For most of global health, an African woman officially exists between her 15th and her 49th birthday.
Before 15, she is a child, mostly invisible in the surveys that drive policy. After 49, she falls off the dashboard. The Demographic and Health Surveys that anchor most national women’s health data only interview women aged 15 to 49. SDG indicator 3.7.1 for sexual and reproductive health uses 15 to 49, and so do most indicators on anaemia, contraception, gender-based violence, HIV in women, and maternal mortality. The category is so deeply embedded that for many programmes, “women” simply means “women of reproductive age,” and “women of reproductive age” simply means 15 to 49.
This category was chosen because it captures the years in which most pregnancies happen, not necessarily because it captures the most important window of African women’s health. All other health conditions women experience, and every other phase of their lives, were structured around that choice.
But, in this framing lies deep systemic exclusion and marginalisation.
A fertility metric in health-category clothing
The 15-49 window is a fertility metric. Demographers settled on it in the early 20th century as a serviceable approximation of female reproductive years. Over time it became the standard age range for the World Fertility Survey, then the DHS Program, then a long list of SDG and WHO indicators.
There were good reasons in 1984, when the first DHS rolled out, to focus a costly household survey on the population most likely to have given birth recently. Birth histories produced child mortality estimates, contraceptive prevalence informed family planning programmes and maternal indicators required women who were, or recently had been, mothers.
Those choices made sense for their time, but they have now hardened into something far broader than their original purpose. A survey instrument designed to measure fertility has, by default, become the lens through which we see African women’s entire health.
The 10 to 14 we do not see
At one end of the spectrum, the framework treats girls aged 10 to 14 as if they were not yet living the lives that women’s health policy addresses.
The average age of menarche in sub-Saharan Africa is around 14 and falling. By 14, many adolescent girls are already menstruating, already exposed to HPV, already at risk of pregnancy, already targeted for child marriage in some settings. Sub-Saharan Africa has the highest rate of adolescent pregnancy in the world, at 109 births per thousand among girls aged 10 to 19, compared with a global average of 42. Yet most household surveys exclude the 10-14 group from individual interviews.
The DHS Program recently acknowledged the problem by developing methods to estimate under-15 fertility from the birth histories of women aged 15 to 19. That is, by asking older adolescents to retrospectively report on what happened to them as children. The data gap they are working around is the gap created by the 15-49 boundary itself.
Half of all mental health disorders in adulthood begin by age 14 and HPV exposure begins with sexual debut. Nutritional status during early adolescence shapes the entire life course of women’s health, including pregnancy outcomes a decade later. None of this is captured for the under-15s by the surveys that drive women’s health policy. Researchers across the African Research, Implementation Science and Education (ARISE) Network have been explicit that evidence gaps are largest for younger adolescents aged 10 to 14. The 15-49 framework is one of the structural reasons why.
The cliff at 49
At the other end, 49 is treated as the year a woman’s health concerns are no longer worth counting.
The biology of this is even more challenging. Perimenopause, the years of hormonal turbulence that precede the final menstrual period, typically begins in a woman’s mid-40s and lasts an average of four to seven years. The mean age of natural menopause in studies from Ghana and other parts of West Africa sits around 47 to 48. A multi-country analysis published in 2023 documented an increasing prevalence of early and premature menopause in low- and middle-income countries, with sub-Saharan Africa and South and Southeast Asia at the front of that trend.
What this means in practice is that the 15-49 window cuts off African women just as, and in many cases before, their most disruptive reproductive transition begins. The hot flushes, sleep disruption, depressive symptoms, cognitive changes, urogenital symptoms, increased cardiovascular risk, and bone density loss that accompany the menopause transition are seen as edge-of-life concerns. Yes, these are midlife concerns for women who are still working, raising families, and, in many African contexts, providing care for both children and parents. These health concerns are systematically excluded from the data tools and surveys that quantify African women’s health.
The decades that follow
Life continues beyond perimenopause, and there is a lot of it.
Life expectancy at birth for women in the African region rose from around 54 years in 2000 to nearly 66 by 2019. Healthy life expectancy has risen too, from about 47 years in 2010 to over 56 by 2021. The continent’s population aged 60 and over is projected to triple from 74 million in 2020 to over 235 million by 2050, the fastest growth of any region in the world.
Most of those older Africans will be women because women live longer than men by an average of about 3 years across the continent, and longer still in some countries. An African woman reaching 50 today can reasonably expect to live another 25 to 30 years. This means that half of their adult lives will not be measured and tracked in any public health metric.
The diseases of the missing decades
This is where the framework’s narrow vision becomes most costly.
Cervical cancer peaks in incidence and mortality among women in their 50s and 60s in most African countries. Recent global analyses report that incidence is shifting younger while mortality continues to concentrate in older age groups, with sub-Saharan Africa bearing a disproportionate share of both. Screening coverage among women aged 30 to 49 in the region has remained essentially flat at 14% since 2000. However, the women who go on to die of cervical cancer mostly do so after 49 when no one is counting.
Breast cancer presents earlier in African women than in Western populations and carries a higher mortality rate, in part because diagnosis happens later and treatment access is poorer. Cardiovascular disease is now the leading non-communicable cause of death among women in many African countries, with risk rising sharply after menopause. Diabetes prevalence in older African women is climbing fast. Bone fractures, dementia, depression, frailty, and the cascading consequences of decades of nutritional deficits all concentrate in the post-50 years. Functional limitations affect about a quarter of the over-60 population and more than half of those over 80.
The Africa CDC and most national NCD strategies recognise the rising burden of cancer and cardiovascular disease as women transition into their later years, but the surveillance infrastructure that drives implementation has its eyes elsewhere.
The deeper problem: women defined by reproduction
Underneath all of this is that the 15-49 framework does not just exclude girls and older women. It encodes a view of women as primarily reproductive and worth measuring only when they are bearing children.
This is why the framework can sit comfortably alongside underfunding of menstrual disorder research, gynaecological cancers in older women, perimenopause and the entire infrastructure of mid- and late-life women’s health. Public health is aware of these conditions, but by failing to count them, these conditions remain underfunded almost by structural default.
Crockett and Cooper, writing in Reproductive Health Matters, stated this plainly - current approaches to global women’s health ignore these serious conditions, harming older women through the perpetuation of gender norms that construe women’s health through a narrow reproductive lens. The reproductive lens is a gender norm.
What rethinking looks like
None of this is an argument for abandoning the 15-49 frame entirely because it does serve a purpose.
It captures the years in which pregnancy-related mortality concentrates, anchors the only globally comparable data series on contraceptive prevalence, allowing trend analysis stretching back four decades.
Replacing or expanding it requires survey expansion, training, longer questionnaires, larger sample sizes for under-15s and over-49s, ethical complexity for interviewing minors, and political resistance from programmes already invested in the existing metrics.
Rather than just making the 15-49 category bigger, we need to ensure that women’s health surveillance matches the actual contours of women’s lives. This means a life-course approach with age-appropriate modules. It also means that we stop treating “reproductive age women” and “women” as synonyms.
The bottom line
There is a quiet violence in being defined by what your body is presumed to do and then erased from the count when it stops doing it. African women have been carrying that erasure for a long time.
We have the demographic evidence, the disease burden data and the life expectancy projections. What we need now is the institutional courage to retire a 1980s category and build something that matches the women African public health is actually meant to serve.