Gender Disparities in Access to Renal Health Care Worldwide

This year, both International women’s day and world kidney day (WKD) were celebrated on The 8th of March. The International society of Nephrology (ISN) and the international federation of kidney foundations (IFKF) selected for this occasion a strong and relevant motto: “Kidneys & Women’s health: Include, Value, Empower”. In fact, the main mission of this event is to raise awareness and reflect on the importance of women’s health and specifically their kidney health [1]. In fact, several data reported that female gender is often associated independently with increased odds of perceived unmet health care needs in both developed and developing countries [2]. In the MENA region for instance, significant inequities in access to health care services and overall health status persist for women, especially in the area of reproductive health. One of the important factors leading to these disparities is the socially assigned gender roles endemic there. Moreover, multiple cultural factors influence delays in health-seeking behaviors for women [3].


Opinion
This year, both International women's day and world kidney day (WKD) were celebrated on The 8th of March. The International society of Nephrology (ISN) and the international federation of kidney foundations (IFKF) selected for this occasion a strong and relevant motto: "Kidneys & Women's health: Include, Value, Empower". In fact, the main mission of this event is to raise awareness and reflect on the importance of women's health and specifically their kidney health [1]. In fact, several data reported that female gender is often associated independently with increased odds of perceived unmet health care needs in both developed and developing countries [2]. In the MENA region for instance, significant inequities in access to health care services and overall health status persist for women, especially in the area of reproductive health. One of the important factors leading to these disparities is the socially assigned gender roles endemic there. Moreover, multiple cultural factors influence delays in health-seeking behaviors for women [3].

Kidney Disease Specificities in Women
Some autoimmune kidney diseases such as lupus nephropathy, as well as urinary tract infections are predominant in the female sex with an increased risk during pregnancy. Furthermore, complications related to pregnancy can induce kidney diseases, such as preeclampsia; that is, in addition to septic abortions and postpartum hemorrhage, a major cause of acute renal failure and death in young women [1,4]. The burden of these obstetric complications is particularly high in developing countries due to inadequate antenatal care facilities. Pregnancy monitoring is, therefore, crucial and represents an excellent opportunity to diagnose possible kidney disease, organize its monitoring and treatment [1,4].

What about Chronic kidney Disease (CKD) and Renal Replacement Therapy in Women?
Population-based studies indicate that CKD epidemiology differs by sex. CKD is more likely to develop in women compared with men, with an average 14% prevalence in women and 12% in men, especially with regard to stage 3 CKD [3,4]. In fact, CKD affects approximately 195 million women worldwide, and is currently the 8th leading cause of death for women, with about 600,000 deaths per year [1]. However, the number of women on dialysis is lower than the number of men. At least three major reasons are recognized so far: CKD progression might be slower in women compared to men as suggested by some authors. Moreover, several observations indicate that psycho-socioeconomic barriers such as lower disease awareness could delay or hurdle the start of dialysis among women [4] and uneven access to care is a major issue in countries with no universal access to healthcare [1]. Additionally, elderly women seem to be more inclined to choose conservative care instead of renal replacement therapy (RRT). Gender inequalities are also noted in CKD outcomes. Prior to dialysis, mortality in CKD patients is higher in men than women; however, this difference is not observed in patients on RRT [4]. What's more, quality of life while on dialysis is poorer in women than men, as women report a higher burden of symptoms [4].
Kidney transplantation is also a field of male / female inequality, due to certain social and cultural aspects. Although access to living donor kidneys among men and women seems equal, women are often donors, whereas, they're less likely to be recipients of kidney transplants, in case of kidney failure, compared to men, and also have reduced access to deceased donor transplantation  [4]. Moreover, the dialysis facility staff, due to its proximity with the patients, also plays a pivotal role in the implementation of these disparities, as prior research has shown that these health professionals have the ability to influence patient's decision making about the transplant process and health behaviors in general. In fact, studies have suggested that limited health disparity knowledge, poor communication, incongruent and culturally incompetent care, and the inability to provide culturally relevant care, could be an explanation to the observed to disparities [5]. A recent American study revealed that dialysis facility staffs were most of the time unaware of differences due to limited experience and observation of gender disparities [5].
Clear insight into differences in the underlying pathophysiology of women's predominant renal diseases as well as socio-cultural factors can help reduce disparities in access to care and outcomes. This is the key to any potential improvement and could be achieved through information and education that target both women and health professionals. Consequently, developing community-based health promotion programs seems to be an effective way to increase the health awareness of women, especially in disadvantaged communities and encourage earlier health-seeking behaviors. Besides, it is essential to act on all forms of inequalities of access to health care for women wherever they take place, so, that women can benefit from different treatments and better medical care.