Abstract and Keywords
The entry outlines a historical and global overview of women’s health in the context of human rights and public health activism. It unravels social myths, traditional norms, and stereotypes impacting women’s health because social workers must understand the diverse factors affecting women’s health in a continually changing and globalized world. There is need for more inclusive feminist and human rights models to study and advocate women’s health. There is as much scope for working with women in a more holistic manner as there is for researching challenging issues and environments shaping women’s health.
Health and ill health are influenced in myriad ways by social, cultural, environmental, economic, and political factors in addition to physiological and medical determinants (Commission on Social Determinants of Health, 2008; Wilkinson & Marmot, 2003). A women-centered conception of health begins with “placing women’s core needs at the centre of analysis”; taking note of all the complexities of education, income, culture, ethnicity, and race; and understanding how women themselves perceive health risks (Ruzek, 1993, p. 6). The World Health Organization (WHO) has recognized gender as an important determinant of health for both men and women because it creates unequal power relations affecting the division of labor, access to food, nutrition, opportunities to education, employment and income, and exposure to physical, sexual, and emotional violence (WHO, 2010). Thus, women’s health has been recognized as being socially, culturally, and economically produced.
Although women’s health issues can be better understood in a specific socioeconomic–cultural and political context, this entry highlights some long-standing debates that have affected women’s health in several countries. It draws attention to the evolving understanding of women’s health based on persistent efforts by advocates of women’s rights and international agencies. It also draws attention to the impacts of globalization in the form of causalization leading to work income insecurity, narrowing national policy space, increased violence, and the strengthening of gender hierarchies and inequalities (Sen & Östlin, 2007). This entry focuses on women’s health conditions from a sociopsychological perspective because social workers must understand the multifarious factors affecting health to strategize, intervene, and advocate for improving women’s health in a more holistic manner.
Evolution of the Concept of Women’s Health
Traditionally, women’s health has revolved around the human female anatomy, especially the sexual and reproductive organs, breasts, and hormones and issues emanating from woman’s role as a child bearer. Women’s experiences of menstruation, pregnancy, and childbirth, which were not diseases but posed health risks, were always the focus of health providers. Healing rituals, birth-giving services, and home remedies were in women’s hands.
Most early Christian theologians, like scholars from most other religions, believed that women were inferior to men, closer to nature, and ambivalent. Thinkers during the 17th century introduced the concept of a mechanistic world, wherein the body was a machine that could be controlled by technology. The male body was the prototype of the machine and because the female body deviated from this prototype, it was considered inherently abnormal or defective and needed to be controlled or corrected by medicines and technology (Helman, 2002). The biomedical model shaped the development of women’s health programs and policies for a long time (Weisman, 1997).
Much of the 19th-century medicine in Western countries perpetuated the 18th-century beliefs, albeit in a less extreme form. Medical discourses were created to control women’s sexuality (Daniluk, 1991), thwart women’s needs for education and financial independence, and underline female subordination (Radek, 2008). During the same period, sexualized theories of insanity were steadily imposed on women who did not show “womanly qualities.” Women’s health was underrated in medical textbooks, biomedical theory, and surgical practice (Carnes, Morrissey, & Geller, 2008).
Over time, across the globe, distinct roles and behaviors of men and women in public and private spaces have affected women’s status in family, society, and polity, which has undermined their general health needs. Traditional norms and practices like female genital mutilation, early marriage, nutritional taboos, especially during pregnancy, son preference, female infanticide, and cultural acceptance of violence (Office of the High Commissioner for Human Rights, 2003) have affected the health of girls and women.
The Movement toward Women’s Health
Analysis of historical processes, strategies, and impacts of social action can be helpful to social workers because it critiques past learnings and stimulates new thought. A quick narration of the steady but simultaneously occurring events that shaped the movement toward women’s health is mentioned below.
Women’s Struggles for Better Health
Since the French Revolution, women have played an active role in fighting battles such as the right to own and sell property, trade, be part of guilds, take custody of their children, divorce, earn higher wages, and enjoy better work conditions (Crowston, 2001, as cited in Fairchilds, 2002; International Labour Organization, 2009; University of Warwick, 2010). Although Mary Wollstonecraft (Unitarian Universalist History and Heritage Society, 1999–2013) began to use the language of women’s rights in 1792, it was not until a century had passed that the world’s first women’s rights convention was held in Seneca Falls, New York, followed by the National Women’s Rights Convention at Worcester in the United States (Antler, 2009; Worcester Women’s History Project, 2013). Women’s rights timelines show a gradual change in their status in some European countries, Australia, Russia, and North America based on education and entrance to universities and the medical and legal professions. Moreover, changes in economic situations (war had opened up new work opportunities) and political environments (women’s suffrage) had led to the opening of public spaces for women (Cengage, 2005).
