Burden of female diseases among adolescents and young adults aged 10–24 years in South Asia and Sub-Saharan Africa, 1990–2021: a systematic analysis from the Global Burden of Disease Study 2021

Graphical abstract

Highlights

• •The burden of female diseases in South Asia and Sub-Saharan Africa remains a significant health concern for adolescent girls and young women.
• •In 2021, over 88 % of countries in South Asia and Sub-Saharan Africa failed to meet the Sustainable Development Goal related to maternal health.
• •The burden of most female cancers and gynecological diseases has significantly increased in both South Asia and Sub-Saharan Africa.
• •Several type-specific female diseases, are increasingly affecting younger adolescents aged 10–14 years in these two regions.

Abstract

Introduction

Female diseases pose significant challenges in South Asia and Sub-Saharan Africa, particularly among adolescent girls and young women, who often receive insufficient attention.

Objectives

To report patterns and trends of female diseases among adolescent girls and young females aged 10–24 years in South Asia and Sub-Saharan Africa from 1990 to 2021.

Methods

We used data from the Global Burden of Disease Study 2021 for 51 countries in South Asia and Sub-Saharan Africa between 1990 and 2021. Joinpoint Regression was used to calculate annual average percentage changes and 95 % confidence intervals to quantify temporal trends.

Results

In 2021, South Asia and Sub-Saharan Africa had high mortality rates of maternal disorders of 6.04 (95 % uncertainty intervals 5.02, 7.39) and 17.69 (14.37, 21.78) per 100,000 population, respectively. The mortality rates for female cancers were approximately 0.98 in both regions, and the incidence rates for gynecological diseases were 16472.83 and 14480.99, per 100,000 population, respectively. From 1990 to 2021, there was an increasing trend in the number of maternal disorder deaths in Sub-Saharan Africa, as well as in all metric rates for most female cancers in both regions, and disability-adjusted life years, prevalence, and incidence rates for gynecological diseases in South Asia. Several female diseases varied across countries and were increasingly affecting younger adolescents aged 10–14 years in both regions. Although countries with lower Socio-demographic Index had a heavier burden of female diseases, no significant association was observed between the Universal Health Coverage effective coverage index and death rates for female cancers or gynecological diseases.

Conclusions

The burden of female diseases remains high among young females in South Asia and Sub-Saharan Africa, with younger adolescents being particularly affected. This underscores the urgent need for targeted interventions and increased investment in healthcare infrastructure to reduce the burden of female diseases in these regions.

Introduction

Female health issues, such as pregnancy and childbirth complications, female cancers, and reproductive health outcomes, are the main contributors to disability-adjusted life-years (DALYs) and deaths among women worldwide [[1], [2], [3], [4], [5]]. The World Health Organization (WHO) reported that although the global maternal mortality ratio decreased at an average annual rate of 2.70 % from 2000 to 2015, this progress slowed to −0.04 % between 2016 and 2020. It indicates a stagnation or a worsening of maternal mortality in most regions worldwide during the first five years of the Sustainable Development Goal (SDG) era [6,7]. In addition to maternal mortality, breast cancer, and cervical cancer emerged as the most prevalent cancers among females worldwide, causing 670,000 and 350,000 deaths respectively in 2022 [4,5]. Furthermore, although findings from the Global Burden of Disease Study (GBD) 2019 suggested a global decrease in gynecological diseases from 1990 to 2019 [8], the burden of gynecological diseases, along with female cancers and maternal disorders, remains severe in low- and middle-income countries, posing a substantial threat to sustainable development and women’s well-being [4,5,8,9]. Therefore, reducing the burden of female diseases in low- and middle-income countries has become a critical challenge that requires urgent attention.

The burden of female diseases is on the rise among the younger population. According to the GBD 2019 Adolescent Mortality Collaborators, an estimated 32.1 % of deaths among adolescents aged 10–24 years globally were attributed to maternal, nutritional, or communicable causes in 2019 [10]. Additionally, breast cancer (2.49 million DALYs [95 % uncertainty intervals (UI) 2.26–2.72)] and cervical cancer (1.56 million DALYs [1.32–1.78]) emerged as the leading causes of DALY burden among adolescents and young females aged 15–39 years [11]. A recent study has reported that the most significant increase in incidence and DALY burden of most female cancers occurred among individuals aged 15–24 years [12]. Furthermore, between 1990 and 2019, the global incidence rate of gynecological diseases increased among females aged 15–29 years, with the 20–24 age group experiencing the highest increase of 0.21 % [8]. However, the health of adolescents and young females, particularly in low- and middle-income countries, tends to be neglected, and comprehensive assessments of the disease burden at a country level are largely unknown [13]. The Global Strategy for Women’s, Children’s, and Adolescents’ Health 2016–2030 and the SDG3.1 aim to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030, highlighting the importance of strategies to prevent maternal mortality among young people [6,7]. Moreover, the WHO Global Breast Cancer Initiative and Cervical Cancer Elimination Initiative have set targets to reduce breast cancer deaths by nearly 2.5 million between 2020 and 2040 and cervical cancer deaths by 300,000 by 2030 globally [5,14]. Therefore, a comprehensive understanding on the burden of female diseases in low- and middle-income countries is crucial for accelerating policy initiatives to achieve the global goals related to mortality caused by these diseases.

WHO reported that the majority of maternal, child, and adolescent deaths were concentrated in two primary regions (i.e., Sub-Saharan Africa and South Asia) [15]. Specifically, in 2023, these two regions accounted for approximately 87 % of global maternal deaths [16]. Although there has been a notable global decline in maternal deaths among adolescents and young adults aged 10–24 years, Sub-Saharan Africa and South Asia continue to experience disproportionately high rates [10]. The risk of maternal mortality for females in Sub-Saharan Africa is 130 times higher than that for females in Europe and North America [15]. Furthermore, limited diagnostic and treatment resources in Sub-Saharan Africa and Southeast Asia contribute to high mortality rates due to breast and cervical cancers [4,17,18]. Breast cancer and cervical cancer ranked first in 28 and 19 countries, respectively, within Sub-Saharan Africa [19]. Additionally, a study based on the GBD 2019 data showed that the incidence and DALY rates of gynecological diseases in Southern and Central Sub-Saharan Africa significantly exceeded the expected levels based on their Socio-demographic Index (SDI) values from 1990 to 2019 [8]. However, the burden of these female diseases among young females aged 10–24 years in Sub-Saharan Africa and South Asia remains inadequately characterized at the country level.

Although the SDI is valuable for monitoring social and economic development at the population level, it inadequately captures other crucial health-related factors, such as the prioritization of societal resources towards healthcare and the integration of novel technological advancements [20]. The Universal Health Coverage (UHC) effective coverage index has emerged as a fundamental global goal, which has been integrated into the SDGs related to health [21,22]. It significantly contributes to advancing maternal health in various ways and serves as an essential component of a comprehensive Reproductive, Maternal, Newborn, Child, and Adolescent Health agenda [23,24]. The implementation of the UHC effective coverage index has the potential to directly reduce financial burdens and benefit pregnant women, particularly those experiencing obstetric complications that require surgical interventions and hospital admissions in countries without robust insurance systems [24]. Therefore, it is imperative to gain a comprehensive understanding of the burden of female diseases from the perspective of the UHC effective coverage index.

In the present study, we used data from the GBD 2021 to report the burden of overall and type-specific maternal disorders, female cancers, and gynecological diseases among adolescent girls and young females aged 10–24 years in Sub-Saharan Africa and South Asia at regional and national levels between 1990 and 2021. Furthermore, we examined the association of the death rate of female diseases with SDI and the UHC effective coverage index.

Materials and methods

Data source

GBD 2021 provides comprehensive data on the annual estimates of incidence, prevalence, mortality, and DALYs for a total of 371 diseases and injuries across 204 countries and territories from 1990 to 2021 [25]. The methodological framework of GBD 2021 closely aligns with that of GBD 2019 [26]. Raw data were collected from diverse sources, including surveillance systems, vital registration, verbal autopsy, police reports, and surveys conducted across all countries and territories. GBD used meta-regression—Bayesian, regularised, trimmed (MR-BRT) to adjust epidemiological data and synthesized data using Disease Modelling Meta-Regression 2.1 (DisMod-MR 2.1), spatiotemporal Gaussian process regression (ST-GPR) disease models and Cause of Death Ensemble model (CODEm), or other customized modeling strategies, to produce internally consistent estimates. GBD 2021 adheres to the 11th edition of the International Classification of Diseases (ICD), ensuring each death is accurately attributed to its primary underlying cause. Detailed information on the data source and estimation procedures used in GBD 2021 has been reported previously [25] and is presented in the Supplementary file on pages 1–3. Covariates used in our study were obtained from Our World in Data (https://ourworldindata.org/).

We used the GBD 2021 cause of death database to estimate the burden of female diseases among adolescent girls and young females aged 10–24 years between 1990 and 2021 across 51 countries and territories in Sub-Saharan Africa and South Asia. We conducted a secondary analysis on prevalence, incidence, mortality, and DALY with estimates presented as counts, rates per 100,000 population, accompanied by 95 % UIs calculated as the 2.5th and 97.5th percentiles. This study strictly adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) statement [27].

