Beyond Maternity: Quantifying the Holistic Disease Burden and Systemic Neglect of Women’s Health in Yemen

Beyond Maternity: Quantifying the Holistic Disease Burden and Systemic Neglect of Women’s Health in Yemen | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond Maternity: Quantifying the Holistic Disease Burden and Systemic Neglect of Women’s Health in Yemen Mamoon Alazazy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8444298/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Yemen faces a dual humanitarian catastrophe—a decade-long armed conflict coupled with one of the world’s most severe health crises. While international attention on women’s health remains fixated on maternal mortality, this paper challenges the “reproduction-centered” paradigm and quantifies the broader disease burden affecting Yemeni women aged 15–49. Using secondary analysis of Global Burden of Disease (GBD) 2021 data, health facility assessments, and humanitarian response documentation, we demonstrate that non-communicable diseases (NCDs) and mental health conditions represent substantial but systematically neglected drivers of female morbidity and mortality. While maternal conditions remain a top cause of death, cardiovascular diseases, mental health disorders, and communicable diseases (TB, cholera) collectively account for significantly greater disability-adjusted life years. Healthcare access for these conditions is severely constrained, with only 21% of health facilities offering NCD and mental health services, compared to maternal health services reaching 20% of facilities. Gender-specific barriers—including the mahram requirement limiting women’s mobility, critical shortages of female health providers, and the gender-blind design of humanitarian responses—perpetuate a “blind spot” in women’s health. We conclude that integrating NCD screening into antenatal clinics, training midwives in mental health first aid, and explicitly incorporating women’s holistic health indicators into humanitarian needs assessments and cluster coordination are essential to address this systemic neglect. Women’s health Non-communicable diseases Yemen Humanitarian response Gender inequality Health systems Women’s leadership Figures Figure 1 1. Introduction Global health discourse has undergone a paradigm shift in recent decades, moving from a narrowly maternal-focused perspective toward a lifespan approach to women’s health.[ 1 ] The World Health Organization’s 2016–2030 Global Strategy for Women’s, Children’s and Adolescents’ Health explicitly calls for integration of maternal, newborn, child and adolescent health with chronic disease prevention and management.[ 2 ] Yet in conflict-affected settings, particularly in Yemen, this holistic vision remains unrealized. Yemen presents an extreme test case of this contradiction. In its tenth year of armed conflict, with 19.5 million people requiring humanitarian assistance and only 55% of health facilities operational, the country’s humanitarian health response remains dominated by a reproductive health paradigm.[ 3 , 4 ] Donors, UN agencies, and international NGOs channel resources primarily into antenatal care, delivery services, and family planning—critical needs, certainly, but increasingly insufficient when the broader epidemiological landscape is considered. Recent evidence from the Global Burden of Disease (GBD) study (2021) reveals a striking reality: in Yemen, non-communicable diseases (NCDs) now account for 49.5% of all deaths, far exceeding communicable, maternal, neonatal, and nutritional diseases (32.0%) and injuries (18.5%).[ 5 ] Age-standardized mortality from conflict-related violence increased precipitously from 1.9 to 50.0 deaths per 100,000 population between 2010 and 2021.[ 5 ] Among the leading causes of disability (years lived with disability, YLDs), dietary iron deficiency, low back pain, depressive disorders, headache disorders, anxiety disorders, and gynecological diseases dominate—yet mental health services are available in only 21% of health facilities nationally.[ 5 , 6 ] Women’s leadership in health systems is critical to addressing this systemic gap. Recent evidence demonstrates that women leaders in health systems produce measurable improvements in financial performance, health outcomes, organizational culture, and system resilience—particularly in resource-constrained settings.[ 7 , 8 ] Yet women remain vastly underrepresented in senior health leadership positions globally (only 25% of leadership roles), with compounding barriers in conflict-affected contexts like Yemen.[ 7 ] The fundamental question guiding this analysis is: What are the true leading causes of death and disability for Yemeni women of reproductive age (15–49), and how does healthcare access for these diverse conditions compare to the currently emphasized maternal health services? By answering this question, we expose not merely a data gap but a systemic failure in humanitarian planning that renders millions of women vulnerable to preventable and treatable conditions outside the reproductive sphere. We additionally examine how women’s leadership presence and capacity in health systems could strengthen response to this multifaceted burden. This paper provides a comprehensive secondary analysis synthesizing GBD data, health facility assessments (HeRAMS), demographic and health surveys (DHS/MICS), humanitarian needs assessments, and qualitative evidence from humanitarian program evaluations to document the extent of this blind spot. We then propose evidence-based integration strategies to address this neglect, with particular attention to women’s leadership roles in implementation. 2. Methods 2.1 Data Sources and Search Strategy This secondary data analysis synthesized evidence from five primary sources: 1. Global Burden of Disease (GBD) 2021 : We extracted age-standardized and crude mortality rates, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for Yemen, stratified by sex and age group (15–49 years). Leading causes of death and disability, as well as major risk factors, were identified. 2. Humanitarian Facility Assessments and Service Availability Data : We reviewed the Health Resources and Services Availability Monitoring System (HeRAMS) Yemen 2023 baseline report, which surveyed 3,507 health facilities for the availability of maternal, child health, NCD, and mental health services. 3. Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) : We extracted indicators on antenatal care coverage, skilled birth attendant utilization, and awareness of key maternal health services. 4. Humanitarian Response Documentation : We analyzed the 2024–2025 Humanitarian Needs Overviews (HNOs), UN appeal documents (WHO 2024 Health Emergency Appeal, UNFPA 2025 Humanitarian Response Brochure), and published evaluations of the Yemen Health Cluster to assess the prioritization of different health needs and coordination gaps. 5. Evidence on Women’s Leadership in Health Systems : We reviewed recent systematic review evidence on women’s leadership impact in health systems, including 8 studies with direct Yemen relevance and comparative evidence from conflict-affected settings, to understand how women’s health leadership presence influences system performance and health outcomes. 2.2 Analysis Framework The analysis was organized around three dimensions: Epidemiological burden We compared the relative magnitude of maternal health conditions versus NCDs and other conditions as causes of death, disability, and premature mortality among women aged 15–49. Service availability and access We compared the proportion of functional health facilities offering maternal health services against those offering NCD, mental health, and integrated screening services. We assessed gender-specific barriers to access. Humanitarian response priorities We analyzed how humanitarian needs assessments, cluster objectives, and funded programs reflected or neglected the identified epidemiological burden. Women’s leadership context We examined how women’s representation in health leadership roles and gaps in women’s health system leadership capacity influence the ability to respond to the holistic disease burden. 2.3 Inclusion and Exclusion Criteria We included English-language peer-reviewed literature, official WHO/UN documents, humanitarian program evaluations, and grey literature (NGO reports, needs assessments) published from 2015 onward, with emphasis on 2020–2025 data to reflect the current humanitarian context. We excluded opinion pieces without empirical grounding and excluded studies that did not disaggregate data by sex or age. For evidence on women’s leadership, we included studies from 2010 onward that examined women’s impact in health system leadership roles. 3. Results 3.1 Epidemiological Burden: NCDs and Mental Health Dominate the Disease Landscape 3.1.1 Mortality and Morbidity by Cause Mortality Profile (GBD 2021) In Yemen, the age-standardized leading causes of death include ischemic heart disease, COVID-19, stroke, hypertensive heart disease, conflict and terrorism, and neonatal disorders.[ 5 ] Notably, maternal disorders rank below these major causes nationally, indicating that while maternal mortality remains high by global standards, it represents a portion rather than the majority of female mortality in this age group. NCDs (principally cardiovascular, respiratory, and metabolic conditions) accounted for 49.5% of all deaths in 2021, substantially exceeding maternal, communicable, and neonatal deaths combined.[ 5 ] The age-standardized mortality rate from conflict and terrorism increased nearly 26-fold in the past decade, underscoring the compounding effects of warfare and health system collapse. Disability Burden (YLDs) The burden of disability tells a complementary story(Fig. 1 ). The leading causes of age-standardized years lived with disability include dietary iron deficiency, low back pain, depressive disorders, headache disorders, anxiety disorders, and gynecological diseases.[ 5 ] Mental health conditions—depression and anxiety—collectively represent a substantial portion of the disability burden, yet mental health services are integrated into only 21% of health facilities nationally.[ 6 ] 3.1.2 Mental Health Crisis: A Neglected Epidemic An estimated 19.5% of Yemen’s population suffers from mental health disorders, predominantly anxiety, depression, post-traumatic stress disorder (PTSD), and severe psychotic disorders.[ 7 ] Yet access to services is severely constrained: approximately 7 million Yemenis require mental health support, but only 120,000 have consistent access.[ 3 ] A critical gender disparity exists: at mental health clinics supported by Médecins Sans Frontières in Hajjah (one of few dedicated mental health services), men account for approximately 70% of patients, indicating severe systemic barriers to women’s access.[ 8 ] These barriers include social and family restrictions on women seeking care without male accompaniment, stigma surrounding mental health, and restricted mobility (particularly the mahram requirement in Houthi-controlled areas, which necessitates a male guardian’s permission for women to travel).[ 8 ] 3.1.3 Cardiovascular and Metabolic Disease Burden Hypertension and cardiovascular disease represent major emerging health challenges in Yemen, yet screening and management capacity is minimal. Among diabetic patients in Yemen, hypertension prevalence is estimated at 36.9%, and hyperlipidemia at 56.57%.[ 9 ] Women show higher prevalence of obesity and abdominal obesity compared to men.[ 9 ] The integration of diabetes screening into pregnancy care remains largely absent, despite gestational diabetes carrying seven times the risk of subsequent type II diabetes and hypertensive disorders in pregnancy doubling or tripling the lifetime risk of cardiovascular disease.[ 10 ] 3.1.4 Tuberculosis and Communicable Diseases Since 2011, tuberculosis incidence has converged between men and women in Yemen, with near-equal male-to-female ratios in recent years—a departure from the global male predominance.[ 11 ] Female TB cases accounted for substantial portions of notified cases, yet gender-specific TB control strategies and screening tailored to women’s contexts remain underdeveloped. Cholera, driven by water and sanitation collapse, represents another major communicable threat. In 2024, Yemen reported over 250,000 suspected cholera cases and 861 deaths—the highest global burden.