New knowledge in histology, pathology, bacteriology, immunology, medical therapeutics, and technology, as well as advances in public health, set off new pathways in understanding disease, morbidity, and mortality. Discoveries of the process of reproduction provided a better understanding of women’s physiology and issues affecting their health. Developments in the field of contraceptives such as the diaphragm, intrauterine devices, and birth control suppository gave women greater control over their bodies. Campaigns like Water Cure Journal, dress reform to eliminate corsets (Seaman, 2009), and promotion of a healthy diet, exercise, and hygiene encouraged rationalistic health practices among upper- and middle-class women. The campaign against the Contagious Diseases Acts of 1864 in England was a fight not only against the double standards of men, who held women solely responsible for the spread of venereal diseases, but also against the medical treatment given to infected women. In the early 20th century, a few birth control crusaders and doctors set up birth control clinics and dared to remove the stigma of obscenity from contraception.
Around the same time, in countries like India, Egypt, China, and Japan, governments and reformers were joining hands to provide education for girls and prevent traditional practices like Sati (widow burning), female infanticide, foot binding, and Geisha and to reform marriage laws. During the mid and late 20th century, women in countries such as India joined nationalist struggles, social reform movements, and anti-arrack movements and raised concerns about the marginalization of women in the workforce (Patel, 1985). By the late 20th century, international conferences and new information technology (Garcia-Moreno & Claro, 1994) helped bridge the gaps between women activists in developed and developing countries.
Around the mid-20th century, women began to engage with newly emerging scientific knowledge to gain greater control over their bodies. The “self-help” clinics and groups formed in the 1970s used medical science information to explore their reproductive organs (Feminist Women’s Health Centers, 1981), to uphold abortion, and to fight against misinformation about the contraceptive pill and hormonal products, and discourage unnecessary hysterectomies and cesarean sections, and the overmedicalization of obstetrics/gynecology and psychiatry (Ruzek, 1978, as cited in Seaman, 2009). Women activists demanded informed consent, disclosure, and scientific proof about benefits of their medical treatments from their doctors (especially in the case of cancer) (Seaman). The Boston Women’s Health Book Collective worked at demystifying women’s health issues as well as producing evidence-based information, which inspired the change in the doctor–woman patient equation (Ruzek, 2007). Over the years, many new issues were added: removal of population control measures that were being imposed by several governments (Gruskin et al., 2008), the need for alternatives to allopathic medicine, issues of sexism in research and ethics in human reproduction research (Norsigian et al., 1999), analysis of drug data for gender effects, battered women’s posttraumatic stress disorder, and the need for improved barrier methods of contraception in light of the emerging human immunodeficiency virus (HIV) epidemic (WHO, 2009).
International Agencies and Women’s Health
International agencies have played a significant role in pushing forward the issue of equality between women and men, despite numerous cultural and religious obstacles, and drawing a focus to women’s health issues (United Nations [UN], 2006). In 1905–1906, the International Association of Labor Legislation urged international agreements to protect women from exploitation in terms of night work and exposure to white phosphorus in the manufacture of matches. Women’s delegations at the 1919 Paris Peace Conference took a step further by demanding equality of opportunity for men and women, equal pay for equal work, limiting the working week to 44 hours, and the suppression of night work for women. The first International Labor Conference (1919) adopted two conventions concerning women: prohibiting night work for women and ensuring maternity protection for working women (International Labor Organization, 2009).
The UN, established to deal with post–World War II ravages and redevelopment, produced a charter of equal and inalienable rights for all human beings proclaiming equal rights for men and women (UN, 1948). The UN’s Economic and Social Council established its Commission on the Status of Women as the principal global policy-making body dedicated exclusively to gender equality and the advancement of women. In addition, the UN encouraged the use of gender-neutral language and declared 1975 the International Women’s Year and 1976–1985 the International Women’s Decade, highlighting the importance of women’s issues. The Convention on the Elimination of All Forms of Discrimination against Women adopted in 1979 by the UN General Assembly aimed at securing equality for women in the enjoyment of all human rights and fundamental freedoms, without discrimination on the basis of sex, by placing legal obligations on states’ parties. The Convention was acknowledged as the first human rights treaty to affirm the reproductive rights of women in the broadest sense. It draws linkages between culture and tradition as influential forces shaping gender roles and family relations and monitors the measures and actions of states to give effect to the provisions.
The WHO, which was set up to develop a global public health perspective, included a few women’s health issues, such as maternal health, in its list of priorities (WHO, 2007). In 1978, the WHO reaffirmed in the Alma-Ata Declaration its promise to utilize human rights principles to realize improved standards of global health (WHO, 1978). Later, its “Health for All” strategy provided a pathway to implementing the right to health. The WHO set the standard for health equity (Ncayiyana, Goldstein, & Goon, 1995).
