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Global trends in women's health
International
Journal
of Gynecology
& Obstetrics
58 (1997)
5-11
Global trends in women’s health M.F. Fathalla* Assiut,
Egypt
Abstract Global trends in women’s health have to be looked at in the broader context of the definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. Our species is undergoing a historical bio-social evolution, with women positioned to have more power over their bodies and their lives. The implications for women’s health are vast. Our profession has to face new challenges. The woman behind the mother is finally emerging, and making her presence felt. A reproductive evolution is sweeping the globe, with women having to lead a contraceptive life. A contraceptive technology revolution has benefited hundreds of millions, but the task is still unfinished. Demand for quality is substituting a desire for quantity in human reproduction. Sexual health is becoming an important psychosocial component of our health and well-being. The mature adult woman and the elderly woman are rising to an important place in our health care. The widening bio-social gap in adolescents dictates an increasing need for appropriate promotive, preventive and curative health care. One global trend in women’s health unfortunately did not happen. Maternity is still, unnecessarily, a major cause of death and morbidity for women in developing countries. 0 1997 International Federation of Gynecology and Obstetrics Keywords:
Women’shealth; Contraception; Sexuality; Ageing; Adolescence
1. Introduction In the Constitution of the World Health Organization, health is defined as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. This definition, idealistic as it may look, is nowhere as relevant and applicable as in women’s health. Women’s physical health cannot be separated
* P.O. Box 30, Assuit, 0020.7292/97/$17.00 PII
SOO20-7292(97)
Egypt.
Fax:
+ 20 88 337333.
0 1997 International 02856-7
Federation
of Gynecology
from their mental and social well-being. Women’s health is not about the absence of disease. A woman who is carrying an unwanted pregnancy cannot be considered healthy simply because her blood pressure is normal and the fetus has a normal biophysical profile. Global trends in women’s health have to be looked at in this broader context of the definition of health. In the past few decades, the world has been witnessing a major social upheaval, where women are positioning themselves to have more power over their bodies and on their lives. Our and Obstetrics
6
species is tion. The vast. The obstetrics lenges.
M.F.
Fathalla
/International
Journal
undergoing a historical bio-social evoluimplications for women’s health are profession of women’s health care, and gynecology, has to face new chal-
2. The emergence of the woman behind the mother The human race has already fulfilled the divine-given task to be fruitful and to multiply and replenish the earth and to have dominion over every living thing. Many think that it has even overdone it, and that the health of our fragile planet is now being compromised. From now on, we have to steer a new course into the future. The world will never again be the same. Throughout human history, the potential of women has been suppressed to serve the survival needs of our species. After fulfilling the obligation to replenish the earth, with hundreds of millions of women sacrificing their lives in the process, women are looking for and they deserve and they will get a final reward. With small families now the norm, and with the ability of women to regulate and control their fertility, the woman is finally emerging from behind the mother. Childbearing is becoming a function of women, and not the function of women. Women are becoming producers, and not only reproducers. The world is making the discovery that women are not mobile wombs. They are human beings, in their own right. International efforts to establish the rights of women culminated in 1979 with the United Nations General Assembly’s adoption of the Convention on the Elimination of All Forms of Discrimination against Women. The Convention confronts stereotypes, customs and norms that give rise to the many legal, political and economic constraints on women. One-hundred and two countries have ratified the Convention, legally binding themselves to incorporate the Convention’s demands in their policies. The Programme of Action, adopted by the 1994 International Conference on Population and Development, devoted a full chapter to gender equality, equity and empowerment of women. It recommended that ‘Countries should act to empower women and
of Gynecology
& Obstetrics
58 (1997) 5-11
should take steps to eliminate inequalities between men and women as soon as possible’ [l]. The changing role of women has dramatic implications for societies. The transition is painful and is an uphill struggle. Women in many societies are unfortunately still speaking their common language of silence, and are not fighting for their god-given rights to be men’s equals. We, as health professionals entrusted with the health of women, cannot be neutral in the social struggle of women. We have to stand beside women and behind women. We have to speak for women’s rights, because we know more than others that powerlessness of women is a serious health hazard [2]. Throughout the major part of human history, the role of the woman has been defined in terms of her reproductive potential. This is also how our profession of obstetrics and gynecology has been shaped in the past. Our profession is facing a challenge and has to adapt, to continue to be relevant to the health needs of women and responsive to women’s perspectives. We need to change from organ healers to physicians to the whole woman [3]. Our profession should evolve into the profession of women’s health. Because women are women they have specific health needs and problems. First, they have health needs and problems related to the sexual and reproductive function. Second, they have an elaborate and delicate reproductive system liable to disease and or dysfunction, even if it was not put to function, and even after it has been put out of function. Third, women are subject to diseases of other body systems as men are, and many of these diseases show gender differences, and some are directly influenced by hormonal changes and/or the reproductive function in women. Last but not least, because women are women they are still exposed to social diseases. 3. The reproductive
evolution
A reproductive evolution has been central to the emergence of the woman behind the mother. A dramatic change in people’s reproductive behavior began in the 19th century in the North-
M.F.
