determinant of health inform women's health service delivery in countries around the world. women's health services such as leichhardt women's community health centre which was established in 1974 and was the first women's health centre established in australia is an example of women's health approach to service delivery. women's health is an issue which has been taken up by many feminists, especially where reproductive health is concerned and the international women's movement was responsible for much of the adoption of agendas to improve women's health. biological factors factors that specifically affect the health of women vs. men are most evident in those related to reproduction, but sex differences have been identified from the molecular to the behavioral scale. some of these differences are subtle and difficult to explain, partly due to the fact that it is difficult to separate the health effects of inherent biological factors from the effects of the surrounding environment they exist in. women's xx sex chromosomes compliment, hormonal environment, as well as sex-specific lifestyles, metabolism, immune system function, and sensitivity to environmental factors are believed to contribute to sex differences in health at the levels of physiology, perception, and cognition. women can have distinct responses to drugs and thresholds for diagnostic parameters. all of these necessitate caution in extrapolating information derived from biomarkers from one sex to the other. young women and adolescents are at risk from stis, pregnancy and unsafe abortion, while older women often have few resources and are disadvantaged with respect to men, and also are at risk of dementia and abuse, and generally poor health. reproductive and sexual health main article: reproductive health women experience many unique health issues related to reproduction and sexuality and these are responsible for a third of all health problems experienced by women during their reproductive years (aged 15–44), of which unsafe sex is a major risk factor, especially in developing countries. reproductive health includes a wide range of issues including the health and function of structures and systems involved in reproduction, pregnancy, childbirth and child rearing, including antenatal and perinatal care. global women's health has a much larger focus on reproductive health than that of developed countries alone, but also infectious diseases such as malaria in pregnancy and non-communicable diseases (ncd). many of the issues that face women and girls in resource poor regions are relatively unknown in developed countries, such as female genital cutting, and further lack access to the appropriate diagnostic and clinical resources. maternal health main article: maternal health midwifery training in papua new guinea maternal health clinic in afghanistan pregnancy presents substantial health risks, even in developed countries, and despite advances in obstetrical science and practice. maternal mortality remains a major problem in global health and is considered a sentinel event in judging the quality of health care systems. adolescent pregnancy represents a particular problem, whether intended or unintended, and whether within marriage or a union or not. pregnancy results in major changes in a girl's life, physically, emotionally, socially and economically and jeopardises her transition into adulthood. adolescent pregnancy, more often than not, stems from a girl's lack of choices. or abuse. child marriage (see below) is a major contributor worldwide, since 90% of births to girls aged 15–19 occur within marriage. maternal death main article: maternal deaths in 2013 about 289,000 women (800 per day) in the world died due to pregnancy-related causes, with large differences between developed and developing countries. maternal mortality in western nations had been steadily falling, and forms the subject of annual reports and reviews. yet, between 1987 and 2011, maternal mortality in the united states rose from 7.2 to 17.8 deaths per 100,000 live births, this is reflected in the maternal mortality ratio (mmr). by contrast rates as high as 1,000 per birth are reported in the rest of the world, with the highest rates in sub-saharan africa and south asia, which account for 86% of such deaths. these deaths are rarely investigated, yet the world health organization considers that 99% of these deaths, the majority of which occur within 24 hours of childbirth, are preventable if the appropriate infrastructure, training, and facilities were in place. in these resource-poor countries, maternal health is further eroded by poverty and adverse economic factors which impact the roads, health care facilities, equipment and supplies in addition to limited skilled personnel. other problems include cultural attitudes towards sexuality, contraception, child marriage, home birth and the ability to recognise medical emergencies. the direct causes of these maternal deaths are hemorrhage, eclampsia, obstructed labor, sepsis and unskilled abortion. in addition malaria and aids complicate pregnancy. in the period 2003–2009 hemorrhage was the leading cause of death, accounting for 27% of deaths in developing countries and 16% in developed countries. non-reproductive health remains an important predictor of maternal health. in the united states, the leading causes of maternal death are cardiovascular disease (15% of deaths), endocrine, respiratory and gastrointestinal disorders, infection, hemorrhage and hypertensive disorders of pregnancy (gronowski and schindler, table ii). in 2000, the united nations created millennium development goal (mdg) 5 to improve maternal health. target 5a sought to reduce maternal mortality by three quarters from 1990 to 2015, using two indicators, 5.1 the mmr and 5.2 the proportion of deliveries attended by skilled health personnel (physician, nurse or midwife). early reports indicated mdg 5 had made the least progress of all mdgs. by the target date of 2015 the mmr had only declined by 45%, from 380 to 210, most of which occurred after 2000. however this improvement occurred across all regions, but the highest mmrs were still in africa and asia, although south asia witnessed the largest fall, from 530 to 190 (64%). the smallest decline was seen in the developed countries, from 26 to 16 (37%). in terms of assisted births, this proportion had risen globally from 59 to 71%. although the numbers were similar for both developed and developing regions, there were wide variations in the latter from 52% in south asia to 100% in east asia. the risks of dying in pregnancy in developing countries remains fourteen times higher than in developed countries, but in sub-saharan africa, where the mmr is highest, the risk is 175 times higher. in setting the mdg