In 1994, in response to women activists’ concerns about reproductive health and rights, the world leaders at the International Conference on Population and Development promised “to promote women’s needs more actively . . . until we can safely say that equality has been reached” (Germain & Kyte, 2001, p. 2). A universal agenda for women’s health emerged through the definition of reproductive health: “Reproductive health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity, in all matters relating to reproductive system and to its functions and processes” (UN, 1995). The Fourth World Conference on Women held in Beijing in 1995 not only reaffirmed the Cairo Conference definition of reproductive health but also advanced it to include wider issues like inequality, education, training, poverty, violence, decision making, governance, peace, development, and human rights (Cook & Fathalla, 1996).
Challenges in Attaining Health and Well-Being for Women
It is important to understand the barriers and challenges affecting the health and well-being of women so that corrective measures can follow. For example, cardiovascular disease is now known to be a major cause of death among women. However, neglect and apathy generally lead to delay in diagnosis and treatment seeking. Hence, development of effective health promotion and prevention strategies could be undertaken (WHO, 2007).
A few ongoing challenges hindering improvement in women’s health are discussed below.
Reducing Maternal Mortality
Since its inception, the WHO placed maternal and child health on the public health agenda. However, in 1985, a critique of the maternal and child health program questioned the neglect of the “mother” in the program (Rosenfield & Maine, 1985). Pregnancy and birth-giving continue to pose major health risks for women in several regions. Although the strategy of attaining the Millennium Development Goals has helped in reducing maternal mortality, in 2010 there were about 287,000 maternal deaths worldwide (UN, 2013a). The largest proportion of such deaths are caused by obstetric hemorrhage, mostly during or just after delivery, followed by eclampsia, sepsis, complications of unsafe abortion (mainly outside hospital settings), and indirect causes, such as malaria and HIV (UN, 2011). A large number of deaths of infants and children below the age of five are closely linked to maternal health and most are preventable (WHO, 2009).
Evidence from a study of 30,000 abstracts showed that maternal risk factors and delays in accessing care are critical contributors to maternal and neonatal mortality. There is a greater likelihood of maternal deaths among women who are poor, have many children, are poorly educated, are either very young or in the high-risk age group, have less access to skilled midwifery care, and are subjected to gender discrimination (Lawn et al., 2009). A historical compilation of data from 14 countries (over 200 years) showed that three important factors had led to a decline in maternal mortality in different countries: (i) offering midwifery services for delivery care (in Sweden, Denmark, and the Netherlands); (ii) expansion of the use of skilled attendants at delivery, together with a decline in fertility (Malaysia and Sri Lanka); and (iii) improved access to obstetric and general health care, improved blood transfusion, and the availability of new antibiotics for all high-income groups (Hanson, 2010). A multicountry study using data from 48 countries from Sub-Saharan Africa, South Asia, and Southeast Asia that have the world’s highest rates of maternal and child mortality showed that most poor women deliver at home and without a trained birth attendant. The study recommended that efforts to reduce maternal deaths should be based in the community and must aim at making home births safer. The results suggested that the uptake of emergency obstetric care services could also be improved with community-based approaches (Montagu, Yamey, Visconti, Harding, & Yoong, 2011). Barriers to the use of health facilities such as cost, access, perceived quality, and cultural preferences for home deliveries may be overcome by developing new holistic strategies that include a greater understanding of the sociocultural realities of women’s situations (Manandhar et al., 2004). Recently in Eritrea, one of the four African countries said to be on track to achieve Millennium Development Goal 5 on maternal health, strategies that have worked include intensified maternal health campaigns, increased awareness of maternal issues in the country, local-language training sessions in rural areas to improve traditional birth attendants’ delivery skills, and better preparedness for difficult labor (UN, 2013b).
Despite the knowledge emerging from successful interventions to reduce maternal mortality, there seems to be uncertainty about the best way to deliver the interventions on a large scale (Montagu et.al., 2011). There is a need to focus attention on developing countries where the maternal mortality ratio is still 15 times higher than in developed regions. Long-term strategies like increasing secondary education for girls need wider and more intense promotion because they are associated with raising the age at marriage, lowering fertility, improving maternal health, and decreasing child mortality (Schultz, 1993). Higher level of education also reduces vulnerability to HIV/AIDS (Mathur, Greene, & Malhotra, 2003). Social workers can delve deeper into building culturally appropriate community responsiveness to programs and enable women from low-income groups to utilize them. They could also translate community experiences into long-term, local interventions and advocate macrolevel changes.
The Pro-life/Pro-choice Debate
Over the centuries, anti–birth control groups used religious, cultural, social, and political power (often violent) to deny women reproductive decision making because of a concern for maintaining healthy social fabric, to control women’s immorality or safeguard social order and property rights, or because of eugenic concerns (Eager, 1973, as cited in Rust, 2010).