Data and definitions

GBD 2021 categorized diseases and injuries into four hierarchical levels. Level 1 comprises communicable, maternal, neonatal, and nutritional diseases, non-communicable diseases, injuries, and other outcomes related to the COVID-19 pandemic. Level 2 comprises 22 clusters of causes, each of which is categorized under level 1 causes. Level 3 includes 175 causes, including 132 specific causes and 43 clusters of level 4 causes. Level 4 comprises 302 specific causes, with 170 of these belonging to the 43 clusters at level 3, while the remaining 132 are specific causes at level 3 that are not further subdivided at this level [25]. In this study, we included total maternal disorders classified at level 3 and 10 type-specific maternal causes classified at level 4 (i.e., maternal hemorrhage, maternal sepsis and other maternal infections, maternal hypertensive disorders, maternal obstructed labor and uterine rupture, maternal abortion and miscarriage, ectopic pregnancy, indirect maternal deaths, late maternal deaths, maternal deaths aggravated by HIV/AIDS, and other maternal disorders), 4 female cancers at level 3 (breast cancer, cervical cancer, uterine cancer, and ovarian cancer), 1 total gynecological diseases at level 3, and 7 type-specific gynecological diseases at level 4 (uterine fibroids, polycystic ovarian syndrome, female infertility, endometriosis, genital prolapse, premenstrual syndrome, other gynecological diseases). The underlying causes hierarchy for female diseases in GBD 2021 is shown in Table S1.

We report the prevalence and incidence rates of female diseases because these GBD metrics effectively highlight the characteristics and rapid changes observed in female diseases. Furthermore, we provide mortality and DALY rates of female diseases. Years lived with disability (YLDs) were calculated by multiplying the estimated prevalence of each specific consequence, stratified by age, sex, location, year, and cause, by its corresponding disability weights. Years of life lost (YLLs) were calculated by multiplying the estimated number of deaths, stratified by age, sex, location, year, and cause, by the GBD standard life expectancy at the age when death occurred. DALYs were calculated by aggregating YLDs and YLLs [25].

GBD 2021 introduced SDI, which is a composite indicator that combines lag-distributed income per capita, total fertility rate for those under the age of 25 years, and average education level among individuals aged 15 years or older, with scores ranging from 0 to 1 [28]. The UHC effective coverage index, ranging from 0 to 100, was developed using 23 effective coverage indicators that measure access to essential health services, including interventions associated with maternal and neonatal care, family planning, vaccination, and treatment of HIV, cancer, and diabetes across the lifespan. Each of these 23 indicators is weighted according to the population health gains. A higher UHC effective coverage index indicates better access to high-quality health services [21].

Data analysis

We used the number, rate, and percentage of mortality, DALYs, prevalence, and incidence, as well as the average annual percentage change (AAPC) from 1990 to 2021 to quantify the burden trends of female diseases among adolescent girls and young females at regional (Sub-Saharan Africa and South Asia) and country levels (51 countries). We compared our results with those in the European Union consisting of high and high-middle SDI countries. The metrics were presented as number, percentage, and rate per 100,000 population with corresponding 95 % UIs. We used Joinpoint Regression Program software (version 4.9.0.0, National Cancer Institute, USA) to calculate the AAPC and 95 % confidence interval (CIs) for these metrics between 1990 and 2021 to reflect the direction and magnitude of temporal trends. An AAPC > 0 with a 95 % CI that excludes zero indicates a significantly increasing trend, whereas an AAPC estimation < 0 with a 95 % CI that excludes zero indicates a significantly decreasing trend. Similarly, total percentage changes from 1990 to 2021 were considered significant if the 95 % UI did not include zero. We performed subgroup analyses stratified by age groups including 10–14 years, 15–19 years, and 20–24 years. We used Spearman correlation analyses to examine the association of the mortality rate of female diseases (i.e., maternal disorders, female cancers, and gynecological diseases) with the SDI or UHC effective coverage index in 2021. Moreover, we used multivariate linear regression analyses to evaluate the association between the mortality rate of female diseases and SDI or UHC with the adjustment for population density, deaths in ongoing conflicts in a country, labor force participation rate of women, and non-methane volatile organic compounds emissions from all sectors that might be confounding factors [[29], [30], [31], [32]]. Methods in detail are presented in the Supplementary file on pages 1–3. Data analysis was conducted using R (version 4.3.2). Two-tailed P values < 0.05 indicate statistical significance.

Results

We included a total of 5 countries (4 low-middle SDI countries and 1 low-SDI country) in South Asia and 46 countries (26 low-SDI, 16 low-middle SDI, and 4 middle SDI countries) in Sub-Saharan Africa (Table S2).

In 2021, the total maternal mortality rate was 6.04 (95 % UI 5.02, 7.39) per 100,000 population in South Asia, 17.69 (14.37, 21.78) per 100,000 population in Sub-Saharan Africa, accounting for 7.44 % and 13.55 % of all-cause mortality, respectively (Table 1 and Table S3). The mortality rate of total maternal disorders in Sub-Saharan Africa and South Asia was 294.83 and 100.67 times that of the EU, respectively (Table 1). The maternal mortality ratio (per 100,000 live births) was 135.79 (113.29, 168.26) in South Asia and 211.20 (171.76, 260.69) in Sub-Saharan Africa, which were 29.3 and 45.5 times that of the EU (4.64, [4.18, 5.12]), respectively (Table S4). The proportion of deaths due to maternal disorders relative to all-cause burden in South Asia and Sub-Saharan Africa was 17.34 and 31.59 times that of the EU (Table S3). Similar results were found for the DALY, prevalence, and incidence rate of maternal disorders (Table 1 and Table S3). The leading two level 4 causes of death and DALY per 100,000 population attributed to maternal disorders were maternal hemorrhage and maternal hypertensive disorders in South Asia and Sub-Saharan Africa (Table 1, Fig. 1A-B, and Fig. S1). The leading level 4 cause of incidence of maternal disorders was maternal abortion and miscarriage in South Asia and Sub-Saharan Africa (Table 1 and Fig. S2). Comparable patterns were observed for other metrics of type-specific maternal disorders (Table 1 and Figs. S3-4).

Table 1.

Burden of female diseases (per 100,000 population) in adolescents and young adults aged 10–24 years in South Asia and Sub-Saharan compared to that in the European Union, 1990–2021.