[ 12 ] Diarrheal diseases remain among the top 10 causes of death, affecting women disproportionately through water collection responsibilities and nutritional depletion during lactation. 3.2 Healthcare Access Landscape: A Striking Disparity 3.2.1 Maternal Health Service Availability vs. NCD and Mental Health Services A critical disparity emerges when comparing service availability (Table 1 ). Of the 3,507 health facilities assessed through HeRAMS, only 20% provide comprehensive maternal and newborn health services.[ 3 ] Yet disturbingly, services for non-communicable diseases and mental health conditions are available in only 21% of facilities—a nearly identical proportion.[ 6 ] This apparent equivalence masks a systematic deprioritization of NCDs and mental health in humanitarian funding and planning. Table 1 Maternal Health Service Availability vs. NCD and Mental Health Services Service Category Facilities Offering Service (%) Reference Maternal and newborn health (comprehensive) 20% [ 3 ] NCD and mental health services (full availability) 21% [ 6 ] Antenatal care (any level) 45% [ 3 , 4 ] Clinical management of rape (CMR) 5% [ 4 ] Mental health integrated into primary care < 5% [ 4 ] Antenatal care reaches approximately 45% of facilities at any level, yet many lack the clinical practices, tracer medications, and supplies necessary for effective coverage.[ 13 ] Four out of ten women of childbearing age receive no antenatal care from a skilled provider, and six out of ten births occur without a skilled birth attendant.[ 3 ] 3.2.2 Gender-Specific Barriers to Care Access The Mahram Requirement and Mobility Restrictions In Houthi-controlled northern areas, women are required by authorities to be accompanied by a male guardian (mahram) when traveling.[ 14 , 15 ] This institutional barrier directly impedes access to health facilities, particularly for single women, divorcées, and women-headed households. Qualitative research documents that women cite fear of harassment, insecurity, and inability to travel independently as primary reasons for delaying or forgoing healthcare.[ 2 ] Shortage of Female Health Providers: A Critical System Gap A critical bottleneck in service delivery is the severe shortage of female health providers. Strong cultural norms in Yemen—common across the region—inhibit women from accepting care from male providers, particularly for gynecological and reproductive health conditions.[ 4 ] Yet female doctors are increasingly scarce in rural areas due to: • Worsening security and living conditions deterring female practitioners • Lack of financial incentives to work in remote locations • Declining opportunities for medical education for women • The requirement that female health workers often need a male guardian to accompany them in conservative areas, adding to operational costs[ 4 ] • Wage arrears affecting approximately 50,000 health workers, forcing women to leave the profession[ 16 ] Addressing this gap requires deliberate investment in women’s health leadership and pipeline development. Evidence from recent systematic reviews demonstrates that formal mentorship programs, transparent career pathways, and policy support for women’s advancement in health leadership produce measurable improvements in health system capacity and sustainability.[ 7 ] In 2025, as humanitarian funding for reproductive health services contracted by 60%, UNFPA halted support for approximately 800 midwives—nearly half of those planned to be trained—resulting in an estimated 600,000 women losing access to trained midwifery services.[ 17 ] Economic Barriers Medical staff salaries remain irregular and insufficient (some midwives report receiving only $ 42 monthly), forcing healthcare workers into financial insecurity and limiting their capacity to work in underserved areas.[ 17 ] Poverty among beneficiaries exacerbates access: 78–84% of Yemen’s population lives in poverty, with women the most vulnerable.[ 18 ] Transportation to health facilities requires resources many families lack, with some pregnant women undertaking 7–8-hour journeys on foot or by animal to reach facilities.[ 15 ] 3.3 Humanitarian Response Architecture: A Gender-Blind System 3.3.1 Health Cluster Coordination and Gaps An evaluation of the Yemen Health Cluster (2015–2020) revealed systematic gaps in coordination and prioritization.[ 19 ] While the cluster effectively coordinated life-saving communicable disease response and reproductive health services in some contexts, critical limitations included: • Non-prioritized agendas : Mental health services, non-communicable diseases, services for senior citizens, and persons with disabilities were explicitly not prioritized in cluster strategic plans.[ 19 ] • Insufficient exit strategies : No systematic planning for health system recovery or transition from humanitarian to development-oriented support. • Coordination challenges : Political fragmentation, lengthy bureaucratic procedures, and divided Ministry of Health structures (reflecting the de facto governance divide between north and south) created barriers to timely, coordinated response.[ 19 ] • Women’s leadership gaps : Minimal representation of women in formal health cluster coordination structures and senior leadership roles, limiting gender-responsive analysis and program design. 3.3.2 Humanitarian Needs Assessments: Gender-Blind Indicators The 2024 Humanitarian Needs Overview (HNO) for Yemen identifies 19.5 million people in need of humanitarian assistance, including 5 million women of reproductive age specifically requiring sexual and reproductive health services.[ 20 ] However, the HNO framework uses primarily reproductive health indicators to capture women’s health needs: • Antenatal care coverage • Skilled birth attendant utilization • Maternal mortality rates • Unmet family planning needs • Gender-based violence prevalence Conspicuously absent are indicators capturing: - Cardiovascular disease risk and hypertension screening in women - Mental health prevalence and access to services, disaggregated by sex - NCD mortality and morbidity burden specific to women - Women’s access to chronic disease management services - Disability prevalence and rehabilitative service access among women - Women’s representation in health leadership and policy roles This indicator gap directly influences funding priorities: reproductive health programming receives disproportionate resource allocation relative to the epidemiological burden of NCDs and mental health. 3.3.3 Funding Allocation and Service Coverage Gaps UNFPA, the UN’s primary reproductive health agency in Yemen, leads coordination and funding of sexual and reproductive health services. The 2025 UNFPA humanitarian appeal requested $ 70 million; as of mid-2025, only approximately 33% was funded.[ 17 ] However, of the funded reproductive health activities, antenatal care and emergency obstetric care remain primary focuses, while NCD screening and integration services receive minimal attention. The Health Cluster’s overall 2024 funding represented only 49.5% of the $ 249.5 million required to provide needed critical services.[ 3 ] This chronic underfunding, combined with a reproductive health-centric prioritization, leaves broader women’s health needs—cardiovascular, mental, metabolic—systematically undersourced. 4. Discussion 4.1 The “Reproductive Health Blind Spot”: How Focusing on Maternity Creates Systemic Neglect The concentration of humanitarian health resources on maternal health and family planning creates what we term a “reproductive health blind spot” —a framework wherein non-reproductive women’s health conditions, though epidemiologically substantial, remain invisible in needs assessments, coordination mechanisms, and funding allocations. This blind spot is not a historical artifact but actively reproduced through contemporary humanitarian architecture. The cluster approach, while vital for coordinated response, institutionalizes silos: sexual and reproductive health (led by UNFPA) operates separately from mental health (integrated into health clusters but underfunded) and NCD response (absent from cluster strategic frameworks entirely in Yemen). Women experiencing depression, hypertension, or diabetic complications cannot access integrated care because the humanitarian system does not conceptualize or fund such integration. The epidemiological case is compelling Among Yemeni women aged 15–49, the burden from mental health conditions and cardiovascular diseases substantially exceeds that from maternal causes when YLDs are considered. Yet humanitarian responses allocate resources inversely to this burden. 4.2 Intersectionality of Gender Inequality and Health Access The gender-specific barriers documented above are not independent obstacles but constitute an interconnected system of inequality that systematically excludes women from health services across the full spectrum of conditions. The mahram requirement , a legal/cultural practice now institutionalized by Houthi authorities in the north, creates a structural dependency: women cannot freely access health facilities without male authorization. This barrier affects not only antenatal care but all healthcare seeking—including treatment for mental health crises, hypertensive emergencies, and chronic disease management. The shortage of female health providers reflects and reinforces gender norms that constrain women’s employment and health leadership. The declining opportunities for medical education for women, combined with financial insecurity and mobility restrictions on female health workers themselves, create a self-perpetuating cycle: as fewer women enter health professions and advance to leadership roles, the cultural barrier to women accepting male providers persists, widening access disparities. Evidence on women’s leadership in health systems demonstrates that increasing women’s representation in leadership produces measurable improvements in organizational culture, staff retention, and willingness of female staff to work in challenging environments.[ 7 ] This leadership gap thus directly impacts health worker availability and women’s service access. Economic vulnerability , documented by the 78–84% poverty rate among Yemenis, disproportionately affects women’s health access. Women, as household managers responsible for water collection and food preparation during a cholera epidemic, face elevated communicable disease risk. As primary caregivers for children and elderly, they defer their own healthcare. As widows or divorcées (increasingly common due to conflict deaths), they lose household resources and male support networks but gain independence—a net loss for health access in a context where mahram requirements apply. 4.3 The Case for Integration: NCD Screening in Antenatal Care Despite 80% of health facilities lacking capacity for comprehensive NCD and mental health services, pregnancy represents a high-utility opportunity for health screening and intervention . Evidence from other conflict-affected settings demonstrates the feasibility and value of integrated approaches. In Sierra Leone, integration of gestational diabetes screening into antenatal care (2017–2022) yielded a national GDM protocol, enhanced HCP training, and sustainable institutional capacity.[ 20 ] Similar integration for hypertension screening in pregnancy has proven effective in diverse humanitarian settings and models for expansion to mental health and other NCDs.[ 10 ] The clinical rationale is sound - Pregnancy-associated hypertension (pre-eclampsia, eclampsia) is a leading cause of maternal death but also signals 2–3 times increased lifetime risk of cardiovascular disease. - Gestational diabetes indicates 7 times higher risk of subsequent type II diabetes. - Perinatal mental health disorders (depression, anxiety, PTSD) affect 10–20% of pregnant women globally and are undertreated even in resourced settings. The practical opportunity exists : Approximately 65% of women globally access antenatal care at least once with a skilled provider.[ 10 ] In Yemen, despite low overall coverage, women demonstrate remarkable willingness to travel for pregnancy-related care.