’s health field. Q (Anderson): I would like to ask you about the political aspects of women’s health. You highlighted the devastating impact of unsafe abortion and that in part relates to provision of family planning ser vices. The US has in the past had a poor record on this. A (Gronowski): I didn’t touch on this argument mainly for lack of time. I think that political effects on women’s healthcare are major and are at many levels. Related to the reproductive area, in the US there is much discussion about whether insurance should cover contraception. In my opinion, to deny women contraception has a huge impact on health care. In all aspects of health research, statistical data on gender aspects needs to be gathered. Comment (Nour): Politics plays a huge role in women’s health and I would like to add that this problem is not only linked to unsafe abortion but to all the aspects of pregnancy. The specialty of obstet rics and gynecology should be more and more involved in all the aspects of women’s heath to avoid health disasters.
informa h e a lth c a re
ORIGINAL ARTICLE
G lobal w o m e n ’s h ea lth - A glob al p ersp ectiv e
NAWAL M. N O U R Global Obstetrics and Gynecology, Health Brigham and Women’s Hospital, Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, USA A bstract
The burden of disease and public health issues affecting girls and women throughout their lives is significantly greater in resource-poor settings. These women and girls suffer from high rates of maternal mortality, obstetric fistulas, female geni tal cutting, HIV/AIDS, malaria in pregnancy, and cervical cancer. Although the Millennium Development Goals (MDGs) are being met in some nations, the majority of the goals will not be reached by 2015. In addition, insufficient attention is given to non-communicable and chronic diseases such as diabetes, hypertension, hypercholesterolemia, cardiovascular diseases, stroke, obesity, and chronic respiratory diseases. A life-course approach that includes improvements in earlier-life factors such as diet and exercise is necessary to improve women’s long-term health outcomes. Innovative diagnostic tools and treatment strategies along with cost-effective health service delivery systems are needed to make a significant impact on women’s and girls’ health worldwide. K eyW ords: Global women’s health, maternal mortality, female genital cutting
Introduction Global health has been defined as the ‘area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide’ [1], Practitioners who work in global health strive to improve health, reduce disparities, and protect populations against global threats regardless of national borders [2]. Prior to ‘global health’, the term ‘international health’ was frequently used. However, this term was thought to be restrictive, as it focused mainly on infectious dis eases as well as maternal and child health. ‘Global health’ implies a more holistic approach whose pur pose is to improve health in resource-poor areas through collaborative research and clinical care. The field of global health is rapidly expanding. Academic institutions, medical schools, hospitals, and medical residency programs are adding global health to their curricula. Clinical global health fel lowships are now offered after physicians graduate from residency. Many of the fellowships include a master’s degree in public health and are designed to provide physicians with additional clinical and research training in resource-poor settings. Gradu ates expect to gain first-hand training and the expe
rience necessary to work in health care settings with limited facilities and infrastructure. These fellow ships help improve the practitioner’s ability to bring up-to-date medical knowledge to underserved areas of the world. Global women’s health focuses primarily on obstetric and gynecologic issues including family planning, pregnancy, delivery, sexually transmitted diseases, gynecologic diseases and cancers, meno pause, as well as infectious and non-communicable diseases (NCD) in resource-poor settings. Women and girls in these regions suffer from diseases and medical outcomes that may no longer exist in devel oped nations. Maternal mortality, obstetric fistulas, female genital cutting, HIV/AIDS, malaria in preg nancy, and cervical cancer are dramatically more prevalent in resource-poor settings, where many clin ical and diagnostic tools are not always available.