Cause	South Asia			Sub-Saharan			European Union
	1990	2021	AAPC_95%CI	1990	2021	AAPC_95%CI	1990	2021	AAPC_95%CI
Death rate per 100,000 population
Maternal disorders	39.82 (35.60, 43.59)	6.04 (5.02, 7.39)	−5.88 (−6.53, −5.24)	36.49 (30.76, 41.99)	17.69 (14.37, 21.78)	−2.29 (−2.36, −2.21)	0.40 (0.36, 0.44)	0.06 (0.06, 0.07)	−5.81 (−6.56, −5.05)
Maternal abortion and miscarriage	3.50 (2.56, 4.60)	0.41 (0.29, 0.56)	−6.71 (−7.36, −6.06)	6.51 (5.34, 7.65)	1.67 (1.35, 2.09)	−4.24 (−4.39, −4.09)	0.10 (0.08, 0.12)	0.00 (0.00, 0.00)	−10.05 (−11.24, −8.84)
Maternal deaths aggravated by HIV/AIDS	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	2.84 (1.20, 4.51)	0.30 (0.18, 0.41)	0.10 (0.06, 0.14)	−3.51 (−3.77, −3.25)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	−3.96 (−4.66, −3.26)
Maternal hemorrhage	15.50 (12.37, 18.41)	2.07 (1.65, 2.62)	−6.36 (−6.69, −6.02)	8.56 (7.07, 10.04)	4.31 (3.33, 5.50)	−2.13 (−2.25, −2.00)	0.07 (0.06, 0.08)	0.01 (0.01, 0.01)	−6.32 (−7.43, −5.20)
Maternal hypertensive disorders	5.49 (4.65, 6.34)	1.34 (0.99, 1.77)	−4.41 (−4.85, −3.97)	7.72 (6.34, 8.93)	3.65 (2.93, 4.56)	−2.35 (−2.46, −2.24)	0.07 (0.06, 0.08)	0.01 (0.01, 0.01)	−5.66 (−6.68, −4.62)
Maternal obstructed labor and uterine rupture	3.17 (2.19, 4.47)	0.39 (0.26, 0.56)	−6.70 (−7.06, −6.34)	1.66 (1.36, 1.97)	0.79 (0.63, 0.97)	−2.41 (−2.57, −2.25)	0.01 (0.01, 0.01)	0.00 (0.00, 0.00)	−4.26 (−5.48, −3.03)
Maternal sepsis and other maternal infections	2.37 (1.88, 3.00)	0.50 (0.37, 0.66)	−4.77 (−5.37, −4.16)	5.53 (4.44, 6.65)	2.25 (1.77, 2.85)	−2.86 (−2.93, −2.8)	0.04 (0.03, 0.05)	0.00 (0.00, 0.00)	−9.29 (−10.2, −8.38)
Indirect maternal deaths	5.13 (4.22, 6.13)	0.56 (0.44, 0.70)	−6.94 (−7.26, −6.63)	1.83 (1.53, 2.12)	1.40 (1.14, 1.72)	−0.83 (−0.93, −0.73)	0.01 (0.01, 0.02)	0.01 (0.01, 0.01)	−3.03 (−3.81, −2.25)
Late maternal deaths	0.61 (0.41, 0.93)	0.16 (0.11, 0.25)	−4.22 (−4.52, −3.93)	0.39 (0.28, 0.57)	0.28 (0.19, 0.42)	−1.09 (−1.22, −0.97)	0.02 (0.02, 0.03)	0.01 (0.01, 0.01)	−3.13 (−4.16, −2.09)
Ectopic pregnancy	0.06 (0.05, 0.08)	0.07 (0.06, 0.09)	0.56 (0.11, 1.02)	1.30 (1.05, 1.55)	0.97 (0.78, 1.21)	−0.95 (−1.04, −0.85)	0.01 (0.01, 0.01)	0.00 (0.00, 0.00)	−5.87 (−7.04, −4.67)
Other direct maternal disorders	3.98 (2.97, 5.05)	0.53 (0.41, 0.68)	−6.41 (−7.07, −5.74)	2.69 (2.24, 3.13)	2.27 (1.80, 2.91)	−0.51 (−0.68, −0.34)	0.07 (0.06, 0.08)	0.02 (0.02, 0.02)	−4.05 (−5.25, −2.83)
Women cancer
Breast cancer	0.22 (0.18, 0.26)	0.45 (0.33, 0.61)	2.37 (2.30, 2.45)	0.16 (0.14, 0.19)	0.24 (0.18, 0.32)	1.39 (1.28, 1.51)	0.11 (0.10, 0.11)	0.06 (0.05, 0.06)	−1.93 (−2.47, −1.4)
Cervical cancer	0.44 (0.35, 0.55)	0.31 (0.25, 0.40)	−1.00 (−1.72, −0.28)	0.75 (0.59, 0.95)	0.58 (0.46, 0.74)	−0.81 (−0.92, −0.70)	0.11 (0.10, 0.12)	0.04 (0.03, 0.04)	−3.33 (−3.48, −3.18)
Ovarian cancer	0.11 (0.08, 0.15)	0.21 (0.13, 0.28)	2.12 (1.99, 2.25)	0.09 (0.07, 0.13)	0.14 (0.10, 0.18)	1.36 (1.28, 1.44)	0.18 (0.17, 0.19)	0.10 (0.09, 0.11)	−1.82 (−1.97, −1.66)
Uterine cancer	0.01 (0.01, 0.01)	0.01 (0.01, 0.02)	0.63 (0.39, 0.87)	0.01 (0.01, 0.01)	0.01 (0.01, 0.01)	0.24 (0.12, 0.35)	0.01 (0.01, 0.01)	0.01 (0.01, 0.01)	−1.19 (−1.45, −0.92)
Gynecological diseases	0.12 (0.07, 0.23)	0.10 (0.07, 0.15)	−0.64 (−1.39, 0.12)	0.12 (0.07, 0.20)	0.13 (0.06, 0.18)	0.39 (0.24, 0.53)	0.01 (0.01, 0.01)	0.00 (0.00, 0.00)	−3.69 (−3.97, −3.40)
Endometriosis	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	0.44 (−0.42, 1.30)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	1.61 (1.46, 1.75)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	−4.40 (−4.98, −3.81)
Genital prolapse	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	−1.25 (−1.77, −0.74)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	−1.19 (−1.37, −1.01)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	−7.46 (−9.77, −5.09)
Uterine fibroids	0.02 (0.01, 0.04)	0.02 (0.01, 0.03)	−0.60 (−1.47, 0.28)	0.00 (0.00, 0.01)	0.01 (0.00, 0.01)	0.5 (0.29, 0.70)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	−7.00 (−7.72, −6.27)
Other gynecological diseases	0.09 (0.05, 0.20)	0.08 (0.05, 0.13)	−0.64 (−1.37, 0.09)	0.11 (0.06, 0.20)	0.13 (0.06, 0.17)	0.38 (0.23, 0.52)	0.01 (0.01, 0.01)	0.00 (0.00, 0.00)	−3.51 (−3.79, −3.23)
DALY rate per 100,000 population
Maternal disorders	2821.61 (2527.56, 3087.09)	443.27 (370.30, 536.96)	−5.77 (−6.37, −5.17)	2630.85 (2223.83, 3030.64)	1292.38 (1067.21, 1583.36)	−2.25 (−2.32, −2.17)	43.57 (36.43, 52.92)	10.58 (7.94, 14.03)	−4.57 (−5.04, −4.11)
Maternal abortion and miscarriage	246.78 (183.03, 323.19)	29.73 (21.63, 40.56)	−6.60 (−7.22, −5.98)	457.52 (375.14, 537.53)	119.07 (95.76, 148.34)	−4.16 (−4.26, −4.07)	8.41 (6.79, 10.21)	0.92 (0.60, 1.42)	−7.02 (−7.81, −6.21)
Maternal deaths aggravated by HIV/AIDS	0.03 (0.01, 0.05)	0.09 (0.04, 0.17)	2.70 (0.85, 4.58)	20.72 (12.76, 28.71)	6.79 (4.01, 9.91)	−3.52 (−3.78, −3.26)	0.00 (0.00, 0.01)	0.00 (0.00, 0.00)	−3.97 (−4.65, −3.27)
Maternal hemorrhage	1083.70 (872.01, 1285.27)	148.31 (119.59, 186.01)	−6.28 (−6.60, −5.96)	613.38 (505.23, 718.46)	311.17 (241.34, 395.28)	−2.10 (−2.23, −1.98)	8.40 (6.39, 11.01)	1.69 (1.21, 2.31)	−5.13 (−5.71, −4.54)
Maternal hypertensive disorders	391.25 (333.78, 449.99)	96.33 (71.92, 127.37)	−4.38 (−4.77, −3.99)	560.53 (466.29, 650.38)	269.27 (219.74, 332.42)	−2.30 (−2.40, −2.19)	7.71 (5.98, 10.47)	2.10 (1.41, 3.14)	−4.28 (−4.86, −3.69)
Maternal obstructed labor and uterine rupture	241.18 (172.69, 332.50)	34.85 (25.24, 47.29)	−6.11 (−6.48, −5.73)	144.94 (120.68, 173.68)	74.01 (59.62, 90.32)	−2.13 (−2.27, −1.99)	2.59 (1.33, 4.30)	1.01 (0.51, 1.71)	−3.03 (−3.35, −2.71)
Maternal sepsis and other maternal infections	174.37 (139.76, 219.44)	38.71 (29.32, 49.98)	−4.62 (−5.17, −4.06)	391.60 (315.25, 470.82)	161.09 (127.36, 201.08)	−2.83 (−2.90, −2.76)	6.73 (4.46, 10.07)	1.75 (0.91, 2.88)	−4.26 (−4.46, −4.07)
Ectopic pregnancy	4.74 (3.84, 5.73)	5.25 (4.10, 6.71)	0.35 (−0.10, 0.80)	91.43 (73.78, 108.76)	68.02 (54.39, 84.47)	−0.95 (−1.05, −0.86)	1.06 (0.92, 1.24)	0.20 (0.16, 0.25)	−5.39 (−5.93, −4.85)
Indirect maternal deaths	356.13 (293.22, 424.52)	39.21 (31.04, 49.13)	−6.93 (−7.25, −6.61)	127.54 (107.03, 148.00)	97.93 (79.62, 120.50)	−0.82 (−0.92, −0.72)	1.02 (0.90, 1.15)	0.40 (0.35, 0.47)	−3.02 (−3.81, −2.24)
Late maternal deaths	42.35 (28.20, 63.93)	11.14 (7.69, 17.17)	−4.15 (−4.49, −3.81)	27.44 (19.53, 39.62)	19.53 (13.45, 29.10)	−1.09 (−1.21, −0.96)	1.49 (1.04, 2.09)	0.54 (0.38, 0.80)	−3.12 (−4.15, −2.09)
Other direct maternal disorders	281.08 (211.98, 355.06)	39.65 (30.76, 50.09)	−6.22 (−6.82, −5.61)	195.75 (163.75, 228.41)	165.50 (132.49, 210.21)	−0.52 (−0.73, −0.30)	6.16 (5.37, 7.16)	1.96 (1.63, 2.37)	−3.58 (−4.45, −2.70)
Female cancer
Breast cancer	15.29 (12.66, 18.22)	31.89 (23.07, 43.23)	2.39 (2.32, 2.47)	11.36 (9.54, 13.57)	17.32 (12.71, 22.56)	1.42 (1.3, 1.53)	7.89 (7.49, 8.32)	4.51 (4.16, 4.92)	−1.75 (−2.37, −1.13)
Cervical cancer	31.11 (24.92, 38.44)	21.94 (17.78, 28.22)	−0.98 (−1.7, −0.26)	52.32 (41.31, 66.31)	40.78 (32.14, 51.86)	−0.79 (−0.90, −0.69)	7.69 (7.09, 8.35)	2.87 (2.55, 3.22)	−3.22 (−3.37, −3.07)
Ovarian cancer	8.19 (6.00, 11.11)	15.25 (9.49, 19.90)	2.14 (2.01, 2.27)	6.80 (4.68, 9.37)	10.50 (7.37, 13.30)	1.38 (1.30, 1.46)	13.34 (12.75, 14.02)	7.51 (6.99, 8.07)	−1.79 (−1.95, −1.63)
Uterine cancer	0.57 (0.39, 0.74)	0.70 (0.48, 1.13)	0.65 (0.41, 0.90)	0.58 (0.42, 0.73)	0.62 (0.45, 0.83)	0.25 (0.14, 0.37)	0.67 (0.63, 0.71)	0.50 (0.46, 0.54)	−1.04 (−1.30, −0.79)
Gynecological diseases	415.19 (268.37, 617.14)	438.74 (275.57, 664.51)	0.18 (0.16, 0.20)	395.61 (257.61, 585.51)	384.00 (249.27, 567.18)	−0.10 (−0.11, −0.09)	528.93 (355.40, 781.65)	521.57 (351.09, 771.72)	−0.04 (−0.07, −0.01)
Endometriosis	67.31 (36.38, 115.15)	46.74 (25.66, 77.63)	−1.14 (−1.21, −1.07)	64.55 (35.55, 106.40)	44.42 (24.20, 73.05)	−1.20 (−1.23, −1.18)	47.88 (25.68, 81.35)	44.02 (24.04, 75.19)	−0.26 (−0.56, 0.04)
Female infertility	11.19 (2.85, 30.31)	17.48 (4.70, 42.97)	1.54 (0.60, 2.50)	7.53 (2.17, 18.23)	6.38 (1.52, 17.12)	−0.55 (−0.79, −0.32)	2.87 (0.53, 8.43)	3.46 (0.49, 12.54)	0.63 (0.41, 0.85)
Genital prolapse	0.52 (0.22, 1.13)	0.43 (0.17, 0.93)	−0.7 (−0.84, −0.56)	0.27 (0.10, 0.61)	0.24 (0.09, 0.56)	−0.37 (−0.41, −0.32)	0.19 (0.06, 0.47)	0.18 (0.05, 0.46)	−0.21 (−0.33, −0.09)
Polycystic ovarian syndrome	7.18 (3.20, 15.12)	12.99 (5.64, 27.20)	1.97 (1.88, 2.05)	5.84 (2.50, 12.39)	7.86 (3.40, 16.51)	1.00 (0.91, 1.09)	34.75 (15.51, 71.81)	38.91 (17.10, 79.05)	0.35 (0.32, 0.39)
Premenstrual syndrome	274.00 (162.19, 443.10)	297.17 (170.99, 481.94)	0.26 (0.23, 0.28)	227.50 (132.88, 376.80)	232.80 (134.27, 384.81)	0.07 (0.03, 0.10)	276.93 (157.25, 455.69)	269.50 (152.16, 442.48)	−0.08 (−0.10, −0.05)
