Women’s work: chief medical officer Catherine Calderwood on tackling the taboos in women’s health

“It was a shock when I first heard about it,” Scotland’s chief medical officer, Dr Catherine Calderwood, tells Holyrood regarding the recent British Heart Foundation research that found that women are less likely to be diagnosed and treated for heart attacks than men because of unconscious bias in the system.

It was not the number of women affected that surprised her, but the issues with access to diagnosis.

“I would be aware about how much heart disease there is in women.

“That statistic of three times as many women die from heart disease as from breast cancer, I think, would surprise lots of people because there’s a lot of talk about breast cancer – and quite rightly so.

“So that didn’t surprise me, because cardiac disease in general, it’s very common.

“But I suppose what did surprise me was the part of the treatment pathway where women are not diagnosed. They present differently.

“If you google ‘heart attack’, there isn’t a single picture of a woman, it’s all men with white hair who are clutching their chests, and so the perceived wisdom is that that’s what a heart attack looks like, it’s who it is that gets it.

“So there’s this real under-diagnosis of women, because even the tests that we do are more likely to pick up the problem in men than in women.”

This is just one of a range of issues that will feature in the Scottish Government’s forthcoming women’s health plan.

Announced as part of the 2019-20 programme for government, the plan will cover areas such as contraception and abortion services, menopause, maternity services, conditions such as endometriosis that only affect women and reducing inequalities in women’s health.

One of the reasons that such a plan is needed is because we are dealing with “quite a fragmented health service and, to some extent, policy”.

“I think there has always been a fragmentation, really, of how we look at women’s health,” says Calderwood, in part, because women’s health is not “a thing”, unlike, say, diabetes, so bringing together different experts is difficult as they are not all working in the same area.

Another issue is that many areas of women’s health such as periods, childbirth, incontinence and menopause are considered embarrassing and difficult to talk about and relate to historic taboos and shame.

She notes, for example, that maternity hospitals have often been built separately from other hospitals and that women’s health has been lumped together with children’s health.

 “They actually were often side by side, women and children’s always put together.

“Remind me why that would be a thing. Are women like children? They have children, but why… traditionally, our services are women and children’s. There is no medical logic for that.”

But the taboo around certain subjects such as periods has begun to be broken recently.

“It’s been very interesting the conversations about period poverty in particular, because I think there’s been a lot of that, the whole taboo around periods and that not talking about it, and period poverty has probably brought something into the public domain because it was to do with poverty and actually, that conversation becomes more natural.”

And it is a similar situation with the menopause.

“I think the menopause as well, people are afraid to talk about it, because they feel … I’ve got the symptoms, does that make me less able, does that make me less able at my work … is there something that I have lost, so there’s all of that, but I think also, just the complete lack of understanding of it, people don’t even talk to their own families, partners.”

Part of that could be the feeling women have that to complain about problems with periods or symptoms of the menopause might be construed as undermining the cause of equality in the workplace, to ask for time off or special treatment simply because of issues that come from the biology of being a woman.

Calderwood agrees, but suggests that women shouldn’t be putting up with pain, where in other situations they would seek treatment.

“I suppose the difference there is that I think if you looked at, say, back pain versus period pain, what I say to women is, if your pain is bad like that, you need to sort that out because you’re going to have that every month … so people wouldn’t in that much pain, taking time off work, not go and see somebody about their back.

“But it’s as if, well, it’s just a period, so why am I making a fuss, surely I can just crack on with this … And there’s probably that same feeling about the menopause – every woman is going to go through this, why am I not able to just get on with it?”

The issue of access to healthcare and women not seeking help when they could get medical treatment for what they are experiencing isn’t new.

Calderwood notes: “It’s a recurring theme about women and access to healthcare, in particular, when it’s to do with what would have been traditionally seen as women’s issues where it’s embarrassing.”

This ties in with work on endometriosis, where, on average, it takes seven and a half years to get a diagnosis, which is partly due to symptoms that could be quite a lot of other things and partly, Calderwood suggests, because many women put up with the pain for quite a long time, just taking painkillers, before they even seek a diagnosis.

As well as specialised endometriosis services, including centres of excellence, one of the keys to all this is, to a certain extent, women being active in asking questions, doing their own research and pushing for diagnosis.

But in encouraging women to proactively do research and seek help, is there is a risk of exacerbating existing inequalities, where those who are most capable of finding information and pushing for treatment get help?

This is also something that will be tackled in the women’s health plan, which will specifically be looking at ways to reduce areas of inequality in women’s health.

