Social Factors Shaping African Women’s Health

 

By: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), MSc (Public Health), Freelance Medical Writer. Editorial and Medical review by the DLHA Team.

A gathering of African women at a social activities. Click on image to enlarge.

 

Highlights

• African women deserve the fundamental right to good health, but social factors significantly hinder their access.

• Over their lifetime, African women face health challenges due to communicable and non-communicable diseases, reproductive health problems and gender-based violence

• These health challenges faced by women in Africa are rarely addressed adequately.

• African women have high rates of maternal mortality, anaemia, HIV transmission and a lower life expectancy compared to their Western counterparts.

• Economic factors, low literacy levels, unfavourable cultural norms, the political and legal climate, health system factors and an unhealthy environment lead to unfavourable health outcomes for women.

• Improving women's health in Africa requires a multisectoral approach involving economic empowerment, education, political inclusion, healthcare system reforms, and community support.

 

Overview of Women's Health in Africa

Like every other person living in the society, African women also deserve to have the fundamental right to good health. Unfortunately, most African women have not been able to access this right due to social factors that negatively impact their health. The statistics are alarming. Maternal mortality predominantly contributes to the mortality statistics in this region. 

Every year, approximately 287,000 women die due to complications in pregnancy and childbirth, more than half of these deaths occur in Africa. [1] Globally, about 468 million women have anaemia and the majority of these are Africans. These kinds of data are frequently encountered while discussing the health of African women.

Over their life course (childhood to adulthood), women experience changes in their health needs that rarely get the required attention. The life expectancy of African women is significantly reduced when compared to their Western counterparts. This is due to a myriad of environmental and sociocultural factors that affect the livelihood of people in this region. According to data from the World Health Organization (WHO), the average life expectancy of women in the Africa WHO region is 58 years compared to more than 80 years in other climes.

The female gender in Africa is at risk of death or being significantly disabled from issues relating to childbirth, gender-based violence, communicable diseases, non-communicable diseases and cancers. As of 2020, a Joint United Nations Program on HIV/AIDS(UNAIDS) report showed that women and girls contributed to 63% of new HIV infections in sub-Saharan Africa.

Related: 12 Top African Women's Health Issues And How To Take Action

 

Why Is Identifying Social Factors Shaping African Women’s Health Important?

There is an adage from the Eastern region of Nigeria that states "A man who cannot say where the rains began to beat him will not be able to say where they stopped beating him." It simply means that determining the end may be difficult if the genesis of anything is unknown. Recognising an issue is half of the solution.

Stakeholders in health often spend a lot of time discussing and strategizing about how to enhance the health of African women. However, we sometimes fail to do a root cause analysis of African women's health challenges. Some of these issues are frequently disregarded in the formulation and implementation of public policies. There is a fundamental need to rethink approaches to improving women’s health by taking notice of the social factors that affect their health. This understanding would facilitate targeted interventions for the improvement of women’s health in Africa. 

This article aims to identify and review the root causes of social factors impeding women’s health in Africa towards developing targeted public policy solutions.

           

What Are the Social Factors Shaping African Women’s Health?

The social factors that shape women’s health iin Africa nclude: 

• Economic 
• Low/lack of Education and health literacy
• Cultural 
• Political and Legal 
• Health system
• Social support 
• Environmental 

While some of these factors are limited to women, some cut across both genders.

Social factors shaping African women's health. Click on image to enlarge. 

 

Economic Factors

The African continent raises women to traditionally have a role only at home. Because of this, priority is not placed on making them financially viable. Weak financial capacity has been identified as a determinant of poor health conditions.  Most women are either unemployed or underemployed and this affects their inclusive participation, decision making and access to health care.[2]  

Women also have limitations in accessing micro credits and other social services that will improve their economic status. Furthermore, women’s right to property ownership also hinders their economic empowerment. The lack of economic empowerment significantly limits a woman’s access to preventive and curative care as health expenditure in Africa is mostly out-of-pocket (OOP).

Education and Health Literacy

Education is identified as a key determinant of health generally. For women, access to education is linked to improved maternal health, reduced number of children, improved child survival and reduced risk of contracting HIV. It closes the gender gap in both health and mortality. [3] Lack of formal education directly influences health outcomes. It also indirectly worsens health outcomes through a lack of employment and income. 

Education influences a person’s behaviour and opportunities. It therefore reduces socioeconomic and gender disparity in health access. Findings from the National Demographic Health Survey in Nigeria (NDHS) showed that up to 35% of women aged 15-49 years had no form of education, unlike 22% of their male counterparts. [4] This scenario is similar to the situation in many other African countries.

Because of the low level of education among women in Africa, they are rarely qualified to occupy key executive or management positions that would make them stakeholders in policy making. The situation has been improving over the years although there is still a deficit, especially in the grassroots.