Fathalla
/International
Journal
ern hemisphere of our globe. During the second half of the 20th century, the change has been sweeping the Southern hemisphere. The world is experiencing an unprecedented decline in fertility. Fertility level is measured by demographers as the total fertility rate (TFR), which reflects the average total number of children that a woman would have by the end of her reproductive life if current fertility patterns remain unchanged. The total fertility rate continues to decline in all of the world regions in recent decades, and are expected to continue to do so in the coming years and to drop to 2.36 by the year 2020-2025 [4]. The pace of fertility decline has been very steep in developing countries. Between the mid-1960s and the present, 17 countries have had fertility declines of more than 50%, and an additional 31 countries have had declines exceeding 25% [5]. The adoption of a smaller family norm, with consequent decline in total fertility, should not be viewed only in demographic terms. It means that people, and particularly women, are empowered to take control of their fertility and to plan their lives; it means that more children are born by choice, not by chance, and that births can be planned to take place at optimal times for childbearing to ensure better health for women and children; and it means that families are able to invest relatively more in a smaller number of beloved children, trying to prepare them for a better future [6]. It means that women are spending less and less of their lives childbearing and child-rearing, and are having broader choices in their lives. What we are witnessing is a major evolutionary jump that is science-mediated, rather than brutally imposed by nature. Our reproductive function is being voluntarily adapted to dramatic new realities. 4. Contraceptive
life
Homo sapiens has escaped the grip of nature in evolution to become a self-evolving animal. The recent dramatic evolution in human reproductive behavior is not followed or accompanied by a change in the anatomy and/or function of the reproductive system, as would have been expected in other major evolutionary jumps mediated by
of Gynecology
& Obstetrics
58 (1997)
5--l 1
7
Mother Nature. As a consequence, Homo sapiens has to accomplish its reproductive evolution while retaining a reproductive system geared to high fertility. Women, or their partners, have to use contraception. Women have a span of about 30 reproductive years, during which they were meant by Nature to get pregnant. If women are to bear only one or two children, they will spend only 1-3 years in childbearing. For the remaining years, they, or their partners, will have to lead a contraceptive life if they are to remain sexually active. Contraceptive technology, from now on, will play a crucial role in reproductive life. The change to contraceptive life has been sweeping the world. Levels of contraceptive use are estimated as percentages of currently married women of reproductive age (15-49), including where possible, those in consensual unions. According to the latest United Nations estimates, of the 899 million currently married women of reproductive age in the world, 57% are using contraception at any one time [7]. The prevalence among developing countries as a whole is 53’S, and in the more developed countries 72%. The date to which these estimates pertain is approximately 1990, according to data available through 1993. Considering the lag between the time of data collection and the current period, the level of contraceptive use in the developing countries is likely to have been about 55% in 1993 [g]. In view of the major worldwide expansion in the use of modern methods of contraception by healthy women over prolonged periods of time, contraceptive safety has become an important issue in women’s health. In developed countries, where the number of women using contraceptives is much larger than the number of those who are pregnant, and where maternal mortality rates are very low, reproductive mortality attributable to contraceptive use assumes a relatively large dimension [9]. In developing countries, reproductive mortality attributable to contraceptive use is still insignificant compared with maternal mortality. 5. The contraceptive
technology revolution
A scientific revolution in contraceptive technology in the past few decades has helped hun-
8
M.F.
Fathalla
/International
Journal
dreds of millions of people to achieve their aspirations to regulate and control their fertility. The fruits of science have been enjoyed by people living in the most varied circumstances, in the skyscrapers of Manhattan, in peri-urban slums in Latin America, in rural communities of the Indian subcontinent; people in all socio-economic strata; people with different cultures, religious beliefs and value systems; and people postponing a first pregnancy, spacing their children or putting the limit on childbearing. Until the middle of the present century, contraceptive choice was limited to either coitus-related methods which lacked in effectiveness, or permanent methods. Contraceptive choices have now been broadened [lo]. Contraception was moved outside the bedroom by the development of systemic methods such as the pill. People no longer had to make the choice between a method to be used at every coitus or a permanent method; long-acting reversible methods now offer protection ranging from 1 month to several years. Also, highly effective but reversible methods became an available option. Technical developments have allowed sterilization to be performed as an out-patient procedure and without the need for general anesthesia. But perhaps the most significant development, brought about by the contraceptive technology revolution, has been the empowerment of women. For the first time, women had at their disposal effective methods that they can use to regulate and control their fertility, without being too dependent on the cooperation of the male partner. There is still a need for new contraceptive methods. This is not because currently available methods are not good, but because they are not adequate to meet the widely diverse needs of all the hundreds of millions of people using contraception now and in the future. There is not, and there probably will never be, an ideal method of contraception for all users, but there can be a variety of ‘ideal methods’ for the needs of different users [ll]. Science is ripe for a Contraception21 initiative to launch a second contraceptive technology revolution [lo]. While advances in cell and molecular biology and in biotechnology have opened new frontiers for medical and biological
of Gynecology
& Obstetks
58 (1997) 5-11
sciences, the field of contraceptive research and development is yet to benefit from the opportunities provided by these new advances. The second contraceptive technology revolution should not be demographic-driven or completely science-driven. It should be driven by a woman-centered approach, to provide women and men with the contraceptive technologies they need and miss in currently available methods [12]. 6. Quality vs. quantity With the adoption of a small family norm, demand for quality of births has substituted for quantity of births. Aldous Huxley’s vision in his famous novel of a brave new world, where people get the embryos they ask for, is not too far away. New frontiers of science have opened the way for hitherto unimaginable reproductive technologies that made possible artificial insemination, in vitro fertilization, embryo transfers, surrogate motherhood, cryogenic storage of sperm and ova, genetic selection, and prenatal diagnosis, including sex determination. To seek the birth, through the use of these new technologies, of only healthy babies is a legitimate request. The new technologies may, however, be abused to seek babies with certain demographic characteristics. Although most of these technologies have as yet no significant demographic impact, there is already serious concern about possible alterations in sex composition of populations, when the desire for quality is translated as a desire for a son. Ultrasound, amniocentesis and chorionic villus sampling are modem technologies that have been abused for prenatal sex diagnosis, and where pregnancy termination services are available, for selective abortion of the female fetus [13]. 7. Sex: a duty became a pleasure In the evolution of Homo sapiens, the temporal relationship between sex and reproduction has been severed. It must have taken our ancestors such a long time to realize any relationship between the act and the event, probably not until they began to observe domesticated animals. In
M.F.
