In 2013, anthropologist Lila Abu-Lughod famously asked the question, “Do Muslim Women Need Saving?” She challenged the stereotype of the Muslim woman, who is often portrayed solely as oppressed, meek, and subject to appalling practices like so-called “honor” killings. While not denying the existence of these injustices, Abu-Lughod argues that an artificial concern for women based on these perceptions has been used to justify foreign intervention. Yet a similar form of discounting Arab women occurs in many of the countries of the Middle East and North Africa.
In a number of Arab states, women’s health is poorly resourced and some aspects may be considered inappropriate to discuss openly. Educational and economic gender disparities have made women less aware of their health needs and rights and less able to receive the services they desire. Both perspectives of women––those from within and without––claim to be rooted in a push for their protection. In reality, the lives of these women are complex and there are powerful ways to protect their health and well-being that should be grounded in gender-inclusive policies and shifting cultural gender norms.
Sociocultural Factors Unique to Arab Women’s Health
Women of the Arab world are diverse in terms of ethnicity, religion, and culture. Nevertheless, there are some regional trends that uniquely affect the approach to health care in the region. Islam and other spiritual elements play a significant role in women’s view and response to their health needs across educational and socioeconomic lines. As one Palestinian woman said in a 2013 study, “Of course screening for cancer is important … but it won’t change the fact that health and illness are in the hands of Allah.” While religiosity offers comfort in the face of ill health, it may cause some to avoid seeking health care until absolutely necessary.
Cultural beliefs and traditions are also considered a valid consideration in health. One example is the belief that some mental disorders are in fact manifestations of the “evil eye” or the influence of jinn, leading a person to seek care from a traditional healer rather than a medical professional. The same cultural beliefs have caused a higher prevalence of complementary and alternative medicines in Arab countries than in many other regions, especially those practiced by women. These traditions can range from prayer and use of blessed water from Mecca (Zamzam water), to ingesting honey, camel milk, or herbs like yansoon (anise), to practices like al-hijamah (cupping therapy). While some of these traditions have shown clinical efficacy or are not harmful, some of these herbs have been found to have safety issues. Women with limited education, or those living in areas with limited access to health care facilities, are especially likely to utilize these traditional techniques.
Refugee women have specific needs that humanitarian agencies try to address, but gender disparities persist in the care of these extremely vulnerable populations.
The Arab world also hosts a disproportionate share of the world’s refugee population, half of which is comprised of women. Refugee women have specific needs that humanitarian agencies try to address, but gender disparities persist in the care of these extremely vulnerable populations. A study of Palestinian refugee women in Jordan found that due to their care provision from the United Nations Relief and Works Agency, they were more likely to use contraceptives than Jordanian women, who relied on government services. At the same time, refugee women are at higher risk for domestic abuse. Women in refugee camps are also more subject to rape and sexual harassment; they are also at higher risk for sex trafficking. This indicates that it is easier to provide goods and services than change norms and behaviors.
Advances in Reversing Maternal Mortality Rates
Maternal mortality, as defined by the World Health Organization, is the death of a woman either while pregnant or shortly after. Because these deaths are typically preventable in a functional health system, maternal mortality has long been used as a reflection of a country’s overall health status. Additionally, the correlation of maternal mortality rates with socioeconomic, political, and cultural factors has rendered this statistic one of the ways to assess a country’s overall development. By this measure, the Arab world has progressed in recent decades, achieving significant reductions in maternal mortality in most countries. Exceptions include Somalia, with one of the highest rates in the world, and Yemen. Both are very poor countries with high levels of conflict and ineffective governance.
On the other side of the spectrum, the Gulf states report some of the lowest maternal mortality rates in the world. Yet few would argue that these states are bastions of women’s equality. Lebanon made decreasing maternal mortality a priority after its civil war; as a result, the country reported the greatest rate of reduction in the Middle East for many years in a row. Algeria, however, made similar investments but its maternal mortality rate remains high, in part due to migration and poor infrastructure. While a country’s economic status is a significant predictor of its ability to decrease negative health outcomes for women, there are clearly other factors to consider.
Unhealthy Gender Norms
The decrease in maternal mortality follows other positive trend lines for women in the Arab world, including significant increases in literacy, educational attainment, and employment in recent decades. However, traditional gender norms in many Arab countries persist, affecting women’s health and autonomy. While this is in part attributed to more strict interpretations of religious texts in some states, other factors like the perpetuation of poverty, conflict, and authoritarian regimes have contributed significantly to gender disparities across the region. These norms become internalized expectations and are often supported by the women as well. Many women across the Arab region choose—or are expected—to put aside their own health and well-being to prioritize the care of their families.