Uterine fibroids	1.89 (0.79, 3.21)	1.67 (1.01, 2.62)	−0.48 (−1.22, 0.27)	0.66 (0.35, 0.97)	0.70 (0.33, 1.07)	0.21 (0.08, 0.34)	0.33 (0.19, 0.55)	0.26 (0.13, 0.48)	−0.83 (−0.87, −0.79)
Other gynecological diseases	53.09 (31.58, 81.13)	62.26 (37.97, 95.33)	0.53 (0.46, 0.61)	89.27 (50.80, 140.93)	91.60 (52.64, 144.33)	0.07 (0.04, 0.11)	165.97 (97.98, 255.23)	165.24 (99.42, 255.76)	−0.03 (−0.12, 0.07)
Prevalence rate per 100,000 population
Maternal disorders	663.88 (484.95, 902.43)	300.79 (222.41, 410.94)	−2.55 (−2.84, −2.25)	1036.75 (758.83, 1403.01)	693.08 (500.05, 940.39)	−1.32 (−1.42, −1.22)	270.36 (195.07, 368.65)	98.83 (71.95, 134.19)	−3.23 (−3.44, −3.02)
Maternal abortion and miscarriage	31.91 (18.13, 50.50)	15.34 (8.38, 24.39)	−2.33 (−2.43, −2.24)	29.14 (16.68, 45.70)	19.67 (11.17, 31.00)	−1.25 (−1.29, −1.21)	13.54 (7.70, 21.00)	5.81 (3.46, 8.94)	−2.66 (−2.81, −2.52)
Maternal hemorrhage	179.19 (116.96, 276.45)	94.15 (59.27, 145.38)	−2.04 (−2.08, −2.01)	329.82 (215.70, 499.02)	223.12 (146.38, 326.56)	−1.25 (−1.29, −1.22)	103.80 (63.90, 162.48)	30.10 (19.16, 48.80)	−3.94 (−4.08, −3.80)
Maternal hypertensive disorders	180.52 (98.95, 310.50)	74.69 (40.35, 127.74)	−2.75 (−3.41, −2.09)	431.44 (240.44, 709.85)	288.51 (163.59, 470.79)	−1.31 (−1.49, −1.13)	61.15 (32.81, 106.55)	26.27 (15.27, 43.17)	−2.42 (−2.81, −2.03)
Maternal obstructed labor and uterine rupture	72.00 (47.25, 107.89)	24.33 (15.51, 36.30)	−3.52 (−3.69, −3.36)	91.75 (57.85, 143.29)	58.73 (38.46, 87.94)	−1.45 (−1.56, −1.35)	6.87 (3.32, 11.72)	2.80 (1.45, 4.63)	−2.85 (−2.94, −2.76)
Maternal sepsis and other maternal infections	199.24 (104.80, 333.13)	91.14 (49.79, 150.95)	−2.48 (−2.55, −2.41)	157.08 (85.61, 277.43)	103.55 (57.30, 179.98)	−1.34 (−1.38, −1.31)	84.02 (46.15, 132.32)	33.30 (18.64, 51.43)	−2.96 (−3.05, −2.87)
Ectopic pregnancy	4.36 (2.60, 7.05)	1.96 (1.16, 3.17)	−2.54 (−2.58, −2.49)	4.77 (2.84, 7.71)	3.07 (1.83, 4.97)	−1.41 (−1.46, −1.36)	1.60 (0.94, 2.59)	0.63 (0.38, 1.00)	−2.98 (−3.12, −2.84)
Female cancer
Breast cancer	3.08 (2.57, 3.66)	9.98 (7.27, 13.38)	3.84 (3.73, 3.94)	2.22 (1.90, 2.59)	4.64 (3.37, 6.04)	2.40 (2.29, 2.51)	5.74 (5.33, 6.20)	5.87 (5.38, 6.41)	0.15 (−0.28, 0.59)
Cervical cancer	7.28 (5.87, 9.03)	8.62 (7.00, 11.17)	0.62 (−0.03, 1.27)	11.00 (8.62, 13.94)	12.33 (9.71, 15.60)	0.32 (0.19, 0.45)	5.73 (5.19, 6.34)	3.58 (3.15, 4.09)	−1.56 (−1.74, −1.37)
Ovarian cancer	3.58 (2.61, 4.87)	8.41 (5.26, 11.01)	2.89 (2.75, 3.02)	2.93 (2.00, 3.90)	5.34 (3.71, 6.72)	1.91 (1.81, 2.00)	9.75 (9.13, 10.44)	6.50 (5.98, 7.16)	−1.23 (−1.37, −1.09)
Uterine cancer	0.16 (0.11, 0.20)	0.29 (0.21, 0.45)	1.91 (1.61, 2.21)	0.15 (0.11, 0.19)	0.22 (0.16, 0.30)	1.09 (0.98, 1.20)	0.63 (0.59, 0.68)	0.78 (0.72, 0.84)	0.60 (0.30, 0.90)
Gynecological diseases	36003.43 (28550.68, 42763.20)	39501.67 (31460.63, 46882.31)	0.30 (0.28, 0.31)	30672.11 (24259.03, 37075.98)	31014.38 (24363.63, 37866.15)	0.03 (0.02, 0.05)	39733.92 (32193.93, 47007.71)	38985.37 (31490.42, 46287.17)	−0.06 (−0.08, −0.05)
Endometriosis	726.93 (435.20, 1129.66)	501.59 (296.70, 775.93)	−1.16 (−1.22, −1.1)	698.10 (414.70, 1076.44)	476.65 (283.34, 729.46)	−1.22 (−1.24, −1.20)	513.16 (310.48, 795.18)	472.82 (290.23, 731.50)	−0.26 (−0.58, 0.05)
Female infertility	1732.26 (631.98, 3768.18)	2935.76 (1189.01, 5622.51)	1.71 (0.9, 2.53)	1258.02 (513.04, 2336.29)	1069.57 (359.24, 2166.98)	−0.55 (−0.79, −0.31)	458.82 (119.96, 1065.03)	541.01 (106.47, 1599.37)	0.58 (0.34, 0.82)
Genital prolapse	157.93 (96.92, 239.07)	130.15 (76.65, 206.62)	−0.71 (−0.83, −0.59)	79.96 (41.09, 139.50)	72.41 (36.27, 127.62)	−0.34 (−0.39, −0.29)	58.79 (26.88, 107.84)	55.49 (25.24, 102.90)	−0.19 (−0.32, −0.05)
Polycystic ovarian syndrome	771.41 (529.10, 1111.77)	1440.81 (981.90, 2057.25)	2.09 (2.00, 2.18)	645.37 (427.32, 953.53)	872.57 (584.44, 1266.09)	1.01 (0.93, 1.09)	3829.08 (2654.54, 5314.65)	4246.35 (2986.42, 5928.64)	0.32 (0.29, 0.35)
Premenstrual syndrome	32443.41 (24158.04, 39873.75)	35017.37 (25804.13, 43501.89)	0.24 (0.22, 0.26)	26927.86 (19783.30, 34071.66)	27411.65 (19990.62, 35086.14)	0.05 (0.01, 0.08)	32521.80 (23498.83, 41105.24)	31711.00 (23008.51, 40164.53)	−0.08 (−0.09, −0.06)
Uterine fibroids	338.24 (214.03, 487.60)	373.14 (234.30, 541.09)	0.33 (0.29, 0.38)	444.65 (289.23, 641.45)	438.55 (281.77, 635.95)	−0.03 (−0.07, 0.02)	661.31 (468.10, 934.16)	654.86 (467.62, 909.23)	−0.02 (−0.05, 0.02)
Other gynecological diseases	2821.56 (1924.68, 4213.07)	3554.41 (2426.49, 5262.91)	0.75 (0.66, 0.84)	2937.31 (1973.35, 4136.34)	2969.31 (1981.19, 4190.47)	0.04 (0.01, 0.06)	7415.42 (5402.21, 10125.70)	6999.65 (5150.10, 9410.00)	−0.18 (−0.21, −0.15)
Incidence rate per 100,000 population
Maternal disorders	10465.57 (8424.50, 12639.81)	4807.66 (3768.12, 5862.05)	−2.47 (−2.56, −2.39)	10453.41 (8519.52, 12404.19)	6913.96 (5608.35, 8196.06)	−1.34 (−1.38, −1.30)	4201.37 (3437.23, 4956.71)	1702.00 (1412.50, 1980.22)	−2.91 (−3.05, −2.77)
Maternal abortion and miscarriage	3880.21 (2575.29, 5551.18)	1864.49 (1197.90, 2695.22)	−2.33 (−2.43, −2.24)	3541.79 (2370.46, 5017.79)	2390.70 (1590.87, 3405.89)	−1.25 (−1.29, −1.21)	1646.82 (1120.48, 2303.24)	706.07 (503.43, 952.97)	−2.67 (−2.81, −2.52)
Maternal hemorrhage	871.63 (587.19, 1294.72)	399.96 (268.19, 594.09)	−2.46 (−2.54, −2.38)	1569.36 (1066.46, 2262.78)	994.80 (667.68, 1436.82)	−1.45 (−1.49, −1.41)	565.79 (379.59, 817.39)	192.96 (138.16, 261.84)	−3.38 (−3.54, −3.22)
Maternal hypertensive disorders	1095.17 (806.42, 1478.78)	462.82 (339.72, 633.22)	−2.61 (−3.12, −2.09)	2206.90 (1559.22, 2946.95)	1506.99 (1079.50, 1995.62)	−1.25 (−1.39, −1.12)	274.40 (177.00, 422.30)	120.58 (85.12, 169.42)	−2.34 (−2.60, −2.08)
Maternal obstructed labor and uterine rupture	1804.10 (1020.11, 2701.63)	825.84 (456.72, 1222.04)	−2.49 (−2.55, −2.44)	798.18 (486.99, 1320.50)	521.18 (322.77, 867.01)	−1.38 (−1.49, −1.27)	499.48 (288.16, 715.03)	203.74 (123.25, 277.94)	−2.85 (−2.93, −2.76)
Maternal sepsis and other maternal infections	2283.94 (1508.66, 3194.92)	1016.05 (660.99, 1423.82)	−2.59 (−2.64, −2.54)	1756.98 (1185.77, 2528.52)	1126.45 (755.75, 1639.45)	−1.43 (−1.47, −1.39)	1020.07 (789.74, 1185.45)	401.74 (322.84, 456.25)	−2.98 (−3.08, −2.89)
Ectopic pregnancy	530.52 (354.19, 754.75)	238.49 (157.28, 337.47)	−2.54 (−2.58, −2.49)	580.20 (396.42, 839.17)	373.84 (254.01, 537.33)	−1.41 (−1.46, −1.36)	194.80 (132.06, 274.46)	76.91 (53.35, 109.37)	−2.98 (−3.12, −2.84)
Female cancer
Breast cancer	0.41 (0.34, 0.49)	1.26 (0.91, 1.69)	3.62 (3.52, 3.71)	0.30 (0.25, 0.35)	0.59 (0.43, 0.77)	2.23 (2.12, 2.34)	0.67 (0.62, 0.72)	0.67 (0.62, 0.73)	0.09 (−0.35, 0.53)
Cervical cancer	1.25 (1.00, 1.54)	1.30 (1.05, 1.69)	0.19 (−0.56, 0.93)	1.96 (1.53, 2.51)	1.98 (1.55, 2.54)	−0.01 (−0.12, 0.1)	0.75 (0.68, 0.83)	0.44 (0.39, 0.51)	−1.67 (−1.83, −1.52)
Ovarian cancer	0.57 (0.41, 0.77)	1.25 (0.78, 1.63)	2.69 (2.56, 2.82)	0.46 (0.32, 0.62)	0.80 (0.56, 1.01)	1.74 (1.65, 1.84)	1.34 (1.26, 1.43)	0.87 (0.80, 0.96)	−1.32 (−1.45, −1.18)
Uterine cancer	0.02 (0.01, 0.03)	0.04 (0.03, 0.06)	1.80 (1.52, 2.09)	0.02 (0.01, 0.02)	0.03 (0.02, 0.04)	1.00 (0.88, 1.12)	0.07 (0.07, 0.08)	0.09 (0.08, 0.10)	0.54 (0.24, 0.84)
Gynecological diseases	15419.77 (12189.66, 18770.60)	16472.83 (12901.63, 20063.87)	0.21 (0.18, 0.24)	14403.65 (11253.63, 17787.15)	14480.99 (11256.72, 18042.70)	0.01 (−0.01, 0.04)	19974.64 (15804.00, 24327.03)	19505.59 (15433.20, 23792.11)	−0.07 (−0.09, −0.06)
Endometriosis	253.01 (152.66, 392.44)	172.42 (100.74, 267.64)	−1.20 (−1.25, −1.15)	246.01 (144.02, 384.71)	166.27 (95.86, 258.27)	−1.25 (−1.27, −1.23)	153.95 (89.30, 232.37)	142.70 (85.33, 213.53)	−0.23 (−0.47, 0.01)
Genital prolapse	74.10 (49.46, 105.94)	55.59 (36.75, 78.81)	−0.99 (−1.08, −0.90)	31.82 (18.42, 49.22)	28.43 (16.19, 44.65)	−0.39 (−0.47, −0.32)	21.40 (11.44, 35.28)	20.47 (10.90, 33.66)	−0.14 (−0.30, 0.02)
Polycystic ovarian syndrome	94.25 (65.54, 133.85)	155.26 (108.42, 217.55)	1.66 (1.58, 1.74)	81.10 (55.40, 117.47)	107.23 (74.05, 154.50)	0.94 (0.89, 0.98)	392.68 (276.78, 546.36)	471.73 (332.26, 658.79)	0.63 (0.56, 0.69)
Premenstrual syndrome	12132.43 (8896.35, 15329.49)	12603.24 (9120.22, 16110.70)	0.12 (0.1, 0.13)	10057.63 (7341.58, 13010.83)	10146.61 (7267.90, 13170.29)	0.02 (0.00, 0.04)	11345.05 (7944.03, 14869.73)	11101.00 (7815.92, 14508.93)	−0.06 (−0.08, −0.04)
Uterine fibroids	68.21 (35.71, 106.09)	78.54 (40.28, 127.30)	0.47 (0.42, 0.51)	91.82 (48.71, 142.49)	90.60 (48.03, 140.11)	−0.02 (−0.07, 0.02)	94.51 (54.93, 143.84)	96.47 (56.13, 143.90)	0.06 (0.02, 0.11)
Other gynecological diseases	2797.78 (1968.34, 3806.47)	3407.78 (2396.06, 4559.82)	0.65 (0.58, 0.71)	3895.27 (2595.01, 5497.09)	3941.85 (2619.93, 5569.28)	0.04 (0.01, 0.06)	7967.06 (5613.44, 10578.63)	7673.22 (5467.66, 10256.04)	−0.13 (−0.16, −0.10)