Fathalla
/International
Journal
our fellow mammals, the female will only be attractive to the male and receptive to his advances if she is ovulating and ready to conceive. In our fellow primates, the female never fails to advertise the fact that she is ovulating. External sexual organs undergo a change in size or color that is clearly visible and that makes her sexually attractive to the male. At other times, she will have little or no appeal for him. The sexual receptivity of the human female has completely emancipated from hormonal control. The human female has also succeeded though evolution to hide completely all external evidence of ovulation. The dissociation of the act of sex from reproduction was an ingenious mechanism for reproductive efficiency. Mother Nature was not as much keen on our pleasure, as on ensuring the survival of the species. Making sex perpetually available encouraged the pair bond and favored the development of the family institution, as an essential mechanism for care of the children. Other mammals produce infants who are able to run sufficiently well to keep up with the herd less than 30 minutes after birth. The human newborn, on the other hand, has a long period of yearsof extreme dependence and helplessness during which it needs to be taken care of, before being able to survive on its own. With reproduction receding further into the background, the role of sex in our lives is going to evolve further. It will ‘sublime into an expression of love. As such, sex will increasingly be an important component in our psycho-social wellbeing, and less and less a tool of reproduction. We are beginning to witness the implications of this evolution for sexual behavior. One of the most disappointing aspects of medicine during the past 25 years has been the great increase in the incidence of infections caused by sexually-transmitted agents. STDs are now the most common group of notifiable infectious diseases in most countries. The World Health Organization’s minimal estimate for the yearly incidence of bacterial and viral STDs (excluding HIV infection) is 130 million [14]. The pandemic of Human Immunodeficiency Virus (HIV) infection, which appears to have com-
of Gynecology
& Obstetrics
58 (1997) 5-11
9
menced in the late 1970s or early 1980s as a disease mostly of men, is now becoming a major threat for the health of women and children in developing countries. By definition, STDs affect both men and women but the disease burden on women is much heavier. A recent World Bank report ranked sexuallytransmitted diseases as the second major cause (after maternal) of the disease burden in young adult women in developing countries, accounting for 8.9% of the total disease burden in that age group [15]. Among males of the same age group (15-44), STDs were not among the first 10 causes and accounted only for 1.5% of the disease burden. For a mix of biological and social reasons, women are more likely to be infected, are less likely to seek care, are more difficult to diagnose, suffer more severe disease sequelae, and are more subject to social discrimination and consequences [31. The most effective method available for protection against STDs, the condom, is controlled by men. An effective method of protection, that a woman can use without the need or necessity of her partner’s cooperation, simply does not yet exist. 8. The rise of the mature adult woman
Women live, on average, longer than men, in both developed and developing countries. United Nations projections indicate that this trend will continue in the 21st century [16]. This advantage of women is variously attributed to an inherent biological advantage, a more healthy life-style behavior (less consumption of alcohol and tobacco), and to environmental factors (more dangerous work activities performed by meni. The human female was not well equipped in evolution for this extended longevity. Cessation of ovarian function, and the menopause, was probably imposed by nature on the human female, on the basis of life expectancy assessment. To ensure that a newborn gets good care from a living and healthy mother, nature put a limit to the ability of women to bear children after a certain age, by stopping ovarian function. Women in many countries now, and in more countries in the 21st century, can confidently expect to lead a
10
M.F.