[ 10 ] As one expert notes: “When they find out they’re pregnant, women will walk [hundreds of] kilometers just to talk to a health care professional. So this is our opportunity to actually promote health in terms of NCD risk factors.”[ 10 ] Implementation pathway Training antenatal care providers to conduct basic screening for hypertension (blood pressure measurement), gestational diabetes (capillary glucose testing), and perinatal mental health (validated screening tools such as the Edinburgh Postnatal Depression Scale) requires modest additional resources and can be integrated into existing ANC visit protocols. Referral pathways for positive screens—including linkage to postpartum NCD management—leverage the existing obstetric care infrastructure. Women health leaders in ANC services are positioned to champion this integration and model holistic care approaches. 4.4 Midwives as Frontline NCD and Mental Health Responders For most Yemeni women, community midwives represent the only accessible source of health care .[ 21 ] The National Yemeni Midwifery Association (NYMA), founded in 2004 with over 3,000 members across 22 governorates, constitutes an extensive community-based workforce—yet remains vastly underutilized for holistic women’s health. Qualitative research on midwives working with women experiencing violence in Yemen documents that midwives already provide psychological support, basic healthcare, and referrals in the absence of formal mental health systems.[ 21 ] Yet they lack formal training, treatment guidelines, and institutional support to systematize this work. Women midwives particularly can serve as trusted providers and role models for advancing women’s health leadership. Recommended intervention: Mental Health First Aid (MHFA) for Midwives Brief, evidence-based training modules (8–12 hours) can equip midwives to: - Recognize symptoms of depression, anxiety, and PTSD in pregnant and postpartum women - Provide psychological first aid, stress management, and supportive counseling - Implement basic psychoeducation on perinatal mental health - Establish referral pathways to advanced services The Midwifery Champions Program, operating in humanitarian settings including South Sudan and Haiti, demonstrates that community midwives can effectively deliver mental health first aid with appropriate training and supervision.[ 22 ] In Yemen, given the absence of formal mental health infrastructure in most areas, midwife-delivered mental health first aid represents a pragmatic, culturally acceptable, and sustainable response. 4.5 Strengthening Women’s Health Leadership to Sustain Integration The success of integrated NCD-maternal health services and mental health first aid training depends critically on adequate women’s health leadership. Recent systematic review evidence demonstrates that: 1. Women leaders produce superior organizational outcomes : Women health leaders demonstrate strong financial management, improved staff retention, enhanced innovation in practice adoption, and stronger engagement with ethical and equity initiatives.[ 7 ] 2. Women leaders champion gender-responsive programming : Organizations with women leaders are more likely to implement policies supporting gender equity, women worker safety, and inclusive service design.[ 7 ] 3. Women leaders create leadership pipelines for other women : Women in leadership actively mentor other women and work to create advancement systems—establishing virtuous cycles that improve women’s representation over time.[ 7 ] 4. Women leaders are particularly effective in crisis/conflict settings : While resource constraints affect all leaders, evidence suggests women leaders in conflict-affected contexts show particular resilience, adaptability, and focus on sustainability and ethical practice.[ 7 ] Strategic investments in women’s health leadership include - Establishing transparent, merit-based promotion pathways for women health workers - Creating formal mentorship programs matching senior and emerging women health leaders - Integrating gender-responsive competencies into health management training - Ensuring women’s participation in health system strengthening and cluster coordination structures - Providing security provisions and wage assurance to enable women health workers’ retention 4.6 Closing the Indicator Gap: Women’s Health in Humanitarian Needs Assessments The absence of NCD and mental health indicators from humanitarian needs assessments reflects not a lack of data but a conceptual limitation in how humanitarian needs are framed and measured. The Global Indicator Framework for SDG 5 (Gender Equality) includes sexual and reproductive health indicators, but gender-specific NCD burden and access remains under captured in humanitarian contexts(Table 2 ). Table 2 Recommended indicator additions to future HNOs and cluster reporting Health Domain Proposed Indicators Data Source Mental health Prevalence of depression/anxiety among women 15–49 (%; 95% CI); % women with access to mental health services; gender gap in mental health service access Population surveys, facility assessments Cardiovascular health % women 15–49 aware of hypertension risk; % with BP screening in past 12 months; hypertension prevalence by sex DHS/MICS modules; facility surveys Metabolic disease Type 2 diabetes prevalence in women; % with diabetes screening access; GDM screening in ANC (%) DHS/MICS; facility assessments Communicable disease TB incidence ratio (M:F); female TB case detection rate; % women accessing TB-DOTS TB surveillance data Service integration % ANC facilities with integrated NCD/mental health screening; % facilities with referral pathways for positive screens HeRAMS; cluster assessments Health leadership % women in senior health system leadership roles; % women facility directors; women’s representation in cluster coordination Ministry of Health data; cluster records Incorporating these indicators into the official HNO framework would: 1. Make gender-disaggregated disease burden visible to donors and planners 2. Establish baseline data for monitoring progress 3. Create accountability for integration initiatives 4. Align humanitarian response with epidemiological reality 5. Track progress on women’s health leadership advancement 4.7 Limitations and Considerations This analysis has several important limitations: 1. Data gaps : Yemen’s humanitarian crisis, security constraints, and limited surveillance capacity mean epidemiological data are incomplete. GBD estimates are modeled outputs, not complete country surveillance data. Mental health prevalence estimates (19.5%) derive from limited studies and may underestimate true burden due to stigma and underreporting in this context. 2. Generalizability : While Yemen presents an extreme case, findings regarding reproductive health-centric humanitarian response and gender-specific access barriers may reflect broader patterns in conflict-affected contexts. However, context-specific implementation will be essential. 3. Attribution complexity : Distinguishing whether women’s health neglect results from insufficient resources, systemic prioritization choices, or gender-based discrimination requires further research. Likely, all three factors operate concurrently. 4. Implementation challenges : While integrating NCD screening into ANC is evidence-based, actual implementation in Yemen faces formidable barriers: competing health worker time, supply chain constraints, lack of treatment protocols, and limited referral capacity. The proposal requires explicit resource allocation and technical support. 5. Women’s leadership data limitations : While evidence on women’s leadership in health is growing, limited studies specifically examine women’s leadership in conflict-affected Yemen. The 8 Yemen-specific studies identified in the systematic review on women’s leadership provide contextual grounding, but additional primary research is needed to understand Yemen-specific barriers and enablers for women’s advancement. 5. Conclusions and Recommendations 5.1 Key Findings 1. Epidemiological reality diverges from humanitarian priorities : Non-communicable diseases and mental health conditions represent substantial causes of death and disability among Yemeni women aged 15–49, yet humanitarian response remains fixated on reproductive health alone. 2. Healthcare access for women is constrained across all domains : Only 20% of facilities provide maternal health services and 21% provide NCD/mental health services, indicating systemic inadequacy across the health system, not selective reproductive health focus. 3. Gender inequality operates through interconnected mechanisms : The mahram requirement, female health provider shortage, economic vulnerability, and systemic health invisibility combine to create compound barriers to women’s health access. 4. Humanitarian architecture fails to capture women’s holistic health needs : Humanitarian needs assessments, cluster coordination, and funding mechanisms are structured around reproductive health, rendering other conditions invisible and therefore unfunded. 5. Women’s health leadership is essential for system-wide change : Evidence demonstrates that women leaders in health systems produce superior outcomes, champion gender-responsive programming, and create sustainability—yet women remain vastly underrepresented in Yemen’s health system leadership roles. 5.2 Recommendations For humanitarian agencies and coordination bodies (WHO Health Cluster, OCHA, UNFPA) : 1. Integrate NCD screening into antenatal care services : Develop and disseminate simplified protocols for blood pressure measurement, gestational diabetes screening (capillary glucose), and perinatal mental health screening in ANC settings. Allocate technical assistance and supplies to support implementation. Task women health leaders with protocol development and rollout. 2. Establish Mental Health First Aid training for midwives : In partnership with NYMA, design and deliver 10-hour MHFA modules tailored to midwifery contexts. Provide certification, supervision, and linking to psychosocial support services. Prioritize training for community midwives in rural areas with no alternative mental health resources. Develop women midwife trainers to lead this initiative. 3. Revise humanitarian needs assessment frameworks : Expand HNO indicators to include sex-disaggregated NCD prevalence, mental health service access gaps, cardiovascular disease awareness, integrated service availability, and women’s health system leadership representation. Establish baseline data collection in 2026 HNO cycle. 4. Create dedicated NCD and mental health working groups within the Health Cluster : Parallel to the reproductive health working group, establish formal coordination mechanisms for NCD and mental health response, with explicit budget lines and cluster lead responsibilities. Ensure women’s representation in working group leadership. 5. Establish women’s health leadership development programs : Create transparent promotion pathways, formal mentorship programs, and peer support networks for women health workers and leaders. Integrate gender-responsive health management training into capacity-building activities. For donors and resource mobilization : 6. Ring-fence funding for NCD and mental health integration : Donors should allocate proportional funding to NCD/mental health activities reflecting epidemiological burden (approximately 49.5% of health burden). Create incentives for integrated programming combining reproductive and non-reproductive women’s health. 7. Support sustainability of the midwifery workforce with explicit gender focus : Fund UNFPA and midwifery association capacity-building programs at levels matching humanitarian needs, particularly for training in NCD/mental health first aid and integrated service delivery. Include support for women midwife leaders and mentorship. 8. Fund women’s health leadership strengthening : Allocate dedicated resources for women health workers’ professional development, security provisions, wage assurance, and leadership advancement—recognizing that women’s leadership presence is essential to health system strengthening. For advocacy and evidence generation : 9. Conduct targeted research on gender-specific health barriers and women’s leadership : Qualitative and operational research on the mahram system’s health impact, female health provider retention and leadership pathways, and women’s health-seeking decision-making should inform program design. Prioritize participatory research with women health workers and women’s organizations. 