RCOG position statement: Poverty, deprivation and women’s health

Introduction

Understanding and responding to how the wider contexts of women’s lives shape their health is crucial to sustainably addressing health inequalities across the life course and supporting reproductive opportunity, choice and outcomes.

Economic and social policies, the environment in which we live, and the distribution of wealth, power and resources in society can be more important than health care or choices in influencing health outcomes.^[1] These factors can lead to health inequalities – avoidable, unfair and systematic differences in health^[2] – and play an important part in women’s ability to choose to have children or not have children, have a healthy pregnancy, and to parent their children in safe and sustainable communities.^[3]

The health system has an important role in tackling health inequalities, but it cannot do this alone. This position statement sets out some of the wider changes needed to support the NHS and to sustainably improve the health of women, girls and other people accessing obstetric and gynaecology services in the UK, with a focus on tackling poverty and deprivation.

Key recommendations for UK governments:

Action to tackle inequalities in women’s health requires coordinated and collective efforts from all parts of government. All government initiatives to improve women’s health, including specific women’s health plans and strategies, must make visible and strong connections with all relevant departments to achieve sustainable and long-term improvements to the wider factors shaping women’s health.
As one of over 200 members of the Inequalities in Health Alliance, we are calling for the UK Government to introduce a cross-government strategy to reduce health inequalities, underpinned by the necessary funding settlement.
Action to tackle health inequalities and their causes must take an intersectional approach, always considering and responding to the ways in which inequalities intersect to shape health outcomes. This includes responding to the multiple forms of discrimination and violence in society, including racism and gender-based violence.
The UK Government must ensure the social security system works for women throughout their lives, and support equitable access to work which is secure, safe and pays enough to maintain good health.
Governments must support health at the population level by ensuring public health services are adequately funded and available to everyone who needs them, and that everyone can easily access healthy food.

You can download a PDF version of our position statement below:

Poverty Deprivation And Womens Health PDF 840kb

How do poverty and deprivation influence women’s health and reproductive options?

Poverty [lacking financial resources to meet needs] and deprivation [lacking many resources, including those that shape our health],^[4] can have a significant health impact across women’s lives.

This includes cutting lives short. Across the UK, women living in the most deprived areas have a life expectancy many years shorter than their least deprived counterparts.^[5] In England, the disparity in female life expectancy between the most and least deprived areas is eight years, with those from the most deprived areas also living 20 years fewer in good general health.^[6] Similar disparities are found in Scotland, Wales and Northern Ireland.^[7]

Poverty and deprivation can affect the health of women and people accessing obstetrics and gynaecology services through many routes, including:

Making it harder to live healthily – our ability to adopt healthy behaviours is influenced by the circumstances in which we live.^[8] For example, having the resources to buy healthy food, or access to green, safe and affordable spaces to be physically active in. Poverty can also make adopting healthy behaviours more difficult due to the need to focus on coping in the short-term rather than making decisions that support longer-term health.^[9]
Affecting mental health – unemployment, poor quality work and insufficient income are associated with poor long-term mental health.^[10] People seeking help for issues related to poverty or deprivation may also experience shame or stigma.^[11] Deprivation also increases the risk of perinatal mental illness.^[12]
Increasing chronic stress – coping with adversity and day-to-day shortages of essentials like food or money can negatively affect mental and physical health, including through the production of the hormone cortisol, which has multiple negative health impacts.^[13]
Making access to health care more difficult – for example due to insecure work, the cost of travelling to appointments, or difficulties paying for childcare. There is a strong link between deprivation and delayed access to, and low engagement with, antenatal care, which is important for a healthy pregnancy.^[14]
Making maintaining basic hygiene difficult – having insufficient income to buy items such as period or continence products, shampoo or toothpaste can impact physical and mental health, as well as participation in education and work.^[15]
Greater exposure to the health impacts of climate change and pollution – living in poverty or deprivation can make it harder to respond to the impacts of a changing climate. For example, extreme weather can disrupt growing conditions for fruit and vegetables, resulting in price increases that can make healthy food even more unaffordable.^[16] More deprived communities are more likely to live in heavily polluted urban areas, and so are at greater risk of the adverse health outcomes of air pollution.^[17]

Tackling the causes of poverty and deprivation is crucial to addressing persistent inequalities in maternal and perinatal outcomes. Women and people who are in good health have a better of chance of becoming pregnant, having a safe and healthy pregnancy and giving birth to a healthy baby,^[18] while poorer general health linked to poverty and deprivation can lead to increased risk of adverse pregnancy outcomes. Women from deprived areas of the UK are more likely than those in less deprived areas to die during or shortly after pregnancy, and this disparity has increased in recent years.^[19] Research has attributed 24% of stillbirths in England to socioeconomic inequality,^[20] and reductions in the national stillbirth rate in recent years have been more marked in the least deprived areas.^[21]

