WOMEN, MATERNAL,

AND CHILD HEALTH: A GLOBAL HEALTH ISSUE

Yuri Nurdiantami, Apt., MPH
Introduction
Gender vs Sex?
- Gender is non biologic characteristics subjected to a human because of his/her sex
-Socially constructed characteristics of man and woman Gender has to do with societal norms
about the roles of women and their social postion relative to men.

This special characteristics influence the health of a woman

WOMEN
Determinant’s of Women Health
Biological Determinants
• Women face a number of unique biological risks, such as iron deficiency anemia related to
menstruation, complications of the pregnancy, ovarian cancer, breast cancer.
• Women are also biogicaly more susceptible to some sexually transmitted infections than men
are, including to the HIV virus

Social Determinants
• Social determinants relate to gender norms, which assign different roles and values to males
and females, usually to the disadvantage of females. In many societies, women’s inferior
status leads to social, health, and economic problems for women than men do not face
Women’s health problem
u Related to reproductive health
1. Pregnancy and delivery
2. Breast feeding
3. Family planning
u Gynecological problem: different problems in age cycle
u Disease that a woman has higher risk than a man, ex. COPD related
to cooking fuel
u Health problem related to sexual violence
Genderbased problems which
affect women’s health
Access to health service
Unequal opportunities to study and work
Lack of nutrition
Psychological well being
Adherence to a treatment
Inadequate information
Sexual violence
Lack of political power to advocate their condition (ex. Work leave,
breastfeeding space, secured transportation)
The Burden of Health Condition for Females

Sex-Selective Abortion Female Genital Sexually Transmitted Violance and Sexual

Cutting Infections Abuse Against Women

Maternal Morbidity Unsafe Abortion Obstetric Fistula

and Mortality
Adolescent girls
u Highest causes of death globally: Self-inflicted injuries, road traffic injuries
and drowning
u Depressive disorders and schizophrenia are leading causes of ill
health.
u Risk of HIV infection: Twice among adolescent girls and young women
(15-24 years) compared to boys and young men in the same age group.
u More than 15 million of the 135 million live births worldwide are among
girls aged 15-19 years
u An estimated three million unsafe abortions occur globally every year
among girls aged 15-19 years.
u Increased use of tobacco and alcohol among young girls
 Reproductive age
(15-44 years old)
u Causes of death in developing countries: HIV/AIDS, with unsafe sex being the
main risk factor in developing countries.
u Maternal deaths are the second biggest killer of women of reproductive age.
Every year, approximately 830/day women die due to complications in
pregnancy and childbirth, 99% of them are in developing countries.
u About 35% of women worldwide have experienced either intimate partner
violence or non-partner sexual violence in their lifetime.
Cause of death and ill health of women
in reproductive ages
Older women
u Women live longer than men
u Non communicable disease, mostly related to the life style when
they are younger
u Older women experience more disability than men because of lower
access to care
Family planning
Family planning
u It is estimated that 225 million women in developing country would like to delay
or stop childbearing but does not get access to the contraception
u Limited access
u Limited choice of method
u Poor service quality
u Fear of side effect
u Cultural or religious barrier
u Gender based barriers
u User and provider bias
Gynecological problems
Sexually transmitted infection
u Each year, there are an estimated 357 million new infections with 1 of 4 STIs:
chlamydia, gonorrhoea, syphilis and trichomoniasis.
u More than 290 million women have a human papillomavirus (HPV) infection.
u STIs such as HSV type 2 and syphilis can increase the risk of HIV acquisition.
u Over 900 000 pregnant women were infected with syphilis resulting in
approximately 350 000 adverse birth outcomes including stillbirth in 2012
u Serious consequence beyond the direct complication, ex. Infertility, mother
to child transmission
u DALYs lost because of gonorrhea and chlamydia infection in women is 10
times more than in men
Gynecological problem
Abortion
u 22 millions unsafe abortion annually, 47 000 death, and 5 millions
complication
u 220 deaths/100 000 unsafe abortion in developing world
u520 deaths/100 000 unsafe abortion in Sub Saharan Africa

