tag:theconversation.com,2011:/us/topics/maternal-health-1545/articlesMaternal health – The Conversation2024-02-14T12:21:06Ztag:theconversation.com,2011:article/2213512024-02-14T12:21:06Z2024-02-14T12:21:06ZMaternal death rates in the UK have increased to levels not seen for almost 20 years – experts explain why<figure><img src="https://images.theconversation.com/files/573790/original/file-20240206-20-yeglh4.jpeg?ixlib=rb-1.1.0&rect=0%2C6%2C2305%2C1518&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>Maternal death rates are widely considered to reflect a country’s overall wellbeing and the quality of the healthcare system. </p>
<p>In most high-income countries, giving birth is a <a href="https://www.who.int/publications/i/item/9789240068759">relatively safe experience</a>. Nevertheless, maternal deaths still happen and are <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00247-4/fulltext">increasing in many countries</a> around the world. </p>
<p><a href="https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022">Recent data from the UK</a> show that death rates during pregnancy and the period shortly after are reaching levels not seen in the country for almost 20 years. It is important to understand why this is happening and what needs to be done to stop this worrying trend. </p>
<h2>COVID-19 not the only factor</h2>
<p>As the world continues to recover from the effects of a pandemic, it would be easy to blame the increase in maternal deaths directly on COVID-19 infection. Coronavirus may be part of the reason, but it is not the full picture. When the women who died directly from COVID-19 are not included in statistics, the UK maternal mortality rates are <a href="https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022">still higher</a> than they were before the pandemic. This suggests there are larger issues with maternity care and the wider health system. </p>
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<p>During pregnancy the immune system changes to protect the growing baby. This means that pregnant women are at higher risk from some infections than those who are not pregnant. Large <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2779182">multi-country studies</a> have shown that women who get COVID-19 are more likely to need intensive care if they are pregnant or recently pregnant. </p>
<p><a href="https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022">In the UK from 2020 to 2022</a>, COVID-19 was responsible for 14% of maternal deaths. This did not have to be the case. Studies clearly show that the <a href="https://jamanetwork.com/journals/jama/fullarticle/2790608">COVID-19 vaccine is safe in pregnancy</a> – but many pregnant women are still hesitant to get vaccinated. </p>
<h2>Pregnancy and inequality</h2>
<p>Being pregnant or recently pregnant <a href="https://www.npeu.ox.ac.uk/news/2188-new-report-highlights-persistent-inequalities-and-continued-inequitable-care-for-pregnant-women">leads to inequitable care</a>. Pregnant women are often <a href="https://www.bmj.com/content/380/bmj-2022-071278">excluded from medical research</a>. This means that they do not have the evidence necessary to make informed choices about their health and the health of their baby. It also means that the people caring for pregnant women do not feel prepared to offer advice or treatment. <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2023/MBRRACE-UK_Maternal_Compiled_Report_2023.pdf">Enquires into the care of pregnant women with COVID-19</a> showed that many were denied treatments known to be effective just because they were pregnant.</p>
<p>Inequalities are even greater when a pregnant woman belongs to an ethnic minority or socio-economically disadvantaged group. Black women and women living in the 20% most deprived areas of the UK have <a href="https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022">unjustly high maternal mortality rates</a>. This is <a href="https://www.bmj.com/content/379/bmj-2022-070621">not a problem unique to the UK</a>. Nor is this a new problem. The problems faced by minority groups when accessing healthcare are <a href="https://www.birthrights.org.uk/campaigns-research/racial-injustice/">well known</a> and widespread. They were also made worse by the COVID-19 pandemic. </p>
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<p>The pandemic placed unprecedented stress on health care systems all over the world. It created new strains due to increased demand for services, staff shortages and <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00088-2/fulltext">burnout</a>. It also revealed cracks in established services and changed the way that care was provided.</p>
<p>Maternity care was not immune to pressures of the pandemic. Most women who die in high-income countries are <a href="https://www.bmj.com/content/379/bmj-2022-070621">not dying from pregnancy complications</a> such as bleeding. However, rates for these direct deaths are <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2023/MBRRACE-UK_Maternal_Compiled_Report_2023.pdf">rising in the UK</a>. Pregnancy complications can be managed if women have timely access to quality care and skilled health professionals. It is becoming increasingly clear that this may not always be the case in current under-pressure health systems. </p>
<h2>Overstretched health system</h2>
<p>In the era of COVID-19, services that should be easily available to women are becoming increasingly difficult to access. The current maternity population is more complex than it once was. Women giving birth are often older and many are overweight or obese. Many women also have other medical or mental health conditions that require additional care in pregnancy. From <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2023/MBRRACE-UK_Maternal_Compiled_Report_2023.pdf">2019 to 2021</a> 12% of the women who died in the UK had severe and multiple disadvantages including a mental health diagnoses, substance use or domestic abuse. </p>
<p>The changing maternal population needs enhanced services that can adjust to fit their individual needs. But access to specialised care was irregular or lost during the pandemic. This is especially true for care before or after pregnancy. Many women do not get the care they need before conceiving and many more are falling through the cracks after they have their baby. Mental health conditions are an important example of this. Almost half of maternal deaths in the year after pregnancy are due to <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2023/MBRRACE-UK_Maternal_Compiled_Report_2023.pdf">suicide or substance use</a>. Access to maternal mental health services is improving but more capacity is still needed. </p>
<p>The pandemic exposed and accelerated the cracks in health systems, and, as these latest figures show, this has set back progress towards safer pregnancy in the UK by decades. As a barometer of a nation’s health, this is a statistic we cannot ignore. Novel approaches and investment are needed to ensure every woman gets the individualised and equitable care they need before, during and after pregnancy.</p><img src="https://counter.theconversation.com/content/221351/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marian Knight receives funding from the Healthcare Quality Improvement Partnership and the National Institute for Health and Care Research. </span></em></p><p class="fine-print"><em><span>Allison Felker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Maternal mortality in the UK is the highest for decades - as a barometer for a nation’s health, this is a statistic we cannot ignoreAllison Felker, Senior Researcher - MBRRACE-UK, University of OxfordMarian Knight, Professor of Maternal and Child Population Health, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2119912023-08-31T16:38:29Z2023-08-31T16:38:29ZZuranolone for postpartum depression: Hope, hype or both?<figure><img src="https://images.theconversation.com/files/545577/original/file-20230830-29-opoz13.jpg?ixlib=rb-1.1.0&rect=343%2C49%2C3084%2C2103&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While zuranolone represents an exciting advance in the treatment of postpartum depression, many questions about its potential impact remain unanswered. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/zuranolone-for-postpartum-depression-hope-hype-or-both" width="100%" height="400"></iframe>
<p>While mothers with <a href="https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/postpartum-depression">postpartum depression</a> have always faced barriers accessing the care they need, things have been particularly bad since the onset of the COVID-19 pandemic. </p>
<p>Prior to COVID-19, it was thought that up to <a href="https://www.ncbi.nlm.nih.gov/books/NBK37740/">one in five</a> women would develop depression in the first postpartum year, but the stresses and service disruptions associated with the pandemic increased this to <a href="https://doi.org/10.1016/S2215-0366(21)00074-2">one in three</a>. However, the pandemic also coincided with a period of significant innovation in treatment that may increase access to and effectiveness of care.</p>
<h2>Medications specifically for PPD</h2>
<p>One exciting development was the United States Food and Drug Administration’s approval of the medication brexanolone in <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-post-partum-depression">early 2019</a>. It represented the first of an entirely new class of medicines for postpardum depression (PPD), which target the steep decrease in hormones after delivery. Brexanolone is a synthetic version of allopregnanolone, a naturally occurring substance made from progesterone, that helps the brain regulate stress. </p>
<p>Its approval in the U.S. was especially notable for two reasons: it was the first medicine approved specifically for the treatment of PPD, and it takes effect especially quickly — within 60 hours. </p>
<p>While it represents a significant breakthrough, it must be given intravenously in hospital over 2½ days, and <a href="https://www.cbc.ca/news/health/zulresso-postpartum-depression-1.5064086">can cost as much as USD$34,000</a> per course.</p>
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<img alt="Out-of-focus image of exhausted woman sitting on the floor beside a crib" src="https://images.theconversation.com/files/545573/original/file-20230830-27-ye7dqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545573/original/file-20230830-27-ye7dqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545573/original/file-20230830-27-ye7dqi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545573/original/file-20230830-27-ye7dqi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545573/original/file-20230830-27-ye7dqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545573/original/file-20230830-27-ye7dqi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545573/original/file-20230830-27-ye7dqi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">During the pandemic, as many as one in three new mothers may have experience postpartum depression.</span>
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<p>On Aug. 4, the U.S. FDA <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression">approved zuranolone</a>, another allopregnanolone derivative. Unlike brexanolone, zuranolone can be taken in pill form over two weeks, which is much shorter than traditional antidepressants which are usually prescribed for several months. </p>