Lack of education reduces access to health education as the uneducated will not be able to access health literacy information delivered through print and electronic media or a non-native language. This is why there are a lot of deaths due to preventable diseases like cervical cancer.

Cultural and Social Norms

There are cultural and social norms in Africa that reduce the rights of women leading to gender inequality and inequity.  African society is predominantly patriarchal. Thus the power relationship between a woman and her husband influences access to and control over resources and decisions on how to expend resources. This ultimately has implications for her health. A culture in which women have to obtain consent and financial help from their husbands before accessing health care is inimical to the health of women. [2]

This handicap is also supported by a study that found that a husband’s perception of pregnancy affects the utilisation of maternal care by the wife. [5] There are cases in which women couldn’t receive life-saving medical care because their husbands or in-laws refused to consent. [5] 

Harmful cultural practices like Female Genital Mutilation (FGM) increase the risk of infection, bleeding, infertility and even death. Data shows that of the 230 million girls and women who have undergone FGM, 144 million are in Africa.  

In addition, early marriage is a cultural norm in some localities. This increases the risk of reproductive problems like obstructed labour and vesicovaginal fistula (an abnormal connection between the bladder and the vagina).  Early marriage also reduces the chances of getting educated and having gainful employment.

Other harmful cultural practices include male (son) preference, wife inheritance (forced inheritance of a widow by the husband's male relatives), child slavery, gender-based violence and food taboos. Gender discrimination is tolerated in some African countries and this encourages sexual coercion and sexual violence against women. The adolescence period is a time of marked vulnerability to sexual violence, especially for girls. 

Exclusion from land and property ownership is another social norm that increases the financial and social vulnerability of women.

Political and Legal Factors

The political environment determines the availability, accessibility and quality of health services. Therefore a favourable political climate is imperative for the improvement of the health of the populace.

The political and legal climate in Africa at the moment does not give women enough room to attain the best possible state of health. The political climate is marred by violence, torture and intimidation and this reduces women’s participation in politics. Their poor representation in politics reduces their power to influence laws and policies that will improve the health status of their gender.

Government policies determine the budgetary allocation to health, access to health insurance, and the allocation of health personnel. In most African countries the budgetary allocation is less than desired. The implication is increased out-of-pocket health expenditure.

Another issue that adversely affects the health of women in Africa is the absence of laws that facilitate access to reproductive health services, leading to an increase in the rates of unwanted pregnancies and unsafe abortions.  There is also poor adoption of international regulations/charters that improve women’s health and poor enforcement of local regulations.  The Abuja Declaration of 2001 and the Maputo Protocol of 2003 are examples of international agreements reached by African Heads of State that are yet to be ratified by some member states. Even in some countries that ratified them, they are yet to be implemented.

Related: 6 Conditions that Put Pregnant African Women at Risk of Death

Healthcare System Factors

The inability to provide quality healthcare to women in Africa is one of the drivers of the dismal women's health statistics in Africa.  Universal Health Coverage (UHC) ensures that all people have access to the full range of health services they need, when and where they need it without financial hardship. Unfortunately, most African women are still unable to optimally access health care due to a myriad of factors. [6] 

A woman sitting and her mid-upper arm circumference being measured with a tape by a nurse (standing). Credit.

 

In Africa, there is a disproportionate distribution of health facilities with more located in the urban areas, leaving the predominantly rural population underserved. Even where the facilities are present, they are poorly equipped and poorly staffed.  Primary health care is crucial to achieving UHC, but in most locations, primary health care is either not available or nonfunctional. Because of the suboptimal primary health care, maternal health care is also significantly affected. 

An African woman standing with her back to the camera with her toddler son on her left arm, Credit. 

 

Africa faces a critical shortage of qualified and motivated health workers. This has been made worse by the current wave of brain drain or human capital flight that has hit the region.  This is coupled with insufficient training of health personnel to fill the existing gap.

Most African countries still have budgetary allocations that are well below 10%. This poor budgetary allocation to health and insufficient insurance coverage leads to high out-of-pocket spending on health. This has been shown to impair access to health by African women who are already economically disadvantaged. The resultant effect is poor health outcomes. Fortunately, it is not all bleak as some African countries like Rwanda have improved access to health services by implementing a health financing scheme to cover more than 90% of their population. 

The resultant effect of all these challenges is that the poorly educated, unemployed or underemployed woman living in a patriarchal society will not be able to sufficiently access these health services. I recently encountered a 26-year-old woman whose two-year-old child never received any form of vaccination. The reason she gave for the lack of vaccination was the absence of a primary health care centre in her locality.