Fathalla
/International
Journal
healthy life for more than 20 years after the menopause. The human female will now have to lead long years of life without the benefit of their endogenous production of oestrogen, making them more liable to bone fragility and cardiovascular disease, apart from other impact on quality of life. Hormone replacement therapy is becoming available to correct this hormonal deficiency. Scientific progress is still needed to develop hormonal preparations that target tissues where the beneficial effect is needed and that leave out tissues where the exogenous therapy can have adverse effects. Gynecologists will have to deal more and more with health problems of aging women, within a complex web of physical, mental and social factors that impact on their well-being. 9. Adolescence
and the widening
‘bio-social’
gap
Nature has delayed the onset of puberty in the human species more than in any other mammal, to ensure physical and mental maturity in the mother (and father) and to allow enough time for the transmission of intergenerational knowledge and skills, before taking on the responsibility of parenthood. During the period of adolescence, defined as the period of transition from childhood to adulthood, three developments take place. Biological development progresses from the point of the initial appearance of the secondary sex characteristics to that of sexual maturity; psychological processes and cognitive and emotional patterns develop from those of a child to those of an adult; and a transition is made from the state of total socio-economic dependence to one of relative independence. Two trends are taking place in almost every society, though at different paces: a trend towards an earlier onset of biological maturation and a trend towards delay in socioeconomic maturation, with a resultant wider biosocial gap in human development. Today, girls everywhere are becoming sexually mature at an earlier age than previous generations. Genetic, health and socio-economic factors influence the wide variations in age of menarche among dif-
of Gynecology
& Obstetkcs
58 (1997) 5-11
ferent countries. Since boys and girls have now to spend more years in school, learning and training, before they can enter the complex labor market, the period of socio-economic dependence is prolonged. Adolescents are left with difficult choices in sexual behavior: premarital sex, early marriage or abstinence. The different patterns predominate in different countries, and patterns of transition exist. Premarital sex is now the predominant pattern in developed countries and some parts of the developing world including parts of Latin America and the Caribbean. There is also evidence of a similar trend in other regions. This choice often carries with it an increased prevalence of STDs, unwanted pregnancy and abortion, with adverse health and social consequences. Early marriage is a predominant pattern in many parts of the developing world, notably Asia and Africa. It carries with it a curtailing of the socio-economic development of the girls, often limiting their role in life to a childbearing and child-rearing career, and the assumption of parental responsibility before social maturity. Abstinence and delayed marriage seems to be a declining pattern, with the possible exception, at least until recently, of China. Adolescents are a sizeable group of world population. In 1990, people aged 15-24 accounted for 19.1% of world population, 14.8% in developed regions, and 20.4% in less developed regions [16]. The bio-social gap will continue to widen for other world regions, where the gap is still narrow. Adolescence and the widening bio-social gap are not a problem in themselves. The problem is in the need to come to grips with the new realities of adolescence. Misconceptions are contributing to turning what should be a normal positive phase in growth and development into a problem. Gynecologists will have increasing responsibilities for promotive, preventive and curative health care of adolescent girls. 10. The trend that did not happen
A recent WHO/UNICEF report, based on 1990 data, estimated the total number of maternal deaths to be 585000/year, a 20% increase
M.F.
Fathalla
/International
Journal
over previous estimates [17]. Maternal mortality rates have been decreasing in countries where it was already low. There has been little progress in other countries. In terms of numbers, the total maternal deaths has been increasing rather than decreasing. These women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving. The tragedy of maternal mortality is not just a health problem. It is a human rights issue [18]. It is the women’s right to life, to which governments and societies should be held accountable.
of Gynecoloo [Xl
[91
[lOI
ill1 [El
References [l]
[2]
[3] [4]
[S]
[h]
[7]
United Nations. Report of the International Conference on Population and development (Cairo, 5-13 September 1994). United Nations A/CONF.171/13, 1994. Fathalla MF. The impact of reproductive subordination on women’s health family planning services. Am Univ Law Rev 1994; 44: 1179-1190. Fathalla MF. Women’s health: an overview. Int J Gynecol Obstet 1994; 46: 105-118. United Nations. World Population Prospects: The 1992 Revision. Annex Tables. New York: United Nations, 1992. Ross JA, Mauldin WP, Green SR, Cooke ER. Family planning and child survival programs as assessed in 1991. New York: The Population Council, 1992: 1. Fathalla MF. Family planning and reproductive health --a global overview. In: Graham-Smith F, editor. Population - the complex reality. A report of the Population Summit of the world’s scientific academies. Colorado: The Royal Society, London and North American Press. 1994: 251-270. United Nations. World contraceptive use 1994. United Nations Department for Economic and Social Information and Policy Analysis, ST/ESA/SER.A/143. New York. 1994.
& Obstetrics
58 (1997) 5- 11
United Nations. Experiences concerning development strategies and programmes. and Appraisal of the World Population United Nations. A/Conf.171/4. 1994. Bcrdl V. Reproductive mortality. Br 632-634.
DC, Fletcher JC. selection in 19 nations. 135991366.
[151 [IhI
[171
[181
population and Fourth Review Plan of Action. Med
J 1979:
2:
Fathalla MF. Mobilization of resources for a second contraceptive technology revolution. In: Van Look PFA and Peres-Palacios G, editors. Contraceptive research and development 1984 to 1994. The road from Mexico City to Cairo and beyond. Oxford University Press: The World Health Organization, 1994: 527-524. Fathalla MF. Tailoring contraceptivec to human needs. People 1990: 17: 3-5. Fathalla MF. Fertility control technology: A womencentered approach to research. In: Sen G. Germain A, Chen LC, editors. Population Policies Reconsidered ~ Health, Empowerment and Rights. Boston. MA: Harvard University Press, 1994: 2233234.
