The state of women's health in the European Community

Executive summary

Introduction
Social and Demographic Trends
Selected Health Indicators
Morbidity
Causes of Death and Trends in Female Mortality
Health Determinants and Health Promotion
Special Issues in Women's Health
Conclusions

1. Introduction

This report provides an overview of the health of women in the European Community (EC), highlighting both differences and similarities within and between the Member States. It examines the main causes of mortality and morbidity at different phases of women's lives as well as a number of individual and social determinants which influence women's health within the context of evolving demographic and social trends.
The main data sources include the World Health Organization's Health for All (HFA) database, various reports and data from the Statistical Office of the European Communities (Eurostat), and an EC-wide Eurobarometer survey, sponsored by DG V and carried out in early 1996. The latter survey contained a number of questions on women's health which are analysed in this report.
The data obtained from sources are, despite continuing improvements in quality, somewhat limited in their comprehensiveness and comparability. The choice of topics included in this report is to a large extent the result of these constraints. The report focuses on women aged 15 years and older, because most gender-specific health data at the EC level concentrate on this age-group.
The report consists of 8 sections. Section 1 introduces the report, Section 2 summarises the social and demographic trends affecting women, and Section 3 provides an overview of selected health indicators. Supplementing this information, Section 4 describes selected morbidity measures, while Section 5 concentrates on the main causes of death among women. Section 6 contains a discussion of various health determinants, while Section 7 describes a number of emerging health issues for women. Section 8 concludes the report.

2. Social and Demographic Trends

Women - totalling 191 million - constitute 51.2% of the population in the EC. This percentage is remarkably stable across the Member States, varying only from a low of 50.4% in Ireland to a high of 51.8% in Portugal. There is, however, considerable variation in the percentage of women across age-groups. In the group of women under 20 years of age, there are only 95 women for every 100 men, while among 80-year-olds, there are about 221 women for every 100 men. This so-called feminization ratio is particularly high in the older age-group because in the EC women on average live over 6 years longer than men.
Women's lives have changed significantly in the EC during the past three decades. The rate of marriage has declined (by almost one third) since 1960, while the rate of divorce has almost doubled(except in Ireland). At the same time, the average age of first marriage and the age at first birth have risen to 26.1 and 28.6 years, respectively.
At the same time, women's labour force participation has increased tremendously, although considerable variations exist in this area across the Member States. Concomitant with the increase in labour force participation has been an increase in women's unemployment rates, which tend to be higher than those of men.
When measuring women's position in society relative to men, women in the EC do well in comparison with women elsewhere. Within the EC, the Nordic Member States have the highest rates of gender equality, in part because of high levels of education and income relative to men.

3. Selected Health Indicators

Women in the EC enjoy a high level of health as measured by a variety of health indicators. Life expectancy has been rising continuously for decades and has reached 80 years, which is well over 6 years higher than the corresponding average for EC men. This average, however, hides considerable variation across the Member States, ranging from a high of 81.9 years in France to a low of 77.8 years in Denmark.
Infant mortality has also been improving to the point that the most recent data (1992) indicate that only 6.9 (female) children out of 1000 live births die before the age of 1 year. This is a decline of 68% since 1970. Maternal mortality rates have also declined significantly (79% since 1970) to 7 deaths per 100,000 women.
According to ratings of self-perceived health status, women in the EC regard themselves as healthy (or very healthy). On average just over 62% report being in good or very good health. Rates vary across the Member States and across age-groups, with older women reporting lower levels of health, which is to be expected.
Height measurements indicate that women have been getting considerably taller during the past decades. Younger cohorts (18-29 year-olds) are almost 5 cm taller than older cohorts (60 years and older).

4. Morbidity

Disease-specific morbidity measures are virtually non-existent at the EC level. Instead aggregate measures, such as short- and long-term disability and health care utilisation, are reported.
In spite of women's generally good health status, they report significant levels of disability due to long-term illness. On average, almost one out of four women report limitations in their daily activities to some extent (17.3%) or severely (6.3%) because of long-standing illness. This average varies from a high of 30% (in Finland and Portugal) to a low of 15% (in Luxembourg) and increases with age. More than half of all women aged 75 years and older report such activity limitations.
On a short-term basis, women also report considerable activity limitations. About 14% of women report having had to cut down on their activities in the past two weeks because of illness and injury, while 3% report having experienced such restrictions because of emotional or mental health problems. Among women aged 65 years and older, the corresponding figures are 25% and 5% respectively.
While not all chronic and short-term disability necessarily needs a doctor's attention, apparently a significant amount does. The results of the 1996 Eurobarometer survey indicate that on average one out of three women has consulted with a physician (in person or by telephone) in the past two weeks. Not surprisingly, older women report higher rates of consultation.
A small percentage of serious illnesses is likely to require hospitalisations. On average 10% of EC women report having had one or more (non-birth) hospitalisations in the past year, staying about 10 days in the hospital in total. Older women are about twice as likely as younger women to have been hospitalised, and they tend to stay longer as well.