targets, skilled assisted birth was considered a key strategy, but also an indicator of access to care and closely reflect mortality rates. there are also marked differences within regions with a 31% lower rate in rural areas of developing countries (56 vs. 87%), yet there is no difference in east asia but a 52% difference in central africa (32 vs. 84%). with the completion of the mdg campaign in 2015, new targets are being set for 2030 under the sustainable development goals campaign. maternal health is placed under goal 3, health, with the target being to reduce the global maternal mortality ratio to less than 70. amongst tools being developed to meet these targets is the who safe childbirth checklist. improvements in maternal health, in addition to professional assistance at delivery, will require routine antenatal care, basic emergency obstetric care, including the availability of antibiotics, oxytocics, anticonvulsants, the ability to manually remove a retained placenta, perform instrumented deliveries, and postpartum care. research has shown the most effective programmes are those focussing on patient and community education, prenatal care, emergency obstetrics (including access to cesarean sections) and transportation. as with women's health in general, solutions to maternal health require a broad view encompassing many of the other mdg goals, such as poverty and status, and given that most deaths occur in the immediate intrapartum period, it has been recommended that intrapartum care (delivery) be a core strategy. new guidelines on antenatal care were issued by who in november 2016. complications of pregnancy main article: complications of pregnancy in addition to death occurring in pregnancy and childbirth, pregnancy can result in many non-fatal health problems including obstetrical fistulae, ectopic pregnancy, preterm labor, gestational diabetes, hyperemesis gravidarum, hypertensive states including preeclampsia, and anemia. globally, complications of pregnancy vastly outway maternal deaths, with an estimated 9.5 million cases of pregnancy-related illness and 1.4 million near-misses (survival from severe life-threatening complications). complications of pregnancy may be physical, mental, economic and social. it is estimated that 10–20 million women will develop physical or mental disability every year, resulting from complications of pregnancy or inadequate care. consequently, international agencies have developed standards for obstetric care. obstetrical fistula main article: obstetrical fistulae women in an ethiopian fistula hospital of near miss events, obstetrical fistulae (of), including vesicovaginal and rectovaginal fistulae, remain one of the most serious and tragic. although corrective surgery is possible it is often not available and of is considered completely preventable. if repaired, subsequent pregnancies will require cesarean section. while unusual in developed countries, it is estimated that up to 100,000 cases occur every year in the world, and that about 2 million women are currently living with this condition, with the highest incidence occurring in africa and parts of asia. of results from prolonged obstructed labor without intervention, when continued pressure from the fetus in the birth canal restricts blood supply to the surrounding tissues, with eventual fetal death, necrosis and expulsion. the damaged pelvic organs then develop a connection (fistula) allowing urine or feces, or both, to be discharged through the vagina with associated urinary and fecal incontinence, vaginal stenosis, nerve damage and infertility. severe social and mental consequences are also likely to follow, with shunning of the women. apart from lack of access to care, causes include young age, and malnourishment. the unfpa has made prevention of of a priority and is the lead agency in the campaign to end fistula, which issues annual reports and the united nations observes may 23 as the international day to end obstetric fistula every year. prevention includes discouraging teenage pregnancy and child marriage, adequate nutrition, and access to skilled care, including caesarean section. sexual health main article: sexual health contraception main articles: contraception and family planning family planning association: kuala terengganu, malaysia the ability to determine if and when to become pregnant, is vital to a woman's autonomy and well-being, and contraception can protect girls and young women from the risks of early pregnancy and older women from the increased risks of unintended pregnancy. adequate access to contraception can limit multiple pregnancies, reduce the need for potentially unsafe abortion and reduce maternal and infant mortality and morbidity. some barrier forms of contraception such as condoms, also reduce the risk of stis and hiv infection. access to contraception allows women to make informed choices about their reproductive and sexual health, increases empowerment, and enhances choices in education, careers and participation in public life. at the societal level, access to contraception is a key factor in controlling population growth, with resultant impact on the economy, the environment and regional development. consequently, the united nations considers access to contraception a human right that is central to gender equality and women's empowerment that saves lives and reduces poverty, and birth control has been considered amongst the 10 great public health achievements of the 20th century. to optimise women's control over pregnancy, it is essential that culturally appropriate contraceptive advice and means are widely, easily, and affordably available to anyone that is sexually active, including adolescents. in many parts of the world access to contraception and family planning services is very difficult or non existent and even in developed counties cultural and religious traditions can create barriers to access. reported usage of adequate contraception by women has risen only slightly between 1990 and 2014, with considerable regional variability. although global usage is around 55%, it may be as low as 25% in africa. worldwide 222 million women have no or limited access to contraception. some caution is needed in interpreting available data, since contraceptive prevalence is often defined as "the percentage of women currently using any method of contraception among all women of reproductive age (i.e., those aged 15 to 49 years, unless otherwise stated) who are married or in a union. the "in-union" group includes women living with their partner in the same household and who are not married according to the marriage laws or customs of a country." this definition is more suited to the more restrictive concept of family planning, but omits the contraceptive needs of all other