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CHAPTER 1: SOCIAL AND CULTURAL FACTORS

It is difficult to understand the dramatic changes affecting women’s health over the course of the 20^th century without investigating the social and cultural context in which those changes occurred. Indeed, the very definition of what constituted women’s health evolved over time. The goals and perspectives of women’s health advocates changed to reflect shifting social mores and economic conditions. The welcome news is that at the end of the 20^th century, women’s health had advanced dramatically during the course of the previous 100 years. Women were enjoying a level of care that had nearly doubled their average life span over the course of the century. As both recipients and providers of health care, women were involved in every phase of medical research, practice, and knowledge.

Changing Definitions of Women’s Health

In the early 20^th century, women’s health was primarily equated with maternal health and the role of women as mothers. With the birth control movement of the 1920s, the definition of women’s health began to include issues of reproductive health and control over the spacing (or timing) of each child’s birth. By the 1960s and 1970s, reproductive health issues were at the center of a new wave of women’s health activism. These issues included the controversial legalization of abortion and the de-medicalization of pregnancy and childbirth. By the last decades of the century, the definition of women’s health had expanded to include many other social, legal, medical, and economic issues. Topics such as stress, violence, poverty, and discrimination began to find their places within debates and discussions of women’s health. Women were also more likely than men to be victims of child abuse, domestic violence, and gender discrimination, problems that were increasingly recognized as public health issues. Moreover, many issues, such as AIDS (acquired immunodeficiency syndrome), heart disease, violence, or occupational hazards, once associated predominately with men’s health, joined the realm of women’s health issues.

(Time capsule items: Bumper Stickers; Women’s Health Buttons, Ms. Magazine devoted to domestic violence.)

Women as Health Advocates

Throughout American history, women have been on the front lines of health activism and reform. During the course of the 20^th century there were three major periods of women’s health activism: the Progressive Era (1890– 1930), the 1960s and 1970s, and the early 1990s.¹ The Progressive Era gave rise to two separate movements: 1) the reformers who spearheaded the formation of government offices and policies to expand maternal and child health services and 2) the birth control advocates. The first group consisted largely of middle-class white women who came out of the Settlement House Movement and used their influence to affect public policy. The birth control advocates worked more at the ground level, exercising peaceful civil disobedience to overturn restrictions on the distribution of birth control information and devices.

The movement of the 1960s and 1970s was largely a grass-roots effort challenging the male-dominated and medicine-based system of health information and care.² It gave rise to the widespread development of women-based health clinics and self-health publications.

In the 1990s, women’s health reached unprecedented levels of political and public clout. This was due to a combination of women’s increased marketing power as health consumers; the success of disease-based groups like the breast cancer coalitions; the election and appointment of a critical mass of women in Congress and the federal government; and the increasing number of women in medicine. This era brought to light long-standing gender/sex inequities in clinical research and practice. Slowly, the scope of women’s health was also expanded to incorporate issues of racial and social diversity.

Women as Health Care Professionals

It was not until the mid-19^th century that the first female student in the United States was admitted to a male medical school and graduated to become a physician. Later, women created their own medical schools and women’s hospitals to train and practice as physicians. However, they often had difficulty being accepted as true professionals by both male physicians and patients of both genders. In frontier and rural environments, however, women were more likely to be accepted, since physicians were scarce. Women physicians during the late 19^th and early 20^th centuries were increasingly challenged by so-called “heroic” medical practices that relied on purgatives, bloodletting, and other extreme procedures, such as “Battey’s operation.” This surgery removed a woman’s ovaries, not only for medical reasons, but as an alleged cure for psychological ills, real or imagined, including nymphomania, epilepsy, and neurasthenia.