10. Establish mechanisms for women’s health advocacy : The National Yemeni Midwifery Association and women’s civil society organizations should be resourced to advocate for holistic women’s health integration in humanitarian response and policy, and to champion women’s advancement in health leadership. 5.3 Conclusion Yemen exemplifies a humanitarian health paradox: while maternal mortality receives substantial international attention, the broader health crises—mental illness, cardiovascular disease, communicable diseases, and chronic disabilities—that burden Yemeni women remain largely invisible and unfunded. This systemic neglect reflects not data scarcity but structural limitations in humanitarian architecture and a failure to operationalize the principle of holistic, life-course women’s health. Additionally, women’s critical underrepresentation in health system leadership roles limits the system’s capacity to identify and respond to this broad disease burden and to champion gender-responsive programming. Addressing this blind spot requires neither new technologies nor additional research but rather a deliberate reorientation of humanitarian priorities toward alignment with epidemiological reality and deliberate investment in women’s health leadership. Integrating NCD and mental health screening into antenatal care, training midwives as frontline mental health first-aid providers, explicitly incorporating women’s health indicators into humanitarian needs assessments, and strategically advancing women’s representation in health system leadership are feasible, evidence-based interventions that could substantially improve health outcomes for millions of Yemeni women. As the humanitarian community increasingly recognizes the need for integrated, person-centered health approaches and gender-responsive health system strengthening in conflict settings, Yemen offers a compelling case study—and a call to action—for moving beyond maternity-centric frameworks toward a genuinely holistic vision of women’s health and women’s leadership in health systems. Declarations Conflicts of Interest: Authors declare no competing interests. Funding: This research received no specific grant from any public, commercial, or not-for-profit funding agency. Author Contribution The paper makes three distinct contributions:1. First quantification of the humanitarian-epidemiological mismatch in Yemen: Using GBD 2021 data alongside HeRAMS facility assessments and humanitarian response documentation, I demonstrate that humanitarian funding allocation is fundamentally misaligned with disease burden.2. Introduction of the "reproductive health blind spot" framework: This conceptual contribution explains how humanitarian silos (UNFPA leading reproductive health separately from mental health and NCD response) systematically render non-reproductive women's health conditions invisible, despite their substantial epidemiological burden.3. Evidence-based integration strategies grounded in comparative contexts: The recommendations (NCD screening in antenatal care, mental health first aid training for midwives, humanitarian indicator reform) are evidence-based using examples from Sierra Leone, Kenya, and other conflict-affected settings, demonstrating feasibility even in resource-constrained contexts. Data Availability: All data sources are cited and publicly available through WHO, UNFPA, and humanitarian response databases referenced in the manuscript. References Lancet Commission on Women’s Health. (2015). The Lancet Global Health. URL: https://www.thelancet.com/ World Health Organization. Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030). Geneva: WHO; 2016. WHO. Yemen Health Emergency Appeal 2024. Geneva: Emergency Response Coordination Centre; 2024. UNFPA. Yemen Humanitarian Response Brochure 2025. Yemen Country Office, UNFPA; 2025. Mubarik S, et al. Health dynamics in war-torn Yemen: insights from 32 years of epidemiological surveillance. BMC Med. 2025;23(49). 10.1186/s12963-025-00363-3 . WHO. HeRAMS Yemen Baseline Report 2023: Non-communicable Disease and Mental Health Services. Emergency Health Operations Centre, Eastern Mediterranean Regional Office; 2023. Alazazy M. (2025). Mapping Women’s Leadership Impact in Yemen’s Conflict-Affected Health Systems: A Systematic Review to Inform Gender-Responsive Health Policy and Practice. https://doi.org/10.21203/rs.3.rs-8339711/v1 Alhariri W et al. (2021). The Right to Mental Health in Yemen. PLOS ONE , 16(5). PMC ID: PMC8233030. Gunaid AA et al. (2024). The Prevalence of Cardiovascular Risk Factors in Patients with Diabetes in Yemen: Systematic Review and Meta-Analysis. PLOS ONE , 19(10). PMC ID: PMC11608648. George Institute for Global Health. A window of opportunity: the integration of NCD services with pre-conception and maternal care. Sydney: University of Sydney; 2024. Al-Shehari WA et al. (2022). Prevalence and surveillance of tuberculosis in Yemen from 2006 to 2018: an epidemiological assessment. PLoS Medicine , 19(8). PMC ID: PMC9354476. WHO Eastern Mediterranean Regional Office. (2024). Yemen reports the highest burden of cholera globally. EMRO News Brief, December 23, 2024. World Bank. Yemen Health Policy Note: Input to PN no. 4. on Inclusive Services. Health and Nutrition Sector Unit, Middle East and North Africa Region; 2021. Salem A et al. (2025). Healthcare accessibility in Yemen’s conflict zones. Frontiers in Public Health , 13(1235687). PMC ID: PMC12261687. ECDHR (Espace de Citoyenneté et de Droits Humains). (2025). The Impact of the Mahram System on Yemeni Women’s Rights. Policy Brief, January 2025. Alazazy M. (2025). Mapping Women’s Leadership Impact in Yemen’s Conflict-Affected Health Systems. Reference to wage arrears affecting 50,000 health workers. UNFPA. (2025). Health Workers Lose Support Structures as Pregnant Women Die: The Reality of Funding Cuts in Yemen. Humanitarian Situation Report #2, March 2025. FAO, CARE. The gender-differentiated impacts of multiple crises: Yemen rapid gender analysis. Rome: FAO; 2023. Al-Awlaqi S et al. (2022). The National Health Cluster in Yemen: an evaluation of its effectiveness in coordination and response. BMC Health Services Research , 22(318). PMC ID: PMC8943786. UN Office for the Coordination of Humanitarian Affairs (OCHA). Yemen Humanitarian Needs Overview 2024. OCHA Regional Office for the Middle East, North Africa and Central Asia; 2024. Al-Zumair M et al. (2025). Midwives’ experiences working with women and girls experiencing interpersonal violence in Yemen. BMC Pregnancy and Childbirth , 25(123). PMC ID: PMC11968663. International Confederation of Midwives. (2024). The Role of Midwives in Humanitarian Crises. Position Paper and Practice Guide, November 2024. Additional Declarations No competing interests reported. Supplementary Files SupplementaryDataTables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":130756,"visible":true,"origin":"","legend":"\u003cp\u003eDisease Burden Distribution Among Yemeni Women (15-49 years): Mortality vs. Disability, GBD 2021\u003c/p\u003e","description":"","filename":"Figure1DiseaseBurdenDistributionAmongYemeniWomen1549yearsMortalityvs.DisabilityGBD2021.png","url":"https://assets-eu.researchsquare.com/files/rs-8444298/v1/a5744104f2ecd2b36445175b.png"},{"id":99802039,"identity":"b9d53379-45dd-48f2-8cba-7504ac6a78b7","added_by":"auto","created_at":"2026-01-08 14:07:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2398000,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8444298/v1/eb026c47-e2e3-4107-9943-6703e6aab782.pdf"},{"id":99374006,"identity":"06f5f621-d077-4675-9e98-229097405a2e","added_by":"auto","created_at":"2026-01-02 07:10:20","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14615,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryDataTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8444298/v1/889f787c87d4119fb06d4379.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Maternity: Quantifying the Holistic Disease Burden and Systemic Neglect of Women’s Health in Yemen","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eGlobal health discourse has undergone a paradigm shift in recent decades, moving from a narrowly maternal-focused perspective toward a lifespan approach to women\u0026rsquo;s health.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] The World Health Organization\u0026rsquo;s 2016\u0026ndash;2030 Global Strategy for Women\u0026rsquo;s, Children\u0026rsquo;s and Adolescents\u0026rsquo; Health explicitly calls for integration of maternal, newborn, child and adolescent health with chronic disease prevention and management.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Yet in conflict-affected settings, particularly in Yemen, this holistic vision remains unrealized.\u003c/p\u003e \u003cp\u003eYemen presents an extreme test case of this contradiction. In its tenth year of armed conflict, with 19.5\u0026nbsp;million people requiring humanitarian assistance and only 55% of health facilities operational, the country\u0026rsquo;s humanitarian health response remains dominated by a reproductive health paradigm.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Donors, UN agencies, and international NGOs channel resources primarily into antenatal care, delivery services, and family planning\u0026mdash;critical needs, certainly, but increasingly insufficient when the broader epidemiological landscape is considered.\u003c/p\u003e \u003cp\u003eRecent evidence from the Global Burden of Disease (GBD) study (2021) reveals a striking reality: in Yemen, non-communicable diseases (NCDs) now account for 49.5% of all deaths, far exceeding communicable, maternal, neonatal, and nutritional diseases (32.0%) and injuries (18.5%).[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Age-standardized mortality from conflict-related violence increased precipitously from 1.9 to 50.0 deaths per 100,000 population between 2010 and 2021.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Among the leading causes of disability (years lived with disability, YLDs), dietary iron deficiency, low back pain, depressive disorders, headache disorders, anxiety disorders, and gynecological diseases dominate\u0026mdash;yet mental health services are available in only 21% of health facilities nationally.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s leadership in health systems is critical to addressing this systemic gap. Recent evidence demonstrates that women leaders in health systems produce measurable improvements in financial performance, health outcomes, organizational culture, and system resilience\u0026mdash;particularly in resource-constrained settings.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Yet women remain vastly underrepresented in senior health leadership positions globally (only 25% of leadership roles), with compounding barriers in conflict-affected contexts like Yemen.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe fundamental question guiding this analysis is: \u003cb\u003eWhat are the true leading causes of death and disability for Yemeni women of reproductive age (15\u0026ndash;49), and how does healthcare access for these diverse conditions compare to the currently emphasized maternal health services?\u003c/b\u003e By answering this question, we expose not merely a data gap but a systemic failure in humanitarian planning that renders millions of women vulnerable to preventable and treatable conditions outside the reproductive sphere. We additionally examine how women\u0026rsquo;s leadership presence and capacity in health systems could strengthen response to this multifaceted burden.\u003c/p\u003e \u003cp\u003eThis paper provides a comprehensive secondary analysis synthesizing GBD data, health facility assessments (HeRAMS), demographic and health surveys (DHS/MICS), humanitarian needs assessments, and qualitative evidence from humanitarian program evaluations to document the extent of this blind spot. We then propose evidence-based integration strategies to address this neglect, with particular attention to women\u0026rsquo;s leadership roles in implementation.