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As discussed by a well-known scholar and practitioner of women’s health, “being born female is dangerous for your health.” Some of the health conditions that women face are biologically determined. Others are socially determined. Some result from the interplay between biological and social determinants of health. The inferior social status of women in many cultures, however, is reflected in certain health conditions that women face and in some of the differentials that favor men between the health of men and the health of women. As one looks globally at the health of women, it is important to think broadly of their health and go beyond the traditional focus on reproductive health issues. In low-income countries, Group I causes, including HIV/AIDS, TB, malaria, and maternal causes continue to be the leading causes of deaths of females 15 to 49 years of age. The same causes are of special importance for females of that age group in lower middle-income countries, but ischemic heart disease and stroke rise in importance in this group. As one moves to upper middle-income countries, HIV/AIDS continues to be important, but road injuries, ischemic heart disease, stroke, and breast cancer are also in the top five causes of death. In high-income countries, self-harm is the leading cause of death in this age group, and breast cancer, drug use disorders, road injuries, and ischemic heart disease are also in the top five causes of death. Clearly, maternal causes remain an important cause of female death. However, reducing premature deaths of females, especially in low- and middle-income countries, will require a focus on a number of Group I causes, self-harm, and the growing burden in those countries of noncommunicable diseases. Improving the health status of females, especially poor women in low- and middle-income countries, will also require attention to some of the specific issues noted earlier in the chapter. One is nutrition. Another is sex-selective abortion. A third is discriminatory healthcare practices toward young girls that cause these girls to suffer higher rates of mortality before age 5 than boys. Sexually transmitted infections are an important cause of DALYs for women in the reproductive age group, especially in sub-Saharan Africa. Female genital mutilation is a practice that is widespread, especially in parts of Africa, and it is associated with important morbidity and disability for women. Violence against women is also a central cause of ill health for women. About 300,000 women die each year of maternal causes; about 40,000 of these deaths are due to unsafe abortions. Complicated labor that is not properly attended can also lead to problems, such as fistula, from which an estimated 2 million women suffer worldwide. The risk of maternal morbidity, disability, and mortality is increased by having a stunted mother, young age at marriage, young age at first birth, having more than five children, and having closely spaced pregnancies. The lack of access to family planning and the demand for it is at the foundation of some of these problems. This is particularly the case in some places in South Asia and much of sub-Saharan Africa, where total fertility remains high and the coverage of family planning remains low. Increasing the uptake of family planning to delay the age at first birth, increase birth intervals, and reduce the number of births per woman would save lives, especially in low- and middle-income countries with weak emergency obstetric care. The costs of women’s health problems are very substantial. In many societies, women are the primary caregivers to children, and when the health of the mother suffers, there is often a negative effect on the health of the children as well. In addition, women play important economic roles in many families, and the morbidity, disability, and mortality associated with particular problems of women’s health have substantial economic implications. Some countries, such as Sri Lanka, have been able to improve the health of women at relatively low levels of expenditure by making wise choices about investments in health and education. These included increasing female education, providing widespread access to midwives, and ensuring adequate backup for the midwives at hospitals. The quest for universal health coverage in an increasing number of countries should enhance the health of females. Improving the health of females in the future will also require that health systems provide a cost-effective package of services, including nutrition, family planning, prenatal care, deliveries attended by skilled healthcare providers, emergency transportation of women who are having complicated labors, and emergency obstetric services of appropriate quality at a hospital. A number of countries are now undertaking a variety of efforts, including incentive programs, to try to increase the demand for such services and the supply of these services at an appropriate level of quality. In the long run, it will be important to change the gender roles that favor males, promote the education and empowerment of females, promote their prospects for earning income, and educate communities to better understand the health conditions that females face and the measures that can be taken to address them. These measures could help, among other things, to reduce sex-selective abortion, female infanticide, and violence against women, and avoid the three delays that are associated with maternal morbidity, disability, and mortality. They would also promote more attention to the overall health of females and measures to reduce in cost effective and fair ways the leading burdens of disease that females face.
Approximately 5.4 million children around the world died in 2017 before they reached their fifth birthday. This is equal to almost 15,000 young child deaths every day globally. About 47 percent of the deaths take place in the first 28 days; 28 percent in the post neonatal period; and 24 percent between the first and fourth years. The chances of survival for a newborn, an infant, and a young child are vastly different across different settings. The discrepancies within an individual country can be as wide as differences between countries. High-income countries have, on average, about 5 deaths per 1,000 live births for children younger than 5 years. However, the rate in low-income countries is 50 deaths per 1,000 live births, or 10 times higher than the rate in high-income countries. However, in some of the most fragile states the rate can go above 80, as it does in the Central African Republic and in Sierra Leone. The largest cause of death of under-5 children globally is prematurity, which killed almost 18 percent of all of those children who died before reaching age 5 in 2016. Other conditions related to birth, such as birth asphyxia and birth trauma, were responsible for 12 percent of the deaths, and congenital anomalies for almost 9 percent. Pneumonia is the most important infectious killer of children who are younger than 5 years of age and is responsible for about 16 percent of their deaths. The second most important infectious cause of illness and death among children is diarrheal disease, followed by sepsis, malaria, measles, and HIV/AIDS. The social determinants of health have a major impact on the health of young children. Poverty is a significant underlying factor of morbidity and mortality among children, as is the lack of education for mothers. Nutritional status is also a powerful determinant of whether a child lives and thrives. About 45 percent of all deaths of children under 5 years of age are related to children being undernourished. This undernourishment may stem from poor maternal nutrition, suboptimal breastfeeding, infection, or insufficient energy, protein, and the lack of key micronutrients in the child’s diet. Inadequate water and sanitation and poor hygiene practices are major risk factors for childhood illness and death. Household air pollution is also a major risk factor. There are well-known, proven, and cost-effective interventions for substantially reducing the deaths of neonates, infants, and young children. Their deaths do not stem from a failure of knowing what to do. Rather, they stem mostly from a failure to reach all children with these interventions. The key interventions can be oriented in a life-course approach— those important before pregnancy; during pregnancy, birth, and shortly after birth; those needed in the post-neonatal period; and those most important for the young child. The following will be among the most important interventions:
■ Ensuring the health and proper nourishment of the mother
■ Providing access to modern contraceptives
■ Prenatal care and micronutrient supplementation for the mother-to-be
■ Prevention of mother-to-child transmission of HIV/AIDS
■ Attendance at delivery by a skilled birth attendant and referral for emergency obstetric care if needed
■ Appropriate care of the newborn, special measures for low birthweight babies, and referral if needed for illness
■ Early and exclusive breastfeeding for 6 months
■ Hygienic introduction of diverse complementary foods
■ Childhood immunization
■ Bed nets for malaria and regular drug administration for worms
■ Oral rehydration for diarrhea and early diagnosis and treatment for pneumonia