Welcome, in this session we'll speak about the health of women. We'll focus on the burden of disease among women, who's most affected by this burden, and some example of what can be done to address the key burdens of disease that women face. By the time you finish this session, you should be able to describe the key burdens of disease that women face globally. Discuss the women who are most affected by this burden. Note some of the measure of the measures that can be taken to enable women to address the most important health burden that they face. Lets begin with just two vignettes. Sarah lived in Pakistan and was pregnant with her second child. When she went into labor Sarah called in a traditional birth attendant. That's what people generally did in her village. As Sarah's labor continued it became clear that something was wrong. But in Sarah's village, women couldn't seek care at the local hospital without the permission of their husband. Sarah's husband was away in the capital city, Sarah was not able to go to the hospital and later that night Sarah died in childbirth. Carmen lived in the slum in Guatemala City. She was not married, but became pregnant after relations with the man she'd met several months before. In her culture pregnancy without marriage is a source of great shame for woman's family. Fearing the reaction of her family, Carmen sought to get an abortion. Abortions are illegal in Guatemala except to save the life of another. Even though abortions are performed in Guatemala both by licensed and unlicensed medical practitioner. Carmen couldn't afford the fee for an abortion from a licensed practitioner, so she went to an unlicensed one had what we call an unsafe abortion. She bled profusely, and she died before she could be taken to a hospital. Now, with these as a little bit of background, there's also some good news for women's health that we'll be talking about. I want to probe my students just a little bit on, why do you think, Emily. Why do you think we might want to pay special attention to the health of women as we consider the broader topic of global health? >> Women face different health issues than men, such as the issue of child birth. And also, women play a very important role in the family, because they are often responsible for raising the children. >> And Vivek, what would you add? >> Well, I would say, that a mother's health is very directly related to a child's health, and so, by ensuring that the mother is taken care of properly, you're also ensuring that the next generation is taken care of. >> In fact, I think, the data says that a child who's mother dies in childbirth is 50%, half of all the children who's mothers die in childbirth, I believe will die in their first year of life. Rachel, what would you add as reasons why studying, and thinking about the health of women is of such special importance? >> I would add that women often trace gender discrimination onto any areas of life, and that discrimination creates unique health disparities between men and women. >> And Shaelyn, is there anything that you would like to add? >> Let see, we've covered some of the big ones. I think there's also issues in access for women particularly like related to contraception. That's also a challenge that men don't face that women do that can be difficult especially if women wish to control their reproductive health. >> All thoughtful comments. So let's look at a graphic that I hope you'll find nicely summarizes some of these issues that the students have raised about why it's so important to think about the health of women as we think about global health. The first, as one of the students said, is women are often victims of discrimination. Which can harm their health or reduce their ability to seek health services. Women face many unique problems such as cervical cancer, ovarian cancer and only they can give birth. There are often unjustifiable differentials in the health of men and women as was also pointed out. There are enormous social and economic consequences on the affected woman, families and societies, as Vivik mentioned in his own comments. There are low cost interventions that could lead to many deaths and many dallies averted. But a substantial share of these are not being used sufficiently or not taken to scale in some of the countries where they are most important. And lastly investing in the health and education of woman, we know are really high yielding investments that have a big benefit for families, for communities for nations, and for the world as a whole. Now in short, when you think about this, I want to use a phrase that one of my former colleagues and good friends coined in an important article that she wrote about women's health, and that is that being born female is dangerous to your health. I think whenever we're thinking about the health of women, perhaps particularly in low and middle income settings, and maybe in more than in others, we have to keep in mind this notion that being born female is dangerous to your health. To understand the key issues that affect the health of women, it's important to understand some of the biological and some of the social determinants of women's health. Some issues clearly relate to biology, such as ovarian cancer. Or cervical cancer or the fact that women had more expose mucosal areas and more susceptible in a greater risk of HIV than men are. Other health issues referred to or relate to the social status of women. Such as families that might encourage strongly or push them into getting married very young. Having their first birth very young, having a large number of children, and having them in quick succession. Or this would also be true of intimate partner violence and other violence against women, which is so common in so many countries. And some nutritional concerns might also relate to social determinants. In societies where a women might eat last and might eat less, or girls might be fed less than boys are fed. So let's look now at what are some of the leading causes of deaths and then dallies for a women. And I want to say that we are going to talk a fair amount about women's reproductive health. But when we think about the health of women globally, it's important to think about women as people. A lot of the studies, a lot of the literature, a lot of the practice concerning the health of women has addressed women's reproductive health issues. They're very important. But the health issues that women face, and the measures needed to enable better health of women wherever they live, go well beyond just the issues concerning reproductive health. So let's look at the leading causes of death for females in low and middle income countries here, high-income countries here for 2013. And what we see is a pattern that we might expect which is stroke and heart disease being the leading causes of death both in low and middle income countries and in high income countries, but this is also, of course, for all ages. We also see, though, in here for women in low and middle income countries. Lower respiratory infections, which refers both to young children and older adults. Diarrheal diseases which predominately will refer to young girls. HIV/AIDS in a world in which the epidemic has been feminized, in which more women are infected than men. TB, which is a major killer of women, and now I think the leading infectious cause of death in the world. And malaria, which is very important both for young children, but also for