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data Sources and Search Strategy\u003c/h2\u003e \u003cp\u003eThis secondary data analysis synthesized evidence from five primary sources:\u003c/p\u003e \u003cp\u003e1. \u003cb\u003eGlobal Burden of Disease (GBD) 2021\u003c/b\u003e: We extracted age-standardized and crude mortality rates, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for Yemen, stratified by sex and age group (15\u0026ndash;49 years). Leading causes of death and disability, as well as major risk factors, were identified.\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eHumanitarian Facility Assessments and Service Availability Data\u003c/b\u003e: We reviewed the Health Resources and Services Availability Monitoring System (HeRAMS) Yemen 2023 baseline report, which surveyed 3,507 health facilities for the availability of maternal, child health, NCD, and mental health services.\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eDemographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS)\u003c/b\u003e: We extracted indicators on antenatal care coverage, skilled birth attendant utilization, and awareness of key maternal health services.\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eHumanitarian Response Documentation\u003c/b\u003e: We analyzed the 2024\u0026ndash;2025 Humanitarian Needs Overviews (HNOs), UN appeal documents (WHO 2024 Health Emergency Appeal, UNFPA 2025 Humanitarian Response Brochure), and published evaluations of the Yemen Health Cluster to assess the prioritization of different health needs and coordination gaps.\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eEvidence on Women\u0026rsquo;s Leadership in Health Systems\u003c/b\u003e: We reviewed recent systematic review evidence on women\u0026rsquo;s leadership impact in health systems, including 8 studies with direct Yemen relevance and comparative evidence from conflict-affected settings, to understand how women\u0026rsquo;s health leadership presence influences system performance and health outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Analysis Framework\u003c/h2\u003e \u003cp\u003eThe analysis was organized around three dimensions:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEpidemiological burden\u003c/strong\u003e \u003cp\u003eWe compared the relative magnitude of maternal health conditions versus NCDs and other conditions as causes of death, disability, and premature mortality among women aged 15\u0026ndash;49.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eService availability and access\u003c/strong\u003e \u003cp\u003eWe compared the proportion of functional health facilities offering maternal health services against those offering NCD, mental health, and integrated screening services. We assessed gender-specific barriers to access.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHumanitarian response priorities\u003c/strong\u003e \u003cp\u003eWe analyzed how humanitarian needs assessments, cluster objectives, and funded programs reflected or neglected the identified epidemiological burden.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eWomen\u0026rsquo;s leadership context\u003c/strong\u003e \u003cp\u003eWe examined how women\u0026rsquo;s representation in health leadership roles and gaps in women\u0026rsquo;s health system leadership capacity influence the ability to respond to the holistic disease burden.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eWe included English-language peer-reviewed literature, official WHO/UN documents, humanitarian program evaluations, and grey literature (NGO reports, needs assessments) published from 2015 onward, with emphasis on 2020\u0026ndash;2025 data to reflect the current humanitarian context. We excluded opinion pieces without empirical grounding and excluded studies that did not disaggregate data by sex or age. For evidence on women\u0026rsquo;s leadership, we included studies from 2010 onward that examined women\u0026rsquo;s impact in health system leadership roles.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Epidemiological Burden: NCDs and Mental Health Dominate the Disease Landscape\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Mortality and Morbidity by Cause\u003c/h2\u003e \u003cp\u003e \u003cb\u003eMortality Profile (GBD 2021)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn Yemen, the age-standardized leading causes of death include ischemic heart disease, COVID-19, stroke, hypertensive heart disease, conflict and terrorism, and neonatal disorders.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Notably, maternal disorders rank below these major causes nationally, indicating that while maternal mortality remains high by global standards, it represents a portion rather than the majority of female mortality in this age group.\u003c/p\u003e \u003cp\u003eNCDs (principally cardiovascular, respiratory, and metabolic conditions) accounted for 49.5% of all deaths in 2021, substantially exceeding maternal, communicable, and neonatal deaths combined.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The age-standardized mortality rate from conflict and terrorism increased nearly 26-fold in the past decade, underscoring the compounding effects of warfare and health system collapse.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDisability Burden (YLDs)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe burden of disability tells a complementary story(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The leading causes of age-standardized years lived with disability include dietary iron deficiency, low back pain, depressive disorders, headache disorders, anxiety disorders, and gynecological diseases.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Mental health conditions\u0026mdash;depression and anxiety\u0026mdash;collectively represent a substantial portion of the disability burden, yet mental health services are integrated into only 21% of health facilities nationally.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Mental Health Crisis: A Neglected Epidemic\u003c/h2\u003e \u003cp\u003eAn estimated 19.5% of Yemen\u0026rsquo;s population suffers from mental health disorders, predominantly anxiety, depression, post-traumatic stress disorder (PTSD), and severe psychotic disorders.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Yet access to services is severely constrained: approximately 7\u0026nbsp;million Yemenis require mental health support, but only 120,000 have consistent access.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA critical gender disparity exists: at mental health clinics supported by M\u0026eacute;decins Sans Fronti\u0026egrave;res in Hajjah (one of few dedicated mental health services), men account for approximately 70% of patients, indicating severe systemic barriers to women\u0026rsquo;s access.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] These barriers include social and family restrictions on women seeking care without male accompaniment, stigma surrounding mental health, and restricted mobility (particularly the mahram requirement in Houthi-controlled areas, which necessitates a male guardian\u0026rsquo;s permission for women to travel).[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3 Cardiovascular and Metabolic Disease Burden\u003c/h2\u003e \u003cp\u003eHypertension and cardiovascular disease represent major emerging health challenges in Yemen, yet screening and management capacity is minimal. Among diabetic patients in Yemen, hypertension prevalence is estimated at 36.9%, and hyperlipidemia at 56.57%.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Women show higher prevalence of obesity and abdominal obesity compared to men.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] The integration of diabetes screening into pregnancy care remains largely absent, despite gestational diabetes carrying seven times the risk of subsequent type II diabetes and hypertensive disorders in pregnancy doubling or tripling the lifetime risk of cardiovascular disease.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.1.4 Tuberculosis and Communicable Diseases\u003c/h2\u003e \u003cp\u003eSince 2011, tuberculosis incidence has converged between men and women in Yemen, with near-equal male-to-female ratios in recent years\u0026mdash;a departure from the global male predominance.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Female TB cases accounted for substantial portions of notified cases, yet gender-specific TB control strategies and screening tailored to women\u0026rsquo;s contexts remain underdeveloped.\u003c/p\u003e \u003cp\u003eCholera, driven by water and sanitation collapse, represents another major communicable threat. In 2024, Yemen reported over 250,000 suspected cholera cases and 861 deaths\u0026mdash;the highest global burden.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Diarrheal diseases remain among the top 10 causes of death, affecting women disproportionately through water collection responsibilities and nutritional depletion during lactation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Healthcare Access Landscape: A Striking Disparity\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Maternal Health Service Availability vs. NCD and Mental Health Services\u003c/h2\u003e \u003cp\u003eA critical disparity emerges when comparing service availability (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the 3,507 health facilities assessed through HeRAMS, only 20% provide comprehensive maternal and newborn health services.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Yet disturbingly, services for non-communicable diseases and mental health conditions are available in only 21% of facilities\u0026mdash;a nearly identical proportion.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] This apparent equivalence masks a systematic deprioritization of NCDs and mental health in humanitarian funding and planning.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaternal Health Service Availability vs. NCD and Mental Health Services\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacilities Offering Service (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal and newborn health (comprehensive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNCD and mental health services (full availability)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntenatal care (any level)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical management of rape (CMR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental health integrated into primary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAntenatal care reaches approximately 45% of facilities at any level, yet many lack the clinical practices, tracer medications, and supplies necessary for effective coverage.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Four out of ten women of childbearing age receive no antenatal care from a skilled provider, and six out of ten births occur without a skilled birth attendant.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Gender-Specific Barriers to Care Access\u003c/h2\u003e \u003cp\u003e \u003cb\u003eThe Mahram Requirement and Mobility Restrictions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn Houthi-controlled northern areas, women are required by authorities to be accompanied by a male guardian (mahram) when traveling.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This institutional barrier directly impedes access to health facilities, particularly for single women, divorc\u0026eacute;es, and women-headed households. Qualitative research documents that women cite fear of harassment, insecurity, and inability to travel independently as primary reasons for delaying or forgoing healthcare.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cb\u003eShortage of Female Health Providers: A Critical System Gap\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA critical bottleneck in service delivery is the severe shortage of female health providers. Strong cultural norms in Yemen\u0026mdash;common across the region\u0026mdash;inhibit women from accepting care from male providers, particularly for gynecological and reproductive health conditions.