Poverty and deprivation can influence women’s reproductive options, choices and outcomes. DHSC figures show that the number of abortions for residents of England and Wales in January to June 2022 increased 17% from the same period in 2021.^[22] Organisations including the RCOG and Faculty of Sexual and Reproductive Healthcare have expressed concerns that recent increases may indicate the impact of the recent rise in the cost of living, as well as ongoing unmet need for contraception.^[23]

Recommendations

Cross-government working to tackle health inequalities

Attention to the wider contexts of women’s lives and the ‘causes of the causes’ of their ill health^[24] is an essential part of understanding and sustainably addressing health inequalities. Interventions aiming to change individual behaviour alone will not sustainably improve outcomes or reduce health inequalities.

Action to tackle inequalities in women’s health requires coordinated and collective efforts from all parts of government. All government initiatives to improve women’s health, including specific women’s health plans and strategies, must make visible and strong connections with other relevant departments whose policies shape women’s health outcomes, as set out in this statement. This is key to achieving sustainable and long-term improvements to the wider factors shaping women’s health.

Additionally, governments must ensure women’s health is considered in all policies – for example, responses to health threats such as climate change must consider the specific impacts on women’s health, particularly reproductive health and health in pregnancy.

As one of over 200 members of the Inequalities in Health Alliance, we are calling for the UK Government to introduce a cross-government strategy to reduce health inequalities, underpinned by the necessary funding settlement, with clear measurable goals that consider the role of every department and every available policy lever.^[25] This is an essential step towards co-ordinating and supporting action on all recommendations set out below.

Taking an intersectional approach to tackle discrimination and poor health

Political and cultural factors, including the social categories someone is or is perceived as being a part of, can also shape the factors that influence our health.^[26] Disadvantage that follows the lines of social categories, such as gender, disability, race, ethnicity, sexual orientation, gender identity or religion, is also known as structural inequality.^[27] Examples of structural inequality include:

Gender – women in the UK earn less than men across their lifetime [the ‘gender pay gap’] and are more likely than men to be living in poverty.^[28] This is due to a combination of economic and social factors, such as the unequal division of caring responsibilities which means that more women are more likely to work part time.^[29]
Race – racial discrimination can profoundly shape people’s living and working conditions.^[30]For example, research has found that to get a positive response from employers, British people from minoritised ethnic backgrounds have to send more job applications compared to their white counterparts.^[31]

People are members of multiple social categories, and disadvantages and discrimination can intersect and compound throughout their lives. It is important that UK governments take an intersectional approach to understanding health inequalities, considering how inequalities relating to all aspects of women’s identity shape their health.^[32] For example, gendered inequalities intersect with and compound structural racial inequalities in the labour market, and as a result racially minoritised women are overrepresented in lower paid, insecure jobs, and at higher risk of being underemployed.^[33]

For good health, people need to live in a safe society where they are not at risk of violence. Gender-based violence is underreported and so statistics can be unreliable, however we know this is still an issue affecting women’s lives and health across the UK. For example, in England and Wales around one in four women are thought to experience domestic abuse during their lifetime, and Rape Crisis has calculated that that one in four women in England and Wales have been raped or sexually assaulted as an adult.^[34] The UK governments must to recognise and respond to the multiple forms of discrimination and violence in society, including racism and gender-based violence.

Improving health at the population level – supporting public health

Behaviours which affect health, such as smoking, alcohol consumption, diet and exercise, relate to access to public health services, and also the wider contexts in which people live. They are also drivers of health inequalities in the UK.^[35] Sustainable improvements therefore require population-level actions which aim to support everyone’s health, alongside concerted action to address the root causes of deprivation.

Supporting people to live healthily requires government policy which recognises and addresses the role played by the wider environment and the private sector in influencing individual behaviour and shaping health.^[36] This includes action to tackle the advertising, promotion, relative expense and availability of healthy and unhealthy food, alcohol, and tobacco.^[37]

Ensuring women can maintain good health and take decisions about their reproductive, preconception and pregnancy health requires UK governments to ensure that public health services are adequately funded and accessible. However, the Health Foundation has estimated that reductions in spend on a real-terms per person basis for the English public health grant between 2015/16 and 2024/25 include a 40% reduction for sexual health services, 35% reduction for public health advice and a 31% reduction for drug and alcohol services for young people.^[38]

Under-resourced public health services can have impacts on both women’s health and their reproductive options, for example through unmet need in sexual and reproductive healthcare [SRH]. Abortion rates for women over 30 have been increasing over the last ten years, and whilst there is no evidence of direct causation, the RCOG, the Faculty of Sexual and Reproductive Healthcare and the Royal College of General Practitioners are concerned that this indicates an unmet need for contraception.^[39]

Ensuring women can maintain good health and take decisions about their reproductive needs requires UK governments to ensure that public health services are adequately funded and accessible. In England, the UK Government should commit to increasing the public health grant to ensure that these vital services are accessible to everyone who needs them.

