|DR. J. K. SEHGAL MEMORIAL ORATION
|Year : 2011 | Volume
| Issue : 4 | Page : 247-251
Women's health: Beyond reproductive years
Vibha1, Ananya Ray Laskar2
1 Director Professor & Head, Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India
2 Assistant Professor, Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India
|Date of Web Publication||30-Jan-2012|
Director Professor & Head, Department of Community Medicine, Lady Hardinge Medical College, C. P New Delhi - 110001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
With changing demographic profile India has more older women than men as life expectancy for women is 67.57 as against 65.46 for men. Gender differences in the aging process reflect biological, economic, and social differences. Both social and health needs of the older women are unique and distinctive as they are vulnerable. The social problems revolve around widowhood, dependency, illiteracy and lack of awareness about the policies and programmes from which they can benefit. Among the medical problems, vision (cataract) and degenerative joint disease top the list, followed by neurological problems. Lifestyle diseases form another single-most important group of health problems in the elderly women. The risk of cardiovascular disease doubles with the outcome being poorer than men. The most common causes of death among women above the age of 60 years are stroke, ischemic heart disease and COPD. Hypertensive heart disease and lower respiratory tract infections contribute to mortality in these women. Common malignancies viz. Cervical, breast and uterus in women are specific to them and account for a sizeable morbidity and mortality. In a study done at Lady Hardinge medical college in Delhi, Hypertension (39.6%) and obesity (12-46.8%) were very common in postmenopausal women. Half or more women had high salt and fat intake, low fruit and vegetable intake and stress. There is a need to recognize the special health needs of the women beyond the reproductive age, to be met through strengthening and reorienting the public health services at all levels starting from primary health care to secondary till tertiary care level with adequate referral linkages. All policies and programs need to have a gender perspective. At present there is lack of sensitization and appropriate training of the health personnel in dealing with the needs of elderly. Women too need to be aware to adopt healthy lifestyle and seek timely care.
Keywords: Elderly females, Social and health needs, Non-communicable diseases
|How to cite this article:|
Vibha, Laskar AR. Women's health: Beyond reproductive years. Indian J Public Health 2011;55:247-51
Dr. J.K. Sehgal Memorial Oration was delivered at 55th All India Conference of IPHA, held at Belgaum, Karnataka in 2011.
| Background|| |
Concerns regarding women's health in India have centered on maternal care and contraception. The concepts of safe motherhood and reproductive health were introduced in the last two decades. In recent years, some importance has also been given to the health of adolescent girls. However, health of the women beyond their reproductive age has largely remained a neglected issue till now.
Throughout her life, a woman plays different social roles, viz. daughter, wife, mother, grandmother and care giver, which influence the health of her family. While older men have the privilege to retire from work, women are never relieved of their social responsibilities. At this stage, the protective advantage of hormones is lost and women become more vulnerable to certain diseases than men. It is time now to focus on issues concerning health of this special group.
| Demographic Transition|| |
In this period of demographic transition, death rates have declined considerably while birth rate is also declining. This has resulted in a rapidly expanding population over the last few decades. Due to provision of better medical facilities, life expectancy has increased and this has led to a rise in the number and proportion of the elderly people. The proportion of elderly persons in India, which was 6.5% in 1981, grew to 6.8% in 1991 and became 7.4% in 2001. 
According to the current estimates (2010), life expectancy for women is 67.57 years as against 65.46 years for men.  Hence, there are more elderly women in India as compared to men. According to National Sample Survey Organisation (NSSO) (60 th round) conducted in 2004, the proportion of elderly women is 71/1000 in rural areas as compared to men whose proportion is 70/1000. This difference is more in urban areas where the proportion of elderly women and men is 71/1000 and 62/1000, respectively.  In our country, the sex ratio favorable to females is seen only in the age group of 65 years and above. Hence, the problems of old age will be exacerbated among elderly women owing to public policy failures with respect to access to social and material resources.
Due to longer life span of women and general societal norm of marrying men older than themselves, the increasing proportion of widowhood is a major concern. The proportion of women and men in the elderly population has important implications for policymakers, as they have different experiences and problems. In India, women are more likely than men to be widowed, illiterate and out of paid employment.
Due to change in their social status and outlook, the elderly women mostly remain unconsidered, which adversely affects their health. With breaking down of the joint family system, they suffer from loneliness. In terms of living arrangements, it is clear that women are at a disadvantage. As per NSSO 52 nd round, the term "living arrangements" is used to refer to one's household structure in terms of type of family, headship, place of stay, people staying along and kind of relationship maintained among them.  A multicentric study conducted by Ministry of Health and Family Welfare (MOHFW) in collaboration with World Health Organization (WHO) reported that 69.5% of women are living with spouse or family. The proportion of elderly women living alone is more (7.1%) as compared to men (4.5%) living alone. Ironically, women have lower social expectations from their family. However, their financial expectations are higher as compared to men in this age group. 