1131 Wertz [141
I1
Prenatal diagnosis and sex Sot Sci Mcd 1993: 137:
World Health Organization. Implementation global strategy for health for all by the year Second Evaluation and Eighth Report on the Health Situation. WHO A45/3. WHO. Geneva. World Bank. World Development Report 1993 vesting in Health. New York: Oxford University 199.:.
of
the 2000. World 1992. - InPress,
IJnited Nations. Concise Report on the World Population Situation in 1991, with a special emphasis on age structure. United Nations Department of International Economic and Social Affairs. ST/ESA/SER.A/126 New York, 1992. World Health Organization and UNICEF. Revised 1990 estimates of maternal mortality -- a new approach by WHO and UNICEF. WHO/FRH/MSM/96.11. UNICEF/PLN/96.1., 1996. Fathalla MF. The tragedy of maternal mortality in dcveloping countries: a health problem or a human rights issue. NY Nytt om U-landshalsovard (News on Health Care in Developing Countries 1993: 7: 4-h.
Journal
of Gynecology
& Obstetrics
58 (1997)
5-11
Global trends in women’s health M.F. Fathalla* Assiut,
Egypt
Abstract Global trends in women’s health have to be looked at in the broader context of the definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. Our species is undergoing a historical bio-social evolution, with women positioned to have more power over their bodies and their lives. The implications for women’s health are vast. Our profession has to face new challenges. The woman behind the mother is finally emerging, and making her presence felt. A reproductive evolution is sweeping the globe, with women having to lead a contraceptive life. A contraceptive technology revolution has benefited hundreds of millions, but the task is still unfinished. Demand for quality is substituting a desire for quantity in human reproduction. Sexual health is becoming an important psychosocial component of our health and well-being. The mature adult woman and the elderly woman are rising to an important place in our health care. The widening bio-social gap in adolescents dictates an increasing need for appropriate promotive, preventive and curative health care. One global trend in women’s health unfortunately did not happen. Maternity is still, unnecessarily, a major cause of death and morbidity for women in developing countries. 0 1997 International Federation of Gynecology and Obstetrics Keywords:
Women’shealth; Contraception; Sexuality; Ageing; Adolescence
1. Introduction In the Constitution of the World Health Organization, health is defined as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. This definition, idealistic as it may look, is nowhere as relevant and applicable as in women’s health. Women’s physical health cannot be separated
* P.O. Box 30, Assuit, 0020.7292/97/$17.00 PII
SOO20-7292(97)
Egypt.
Fax:
+ 20 88 337333.
0 1997 International 02856-7
Federation
of Gynecology
from their mental and social well-being. Women’s health is not about the absence of disease. A woman who is carrying an unwanted pregnancy cannot be considered healthy simply because her blood pressure is normal and the fetus has a normal biophysical profile. Global trends in women’s health have to be looked at in this broader context of the definition of health. In the past few decades, the world has been witnessing a major social upheaval, where women are positioning themselves to have more power over their bodies and on their lives. Our and Obstetrics
6
species is tion. The vast. The obstetrics lenges.
M.F.
Fathalla
/International
Journal
undergoing a historical bio-social evoluimplications for women’s health are profession of women’s health care, and gynecology, has to face new chal-
2. The emergence of the woman behind the mother The human race has already fulfilled the divine-given task to be fruitful and to multiply and replenish the earth and to have dominion over every living thing. Many think that it has even overdone it, and that the health of our fragile planet is now being compromised. From now on, we have to steer a new course into the future. The world will never again be the same. Throughout human history, the potential of women has been suppressed to serve the survival needs of our species. After fulfilling the obligation to replenish the earth, with hundreds of millions of women sacrificing their lives in the process, women are looking for and they deserve and they will get a final reward. With small families now the norm, and with the ability of women to regulate and control their fertility, the woman is finally emerging from behind the mother. Childbearing is becoming a function of women, and not the function of women. Women are becoming producers, and not only reproducers. The world is making the discovery that women are not mobile wombs. They are human beings, in their own right. International efforts to establish the rights of women culminated in 1979 with the United Nations General Assembly’s adoption of the Convention on the Elimination of All Forms of Discrimination against Women. The Convention confronts stereotypes, customs and norms that give rise to the many legal, political and economic constraints on women. One-hundred and two countries have ratified the Convention, legally binding themselves to incorporate the Convention’s demands in their policies. The Programme of Action, adopted by the 1994 International Conference on Population and Development, devoted a full chapter to gender equality, equity and empowerment of women. It recommended that ‘Countries should act to empower women and
of Gynecology
& Obstetrics
58 (1997) 5-11
should take steps to eliminate inequalities between men and women as soon as possible’ [l]. The changing role of women has dramatic implications for societies. The transition is painful and is an uphill struggle. Women in many societies are unfortunately still speaking their common language of silence, and are not fighting for their god-given rights to be men’s equals. We, as health professionals entrusted with the health of women, cannot be neutral in the social struggle of women. We have to stand beside women and behind women. We have to speak for women’s rights, because we know more than others that powerlessness of women is a serious health hazard [2]. Throughout the major part of human history, the role of the woman has been defined in terms of her reproductive potential. This is also how our profession of obstetrics and gynecology has been shaped in the past. Our profession is facing a challenge and has to adapt, to continue to be relevant to the health needs of women and responsive to women’s perspectives. We need to change from organ healers to physicians to the whole woman [3]. Our profession should evolve into the profession of women’s health. Because women are women they have specific health needs and problems. First, they have health needs and problems related to the sexual and reproductive function. Second, they have an elaborate and delicate reproductive system liable to disease and or dysfunction, even if it was not put to function, and even after it has been put out of function. Third, women are subject to diseases of other body systems as men are, and many of these diseases show gender differences, and some are directly influenced by hormonal changes and/or the reproductive function in women. Last but not least, because women are women they are still exposed to social diseases. 3. The reproductive
evolution
A reproductive evolution has been central to the emergence of the woman behind the mother. A dramatic change in people’s reproductive behavior began in the 19th century in the North-
M.F.