By the early 20th century, many countries began to legalize abortions with the idea of protecting the lives and health of women. Recent global data show that abortion is granted in 29% of all countries on the basis of a woman’s request. In the other countries, a woman must have a valid legal reason for abortion, such as rape or incest, economic or social causes, or saving her life or preserving her physical and mental health (UN, 2011). In countries where abortion is illegal or restricted, it is common for women to travel to neighboring countries with more liberal laws. For instance, about 6,000 Irish women travel to England each year for abortions (International Planned Parenthood Federation, 2007). Women undergoing abortions are penalized more than men, although men are often equally if not more responsible for the abortion decision. In Nepal, 0.3% of males and 20% of females are fined for flouting abortion laws (Mishra, 2001). In some countries where abortion is legal on broad grounds (for example, India and South Africa), access to services provided by qualified personnel is uneven. In India, where abortion is legal through the National Medical Termination of Pregnancy Act of 1971, there are only 10 abortion centers per 1 million people; these are located mainly in urban areas, resulting in difficult access for the 70% of Indian women who live in rural areas (Singh, Wulf, Hussain, Bankole, & Sedgh, 2009). A large number of women continue to be unaware of their right to abortion. They therefore carry a burden of shame and guilt and must face a number of financial and geographic obstacles to obtain services under safe, sanitary conditions from trained professionals. Lack of confidentiality and a patriarchal attitude of providers are also major obstacles for women needing abortion services (S. Singh et al.).
According to a UN study, unsafe abortion kills about 68,000 women each year. Many women who have postabortion health problems (medical complications, injuries, and infertility) ensuing from illegal or unsafe abortions are unlikely to seek and receive further treatment (Grimes et al., 2006). There is a proven link between illegal and unsafe abortions and maternal mortality. Abortion is one of the three leading causes of maternal mortality (WHO, 2011a). Of 46 million abortions performed every year, 20 million are performed illegally by unskilled providers or in an environment where even minimal medical facilities are unavailable (WHO, 2012). Approximately three million adolescent women (15–19 years old) in developing countries undergo unsafe abortions each year (WHO, 2012).
Evidence shows abortion rates and maternal mortality caused by unsafe abortions are the lowest in countries with the most permissive abortion laws (the Netherlands, Canada, and Sweden) (Mishra, 2001). Despite efforts made by UN agencies to promote legalization and provision of safe abortions globally, safe abortion is yet to emerge as a right and requires urgent attention from public health and human rights agencies.
The social worker’s role as a vulnerable client’s advocate lies mainly in facilitating self-determination and enabling access to safe and legal abortion. This role sometimes requires the social-work professional to move beyond personal values and beliefs and break legal and structural barriers (Ely, Flaherty, Shevawn, & Noland, 2012).
Need for Special Family-Planning Programs
The 19th-century women’s crusade for the right to birth control was overpowered in the 20th century by the concept of the family-planning program, which emanated from the Malthusian theory of poverty, depletion of natural resources, and the fertility of the poor and the “unfit” (Nilsson, 2013). This led to a major change in perspective; the focus shifted from middle- and upper-class women to poor and vulnerable women, and the individual choice of contraceptives became a choice promoted by governments and funders for population control. Birth control technologies were seen as supportive to the colonial powers (Ross, 2000) and national security (Robinson & Ross, 2007) and as contributing to eugenics (Eager, 1973, as cited in Rust, 2010). After World War II, population growth was declared a major hurdle to economic development and many political leaders, economists, public health practitioners, and sociologists of the newly independent states concurred with the theory.
As population control program funds flowed in freely, they ushered in vertical, nonintegrated, target-driven family-planning programs. Proponents of health and human rights who valued the efforts made toward contraceptive outreach for needy couples questioned the ethics of disproportionate funding for family-planning programs, as well as the coercion and manipulation of informed consent. The concept of informed consent with regard to health personnel providing information about the procedure of contraceptive use, reliability of the method, potential side effects and health risks, and advice to patients was generally diluted because of the culture of incentives and corruption (Bongaarts, Cleland, Townsend, Bertrand, & Gupta, 2012) and exploitation of women’s vulnerabilities.
Abundant literature indicates an accelerated decrease in birth rates over short spans in countries with high fertility rates as a result of family-planning programs (Robinson & Ross, 2007). However, when reviewed from a gender perspective, the literature reflects the sidelining of broader, more sustainable approaches of tackling underdevelopment and poverty and statistical proof that the education of women has the potential to bring about fertility decline, greater autonomy, and social change. In many Asian and North African countries, where a strong “son preference” continues despite attempts at reforms, special family-planning programs enforcing the “one/two-child only” norm have proved to be detrimental to the survival of female children (Abrejo, Shaikh, & Rizvi, 2009; Duggal & Ramachandran, 2004). The myopic approach has amounted to not only a denial of women’s reproductive freedom and rights (Sen, Germain, & Chen, 1994), but also a greater “social loss” (Sen, 1995, p. 17). Moreover, the family-planning programs have been unsuccessful in empowering women to communicate with their partners and demand safe sexual practices from them. This can be seen from the continuing rise in new sexually transmitted infections (STI) and HIV infections, especially among young women (Aral Sevgi, Mead, Manhart, & Holmes, 2006).