AAPC, average annual percentage change (presented as %); DALY, Disability-Adjusted Life-Years.

Fig. 1.

Death and DALY rates (per 100,000 population) of female diseases among adolescents and young females aged 10–24 years across countries in South Asia and Sub-Saharan Africa, in 2021. A, Death rate of maternal disorders; B, DALY rate of maternal disorders; C, Death rate of female cancers; D, DALY rate of female cancers; E, Death rate of gynecological diseases; F, DALY rate of gynecological diseases. DALY, Disability-Adjusted Life-Years.

In 2021, the mortality rate of female cancers in South Asia and Sub-Saharan Africa was 4.67 and 4.62 times that of the EU, respectively (Table 1). The leading two level 3 causes of cancer death per 100,000 population were breast cancer and cervical cancer in both South Asia and Sub-Saharan Africa, which accounted for 7.88 % and 5.43 % of total cancer deaths in South Asia, and 4.90 % and 11.59 % in Sub-Saharan Africa, respectively (Table 1, Fig. 1 C-D, Fig. S5, and Table S5). The mortality rate of breast cancer and cervical cancer in South Asia was 7.50 and 7.75 times that of the EU, respectively (Table 1 and Fig. S5). The mortality rate of breast cancer and cervical cancer in Sub-Saharan Africa was 4.0 and 14.5 times that of the EU (Table 1 and Fig. S5). Although the prevalence rate and incidence rate of breast cancer in Sub-Saharan Africa were comparable to those in the EU, the DALY and death rates were much higher in Sub-Saharan Africa compared to those in the EU (Table 1 and Fig. S5). In South Asia, the proportions of breast cancer and cervical cancer deaths to total cancer deaths were 3.89 and 4.03 times those of the EU, respectively. In Sub-Saharan Africa, these proportions were 2.42 and 8.59 times those of the EU, respectively (Table S5).

In 2021, the total mortality rate per 100,000 population due to gynecological disease was 0.10 (0.07, 0.15) in South Asia and 0.13 (0.06, 0.18) in Sub-Saharan Africa, accounting for 0.12 % and 0.10 % of all-cause death, respectively (Table 1 and Table S3). The mortality rate in South Asia and Sub-Saharan Africa was 28.56 and 38.79 times that of the EU (Table 1). The proportion of gynecological disease relative to all causes of death in South Asia and Sub-Saharan Africa was 5.13 and 4.33 times that of the EU (Table S3). The prevalence rate per 100,000 population due to gynecological disease was 39501.67 (31460.63, 46882.31) and 31014.38 (24363.63, 37866.15) in South Asia and Sub-Saharan Africa, which accounted for 40.17 % and 31.39 % of all-cause burden in females (Table 1 and Table S3). In addition to the death rate of other gynecological diseases, premenstrual syndrome was the leading level 4 cause of prevalence, incidence, and DALY rates of gynecological disease per 100,000 population in both South Asia and Sub-Saharan Africa (Table 1, Fig. 1E-F, and Fig. S6). The burden of female infertility appeared highest in South Asia, followed by Sub-Saharan Africa and the EU (Table 1 and Fig. S6). Although the prevalence rate and incidence rate of uterine fibroids in South Asia and Sub-Saharan Africa were similar to or even lower than those in the EU, the death and DALY rates were substantially higher compared to those in the EU (Table 1 and Fig. S6).