Fathalla
/International
Journal
ern hemisphere of our globe. During the second half of the 20th century, the change has been sweeping the Southern hemisphere. The world is experiencing an unprecedented decline in fertility. Fertility level is measured by demographers as the total fertility rate (TFR), which reflects the average total number of children that a woman would have by the end of her reproductive life if current fertility patterns remain unchanged. The total fertility rate continues to decline in all of the world regions in recent decades, and are expected to continue to do so in the coming years and to drop to 2.36 by the year 2020-2025 [4]. The pace of fertility decline has been very steep in developing countries. Between the mid-1960s and the present, 17 countries have had fertility declines of more than 50%, and an additional 31 countries have had declines exceeding 25% [5]. The adoption of a smaller family norm, with consequent decline in total fertility, should not be viewed only in demographic terms. It means that people, and particularly women, are empowered to take control of their fertility and to plan their lives; it means that more children are born by choice, not by chance, and that births can be planned to take place at optimal times for childbearing to ensure better health for women and children; and it means that families are able to invest relatively more in a smaller number of beloved children, trying to prepare them for a better future [6]. It means that women are spending less and less of their lives childbearing and child-rearing, and are having broader choices in their lives. What we are witnessing is a major evolutionary jump that is science-mediated, rather than brutally imposed by nature. Our reproductive function is being voluntarily adapted to dramatic new realities. 4. Contraceptive
life
Homo sapiens has escaped the grip of nature in evolution to become a self-evolving animal. The recent dramatic evolution in human reproductive behavior is not followed or accompanied by a change in the anatomy and/or function of the reproductive system, as would have been expected in other major evolutionary jumps mediated by
of Gynecology
& Obstetrics
58 (1997)
5--l 1
7
Mother Nature. As a consequence, Homo sapiens has to accomplish its reproductive evolution while retaining a reproductive system geared to high fertility. Women, or their partners, have to use contraception. Women have a span of about 30 reproductive years, during which they were meant by Nature to get pregnant. If women are to bear only one or two children, they will spend only 1-3 years in childbearing. For the remaining years, they, or their partners, will have to lead a contraceptive life if they are to remain sexually active. Contraceptive technology, from now on, will play a crucial role in reproductive life. The change to contraceptive life has been sweeping the world. Levels of contraceptive use are estimated as percentages of currently married women of reproductive age (15-49), including where possible, those in consensual unions. According to the latest United Nations estimates, of the 899 million currently married women of reproductive age in the world, 57% are using contraception at any one time [7]. The prevalence among developing countries as a whole is 53’S, and in the more developed countries 72%. The date to which these estimates pertain is approximately 1990, according to data available through 1993. Considering the lag between the time of data collection and the current period, the level of contraceptive use in the developing countries is likely to have been about 55% in 1993 [g]. In view of the major worldwide expansion in the use of modern methods of contraception by healthy women over prolonged periods of time, contraceptive safety has become an important issue in women’s health. In developed countries, where the number of women using contraceptives is much larger than the number of those who are pregnant, and where maternal mortality rates are very low, reproductive mortality attributable to contraceptive use assumes a relatively large dimension [9]. In developing countries, reproductive mortality attributable to contraceptive use is still insignificant compared with maternal mortality. 5. The contraceptive
technology revolution
A scientific revolution in contraceptive technology in the past few decades has helped hun-
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dreds of millions of people to achieve their aspirations to regulate and control their fertility. The fruits of science have been enjoyed by people living in the most varied circumstances, in the skyscrapers of Manhattan, in peri-urban slums in Latin America, in rural communities of the Indian subcontinent; people in all socio-economic strata; people with different cultures, religious beliefs and value systems; and people postponing a first pregnancy, spacing their children or putting the limit on childbearing. Until the middle of the present century, contraceptive choice was limited to either coitus-related methods which lacked in effectiveness, or permanent methods. Contraceptive choices have now been broadened [lo]. Contraception was moved outside the bedroom by the development of systemic methods such as the pill. People no longer had to make the choice between a method to be used at every coitus or a permanent method; long-acting reversible methods now offer protection ranging from 1 month to several years. Also, highly effective but reversible methods became an available option. Technical developments have allowed sterilization to be performed as an out-patient procedure and without the need for general anesthesia. But perhaps the most significant development, brought about by the contraceptive technology revolution, has been the empowerment of women. For the first time, women had at their disposal effective methods that they can use to regulate and control their fertility, without being too dependent on the cooperation of the male partner. There is still a need for new contraceptive methods. This is not because currently available methods are not good, but because they are not adequate to meet the widely diverse needs of all the hundreds of millions of people using contraception now and in the future. There is not, and there probably will never be, an ideal method of contraception for all users, but there can be a variety of ‘ideal methods’ for the needs of different users [ll]. Science is ripe for a Contraception21 initiative to launch a second contraceptive technology revolution [lo]. While advances in cell and molecular biology and in biotechnology have opened new frontiers for medical and biological