pregnant women as well. And of course, we don't see on high-income countries in the top ten list of leading causes of death, tuberculosis, diarrheal disease or malaria. Let's look now at how this might change if we look at leading causes of disability adjusted life years for females in low and middle income countries and high income countries again for 2013. And here, again, as we might anticipate, or hopefully as we would anticipate, we see causes such as musculoskeletal problems and depressive disorders that didn't appear in deaths because these are conditions that are largely associated with disability. Depressive disorders can be linked, as you know, to death. But by and large these are causes that are much more important for disability than they are for death. And we see in both places the exceptional importance to women's health of depressive disorders. At the same time, other musculoskeletal disorders are very important. And only come up when we begin to think in disability adjusted life years. In high income countries, we see sensory organ disorders are also very important. And that's vision and hearing loss, for example. And it's also really important to understand that hopefully the world will continue to make progress economically. And as it does so, we should expect that this burden of disease will move more and more into one that looks like this. And as these countries get better and better off, women we should expect in the absence of major changes will suffer substantial amounts of disability from musculoskeletal disorders from depressive disorders, and from sensory disorders as well. Now, I want to elaborate very briefly on a number of issues that concerns women's health. There are many, and one could go on at great length. I want to encourage you to take a look at them on your own, but I'm just going to talk about a few. First I want to say something about female genital mutilation. The world health organization categorizes FGM into four different types, depending on the amount of cutting that's done. Half of the girls that go through female genital mutilation are cut by the time they're five and the rest by the time they're 15. The number of girls who undergo FGM is declining, but it's estimated that about 3 million girls are cut every year. When FGM is performed initially it can lead to shock or pain, it's also associated with infection. Because the instruments for cutting are not always clean and it can also be associated with acute hemorrhage. Over the long term it can have a number of deleterious health defects including retention of urine, infertility, and obstructive labors. And the baby is born to a woman who undergone FGM are also more likely to need resuscitation after birth or to die a neonatal death. Sexually transmitted infections are a very important cause of ill health and the World Health Organization has estimated, or I think maybe the Institute of Health Metrics, an evaluation burden of disease study has estimated that about 1% of the burden of disease among women in sub Saharan Africa is attributable to sexually transmitted infections other than HIV. These infections as many of you will understand can have really negative health consequences Including pelvic inflammatory disease, ovarian abscesses, and infertility. Violence and sexual abuse against women are also very common in the world. Sexual abuse is usually defined to include rape, sexual assault, sexual molestation, sexual harassment, and incest. Now the data on this varies widely, but all of the data suggests that this is a very common problem globally, with some places having higher rates than other places. A 2006 study done by UN AID suggested somewhere between 10 and 50% of women worldwide have been abused physically by an intimate partner at least once in their lives. UN AID study also noted that between 20 and about 50% of adolescent girls aged 10 to 25 report that their first sexual experience was actually forced. Another study on intimate partner violence indicated that about 1/3 of women worldwide they'd been beaten, coerced into sex, or subjected to extreme emotional abuse. Unsafe abortion is also very, very common. Safe abortion is abortion that's carried out by licensed providers in safe and hygienic circumstances, where there's appropriate followup as well. Unsafe abortion is the opposite of this and in countries in which abortion is not safe and legal many women and families turn to unsafe abortions. In fact, the World Health Organization estimates that there are about 22 million unsafe abortions in the world every year. And that about 19 million of these take place in low and middle income countries. This is also very important because it's estimated that about 13% of all of the maternal deaths in the world are attributable to unsafe abortion. I also want to talk for a minute about obstetric fistula. Obstetric fistula is a condition in which a hole opens up in a woman between the bladder and the vagina or between the rectum and the vagina. It's usually the result of prolonged or failed childbirth. As a consequence of this, urine or feces can leak through the vagina. Clearly, obstetric fistula can have enormous social consequences. Because a woman who suffers one is leaking feces or urine is almost certainly going to be stigmatized, often by her family or by the community around her. It's difficult to get good estimates of the number of women who suffer from obstetric fistula every year, but the best estimates suggest that it's somewhere between 50 to 100,000 per year. And there are about 2 million women in the world who have suffered and are living with obstetric fistula. The risks of fistula, as I mentioned, are obstructed delivery and a lack of emergency obstetric care. Let's move on now to talk about maternal morbidity and mortality. There are about 289,000 that in most recent estimates that there are just under 300,000 women who die in maternal death every year. This figure would be a decline of about 45% compared to the data in 1990. As everyone would understand, women in high income countries don't die very often of maternal causes and about 99% of all of the maternal deaths in the world are thought to be in low and middle income countries. And in fact 2/3 of those deaths occur in a relatively small number of large countries that still have major gaps in the provision of prenatal care, skilled attendants at delivery, and emergency obstetric care. And those countries include India, Nigeria, the Democratic Republic of Congo, Ethiopia, Indonesia, Pakistan, Tanzania and China. Now let's look for a minute at maternal mortality ratios for World Bank regions, high income countries and globally. And here what we see is really substantial differences. Again, in the high income countries, this is the number of women who die of maternal causes for every 100000 live births. And here what we see is this is a quite a rare event happily In high income countries. But we also see is that the rate of maternal mortality ratio in Sub-Saharan Africa is more than 30 times the ratio in the high income countries. And we can see in South Asia that the rate is more than 10 times, the ratio is more than 10 times that in high income countries. And as we'll discuss further, this reflects the status of woman, it reflects the economic empowerment and agency of women. It also reflects the opportunities that women have to access good prenatal care, skilled attendants and delivery and emergency obstetrics care.