<p>Early studies of zuranolone suggest PPD symptom improvement can be observed <a href="https://doi.org/10.1001/jamapsychiatry.2021.1559">as early as three days</a> after starting the treatment. This is an unusually rapid response to an antidepressant medication, which usually <a href="https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/antidepressant-medications">take effect over several weeks</a>. </p>
<h2>Behind the hype</h2>
<p>The <a href="https://www.vogue.com/article/zuranolone-postpartum-depression-explainer">fanfare</a> that <a href="https://www.cbc.ca/radio/thecurrent/postpartum-depression-pill-zuranolone-offers-hope-1.6935868">has accompanied</a> these <a href="https://www.cnn.com/2019/03/19/health/postpartum-depression-drug-fda-bn/index.html">medications</a> also has the potential to increase awareness of PPD, suggesting a biological explanation for a condition associated with <a href="https://doi.org/10.1080/02646838.2020.1754372">so much self-blame</a>, encouraging more people to seek treatment and increasing screening and detection efforts among health-care providers. </p>
<p>If approved in Canada, it would also add to the array of effective treatments that already exist. These include evidence-based talking therapies like cognitive behavioural therapy and interpersonal psychotherapy, which are <a href="https://journals.sagepub.com/doi/epub/10.1177/0706743716659276">first-line treatments</a> for mild to moderate PPD. </p>
<p>Antidepressant medications like the <a href="https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/ssri-antidepressants/overview/">selective serotonin re-uptake inhibitors</a> (SSRIS, such as sertraline and escitalopram) are also widely available and usually recommended as second-line therapies for most individuals with PPD. </p>
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<span class="caption">The fanfare surrounding new medications for zuranolone also has the potential to increase awareness of PPD.</span>
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<p>Although psychotherapy and antidepressants can help most individuals with PPD, timely access to talking therapies is relatively rare within publicly funded health-care systems, and many <a href="https://doi.org/10.1111/j.1523-536X.2006.00130.x">prefer to avoid</a> antidepressant medications during pregnancy and lactation if they can.</p>
<p>While zuranolone represents an exciting advance, many questions about its potential impact remain unanswered. </p>
<p>To date, just <a href="https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.20220785">two clinical trials</a> <a href="https://doi.org/10.1001/jamapsychiatry.2021.1559">in humans exist</a>, and eligibility for these studies was restricted to a very small subset of those with PPD. Only individuals with more severe depression that emerged between the third trimester of pregnancy and four weeks post-delivery could be enrolled. </p>
<p>Researchers also only studied zuranolone’s effects over six weeks, and no information on its safety during pregnancy and lactation is available (participants had to agree to stop breastfeeding while taking the medication). </p>
<p>Despite the excitement surrounding its U.S. approval, the cost of zuranolone is likely to be high, and it is not known if it will be approved in Canada. Finally, it is unclear if this medication will be covered by public or private insurers, which could put it out of reach for many with PPD who could need it the most. </p>
<h2>PPD is still underdiagnosed</h2>
<p>The development of innovative new medications is exciting and can generate significant hope for those affected. However, it is important in this case that we not lose sight of the fact that PPD is a <a href="https://doi.org/10.1017/S1092852914000510">vastly underdetected and undertreated problem</a> for which safe and effective treatments already exist. </p>
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<img alt="Two women pushing strollers in park, seen from behind" src="https://images.theconversation.com/files/545575/original/file-20230830-24-3j5cxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545575/original/file-20230830-24-3j5cxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545575/original/file-20230830-24-3j5cxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545575/original/file-20230830-24-3j5cxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545575/original/file-20230830-24-3j5cxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545575/original/file-20230830-24-3j5cxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545575/original/file-20230830-24-3j5cxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Inexpensive self-care interventions like improving social and practical supports, sleep hygiene, relaxation techniques, exercise and taking time for oneself can also be helpful.</span>
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<p>Free screening tools such as the <a href="http://www.perinatalservicesbc.ca/Documents/Resources/HealthPromotion/EPDS/EPDSQuestionnaireApril2013.pdf">Edinburgh Postnatal Depression Scale</a> can be used to help detect PPD, and psychotherapy along with several existing antidepressants <a href="https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/postpartum-depression">can be effective and safe</a> during pregnancy and lactation.</p>
<p>Inexpensive <a href="https://www.canada.ca/en/public-health/services/child-infant-health/postpartum-health-guide.html#a1.6">self-care interventions</a> like improving social and practical supports, sleep hygiene, relaxation techniques, exercise and taking time for oneself can also be helpful, but can be challenging to engage in with a newborn. </p>
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Read more:
<a href="https://theconversation.com/heart-rate-variability-and-self-compassion-two-tools-to-help-postpartum-mothers-make-exercise-decisions-193548">Heart rate variability and self-compassion: Two tools to help postpartum mothers make exercise decisions</a>
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<p>Although provincially funded psychotherapy can be difficult to access, research and <a href="https://www.stcatharinesstandard.ca/life/health-wellness/mothers-experiencing-postpartum-depression-aided-by-online-therapy-delivered-by-niagara-public-health-nurses/article_238ee7dd-6b7b-5165-b6e7-1b80cdcc252a.html">efforts to apply findings</a> are starting to bring together the fragmented network of community organizations and traditional and public health services to try to increase access in Canada. </p>
<p>Research into treatments for PPD and the federal government’s actions in appointing a <a href="https://www.pm.gc.ca/en/mandate-letters/2021/12/16/minister-mental-health-and-addictions-and-associate-minister-health">Minister of Mental Health and Addictions</a> and prioritizing perinatal parents are also cause for genuine optimism. </p>
<p>While zuranolone is raising awareness about PPD, it’s important to <a href="https://www.ourcommons.ca/Content/Committee/441/FEWO/Brief/BR11978299/br-external/VanLieshoutRyan-Brief-e.pdf">highlight the need</a> to develop national quality standards and Canadian-specific stepped-care models and care pathways. That would enable people to access existing treatments in a more timely manner, which would go a long way in helping Canada become the best country in the world to have a baby.</p><img src="https://counter.theconversation.com/content/211991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ryan Van Lieshout receives funding from The Canada Research Chairs Program, The Canadian Institutes of Health Research, and The Daymark Foundation. </span></em></p>Amid the fanfare about a new medication for postpartum depression, it’s important to remember that PPD is underdiagnosed and undertreated, and that safe and effective treatments already exist.Ryan Van Lieshout, Canada Research Chair in Perinatal Mental Health, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2073602023-08-29T15:34:41Z2023-08-29T15:34:41ZWhen being a new mum feels overwhelming, here’s some expert advice on what you need to know<figure><img src="https://images.theconversation.com/files/542176/original/file-20230810-11401-f0k38u.jpg?ixlib=rb-1.1.0&rect=11%2C15%2C2544%2C1686&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Being a new mother can take a lot of adjustment. </span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/parents-looking-at-their-baby-3584088/">pexels?nappy</a></span></figcaption></figure><p>We are sold the idea that becoming a new mother is the <a href="https://psycnet.apa.org/record/2016-38769-001">happiest time of your life</a>. But for many women, the reality doesn’t fit that perfect picture. Yes, they may love their baby very much but the broader impact of having a baby and becoming a mother can feel far more complex. </p>
<p>Research shows that when we look at happiness over our lifetime, the year after having a baby can be one of our <a href="https://psycnet.apa.org/record/2013-15090-008">lowest points</a>. It’s not about our relationship with our baby but rather the other parts of our lives that have changed so much. Social media hasn’t helped any of this. We are all tempted to just share the best bits, thinking we need to hide our feelings because we think <a href="https://psycnet.apa.org/record/2018-45585-002">everyone else is so happy</a>. But speaking out helps everyone. </p>
<p><a href="https://www.independent.co.uk/news/health/negative-thoughts-new-parents-baby-pregnant-children-parenting-b694300.html">It’s normal</a> to experience some challenging emotions when you become a new parent. You might not immediately bond with your baby, wondering why that flash of love didn’t appear. You might grieve for your old life and identity. You might feel trapped, wanting to escape yet at the same time feeling you can’t leave your baby. </p>
<p>Worries about not being “good enough” for your baby are also common. But honestly, you don’t need to get it right all the time. You are more than enough for your baby. None of these very normal reactions to change mean that you don’t love your baby.</p>
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<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
<p><em>You may be interested in:</em></p>
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<p><em><a href="https://theconversation.com/five-old-contraception-methods-that-show-why-the-pill-was-a-medical-breakthrough-207572">Five old contraception methods that show why the pill was a medical breakthrough
</a></em></p>
<p><em><a href="https://theconversation.com/the-orgasm-gap-and-why-women-climax-less-than-men-208614">The orgasm gap and why women climax less than men</a></em></p>
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<p>But knowing when these are normal feelings and when you might need support is important. At least <a href="https://maternalmentalhealthalliance.org/about/perinatal-mental-health/">one in five</a> new mothers will experience a mental health issue after birth. Though this is likely an underestimation because many hide these feelings. But hiding them just prevents you from getting the support you need. So here are some signs to look out for:</p>
<p><strong>Postnatal depression:</strong> <a href="https://www.mind.org.uk/information-support/types-of-mental-health-problems/postnatal-depression-and-perinatal-mental-health/postnatal-and-antenatal-depression/">Depression</a> isn’t simply feelings of sadness. In fact, anxiety, about something specific or a general feeling of dread is common. You might lose pleasure in doing things, feel hopeless about the future, or feel very low about yourself. </p>