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sciences, the field of contraceptive research and development is yet to benefit from the opportunities provided by these new advances. The second contraceptive technology revolution should not be demographic-driven or completely science-driven. It should be driven by a woman-centered approach, to provide women and men with the contraceptive technologies they need and miss in currently available methods [12]. 6. Quality vs. quantity With the adoption of a small family norm, demand for quality of births has substituted for quantity of births. Aldous Huxley’s vision in his famous novel of a brave new world, where people get the embryos they ask for, is not too far away. New frontiers of science have opened the way for hitherto unimaginable reproductive technologies that made possible artificial insemination, in vitro fertilization, embryo transfers, surrogate motherhood, cryogenic storage of sperm and ova, genetic selection, and prenatal diagnosis, including sex determination. To seek the birth, through the use of these new technologies, of only healthy babies is a legitimate request. The new technologies may, however, be abused to seek babies with certain demographic characteristics. Although most of these technologies have as yet no significant demographic impact, there is already serious concern about possible alterations in sex composition of populations, when the desire for quality is translated as a desire for a son. Ultrasound, amniocentesis and chorionic villus sampling are modem technologies that have been abused for prenatal sex diagnosis, and where pregnancy termination services are available, for selective abortion of the female fetus [13]. 7. Sex: a duty became a pleasure In the evolution of Homo sapiens, the temporal relationship between sex and reproduction has been severed. It must have taken our ancestors such a long time to realize any relationship between the act and the event, probably not until they began to observe domesticated animals. In
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our fellow mammals, the female will only be attractive to the male and receptive to his advances if she is ovulating and ready to conceive. In our fellow primates, the female never fails to advertise the fact that she is ovulating. External sexual organs undergo a change in size or color that is clearly visible and that makes her sexually attractive to the male. At other times, she will have little or no appeal for him. The sexual receptivity of the human female has completely emancipated from hormonal control. The human female has also succeeded though evolution to hide completely all external evidence of ovulation. The dissociation of the act of sex from reproduction was an ingenious mechanism for reproductive efficiency. Mother Nature was not as much keen on our pleasure, as on ensuring the survival of the species. Making sex perpetually available encouraged the pair bond and favored the development of the family institution, as an essential mechanism for care of the children. Other mammals produce infants who are able to run sufficiently well to keep up with the herd less than 30 minutes after birth. The human newborn, on the other hand, has a long period of yearsof extreme dependence and helplessness during which it needs to be taken care of, before being able to survive on its own. With reproduction receding further into the background, the role of sex in our lives is going to evolve further. It will ‘sublime into an expression of love. As such, sex will increasingly be an important component in our psycho-social wellbeing, and less and less a tool of reproduction. We are beginning to witness the implications of this evolution for sexual behavior. One of the most disappointing aspects of medicine during the past 25 years has been the great increase in the incidence of infections caused by sexually-transmitted agents. STDs are now the most common group of notifiable infectious diseases in most countries. The World Health Organization’s minimal estimate for the yearly incidence of bacterial and viral STDs (excluding HIV infection) is 130 million [14]. The pandemic of Human Immunodeficiency Virus (HIV) infection, which appears to have com-
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menced in the late 1970s or early 1980s as a disease mostly of men, is now becoming a major threat for the health of women and children in developing countries. By definition, STDs affect both men and women but the disease burden on women is much heavier. A recent World Bank report ranked sexuallytransmitted diseases as the second major cause (after maternal) of the disease burden in young adult women in developing countries, accounting for 8.9% of the total disease burden in that age group [15]. Among males of the same age group (15-44), STDs were not among the first 10 causes and accounted only for 1.5% of the disease burden. For a mix of biological and social reasons, women are more likely to be infected, are less likely to seek care, are more difficult to diagnose, suffer more severe disease sequelae, and are more subject to social discrimination and consequences [31. The most effective method available for protection against STDs, the condom, is controlled by men. An effective method of protection, that a woman can use without the need or necessity of her partner’s cooperation, simply does not yet exist. 8. The rise of the mature adult woman
Women live, on average, longer than men, in both developed and developing countries. United Nations projections indicate that this trend will continue in the 21st century [16]. This advantage of women is variously attributed to an inherent biological advantage, a more healthy life-style behavior (less consumption of alcohol and tobacco), and to environmental factors (more dangerous work activities performed by meni. The human female was not well equipped in evolution for this extended longevity. Cessation of ovarian function, and the menopause, was probably imposed by nature on the human female, on the basis of life expectancy assessment. To ensure that a newborn gets good care from a living and healthy mother, nature put a limit to the ability of women to bear children after a certain age, by stopping ovarian function. Women in many countries now, and in more countries in the 21st century, can confidently expect to lead a