As reported in NSSO 52 nd round (1995-1996), 72% of elderly women, both in rural as well as urban areas, are economically fully dependent on their families. The proportion of partially dependent women in rural and urban areas is 12.4% and 9.5%, respectively. Only 24% of elderly women are economically active as against 44% of men who are economically active. Dependency ratio for the old has been rising from 105 per 1000 in 1961 to 118 per 1000 in 1991 and 131 per 1000 in 2001. It is projected to be 161 by 2021.  Low literacy is also a problem among women in this age group. This leads to less occupational opportunities, hence leading to less economic security. 
| Perception of Health|| |
As far as the health status is concerned, women's perception of their own health is poor as compared to men. As per the report of NSSO 60 th round (2004), in urban areas, only 43/1000 women without sickness perceived their health to be excellent or very good. The figure is 81/1000 in case of men. 770 women per 1000 perceived their health to be fair or good, while 187/1000 thought they had poor health.  It is also observed that women resist more than men in receiving and accepting any kind of correctional help or support. This tends to alienate and push the elderly, especially women, into a cycle of depression and social isolation. 
| Non-Communicable Diseases among Women Beyond Reproductive Age Group|| |
The age at which natural menopause occurs is between 45 and 55 years for women worldwide. Women spend a significant part of their lives in the postmenopausal state. Nationwide data suggest that this age group is more vulnerable to developing non-communicable diseases (NCDs) than the reproductive age group. There are a number of factors that increase the vulnerability of women beyond reproductive years and thus point toward specific health needs of this segment of population. Of late, some attention has been focused on the health of elderly women as far as policy matters and research is concerned; however, postmenopausal women below 60 years have been totally left out.
The most common cause of death among women above the age of 60 years is stroke, leading to 21.7% of deaths. It is closely followed by ischemic heart disease (IHD) which leads to 19.8% of deaths. Chronic obstructive pulmonary disease (COPD) has been incriminated in 11% of deaths. Hypertensive heart disease and lower respiratory tract infections contribute to 3.7% and 3.4% of deaths, respectively. 3.2% of deaths have been attributed to diabetes, while cancers of different sites cause 6.6% of deaths. 
Owing to the decline in health and social status, the women have a feeling of worthlessness. Lack of finances and dependence on others may lead to a feeling of being a burden on the family. These may have an adverse effect on their mental health. A meta-analysis by National Commission for Mental Health has estimated the prevalence of mental illness to be 31/1000 among women above 60 years of age. 
More women are confined to bed as compared to men. As reported by NSSO 60 th round (2004), the proportion of women in the age group 60-64 years who were confined to bed was 34/1000, both in rural and urban areas. The proportion of men of same age group having such disability was 27/1000 in rural areas, while it was 33/1000 in urban areas. In the age group 64-69 years, 63/1000 women were confined to bed as compared to 34/1000 men in urban areas. The rates for the age group 70-74 years were 132/1000 women as compared to 79/1000 men in rural areas and 116/1000 women as compared to 77/1000 men in urban areas. The situation gets worsened with increase in age. The proportion of women 80 years and above who could not move and were confined to bed was as high as 326 and 323 per 1000 in rural and urban areas, respectively, as against 220 and 239 per 1000 in case of men in rural and urban areas, respectively. 
The extent of physical disabilities is also more in women. However, the proportion of women who use appliances is less. Most common disabilities are locomotor and visual. In the multicentric study conducted by MOHFW in collaboration with WHO, it was found that 46.8% of the elderly women suffered from poor vision. Nearly 19% of the women had difficulty in hearing, but only 3.6% of them used hearing aid. 
Many of the problems are accepted as part of the aging process and are not reported by women even during surveys. Osteoporosis is common, but identified only at the time of fractures which may occur due to minor injuries. Significant decrease in serum calcium has been reported in postmenopausal women. The prevalence of osteoporosis ranged from 52% in urban areas to 76% in rural areas. 
The proportion of overweight as well as underweight women is also more than that of men, i.e. women have poorer scores on both the sides of spectrum of malnutrition than men. The multicentric study to establish epidemiological data on health problems of the elderly reported that 28.5% of women had body mass index (BMI) >25, while 27.5% of men had BMI >25. The proportion of women who had BMI <18.5 was 17.7% as compared to men whose proportion was 15.6%. Laboratory findings suggested high serum cholesterol in 33.9% of women and 30.9% of men. Anemia (Hb ≤10 g/dl) was found in 21.6% of women as against 11.4% of men. 