<p><strong>Anxiety and intrusive thoughts:</strong> We all have moments where we imagine ourselves dropping our baby. Sometimes however these thoughts become <a href="https://www.verywellfamily.com/overcoming-postpartum-ocd-and-intrusive-thoughts-5187982">repetitive, frequent</a> and we can’t make them go away. You might find yourself <a href="https://www.mind.org.uk/information-support/types-of-mental-health-problems/postnatal-depression-and-perinatal-mental-health/perinatal-anxiety/">unable to sleep</a> or waking too early. You might feel restless, overwhelmed in public or feel shaky. </p>
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<img alt="Woman lying in bed with baby." src="https://images.theconversation.com/files/542180/original/file-20230810-12281-ellk87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542180/original/file-20230810-12281-ellk87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542180/original/file-20230810-12281-ellk87.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542180/original/file-20230810-12281-ellk87.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542180/original/file-20230810-12281-ellk87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542180/original/file-20230810-12281-ellk87.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542180/original/file-20230810-12281-ellk87.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">It’s normal for life to seem radically altered and to feel a loss of identity.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/a-woman-resting-on-the-bed-with-her-baby-on-top-6849528/">pexels rdne stock project</a></span>
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<p><strong>Postnatal rage:</strong> We often don’t talk about rage when it comes to mothers but it’s <a href="https://www.irishtimes.com/life-and-style/health-family/i-was-a-charging-brutal-half-animal-the-ugly-truth-about-postnatal-rage-1.2950662">more common</a> that you think. You might find yourself feeling on edge or irritable and then snap when something small goes wrong. Hormonal fluctuations and a lack of sleep might exacerbate this but more often it’s a reaction to feeling overwhelmed, powerless and unsupported. </p>
<p><strong>Birth or breastfeeding trauma:</strong> Many women have some difficult memories of birth but sometimes, even if you are able to talk them over with friends afterwards, <a href="https://www.youtube.com/watch?v=A43qlYkSMyU">these don’t go away</a>. You might find yourself having flashbacks, feel unable to go near the hospital or anything that reminds you of the birth, or feel very angry about your experience, or blame yourself. </p>
<p>Your sleep or appetite might be affected, or you might feel very jumpy or on edge. Sometimes these feelings are linked to physical events during the birth, but often they’re more about how you felt or were treated.</p>
<p>Increasingly similar feelings of trauma or grief are being recognised around <a href="https://welldoing.org/article/why-breastfeeding-grief-trauma-matter">infant feeding experiences</a>. If you experienced breastfeeding difficulties or had to stop before you were ready, you might be feeling guilt, anger or loss about that, despite your baby thriving. </p>
<h2>Getting support</h2>
<p>If you’re feeling overwhelmed by the emotions you are experiencing or find your sleep, energy or appetite is affected, here are some things to try:</p>
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<span class="caption">Don’t suffer in silence, get as much support and help as you can.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/young-working-mother-cuddling-baby-and-using-laptop-at-home-7282818/">Pexels/sarah chai</a></span>
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<p><strong>Talk to friends:</strong> Sometimes just sharing how we feel and realising that others feel this way can help us realise we are not alone </p>
<p><strong>Discuss with your health visitor or GP:</strong> They can help you understand how you are feeling and discuss different treatments such as counselling and medication</p>
<p><strong>Contact one of the many organisations that can help:</strong> The <a href="https://maternalmentalhealthalliance.org/resources/mums-and-families/">Maternal Mental Health Alliance</a> has a list of contacts. You can talk through difficult infant feeding experiences with a <a href="https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/breastfeeding/help-and-support/">breastfeeding charity</a>. Many doulas (a person who can support you through pregnancy, labour and birth) also offer help to explore <a href="https://doula.org.uk">how you are feeling</a> about your birth and caring for your baby. </p>
<p><strong>Focus on looking after yourself, too:</strong> Your diet, activity levels and time outdoors can all affect how you feel. Do not be afraid to ask others for help or to use sources such as childcare to get some time for you to be able to do this. Explain to them how you feel and what you need. </p>
<p><strong>Creativity is good:</strong> The <a href="https://www.maternaljournal.org/">Maternal Journal</a> project holds in-person and online group sessions supporting you to explore how art can help, while also caring for your baby. </p>
<p><strong>Try baby massage:</strong> It can help you to slow down and connect with your baby. And it can help increase <a href="https://pubmed.ncbi.nlm.nih.gov/11246096/">oxytocin levels</a> in you both, calming your system.</p>
<p><strong>Explore some grounding techniques:</strong> <a href="https://www.healthline.com/health/grounding-techniques#physical-techniques">These can help you</a> to manage your anxiety. When you feel symptoms of anxiety, look for things in the environment around you. Try and find five things that are blue. Or five things that are soft. Count them and say them out loud. </p>
<p>Most of all remember that none of these feelings are anything to do with how much you love your baby or how well you care for them. Often mothers experiencing mental health difficulties are highly attuned to their baby’s needs because they are so worried about not getting it right. Your baby will be fine, but it’s important that you are too.</p><img src="https://counter.theconversation.com/content/207360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Brown has received funding from the ESRC, MRC, NIHR, HEFCW, UKRI, Infant feeding charities and Public Health Wales. She is a trustee for First Steps Nutrition Trust.</span></em></p>New motherhood is often portrayed as a time of joy but it can also be filled with fears and complicated feelings. Here’s how you can get help and support.Amy Brown, Professor of Child Public Health, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2102532023-08-18T12:38:57Z2023-08-18T12:38:57ZRisk of death related to pregnancy and childbirth more than doubled between 1999 and 2019 in the US, new study finds<figure><img src="https://images.theconversation.com/files/542870/original/file-20230815-17-eor4q4.jpg?ixlib=rb-1.1.0&rect=6%2C20%2C4454%2C3845&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maternal death rates are higher in the U.S. than in other high-income countries.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pregnant-woman-holding-teddy-bear-against-stomach-royalty-free-image/73448795?phrase=death+pregnancy&adppopup=true">Tetra Images/Getty Images</a></span></figcaption></figure><p>Black women were more likely to die during pregnancy or soon after in every year from 1999 through 2019, compared with Hispanic, American Indian and Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and white women. That is a <a href="https://doi.org/10.1001/jama.2023.9043">key finding of our recent study</a> published in the Journal of the American Medical Association. The risk of maternal death increased the most for American Indian and Alaska Native women during that time frame. </p>
<p>Maternal deaths refers to death from any cause except for accidents, homicides and suicides, during or within one year after pregnancy. </p>
<p>Notably, maternal mortality rates more than doubled for every racial and ethnic group from 1999 through 2019. Most maternal deaths are considered preventable because, in the U.S., maternal deaths are most often caused by <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief.html">problems that have very effective treatments</a>, including bleeding after delivery, heart disease, high blood pressure, blood clots and infections.</p>
<p>Previous research has focused on <a href="https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer">high rates of maternal mortality in the Southern U.S.</a>, but our results showed that there are high-risk populations throughout the country. </p>
<p>For Black women in 2019, the states with the highest maternal mortality ratios – meaning the proportion of maternal deaths per 100,000 live births – were Arizona, New Jersey, New York and Georgia, along with the District of Columbia. Each had a maternal mortality ratio greater than 100 for Black women. In comparison, the national maternal mortality ratio for all women in the U.S. was 32.1 in 2019. </p>
<p>Among American Indian and Alaska Native women, the states with the largest increases in maternal mortality between the first half of the time period (1999-2009) and the second half (2010-2019) were Florida, Kansas, Illinois, Rhode Island and Wisconsin. In each of these states, risk of maternal death increased by more than 162%. Across the whole U.S., maternal mortality for American Indian and Alaska Native women was higher in 2019 than in all other years. Some individuals other than women, including girls, transgender men and people who identify as nonbinary, are also at risk of maternal death.</p>
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<h2>Why it matters</h2>
<p>In order to prevent maternal deaths in the U.S., it’s crucial to understand who is most at risk. Prior to our study, estimates of maternal mortality for racial and ethnic groups within every state had never been released. </p>
<p>The U.S. has a high rate of maternal mortality <a href="https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer">compared to other high-income countries</a>, despite <a href="https://doi.org/10.1377/hlthaff.23.3.10">spending more per person on health care</a>. Disparities in maternal mortality have persisted for many decades. </p>
<p>Because <a href="https://theconversation.com/more-than-4-in-5-pregnancy-related-deaths-are-preventable-in-the-us-and-mental-health-is-the-leading-cause-193909">most maternal deaths are preventable</a>, interventions have the potential to make a significant difference. Better prevention of <a href="https://theconversation.com/us-preterm-birth-and-maternal-mortality-rates-are-alarmingly-high-outpacing-those-in-all-other-high-income-countries-203745">related events, such as preterm birth</a>, is also necessary. We hope that our research continues to help policymakers and health care leaders put solutions in place to better prevent these deaths from happening. </p>
<p>Recently, U.S. Democratic Senators <a href="https://www.booker.senate.gov/news/press/booker-menendez-cosponsor-reintroduction-of-legislation-to-lower-death-rates-for-women-of-color-following-alarming-study-that-found-maternal-mortality-doubled-in-the-us">Cory Booker and Bob Menendez of New Jersey</a>, <a href="https://www.warnock.senate.gov/newsroom/press-releases/following-alarming-study-that-maternal-mortality-doubled-in-the-u-s-senators-reverend-warnock-padilla-reintroduce-legislation-to-lower-death-rates-for-women-of-color/">Raphael Warnock of Georgia, and Alex Padilla of California</a> reintroduced the <a href="https://www.congress.gov/bill/117th-congress/house-bill/1212">Kira Johnson Act</a> to improve maternal health outcomes for racial and ethnic minority groups and other underserved populations, citing our study. </p>