Doubts have also been raised as to whether the “passive” family-planning programs with incentives are coercive in actuality. Although some believed that the incentive approach (money and other resources) compensated individuals for the out-of-pocket and opportunity costs of family planning, activists have argued that the incentives are bribes given to needy people to relinquish their reproductive rights. Although the International Conference on Population and Development had denounced the family-planning target approach, many countries continue to use it as a matter of administrative habit. For example, in India, reviews of the function of the “Target Free Approach” concluded that the service providers who were trained for four decades to work for targets could not make an easy transition to the new approach (Human Rights Watch, 2012).
More than a decade ago, the UN Population Fund (UNFPA) evaluated eight of its family-planning programs to examine six aspects of quality of care: choice of method, technical competence, informing and counseling clients, interpersonal relations, mechanisms to encourage continuation, and appropriateness and acceptability of services (UNFPA, 1994). Some of the suggestions remain relevant in the early 21st century: promotion of a mix of contraceptives (including male contraception and responsible parenthood among men), making the family-planning program responsive to the needs of different population groups who are aware of contraceptives choices, and the provision of appropriate training and infrastructure development.
Need for Quality and Women-Controlled Contraceptives
The quality of contraceptives for women is another aspect that has suffered because of the apathy of governments, funding agencies, and contraceptive development agencies. Although the number of nonpermanent contraceptives for women has increased, most do not fulfill the three requirements of contraceptives: safety, reliability, and reversibility. Women suffer a number of side effects from contraceptive use, adding to their ill health (Bayer HealthCare Pharmaceuticals, Inc., 2013; International Agency for Research on Cancer, 2007; Kahlenborn, Modugno, Potter, & Severs, 2006; Nelson, 2008). The neglect of side effects by providers is apparent in developing countries such as India and Bangladesh, where service providers have paid little attention to the management of reproductive tract infections while providing intrauterine devices (Talukder, Rob, & Rahman, 2009). Despite medical advances, the quality of services provided at female sterilization camps in India to meet family-planning targets has continued to be poor (Human Rights Watch, 2012; Mavalankar & Sharma, 1999), many times to the extent of violating women’s human rights.
Global research on female contraceptives in the past few decades since the late eighties has moved rapidly toward long-term contraceptives such as the vaginal ring and implants and emergency contraceptives (such as the I-pill and Emergency (E-) Pill), which do not protect women from sexually transmitted diseases. Ethical issues in research, clinical trials, and marketing continue to be neglected (Holdcroft, 2007). For example, personal testimonies of Norplant users show that it was not only unethically tested with women from developing countries such as Bangladesh (Population Research Institute, 1996), but also linked to subsidies for welfare recipients in countries like the United States (Nolan, 1994). Denial of contraceptive services has also occurred when the removal of Norplant was made inaccessible because of fees charged in countries such as Ghana, Bangladesh, and Indonesia (Ramchandran & Upadhyay, 2007). The demand for good-quality, low-cost, and safe, woman-controlled contraceptives that also provide protection from sexually transmitted diseases seems to be neglected since the focus is on mere promotion (Nalwadda, Mirembe, Byamugisha, & Faxelid, 2010; Nalwadda, Tumwesigye, Faxelid, Byamugisha, & Mirembe, 2011; Soumini & Sarma, 2004).
There is a need for policy makers to not only take serious note of women’s contraceptive requirements, but also move persistently toward breaking the stereotypes about men’s inability to handle the responsibility of contraception (Glasier et al., 2000). Although family-planning programs have been operational worldwide for more than six decades and sufficient proof exists that condoms are one of the most effective ways of preventing STIs and HIV (Holmes, Levine, & Weaver, 2004), male condom use still requires persuasive promotion strategies.
Greater awareness among men and women about male condom usage is an important step in placing men and women on an equal footing with regard to the enjoyment of reproductive and sexual rights and freedom. From the social-work perspective, these changes will be possible and sustainable only if the patriarchal norms of malehood, virility, sexual pleasure, sexual power, and decision making are challenged and the fears and misconceptions surrounding contraception are dispelled. A structural reversal of contraceptive services to make them male-friendly is also important (Cohen & Burger, 2000). Suggestions have been made regarding including more men in social work practice and the strengthening of profeminist practice (Pease & Camilleri, 2001, as cited in Pease, 2001).
Medicalization of Women’s Health
Although the second wave of the feminist movement benefited from the new medical knowledge, it also attempted to demedicalize birth control, demystify women’s sexual and reproductive process, develop women-centered health centers, understand alternative health systems, and change the doctor–patient relationship. From the biomedical perspective human conditions and problems have been defined, studied, and treated as medical conditions and involve a specific method of social control.