Female genital mutilation

u Intentional procedure that injure female genital organ without medical
reason
u No health benefit for the girls
u More than 200 million girls and women alive today have experienced FGM
in 30 countries in Africa, the Middle East and Asia where FGM is
concentrated.
u Violation of the human rights of girls and women.
 Sexual Violence
any sexual act or attempt to obtain a sexual act by violence directed
against a person's sexuality, regardless of the relationship to the victim

Physical and mental health impact:

u Injury
u increased risk of reproductive health problem,
u transmission of IMS,
u suicide
u different mental disturbance
u Almost one third (30%) of all women who have been in a relationship have
experienced physical and/or sexual violence by their intimate partner. The
estimates range from 23.2% in high-income countries to 37.7% in the South-
East Asia region.
Source: https://en.wikipedia.org/wiki/Sexual_violence#/media/File:Table.GIF
Medical response to sexual
violence victims
u Treat emergency injury
u Collect evidence of violence for legal procedure
u Prevention of IMS
u Prevention of hepatitis
u Prevention of HIV
u Prevention of pregnancy
u Psychological and mental health support
 Health disparity by sex
u In general, women live longer than men because of biological and behavioral
protection
u In Low income countries, women’s life expectancy became the
same as men
u Some diseases tend to have higher prevalence in women due to non biologic factor:
u Less access to health care because of different woman man positition
u Society preference on boy or man
u The disease related to that: COPD, malaria in pregnant woman
Why invest on women’s health ?
Women’s status and empowerment affect their maternal health (including
access to and use of services during pregnancy and childbirth)
Maternal health effects survival and long term well being of the child
through its effect on their education, growth, and care
Maternal death and illness is costly for families
Maternal health affects economic productivity and overall health service
delivery
Maternal health interventions are cost effective
MATERNAL
Source:
http://www.who.int/mediacentre/factsheets/fs334/en
/
 Maternal Mortality Ratios for World Bank Regions, High-Income
Countries, and Globally, 2014

600
547

500
Deaths per 100,000 Live Births

400

300

200 182

100 81 67 59
16 10
0
Sub-Saharan South Asia Middle East & Latin America & East Asia & Europe & High Income
Africa North Africa Caribbean Pacific Central Asia
Region
Source: Data from World Bank. Data: Maternal mortality ratio. Data from the World Bank. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-8S-Z4-ZJ-XD-Z7-ZG?display=graph. Accessed Sptmbr
3
 Maternal health indicators
Global Indonesia
Maternal mortality 216/100 000 live births 346/100 000 live births
Percentage of birth 73% 83.1%
assisted by skilled birth
attendants
Contraception 57.4% 57.9%
coverage
Pregnant women 58% 86.9%
receiving sufficient pre-
natal care

Gap of maternal mortality ratio between developing and developed countries: 239 vs 12 per 100 000
Source: http://gamapserver.who.int/mapLibrary/Files/Maps/Global_mmr_2015.png [Accessed: March
2018]
 Cause of maternal death
u severe bleeding (mostly bleeding after childbirth)
u infections (usually after childbirth)
u high blood pressure during pregnancy (pre-eclampsia and
eclampsia)
u complications from delivery
u unsafe abortion
 Strategies to decrease maternal mortality
u eliminate inequalities in access to and improve quality of reproductive,
maternal, and newborn health care services;
u ensuring universal health coverage for comprehensive reproductive, maternal,
and newborn health care;
u managing all causes of maternal mortality, reproductive and maternal
morbidities, and related disabilities; and
u strengthening health systems to respond to the needs and priorities of women
and girls
u ensuring accountability
Reduce the global maternal mortality ratio to less than 70 per 100 000 births, with no
country having a maternal mortality rate of more than twice the global average by
2030

By 2030, ensure universal access to sexual and reproductive health-care services,

including for family planning, information and education, and the integration of
reproductive health into national strategies and programmes
The Unfinished Agenda:
Key Maternal Health Challenges
• Gender inequalities