When stratified for age groups, the burden of most maternal disorders, female cancers, and gynecological diseases increased with age in the regions of South Asia and Sub-Saharan Africa (Figs. S7-18 and Table S6). However, the incidence rate of polycystic ovarian syndrome among females aged 10–14 years and 15–19 years was largely higher than that among those aged 20–24 years, and the incidence rate of premenstrual syndrome was highest among those aged 15–19 years when compared to those aged 10–14 and 20–24 years (Fig. S18 and Table S6).

At the country level, Chad had the highest rates of death and DALY due to maternal disorders in 2021, at 50.03 (32.38, 71.19) and 3577.10 (2331.48, 5051.42) per 100,000 population, respectively (Fig. 1 A-B and Table S7). In 2021, forty-five of 51countries exceeded the SDG target level of 70 maternal deaths per 100,000 live births (Table S4). Djibouti had the highest maternal mortality ratio of 784.55 (385.42, 1342.87) per 100,000 live births (Table S4). In 2021, Pakistan had the highest DALY and death rates due to female cancers, at 150.76 (88.89, 231.72) and 2.12 (1.25, 3.27) per 100,000 population, respectively (Fig. 1 C-D and Table S7). Zimbabwe had the highest death rate of gynecological disease, at 0.37 (0.19, 0.64) per 100,000 (Fig. 1 E and Table S7). Pakistan had the highest DALY rates of gynecological disease in 2021, at 445.13 (284.23, 652.52) per 100,000 (Fig. 1 F and Table S7). The death rate from maternal disorders exceeded 10 per 100,000 in 35 (68.6 %) countries and territories, while the death rate from female cancers was greater than 1 per 100,000 in 26 (51.0 %) countries and territories (Fig. 1A, Fig. 1C, and Table S7). All 51 (100 %) countries and territories reported a DALY rate of gynecological disease exceeding 300 per 100,000 (Fig. 1 F, and Table S7). The prevalence and incidence rate of these diseases at country levels are presented in Figs. S19-24.

From 1990 to 2021, the maternal mortality rate decreased, with AAPCs of −5.88 % (95 % CI −6.53, −5.24) in South Asia, −2.29 % (−2.36, −2.21) in Sub-Saharan Africa, and −5.81 % (−6.56, −5.05) in the EU, respectively (Table 1 and Fig. 2). However, there was a notable increase in the number of deaths (from 29,137 to 33,393), DALY (2,100,684 to 2,440,056), prevalence (827,825 to 1,308,551), and incidence (8,346,841 to 13,053,774) due to maternal disorders in Sub-Saharan Africa, with a stable percent of death and DALY (Fig. S25). Over the past three decades, the mortality rate of most type-specific maternal disorders in level 4 causes has significantly decreased by more than 60 % in both the EU and South Asia regions, in stark contrast, the decline in Sub-Saharan Africa has been less than 60 % (Table S8 and Figs. S26-35). Less decline in rates of DALY, prevalence, and incidence of most type-specific maternal disorders was similarly observed in Sub-Saharan Africa compared to South Asia and the EU (Table S8 and Figs. S26-39).

Fig. 2.

Change in burden rate (per 100,000 population) of maternal disorders, breast cancer, cervical cancer, uterine cancer, ovarian cancer, and gynecological diseases among adolescents and young females aged 10–24 years in South Asia and Sub-Saharan Africa compared to that in the European Union, 1990–2021. DALY, Disability-Adjusted Life-Years.

From 1990 to 2021, contrary to the mortality rate due to female cancers in the EU region, the death rate of breast cancer, ovarian cancer, and uterine cancer increased by 1.07-fold (AAPC 2.37 %), 85.35 % (AAPC 2.12 %), 21.87 % (AAPC 0.63 %) in South Asia and 51.38 % (AAPC 1.39 %), 53.68 % (AAPC 1.36 %), and 6.99 % (AAPC 0.24 %) in Sub-Saharan Africa from 1990 to 2021, respectively (Table 1, Fig. 2, and Table S8). Although the death rate of cervical cancer decreased, especially in Sub-Saharan Africa, the number and percent of cervical cancer increased in both regions (Fig. 2 and Fig. S40). Similar increases in other burden metrics of these female cancers are shown in Figs. S40-47.

From 1990 to 2021, the DALY, prevalence, and incidence rates due to overall gynecological diseases increased significantly in South Asia, whereas the death rate increased in Sub-Saharan Africa (Fig. 2, Table S8, and Figs. S48-49). For type-specific gynecological diseases, the increase in DALY, prevalence, and incidence rates of polycystic ovarian syndrome was higher in South Asia and Sub-Saharan Africa than that in the EU (Table S8 and Figs. S50-53). Contrary to the EU region, the DALY, prevalence, and incidence rates of premenstrual syndrome increased in South Asia and Sub-Saharan Africa (Table S8 and Figs. S50-52, 54). Furthermore, the DALY and prevalence rates of female infertility, as well as the prevalence and incidence rates of uterine fibroids increased only in South Asia (Table S8 and Figs. S50-51, 55-56). Although the death and DALY rates for genital prolapse decreased from 1990 to 2021 in South Asia and Sub-Saharan Africa, the proportion of death from this specific condition relative to all-cause mortality tended to increase (Figs. S49-50, 57). The burden of other gynecological diseases is presented in Figs. S58-59.

When stratified for age groups, the changes in the burden of maternal disorders and female cancers from different age subgroups were similar to the overall findings. However, the rate of maternal deaths aggravated by HIV/AIDS in both regions, particularly in South Asia, started to increase from the age of 10–14 years (Table S9). The death rate of gynecological diseases, particularly endometriosis and uterine fibroids, started to increase annually from the age of 10–14 years in Sub-Saharan Africa (Table S6). The DALY, prevalence, and incidence rates of polycystic ovary syndrome showed an increasing trend starting from a young age group of 10–14 years, with the total percentage increase being significantly higher in South Asia and Sub-Saharan Africa compared to the EU (Table S9). In contrast to the EU region, the DALY and prevalence rates of premenstrual syndrome started to increase among adolescents aged 15–24 years in South Asia and Sub-Saharan Africa (Table S9).

At the country level, there was a decreasing trend in the death rate for type-specific maternal disorders from 1990 to 2021 in almost all countries (Fig. 3 A). However, the death rate of ectopic pregnancy and indirect maternal deaths increased in 13 and 13 out of 51 countries, respectively, although the increase was only significant in Zimbabwe (total percentage change: 79.08 %, 95 % UI 1.32 %, 219.38 %) and Bangladesh (89.87 %, 95 % UI 11.96 %, 193.49 %) for ectopic pregnancy, and in South Africa (134.47 %, 95 % UI 35.47 %, 276.28 %) and Lesotho (98.12 %, 95 % UI 0.67 %, 290.73 %) for indirect maternal deaths (Table S10). The rate of maternal deaths aggravated by HIV/AIDS increased significantly by more than 100 % in 10 countries (Pakistan, Djibouti, Gambia, Eswatini, India, Lesotho, Bangladesh, Madagascar, South Africa, and Mozambique) out of 51 from South Asia (3 out of 5 countries) and Sub-Saharan Africa (7 out of 46 countries) (Table S10). The total percentage increases in the death rate for breast cancer and ovarian cancer were observed in 49 and 50 out of 51 countries, respectively, although the increase was statistically significant in 12 countries (Malawi, Lesotho, Zimbabwe, Sierra Leone, Pakistan, Eritrea, Uganda, Comoros, Liberia, Kenya, Congo, India) and 11 countries (Cabo Verde, Zimbabwe, Uganda, Gambia, Lesotho, Liberia, Sierra Leone, Pakistan, Congo, Senegal, Kenya), respectively (Fig. 3 B and Table S10). The incidence rate of polycystic ovarian syndrome increased in nearly all countries in the regions of South Asia and Sub-Saharan Africa, highest in Equatorial Guinea (Fig. 3 C and Table S10). The other metrics of these diseases at the country level have been shown in Figs. S60-68 and Table S10.

Fig. 3.

Burden of type-specific female diseases among adolescents and young females aged 10–24 years across countries in South Asia and Sub-Saharan Africa in 1990 and 2021. A, death rate of type-specific maternal disorders; B, death rate of type-specific female cancers; C, incidence rate of type-specific gynecological diseases. BC, Breast cancer; CC, Cervical cancer; EM, Endometriosis; EP, Ectopic pregnancy; FI, Female infertility; GP, Genital prolapsed; IMD, Indirect maternal deaths; LMD, Late maternal deaths; MOL&UR, Maternal obstructed labor and uterine rupture; MH, Maternal hemorrhage; MS, Maternal sepsis and other maternal infections; MHD, Maternal hypertensive disorders; MAM, Maternal abortion and miscarriage; MHIV, Maternal deaths aggravated by HIV/AIDS; Others, Other direct maternal disorders; Others, Other gynecological diseases; OC, Ovarian cancer; POS, Polycystic ovarian syndrome; PS, Premenstrual syndrome; UC, Uterine cancer; UF, Uterine fibroids.