In 1900, 6 percent of physicians were women. Although women were discouraged from practicing medicine during World War I, in World War II women were recruited and trained as doctors. However, any progress in promoting more women to become physicians had all but disappeared by 1960, when only 7 percent of physicians were women. This was due largely to narrow quotas that restricted women’s admissions to all but the women’s medical schools. A gender discrimination suit brought against some medical schools in 1970 by the Women’s Equity Action League opened the doors for female admissions into medical schools. By the year 2000, nearly 46 percent of new medical school enrollees were women. In the 1990s, women’s health issues began to be included in medical school curricula and clinical competencies.^3,4

(Time capsule item: Journal of the American Medical Women’s Association Supplement: Cultural Competency and Women’s Health in Medical Education.)

The first nursing schools, formed in the late 1800s, included both men and women. Men dominated the field in the South and in the military. In the early 1900s, there was a push to professionalize the field, efforts that were often led by women who were also active in the suffragette movement. Over the course of the 20^th century, nursing became professionalized and a predominately female field. As such, it retained less status and lower pay than other male-dominated medical professions.

The training and practice of midwifery was also becoming more professionalized and regulated. However, with the shift from home births to hospital deliveries during the first half of the century, the role and status of midwives decreased, especially among white women. Births attended by midwives dropped from 40 percent in 1915 to 11 percent in 1935.⁵ Midwifery, however, experienced a rebound in the 1970s, as women returned to more natural childbirth methods and settings.

In 1900, 90 percent of all births occurred at home, whereas in 1950, 90 percent of all births occurred in the hospital. Surgical procedures such as cesarean births and episiotomies became far safer, but many believed they were ultimately overused by the latter half of the century.⁶

(Time capsule items: Sonogram of a fetus; Be Good to Your Baby Before It Is Born; Pregnancy Calendar.)

Women’s Employment and Health

In 1900, women made up 18 percent of the paid labor force. World War II introduced women to jobs traditionally held by men. Consequently, by 1950, women represented 30 percent of the paid labor force. By the late 1990s, nearly one-half (46 percent) of the labor force was female.⁷ Increasing numbers of women with small children joined the labor force, swelling the ranks of those contending with both work and family pressures. This dual role decreased women’s leisure time and increased their level of stress. Although nearly half of women were in the labor force, they remained more likely to live in poverty than men. Their earnings remained lower than those of men not only in the labor force but also from other sources such as rents, investments, or pensions.⁸ In addition, some working women who became pregnant or had to unexpectedly care for loved ones lost their jobs or were forced to quit. To address this situation, Congress passed the Family and Medical Leave Act in 1993. The Act enabled women and men to take up to three months off in a 12-month period to take care of family matters without losing their jobs.

During this time, many women were also adjusting to a new demand on their time. As the population aged, many women found themselves also serving as the primary caregivers for their elderly parents, older family members, elderly neighbors without family or family members living nearby, and children with severe disabilities. The need for day care for the elderly, home help, and quality nursing homes to help sustain and support the work of overburdened caregivers was a need that had reached national attention by the end of the century.

(Time capsule item: Map of National Centers of Excellence in Women’s Health and National Community Centers of Excellence in Women’s Health.)

Women’s Access to Health Insurance

In the 19^th century, little health insurance was provided by employers. Mutual Aid Societies, some labor unions, fraternal associations, and occasionally individual employers provided paid sick leave for workers.⁹ In 1965, legislation was passed as part of President Lyndon B. Johnson’s War on Poverty Initiative to provide a national health plan for the elderly, Medicare, and a state-based plan for the poor, Medicaid.

(Time capsule items: Medicare and You; Federal Employees Health Benefits Plans booklet.)

During the 20^th century, health care advocates (many of them women) did much to improve and advance women’s health. They expanded women’s health care services, inserted women’s issues into health care training, forced institutional shifts towards women-centered services, and increased women’s abilities to access health information and knowledge. The term women’s health eventually became part and parcel of mainstream political, economic, and medical discussions. Although still largely over-represented in the lower pay scales and ranks, women continued to enter the medical and health professions and other professional careers in increasing numbers. However, many working women remained without access to health insurance or were under insured. In the face of rapidly increasing health care costs and lack of basic health coverage for all Americans, the challenge of ensuring women’s access to quality health services remains. It is a dilemma that will continue to follow women’s health reformers into the 21^st century.

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Last Updated: June 2002

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