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healthy life for more than 20 years after the menopause. The human female will now have to lead long years of life without the benefit of their endogenous production of oestrogen, making them more liable to bone fragility and cardiovascular disease, apart from other impact on quality of life. Hormone replacement therapy is becoming available to correct this hormonal deficiency. Scientific progress is still needed to develop hormonal preparations that target tissues where the beneficial effect is needed and that leave out tissues where the exogenous therapy can have adverse effects. Gynecologists will have to deal more and more with health problems of aging women, within a complex web of physical, mental and social factors that impact on their well-being. 9. Adolescence
and the widening
‘bio-social’
gap
Nature has delayed the onset of puberty in the human species more than in any other mammal, to ensure physical and mental maturity in the mother (and father) and to allow enough time for the transmission of intergenerational knowledge and skills, before taking on the responsibility of parenthood. During the period of adolescence, defined as the period of transition from childhood to adulthood, three developments take place. Biological development progresses from the point of the initial appearance of the secondary sex characteristics to that of sexual maturity; psychological processes and cognitive and emotional patterns develop from those of a child to those of an adult; and a transition is made from the state of total socio-economic dependence to one of relative independence. Two trends are taking place in almost every society, though at different paces: a trend towards an earlier onset of biological maturation and a trend towards delay in socioeconomic maturation, with a resultant wider biosocial gap in human development. Today, girls everywhere are becoming sexually mature at an earlier age than previous generations. Genetic, health and socio-economic factors influence the wide variations in age of menarche among dif-
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ferent countries. Since boys and girls have now to spend more years in school, learning and training, before they can enter the complex labor market, the period of socio-economic dependence is prolonged. Adolescents are left with difficult choices in sexual behavior: premarital sex, early marriage or abstinence. The different patterns predominate in different countries, and patterns of transition exist. Premarital sex is now the predominant pattern in developed countries and some parts of the developing world including parts of Latin America and the Caribbean. There is also evidence of a similar trend in other regions. This choice often carries with it an increased prevalence of STDs, unwanted pregnancy and abortion, with adverse health and social consequences. Early marriage is a predominant pattern in many parts of the developing world, notably Asia and Africa. It carries with it a curtailing of the socio-economic development of the girls, often limiting their role in life to a childbearing and child-rearing career, and the assumption of parental responsibility before social maturity. Abstinence and delayed marriage seems to be a declining pattern, with the possible exception, at least until recently, of China. Adolescents are a sizeable group of world population. In 1990, people aged 15-24 accounted for 19.1% of world population, 14.8% in developed regions, and 20.4% in less developed regions [16]. The bio-social gap will continue to widen for other world regions, where the gap is still narrow. Adolescence and the widening bio-social gap are not a problem in themselves. The problem is in the need to come to grips with the new realities of adolescence. Misconceptions are contributing to turning what should be a normal positive phase in growth and development into a problem. Gynecologists will have increasing responsibilities for promotive, preventive and curative health care of adolescent girls. 10. The trend that did not happen
A recent WHO/UNICEF report, based on 1990 data, estimated the total number of maternal deaths to be 585000/year, a 20% increase
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over previous estimates [17]. Maternal mortality rates have been decreasing in countries where it was already low. There has been little progress in other countries. In terms of numbers, the total maternal deaths has been increasing rather than decreasing. These women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving. The tragedy of maternal mortality is not just a health problem. It is a human rights issue [18]. It is the women’s right to life, to which governments and societies should be held accountable.
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United Nations. Report of the International Conference on Population and development (Cairo, 5-13 September 1994). United Nations A/CONF.171/13, 1994. Fathalla MF. The impact of reproductive subordination on women’s health family planning services. Am Univ Law Rev 1994; 44: 1179-1190. Fathalla MF. Women’s health: an overview. Int J Gynecol Obstet 1994; 46: 105-118. United Nations. World Population Prospects: The 1992 Revision. Annex Tables. New York: United Nations, 1992. Ross JA, Mauldin WP, Green SR, Cooke ER. Family planning and child survival programs as assessed in 1991. New York: The Population Council, 1992: 1. Fathalla MF. Family planning and reproductive health --a global overview. In: Graham-Smith F, editor. Population - the complex reality. A report of the Population Summit of the world’s scientific academies. Colorado: The Royal Society, London and North American Press. 1994: 251-270. United Nations. World contraceptive use 1994. United Nations Department for Economic and Social Information and Policy Analysis, ST/ESA/SER.A/143. New York. 1994.
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