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Yet female doctors are increasingly scarce in rural areas due to:\u003c/p\u003e \u003cp\u003e\u0026bull; Worsening security and living conditions deterring female practitioners\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of financial incentives to work in remote locations\u003c/p\u003e \u003cp\u003e\u0026bull; Declining opportunities for medical education for women\u003c/p\u003e \u003cp\u003e\u0026bull; The requirement that female health workers often need a male guardian to accompany them in conservative areas, adding to operational costs[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e\u0026bull; Wage arrears affecting approximately 50,000 health workers, forcing women to leave the profession[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAddressing this gap requires deliberate investment in women\u0026rsquo;s health leadership and pipeline development. Evidence from recent systematic reviews demonstrates that formal mentorship programs, transparent career pathways, and policy support for women\u0026rsquo;s advancement in health leadership produce measurable improvements in health system capacity and sustainability.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn 2025, as humanitarian funding for reproductive health services contracted by 60%, UNFPA halted support for approximately 800 midwives\u0026mdash;nearly half of those planned to be trained\u0026mdash;resulting in an estimated 600,000 women losing access to trained midwifery services.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cb\u003eEconomic Barriers\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMedical staff salaries remain irregular and insufficient (some midwives report receiving only \u003cspan\u003e$\u003c/span\u003e42 monthly), forcing healthcare workers into financial insecurity and limiting their capacity to work in underserved areas.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Poverty among beneficiaries exacerbates access: 78\u0026ndash;84% of Yemen\u0026rsquo;s population lives in poverty, with women the most vulnerable.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Transportation to health facilities requires resources many families lack, with some pregnant women undertaking 7\u0026ndash;8-hour journeys on foot or by animal to reach facilities.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Humanitarian Response Architecture: A Gender-Blind System\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Health Cluster Coordination and Gaps\u003c/h2\u003e \u003cp\u003eAn evaluation of the Yemen Health Cluster (2015\u0026ndash;2020) revealed systematic gaps in coordination and prioritization.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] While the cluster effectively coordinated life-saving communicable disease response and reproductive health services in some contexts, critical limitations included:\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eNon-prioritized agendas\u003c/b\u003e: Mental health services, non-communicable diseases, services for senior citizens, and persons with disabilities were explicitly not prioritized in cluster strategic plans.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eInsufficient exit strategies\u003c/b\u003e: No systematic planning for health system recovery or transition from humanitarian to development-oriented support.\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eCoordination challenges\u003c/b\u003e: Political fragmentation, lengthy bureaucratic procedures, and divided Ministry of Health structures (reflecting the de facto governance divide between north and south) created barriers to timely, coordinated response.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eWomen\u0026rsquo;s leadership gaps\u003c/b\u003e: Minimal representation of women in formal health cluster coordination structures and senior leadership roles, limiting gender-responsive analysis and program design.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Humanitarian Needs Assessments: Gender-Blind Indicators\u003c/h2\u003e \u003cp\u003eThe 2024 Humanitarian Needs Overview (HNO) for Yemen identifies 19.5\u0026nbsp;million people in need of humanitarian assistance, including 5\u0026nbsp;million women of reproductive age specifically requiring sexual and reproductive health services.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] However, the HNO framework uses primarily reproductive health indicators to capture women\u0026rsquo;s health needs:\u003c/p\u003e \u003cp\u003e\u0026bull; Antenatal care coverage\u003c/p\u003e \u003cp\u003e\u0026bull; Skilled birth attendant utilization\u003c/p\u003e \u003cp\u003e\u0026bull; Maternal mortality rates\u003c/p\u003e \u003cp\u003e\u0026bull; Unmet family planning needs\u003c/p\u003e \u003cp\u003e\u0026bull; Gender-based violence prevalence\u003c/p\u003e \u003cp\u003e \u003cb\u003eConspicuously absent\u003c/b\u003e are indicators capturing: - Cardiovascular disease risk and hypertension screening in women - Mental health prevalence and access to services, disaggregated by sex - NCD mortality and morbidity burden specific to women - Women\u0026rsquo;s access to chronic disease management services - Disability prevalence and rehabilitative service access among women - Women\u0026rsquo;s representation in health leadership and policy roles\u003c/p\u003e \u003cp\u003eThis indicator gap directly influences funding priorities: reproductive health programming receives disproportionate resource allocation relative to the epidemiological burden of NCDs and mental health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Funding Allocation and Service Coverage Gaps\u003c/h2\u003e \u003cp\u003eUNFPA, the UN\u0026rsquo;s primary reproductive health agency in Yemen, leads coordination and funding of sexual and reproductive health services. The 2025 UNFPA humanitarian appeal requested \u003cspan\u003e$\u003c/span\u003e70\u0026nbsp;million; as of mid-2025, only approximately 33% was funded.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] However, of the funded reproductive health activities, antenatal care and emergency obstetric care remain primary focuses, while NCD screening and integration services receive minimal attention.\u003c/p\u003e \u003cp\u003eThe Health Cluster\u0026rsquo;s overall 2024 funding represented only 49.5% of the \u003cspan\u003e$\u003c/span\u003e249.5\u0026nbsp;million required to provide needed critical services.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] This chronic underfunding, combined with a reproductive health-centric prioritization, leaves broader women\u0026rsquo;s health needs\u0026mdash;cardiovascular, mental, metabolic\u0026mdash;systematically undersourced.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.1 The \u0026ldquo;Reproductive Health Blind Spot\u0026rdquo;: How Focusing on Maternity Creates Systemic Neglect\u003c/h2\u003e \u003cp\u003eThe concentration of humanitarian health resources on maternal health and family planning creates what we term a \u003cb\u003e\u0026ldquo;reproductive health blind spot\u0026rdquo;\u003c/b\u003e\u0026mdash;a framework wherein non-reproductive women\u0026rsquo;s health conditions, though epidemiologically substantial, remain invisible in needs assessments, coordination mechanisms, and funding allocations.\u003c/p\u003e \u003cp\u003eThis blind spot is not a historical artifact but actively reproduced through contemporary humanitarian architecture. The cluster approach, while vital for coordinated response, institutionalizes silos: sexual and reproductive health (led by UNFPA) operates separately from mental health (integrated into health clusters but underfunded) and NCD response (absent from cluster strategic frameworks entirely in Yemen). Women experiencing depression, hypertension, or diabetic complications cannot access integrated care because the humanitarian system does not conceptualize or fund such integration.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThe epidemiological case is compelling\u003c/strong\u003e \u003cp\u003eAmong Yemeni women aged 15\u0026ndash;49, the burden from mental health conditions and cardiovascular diseases substantially exceeds that from maternal causes when YLDs are considered. Yet humanitarian responses allocate resources inversely to this burden.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Intersectionality of Gender Inequality and Health Access\u003c/h2\u003e \u003cp\u003eThe gender-specific barriers documented above are not independent obstacles but constitute an \u003cb\u003einterconnected system of inequality\u003c/b\u003e that systematically excludes women from health services across the full spectrum of conditions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe mahram requirement\u003c/b\u003e, a legal/cultural practice now institutionalized by Houthi authorities in the north, creates a structural dependency: women cannot freely access health facilities without male authorization. This barrier affects not only antenatal care but all healthcare seeking\u0026mdash;including treatment for mental health crises, hypertensive emergencies, and chronic disease management.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe shortage of female health providers\u003c/b\u003e reflects and reinforces gender norms that constrain women\u0026rsquo;s employment and health leadership. The declining opportunities for medical education for women, combined with financial insecurity and mobility restrictions on female health workers themselves, create a self-perpetuating cycle: as fewer women enter health professions and advance to leadership roles, the cultural barrier to women accepting male providers persists, widening access disparities. Evidence on women\u0026rsquo;s leadership in health systems demonstrates that increasing women\u0026rsquo;s representation in leadership produces measurable improvements in organizational culture, staff retention, and willingness of female staff to work in challenging environments.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] This leadership gap thus directly impacts health worker availability and women\u0026rsquo;s service access.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEconomic vulnerability\u003c/b\u003e, documented by the 78\u0026ndash;84% poverty rate among Yemenis, disproportionately affects women\u0026rsquo;s health access. Women, as household managers responsible for water collection and food preparation during a cholera epidemic, face elevated communicable disease risk. As primary caregivers for children and elderly, they defer their own healthcare. As widows or divorc\u0026eacute;es (increasingly common due to conflict deaths), they lose household resources and male support networks but gain independence\u0026mdash;a net loss for health access in a context where mahram requirements apply.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.3 The Case for Integration: NCD Screening in Antenatal Care\u003c/h2\u003e \u003cp\u003eDespite 80% of health facilities lacking capacity for comprehensive NCD and mental health services, pregnancy represents a \u003cb\u003ehigh-utility opportunity for health screening and intervention\u003c/b\u003e. Evidence from other conflict-affected settings demonstrates the feasibility and value of integrated approaches.\u003c/p\u003e \u003cp\u003eIn Sierra Leone, integration of gestational diabetes screening into antenatal care (2017\u0026ndash;2022) yielded a national GDM protocol, enhanced HCP training, and sustainable institutional capacity.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Similar integration for hypertension screening in pregnancy has proven effective in diverse humanitarian settings and models for expansion to mental health and other NCDs.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThe clinical rationale is sound\u003c/strong\u003e \u003cp\u003e- Pregnancy-associated hypertension (pre-eclampsia, eclampsia) is a leading cause of maternal death but also signals 2\u0026ndash;3 times increased lifetime risk of cardiovascular disease. - Gestational diabetes indicates 7 times higher risk of subsequent type II diabetes. - Perinatal mental health disorders (depression, anxiety, PTSD) affect 10\u0026ndash;20% of pregnant women globally and are undertreated even in resourced settings.