A review was done to evaluate the access of women to healthcare for high blood pressure and diabetes in South Africa. [7] The results showed that factors that limited access to care for these non-communicable diseases were; 

• the perception of healthcare services
• drug stock out
• an inadequate workforce
• limited availability of equipment
• transportation difficulties and 
• lack of affordability 

Social Support Networks

In Africa, families are organised communally. A family's understanding of an illness is influenced by societal standards, education, religion, and culture. Members of the family cannot seek orthodox care if they believe that the origin of their ailment is spiritual. As a result, a woman's access to healthcare is significantly influenced by how her extended family views her condition. [8]

The ancestry-focused, patriarchal, male-dominated extended family structure promotes a man's primary duty to his parents and siblings. Such an arrangement may affect a woman’s confidence, decision-making power and access to health care. Some families also have food taboos and this may also affect the health of women, especially during pregnancy.

Women's groups contribute to the advancement of women's rights by providing a forum for women to relate their challenges and collaboratively propose solutions. They also help to mobilise investment resources, which boosts their economic empowerment. Community-based support can also empower women by promoting healthier habits and campaigning for improved health policy. 

Eleven women sitting on the floor with smiles on their faces There is a girl beside the mother and a boy standing behind them, Click on image to enlarge. Credit.

 

However, some of these community groups may negatively affect access to health.  There are societies in Africa where such women groups are instrumental in enforcing harmful practices like female genital mutilation (FGM), early marriage and widowhood rites.

Strong social support networks improve psychological resilience in women facing intimate partner violence (IPV). A study supporting the notion of resilience from social support discovered that women with supportive communities had higher psychological resilience, for depression and post-traumatic stress disorder. [9] Non-Governmental Organizations have been instrumental in improving women’s health in this regard as they help to strengthen women’s capacities economically, socially, politically and culturally. Women have relied on social support networks like the Network of People Living with HIV/AIDS in Nigeria (NEPWAN) to cope with stigmas, depression and familial concerns

Environmental Factors

Environmental factors like poor housing, lack of access to clean water, overpopulation, poor drainage and sewage facilities, and air and noise pollution have detrimental effects on women’s health in Africa. The risk of diseases like malaria and other vector-borne infections is significantly increased in an unhealthy environment. 

An African  girl is sitting on a bed, reading a magazine with the insecticide-treated net hung on the bed. Click on image to enlarge. Credit. 

 

It is estimated that between now and 2050, more than half of global population growth is expected to occur in Africa. This implies reduced access to clean water, sanitation and hygiene. In many regions of Africa, women bear the brunt of this and are responsible for fetching water and collecting firewood from distant locations, tasks that expose them to physical strain and environmental hazards, 

Two women with heavy jerry cans strapped on their backs walking on a rocky terrain. Click on image to enlarge. Credit.

 

Women are often burdened with the responsibility of cooking with firewood or other solid fuels in poorly ventilated homes, exposing them to harmful smoke. Air pollutants like Nitrogen dioxide (NO2) and Ozone resulting from indoor stoves have been linked with reduced fertility, increased pregnancy complications. and respiratory problems [10,11, 12]  Air pollution causes climate change and its unmitigated effect on crop production reduces food security and increases the burden of malnutrition.

In some urban slums and rural communities, unfavourable living conditions and inadequate waste disposal techniques increase the risk of water and food-borne diseases such as cholera and typhoid. In addition, insecurity in some African urban slums increases criminality and sexual violence, such as rape.

 

Effective solutions for improving African Women's Health

Investing in women’s health is crucial as the health of the woman directly affects her children. It is an investment into the future. It also leads to economic development as women form up to 50% of the workforce.  Improving the health of women in Africa requires a multisectoral approach. This will involve targeted interventions aimed at improving the social determinants. Policymakers, development partners, in-country health sector stakeholders and community stakeholders need to work in synergy to deliver these interventions.

The interventions should include

I. Public policy reforms::

• Economic empowerment by granting access to microloans (credit) and creating a conducive work culture that enables women to fully take part in the job market, even as nursing mothers.

• Commitment of more resources to the enforcement of girl child education. In addition, social norms that limit women's literacy should be challenged and corrected. 

• Elevating women's voices by encouraging inclusion in politics and attainment of top political positions that would make them participate in decision-making.

• Strong political will to launch and sustain women's health-focused investments and activities. Women must be involved as essential stakeholders. Programmes and policies aimed to enhance women's health should therefore recognise women's capability to mobilise resources and take advantage of their ability to initiate change.

• Community education and awareness campaigns on changing social norms and cultures that negatively impact women’s health.

• Promoting legal reforms to preserve women's reproductive health and social rights, enabling access to reproductive health care.  A strong legal framework also makes it easier to turn policy into actionable steps.

• Developing a health system responsive to women’s needs and providing quality, accessible and comprehensive healthcare to women and girls, especially those in isolated communities. This will include the provision of Emergency Obstetric Care in rural communities.