Maternal mortality In developed nations, when a mother dies in labor and her baby is delivered, it is considered a tragedy. An autopsy may be performed, committees evaluate whether there was any deviation from the standard
Correspondence: N. M. Nour, Global Obstetrics and Gynecology, Health Brigham and Women’s Hospital, Department of Obstetrics and Gynecology, Harvard Medical School, 75 Francis Street, Boston, MA, USA. E-mail: [email protected] ISSN 0036-5513 print/ISSN 1502-7686 online © 2014 Informa Healthcare DOI: 10.3109/00365513.2014.936673
Global women’s health
of care, and hospital guidelines and policy may change as a result of lessons learned. However, almost 800 women die per day from pregnancyrelated causes worldwide. Maternal mortality rates in developed nations (16 per 100,000 births) are much lower than in resource-poor countries, where as many as 1,000 women die per 100,000 births. Sub-Saharan Africa and South Asia bear the highest maternal mortality rates. Although these deaths are also seen as tragic, in-depth analysis of each death is rarely performed. Unfortunately, current medical knowledge, treatment, and care could prevent 99 % of these deaths, but the health systems in these regions lack the necessary infrastructure, training, and facilities [3]. In resource-poor nations, poverty significantly exacerbates already poor maternal health outcomes. Economic factors affect road conditions, hospital facilities, and the availability and quality of medical equipment and supplies. Medical factors include extremely limited access to skilled birth attendance and emergency obstetric care. Cultural attitudes towards child marriages, contraception, home births, and recognizing emergencies when they arise also affect maternal outcomes. Direct causes such as postpartum hemorrhage, eclampsia, obstructed labor, sepsis, and unsafe abor tions are the main contributors to maternal mortal ity; others include malaria and AIDS during pregnancy [3]. Pregnant women must receive routine antenatal care, skilled care during labor, and basic emergency obstetric care. Treatments such as antibi otics, oxytocics, anticonvulsants, manual removal of retained placenta, instrumented deliveries, and post partum care significantly decrease women’s risk of death [4]. Only 46 % of women in resource-poor regions have skilled birth attendants (midwives, trained nurses, or doctors) during their delivery. Encouragingly, since 1990 maternal mortality rates have dropped by half. In 2010, 287,000 women died during pregnancy, delivery, and postpartum. Research shows that programs focused on patient and com munity education, prenatal care, emergency obstet rics, adequate transportation, and building nearby centers that perform cesarean sections were the most effective [3]. O b stetric fistula
Obstetric fistulas (OF), sometimes called the ‘near miss’ of maternal mortality, are quite rare in devel oped nations, but in resource-poor nations over 2 million women are now living with OF, and about 100,000 new cases occur every year. The highest incidence is in Africa and parts of Asia [5]. As many as 10-20 million women will experience childbirth complications resulting in vesico- or rectovaginal fistulas and subsequent infertility [6], When women experience prolonged obstructed
9
labor, the shoulders of the fetus become trapped behind the bony pelvis. The continuous pressure from the fetal head in the vagina restricts the blood supply to the vaginal and rectal tissue, producing ischemia. Eventually, without a cesarean section, this situation results in fetal demise. Days pass, the fetus becomes gelatinous and eventually is expelled. The vaginal and rectal tissue becomes necrotic and develops into a vesicovaginal fistula or a rectovag inal fistula, or both. Women are incontinent of urine and/or stool and may also develop vaginal stenosis, infertility, foot drop, and depression.They are rejected by society and are kept separate from other family members. The main contributors to OF are an immature pelvis (usually among adoles cents), first pregnancy, malnourishment, and min imal or no access to a surgical facility. According to the United Nations Population Fund, the main causes of OF are ‘the three delays’: delay in seeking medical attention, delay in reaching a medical facility, and the delay in receiving medical care upon arrival at the medical facility [7], UN organizations, hospitals, governments, and grass roots organizations have directed much attention and energy to decreasing the number of OFs. More effort must be made to keep girls in school, prevent early marriages, improve nutrition, and increasing OF awareness. In many resource-poor regions, more gynecologists are being trained in the surgical tech niques of fistula repair. Most OFs can be surgically corrected, but ensuring the success of that first sur gery is critical; if the first repair fails, the chance of any successful repair is bleak. Once the fistula is repaired, women must understand that subsequent pregnancies require a cesarean section, and they must return to a health center at the end of their pregnancies. F em ale genital cutting
Female genital cutting (FGC) is defined as ‘all pro cedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other nontherapeutic reasons’ [8]. According to the World Health Organization (WHO), more than 130 million women worldwide have undergone FGC, primarily in parts of Africa and Asia. The practice transcends religions, geography, and socioeconomic status but clearly provokes passionate controversy. The main reasons given for perpetuating FGC include improving hygiene and fertility, preserving chastity, marking a rite of passage, ensuring mar riageability, and enhancing sexual pleasure for men. The World Health Organization categorized FGC into four types. Type I involves removing part or the entire clitoris. Type II includes removing part or all of the clitoris and labia minora and/or majora. Type III (the most severe) involves removing all or part of
10
N. M. Nour
the external genitalia, including suturing the rem nant tissue over the urethra and introitus (known as infibulation); a small hole on the infibulated scar is left open for urination and menses. Type IV is the mildest and includes pricking, piercing, cutting, scraping, or burning the genitalia. Immediate impacts on health include hemorrhage, infection, sepsis, and even death. Long-term complications include dyspareunia, dysmenorrheal, vaginitis, and cystitis [9]. Labor and delivery become more difficult, and a knowledgeable person is needed to defibulate (open the scar) prior to pregnancy (to prevent dyspareunia) or delivery (to facilitate birth) [10]. Grassroots, national, and international organizations have worked to encourage abandonment of this practice. In some nations FGC has been outlawed, but enforcement is difficult. Educating and empowering girls, women, families, and religious leaders about the health and human rights issues surrounding FGC has been an effective means of stopping this practice.
