For women around the globe, the second year of the COVID-19 pandemic brought more health challenges than the first.
In 2020, the medical technology company Hologic launched a global survey in partnership with Gallup to assess how well women's health needs were being met. Countries were scored based on women's responses to questions in five categories: general health, preventative care, mental health, safety and basic needs like food and shelter.
The overall score for the in 2021 was just 53 out of 100, one point lower than in 2020.
No country scored higher than 70 points in 2021, with Taiwan, Latvia, Austria and Denmark in the top spots. Three countries scored fewer than 40 points: Afghanistan, Congo and Venezuela. The United States landed in 23rd place, with 61 points out of 100.
"The economic and psychological burden of the pandemic will weigh down many households for a while, and we know that it particularly affected women," said Gertraud Stadler, director of the Institute of Gender in Medicine at the Charite hospital in Berlin, who was not involved in the survey.
In fact, women were more stressed, worried, sad and angry in 2021 than they were at any other point in the past decade, according to a Gallup survey that factored into the Global Women's Health Index rankings.
Women were also more likely than men to say that they didn't have enough money to afford food in 2021, a share that rose from 34% of women in 2020 to 37% in 2021.
"We understand you can only impact and improve what you measure," said Dr. Susan Harvey, vice president of worldwide medical affairs at Hologic and former director of breast imaging at Johns Hopkins School of Medicine.
"Overall, the data is sobering. And we understand that we need women to be healthy to fully engage and be empowered. It's clear that the time has come to work together and begin to find solutions and improve women's health care."
'The world is failing women'
According to Hologic and Gallup, the five key areas assessed in the Global Women's Health Index can explain most of the variation in a woman's life expectancy at birth.
For example, they found that women who said they had seen a health care professional in the past year had an average life expectancy that was two years longer than those who hadn't.
Preventive care is one area where the United States scored better in 2021 than in 2020. It ranked second best in this dimension in the Global Women's Health Index, after only Latvia.
"It was a small improvement, but we have to be joyful about that," Harvey said. "Overall, though, the world is failing women in preventive care."
About 1.5 billion women did not have access to preventive care last year, she said. And globally, fewer than 1 in 8 women were screened for cancer at any point in the past year, according to the survey.
Although the remedy for this shortcoming might seem more straightforward, experts say it actually reflects the multiple layers of challenges women face.
Women "are always the last to take care of ourselves. We are the chief medical officers of our families," said Katie Schubert, president and chief executive officer of the Society for Women's Health Research, an activist group based in the US that was not involved in the new study.
"This goes back to a lot of those different burdens that women are taking on, both from the perspective of being a caregiver but also being a part of their community."
In the U.S., for example, Schubert says, women are more likely to go to a well visit for their child than they are for themselves. And the share of women who don't show up for a key doctor's visit at six weeks postpartum is "pretty striking."
Maternal health needs attention
Despite some improvement, the U.S. remains a poor outlier in overall women's health -- in part because of maternal health, an area that experts agree deserves more attention worldwide.
Opinions of health and safety among women in the U.S. dropped in 2021 Global Women's Health Index, as did measures of individual health, including pain and general health problems.
One safety-related question asked women to assess whether pregnant women where they live get high-quality health care. A published in June found that maternal mortality in the US spiked in the first year of the pandemic, especially among Hispanic and Black women. And new data from the U.S. Centers for Disease Control and Prevention found that more than 4 in 5 pregnancy-related deaths were preventable.
Wealthy nations generally scored better than low-income nations in the Global Women's Health Index. In fact, the gap in scores between high- and low-income countries nearly doubled from 2020 to 2021, with an average difference of more than 20 points. But life expectancy in the US was lower than average, despite spending on health care that was well above average.
In some ways, broader gender disparities in health care are already well-known around the world.
For example, women seeking medical help for a heart attack in many countries take longer to get a correct diagnosis, are treated less consistently and are less likely to attend cardiac rehabilitation, Stadler said.
"All of this combines to worse outcomes and higher mortality in women than in men," she said.
Experts agree that improving women's health will lift society as a whole.
"Women often have the role of health manager in their families and communities. And they are taking on a large share of care work, so children, partners, parents benefit as well from women's health," Stadler said.
And the effects are wide-reaching.
"Without this foundational health and well-being of women, we won't be able to advance any of the goals related to economic stability or equity in socioeconomic development," Schubert said. "That really all stands on the shoulders of a healthy environment, a healthy person and healthy outcomes."
But gender equality -- in health and other aspects of life -- is still far from reality.
Schubert noted that the COVID-19 vaccine trials did not include pregnant women.
"My hope would be that we can better prepare to be more inclusive and extensive in our biomedical research moving forward, regardless of whether we're dealing with a pandemic or some other public health emergency," she said. But the pace of change has been "excruciatingly slow."
Much of what is measured in the Global Women's Health Index aligns with objectives identified by the United Nations in its Sustainable Development Goals.
And a published by UN Women and the UN Department of Economic and Social Affairs this month found that at the current pace of progress, gender equality will not be achieved by 2030, as originally intended with the Sustainable Development Goals. Instead, it will take centuries.
"It is critical that we rally now to invest in women and girls to reclaim and accelerate progress," Sima Bahous, executive director of UN Women, said of that report. "The data show undeniable regressions in their lives made worse by the global crises -- in incomes, safety, education, and health. The longer we take to reverse this trend, the more it will cost us all."
But there is some hope.
"My hope is that we come out stronger from the pandemic," Stadler said. "The pandemic has brought the importance of preventive behaviors to more people's attention. People learned a lot about the importance of joint action to protect each other."