Many women across the Arab region choose—or are expected—to put aside their own health and well-being to prioritize the care of their families.
Aside from the disempowerment aspect, these gender norms can be dangerous; one study from Saudi Arabia in 2014 found that women experiencing heart issues reported a pre-hospital delay more than double that of men because they were either waiting for a male’s permission to seek medical help or prioritizing household duties over their own health, or they believed that they should not be attracting attention. The Saudi male guardianship system has been notorious for its restrictions on women, including on their health: it was not until 2012 that adult women could sign their own forms at health facilities without a guardian. While there is no law prohibiting women from seeing male doctors, a woman’s guardian can delay or impede her seeking such care with no consequence, as many Arab men prefer that female family members receive care from women providers. Yet the Eastern Mediterranean Region reports one of the lowest rates of female physicians in the world: only 35 percent. At the same time, women make up 79 percent of nurses, who are often underpaid and not viewed as authoritative as doctors. It is noteworthy that while some women and more conservative family members may prefer that a woman see a female doctor, in some instances the perception of a woman as a caretaker may lead both men and women to prefer a female provider, such as when receiving counseling services.
Reproductive and Maternal Health
Even in states with the resources to pursue high-level health initiatives, a woman’s health may not be broadly addressed outside of her role as a person who may get pregnant. While it is socially accepted to pursue a target like reduced maternal mortality, for example, it is still controversial in some circles to discuss issues like a woman’s mental health during pregnancy or after losing a child, contraception, and abortion. Having many children is still valued in many Arab households, although fertility rates have dropped significantly. In the 1980s, it was not uncommon for an Arab woman to have six or seven children. Today, there are few Arab states where women have more than three children. These changes are due in large part to the increased education of women, the decline in arranged marriages, the trend of younger couples moving away from their hometowns and families, and the desire in many households to invest more resources in fewer children, especially considering the volatility in the region. Yet in some states, primarily in the Gulf, fertility rates have dropped to the point where the population may not be able to maintain its size. Additionally, norms on childbearing persist; for many couples, it is the man who makes decisions on family planning and spacing between children. In Oman, for example, less than one percent of women reported using contraception before their first child because their husbands decided whether contraception was used, and most were expected to have a child shortly after marriage.
Norms on childbearing persist; for many couples, it is the man who makes decisions on family planning and spacing between children.
Practices like early and forced marriage have been decreasing overall, but they are still present even in the highly developed Gulf states. For instance, 20 percent of women in the Arab region report marrying before age 18, which further puts women’s health at risk. Female genital mutilation (FGM), also decreasing in prevalence, is still common in countries like Sudan and Egypt, where fully 87 percent of women have undergone FGM. Abortion, an issue considered taboo across the Arab world, is permitted in most Arab states if the mother’s life is in danger, and other exceptions exist in some countries for fetal impairment or in instances of rape. Many of the existing anti-abortion laws are remnants of the colonial era and, in reality, abortion practices vary. For example, an abortion is criminalized in Lebanon and Morocco, but women with means can easily obtain one if needed, thus perpetuating economic disparities.
As most of the countries in the Arab world have experienced significant development and growth in recent decades, non-communicable diseases like heart disease, cancer, and diabetes have increasingly become the leading causes of death for both genders. Many of these ailments are brought about by lifestyle choices, and this is especially evident with women. Lack of women-specific health and fitness facilities, a cultural predilection for modest dress in most Arab states, and a woman’s primary role as a caregiver to others are factors that make it difficult for women to engage in exercise. Coupled with physically undemanding jobs, the rise of domestic help in the Gulf states, and an increase in poor diet habits, the obesity gender gap is higher in the Arab world than any other region. In Tunisia, more than a third of women are obese, compared to less than 10 percent of men. In Kuwait, where men’s obesity rates are already a staggering 35 percent, more than half of all adult women are classified as obese. Most of these individuals will experience comorbidities with obesity: Kuwait’s first national health survey in 2013 found that 77 percent of obese women were also diabetic and multiple studies over the past two decades have found similar correlates throughout the Arab world.
Breast cancer incidence varies significantly across Arab countries, from 14 to 42 percent of all cancers in women, and is one of the most common cancers that afflicts women in the region.
It is thought that these lifestyle factors, coupled with longer life spans in the region, are leading to significant rises in cancer rates. Breast cancer incidence varies significantly across Arab countries, from 14 to 42 percent of all cancers in women, and is one of the most common cancers that afflicts women in the region. Obesity has been shown to be a significant risk factor for breast cancer in Arab women, along with illiteracy and lack of education. Aside from lack of exercise and poor diets, behaviors like smoking have persisted in some Arab states despite their reduction across the world. Women in Lebanon report the highest female smoking rates in the region, using both cigarettes (37.7 percent of women) and water pipes (21.6 percent). As this increase in smoking among women is relatively recent, we should expect an increase in lung cancer cases in coming decades.