<h2>What’s next</h2>
<p>We would like to investigate how the most common causes of maternal death, such as blood clots, high blood pressure and mental health issues, are contributing to the overall estimates. </p>
<p>Understanding these trends will help clinicians and policymakers tailor solutions to be as effective as possible. </p>
<p>Our study did not include data from the pandemic years. So far, maternal mortality has only been reported at the national level for those years, but reports suggest that maternal mortality rates have increased since the start of the COVID-19 pandemic and that <a href="https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.pdf">racial disparities have only gotten worse</a>.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p><img src="https://counter.theconversation.com/content/210253/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Fleszar receives funding from Gates Ventures, LLC. </span></em></p><p class="fine-print"><em><span>Allison Bryant Mantha receives funding from Gates Ventures, LLC.</span></em></p><p class="fine-print"><em><span>Catherine O. Johnson receives funding from the National Heart, Lung, and Blood Institute and Gates Ventures, LLC.</span></em></p><p class="fine-print"><em><span>Greg Roth receives funding from the National Heart, Lung, and Blood Institute and Gates Ventures, LLC.</span></em></p>Black women died during or soon after pregnancy at higher rates than any other racial group in every year from 1999 to 2019. American Indian and Alaska Native women had the greatest increase in risk during this period.Laura Fleszar, Public Health Researcher at the Institute for Health Metrics and Evaluation, University of WashingtonAllison Bryant Mantha, Associate Professor of Obstetrics, Gynecology and Reproductive Biology , Harvard UniversityCatherine O. Johnson, Research Scientist in Public Health, University of WashingtonGreg Roth, Associate Professor of Medicine and Adjunct Associate Professor of Health Metrics Sciences, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2105922023-08-16T15:14:18Z2023-08-16T15:14:18ZNigerian women ensure they get the best possible healthcare by managing unequal power relations with men<figure><img src="https://images.theconversation.com/files/541539/original/file-20230807-31794-nxav4q.jpg?ixlib=rb-1.1.0&rect=9%2C0%2C6221%2C4147&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rural women in Nigeria negotiate healthcare decisions with their partners. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/cameroonian-refugee-couple-that-ran-away-with-dozens-of-news-photo/1239282860?adppopup=true">Kola Sulaimon/AFP via Getty Images</a></span></figcaption></figure><p>Nigeria is a patriarchal society. Authority is vested in men, who tend to exert power and control over women in various spheres of life. This has an impact on women’s health and decisions about their healthcare.</p>
<p>Women’s health is affected not only by medical conditions and childbearing, but also by cultural behaviour and traditions. Social factors such as gendered access to healthcare or employment also affect people’s capacity to lead healthy lives. </p>
<p>The Nigerian feminist scholar Obioma Nnaemeka has described feminism in an African context as a matter of <a href="https://doi.org/10.1086/378553">negotiation</a> and compromise. She calls it “negofeminism”. It involves “give and take” instead of confrontational exchanges. </p>
<p>This concept helped me, as a <a href="https://www.researchgate.net/profile/Ogochukwu-Udenigwe">global health researcher</a>, to understand what rural Nigerian women said about seeking healthcare during and after pregnancy. </p>
<p>For our <a href="https://doi.org/10.1186/s12978-023-01647-3">study</a>, my colleagues and I interviewed women and their spouses in two rural communities in southern Nigeria. </p>
<p>Our findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism’s concepts of alliance, community and connectedness were highlighted through men’s constructive involvement in maternal health.</p>
<p>We found women were not passive victims. Instead, they navigated patriarchal environments to yield the best possible maternal health outcomes by gaining control of their healthcare decisions.</p>
<p>Recognising this form of agency can help in formulating policies and programmes that acknowledge how women’s wider social environments influence their health. </p>
<h2>Maternal health in Nigeria</h2>
<p>In Nigeria, limited access to quality healthcare contributes to <a href="https://dhsprogram.com/pubs/pdf/FR359/FR359.pdf#page=411">556 pregnancy-related deaths per 100,000 live births.</a>. UNICEF reports that Nigeria contributes <a href="https://www.unicef.org/nigeria/situation-women-and-children-nigeria">10% of the global pregnancy-related death burden</a>.</p>
<p>Some scholars have argued that women are only able to seek healthcare if they <a href="https://doi.org/10.1177/0162243917736139">can make independent decisions</a>. But this approach often ignores <a href="http://dx.doi.org/10.1136/bmjgh-2020-003808">women’s realities</a>, such as the fact that their social network (mothers, grandmothers, spouses and community members) influences their use of healthcare services. </p>
<p>Nevertheless, as <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-023-01647-3">our study</a> shows, social dimensions don’t necessarily impede women’s autonomy.</p>
<p>Therefore, I believe that discussions of maternal health in an African context need to consider women’s experiences of being “African” and “women”. </p>
<h2>The study</h2>
<p>We <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-023-01647-3">studied</a> two predominantly rural communities in Esan South-East and Etsako West, local government areas of Edo State in southern Nigeria. We conducted five women-only focus group discussions with a total of 39 women, and three men-only focus group discussions with 25 men. Participants were chosen from a database of women participating in maternal health interventions.</p>
<p>We asked them who women first consulted for pregnancy care, and who made the decisions about seeking maternal healthcare. We also asked about their experiences of men’s involvement in maternal and child health.</p>
<p>We categorised their responses as negotiation, collaboration and manoeuvring. </p>
<p>It appeared that men were considered the decision-makers at the household level. Participants said a woman’s spouse should be the first to know of her pregnancy. Both men and women said men should make all the decisions about healthcare during pregnancy, even though it was clear that women sometimes influenced decisions.</p>
<p>Describing her experience, one woman said: </p>
<blockquote>
<p>In the aspect of care, I will tell my husband, so he will decide. After my husband knows, I will go to the hospital to tell the doctor so he can tell me what to do. </p>
</blockquote>
<p>Similarly, men noted that women “cannot just go to healthcare facilities without the husband’s decision”. </p>
<p>But they also made comments like:</p>
<blockquote>
<p>My wife will tell me, ‘take me to go and see the nurse’. When I am not around, she can go see the doctor on her own. It is a normal thing in our community.</p>
</blockquote>
<p>Both men and women said it was important to get skilled care, especially for complications.</p>
<p>The act of the women telling the men can be thought of as a form of negotiation by women to influence decisions on access to maternal healthcare. First, she recognises the patriarchal environment and assigns the decision-making authority to men. But she is also using her agency in that environment.</p>
<p>Notions of men’s responsibility and collective action on maternal health were evident in the study. In these communities, men’s duties as expectant fathers were mainly of financial support to cover costs associated with pregnancy, including clinic visits, cost of delivery, essential medicines and feeding. </p>
<p>It can be argued that in ascribing decision-making authority to men, women benefit from men’s duty and responsibility to be providers. Women said they could not afford the high cost of maternal healthcare on their own. There was “give and take”.</p>
<p>Some women showed their resistance to men’s involvement in their pregnancy. They reported secretly seeking maternal healthcare without informing their partners. In this they were indicating control over their lives. </p>
<h2>Why this matters</h2>
<p>Our findings show that it’s important to involve women’s communities and spouses in maternal health programmes. </p>
<p>We show that patriarchy affords men power over decision-making or financial resources. Women are not passive in these situations, they actively find ways around it to ensure they have access to skilled healthcare during pregnancy.</p>
<p>This study shows that maternal health is not always an individual responsibility – it can be one for the woman’s community and the nation. Ignoring this can undermine programmes and policies aimed at improving women’s health.</p><img src="https://counter.theconversation.com/content/210592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ogochukwu Udenigwe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rural women in Nigeria circumvent patriarchy to make decisions on their healthcare.Ogochukwu Udenigwe, Doctoral Candidate, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2096242023-08-14T15:06:12Z2023-08-14T15:06:12ZTelemedicine can help women get early abortions safely: South African study<figure><img src="https://images.theconversation.com/files/540450/original/file-20230801-29-z5grx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Telemedicine helps women avoid the stigma of abortion</span> <span class="attribution"><span class="source">Manuel Augusto Moreno</span></span></figcaption></figure><p>In South Africa, it is <a href="https://www.gov.za/sites/default/files/gcis_document/201409/act92of1996.pdf">legal</a> to have an abortion upon request until the 13th week of pregnancy. The procedure is performed by trained certified midwives or registered nurses at specific primary care clinics. However, <a href="https://www.frontiersin.org/articles/10.3389/fgwh.2023.1142638/full">social stigma</a> exists around the procedure, and there is a <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-015-0014-y">shortage</a> of services in rural areas where about <a href="https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS?locations=ZA">32% of the population live</a>. </p>
<p>Urban areas near major cities have better access to abortion services, with women in rural areas travelling <a href="https://www.jstor.org/stable/pdf/3776474.pdf?refreqid=excelsior%3Aa8c3cc229fb492b0706fabfbded05fd5&ab_segments=&origin=&initiator=&acceptTC=1">longer hours </a> to access abortion care. </p>
<p>Nonetheless, accessing these services can still be challenging. This is because there is a <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-296">shortage </a> of trained and willing abortion providers. And delays in seeking care are common.</p>
<p>Many health problems and deaths related to unsafe abortions can be prevented by providing <a href="https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(18)30404-2.pdf">comprehensive</a> safe abortion care. The introduction of medical abortion, which involves taking specific pills, has greatly improved access to early abortions. In fact, most abortions in <a href="https://srh.bmj.com/content/45/2/95.long">wealthier</a> countries are now done using these pills alone. Taking the pills at home is just as safe and effective as having the procedure done at a clinic, especially up to the 10th week of pregnancy.</p>