There was an inverse association between the death rate of maternal disorders and both SDI (r = -0.738, P < 0.001) and UHC effective coverage index (r = -0.753, P < 0.001, Figs. S69-70). Although the death rates for female cancers and gynecological diseases were inversely associated with SDI (r = -0.300, P = 0.03; r = -0.285, P = 0.04, respectively), the association with UHC effective coverage index tended to be non-significant (r = -0.221, P = 0.110; r = -0.173, P = 0.220, respectively, Figs. S71-74). Similar results were found after adjusting for population density, deaths in ongoing conflicts in a country, labor force participation rate of women, and non-methane volatile organic compounds emissions from all sectors (Table S11).

Discussion

The systematic analysis found a notable reduction in the burden of maternal disorders in South Asia and Sub-Saharan Africa from 1990 to 2021. However, the number of cases in Sub-Saharan Africa increased gradually during this period. It is concerning that more than 88.0 % of countries in these two regions have not met the SDG target (i.e., maternal mortality ratio less than 70 per 100,000 live births by 2030) in 2021. In both regions, a considerable proportion of the burden from maternal disorders was attributed to maternal hemorrhage and maternal hypertensive disorders. There was a significant increase in the burden rates of breast cancer, ovarian cancer, and uterine cancer in both South Asia and Sub-Saharan Africa. Additionally, there were increases in DALYs, prevalence, and incidence rates of gynecological diseases in South Asia, as well as death rates of such diseases in Sub-Saharan Africa. Alarmingly, certain female diseases, such as polycystic ovarian syndrome and maternal deaths aggravated by HIV/AIDS in both regions (particularly in South Asia), as well as endometriosis and uterine fibroids in Sub-Saharan Africa, are increasingly affecting younger adolescents aged 10–14 years. Country-level data revealed striking disparities. For example, in 2021, Pakistan and Zimbabwe exhibited the highest burden of deaths from female cancers, while Zimbabwe had the highest burden of deaths from gynecological diseases. From 1990 to 2021, Zimbabwe and Pakistan showed a significant increase in death rates of type-specific female diseases such as ectopic pregnancy deaths, maternal mortality aggravated by HIV/AIDS, and breast and ovarian cancers, with the exception of maternal mortality aggravated by HIV/AIDS in Zimbabwe. Furthermore, countries with lower SDI had a heavier burden of female diseases among adolescents and young adults. However, there was no significant association of the UHC effective coverage index with the death rate of female cancers and gynecological diseases.

Notably, the mortality rates of maternal disorders, female cancers, and gynecological diseases in Sub-Saharan Africa and South Asia were still considerably higher than those in the EU in 2021. This discrepancy may be attributed to factors such as maternal malnutrition (e.g., iron deficiency) and unsafe sex practices in these two regions (Table S12). Furthermore, the EU region, which comprises high-income and high-middle-income countries, benefits from well-established and adequately resourced healthcare systems, advanced disease diagnosis capabilities, and a population with a high level of education and health awareness [[33], [34], [35]]. These findings suggest that there is an urgent need for Sub-Saharan African and South Asian countries to learn from European countries in formulating targeted intervention strategies to address these disparities.

Since 1980, maternal mortality has experienced a significant decline as a percentage of overall deaths in most GBD super-regions. However, in Sub-Saharan Africa and South Asia, maternal mortality remains prominent, particularly among adolescents and young adults who are often overlooked [10,36]. In 2021, most countries in Sub-Saharan Africa and South Asia have not achieved the SDG 3.1 target for reducing the maternal mortality ratio among adolescents and young adults. In addition, compared to the EU, these two regions have significantly higher maternal mortality ratios or rates. A study conducted in eight European countries revealed that up to 2019, the maternal mortality ratio was below 11.0 deaths per 100,000 live births [37], which highlights that successful strategies employed by these countries can provide practical insights for tailored interventions to lower maternal mortality. For instance, high-income nations have achieved success by promoting prenatal care, improving hospital access, extending medical aid to postpartum females, and enhancing the overall healthcare system. These could offer valuable insights to low-income countries aiming to reduce their maternal mortality rates [33,38,39]. European countries, including efforts by the Royal College of Obstetricians and Gynecologists in the UK and the European Board and College of Obstetrics and Gynecology, have implemented measures to enhance the quality of obstetrics and gynecology services, which include establishing standards of care and setting training and teaching roles for various sub-specialties [[40], [41], [42]].

Consistent with previous research on the general population [43], this systematic review found that maternal hemorrhage and maternal hypertensive disorders were the leading causes of maternal mortality among adolescents and young adults in Sub-Saharan Africa and South Asia, which suggests that interventions aimed at improving maternal healthcare services, particularly addressing these conditions, are crucial. In addition, despite significant progress in reducing HIV/AIDS-related maternal deaths in Sub-Saharan Africa from 1990 to 2021, the improvements have been uneven. Seven of the 46 countries in Sub-Saharan Africa and 3 of 5 countries in South Asia had an increase of over 100 % and HIV/AIDS-related maternal deaths started to affect young adolescents aged 10–14 years, indicating that key populations like adolescents and young females are still being ignored in HIV programs. HIV/AIDS remains a leading cause of death in adolescents in Sub-Saharan Africa, particularly adolescents aged 10–19 years [44]. In South Asia, easy access to injectable drugs and increasing poverty may jointly contribute to the potential dissemination of HIV to adolescents [45]. Early sexual initiation in Sub-Saharan Africa leads to early exposure to a variety of sexual and reproductive health risks, such as HIV infection [46]. Large age disparity between sexual partners in Sub-Saharan Africa is a significant contributor to the HIV epidemic among adolescents and young women since older male partners are more likely to be HIV-infected than adolescent boys [46]. There was an increase in the proportion of adolescents living in urban settings in Sub-Saharan Africa, leading to higher levels of sexual activity and HIV risks compared to rural areas [46]. Current efforts should aim at prioritizing key populations, promoting education, addressing gender inequalities, harmful norms, and violence against females, strengthening prevention programs, enhancing healthcare infrastructure and accessibility, and implementing an effective intrapartum-care strategy [45,[47], [48], [49]].

A recent study based on the GBD 2021 showed the most significant increases from 1990 to 2021 in the burden rates (i.e., incidence and DALY rates) of female cancers including breast cancer, cervical cancer, and ovarian cancer among individuals aged 15 to 24 years, suggesting a growing impact of these female cancers on younger females [12]. However, this previous study did not concentrate on young females in regions facing substantial health challenges, notably South Asia and Sub-Saharan Africa. Consistent with our findings, a study based on data from both GBD 2021 and the other database for the data source (i.e., Global Cancer Observatory 2022 [GLOBOCAN 2022]), which includes data from mortality databases, national and subnational cancer registries, as well as predictive models, identified breast cancer and cervical cancer as the two leading causes of cancer deaths among adolescents and young adults in Africa and Asia [50]. We further observed a significant increase in the burden rates of breast cancer and ovarian cancer among adolescents and young females aged 10–24 years in South Asia and Sub-Saharan Africa from 1990 to 2021. In contrast to the global trend of decreasing DALY rate of uterine cancer among adolescents and young females aged 15–24 years [12], our study indicated an upward trend in the burden of this cancer in South Asia and Sub-Saharan Africa. The increasing trends for most female cancers in these two regions might be attributed to gender education inequality and westernization factors, including obesity, dietary change, and insufficient physical activity, among adolescents and young females [[51], [52], [53]]. However, we found a decrease in the death and DALY rates of cervical cancer in both regions during this period, potentially attributable to the implementation of human papillomavirus vaccination (HPV) delivery strategies in countries within these two regions, such as Uganda, India, and Bangladesh [54,55]. Moreover, beyond expanding HPV vaccination coverage, the WHO triple-intervention strategy, which encompasses twice-lifetime cervical screening and the treatment of pre-invasive lesions and invasive cancer, holds potential for further reducing cervical cancer deaths in Sub-Saharan Africa and South Asia [56]. These findings underscore the urgent need for policymakers to develop and enforce practical policies, including early detection strategies, the promotion of healthy lifestyles, and providing comprehensive cancer care, particularly in regions with high female cancer rates. Implementing early detection strategies or primary prevention measures could potentially prevent 1.5 million deaths from female cancers annually, while optimal cancer care has the potential to further prevent 800,000 deaths [53]. Evidence suggests that screening, coupled with treatment for female cancers at all stages, is highly cost-effective [57].

Our findings in South Asia are consistent with previous global data from the GBD 2019, which indicated an upward trend in the incidence rate of gynecological diseases among adolescents and young females aged 15–29 years, with the most significant increase observed in the 20–24 age group [8]. The significant upward trend of gynecological diseases in South Asia might be attributed to gender inequality, men’s perspectives on sexual harassment, unequal coverage of health and nutrition interventions for women, early marriage and childbearing [[58], [59], [60]]. We additionally found a higher incidence rate of polycystic ovarian syndrome among adolescents aged 10–19 years and premenstrual syndrome among those aged 15–19 years in South Asia and Sub-Saharan Africa compared to the global trend observed among those aged 10–19 years [8]. To the best of our knowledge, comprehensive epidemiological studies examining polycystic ovarian syndrome among adolescents and young females in South Asia and Sub-Saharan Africa are lacking, which is particularly concerning given the urgent need to improve women's health in these areas [61]. The higher incidence rates of polycystic ovarian syndrome and premenstrual syndrome in younger age groups may be attributed to a combination of hormonal changes, lifestyle habits, and psychological factors. Adolescents, especially those aged 10–14 years, commonly experience irregular menstrual cycles and hormonal fluctuations, which are the primary causes of polycystic ovarian syndrome and premenstrual syndrome [62,63]. Younger adolescents with poor dietary habits and insufficient exercise are prevalent in low- and middle-income countries, which can also contribute to the development of these gynecological conditions [62,64]. For instance, childhood obesity was associated with early initiation of puberty in girls, usually occurring at the age of 10 years. This precocious pubertal development disrupts normal endocrine activity, which potentially increases the risk of polycystic ovarian syndrome [65]. Furthermore, psychosocial factors such as intimate partner violence, anxiety, and stress, which are common among adolescents and young women in low socioeconomic settings, may be associated with the incidence of polycystic ovarian syndrome and premenstrual syndrome [[65], [66], [67], [68]].