The suffering, displacement, and political machinations of the 20th and 21st centuries have been hard on all residents of the Arab world, who report high levels of mental trauma. Yet, many studies have shown that Arab women report a higher prevalence of mental disorders than men, especially with depression. Of the top 10 countries where women report high levels of depression, seven are in the Middle East/North Africa region. Longitudinal research suggests that this is due to many of the factors discussed elsewhere in this brief: domestic violence, lack of empowerment, higher-than-desired birth rates, unmanaged postpartum depression, and socioeconomic disadvantages. The prevalence of postpartum depression in Arab states, with estimates ranging from 10 percent in the UAE to 51.8 percent in Egypt, may be caused by the feeling of not meeting religious or societal expectations, unemployment, a poor relationship with the husband’s family, and lack of understanding of postpartum depression as a valid psychological ailment.
Safety and Abuse
Gender disparities in the Arab world become particularly sobering when considering incidence of intimate partner violence. While estimates vary across surveys, data from the region suggest at least around 30 percent of Arab women have experienced some form of physical, sexual, emotional, or economic abuse, largely due to entrenched norms within some communities that promote male authority over women. At the same time, women are discouraged from reporting abuse or may not even recognize controlling or oppressive behaviors as abuse. In some contexts, sexual harassment is a nearly daily occurrence for women. A landmark 2013 study by the United Nations found that 99.3 percent of women in Egypt reported some form of sexual harassment, especially on the streets or when using public transportation. A follow-up study found that 43 percent of Egyptian men believed that women like the attention from sexual harassment; the same survey found that 71 percent of Moroccan men agreed as well.
Global lockdowns due to the COVID-19 threat have increased the number of women who are looking for help as they are made more vulnerable.
Global lockdowns due to the COVID-19 threat have increased the number of women who are looking for help as they are made more vulnerable. In April 2020, a man in Iraq allegedly set his wife on fire; she later died from the resulting injuries. Sixty two percent of women in Jordan reported being at higher risk for violence during the lockdown, and seven percent of women at a shelter in Egypt revealed that their husbands abused them for the first time after the imposition of the COVID-19 curfew.
Arab women have made significant strides toward gender equality, with some of them giving their freedom or their lives for this goal. Yet as is the case throughout the world, men need to be brought into the process as allies, especially as men hold most decision-making roles—indeed, no Arab country has a female president or prime minister. This is also the case with health and well-being. Only a few Arab countries, including Egypt and Palestine, have a female minister of health. Perhaps as a result, the MENA region reports the fewest laws protecting women from domestic violence and sexual harassment, although reforms have been accelerating in the period since the Arab Spring. Such efforts should be prioritized by policy makers and cultural leaders.
Reform at the top is vital to the protection of women’s health. However, targeting gender norms and stereotypes begins in the home. Men must be educated about the reality of domestic abuse, harassment, and empowerment of the women in their lives. Additionally, Arab women perform 4.5 times more caregiving work than men, which does not permit them time and energy to care for their own health or pursue advanced careers in health care. Gender-transformative initiatives focusing on the attitudes and behaviors of men as well as women will be necessary to change norms and policies throughout the Arab world.
Reducing the stigma of health issues, particularly with mental health, is crucial for improving women’s health in the Arab region. Women should also be encouraged to find support for psychological ailments related to pregnancy, domestic abuse, and feelings of being devalued. The clinical factors of mental health must also be made clearer in some populations so that such issues are considered as another health condition to address with a medical professional, rather than as a personal or moral failing. In particular, postpartum depression should be recognized as a common occurrence with new mothers, one that is easily managed with familial support and, at times, medical intervention.
While health-related data collection is lacking across the Arab world, it is especially inadequate when it comes to issues specific to women’s health, like domestic abuse, abortion, and mental health—and gender-segregated data in general. This is in part due to the common practice of surveying entities, including ministries of health, to avoid controversial questions, as well as populations feeling uncomfortable about reporting on such personal issues. Evidence-based recommendations require data, and in a region with such preexisting gender disparities, it is imperative to track issues of concern or areas for improvement in order to evaluate successes or see where harmful practices or attitudes persist.
Lastly, women, especially those with less formal education, must become a primary audience for public health campaigns that consider issues like diet, exercise, smoking, personal safety, healthy pregnancy, and mental health. States and organizations should also invest in researching the effectiveness of known remedies and integrating them safely into traditional care models, when appropriate.
Yara M. Asi, PhD, is a Lecturer of Health Management and Informatics at the University of Central Florida.