<p>Our recent <a href="https://www.sciencedirect.com/science/article/pii/S2667321523000252#:%7E:text=The%20results%20of%20this%20study,be%20mitigated%20for%20successful%20implementation.">study</a> examined the acceptability of implementing telemedicine (remote medical care using technology) for early medical abortion in South Africa. The goal of our study was to understand how people in South Africa felt about using telemedicine and whether it could be a viable option for expanding access to safe and legal abortion services. </p>
<p>Our findings suggest that telemedicine has the potential to improve access to safe and legal abortion services, particularly in areas where clinics may be far away or difficult to reach. Telemedicine can offer a practical alternative that respects individuals’ autonomy, privacy, and reproductive rights.</p>
<h2>Covid 19 prompted a leap in virtual healthcare</h2>
<p>Telemedicine involves using technology like phones or computers to connect patients with healthcare providers who are not physically present. In the case of early medical abortion, it allows individuals to consult with healthcare professionals, receive guidance, and obtain necessary medications without having to visit a clinic in person.</p>
<p>Telemedicine models may include testing at local clinics and different methods of delivering the medication, such as pick-up points, mail or courier delivery, or prescriptions for local pharmacies. These models can be integrated into existing healthcare facilities or operate outside of the formal health sector in countries where abortion is illegal.</p>
<p>In 1998, South Africa’s Ministry of Health recognised the benefits of integrating <a href="https://deliverypdf.ssrn.com/delivery.php?ID=764097064115114090096026108085077029057062017031026026005090097067007086028080017031101007022041026027017100030071084020006065041034005023078071014107103084098067064065078040074023088070006123003080071092090112084066030118082078087085111077124105124067&EXT=pdf&INDEX=TRUE">telemedicine </a>into their healthcare systems and took action by forming a National Telemedicine Task Team to oversee its introduction in the country’s healthcare services. Despite being a slow process with obstacles, such as technical challenges, the COVID-19 pandemic triggered <a href="https://www.sciencedirect.com/science/article/pii/S2414644722000239#sec0044">significant transformations </a>in health systems worldwide, including South Africa, with the widespread adoption of smart digital technologies supporting virtual healthcare.</p>
<p>We conducted interviews and surveys with people who had <a href="https://www.sciencedirect.com/science/article/pii/S014067362201474X?casa_token=6U1fMbs1v_AAAAAA:RuySP4rMP7Lm5ZHfceISlbSeqIhu_RB13ECJmOGiBG1vb8vjwQF_rm_sj1YDeIumKjlU_nfAywU">experienced</a> early medical abortion using telemedicine in South Africa. The study participants were diverse in terms of age, education, and background.</p>
<h2>“People tend to judge other people when it comes to abortion”</h2>
<p>Overall, our findings showed that telemedicine for early medical abortion was highly satisfactory to participants. Many appreciated the convenience, privacy, and reduced travel costs. The majority of participants felt comfortable using technology to communicate with healthcare providers, and they reported high levels of satisfaction with the telemedicine service.</p>
<p>On privacy, one of the participants said: “People tend to judge other people when it comes to abortion. So, it was easy for the individual, which is me, to communicate with the doctor without anyone knowing what is happening around me,” </p>
<p>Some others believed telemedicine protected them from the judgement they might face at clinics: “For me, it’s better to talk to someone I don’t know because I can express myself more freely. When you talk face-to-face with someone you know, you might feel awkward or judged.”</p>
<p>Importantly, we also found that telemedicine did not compromise quality of care. Participants felt that the telemedicine provided them with the necessary information, support, and medical guidance. They reported feeling well-informed, cared for, and confident in their decision-making throughout the process.</p>
<h2>Looking ahead</h2>
<p>Some of the potential barriers are the digital divide in South Africa. The availability of telemedicine services relies on access to technology and reliable internet connectivity. In some areas, especially rural and underserved communities, limited access to technology could hinder its widespread adoption. Another barrier could be effective communication. If the provider and patient do not share a common language, it can lead to misunderstandings, misdiagnoses, or inadequate medical advice. </p>
<p>Also, telemedicine platforms and resources might predominantly be available in major languages such as English, which can limit access for individuals who are more comfortable speaking other official languages like Zulu, Xhosa, or Afrikaans.
While the findings are promising, further research and consideration are needed to ensure the safe and effective implementation of telemedicine for early medical abortion in South Africa.</p><img src="https://counter.theconversation.com/content/209624/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Remote medical care gives privacy and no travel is necessary. What’s needed now is better access to technology. Language barriers also need to be broken downOluwaseyi Dolapo Somefun, Postdoctoral fellow, University of IbadanDeborah Constant, Adjunct Senior Researcher in the Division of Social and Behavioural Sciences, School of Public Health at the University of Cape Town, University of Cape TownMargit Endler, obstetrician/gynaecologist and researcher, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2037452023-08-03T12:25:11Z2023-08-03T12:25:11ZUS preterm birth and maternal mortality rates are alarmingly high, outpacing those in all other high-income countries<figure><img src="https://images.theconversation.com/files/537367/original/file-20230713-19-6sry09.jpg?ixlib=rb-1.1.0&rect=183%2C15%2C4928%2C3395&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maternal and infant health crises are growing worse in the U.S.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/black-mother-cuddling-sleeping-baby-son-on-sofa-royalty-free-image/758282421?phrase=african+american+baby+sleeping&adppopup=true">LWA/Dann Tardif/Digital Vision via Getty Images</a></span></figcaption></figure><p>Every two minutes, in about the time it takes to read a page of your favorite book or brew a cup of coffee, a woman dies during pregnancy or childbirth, according to a <a href="https://www.who.int/publications/i/item/9789240068759">February 2023 report</a> from the World Health Organization. The report reflects a shameful reality in which maternal deaths have either increased or plateaued worldwide between 2016 and 2020.</p>
<p>On top of that, of every 10 babies born, one is preterm – and every 40 seconds, <a href="https://www.who.int/news/item/09-05-2023-152-million-babies-born-preterm-in-the-last-decade">one of those babies dies</a>. Globally, preterm birth is the <a href="https://www.who.int/news-room/fact-sheets/detail/preterm-birth#">leading cause</a> of death in children under the age of 5, with complications from preterm birth resulting in the death of 1 million children under age 5 each year. </p>
<p>The WHO has designated preterm birth an “<a href="https://www.who.int/news/item/15-11-2022-who-advises-immediate-skin-to-skin-care-for-survival-of-small-and-preterm-babies">urgent public health issue</a>” in recognition of the threat it poses to global health. </p>
<p>Those numbers reflect a worldwide problem, but the U.S. in particular has an abysmal record on both preterm births and maternal mortality: Despite significant medical advancements in recent years, the U.S. suffers from the <a href="https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-graphs/">highest maternal mortality rate</a> among high-income countries globally. And the 2022 March of Dimes Report Card, an evaluation of maternal and infant health, gave the United States <a href="https://www.marchofdimes.org/peristats/reports/united-states/report-card">an extremely poor “D+” grade</a>. That data also revealed that the national preterm birth rate spiked to 10.5% in 2021, representing a record 15-year high. </p>
<p>We are maternal <a href="https://physiology.med.wayne.edu/profile/ad8024">fetal medicine experts</a> and <a href="https://womenshealth.wayne.edu/about/leadership/">scholars of women’s health</a> who focus on treatments and programs to help women have better maternal health, especially those that reduce preterm birth.</p>
<p>Our <a href="https://womenshealth.wayne.edu/">Office of Women’s Health</a> leads the <a href="https://today.wayne.edu/medicine/news/2023/07/11/wsu-leads-statewide-network-to-combat-high-rates-of-pre-term-birth-53745?wonderplugin-box-action=READ+PRESS+RELEASE">SOS Maternity Network</a>, which stands for the Synergy of Scholars in Maternal and Infant Health Equity, a research alliance of maternal fetal medicine physicians across the state of Michigan. </p>
<p>Maternal and infant death are the <a href="https://doi.org/10.1016/S2352-4642(20)30369-2">worst possible outcomes of pregnancy</a>. These numbers make clear just how crucial it is to change this trajectory and to ensure all Americans have practical access to quality reproductive health care.</p>
<h2>Dire state of maternal health care</h2>
<p>Tori Bowie, an elite Olympic athlete, <a href="https://www.npr.org/2023/06/13/1181971448/tori-bowie-an-elite-olympic-athlete-died-of-complications-from-childbirth">tragically lost her life</a> at just age 32 because of complications of pregnancy and childbirth. </p>
<p>Bowie’s story drives home the devastating state of maternal health in the U.S. Maternal mortality is a sad and unexpected ending to the often beautiful journey of pregnancy and childbirth. It means that a baby has to go without its mother’s love, care and comforting touch and at the same time the family has to mourn the sudden loss of their loved one. Unless substantial progress is made for lowering maternal deaths, the lives of over <a href="https://www.who.int/publications/i/item/9789240068759">1 million more women</a> like Bowie could be at risk by the year 2030, if current trends continue. </p>
<p>Unfortunately, the <a href="https://www.marchofdimes.org/peristats/reports/united-states/report-card">maternal and infant health crises are worsening</a> in the U.S., and this association is far from being an unfortunate coincidence. There is an important link between infant health and maternal health, as they both rely on the <a href="https://www.ajmc.com/view/us-has-highest-infant-maternal-mortality-rates-despite-the-most-health-care-spending">accessibility and quality of health care</a>. These U.S. rates have been increasing since 2018, when improved reporting of maternal deaths was adopted. </p>
<p>In 2020, the U.S. maternal mortality rate was 23.8 deaths per 100,000 live births – nearly three times as high as the country with the next-highest rate of 8.7 deaths per 100,000 live births, France.</p>
<p>The number of women who died within a year after pregnancy <a href="https://doi.org/10.1001/jama.2023.9043">more than doubled in the U.S.</a> over the 20-year period of 1999 to 2019. And there are significant racial disparities in this statistic: The highest number of pregnancy-related deaths were recorded among Black women, increasing from 26.7 per 100,000 births to 55.4 per 100,000 during that same time period. </p>
