he’s among the fortunate. Although widowed, her health is better than most, thanks to the extra income she brought into the household, to good nutrition, and to the support she had from her husband. She is active in the community and a local women’s group, encouraging young parents to use family planning and send all their children to school. Her sisters have not been so lucky. Her younger sister is now HIV positive, the result of her husband’s playing around. Her older sister died in childbirth during her seventh pregnancy.

The worldwide population of post-menopausal women is expected to increase by the year 2030 to a total of 1.2 billion. Of these, about 75 per cent will live in developing countries.

The health and circumstances of women in their older years are to a great extent the cumulative outcome of reproductive and sexual health during the earlier years. Women live longer than men and average more years of ill health late in life. Two scenarios become apparent:

Most women who enjoy healthy older years, primarily in industrialized countries, are those who completed at least basic education, who have had few children, good access to reproductive and preventive health care, good nutrition, minimal exposure to work-related stress and injury, and a supportive husband or partner. Their older-age health concerns focus on issues such as hormone replacement and degenerative conditions such as arthritis and osteoporosis.

In developing countries, many older women suffer from chronic health problems caused by years of neglect, discrimination and hardship. Their health reflects inadequate access to basic services, food and nutrition throughout their lives, and the hardships of their childbearing years—including births too early and too closely spaced, poor nutrition and anaemia, and heavy physical labour. Lifelong exposure to smoky kitchens, polluted water, and pesticides may also have harmed their health.

Reproductive health problems after menopause are significantly influenced by the quality of care women receive when younger. Uterine prolapse, urine incontinence, and the debilitating outcome of living with vesicovaginal fistula are examples of post-menopausal health problems that have their origin in poor or no obstetrical care at an earlier age.

Leaving the reproductive years marks an important change for women in social status. In most traditional societies, women exercise more power in the household as mothers-in-law and grand-mothers than they did as younger women. As older women, they have the authority to perpetuate injurious cultural norms such as early marriage and son preference, or to promote new norms for gender equality and women’s empowerment.