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThe practical opportunity exists\u003c/b\u003e: Approximately 65% of women globally access antenatal care at least once with a skilled provider.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In Yemen, despite low overall coverage, women demonstrate remarkable willingness to travel for pregnancy-related care.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] As one expert notes: \u0026ldquo;When they find out they\u0026rsquo;re pregnant, women will walk [hundreds of] kilometers just to talk to a health care professional. So this is our opportunity to actually promote health in terms of NCD risk factors.\u0026rdquo;[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eImplementation pathway\u003c/strong\u003e \u003cp\u003eTraining antenatal care providers to conduct basic screening for hypertension (blood pressure measurement), gestational diabetes (capillary glucose testing), and perinatal mental health (validated screening tools such as the Edinburgh Postnatal Depression Scale) requires modest additional resources and can be integrated into existing ANC visit protocols. Referral pathways for positive screens\u0026mdash;including linkage to postpartum NCD management\u0026mdash;leverage the existing obstetric care infrastructure. Women health leaders in ANC services are positioned to champion this integration and model holistic care approaches.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Midwives as Frontline NCD and Mental Health Responders\u003c/h2\u003e \u003cp\u003eFor most Yemeni women, community midwives represent the \u003cb\u003eonly accessible source of health care\u003c/b\u003e.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] The National Yemeni Midwifery Association (NYMA), founded in 2004 with over 3,000 members across 22 governorates, constitutes an extensive community-based workforce\u0026mdash;yet remains vastly underutilized for holistic women\u0026rsquo;s health.\u003c/p\u003e \u003cp\u003eQualitative research on midwives working with women experiencing violence in Yemen documents that midwives already provide psychological support, basic healthcare, and referrals in the absence of formal mental health systems.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Yet they lack formal training, treatment guidelines, and institutional support to systematize this work. Women midwives particularly can serve as trusted providers and role models for advancing women\u0026rsquo;s health leadership.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommended intervention: Mental Health First Aid (MHFA) for Midwives\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBrief, evidence-based training modules (8\u0026ndash;12 hours) can equip midwives to: - Recognize symptoms of depression, anxiety, and PTSD in pregnant and postpartum women - Provide psychological first aid, stress management, and supportive counseling - Implement basic psychoeducation on perinatal mental health - Establish referral pathways to advanced services\u003c/p\u003e \u003cp\u003eThe Midwifery Champions Program, operating in humanitarian settings including South Sudan and Haiti, demonstrates that community midwives can effectively deliver mental health first aid with appropriate training and supervision.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] In Yemen, given the absence of formal mental health infrastructure in most areas, midwife-delivered mental health first aid represents a \u003cb\u003epragmatic, culturally acceptable, and sustainable\u003c/b\u003e response.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Strengthening Women\u0026rsquo;s Health Leadership to Sustain Integration\u003c/h2\u003e \u003cp\u003eThe success of integrated NCD-maternal health services and mental health first aid training depends critically on adequate women\u0026rsquo;s health leadership. Recent systematic review evidence demonstrates that:\u003c/p\u003e \u003cp\u003e1. \u003cb\u003eWomen leaders produce superior organizational outcomes\u003c/b\u003e: Women health leaders demonstrate strong financial management, improved staff retention, enhanced innovation in practice adoption, and stronger engagement with ethical and equity initiatives.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eWomen leaders champion gender-responsive programming\u003c/b\u003e: Organizations with women leaders are more likely to implement policies supporting gender equity, women worker safety, and inclusive service design.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eWomen leaders create leadership pipelines for other women\u003c/b\u003e: Women in leadership actively mentor other women and work to create advancement systems\u0026mdash;establishing virtuous cycles that improve women\u0026rsquo;s representation over time.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eWomen leaders are particularly effective in crisis/conflict settings\u003c/b\u003e: While resource constraints affect all leaders, evidence suggests women leaders in conflict-affected contexts show particular resilience, adaptability, and focus on sustainability and ethical practice.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStrategic investments in women\u0026rsquo;s health leadership include\u003c/strong\u003e \u003cp\u003e- Establishing transparent, merit-based promotion pathways for women health workers - Creating formal mentorship programs matching senior and emerging women health leaders - Integrating gender-responsive competencies into health management training - Ensuring women\u0026rsquo;s participation in health system strengthening and cluster coordination structures - Providing security provisions and wage assurance to enable women health workers\u0026rsquo; retention\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Closing the Indicator Gap: Women\u0026rsquo;s Health in Humanitarian Needs Assessments\u003c/h2\u003e \u003cp\u003eThe absence of NCD and mental health indicators from humanitarian needs assessments reflects not a lack of data but a conceptual limitation in how humanitarian needs are framed and measured. The Global Indicator Framework for SDG 5 (Gender Equality) includes sexual and reproductive health indicators, but gender-specific NCD burden and access remains under captured in humanitarian contexts(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRecommended indicator additions to future HNOs and cluster reporting\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProposed Indicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eData Source\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevalence of depression/anxiety among women 15\u0026ndash;49 (%; 95% CI); % women with access to mental health services; gender gap in mental health service access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePopulation surveys, facility assessments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCardiovascular health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% women 15\u0026ndash;49 aware of hypertension risk; % with BP screening in past 12 months; hypertension prevalence by sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDHS/MICS modules; facility surveys\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMetabolic disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType 2 diabetes prevalence in women; % with diabetes screening access; GDM screening in ANC (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDHS/MICS; facility assessments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommunicable disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTB incidence ratio (M:F); female TB case detection rate; % women accessing TB-DOTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTB surveillance data\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eService integration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% ANC facilities with integrated NCD/mental health screening; % facilities with referral pathways for positive screens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeRAMS; cluster assessments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth leadership\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% women in senior health system leadership roles; % women facility directors; women\u0026rsquo;s representation in cluster coordination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinistry of Health data; cluster records\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIncorporating these indicators into the official HNO framework would: 1. Make gender-disaggregated disease burden visible to donors and planners 2. Establish baseline data for monitoring progress 3. Create accountability for integration initiatives 4. Align humanitarian response with epidemiological reality 5. Track progress on women\u0026rsquo;s health leadership advancement\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.7 Limitations and Considerations\u003c/h2\u003e \u003cp\u003eThis analysis has several important limitations:\u003c/p\u003e \u003cp\u003e1. \u003cb\u003eData gaps\u003c/b\u003e: Yemen\u0026rsquo;s humanitarian crisis, security constraints, and limited surveillance capacity mean epidemiological data are incomplete. GBD estimates are modeled outputs, not complete country surveillance data. Mental health prevalence estimates (19.5%) derive from limited studies and may underestimate true burden due to stigma and underreporting in this context.\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eGeneralizability\u003c/b\u003e: While Yemen presents an extreme case, findings regarding reproductive health-centric humanitarian response and gender-specific access barriers may reflect broader patterns in conflict-affected contexts. However, context-specific implementation will be essential.\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eAttribution complexity\u003c/b\u003e: Distinguishing whether women\u0026rsquo;s health neglect results from insufficient resources, systemic prioritization choices, or gender-based discrimination requires further research. Likely, all three factors operate concurrently.\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eImplementation challenges\u003c/b\u003e: While integrating NCD screening into ANC is evidence-based, actual implementation in Yemen faces formidable barriers: competing health worker time, supply chain constraints, lack of treatment protocols, and limited referral capacity. The proposal requires explicit resource allocation and technical support.\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eWomen\u0026rsquo;s leadership data limitations\u003c/b\u003e: While evidence on women\u0026rsquo;s leadership in health is growing, limited studies specifically examine women\u0026rsquo;s leadership in conflict-affected Yemen. The 8 Yemen-specific studies identified in the systematic review on women\u0026rsquo;s leadership provide contextual grounding, but additional primary research is needed to understand Yemen-specific barriers and enablers for women\u0026rsquo;s advancement.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e5. Conclusions and Recommendations\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e5.1 Key Findings\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e1. \u003cb\u003eEpidemiological reality diverges from humanitarian priorities\u003c/b\u003e: Non-communicable diseases and mental health conditions represent substantial causes of death and disability among Yemeni women aged 15\u0026ndash;49, yet humanitarian response remains fixated on reproductive health alone.\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eHealthcare access for women is constrained across all domains\u003c/b\u003e: Only 20% of facilities provide maternal health services and 21% provide NCD/mental health services, indicating systemic inadequacy across the health system, not selective reproductive health focus.\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eGender inequality operates through interconnected mechanisms\u003c/b\u003e: The mahram requirement, female health provider shortage, economic vulnerability, and systemic health invisibility combine to create compound barriers to women\u0026rsquo;s health access.