<p>Worse yet, the Centers for Disease Control and Prevention has determined that about <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">84% of such maternal deaths</a> <a href="https://theconversation.com/more-than-4-in-5-pregnancy-related-deaths-are-preventable-in-the-us-and-mental-health-is-the-leading-cause-193909">are preventable</a>.</p>
<figure>
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<figcaption><span class="caption">The U.S. maternal mortality rate for Black women is nearly three times higher than that of white women.</span></figcaption>
</figure>
<h2>Tragic rates of infant mortality and preterm birth</h2>
<p>Notably, in 2020 the U.S. also experienced the <a href="https://www.ajmc.com/view/us-has-highest-infant-maternal-mortality-rates-despite-the-most-health-care-spending">highest infant mortality rate</a> of all high-income countries. The U.S infant mortality rate was 5.4 deaths per 1,000 live births, in contrast to the 1.6 deaths per 1,000 live births in Norway, the country with the lowest infant mortality rate. </p>
<p>You may have heard the term “preemie” before, perhaps when a loved one delivered a baby more than three weeks before the expected due date. A premature birth is one that occurs before the 37th week of pregnancy. Preterm-related causes are responsible for <a href="https://www.marchofdimes.org/peristats/reports/united-states/prematurity-profile">35.8% of infant deaths in the U.S</a>. </p>
<p>Preterm babies are often not fully physiologically prepared for delivery, which can result in a range of medical complications. While preterm births lead to rising infant mortality rates, even those who survive can face health problems such as breathing difficulties, problems with feeding, significant developmental delay and more <a href="https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm#">throughout their lives</a>. Preterm birth also presents additional risks for the mother, as women who deliver preterm are at higher risk for cardiovascular complications later in life.</p>
<p>Thus, preterm birth <a href="https://doi.org/10.1002/14651858.CD007235.pub4">takes a significant toll</a> on families and their communities, with serious ramifications in medical, social, psychological and financial contexts. </p>
<h2>Maternal care during pregnancy is key</h2>
<p>Maternal care appointments and screenings are essential to prevent prenatal complications and a women’s increased risk for developing <a href="https://doi.org/10.1161/CIR.0000000000000961">long-term complications such as cardiovascular disease</a>. For that reason, patients should secure prenatal care as early as possible in the pregnancy and continue to regularly have prenatal care appointments. </p>
<p>Preterm birth can occur unexpectedly in an otherwise normal-seeming pregnancy. It looks no different from the early signs of a typical labor, except that it occurs before 37 weeks of pregnancy. The symptoms of premature labor can include contractions, unusual vaginal discharge, the feeling of pressure in the pelvic area, low dull backache or cramps in the uterus or abdomen. A person who experiences these symptoms during pregnancy should seek medical attention.</p>
<p>Some people are more predisposed to preterm birth based on individual risk factors like substance use, multiple pregnancy – such as twins – infections, race, a medical history of prior preterm delivery and heightened stress levels. Our research team and others have shown that <a href="https://doi.org/10.1080/14767058.2023.2199343">COVID-19 is a known risk factor</a> for preterm birth.</p>
<figure>
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<figcaption><span class="caption">Be aware of the risk factors for preterm birth.</span></figcaption>
</figure>
<p>It’s important to speak with your primary care provider to assess how your current health may affect future pregnancy and whether lifestyle changes – such as adopting a healthy diet and active lifestyle and avoiding smoking and drinking alcohol – can improve your likelihood of a full-term delivery.</p>
<h2>Preterm birth prevention</h2>
<p>The more that pregnant women take ownership of their health and ask their doctors to perform a simple cervical length screening during their pregnancy, the earlier preterm birth can be detected and prevented and the more lives will be saved.</p>
<p>Evidence has shown that patients with a short cervix face a greater risk of the <a href="https://doi.org/10.1002/uog.7673">cervix’s opening too early</a> in pregnancy, resulting in preterm birth and other adverse outcomes. The cervix is the lower section of the uterus, which connects to the vaginal canal. As pregnancy progresses, it stretches, softens and ultimately opens in the process of normal childbirth.</p>
<p>All patients – even those who are seemingly low risk – should ask their doctors to have their cervical length checked by transvaginal ultrasound during pregnancy between 19 and 24 weeks. A short cervical length indicates a high risk of a premature delivery. Luckily, there are treatments available, such as vaginal progesterone, which can prevent preterm birth in women found by ultrasound to have a short cervix. This treatment can <a href="https://doi.org/10.1002/uog.9017">reduce the risk of preterm birth by more than 40%</a>.</p>
<p>We are optimistic that with greater awareness of these issues and a shift in the focus to evidence-based practices coupled with increased access to vulnerable populations, the U.S. can begin to give women like Bowie and so many others the health care they and their infants deserve. </p>
<p><em>This article has been updated to highlight the most recent trends in maternal mortality that were reported on July 3, 2023, and to highlight the stark racial disparities.</em></p><img src="https://counter.theconversation.com/content/203745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sonia Hassan receives funding from Wayne State University. The Office of Women's Health receives funding from the Total Health Care Foundation and the Detroit Medical Center Foundation. </span></em></p><p class="fine-print"><em><span>Hala Ouweini does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A March of Dimes report gave the US a grade of D+ for maternal and infant health care, highlighting that the national preterm birth rate hit 10.5% in 2021, a record 15-year high.Sonia Hassan, Professor of Obstetrics and Gynecology and Maternal Fetal Medicine, Wayne State UniversityHala Ouweini, Research Associate in Women's Health, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2096072023-07-16T09:56:52Z2023-07-16T09:56:52ZAfrica’s groundbreaking women’s rights treaty turns 20 - the hits and misses of the Maputo protocol<figure><img src="https://images.theconversation.com/files/537007/original/file-20230712-25-tmsax3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's been improvements in sexual and reproductive health outcomes.</span> <span class="attribution"><span class="source">Lucian Coman/Shutterstock</span></span></figcaption></figure><p><em>2023 marks two decades since the adoption of the Maputo Protocol. The <a href="https://au.int/en/treaties/protocol-african-charter-human-and-peoples-rights-rights-women-africa">Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa</a> (the Maputo Protocol) is <a href="https://au.int/en/newsevents/20230217/african-union-gender-pre-summit-20-years-maputo-protocol">arguably</a> the most progressive legally binding instrument on women’s and human rights instruments globally. A total of 44 African countries have signed and <a href="https://www.sfcg.org/wp-content/uploads/2015/03/Maputo-Protocol-Baseline-Report.pdf">ratified</a> it. The <a href="https://au.int/sites/default/files/treaties/37077-treaty-charter_on_rights_of_women_in_africa.pdf">Maputo Protocol</a> provides for extensive and progressive women’s rights. These include the right to health and reproduction, inheritance, economic and social welfare, education and training, access to justice and equal protection before the law, and elimination of harmful practices. Reproductive health researcher Anthony Ajayi unpacks the significance of the document in women’s lives over the years.</em></p>
<hr>
<h2>What does it mean for sexual and reproductive rights?</h2>
<p>Articles 2 and 14 made specific provisions to protect the sexual and reproductive rights of women and girls.</p>
<p>Article 2 mandates member countries to enact and implement laws and other measures to curb all forms of discrimination, especially harmful practices that endanger health and general well-being. </p>
<p>Advocacy efforts to end child marriage and female genital cutting are anchored on this specific provision. Such efforts have resulted in 43 African countries now having laws that put the minimum age of marriage at 18 years old or above for both girls and boys. While some of these countries have parental consent exceptions and parallel customary marriage laws, the past ten years have seen more countries remove these exceptions. Also, <a href="https://au.int/sites/default/files/documents/42276-doc-GettingtozeroFGM-FinalWebPages-small.pdf">22 out of 29 African countries</a> practising female genital cutting now have national laws in place banning the practice.</p>
<p>Article 14 mandates member countries to ensure the right to health of women, including sexual and reproductive health. This includes the right to control fertility, decide whether to have children, the number of children and the spacing of children, and choose any method of contraception. </p>
<h2>Has it been effective?</h2>
<p>Since the inception of the Maputo Protocol, most African countries have removed <a href="https://academic.oup.com/heapol/article/30/4/432/558465">user fees</a> for maternal health services in government-owned health facilities. This has increased access to quality maternal healthcare services for marginalised women and girls. As a result, <a href="https://www.who.int/publications/i/item/9789240068759">maternal deaths</a> have declined markedly. </p>
<p>More countries have <a href="https://reproductiverights.org/sites/default/files/documents/World-Abortion-Map.pdf">broadened</a> their laws to allow access to safe abortion in cases of sexual assault, rape, incest, life-threatening fetal anomalies, and when a pregnancy endangers the woman’s mental and physical health or her life. Between 2000 and 2021, 22 African countries expanded their legal grounds for abortion. Six – Cape Verde, South Africa, Tunisia, Mozambique, São Tomé and Príncipe (up to 10 weeks of gestation in Angola) – permit abortion at the woman’s request during the first trimester of pregnancy. More countries have developed and launched post-abortion care guidelines to expand access for women and girls.</p>
<p>The success of the Maputo Protocol in protecting and guaranteeing the rights of women and eliminating discrimination is quite remarkable. Where the rights of women and girls are violated, the Maputo Protocol has become an instrument for seeking legal redress and a tool for seeking accountability. It was referenced in these examples:</p>
<ul>
<li><p>A court ruling in December 2020 found that the Kenya government <a href="https://www.equalitynow.org/news_and_insights/9_ways_maputo_protocol/">violated</a> several human rights instruments, including the Maputo Protocol, for failing to investigate and prosecute cases of sexual and gender-based violence that happened during the post-election violence of 2007. The government was ordered to pay compensation to four of the survivors, amounting to KSh 4 million (about US$40,000) each.</p></li>
