Missing women? The health inequalities impact of low control and gender discrimination: a theory-led systematic review of observational studies

Background Increasing control and empowerment are considered central to efforts to reduce health inequalities. From our critical review of theory, low control emerged as a potentially fundamental mechanism underlying social inequalities in health. Amartya Sen’s theories of “freedom” and “capabilities” to live a long and healthy life focused attention on the health consequences of a lack of freedom for women in contexts with pervasive gender discrimination. We conducted a systematic review to address the question: what is the empirical evidence of the relationship between control in the living environment and health inequalities. Findings on gender inequalities are presented here. Methods Logic models were used to guide our search strategy. Studies were identified by searching seven bibliographic databases, screening reference lists, consulting key informants and searching websites. Observational studies that addressed our review question were included. Data extraction and quality appraisal were carried out by two reviewers, with disagreements brought to the wider team, followed by a narrative synthesis. Results We identified 40 studies that reported findings on the health-related outcomes of low control/discrimination against women, 35 were set in low and middle-income countries. There is evidence that women with low control have reduced freedom of movement and control over determinants of health such as access to food, household resources, healthcare, education, employment and reproductive rights. Low control was associated with increased anxiety, stress and depression, increased childhood malnutrition and mortality, higher fertility, poorer reproductive health and increased violence. Son preference, in societies characterised by low female control and discrimination, is associated with reduced survival of girls; resulting in the phenomenon of “missing women”. The effects of gender discrimination on survival begin before birth through selective abortion of female foetuses, leading to distorted demographics. Conclusions There is empirical evidence of an adverse impact on the health of girls and women living in societies in which they suffer low control and gender discrimination. Measures to improve the economic, social and political position of women are advocated. Key messages From our critical review of theory, low control or powerlessness emerged as a potentially fundamental mechanism underlying social inequalities in health. Our systematic review found evidence that low female control and discrimination at the societal level was associated with reduced survival and other adverse health outcomes for girls and women