Table I. Child marriage prevalence is defined as the percentage of women 20-24 years old who were married or in union before age 18 [11],
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Country
Girls married before 18 (%)
Niger Chad Central African Republic Bangladesh Guinea Mozambique Mali Burkina Faso South Sudan Malawi Madagascar Eritrea India Somalia Sierra Leone Zambia Dominican Republic Ethiopia Nepal Nicaragua
75 68 68 66 63 56 55 52 52 50 48 47 47 45 44 42 41 41 41 41
Child m arriages
Child marriage, defined as marriage under the age of 18, is an ancient custom worldwide. In 2010 it was estimated that 67 million women between the ages of 20 and 24 had been married before the age of 18. It is anticipated that 142 million girls will be married before the age of 18. Child marriages occur most frequently in South Asia, where a 2005 UNICEF study found that 48 % of women aged 15-24 were married before the age of 18; the figures were 42 % in Africa and 29 % in Latin America and the Carib bean. The majority of child marriages under the age of 18 are girls. In Mali the ratio of married girls under 18 to married boys is 72:1; in Kenya it is 21:1; and even in the United States it is 8:1. Since 1948, the United Nations and other international agencies have made efforts to stop child marriage. In many countries, the legal age of marriage is 18. Yet the percentage of girls married before age 18 in Niger is 75 %, in Chad 68 %, in Bangladesh 66 %, and in Nicaragua 41 % [11] (Table I). Some marriages even occur at birth, and the girl is sent to her husband’s home at the age of 7. These statistics indicate how loosely governments enforce these laws. Factors that perpetuate child marriages include ensuring the girl’s financial future, dowry, reinforcing social ties, and ensuring social status. Child marriage is also seen as protective against pre marital sexual activity, unintended pregnancies, and sexually transmitted diseases (STDs) - an even greater concern in this era of HIV/AIDS. While child marriage is driven by poverty, its impact on a girl’s life and health is multifaceted: less formal education, higher risk of sexually transmitted infections such as HIV and human papilloma virus (husbands have had prior sexual partners), malaria, early pregnancy, death during childbirth, and obstetric fistulas. Their
offspring are at increased risk of premature birth and neonatal, infant, and child death. Government and non-governmental policies and programs must edu cate the community, raise awareness, engage local and religious leaders, involve parents, and empower girls through education and employment in order to stop child marriages [12]. Lifespan
Once women have survived their childbearing years, the differences in women’s death rates between developed and developing nations become less extreme. In older populations, NCDs such as cardio vascular diseases, diabetes, cancers, and chronic respiratory diseases are becoming the main causes of death throughout the world, including resource-poor nations, where over 80 % of cardiovascular deaths, 90 % of respiratory deaths, and 67 % of cancers occur. The rate of obesity among women in Latin America, the Middle East, and North Africa is increasing. Health systems are not equipped to meet the chal lenges and changing needs of an older population, and the addition of NCDs to non-communicable diseases creates a ‘double burden’ on the health sys tems of developing nations [13]. There has been a change in lifestyle and diet in resource-poor regions. Diets based primarily on fresh foods and livestock now include processed foods high in sugars and unsaturated fats. Manual labor and regular daily exercise have been replaced by motorized transportation and sedentary employ ment. In addition, cultural perspectives can encour age obesity. Men may desire overweight women, who are seen as personifying wealth and fertility, while thin women can represent poverty and disease.