A social security system that works for women throughout their lives

Women rely more than men on the social security system because of their generally lower earnings, longer lives, and greater caring responsibilities.^[40] A strong, reliable social security system that works for women is a vital foundation for good health across women’s life course, from their earliest years to pension age.

Structural inequalities have meant women, and particularly disabled women and women from ethnic minority backgrounds, have been disproportionately affected by changes to social security and public services over the last decade.^[41] Women, particularly lone mothers, have the highest gap between income and adequate living standards and are the most likely to be living in food insecure households.^[42] The gender pay gap combined with other factors results in pension income inequality in older age.^[43]

There needs to be sustained improvements in social support across women’s life course. This must include ending the two-child limit to universal credit, which overlooks the complexity of the factors in a family’s decision to have another child.^[44] It is also, according to the Child Poverty Action Group, one of the biggest drivers of rising child poverty,^[45] pushing about 50,000 children into poverty every year, and exacerbating the conditions of 150,000 children already living in poverty.^[46] To support this, the UK Government must work in partnership with women experiencing deprivation when designing and delivering policies which affect their lives.

It is also vital that social security benefits keep up with inflation. Real terms cuts can be detrimental to women’s health, exacerbating inequalities in women’s health and pregnancy outcomes.

Women seeking asylum or without official immigration status miss out on mainstream benefits and face a fragmented system of support. UK governments must ensure that additional efforts are taken to ensure that women without official immigration status are supported to maintain good health.^[47] You can read more about the College’s recommendations for migrant women in our position statement.^[48]

Access to good quality work, childcare and parental leave

Women should have access to work which is secure, safe and pays enough to maintain good health. However, the current situation in the UK does not work for women, contributing to poverty, deprivation and poor health. For example:

Cost and accessibility of maternity leave and childcare – Existing maternity pay and leave provisions do not work for many women and their families, with a Maternity Action finding that 73% of over 1,000 women surveyed worried a lot about money while they were pregnant on maternity leave – an increase from 64% in 2022.^[49] An estimated 1.7 million women in the UK are currently prevented from taking on more paid hours of work because of the cost of childcare,^[50] with a survey by Pregnant Then Screwed finding that one third of parents using formal childcare have had to rely on some form of debt to cover their childcare costs.^[51]
Maternity discrimination – in 2016, research by the Equality and Human Rights Commission found that three in four UK women said they had a negative or possibly discriminatory experience during pregnancy, maternity leave, or on return from maternity leave, and 11% felt forced to leave their job.^[52] 15% felt that treatment in the workplace had a negative impact on their health or stress levels during pregnancy, increasing to 25% for single women.^[53]
Insecure work – insecure contracts leave workers without regular guaranteed hours and a predictable income.^[54] They are prevalent in female-dominated sectors such as social care, education and retail, and their use has risen sharply in recent years.^[55] Insecure work can shape health, for example through limiting rights to statutory maternity pay or sick pay, and can hinder people’s ability to plan their lives, look after their children and get to medical appointments.^[56]

Access to affordable childcare can also influence women’s choices around having children. Research shows that for one in five women who had an abortion in the last five years, the cost of childcare was the main reason for their decision.^[57]

The UK Government must support equitable access to work which is secure, safe and pays enough to maintain good health. This must include substantial investment in the childcare system and a comprehensive review of maternity, paternity and parental leave.^[58]

Improving health at the population level – access to affordable, nutritious food

Eating a healthy diet is important for good health throughout our lives. Although the causes of poor diet are multiple and complex, having the money available to buy healthy food is fundamental. However, the Food Foundation calculates that poorest fifth of UK households would need to spend 50% of their disposable income after housing costs on food to eat the Government-recommended healthy diet.^[59] UK Government efforts to address inequalities in women’s health or pregnancy outcomes must recognise and respond to the need for women to have sufficient income or support to be able to eat a healthy diet.