Calderwood cites maternity services as an example. Work has already been done on continuity of care, which has been very successful, with a reduction in stillbirth rates of 23 per cent since 2014, but the success of this has not been equal.

“So, Gypsy Travellers, if we take this as a terrible statistic, if you look at across the whole population, the percentage of women who will have lost a child, so either stillbirth or a child, it is less than one per cent. Gypsy Travellers: 18 per cent.

“And their children die of developing country diseases like diarrhoea.

“It’s access, mostly, so very little antenatal care and then very limited care sought out for when the children are young and they’re often not vaccinated …

“In part, we don’t make it easy, I have to say, there’s something to do with that, and there’s also a sort of cultural issue with healthcare and authority and government.

“So, that’s a huge piece of work, which is not actually just really confined to maternity services, but when you hear that figure, if you’re me, you can’t help but decide to do something different.”

All this is very relevant to Calderwood, whose own professional background is in obstetrics and who was the Scottish Government’s senior medical officer for women’s and children’s health before becoming CMO.

One parallel she draws is that in working in maternity services, she is working with people who are not actually ill – “they are needing guided on a journey that has complications, but most people don’t need medicine or medical care” – but at the same time, when things go wrong, it can have a huge impact.

The other aspect of this is the amount of family involvement and dialogue.

“There’s no other surgeon that invites the partner to sit and watch,” Calderwood points out.

“Surgeons think that’s weird. I mean, I don’t mind that the dad is watching me operate.

“And I always invite – I don’t do caesarean sections anymore, but when I did – I would say to the woman, do you want me to drop the curtain and you can see your baby being born.

“If you’re an orthopaedic surgeon, you do not invite the patient to watch you do the hip replacement.

“That is really a very bizarre [thing] for other specialties. For us, we have families in the theatre.

“And I think we’re really an inclusive [service], so women having children often have other children, so you have to think about school pick-up, you have to think about not having somebody come at eight in the morning because they’re going to have to get the other kids up and out.

“No other healthcare thinks [about that], you know, you just get your appointment and come along.

“So … the long story that I’m getting to here is I think I actually bring loads of that to this CMO job because I think I’m from a background where there’s a huge amount of dialogue.

“I mean, again, no other part of healthcare talks to women, or to people, about how they would like their operation done.

“We say, would you like a caesarean, we might need forceps, we will talk you through that, so we have real dialogue and offer women choice.

“And I think … it’s facetious to say you don’t offer somebody that for their hip replacement, but you don’t, you don’t discuss it.

“So, I think our patients, and their families actually, it’s dads as well, are very, very involved in their care.

“They will often be very knowledgeable. They will have really invested in that time. And again, that’s very different than a lot of other bits of the system.

“And I think that with realistic medicine, all that I talk about with shared decision making and personalising care and that, I think, comes from my roots in maternity care, where the whole family [is involved] and the toddler’s running around the room and you’re having a conversation with somebody with all of that needing to be taken into account.”

Calderwood also brings her personal life experience to her work in women’s health.

“I’ve had three children, one of them was born prematurely. I’ve had a baby in a neonatal unit.

“I used to joke [that] half of what I know as an obstetrician was learned as being a pregnant woman, but I think that there probably isn’t enough of healthcare professionals really understanding what it’s like to be a patient in their own system.

“I wouldn’t say that all orthopaedic surgeons should have a hip replacement, but nearly, because patients are the only people that know the whole system.

“They’re the only ones that know it from the waiting room to the queue to the… and we, the doctor, we only do the bit over here … and so, I talk about that walking in your patient’s shoes.

“And I think that that really, really helps, because all of the people I work with are in a service where a lot of them have used their own service.

“And often it will be your own workplace that you have your [children], my three children were all born in [mine], and that was nice because it is reassuring. I knew the staff.

“That didn’t make me any less scared in labour, I must say – when it’s happening to you, it’s very different. [But] I do think that that definitely helps.

“I myself don’t like having my smear done. I go and have it done because I know it’s the right thing to do, but I don’t look forward to it any more than somebody who doesn’t know how to do smears.

“So I think, is that maybe reassuring that I at least can talk to people about knowing what it’s like?

“And I’m sure it probably makes you have empathy with people, your conversations with people are different.

“Maybe, hopefully, that I bring a bit of that then to being the CMO when you talk to people about what their experience will be, and that’s so important for people to understand where it is they’re coming from.

“And I suppose there’s no consultation I ever have as an obstetrician that I don’t talk about my own children or my own pregnancy.

“And perhaps that maybe makes me bond with the patient, in that there’s something about, well, she knows what she’s talking about because she’s done it herself.”