Notably, our study revealed that from 1990 to 2021, the increase in the burden of female infertility in South Asia was the second most significant contributor to the overall increase in gynecological diseases. This increase can be attributed to several factors, including limited medical resources, inadequate health awareness, early marriage and pregnancy, infections, and inflammation [[69], [70], [71]]. Furthermore, our findings indicate an annual increase in the mortality and DALY rates of endometriosis and uterine fibroids in Sub-Saharan Africa, with a particular impact on adolescents aged 10–14 years, which might be due to factors such as reproductive system maturity, discrepancies between the age of marriage and the legal age of sexual consent, lack of education, inadequate medical care, and insufficient family and societal attention [72,73]. For instance, gender inequalities play a critical role in adolescent sexual and reproductive health throughout adolescence, even as early as the age of 10–14 years [46]. Several countries in Sub-Saharan Africa, such as Chad and Niger, had a prevalence of child marriage before the age of 18 years exceeding 60 % [74]. Access to maternal health services is still limited in most Sub-Saharan African nations. Furthermore, there exists a considerable disparity in the use of maternity care services among adolescent mothers across various countries in Sub-Saharan Africa [75]. These findings underscore the need for policies that promote healthy lifestyles, enhance awareness about the condition, improve access to high-quality healthcare, and provide psycho-social support, with a particular focus on reducing the burden of gynecological diseases among adolescents and young females in these specific regions.

At the country level, similar to estimates from the WHO, United Nations Children’s Fund (UNICEF), United Nations PopulationFund (UNFPA), World Bank Group and United Nations Department of Economic and Social Affairs, Population Division (UNDESA/Population Division) among adolescents aged 15 years in 2020, we found that 10 out of 46 countries in Sub-Saharan Africa have halved their maternal mortality rates between 1990 and 2021, and the top five countries in this region with the highest maternal mortality rates among adolescents were Chad, Nigeria, Somalia, South Sudan, and Central African Republic [6]. Furthermore, we found that the death rate of type-specific maternal disorders varied across countries. However, certain countries, such as Lesotho, Bangladesh, Zimbabwe, South Africa, and Pakistan, are experiencing a significant increase in specific maternal disorders, including the death rate from ectopic pregnancy, indirect maternal deaths, maternal deaths aggravated by HIV/AIDS, and the death rate from breast cancer or ovarian cancer. Potential explanations for this trend may include inadequate healthcare infrastructure, poverty, low education levels, and cultural beliefs. For instance, Bangladesh and Pakistan, South Asia countries with distinct social and cultural norms from Western countries, demonstrate a strong collectivist orientation, where decision-making is often dominated by social controls such as family, culture, religion, and community [76]. In addition, limited resources in the health system and the limited education of healthcare providers in Bangladesh and Pakistan due to poverty pose key barriers to providing adequate maternal health care [76]. Prevailing religious beliefs, colonial history, and low education levels in several Sub-Saharan African countries, including South Africa, Zimbabwe, and Lesotho, have increased vulnerability to HIV/AIDS epidemics and the development of cancers in women [[77], [78], [79]]. Similar to a previous study, Equatorial Guinea exhibited the most significant increase in DALY, prevalence, and incidence rates of polycystic ovarian syndrome, which might be driven by lifestyle change and urbanization [80]. Therefore, there is an urgent need for tailored interventions and policies to reduce the burden of women diseases at the country level. A systematic review suggested several successful strategies including male-partner interventions, mobile health interventions, financial incentives, facility-based and community-based interventions, initiating and enhancing antiretroviral uptake among HIV-positive pregnant women, utilizing antenatal care service, promoting postnatal visits, improving immunization uptake, and providing nutritional supplements to reduce maternal mortality [81]. Additionally, key strategies identified to improve women's health outcomes include training health workers, developing audience-response communication strategies and educational resources for targeted cancer screening, increasing the involvement of primary-care physicians, and implementing cost-reducing interventions [[82], [83], [84]].

Our study also revealed that countries with higher SDI exhibited lower death rates of female diseases among adolescents and young women in South Asia and Sub-Saharan Africa in 2021. Notably, we found non-significant inverse associations of female cancers and gynecological diseases with the UHC effective coverage index. In addition to emphasizing the importance of socioeconomic development in enhancing healthcare access for adolescents and young females, our findings underscore the pivotal role of healthcare service quality and resource availability. It is alarming that none of the 51 countries studied in South Asia and Sub-Saharan Africa achieved the UHC effective coverage index target of 80 out of 100 in 2021 (Table S2) [21]. Additionally, the shortage of human resources in South Asia and Sub-Saharan Africa accounts for over half of the global deficiencies [21]. The generally low quality of UHC may impede its potential to reduce the disease burden. This issue is particularly alarming, given that a substantial proportion of adolescents in these two regions lack access to adequate and high-quality health services, underscoring the urgent need to prioritize substantial investment in adolescent health. In addition, the non-significant association might be explained by economic and technological constraints such as the lack of advanced diagnostic equipment and technologies, as well as specialist care, a shortage of effective inter-disciplinary communication, and low levels of education among women and their families. These factors, which are not adequately captured by the UHC effective coverage index, may result in sub-optimal resource allocation and treatment decision-making, ultimately leading to poor treatment outcomes [85]. Furthermore, medical resources may be excessively concentrated in urban areas, making it difficult for women in rural and remote regions to access timely and effective diagnostic and treatment services [86]. However, the UHC effective coverage index encounters difficulties in accurately reflecting such geographical imbalances. A policy implementation gap may also contribute to the findings. Despite the availability of health insurance coverage aimed at providing “cost-free” service at the point of use, patients occasionally still face out-of-pocket expenditures, which may discourage them from seeking timely medical care [87]. Our findings highlight that policymakers must integrate strategies to address economic, educational, and geographical barriers, thereby ensuring UHC truly serves all, especially vulnerable young females.

To the best of our knowledge, this study represents the first comprehensive estimation of the burden of female diseases among adolescents and young females aged 10–24 years in South Asia and Sub-Saharan Africa from 1990 to 2021, across various age groups and countries. Nevertheless, several limitations must be acknowledged. First, a common issue with all GBD estimates is that inconsistencies in the accessibility of primary data introduce a level of instability to GBD analyses. Strengthening data-collection systems is crucial to improving the quality of primary data. In cases where sufficient data is not available, GBD estimates rely on the out-of-sample predictive validity of the modeling process. Nonetheless, this approach ensures the inclusion of causes or populations with limited or no data into essential benchmarking activities [25]. Second, the estimation of 95 % UIs requires further improvement, as capturing all sources of uncertainty throughout the entire process of burden estimation is challenging. Third, our estimates do not take into account the potential impact of the COVID-19 pandemic on the prevalence and burden of female disease in 2020 and 2021. Fourth, for female cancers, this systematic review mainly focuses on four common cancers including breast cancer, cervical cancer, uterine cancer, and ovarian cancer, excluding other types of female cancers. Fifth, the trends in the burden of female diseases identified in this study should be interpreted with caution, because variations in detection and diagnosis protocols across countries and over time may impact the comparability of results [12]. Sixth, in low-and middle-income countries, inadequate diagnostic capacities may lead to an underestimation of the incidence of female diseases. Seventh, given the unavailability of certain potential factors in GBD data, caution is warranted in interpreting the associations between death of female diseases and SDI or UHC effective coverage index among adolescents and young females, and these associations should not be interpreted as causal.

Conclusions

In conclusion, female diseases including maternal disorders, female cancers, and gynecological diseases pose a significant public health challenge for adolescents and young women in South Asia and Sub-Saharan Africa, with younger adolescents being disproportionately affected. Policymakers should prioritize addressing the rural/urban access gap in this specific population by developing mobile clinics with teams trained in young people-friendly counseling services, address gender inequalities and harmful social norms by legislating marital-age consent reforms, promote education on women’s health, enhance healthcare accessibility and quality by expanding health insurance coverage, and implement effective prevention programs such as community-based cancer screening with male-partner engagement to promote family support. Furthermore, further research is crucial to understanding the underlying causes and identifying effective prevention and treatment strategies for young women in South Asia and Sub-Saharan Africa.

Compliance for ethical requirement

Ethical requirement is not required as the data has been collected from online source.

CRediT authorship contribution statement

Jiahong Sun: Conceptualization, Data curation, Formal analysis, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing. Yongliang Zhu: Formal analysis, Visualization. Danyi Huang: Writing – review & editing. Liuqing Li: Visualization, Writing – review & editing. Mengna Pan: Data curation, Methodology, Visualization, Writing – review & editing. Fei Li: Visualization, Writing – review & editing. Chuanwei Ma: Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Writing – review & editing.

Ethics approval

Not applicable.

Funding

This study was supported by a grant from Guangdong Medical University Introduced High-Level Talent Research Start-Up Funds, Guangdong Province, China.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following are the Supplementary data to this article: