Want to improve the health of women? Electing a female leader helps.

In the final presidential debate of this surreal election, Hillary Clinton came out with an astonishing defense of women’s reproductive rights in what was probably her most powerful statement on the campaign trail.

"The government has no business in the decisions that women make with their families in accordance with their faith, with medical advice," she said, "and I will stand up for that right."

It was the first time a US presidential candidate had ever spoken about abortion so starkly — and not just any candidate: the first-ever female politician to top the presidential ticket of a major party.

This is probably not a coincidence. Around the world, researchers have documented a pattern that’s repeated itself over and over: When women are elected into power, they tend to prioritize health in their legislation, elevate issues that are important to other women, and so they’re more likely than men to have a positive impact on women’s health. In the US, this pattern has been especially strong among Democratic female leaders.

At a time when the health of women in this country has been declining on several key measures, a woman in the Oval Office could be hugely influential in not just reversing some negative trends but also establishing new laws that expand access to health care and reproductive rights.

Woman leaders are more likely than men to push through legislation on women’s health

Hillary Clinton and Donald Trump in the final presidential debate, where their points of view on abortion couldn't have been starker. (Joe Raedle/Getty Images)

Men still vastly outnumber women in political leadership positions. But researchers from around the world have been studying the effects of gender on policymaking when women do gain power. Most of this work looks at legislators, or women elected to local governments, but it suggests that there are very positive gains for women when other women govern.

In this 2011 paper, researchers from the UK and Spain wanted to find out whether woman politicians in India were more likely than their male counterparts to affect positive change in women’s health.

They compared villages with close elections, where there was less than a 3 percent difference between whether a man or woman won an election. The researchers found that "a one standard deviation increase in women’s political representation results in a 1.5 percentage point reduction in neonatal mortality, an outcome that is closely tied to investments in maternal health."

In other words, there was a strong link between female political representation at the village level and improvements in child and maternal health outcomes, at least in the short term. (There’s no researchers linking female leadership to long-term health outcomes, and that kind of correlation would be difficult to establish since so many things influence health in the long run.)

"Raising women’s political representation may be an effective — and novel — way of improving public health delivery in developing countries"

The researchers also discovered that the likelihood of women doing other important things for their health and the health of their families — attending antenatal clinics, breastfeeding, immunizing their children — improved more under female leaders compared to male leaders. "The estimated impacts are large," the researchers wrote, "suggesting that raising women’s political representation may be an effective — and novel — way of improving public health delivery in developing countries."

In another study on more general effects of women as policymakers in India, the researchers determined that "female village chiefs invest more in public goods than do male chiefs," and specifically, public goods their women counterparts were concerned with (in this case, safe drinking water). This study was important because it showed that leaders who happen to be woman prioritized issues that their local female counterparts cared about.

Closer to home, there’s a robust literature demonstrating that woman lawmakers in the US (particularly Democrats) have a track record of being more likely than men to sponsor bills related to education, health care, children’s issues, and welfare policy — all issues that can directly or indirectly impact women’s health.

Michele Swers, a Georgetown University researcher who has written two books on the effect of women representation in Congress, told me she’s seen number examples in her years of research of woman lawmakers in the US helping to boost women’s health. "I think the women [in Congress] are basically stronger advocates for [women’s health]," she summed up.

Swers describes how in the 1980s, when researchers began to discover that an aspirin a day can prevent heart attacks (based on studies only done in men), it was the women in Congress who pushed for the creation of the Office of Research on Women’s Health at the National Institutes of Health and new requirements for quotas on woman representation in clinical research.

In 1990, Congress passed the Breast and Cervical Cancer Mortality Prevention Act. Prior to that law, breast and cervical cancer screening was only available for people who had insurance. But female bipartisan lawmakers noticed the evidence these screenings could have a positive impact on health, and pushed through the legislation so all woman could get access regardless of insurance status.

Things are more polarized nowadays. "In the 1990s, moderate Republican women and Democratic women would cooperate more to try to promote women’s health care including issues related to reproductive rights," said Swers. On this and other partisan issues, Republican women today can be as conservative as Republican men.

Still, Swers says she continues to see bipartisan Congresswomen coming together to improve women’s health around issues that aren’t as polarizing. "Republican women do a lot on human trafficking," she explained. "Sexual assault in the military or sexual assault on campus — that’ll be bipartisan." With Obama’s health care bill came controversy over what should be included in the benefits plan for the basic package of benefits.

"The female senators were pressing for as expansive coverage as possible for contraceptives," Swers observed, "which even [Vice President Joe] Biden was hesitant about."

Women may prioritize health because of interest, personal experience — and social expectations

There are a few reasons why this connection between woman politicians and championing women’s health issues turns up again and again.

Swers says it comes down to priorities and personal experience. "There are plenty of things everyone can advocate for," she said, "but only a certain amount of time to do so. When you have a personal stake or experience in something, you’re more likely to be an aggressive advocate of it."

Cornell University researcher Jyoti Mathad agreed. "When it comes to maternal health and children’s issues, the burden of a lot of that tends to fall on women globally. A woman is the person who is growing the fetus, delivers the baby, the one who can die in childbirth, and the one whose infant may die after childbirth."

Researchers have found state legislators who are women are also more likely to enter politics from health and medical backgrounds, which may influence the kinds of issues they focus on as leaders.

Beyond personal interest, societal expectations play a role, too. Health is a "feminized issue," and women tend to be channeled into ministries or committees that have to do with health, as well as those focused on women’s issues, said Melanie Hughes, co-author of the book Women, Politics, and Power. "We know overall across the world that women in politics tend to prioritize health, and we know voters expect women to prioritize health," she added. So voters look to women leaders to get action on these issues.

Whatever the motivation, the result is the same: Women tend to put forward legislation having to do with health — and women’s health in particular — more often than men in many countries.

Still, there’s an important caveat to add about all this research: We’re much more likely to see case studies and research that come to positive conclusions rather than the negative ones. And we know anecdotally that not all women leaders necessarily champion women’s health issues. There are examples of leaders who actually hurt women and public health. (Look no further than the devastating blow Margaret Thatcher made to the National Health Service in the UK, which hurt access for women.)

So a number of the researchers I spoke to pointed out that it’s not always a simple matter of having a woman in power, but also one who cares about health. And Hillary Clinton has a long track record of focusing on health care generally, and women’s health issues specifically.

Clinton has a long track record on working for women’s health

Then Secretary of State Hillary Clinton in 2010 on a tour of a Cambodia shelter that provides rehabilitation, vocational training, and social reintegration for sex trafficking victims. (Evan Vucci/AFP/Getty Images)

Before there was Obamacare, there was "Hillarycare," the universal health care plan she helped develop in 1993 under the Bill Clinton Administration. When that flopped, Clinton helped dream up and get Congress to pass the Children’s Health Insurance Program, which gave millions of American children from families who were ineligible for Medicaid access to low-cost health care. (In some states, CHIP covers pregnant women, too.)

In 2005, when Clinton was a senator in New York, she worked with Patty Murray (D-WA) to put a hold on George Bush’s nominee for the Food and Drug Administration and force action and a decision on whether emergency contraception would be available over the counter.

As secretary of state, one of Clinton’s key projects was the Global Alliance for Clean Cookstoves. Household air pollution is a major killer globally, and one that disproportionately affects women since they’re the ones cooking and breathing in pollution from poorly-designed stoves or solid fuel emissions. Clinton helped establish the public-private partnership to "improve livelihoods, empower women, and protect the environment by creating a thriving global market for clean and efficient household cooking solutions." It’s still not clear this work has had an impact on this vexing health problem, but, Swers said, "that work is not something you saw under male secretaries of state."

What Clinton wants to do for women (and men and children’s) health if elected

One of Clinton's central campaign promises has been to repeal the Hyde Amendment, also known as the "greatest domestic abortion reduction law ever enacted by Congress." The act bans federal funding for abortions unless they involve cases of rape or a mother’s live is in danger.

As Vox’s Emily Crockett explained, "It’s hard to overstate the impact of Hyde, even compared with the slew of state restrictions that have crippled access to abortion in just the past five years." While restrictions may have closed abortion clinics, the Hyde Amendment, Crockett continued, "makes abortion completely unaffordable for millions of women, and it’s been doing that for 40 years."

Most broadly, Clinton has said she’s committed to defending the Affordable Care Act, instead of repealing it. The ACA expanded health care to 20 million Americans, and made sure insurance companies don’t discriminate against women. She also wants to expand coverage during her tenure. "All states would expand Medicaid coverage to anyone living underneath the poverty line," Vox’s Dylan Matthews explained in a comprehensive piece about her policies, "and subsidies for health care on the exchanges would be more generous."

Put in perspective, Matthews wrote, "The result would leave the United States’ safety net far less generous than that of, say, Sweden. Hospitals aren’t nationalized. Parental leave is 12 weeks, not 480 days per couple. There isn’t a child allowance paid to all families, no strings attached. But a world in which Clinton’s agenda passed is one in which it would be the stated responsibility of government to ensure everyone can afford health care, child care, and college."

While reproductive rights and the Affordable Care Act have come up on the campaign trail, other elements of Clinton's plan have gotten less attention. Her mental health agenda includes a focus on maternal depression and mental health issues post-childbirth, as well as suicide prevention.

Clinton also wants to work to close the wage gap, give workers 12 weeks paid family leave and 12 weeks paid medical leave (when families have a new child, or a sick family member), and double the child tax credit for families with young children or those living below the poverty line.

These policies don’t cover every health concern a woman might have. At a time when obesity rates are rapidly rising among American women, for example, Clinton has barely uttered a word on the issue. She’s also been quiet about whether she’d ramp up funding for women’s health research.

Women’s health in the US is sliding backward on several key measures

If Clinton is elected, her timing will be very apt. Women’s health in America has been going the wrong way on several key measures.

Exactly a year before this election, a blockbuster study came out of Princeton documenting a dramatic rise in mortality among middle-aged white Americans. Hidden in that study was even more dramatic — and surprising — data showing that women’s health has been sliding backward on many important indicators. From 1999 to 2013, while the death rate among middle-aged white women steadily ticked up, white men actually saw decreases in mortality since 2005.

Women are committing suicide more often these days; they’re much more likely to die during child birth than they were in the early 1990s

Women are committing suicide more often these days, they’re much more likely to die during child birth than they were in the early 1990s, their obesity rate is climbing while men’s is plateauing, and they’re now dying of lung cancer and accidental poisonings at a faster rate than ever before.

These are disturbing trends that Hillary Clinton can’t turn around all by herself. A lot of what she would be able to do as president will depend on whether Democrats take control of the Senate.

She’ll be able to push some policies through by executive orders, but others would need get the support of a majority of lawmakers in Congress. For example, she could make changes to the federal workforce, such as requiring paid leave or accommodations to pregnant women and childcare, without Congress. But any changes involving the broader population and taxpayer dollars would need to go through Congress, which could be a major obstacle if the Republicans keep control of both houses.

Regardless, simply drawing attention to these issues through the bully pulpit of the presidency (if she wins it) "could lead to some groundswell of support that might move some of the states to start taking action," Swers said. "She will pay attention to women’s health, make it a priority, and consider pushing federal funds toward it." Her presidency would also mean several senior Democratic women who are in line to chair committees will likely get leadership roles.

There are also the indirect ways through which a woman president could improve women’s health. If a woman leader inspires girls to boost their aspirations for their lives, this could improve their education and income, which would have an impact on their health (since we know higher education and earnings are tied to better health outcomes). "If we think about mental health as also being part of ‘women’s health,’" Hughes added, "women’s presence in visible leadership roles is inspirational and could transform their feelings of self-worth." These gains could be dramatic, and difficult to measure.

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