Our Bodies, Ourselves (166 page)

In many societies, women are less likely to have educational opportunities and to be literate than men. They often lack decision-making power within the household, as well as in the community. The extent to which women have freedom of mobility and can make autonomous decisions has a great impact on their ability to seek health care and on their sexual and reproductive health.
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A woman's life expectancy at birth averages eighty-six years in Japan, eighty-three years in western and southern Europe and Canada, eighty in the United States, seventy-five in Saudi Arabia, seventy-two in Southeast Asia, fifty-three in sub-Saharan Africa, and forty-four in Afghanistan.
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While this great variation is influenced by a country's income and wealth and how evenly that wealth is distributed, life expectancy, especially for women, is also powerfully influenced by sexual and reproductive health and the accessibility of health care services.

For example, a woman in sub-Saharan Africa has a 1 in 22 chance of dying of causes related to pregnancy and childbirth over the course of her reproductive life, compared with a 1 in 5,900 lifetime risk for a woman in the developed world.
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In Africa, after years of slow improvement, life expectancy for women in eleven countries has fallen below fifty years, largely owing to the impact of HIV/AIDS. Although women have longer life expectancy than men in most of the world, when diseases related to sexual and reproductive health are considered, women are 2.2 times more likely to experience disability-adjusted life years lost (DALYs) than men.
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Life expectancy is also related to whether economic resources have been used to provide basic public health services, such as safe drinking water and sanitation; basic or primary-level health care, including immunizations, antenatal care, and well-child programs; and education at least through the primary level to ensure literacy.

Access to education has a powerful effect on a woman's ability to exert more control over personal choices, including whether and when to have children. Better-educated women are more likely to delay childbearing, and literate mothers are better able to care for their children. Policies that promote the education of girls and women therefore lead to reductions in the birth and infant mortality rates, as well as improved health for women and for the community as a whole. Women with more education will generally have fewer children than women with less education, regardless of economic status. Education alone, however, does not guarantee a woman's autonomy to make decisions, even regarding her own health and that of her children. An oppressive fundamentalist regime, for example, can make educational gains irrelevant for women, curtailing mobility, access to contraception, and safe
abortion and increasing her vulnerability to gender-based violence. War and sustained civil conflicts can destroy any opportunity for economic advancement. In other words, knowledge is power only when we have the opportunity to use it.

As economies become more integrated and with the rise of capitalist economic development, women's education levels are rising, and more women are joining the ranks of the formal labor force. These processes are enabling women to live longer, but they are also changing the health risks that women face on a global level. Breast cancer is by far the most common form of cancer in the world, with an estimated 1.3 million new cases in 2008, and it is the second leading cause of cancer deaths, topped only by lung cancer.
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Cancer was once thought of as primarily a disease of the wealthy, but the majority of cancer cases now occur in developing countries.

Changes in lifestyles, such as eating more overall and eating more processed foods, often come along with the other changes brought about by globalization, and these factors are contributing to increases in obesity, diabetes, and heart disease among women. Women in most countries tend to smoke less than men, but women are increasingly being targeted by transnational tobacco companies as a potential growth market.
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In the past, businesses anchored in particular countries perceived a benefit in providing financial support for education, public health, and roads and other infrastructure. As businesses circle the globe seeking the lowest wages and the least restrictive governments, this social contract is under fire, as are public funding and public accountability for services.

Global trade agreements increasingly play a role in determining critical national policies that affect health—from sustainable economic development to the prices and availability of pharmaceuticals and health care and the rights of public health authorities to regulate the safety of food and to reduce harm from tobacco and alcohol products. Campaigns are focusing on expanding the availability of generic drugs, which cost less than patented brand-name drugs, and to involve health concerns directly in trade policy and negotiations.
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As more women have secured access to contraception to avoid unwanted pregnancies, fertility has fallen to an average of 2.5 lifetime births per woman. However, this global birth rate average
masks stark disparities. In the United States, where 79 percent of married women use contraception, women give birth to an average of two children. (Differences by race, ethnicity, and religion are fairly small; white women have an average of 1.8 children, compared with 2.1 children for black women and Asian/Pacific Islanders, and a high of 3.1 children for Latinas.) Women in Africa have the most children, 4.6, while women in Europe have the least, 1.5.
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In sub-Saharan Africa as a whole, fewer than one-fourth of married women use contraception. The average woman gives birth to 5.2 children, with large variations within and between countries. For example, in Niger, only 11 percent of women use a method of contraception, and women have on average more than seven births each.