The process of medicalization has been critiqued by sociologists and feminists because of its tendency to expand the scope of medicine to include general problems and life events, label them as medical problems, and increase dependence on the medical profession. Illich (1976) pointed out that medicalization could lead to serious side effects that are worse than the original condition and render society reliant on the medical profession to cope with life. Sociologists have questioned the changing concepts of normal, expected, and acceptable bodies, behaviors, and health status and the complete disregard of the underlying causes of disease, such as social inequality, poverty, and an unequal distribution of power and resources (Fendrich, 2008). This probing becomes relevant in the context of increasing consumerism in most countries. An editorial in the British Medical Journal (Moynihan, Heath, & Henry, 2002) warned of inappropriate medicalization leading to disease mongering, unnecessary labeling, poor treatment decisions, and economic waste as resources were diverted from treating or preventing more serious diseases. The article also exposed the unethical linkage between medical education and pharmaceutical companies. A series of publications by Mens Sana Monographs focused on medicine as a corporate capitalist enterprise (A. R. Singh & S. A. Singh, 2005).
Although medicalization affects both men and women, critics such as Ehrenreich and English (1978) expressed concern about women’s bodies being medicalized by the predominantly male medical profession. Sociologists such as Oakley and Stacey have argued that medicine is used as an agent of social control, especially affecting women (Williams, Annandale, & Tritter, 1998). Medicalization has changed the way women in some countries experience female life cycle phases such as menstruation, pregnancy, childbirth, aging, and menopause (Helman, 2002). This phenomenon has not found much favor among psychologists, researchers, and feminists (Offman & Kleinplatz, 2004).
What becomes crucial in the debate of medicalization is whether women are more active, discerning consumers who are well informed about risks and benefits and agree to the expansion of medical jurisdiction into their bodies and lives. A study by Siminoff and Fetting (1991) found that breast cancer patients were strongly influenced by the recommendations of health-care professionals when it came to actual treatment decisions. Although legal and social movements and information technology in developed countries have changed the way in which health-care professionals communicate with and share information with their patients (The Society for Women’s Health Research, 2005), evidence exists that the medical decision making of patients continues to be influenced by recommendations made by health-care professionals (Gurmankin, Baron, & Hershey, 2002). In Western countries, the continuing drift toward sexual objectification, commodification, and self-subjectification among women and young girls has been exploited by fashion and beauty products used to sell products and services such as weight-loss diets and breast implants. Women find it difficult to defy consumption patterns created by media hype because they are considered a form of empowerment (Walter, 2010 as cited in Penketh, 2011).
Medicalization must also be reviewed in the gender context because a large number of women are illiterate and have minimal access to information, resources, and decision making with regard to health matters (UNFPA, 2008). Moreover, the literature indicates “physical abuse by health care workers of women undergoing labour” (Freedman, 2005, p. 64) and “disrespectful behavior of service providers” (Govender and Penn-Kekana, 2007, p. 29). Such instances point out the unequal relationship that women patients from developing countries have with health-care providers. Lorenzten discusses how the “normalization” of health problems and ending the doctor–patient relationship could help women show their resistance to hegemonic medical beliefs, especially in the case of women who lack resources and education to challenge “gendered medical knowledge” (Lorentzen, 2008, p. 71, as cited in Abramson, 2010). Reports on “unnecessary hysterectomies” conducted by private doctors under a government insurance scheme in India reveal how unequal relationships between women patients and health-care providers and government agencies work against women (National Human Rights Commission, 2013). Similarly, commercial surrogacy, where poor women “rent out” their wombs or sell their eggs, shows evidence of exploitation of women’s vulnerability and neglect of their human rights (Desai, 2012). However, this area must be researched further from the perspective of women (Scheper-Hughes, 2000).
Countering Violence, HIV, and Poverty
Violence, HIV, and poverty are common social determinants leading to the poor health of women because they intersect and add to women’s vulnerability.
Data from a multicountry study (WHO, 2002) showed that 15% to 71% of women ever in a relationship experienced physical or sexual violence by their intimate partners. Official survey data from India (International Institute for Population Sciences & Macro International, 2007) showed that 37.2% of ever-married women have experienced spousal violence. In 2006, approximately 36% of the total suicides committed in India were by women (Government of India, 2007), which reflects on the mental health status of women. Cultural practices in many Asian and African countries such as female infanticide, dowry killing, honor killing, female genital mutilation, and caste, tribe, and ethnic violence have perpetuated violence against female children and women. Health-care professionals who play a major role in caring for survivors of violence conduct virginity examinations, forced cesarean-section deliveries, hysterectomies, and female genital mutilation (Program for Appropriate Technology in Health, 2002). Acid throwing, rape, and violence, including those occurring during armed conflicts, continue uncontrolled, making public spaces unsafe for girls and women and denying them access to developmental opportunities. Intimate partner violence is an important cause of death, comprising about 40% to 60% of female homicides in many countries. It is also a significant indicator of maternal mortality in India, Bangladesh, and the United States (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002).
Various studies have shown that violence against women has a substantial impact on health. A U.S. study in 2002 found that women who experienced intimate partner abuse were three times more likely to have gynecological problems such as chronic pelvic pain, vaginal bleeding or discharge, vaginal infection, painful menstruation, sexual dysfunction, fibroids, pelvic inflammatory disease, painful intercourse, urinary tract infection, and infertility than were nonabused women. Forced or violent sex can cause physical and mental trauma in addition to damage to internal organs and can result in sexually transmitted infections and HIV (Program for Appropriate Technology in Health, 2002).