<li><p>In December 2019, the ECOWAS Court of Justice found that the ban on pregnant schoolgirls going to school in Sierra Leone was discriminatory and in violation of girls’ right to education, in breach of Articles 2 and 12 of the Maputo Protocol. Since the ruling, the government of Sierra Leone has lifted the ban.</p></li>
<li><p>Article 13 and 17 of Tanzania’s Marriage Act, which set the minimum age of marriage for girls at 15 years and 18 years for boys, was challenged at the appeal court in 2019. Citing the Maputo Protocol, the court upheld the earlier ruling that marriage under the age of 18 was illegal.</p></li>
</ul>
<h2>What have its shortcomings been?</h2>
<p>Progress in realising women’s and girls’ rights remains uneven within and between countries. Eleven countries haven’t ratified the protocol. Twenty-four haven’t fulfilled their reporting obligation to the African Commission on Human and Peoples’ Rights. Consequently, <a href="https://www.oecd.org/gender/data/ensuring-strong-equitable-legal-frameworks-as-an-accelerator-for-gender-equality-in-africa.htm">discriminatory laws</a> persist. And customary, common and civil laws remain in parallel with constitutional provisions. This creates loopholes for the violation of women’s and girls’ rights. </p>
<p>For example, 11 countries (Cameroon, Seychelles, Sudan, South Africa, Burkina Faso, Gabon, Guinea-Bissau, Mali, Niger, Senegal, and Tanzania) permit girls below 18 years to marry. One member state has no minimum age for marriage. But legal reforms are happening in five of these countries.</p>
<p>There’s been improvement in sexual and reproductive health outcomes. But sexual and gender-based violence, child marriage and female genital cutting remain high in <a href="https://gh.bmj.com/content/bmjgh/5/1/e002231.full.pdf">most African</a> countries. <a href="https://www.who.int/publications/i/item/9789240068759">Maternal deaths</a> and <a href="https://unaids.org/sites/default/files/media_asset/data-book-2022_en.pdf">new HIV transmission</a> have declined. But incidences remain relatively high in several countries. </p>
<p>Young people, particularly girls, bear a <a href="https://gh.bmj.com/content/bmjgh/6/2/e004129.full.pdf">disproportionate</a> burden of poor sexual and reproductive health outcomes. This hinders their smooth transition into adulthood and affects their immediate and lifelong health (physical and mental) and socioeconomic wellbeing and empowerment.</p>
<h2>What more needs to be done?</h2>
<p>More advocacy is needed to ensure: </p>
<ul>
<li><p>the remaining 11 countries ratify the protocol</p></li>
<li><p>countries with reservations about some of the articles in the protocol need to address them </p></li>
<li><p>those who have ratified it fully domesticate and implement its provisions. </p></li>
</ul>
<p>Such advocacy should be informed by contextually relevant evidence on sexual and reproductive health, including what works in addressing harmful practices, increasing young people’s access to information and services, and reducing new HIV infections and maternal deaths. </p>
<p>The partnership between all actors working to ensure women’s health and reproductive rights are realised should be reinvigorated and sustained to make certain that gains are consolidated and not reversed. </p>
<p>Entrenching a culture of equity around sexual and reproductive rights will also require tailored engagement with community and religious leaders to build their capacity on matters of sexual and reproductive health. Sustained funding of civil society organisations working to ensure women’s rights is also key, and so is the need to bolster the women’s movement on the continent.</p>
<p><em>Juliet Kimotho, senior advocacy officer at the African Population and Health Research Center, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/209607/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Idowu Ajayi is affiliated with the African Population and Health Research Center. </span></em></p>The success of the Maputo Protocol in protecting the rights of women and eliminating discrimination is remarkable.Anthony Idowu Ajayi, Associate research scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2089382023-07-11T20:06:18Z2023-07-11T20:06:18Z‘I feel guilty for feeling like that.’ One fifth of breastfeeding women report an aversion response<figure><img src="https://images.theconversation.com/files/536213/original/file-20230707-17-qxzykq.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5572%2C3307&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pain-problems-woman-while-breastfeeding-baby-2083148689">Shutterstock</a></span></figcaption></figure><p>The benefits of breastfeeding are <a href="https://theconversation.com/why-breastfed-babies-have-improved-immune-development-new-findings-156008">widely recognised</a>, and many women find it an enjoyable and bonding experience. Women also often face challenges that can make it difficult to breastfeed, such as sore nipples or mastitis. </p>
<p>Women sometimes also experience more <a href="https://onlinelibrary.wiley.com/doi/10.1111/mcn.13536">complex breastfeeding challenges</a>, such as a <a href="https://pubmed.ncbi.nlm.nih.gov/37066597/#:%7E:text=Abstract,breastfeeding%20aversion%20response%20">breastfeeding aversion response</a> – negative feelings that last throughout the feeding session and conflict with the woman’s desire to breastfeed. </p>
<p>Women describe these feelings as overwhelming, uncontrollable and confusing. For some mothers it can <a href="https://www.sciencedirect.com/science/article/abs/pii/S1871519222000014">be visceral</a>, like “fingernails down a chalkboard”. One woman described it as “intense”:</p>
<blockquote>
<p>[…] it was both a mental and physical feeling like you want to throw your child off. You just can’t feel this feeling like you’ve got something crawling underneath your entire skin, that’s why this felt like you wanted to rip your skin off and just, you know, escape it. </p>
</blockquote>
<p>Such descriptions make it clear breastfeeding aversion response is different from <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/breastfeeding-mastitis-and-other-nipple-and-breast-problems">breastfeeding pain</a> and <a href="https://www.breastfeeding.asn.au/resources/d-mer">dysphoric milk ejection reflex</a>, which are both negative breastfeeding sensations that typically happen only during the first few minutes of the feeding session and then stop. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-do-nurse-home-visits-stop-a-few-weeks-after-giving-birth-extending-them-to-2-years-benefits-the-whole-family-194643">Why do nurse home visits stop a few weeks after giving birth? Extending them to 2 years benefits the whole family</a>
</strong>
</em>
</p>
<hr>
<h2>How I came to research breastfeeding aversion</h2>
<p>I experienced breastfeeding aversion when tandem breastfeeding my toddler and newborn. At the time I had completed a masters in public health, and read the book <a href="https://www.goodreads.com/en/book/show/49192506">Adventures in Tandem Nursing</a> by Hilary Flower, which described feelings of tandem breastfeeding aversion. <a href="https://www.breastfeeding.asn.au/resources/tandem-feeding#:%7E:text=The%20term%20'tandem%20feeding'%20is,%2C%20this%20isn't%20true.">Tandem feeding</a> is when siblings who are not twins are breastfeed, either together or at different times. </p>
<p>In 2013 I started a small <a href="https://m.facebook.com/groups/407193142696633/?ref=share&mibextid=S66gvF">online support group</a> for nursing aversion. In 2016, a <a href="https://www.sciencedirect.com/science/article/abs/pii/S0266613816000577">research study</a> described negative sensations while breastfeeding. But research about this breastfeeding challenge remains limited. </p>
<p>Our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.13536">recent study</a> of 5,511 Australian breastfeeding women, found breastfeeding aversion response may be common, and as many as one in five women reported having experienced it. Those who are more at risk are women feeding their first infant, tandem and pregnant breastfeeding mothers, and women breastfeeding around the time of ovulation and menstruation. Further research is needed to investigate if some mothers describe feeling breastfeeding aversion with their newborn as a result of other breastfeeding issues such as nipple pain.</p>
<p>Breastfeeding aversion response can negatively affect maternal identity, and some women in my research <a href="https://opus.lib.uts.edu.au/bitstream/10453/141787/2/f5ee202e-370e-4808-873f-4856e3fbf425.pdf">describe</a> feeling unsupported and isolated. </p>
<blockquote>
<p>It felt like it was something that I was doing wrong, like that it was something that was wrong with me. When I first hadn’t heard of anyone having it, then I was like, why am I experiencing this? Like, why doesn’t anybody else seem to be experiencing it? Why do people say it’s so enjoyable when I am finding it so tough?</p>
</blockquote>
<p>At this point, we don’t know what causes breastfeeding aversion response or whether it is linked to hormones, nutritional status, or evolutionary and genetic factors.</p>
<p>Women who experience breastfeeding aversion response often have difficulty finding understanding and support from others. Practical support from others can help women to continue breastfeeding, including those who are tandem feeding a toddler and newborn. </p>
<p>In our research, one woman <a href="https://www.sciencedirect.com/science/article/abs/pii/S1871519222000014">described</a> how her husband provided practical support.</p>
<blockquote>
<p>[He] would recognise what was happening and would take [child one] away and distract him with something, like ‘let’s go check a letterbox’ or ‘let’s go and feed the chickens’. While I stayed inside and fed [child two] quietly without someone hassling me for that feeding session. </p>
</blockquote>
<p>With helpful support and understanding, many women who experience breastfeeding aversion response can continue to breastfeed and go on to have an overall positive breastfeeding experience.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman breastfeeding baby and older child at the same time" src="https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536221/original/file-20230707-17-uswuw7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Those breastfeeding their first baby or tandem feeding an older child might be at greater risk.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mom-breastfeeding-her-two-sons-tandem-1324285742">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/breastfeeding-is-tough-new-research-shows-how-to-make-it-more-manageable-168432">Breastfeeding is tough: new research shows how to make it more manageable</a>
</strong>
</em>
</p>
<hr>
<h2>What helps?</h2>
<p>Some women in our research said taking a <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.13474">magnesium supplement</a> helped them continue breastfeeding. Others used personal distraction while breastfeeding, such as focusing on their phone. Setting breastfeeding boundaries with older children also helped. </p>
<p>Mothers who experience breastfeeding aversion and are supported to <a href="https://doi.org/10.1016/j.wombi.2022.01.001">continue to breastfeed</a> and achieve their personal breastfeeding goals can report an overall <a href="https://doi.org/10.1111/mcn.13536">positive breastfeeding experience</a>. </p>