5. Causes of Death and Trends in Female Mortality

Across all ages, the most frequent causes of death among women are diseases of the circulatory system, accounting for 43% of all deaths, and cancer, which accounts for 26% of these. Diseases of the respiratory system are responsible for 6% of deaths among women, and suicide and accidents for 5%. The remaining 20% of deaths are due to other causes.
As might be expected, the major causes of death vary with age. Motor vehicle accidents are the main cause for women under 30 years, while suicide is for the 30-34 age-group. Cancer, specifically 'female cancers', such as breast and cervical cancer, is the main cause of death for women aged 35-64 years. For elderly women (65 years and older), diseases of the circulatory system account for most deaths, approximately half of all deaths in this age-group.
Average mortality (for all women) from motor vehicle accidents is 6.42 deaths per 100,000, while mortality from suicide and self-inflicted injury is 6.24 per 100,000. Mortality from cancer among women of all ages is about 150 deaths per 100,000, while mortality from diseases of the circulatory system (heart disease and stroke) is about 248 deaths per 100,000. Mortality due to ischaemic heart disease alone amounts to about 85 deaths per 100,000, while stroke mortality is almost 76 per 100,000.
Breast cancer accounts for 21% of all female cancer deaths in the EC, with a mortality rate of about 31 per 100,000. By contrast, cervical cancer is responsible for only about 2% of all cancer deaths in women, with a mortality rate of about 3 per 100,000.
Mortality from cancer of the respiratory system - predominantly lung cancer - has increased by almost 70% since 1970. It currently accounts for about 9% of all cancer deaths in women, with a mortality rate of 14 per 100,000.

6. Health Determinants and Health Promotion

To a very large extent the two major causes of mortality (heart disease and cancer) are preventable through primary (healthier life styles) or secondary prevention (early detection through, for example, screening). The main risk factors associated with much premature mortality (death before aged 65 years) include smoking, (excessive) alcohol consumption, unhealthy diet, and physical inactivity.
About 28% of all women in the EC smoke, although the rate varies across the Member States. Denmark and Portugal stand out because of their respectively very high (42%) and low rates (12%) of smoking among women. There are no data on average alcohol consumption by women at the EC level, although it is known that women drink less than men.
While data on diet are scarce, data on the outcome of eating patterns (weight) are available from the 1996 Eurobarometer. Specifically, one out of every five women are overweight (or severely overweight) as measured by the body mass index (BMI), while 15% are underweight. Being overweight is a significant risk factor for a number of diseases, in particular heart disease and diabetes.
This survey also provided information about the extent to which, and what types of health check-ups EC women receive. These vary by age-group and by country. For example, 44% of EC women over the age of 65 years has had a heart check-up in the past year, about the same percentage as has had a cholesterol test. The rates for the entire population of women are, of course, lower.
Diabetes testing is less frequent, with around 22% having had a diabetes test in the past year, although among severely overweight women (aged 40 years and older) the rate is 44%. As obesity is a risk factor for non-insulin dependent diabetes, this is to be expected.
About 16% of EC women report having had an osteoporosis test in the past year. In contrast, cancer screening rates are much higher. About 40% of women report a cervical smear in the past year, the same percentage as reporting having had a breast examination by hand. About 18% of women report having had a mammography during the past year.
Because controversy surrounds the topic of mammography in many Member States, the Eurobarometer survey inquired about women's feelings on the subject. Overwhelmingly (more than 90%), and with little variation, women endorsed (free) mammography screening in the age-groups where it has the potential to reduce mortality.

7. Special Issues in Women's Health

Several health issues have emerged during the past decades because of their particular relevance to or importance for women. These include eating disorders, which mostly afflict teenage and young women; HIV and AIDS, which traditionally has been considered a male disease, but to which women have been shown to be more vulnerable; heart disease, which also is largely seen as a man's disease in spite of the significant mortality it causes to women; and osteoporosis which is much more frequent among women than among men. In addition to these issues, family planning and abortion, as well as violence against women, should be added to this list of important women's health issues.
There is a notable lack of data on the incidence and prevalence of eating disorders (bulimia and anorexia nervosa), although the perception is that it has been increasing throughout the EC during the past two decades. Mortality in anorexia sufferers is estimated at 6%, double that for those with bulimia.
With the ageing of society, the incidence of osteoporosis is increasing. Because of the significant morbidity and mortality associated with this disease, osteoporosis is becoming a growing concern for many Member States. Hormone replacement therapy (HRT) contributes to preventing osteoporosis, but its use is still debated by health care providers. Furthermore, women seem to feel less than adequately informed about the costs and benefits of this type of therapy (according to results of the 1996 Eurobarometer survey).

8. Conclusions

This report has sought to provide as comprehensive an overview of women's health issues as possible, given the available data. It is clear that while women live long lives and report feeling quite healthy, they also have significant disability due to chronic illness. Health, as measured by a variety of indicators, typically varies across Member States as well as across age-groups. Not surprisingly, elderly women are in poorer health.
The report has also pointed to a number of policy initiatives which could help reduce the premature mortality among women in the EC.