As per the estimates of 2005, more deaths are caused and disability adjusted life years (DALYs) lost to NCDs in India as compared to communicable diseases. The prevalence of coronary heart disease has been estimated to be 3-4% in rural areas and 8-10% in urban areas. Among the chronic problems, bowel problems, depression, hypertension, diabetes and urinary problems are the most common. Bowel and urinary problems were reported in 31.5% and 11.9% of the women, respectively. As much as 24.8% of the women suffered from depression as shown in [Figure 1]. The prevalence of diabetes in adults in rural areas was reported to be 3.8%, while in urban areas it was 11.8%. Coronary heart disease and diabetes have shown an increase both in urban as well as rural areas. Hypertension was reported in 38.7% and diabetes in 12.7% of the elderly women. Other problems included IHD (6%), asthma (6.1%), COPD (3.9%), tuberculosis (2.1%), paralysis (2.4%), Parkinson's disease (1.4%) and cancers (0.8%) among this group. All these problems were more in women as compared to men. 
India also has the largest number of oral cancers. The age-adjusted incidence varies from 44/100,000 in rural Maharashtra to 121/100,000 in urban New Delhi. Deaths from road traffic accidents and self-inflicted injury have also increased considerably.
A meta-analysis on NCDs by ICMR (2001) revealed the magnitude of cases, DALYs lost and detailed burden of diabetes, IHD and stroke. Although diabetes is more common (37.77 million cases as compared to 22.37 million cases of IHD), IHD is responsible for more DALYs lost and deaths. It was reported that 16 DALYS were lost due to IHD as compared to 2.26 due to diabetes. DALYs lost to cardiovascular diseases (CVDs) among women in India is progressively on the rise. Weighted prevalence for IHD is higher for women as compared to men both in urban and rural areas.  Similar pattern has been observed for diabetes. The meta-analysis reported that prevalence of diabetes varies from 109 to 580 per 1000 in urban areas and from 235.8 to 280 per 1000 in rural areas.
The burden of cancers is higher among women in lesser years of life. Number of cases and DALYs lost are more in women, though deaths are slightly higher in men. Also, incidence rates of cancers among women show an increasing trend with increase in age.  A peculiar difference between cancers among men and women is that while most of the cancers (such as lung, oral cancers) in the former group are closely related to personal habits and lifestyle, cancers among the latter group (cervical or breast cancer) are primarily related to reproductive organs, as is evident from [Figure 2]. 
|Figure 2: Common sites of cancers in female: Extrapolation to population of India, 2004 (ICMR)|
Click here to view
A community-based study was conducted in Lady Hardinge Medical College, New Delhi, from April 2007 to March 2008 to find the prevalence of risk factors for selected NCDs (hypertension, coronary artery disease, diabetes mellitus, obesity and breast cancer) and their relation with socio-demographic factors. It was observed that higher proportion of postmenopausal women fall in the category of pre-hypertension or hypertension. Clinical examination observed that prevalence of hypertension was as high as 39.6% with the mean systolic blood pressure falling in the pre-hypertensive range. 
In the same study, diabetes was detected in 13.9% of the study subjects. 10.6% had impaired glucose tolerance. Majority (82.4%) had raised serum cholesterol. The proportions of overweight and obesity that are risk factors for chronic diseases were as high as 47% and 12%, respectively, as shown in [Table 1]. Mean waist circumference, waist hip ratio and BMI were higher than the normal cut-off values. 
|Table 1: Risk factors for non-communicable diseases among postmenopausal women|
Click here to view
| Recommendations|| |
The health and social status of women beyond reproductive years clearly highlights the need for greater thrust on health care activities as well as social security mechanisms which can cater to their special needs. Awareness generation regarding healthy lifestyles should not only be limited to elderly women, but should also include postmenopausal women below 60 years, along with their caregivers in the family. Information on common health problems in this age and health facilities including where those services are available should be provided. Policies need to be more gender sensitive and should especially focus on women's needs from health and social perspective.
There is a need for greater focus on vulnerable groups such as those belonging to Below Poverty Line or other marginalized sections of the society. At the national level, mixture of pension schemes and social security schemes can help to provide economic aid to these women.
There is a growing need for separate interventions to ensure health of this vulnerable group. Geriatric care needs to be an important component of medical and paramedical education and should include training at a basic level. Health workers at primary level should also be equipped with knowledge and skills in order to address the problems of this special group.
Geriatric Medicine, which has emerged as a specialized branch of medicine, may be given a boost by creation of such posts at secondary and tertiary levels and giving more recognition to this specialty by Medical Council of India. There is a dearth of literature regarding the health and social issues in relation to women in this age group. Thus, it is imperative to encourage more research on current and emerging issues in this field, Geriatrics, with a special emphasis on the women beyond reproductive years.
| References|| |
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|2.||National Programme for the Health Care of Elderly. An Approach towards Active and Healthy Aging Directorate General Health Services, Ministry of Health and Family Welfare, Government of India; 2009. |
|3.||National Sample Survey Organization (NSSO) 60 th Round. Report no. 507: Morbidity: Health Care and Condition of Aged; 2004. |
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[Figure 1], [Figure 2]
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