• Child marriage

• Delaying age of first birth

• Access to contraception

• Complications during childbirth, such as maternal death

and morbidity
 Addressing Maternal Health
• Improve nutrition of adolescent girls
• Community-based interventions aimed at
delaying age at marriage and first birth
• Improve access to culturally appropriate
modern contraceptives & education on
three-year birth intervals
• Promote skilled attendants at delivery
• Increase access and adherence to
prenatal care: including micronutrient
supplementation, monitoring of
hypertension & diabetes, & tetanus
vaccination
• Ensure emergency obstetric care
available
• Improve follow-up of post-
partum care & counseling
Sustainable Development Goal Targets
◦ 5.1 End all forms of discrimination against all women and girls everywhere
◦ 5.2 Eliminate all forms of violence against all women and girls in the public and
◦ private spheres, including trafficking and sexual and other types of exploitation

◦ 5.3 Eliminate all harmful practices, such as child, early and forced marriage and
female genital mutilation

◦ 5.4 Recognize and value unpaid care and domestic work through the provision
of public services, infrastructure and social protection policies and the promotion of
shared responsibility within the household and the family as nationally appropriate
◦ 5.5 Ensure women’s full and effective participation and equal opportunities for
◦ leadership at all levels of decision-making in political, economic and public life
 Sustainable Development Goal Targets
u 5.6 Ensure universal access to sexual and reproductive health and reproductive rights
as agreed in accordance with the Programme of Action of the International
Conference on Population and Development and the Beijing Platform for Action and
the outcome documents of their review conferences

5.aUndertake reforms to give women equal rights to economic resources, as well as

access to ownership and control over land and other forms of property, financial
services, inheritance and natural resources, in accordance with national laws

5.bEnhance the use of enabling technology, in particular information and

communications technology, to promote the empowerment of women

5.cAdopt and strengthen sound policies and enforceable legislation for the promotion
of gender equality and the empowerment of all women and girls at all levels
CHILD
 Neonatal Mortality Rates for World Bank Regions, High-Income
Countries, and Globally, 2015

35

30
30 29

25
Deaths per 1000 Live Births

20

15
13
10 9 9
6
5 3

0
South Asia Sub-Saharan Middle East & East Asia & Latin America & Europe & Central High Income
Africa North Africa Pacific Caribbean Asia
Region

Source: Data from the World Bank. World Development Indicators: Mortality. http://data.worldbank.org/indicator/SH.DYN.NMRT/countries/Z4-ZJ-8S-ZG-Z7-ZQ-XD?display=graph. Accessed Sptmbr 3
2018
 Infant Mortality Rates for World Bank Regions, High-
Income Countries, and Globally, 2015

60
56

50

42
Deaths per 1000 Live Births

40

30

20
20
15 14
10
10
5

0
Sub-Saharan South Asia Middle East & East Asia & Latin America & Europe & Central High Income
Africa North Africa Pacific Caribbean Asia
Region

Source: Data from the World Bank. World Development Indicators: Mortality. http://data.worldbank.org/indicator/SH.DYN.NMRT/countries/Z4-ZJ-8S-ZG-Z7-ZQ-XD?display=graph. Accessed Sptmbr 3
 Under-Five Child Mortality Rates for World Bank Regions, High-
Income Countries, and Globally, 2015

90
83
80

70
Deaths per 1000 Live Births

60
53
50

40

30
23
20 18 17
11
10 6

0
Sub-Saharan South Asia Middle East & Latin America & East Asia & Europe & High Income
Africa North Africa Caribbean Pacific Central Asia
Region

Source: Data from the World Bank. World Development Indicators: Mortality. http://data.worldbank.org/indicator/SH.DYN.NMRT/countries/Z4-ZJ-8S-ZG-Z7-ZQ-XD?display=graph. Accessed Sptmbr 3
 Neonatal, Infant, and Under-Five Child Mortality Rates, by World Bank
Region and for High-Income Countries, 2015

90
83
80

70
Deaths per 1000 Live Births

60 56
53
50
42 Neonatal Mortality
40
Infant Mortality
29 30
30 Under-Five Mortality
23
20 18
20
13 14 15 17
9 9 10 11
10 6 6
3 5
0
Sub-Saharan South Asia Middle East Latin America East Asia & Europe & High Income
Africa & North & Caribbean Pacific Central Asia
Africa
Region

Source: Data from the World Bank. World Development Indicators: Mortality. http://data.worldbank.org/indicator/SH.DYN.MORT/countries/1W-Z4-ZQ-Z7?display=graph. Accessed Sptmbr 3
 Distribution of the Cause of Death, by Income Group, 2015

Low Income Lower-Middle Income

Group III
9% Group III 9%

Group I
29%

Group II Group I
39% 52% Group II
Group I: Communicable,
62% Maternal, Neonatal, and
Nutritional Causes

Group II: Non-Communicable

Diseases
Upper-Middle Income High Income
Group III Group I 6% Group III: Injuries
Group III Group I
6%
9% 8%

Group II Group II
83% 88%

Source: IHME. Global Burden of Disease Heatmap. Accessed March 18, 2017. Available at: http://vizhub.healthdata.org/gbd-compare/.
Causes of Neonatal Death, Globally, By Percentage, 2013

Injuries; 1%
Diarrheal
Preterm birth
diseases; 1%
complications; 35% Tetanus; 2%
Acute lower respiratory infection 5%

Birth asphyxia and birth Other communicable,

trauma; 24% perinatal,
and nutritional
conditions; 7%

Sepsis and other

infections of the Congenital
newborn; 15% anomalies; 10%

Notes: Estimates may not add up to 100% due to rounding

Source: Adapted from Skolnik, R. L. (2015). Global health 101. Burlington, MA: Jones & Bartlett Learning. P.263;; WHO. Global Health Observatory Data Repository: Mortality and global health estimates.
http://apps.who.int/gho/data/view.main.CM300WORLD-CH11?lang=en. Accessed February 28, 2015.
Causes of Post-Neonatal Under-Five Child Death (1-59mos), By Percentage, 2013

Lower respiratory
infections; 23%
Pertussis; 2%
Birth asphyxia and birth
trauma; 2%
Diarrheal diseases; 16%
HIV/AIDS; 3%
Measles; 3%
Malaria; 13% Prematurity; 4%
Meningitis/encephalitis;
4%

Congenital anomalies; 5%
Other communicable,
perinatal, and nutritional Other noncommunicable
conditions; 10%
Injuries; 9% diseases; 7%

Notes: Estimates may not add up to 100% due to rounding

Source: Adapted from Skolnik, R. L. (2015). Global health 101. Burlington, MA: Jones & Bartlett Learning. P.263;; WHO. Global Health Observatory Data Repository: Mortality and global health estimates.
http://apps.who.int/gho/data/view.main.CM300WORLD-CH11?lang=en. Accessed February 28, 2015.
 The Unfinished Agenda: Key Neonatal Health Challenges

• Nutritional status of mother

• Low birthweight

• Prematurity

• Child caring practices

• Deliveries attended by skilled birthing attendants

 Addressing Neonatal Health
• Ensure healthy mothers, who are
immunized against tetanus
• Ensure attended delivery with
emergency care available
• Promote keeping the baby warm
• Increase awareness of the
benefits of kangaroo mother care
• Monitor vaccination
• Promote immediate and
exclusive breastfeeding on a
local and societal level
• Implement community-based
diagnosis & treatment of
pneumonia
• Train community health
workers on referral for
emergency care if needed for
sepsis, etc.
 The Unfinished Agenda: Key Child
Health Challenges
• Maternal health & neonatal • Malaria
health interventions
• Vaccine preventable
diseases
• Exclusive breastfeeding for six
months and hygienic introduction • Hygienic introduction of a
of a diverse complementary diet diverse complementary diet

• Diarrheal diseases
• Mother to child transmission of
HIV • Micronutrient deficiencies
 Addressing Child Health Challenges

• Support maternal health & • Bednet uptake

neonatal
health interventions • Universal immunization

• Promote exclusive breastfeeding • Promote hygienic introduction of a

for six months diverse complementary diet

• Prevention of maternal to child • Train mothers on oral

transmission of HIV rehydration therapy with zinc

• Ensure early confirmed diagnosis • Provide Vitamin A supplementation

&
treatment for malaria • Community-based management of
pneumonia
THE MOST-EFFECTIVE CHILD
HEALTH INTERVENTIONS
 The Cost-effective Child Health Interventions
Most illness and death among young children is due to multiple illnesses or, more
often, malnutrition combined with disease. It is important to ensure that children
have the right combination of preventive and curative interventions.