• Developing and enforcing strong national health policies that will reduce gender inequity and improve the health of women. 

• Implementation of the existing international agreements to improve access to health care for women.

• Making insurance compulsory for women and other vulnerable groups.

• Increasing the budgetary allocation to health with a priority on maternal health services and Primary Health Care.

• Improving management information systems and data collection on women's health indicators through the use of Electronic Medical Records(EMR) and Demographic Health Surveys.  This would provide quality data that would enable data-driven decisions and solutions.

• Ensuring equal distribution of the health workforce in both rural and urban locations. This would be accomplished by creating a positive work environment to minimise brain drain and also training new health workers and retraining current health workers. It will also involve task shifting to lower cadre personnel. 

• Addressing the housing challenges and enforcing environmental laws that reduce pollution and climate change.

• Encouraging women's participation in community-based women's support groups with the right mission and vision. 

II. Women and Community roles:

• Establishment of community women support groups to provide mentorship, peer support, advocacy and community literacy.
• Community stakeholders like religious and traditional leaders should leverage their influence to dispel misconceptions and promote health-seeking behaviours.
• Discouragement of harmful cultural practices by community stakeholders
• Partnership between the community stakeholders and health facilities within the community to enhance access by the vulnerable.
• Advocacy for women’s health rights by Non-Governmental Organizations(NGOs)  and Community-Based Organizations(CBOs) 

Conclusion

Under the Universal Declaration of Human Rights of 1948, Health is a fundamental human right, and women have equal entitlement to it as men. Access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition, and housing, healthy occupational and environmental conditions, and access to health-related education and information, including sexual and reproductive health, are all examples of such rights. Ensuring women's rights requires appropriate investment in women's health. Religious institutions and community leaders, health workers, policymakers, development organisations, and the government all have important roles to play in the drive to improve the health of African women.  

 

References:

1. WHO | Regional Office for Africa [Internet, n.d.]. Cited 2024 Jun 15. Women’s Health. Available from here.  

2. Lowe M, Chen DR, Huang SL. Social and cultural factors affecting maternal health in rural Gambia: an exploratory qualitative study. PLoS One. 2016 Sep 23 11(9):e0163653. doi: 10.1371/journal.pone.0163653. Available from here.

3. Ross CE, Masters RK, Hummer RA. Education and the gender gaps in health and mortality. Demography 2012 Nov 49(4):1157–83. doi: 10.1007/s13524-012-0130-z. Available from here.

4. National Population Commission (NPC) [Nigeria] and ICF. 2019. Nigeria Demographic and Health Survey, 2018, Abuja, Nigeria and Rockville, Maryland, USA: NPC and ICF. Available from here.  

5. Azuh D, Fayomi O, Ajayi L. Socio-cultural factors of gender roles in women’s healthcare utilization in southwest Nigeria. Open Journal of Social Sciences 2015;3(4):105–17. DOI: 10.4236/jss.2015.34013. Available from here.  

6. Azuh D, Ogundipe A, Ogundipe O. Determinants of women's access to healthcare services in sub-Saharan Africa Open Public Health Journal 2019. 12-504. DOI: 10.2174/1874944501912010504   Available from here.  

7. Gizamba J, Davies J, Africa C, Choo-Kang C, Goedecke J, Madlala H, et al. Women’s access to health care for non-communicable diseases in South Africa: A scoping review. [Internet]. F1000Research; 2024 .11:990. doi: 12688/f1000research.123598.2. Available from here.

8. National Research Council (US) Committee on Population; Gribble JN, Preston SH, editors. The Epidemiological Transition: Policy and Planning Implications for Developing Countries: Workshop Proceedings. Washington (DC): National Academies Press (US); 1993. Roles of Women, Families, and Communities in Preventing Illness and Providing Health Services in Developing Countries. Available from here.

9. Machisa, M. T., Christofides, N., & Jewkes, R. (2018). Social support factors associated with psychological resilience among women survivors of intimate partner violence in Gauteng, South Africa. Global Health Action, 11(sup3). doi:10.1080/16549716.2018.1491114. Available from here.

10. Kumari U, Sharma RK, Keshari JR, Sinha A. Environmental Exposure: Effect on Maternal Morbidity and Mortality and Neonatal Health. Cureus. 2023 May 4;15(5):e38548. doi: 10.7759/cureus.38548. Available from here.

11. Conry J. Environmental factors facing women’s health | FIGO [Internet]. 2018 July 30]. Cited 2024 Jun 17. Available from here. 

12.Lamere, C. UNEP highlights environmental impacts on health in Africa. New Security Beat. Wilson Centre. [Internet, 2013 March 20]. Cited 2024 Jun17. Available from here. 

       

 

Published: June 23, 2024

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