Violence during pregnancy has also been associated with increased risk of miscarriage, premature delivery, and low birth weight (Garcia-Moreno & Watts, 2011). A study conducted in Australia on violence by intimate partners showed more ill health and premature deaths among women of reproductive age than any other risk factor, including high blood pressure, obesity, and smoking (VicHealth, 2004). Abused women exhibit significantly higher levels of emotional distress, suicide attempts, physical health limitations, unintended pregnancy, abortion, and miscarriage (Garcia-Moreno, Heise, Jansen, Ellsberg, & Watts, 2005; WHO, 2005). “Intentional injuries” are among the 10 leading causes of disability-adjusted life years for women but not for men, confirming that violence against women remains a public health challenge (WHO, 2010). Social workers must work with survivors of violence not only in hospital settings but also in communities to prevent violence against women and make efforts to reduce their susceptibility to violence.
Women constitute slightly more than half of all people living with HIV (UNFPA, 2008). According to global figures, only 38% of young women (15–24 years old) have accurate and comprehensive knowledge of HIV/AIDS (UNAIDS, 2007). Some sections of women, such as sex workers, trafficked girls, and women and migrant workers, are more vulnerable to violence, sexual abuse, and exploitation in addition to other forms of discriminations and denial of services like legal protection and security, health, insurance, and other support services (WHO, 2005). Although coverage of antiretroviral treatment for women is greater than or equal to that of men, cultural norms treat women as inferior, which makes them susceptible to violent, nonconsensual, unprotected sex, STIs, and HIV transmission. Traditional gender norms encourage men to have more sexual partners and older men to have sexual relations with much younger women, as well as to prevent women from accessing health information and services. An Indian study showed that the risk for reproductive tract infections and STIs was greater in poorer, socially isolated, older, married women whose husbands were engaged in extramarital relationships and had a genital discharge. Poverty, lack of access to a toilet, and a limited ability to negotiate sexual relationships and contraceptive use played a critical role in women’s infection patterns. The study confirmed similar findings in Africa and Asia and the “feminization” of sexually transmitted diseases, including HIV/AIDS (Patel et al., 2006). Because the spread of HIV is both a cause and a consequence of poverty, it requires stronger action on education, nutrition, and child survival (UNAIDS, 2007). Social workers play multiple roles as health educators, counselors, and advocates, helping women to regain control over their lives. There is scope for social workers to be innovators of local interventions for the prevention and protection of human rights of people affected by HIV.
About three-fifths of the world’s 1 billion poorest people (WHO, 2010) are women. Although differences of opinion exist among economists and developmental scientists with regard to poverty and methodological issues of measuring it, women undoubtedly bear the brunt of poverty at family, community, national, and international levels. The recent economic crisis has proved that women are the most vulnerable to changes in economic conditions such as job cuts, and they must maintain the welfare of their families despite rising prices of food and essential commodities, health, travel, and fuel costs (Bethan, 2009; The World Bank, 2009). From childhood, women in Asia and Africa are exposed to numerous health risks because they are underweight and have iron, vitamin A, and zinc deficiencies. Some estimates of prevalence of undernutrition for these two regions are as high as 27% to 51% (WHO, 2002). Poverty has been a major cause of illiteracy and low education, early marriage of girls, use of unsafe cooking fuels, and inadequate safe drinking water, food, and nutrition, which worsen women’s health problems (Stevens, 2004; UNESCO, 2010). Diseases associated with poverty account for 45% of the disease burden in the poorest countries and are easily treatable or preventable (WHO, 2002, as cited in Stevens, 2004). Poverty has also been a major factor in organ and blood transplant and commercial surrogacy, whether in the West in the early 1990s or in developing countries such as India in the early 21st century. Commercial surrogacy is occurring in environments where the public health system is far from equitable and the health industry is unregulated.
Wilkinson and Marmot (2003) have pointed out how different kinds of disadvantages (such as few household assets, low-paying jobs, less education, poor housing) generally tend to concentrate among the same group and are accumulated over several years to affect health status in the long run. This theory is especially relevant in the case of women’s health. A need exists for more research and longitudinal data to examine the interaction between gender roles and socioeconomic position and the socioeconomic patterning of women’s health (Moss, 2002). Such data can be instrumental in ensuring universal health-care delivery. Social workers must take note of health inequalities in local contexts to ensure delivery of universal health services.
Social-work professionals must be on constant alert that, in a world where the chances of patriarchal or religious backlash are high, the rights of girls and women must be persistently protected and fought for afresh.