Access to healthy food is important for a healthy pregnancy. Having a balanced diet before and during pregnancy helps ensure the fetus gets the nutrients needed to grow properly, while overweight or obese can increase the risk of pregnancy complications.^[60] In pregnancy, deprivation is associated with diets poor in specific nutrients, and poor diet appears to contribute to inequalities in pregnancy outcome.^[61]

Obesity [having a BMI of 30 or over] increases the risk of other health conditions, such as type 2 diabetes and heart disease^[62] and is also linked to some types of cancer. For example, it is estimated that around a third of womb cancer – the most common gynaecological cancer – diagnoses are caused by overweight and obesity.^[63] Nearly 40% of women in the most deprived groups in England live with obesity, compared with 22% in the least deprived groups.^[64]

As a member of the Obesity Health Alliance, we support restrictions on promotional tactics including a 9pm watershed on advertising on TV and a ban on paid-for advertising online, and the introduction of measures to encourage reformulation of unhealthy food and drink products.^[65]

In England, Wales and Northern Ireland, the Healthy Start scheme provides pregnant women and families with pre-school aged children from low-income households with a weekly payment to spend on healthy food and milk, and to access vitamins.^[66] However, the scheme has failed to keep up with inflation, and many women and families [one in three people eligible] are missing out on vouchers, particularly in more deprived areas.^[67]

We support the Local Government Association and Food Foundation recommendations to the UK Government to expand and strengthen the Healthy Start scheme, including through urgent investment, widening eligibility criteria, and greater efforts to increase awareness and uptake of the scheme.^[68] We also support efforts to ensure greater uptake of Scotland’s Best Start Foods scheme.^[69]

RCOG, Scientific Impact Paper No. 67: Understanding the relationship between social determinants of health and maternal mortality (2021)
RCOG, RCOG Position Statement: Equitable access to maternity care for refugee, asylum seeking and undocumented migrant women (2022)
RCOG and RCM, Royal College of Midwives and Royal College of Obstetricians and Gynaecologists joint policy statement on domestic abuse (2020)

A note on language

Within this document we use the terms woman and women’s health. However, it is important to acknowledge that it is not only women for whom it is necessary to access women’s health and reproductive services in order to maintain their gynaecological health and reproductive wellbeing. Gynaecological and obstetric services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth.

[1] WHO, Social determinants of health; Marmot M et al, Health Equity in England: The Marmot Review 10 Years On (2020); Institute of Health Equity, Action on the Social Determinants of Health; The King’s Fund, What is a population health approach? (2022); WHO Europe, Fact sheets on sustainable development goals: health targets – Migration and Health (2017); OHID, Health disparities and health inequalities: applying All Our Health (2022); The King’s Fund, What is a population health approach? (2022)

[2] The King’s Fund, What are health inequalities? (2022)

[3] These are the principles of reproductive justice, set out by SisterSong, Reproductive Justice

[4] The Index of Multiple Deprivation (IMD) domains are income, employment, health deprivation and disability, education skills and training, crime, barriers to housing and services, and living environment. People may be considered to be living in poverty if they lack the financial resources to meet their needs, whereas people can be regarded as deprived if they lack any kind of resources, not just income. Office for National Statistics, The English Indices of Deprivation 2019 (IoD2019) (2019)

[5] BMA, Valuing Health: Why prioritising population health is essential to prosperity (2022); Office for National Statistics, Health state life expectancies by national deprivation deciles, England: 2018 to 2020 (2022);

[6] Office for National Statistics, Health state life expectancies by national deprivation deciles, England: 2018 to 2020 (2022);

[7]BMA,Valuing Health: Why prioritising population health is essential to prosperity (2022)

[8] Health Foundation, Addressing the leading risk factors for ill health (2022); OHID, Health disparities and health inequalities: applying All Our Health (2022)

[9] Institute of Health Equity, Health Equity in England: The Marmot Review 10 Years On (2020); Tomson K et al, Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis (2021); The Health Foundation, Money and resources

[10] Marmot M et al, Health Equity in England: The Marmot Review 10 Years On (2020)

[11] Mind, Facts and figures about poverty and mental health

[12] Ban L et al, Impact of socioeconomic deprivation on maternal perinatal mental illnesses presenting to UK general practice (2012)

[13] Institute of Health Equity, Health Equity in England: The Marmot Review 10 Years On (2020); The Health Foundation, Poverty and health: How do our money and resources influence our health? (2018)

[14] Jones G L et al, Understanding the relationship between social determinants of health and maternal mortality (2022); Tomson K et al, Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis (2021)

[15] Big Issue, ‘I begged food bank workers for body wash for my children’: The bleak reality of hygiene poverty in the UK (2022); Plan International UK, Break the barriers: Girls’ experiences of menstruation in the UK (2018)

[16] UK Climate Risk, Summary for England (CCRA3-IA) (2021)