\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eHumanitarian architecture fails to capture women\u0026rsquo;s holistic health needs\u003c/b\u003e: Humanitarian needs assessments, cluster coordination, and funding mechanisms are structured around reproductive health, rendering other conditions invisible and therefore unfunded.\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eWomen\u0026rsquo;s health leadership is essential for system-wide change\u003c/b\u003e: Evidence demonstrates that women leaders in health systems produce superior outcomes, champion gender-responsive programming, and create sustainability\u0026mdash;yet women remain vastly underrepresented in Yemen\u0026rsquo;s health system leadership roles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Recommendations\u003c/h2\u003e \u003cp\u003e \u003cb\u003eFor humanitarian agencies and coordination bodies (WHO Health Cluster, OCHA, UNFPA)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1. \u003cb\u003eIntegrate NCD screening into antenatal care services\u003c/b\u003e: Develop and disseminate simplified protocols for blood pressure measurement, gestational diabetes screening (capillary glucose), and perinatal mental health screening in ANC settings. Allocate technical assistance and supplies to support implementation. Task women health leaders with protocol development and rollout.\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eEstablish Mental Health First Aid training for midwives\u003c/b\u003e: In partnership with NYMA, design and deliver 10-hour MHFA modules tailored to midwifery contexts. Provide certification, supervision, and linking to psychosocial support services. Prioritize training for community midwives in rural areas with no alternative mental health resources. Develop women midwife trainers to lead this initiative.\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eRevise humanitarian needs assessment frameworks\u003c/b\u003e: Expand HNO indicators to include sex-disaggregated NCD prevalence, mental health service access gaps, cardiovascular disease awareness, integrated service availability, and women\u0026rsquo;s health system leadership representation. Establish baseline data collection in 2026 HNO cycle.\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eCreate dedicated NCD and mental health working groups within the Health Cluster\u003c/b\u003e: Parallel to the reproductive health working group, establish formal coordination mechanisms for NCD and mental health response, with explicit budget lines and cluster lead responsibilities. Ensure women\u0026rsquo;s representation in working group leadership.\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eEstablish women\u0026rsquo;s health leadership development programs\u003c/b\u003e: Create transparent promotion pathways, formal mentorship programs, and peer support networks for women health workers and leaders. Integrate gender-responsive health management training into capacity-building activities.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFor donors and resource mobilization\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e6. \u003cb\u003eRing-fence funding for NCD and mental health integration\u003c/b\u003e: Donors should allocate proportional funding to NCD/mental health activities reflecting epidemiological burden (approximately 49.5% of health burden). Create incentives for integrated programming combining reproductive and non-reproductive women\u0026rsquo;s health.\u003c/p\u003e \u003cp\u003e7. \u003cb\u003eSupport sustainability of the midwifery workforce with explicit gender focus\u003c/b\u003e: Fund UNFPA and midwifery association capacity-building programs at levels matching humanitarian needs, particularly for training in NCD/mental health first aid and integrated service delivery. Include support for women midwife leaders and mentorship.\u003c/p\u003e \u003cp\u003e8. \u003cb\u003eFund women\u0026rsquo;s health leadership strengthening\u003c/b\u003e: Allocate dedicated resources for women health workers\u0026rsquo; professional development, security provisions, wage assurance, and leadership advancement\u0026mdash;recognizing that women\u0026rsquo;s leadership presence is essential to health system strengthening.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFor advocacy and evidence generation\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e9. \u003cb\u003eConduct targeted research on gender-specific health barriers and women\u0026rsquo;s leadership\u003c/b\u003e: Qualitative and operational research on the mahram system\u0026rsquo;s health impact, female health provider retention and leadership pathways, and women\u0026rsquo;s health-seeking decision-making should inform program design. Prioritize participatory research with women health workers and women\u0026rsquo;s organizations.\u003c/p\u003e \u003cp\u003e10. \u003cb\u003eEstablish mechanisms for women\u0026rsquo;s health advocacy\u003c/b\u003e: The National Yemeni Midwifery Association and women\u0026rsquo;s civil society organizations should be resourced to advocate for holistic women\u0026rsquo;s health integration in humanitarian response and policy, and to champion women\u0026rsquo;s advancement in health leadership.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e5.3 Conclusion\u003c/h2\u003e \u003cp\u003eYemen exemplifies a humanitarian health paradox: while maternal mortality receives substantial international attention, the broader health crises\u0026mdash;mental illness, cardiovascular disease, communicable diseases, and chronic disabilities\u0026mdash;that burden Yemeni women remain largely invisible and unfunded. This systemic neglect reflects not data scarcity but structural limitations in humanitarian architecture and a failure to operationalize the principle of holistic, life-course women\u0026rsquo;s health. Additionally, women\u0026rsquo;s critical underrepresentation in health system leadership roles limits the system\u0026rsquo;s capacity to identify and respond to this broad disease burden and to champion gender-responsive programming.\u003c/p\u003e \u003cp\u003eAddressing this blind spot requires neither new technologies nor additional research but rather a deliberate reorientation of humanitarian priorities toward alignment with epidemiological reality and deliberate investment in women\u0026rsquo;s health leadership. Integrating NCD and mental health screening into antenatal care, training midwives as frontline mental health first-aid providers, explicitly incorporating women\u0026rsquo;s health indicators into humanitarian needs assessments, and strategically advancing women\u0026rsquo;s representation in health system leadership are feasible, evidence-based interventions that could substantially improve health outcomes for millions of Yemeni women.\u003c/p\u003e \u003cp\u003eAs the humanitarian community increasingly recognizes the need for integrated, person-centered health approaches and gender-responsive health system strengthening in conflict settings, Yemen offers a compelling case study\u0026mdash;and a call to action\u0026mdash;for moving beyond maternity-centric frameworks toward a genuinely holistic vision of women\u0026rsquo;s health and women\u0026rsquo;s leadership in health systems.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of Interest:\u003c/h2\u003e \u003cp\u003eAuthors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any public, commercial, or not-for-profit funding agency.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe paper makes three distinct contributions:1. First quantification of the humanitarian-epidemiological mismatch in Yemen: Using GBD 2021 data alongside HeRAMS facility assessments and humanitarian response documentation, I demonstrate that humanitarian funding allocation is fundamentally misaligned with disease burden.2. Introduction of the \"reproductive health blind spot\" framework: This conceptual contribution explains how humanitarian silos (UNFPA leading reproductive health separately from mental health and NCD response) systematically render non-reproductive women's health conditions invisible, despite their substantial epidemiological burden.3. Evidence-based integration strategies grounded in comparative contexts: The recommendations (NCD screening in antenatal care, mental health first aid training for midwives, humanitarian indicator reform) are evidence-based using examples from Sierra Leone, Kenya, and other conflict-affected settings, demonstrating feasibility even in resource-constrained contexts.\u003c/p\u003e\u003ch2\u003eData Availability:\u003c/h2\u003e \u003cp\u003eAll data sources are cited and publicly available through WHO, UNFPA, and humanitarian response databases referenced in the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLancet Commission on Women\u0026rsquo;s Health. (2015). The Lancet Global Health. 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Midwives\u0026rsquo; experiences working with women and girls experiencing interpersonal violence in Yemen. \u003cem\u003eBMC Pregnancy and Childbirth\u003c/em\u003e, 25(123). PMC ID: PMC11968663.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Confederation of Midwives. (2024). The Role of Midwives in Humanitarian Crises. Position Paper and Practice Guide, November 2024.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Women’s health, Non-communicable diseases, Yemen, Humanitarian response, Gender inequality, Health systems, Women’s leadership","lastPublishedDoi":"10.21203/rs.3.rs-8444298/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8444298/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eYemen faces a dual humanitarian catastrophe\u0026mdash;a decade-long armed conflict coupled with one of the world\u0026rsquo;s most severe health crises. While international attention on women\u0026rsquo;s health remains fixated on maternal mortality, this paper challenges the \u0026ldquo;reproduction-centered\u0026rdquo; paradigm and quantifies the broader disease burden affecting Yemeni women aged 15\u0026ndash;49. Using secondary analysis of Global Burden of Disease (GBD) 2021 data, health facility assessments, and humanitarian response documentation, we demonstrate that non-communicable diseases (NCDs) and mental health conditions represent substantial but systematically neglected drivers of female morbidity and mortality. While maternal conditions remain a top cause of death, cardiovascular diseases, mental health disorders, and communicable diseases (TB, cholera) collectively account for significantly greater disability-adjusted life years. Healthcare access for these conditions is severely constrained, with only 21% of health facilities offering NCD and mental health services, compared to maternal health services reaching 20% of facilities. Gender-specific barriers\u0026mdash;including the mahram requirement limiting women\u0026rsquo;s mobility, critical shortages of female health providers, and the gender-blind design of humanitarian responses\u0026mdash;perpetuate a \u0026ldquo;blind spot\u0026rdquo; in women\u0026rsquo;s health. We conclude that integrating NCD screening into antenatal clinics, training midwives in mental health first aid, and explicitly incorporating women\u0026rsquo;s holistic health indicators into humanitarian needs assessments and cluster coordination are essential to address this systemic neglect.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e","manuscriptTitle":"Beyond Maternity: Quantifying the Holistic Disease Burden and Systemic Neglect of Women’s Health in Yemen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-02 07:10:15","doi":"10.21203/rs.3.rs-8444298/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5347a48-09a9-4b63-8ac6-b749d112a244","owner":[],"postedDate":"January 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-02T07:10:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-02 07:10:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8444298","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8444298","identity":"rs-8444298","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}