In Europe, where 70 percent of married women use contraception, birth rates have fallen below replacement level (2.1 births per woman) in all but a few countries.
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A number of European countries now offer financial incentives to encourage women and families to have more children and supportive workplace policies aim to make childbearing more compatible with remaining
in the workforce. Women in the United Kingdom take thirty-nine weeks of maternity leave, of which ten weeks are paid, while Estonia provides twenty-nine weeks of paid leave. Iceland and Sweden each provide more than ten weeks of paid paternity leave. Conversely, neither the United States nor Australia provides paid maternity leave.
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Some of these policies are paying off, as evidenced by slower declines in the birth rate or even small increases, as seen in Norway, France, and Sweden. However, experts do not expect that these pronatalist policies will cause the birth rate to rise above replacement level.
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Still, such policies have made an impact on gender equality in wages and labor force participation.
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In 2008, an estimated 358,000 maternal deaths occurred around the world, a 34 percent decline from 1990 levels. Although significant, this decline is not sufficiently rapid to reach the target of a three-quarters reduction within the time frames of the Millennium Development Goals.
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While in developed countries such as Sweden, as few as 5 women die per 100,000 live births (the rate is 11 per 100,000 in the United States), in some sub-Saharan African countries, as well as in Afghanistan, nearly 1,400 women die per 100,000 live births. Six countries account for more than 50 percent of all maternal deaths: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo. Overall, 99 percent of all maternal deaths occur in developing countries, and this differential is the largest single public health disparity between low- and high-income countries.
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The leading causes of maternal death include hemorrhage, hypertensive disorders such as eclampsia, infections, and unsafe abortions, but there are geographic variations. For example, hemorrhage is most common in Africa and Asia, while hypertensive disorders and unsafe abortion are leading causes in Latin America and the Caribbean.
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Most maternal deaths result from preventable causes and could be averted if societies placed a higher value on women's lives, enabled women to avoid unwanted pregnancies, and provided more and better-quality prenatal and maternity care, including emergency obstetric
care as well as postnatal care, including access to family planning.

Skilled attendance at birth is a critical step to protecting women's lives—trained professionals can manage complications and identify when women in labor or postpartum require higher levels of care—but access to skilled birth attendants is extremely unequal in many developing countries.
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Only 6 percent of all births in Ethiopia are attended by a trained professional, yet that number disguises wide disparities according to wealth: 30 percent of births to wealthy women are attended by a professional, as compared with only 1 percent of births among the poorest women.
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Often unacknowledged in the focus on reducing maternal deaths is the extent of illness and disability that can result from obstetric complications. Severe complications, such as those requiring admission to an intensive care unit, may occur in anywhere from almost 1 percent to more than 8 percent of births.
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In some cases, women with obstructed labor who do not receive adequate care may develop a fistula—a tear in the wall between a woman's vagina and the bladder and/or rectum that can cause chronic incontinence. The consequences of obstetric fistulas can be devastating to affected women, who may be abandoned by their families and shunned by their communities. Treatment of an obstetric fistula requires surgical reconstruction, and prevention through access to emergency obstetric care is critical.

Because young adolescent mothers are more likely to have obstructed labor and to develop obstetric fistulas, efforts to combat child marriage and delay the first birth are essential strategies. (For more information, visit endfistula.org.)

Eight million children per year die before the age of five, representing, in some developing countries, as many as one child in ten. The leading causes of child deaths are neonatal factors, pneumonia, diarrhea, and malaria. Children are more likely to die if they were born less than twenty-four months after a previous birth.
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Women who have frequent or closely spaced births have higher rates of anemia and other nutritional deficiencies and suffer more frequent complications of pregnancy and childbirth, including death. Women in developing countries generally would prefer not to have their births so closely spaced.
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However, in communities where having a large family is a woman's only way to improve her social status and where being childless or not having sons is grounds for divorce or abandonment, women may feel pressured to have many closely spaced children. Improving life expectancy and reducing maternal and child mortality require a sufficient investment in the accessibility and quality of health care—both primary health care and emergency obstetric care, family planning and safe abortion services, and basic health education, including the health benefits of birth spacing.