In the first 6 months of life, exclusive breastfeeding is crucial because there are important
antibodies in mother’s breast milk

Appropriate and hygienically prepared complementary feeding, a full course of immunization,

insecticide-treated bed nets for malaria prevention, and ORT for children with diarrhea

The basic package of vaccines include vaccines against six major diseases including diphtheria,
whooping cough (pertussis), tetanus, polio, tuberculosis, and measles. Vaccines for hepatitis B,
Haemophilus influenza type b, and rotavirus are increasingly also being used in low- and middle-
countries.

Safe water and sanitation are also key to good health

 Policy and Program Briefs in Women’s Health

1. Addressing Female Genital Cutting in Senegal

2. Reducing Maternal Mortality in Tamil Nadu, India

3. The Reduction of Maternal Deaths in Sri Lanka

4. Reducing Fertility in Bangladesh

5. Obstetric Fistula in Tanzania

Policy and Program Briefs in Child Health

1. Kangaroo Mother Care for Low Birthweight Babies in Indonesia

2. Low Cost Neonatal Incubators in Indonesia

3. The Pneumococcal Vaccine

4. The Rotavirus Vaccine

5. Calcutta Kids
Cases VIGNETTES
1. Suneeta was pregnant with her first child. She lived in northern India where
many families prefer to have sons rather than daughters, especially for their
first-born child. Eager to have a son, Suneeta's husband took her to get a
sonogram to determine the sex of the baby. When they learned the baby
would be a girl, they decided that Suneeta should abort the fetus and try
again to get pregnant, in hopes of having a boy.
2. Sarah lived in rural Pakistan and was pregnant with her second child. When
she went into labor, Sarah called for the traditional birth attendant, as most
women did in her town. As Sarah's labor continued, she and the birth
attendant realized that the labor was complicated. Sarah needed to go to a
hospital to deliver the baby. In this part of Pakistan, however. women could
not be taken to hospitals without their hus-band's permission. Sarah's husband
was working in another city and was not available to give such permission.
Several hours later, Sarah and the baby died at Sarah's home.
Cases VIGNETTES
3. Nassiba was born in a remote part of Tajikistan. At 3 years of age. she
became very ill with measles. She died before her parents could get her to
a health center. Nassiba's birth was never registered because the
registration center was far from her home and her parents could not
afford the registration fee. When Nassiba died, her death was not
recorded either. According to the national records, she never existed.

4. Tirtha was born in far western Nepal 7 months ago. She was the fourth
child in her family. She was eating some baby foods as well as
breastfeeding. One day Tirtha developed persistent diarrhea and became
feverish. Her mother wanted to take Tirtha to the health center, but it
was 2 hours away so she decided to see how Tirtha was feeling the next
day. The next morning Tirtha was dead from dehydration.
References

u http://data.unicef.org/topic/maternal-health/antenatal-care/
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scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet
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u Say, L. et al., 2014. Global causes of maternal death: a WHO systematic analysis. The Lancet.
Global health, 2(6), pp.e323–33. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25103301 [Accessed December 5, 2016].
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the United Nations Population Division., Geneva: World Health Organization.
u World Health Organization, 2009. Women and health, today’s evidence tomorrow's agenda, Geneva.
u http://www.un.org/sustainabledevelopment/gender-equality/
u http://www.un.org/sustainabledevelopment/health/#7e9fb9b0ec8c8e6e6
PPT Pelatihan Kesehatan Global Prof Wiku Adisasmita
Global Health 101 2nd Edition, Richard Skolnik, 2012