Global women’s health Cervical cancer, now rare in W estern nations, is the second leading killer am ong w om en in lowand m iddle-resource settings [14]. A pproxim ately 260,000 w om en die annually from such cancers, 85 % in resource-poor nations. N o t surprisingly, w om en w ith low socioeconom ic status have poor access to health care, b u t custom s and cultural practices p u t girls and w om en at fu rth e r risk when they enforce child m arriages, high parity, and polygam y and condone m ultiple sexual partners am ong husbands. Because of poor infrastructure for screening and prevention, cervical cancer is d etected too late for treatm en t to be effective. A ffordable H PV vaccines are being p roduced and being m ade available to developing nations. H PV testing is now widely available in W estern nations b u t n o t yet affordable in developing nations. In addition, a new H PV test is being designed for areas w ithout electricity. It is accurate, reliable, and affordable and will soon be available in C hina and In d ia [14]. L ow -technology m ethods such as ‘screen and tre a t’ have been prom ising, w ith a sen sitivity o f 77 % and specificity of 86 %, and health providers are easily trained [15]. However, w om en diagnosed w ith cervical cancer have little hope for survival, since it m ay be too advanced for surgery to be an option, and radiation m achines are n o t available in m any o f these nations. O utreach p ro gram s educating w om en and their com m unities on prevention and treatm en t of cervical cancer is n ec essary; governm ents m ust m ake a significant invest m ent in vaccines, H PV screening, and cervical cancer treatm ent. T he M illen n iu m D evelop m en t G oals In 2000, the U n ited N ations established eight M il lennium D evelopm ent Goals (M D G ): eradicating extrem e poverty and hunger, achieving universal prim ary education, prom oting gender equality and em powering wom en, reducing child m ortality rates, im proving m aternal health, com bating HIV/AIDS m alaria and other diseases, ensuring environm ental sustainability, and developing a global partnership for developm ent [16]. T he 2015 deadline for the M D G has encouraged nations to focus on these eight goals. T h e m ost relevant parts of the M D G for w om en’s health are the third, fifth, and sixth goals. M D G 3 specifically stipulates elim inating gender disparity in prim ary and secondary educa tion, preferably by 2005 and at all levels by 2015. A lthough the world has achieved equality in p ri m ary education betw een girls and boys, only two of the 130 countries have achieved it at all levels of education [17]. M D G 5 stipulates reducing the m aternal m ortality ratio by three quarters. Overall, m aternal m ortality has dropped by 47 %, and E ast ern and S outhern Asia and N o rth e rn Africa have reduced m aternal m ortality by two thirds. A ntenatal
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care delivered in countries has increased from 64 % in 1990 to 81 % in 2011. A lthough 50 million babies worldwide are still delivered w ithout skilled birth attendants each year, the rural-urban gap of skilled care is narrow ing [18]. M D G 6 targets halting and then reversing the spread of H IV /A IDs, m alaria, and other m ajor diseases. N ew H IV infections are declining, m ore people are living longer with HIV due to fewer A ID s-related deaths, and access to treatm ent has increased. By 2011, 11 countries achieved universal access to antiretroviral therapy and 8 m illion people are receiving A R T (nearly a six-fold increase from 1.4 m illion in 2010). T he incidence of m alaria has decreased by 17 % since 2000, and m alaria-specific m ortality rates have decreased by 25 %. Since 2000, 1.1 million deaths have been averted [19]. C onclusion T h e M D G s has clearly m ade an im pact on the health o f w om en and girls globally. T hese en co u r aging im provem ents over the last decade are due to collaborative efforts betw een governm ents, in tern atio n al organizations and non-governm ental organizations. Investing in girls’ and w om en’s h ealth and education n o t only benefits the whole fam ily b u t also the com m unity. K eeping girls in school and p o stponing child m arriages n o t only delays pregnancy b u t it decreases the risk of S T D s, m atern al m ortality, and OF. R aising awareness regarding fam ily planning, antenatal services, S T D prevention, and the harm ful effects of F G C are all necessary to advance the status of girls and w om en. W ith an aging population, atten tio n m u st also be focused on N C D s. It is critical to have a co n tin u ed com m itm ent and collaboration in order to im prove health service delivery to girls and w om en worldw ide. Q uestions and answ ers Questions to D r Gronowski and D r N our: Q (Beastall UK): Are you aware of efforts in different parts of the world to prioritize w om en’s health? A (Gronowski): I know m ost about those pro grams in the US and there certainly are long-term research studies as well as the W omen’s H ealth Initia tive. T here are also organizations which are focused on w om en’s health. Certainly W H O and C D C have wom en’s health initiatives bu t I don’t know what is happening in specific countries. I would be surprised if initiatives have not started in other countries in the developed world. Q (Beastall): It is difficult to get funding in devel oped countries since it is a case of recognizing its priority and reallocating funding for it and I think that is m ore difficult in the developing countries.
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N. M. Nour
The question is where does the funding come from? A (Nour): Usually the funds are coming mainly from international organizations such as WHO and from western countries but their interest is variable depending on what is the topic of interest at a par ticular time. Funding goes in cycles; when there is a lack of interest, the funding stops though the prob lem is still there. Comments (Coustan): I would like to point out that the specialty of obstetrics and gynecology is a specific discipline devoted to women’s healthcare and is the longstanding pioneer in the women’s health field. Q (Anderson): I would like to ask you about the political aspects of women’s health. You highlighted the devastating impact of unsafe abortion and that in part relates to provision of family planning ser vices. The US has in the past had a poor record on this. A (Gronowski): I didn’t touch on this argument mainly for lack of time. I think that political effects on women’s healthcare are major and are at many levels. Related to the reproductive area, in the US there is much discussion about whether insurance should cover contraception. In my opinion, to deny women contraception has a huge impact on health care. In all aspects of health research, statistical data on gender aspects needs to be gathered. Comment (Nour): Politics plays a huge role in women’s health and I would like to add that this problem is not only linked to unsafe abortion but to all the aspects of pregnancy. The specialty of obstet rics and gynecology should be more and more involved in all the aspects of women’s heath to avoid health disasters.