The Context of Public Health and Human Rights
Both human rights and public health are modern approaches that may be used to protect the health and well-being of women. Despite differences in historicity, language, and priorities, both approaches recognize the fact that a complex relation exists between individuals and society that impacts their health. Public health assumes the responsibility of assessing global health needs and problems, developing policies designed to address health issues, and providing health care to a maximum number of people. The human rights approach provides principles on which national governments and international health agencies can prioritize the health needs of vulnerable and marginalized sections of society. They provide a foundation for setting norms to protect the rights of individuals and communities. The two initiatives in the 1970s, Primary Health Care and Health for All, which aimed at health equity and universalizing health, are valid even in the early 21st century.
In many developing countries the basic causes of morbidity and mortality, such as malnutrition and infectious diseases, are caused by the failure to meet basic human rights commitments such as safe drinking water, sanitation, and food distribution. The application of human rights principles to public health strategies reinforces the principle of equity. Human rights can be a powerful tool for defining and advancing human development and has special relevance in the context of an inadequate public health system, unregulated private health sector, and denial or discriminations in providing access to health care for women (Mann et al., 1999, as cited in Nadkarni & Vikram, 2009). Moreover, the integration of public health and human rights principles makes it possible to move beyond averages and reach out to the most vulnerable groups of women.
In 1993, Ruzek suggested that more public health attention should be given to developing a social model of women’s health and that low income and education should be considered “risk factors” so that action could follow the assessment. Ruzek made two other relevant suggestions for improving women’s health: (a) treat economic development, income, education, and housing as public health investments and (b) improve the balance between specialists and primary health-care providers so that nurses and midwives are better used (1993, p. 7). The WHO’s position paper for the 1995 World Summit for Social Development in Copenhagen stated that women as a group represent the combined impact of poverty, unemployment, and social disintegration on health. In its strategy for action the WHO sought economic growth accompanied by more equitable access to the benefits of development (WHO, 1995).
The Cairo and Beijing conferences provided a blueprint for public health approaches that are in conformity with human rights. Since then, the world has recognized reproductive health as a subset of health rights that are subsumed under human rights (Dixon-Mueller, 1993, as cited in Mauron, 2012). Improving women’s health requires long-term, multiple-level processes, sociocultural context-specific approaches, and more than medical interventions (Qadeer, 1998). Global strategies such as the Millenium Development Goals require investments in poverty alleviation, enhancing health care and social support systems, eliminating violence against women and girls, promoting gender equality and women’s empowerment, and ending stigma against people living with HIV and discrimination against marginalized groups (Irwin & Scali, 2010; UNAIDS, 2010).
The WHO’s 2010 discussion paper, “Gender, women and primary health care renewal,” reviewed evidence and experiences on making health systems more gender responsive (WHO, 2010). The paper stated a commitment to redeeming the mistakes of the 1980s and 1990s, which had reduced the role of the state, undermined the progress toward universal coverage, and focused on specialized curative services vis-á-vis preventive health care, expansion of the private health sector, and increased use of market mechanisms such as user fees for the public health sector.
Primary health-care reforms are the latest attempt at guiding health system reforms to promote health equity and mitigate the worsening of gender-related health inequities (WHO, 2010, as cited in Chean, Frieson, Socheat, Nirmita, & Mony, 2010). Past experience shows that there is a need to develop national and international health information management systems to capture disaggregated data according to sex. Periodic program assessments, reviews, and evaluations can help to identify gender inequities and analyze the extent to which they have been redressed. Political will, women-centered programs, policies, and budgeting, as well as support and oversight from civil society, human rights, and public health institutions, are imperative for ongoing assessment of policies and programs and for developing more insightful interventions gained from knowledge sharing.
Social Workers’ Sphere of Influence
Social-work practice at both the macro and the micro level aims to reduce discrimination, inequality, poverty, and gender disparities to achieve social justice. A human rights perspective should inform a wide range of social-work activity to address human inequalities, including individual case advocacy in clinical and nonclinical settings; policy advocacy, lobbying, and campaigning; and community development, directly and in alliance with civil society organizations through research, publication, education, and training (Nadkarni & Vikram, 2009).
The feminist and human rights lens can help social workers to better understand the complex relationship between gender and other aspects of identity such as race, class, religion, age, disability, culture, and refugee or migrant status in the context of women’s health. In the current context of marketization and commodification of women’s bodies and health responses, social workers must shift to a more radical antioppressive analysis and practice.
Social-work associations and federations across the globe accept that human rights education in social work is crucial to ensure its application in different cultural settings and thus move beyond the goal of social justice alone. The social-work profession shoulders the responsibility of advocating with and on behalf of women’s health for sexual and reproductive rights and access to health care and all related basic amenities, such as food, water, sanitation, education, and development opportunities, on an equitable basis and in an environment that is free from oppression. Moving away from the biomedical definitions of health, social workers must reformulate the understanding of women’s health issues through an ideological lens. They can add subtexts and variations to the “global zeitgeist,” the spirit of successful women’s projects (Wetzel, 2000), by bringing in learnings from the field to shape macro health policies, keep the violation of human rights in check, and work toward the protection and promotion of women’s health rights, especially for the most vulnerable.
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