<p>Many health professionals are not familiar with complex breastfeeding challenges and so those who are experiencing breastfeeding aversion may feel isolated. The <a href="https://www.breastfeeding.asn.au/">Australian Breastfeeding Association</a> or an accredited <a href="https://iblce.org/">lactation consultant</a> can provide support. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-breastfed-babies-have-improved-immune-development-new-findings-156008">Why breastfed babies have improved immune development – new findings</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/208938/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melissa Morns was the recipient of an Australian Government Research Training Program Stipend Scholarship.</span></em></p>Breastfeeding isn’t always a peaceful, bonding experience between parent and child. As many as 1 in 5 women say that they felt an intense aversion to breastfeeding.Melissa Morns, Ph.D. Candidate Public Health, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2073902023-06-21T12:30:58Z2023-06-21T12:30:58ZOne year after the fall of Roe v. Wade, abortion care has become a patchwork of confusing state laws that deepen existing inequalities<figure><img src="https://images.theconversation.com/files/532284/original/file-20230615-17-u98cyj.jpg?ixlib=rb-1.1.0&rect=22%2C0%2C4914%2C1638&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The range of reproductive health care available to women depends significantly on the state they live in.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sad-young-woman-sitting-looking-out-window-and-royalty-free-image/1132941100?phrase=abortion&adppopup=true">fizkes/iStock via Getty Images Plus</a></span></figcaption></figure><p>In the year since the <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">U.S. Supreme Court’s Dobbs v. Jackson ruling</a> <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">struck down the constitutional right to abortion</a>, society has been seeing the results of a post-Roe world. </p>
<p>While there is no law in the U.S. that regulates what a man can do with his body, the reproductive health of women is now more regulated than it has been in 50 years. And the scope of reproductive health care that women can receive is highly dependent on where they live. </p>
<p>This creates a <a href="https://doi.org/10.1177/10901981221125430">system of inequalities</a> and further exacerbates health disparities.</p>
<p>I am a <a href="https://www.uml.edu/health-sciences/nursing/faculty/collins-fantasia-heidi.aspx">nurse practitioner</a> who <a href="https://scholar.google.com/citations?user=6rrHhmUAAAAJ&hl=en">studies women’s reproductive health across the lifespan</a>. </p>
<p>My research found that college women are concerned about pregnancy, but they lack knowledge and skills about <a href="https://doi.org/10.1097/JFN.0000000000000046">navigating sexual consent</a> and often participate in <a href="https://doi.org/10.1111/j.1939-3938.2011.01108.x">sexual activity without explicit consent</a>, leaving them at risk for not using contraception and exposure to sexually transmitted infections. </p>
<p>These findings indicate that women are at risk of pregnancy at a historic time when women’s reproductive rights in the U.S. are restricted and not guaranteed. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/z4nHG4_Sqhw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A retrospective on Roe v. Wade – and a look ahead.</span></figcaption>
</figure>
<h2>Current state of abortion in the US</h2>
<p>The <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Dobbs v. Jackson ruling</a> returned decisions regarding abortion to individual states. This has led to a <a href="https://theconversation.com/in-the-year-since-the-supreme-court-overturned-roe-v-wade-and-ruled-states-should-decide-the-legality-of-abortion-voters-at-the-state-level-have-been-doing-just-that-4-essential-reads-207299">patchwork of laws</a> that <a href="https://states.guttmacher.org/policies/">span the entire range</a> from complete bans and tight restrictions to full state protection for abortion.</p>
<p>In some states, such as Texas, Louisiana and Mississippi, <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">abortion is banned</a> beginning at six weeks gestational age, when very few women even know they are pregnant. Other states, such as Massachusetts, Vermont, New York and Oregon, have enacted state-level protections for abortion. </p>
<p>The patchwork of state laws also results in a great deal of confusion. In the past year, women’s rights organizations and women’s health advocates have brought numerous <a href="https://www.kff.org/womens-health-policy/issue-brief/legal-challenges-to-state-abortion-bans-since-the-dobbs-decision/#">legal challenges to restrictive abortion laws</a>. These cases have halted the implementation of some of the strictest abortion regulations until additional court rulings are finalized. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protesters gather in a small crowd holding signs including " src="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protesters against a stricter abortion ban stand in the State House lobby on May 23, 2023, in Columbia, S.C.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AbortionSouthCarolina/a08c0479d51341e493cf4850cb1df634/photo?Query=abortion%20bans&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=2705&currentItemNo=12">AP Photo/Jeffrey Collins</a></span>
</figcaption>
</figure>
<h2>Downstream effects for health care professionals</h2>
<p>Abortion training is considered <a href="https://doi.org/10.1097/ACM.0000000000005154">essential health care and a core competency</a> for physicians in obstetrics and gynecology, or OB-GYN, residency programs. Approximately 50% of OB-GYN residency programs are located in states <a href="https://doi.org/10.1097/AOG.0000000000004832">with restricted or highly restricted access to abortion</a>. This will logically result in not only fewer health care providers being trained to perform gynecologic procedures for abortion, but also other conditions such as miscarriage, fetal death and nonviable pregnancies. </p>
<p>In states with changing abortion laws and legal challenges to new laws, <a href="https://www.ama-assn.org/delivering-care/population-care/ambiguous-anti-abortion-laws-are-putting-patients-risk">physicians are uncertain</a> of what procedures can be legally done. <a href="https://www.politico.com/news/2022/05/06/potential-abortion-bans-and-penalties-by-state-00030572">Penalties for violating abortion laws</a> may include arrest, loss of medical license, fines and discipline by state boards of medicine. </p>
<p>As a result, physicians are <a href="https://www.axios.com/2023/04/18/abortion-ban-states-drop-student-residents">choosing to leave states</a> with the <a href="https://www.npr.org/sections/health-shots/2023/05/23/1177542605/abortion-bans-drive-off-doctors-and-put-other-health-care-at-risk">most restrictive abortion laws, and clinics are closing</a>, which is contributing to the current <a href="https://www.cnn.com/2023/04/19/health/abortion-ban-affects-physician-training/index.html">shortage of health care providers</a>.</p>
<h2>Inequalities in health care access</h2>
<p>The unequal access to abortion procedures across the country is most directly affecting the poorest women in the U.S.</p>
<p>Currently, 12 states restrict abortion coverage by private insurance, and more than 30 states <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">prohibit public Medicaid payment</a> for abortion. Women who qualify for Medicaid are among the poorest in the U.S. Lack of access to abortion limits education and wage earning and <a href="https://www.npr.org/2022/08/18/1111344810/abortion-ban-states-social-safety-net-health-outcomes">contributes to poverty</a>. States with the most restrictive abortion laws also have <a href="https://www.axios.com/2022/05/20/abortion-roe-supreme-court-babies-mothers">limited access to pregnancy care</a> and <a href="https://www.usnews.com/news/politics/articles/2022-04-07/social-programs-weak-in-many-states-with-tough-abortion-laws">supportive programs</a> for pregnant and parenting women. </p>
<p>In addition, traveling to a different state to obtain an abortion is often not possible for poor women. Lack of transportation and limited financial resources reduce or eliminate options to obtain an abortion in a different geographic location. </p>
<p>What’s more, states with the most abortion restrictions have some of the <a href="https://worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state">worst pregnancy and maternal health outcomes</a> for women, especially women of color. Pregnancy itself is associated with a <a href="https://doi.org/10.1097%2FAOG.0000000000003762">risk of dying</a>. </p>
<p>Maternal morbidity is the term used to describe short- or long-term <a href="https://www.nichd.nih.gov/health/topics/maternal-morbidity-mortality">health problems that result from pregnancy</a>. Maternal mortality refers to the <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">death of women during pregnancy</a> or within the first six weeks after birth. </p>
<p>For example, Mississippi and Louisiana have the highest rates of maternal mortality in the U.S. and also <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">have the most restrictive abortion laws</a>. Black women have the <a href="https://www.ama-assn.org/print/pdf/node/66881">highest maternal mortality of all races</a> and ethnicities. Women in these states who are unable to terminate a pregnancy have a higher risk of dying as a result of the pregnancy than women in other states. </p>
<p>Additionally, research shows that a <a href="https://doi.org/10.1097/aog.0b013e31823fe923">woman’s risk of dying</a> related to pregnancy or childbirth is about 14 times higher than the risk of death from an abortion. </p>
<p>In addition to the increased risks of death, there are other <a href="https://www.ansirh.org/research/ongoing/turnaway-study">physical and mental health implications</a> associated with carrying an undesired pregnancy to term. Being denied access to abortion is associated with increased anxiety and <a href="https://www.ansirh.org/research/ongoing/turnaway-study">fewer future plans</a> for the next year. Research also shows that not being able to obtain an abortion makes women more likely to <a href="https://doi.org/10.2105/AJPH.2017.304247">live below the federal poverty level</a> and to <a href="https://doi.org/10.1363/psrh.12216">lack partner support</a>. </p>
<p>Conversely, research has shown that there are <a href="https://doi.org/10.1016/j.contraception.2008.07.005">few if any significant negative mental health outcomes</a> among women who have abortions. </p>
<h2>Unsafe abortions</h2>
<p>Restricting legal abortion increases the risk that women will seek out <a href="https://doi.org/10.1016/j.bpobgyn.2010.02.012">pregnancy termination from unskilled people</a> in unsafe settings. Or they may not seek care quickly for pregnancy complications due to fear of being accused of a crime.</p>
<p>In Texas, physicians are <a href="https://www.newyorker.com/news/dispatch/in-the-post-roe-era-letting-pregnant-patients-get-sicker-by-design">reporting an increase in sepsis</a>, or an <a href="https://theconversation.com/sepsis-still-kills-1-in-5-people-worldwide-two-icu-physicians-offer-a-new-approach-to-stopping-it-175650">overwhelming response to infection</a>, from incomplete abortions. These physicians predict that sepsis will become the leading cause of maternal death in Texas. </p>
<p>Prior to 1973, when Roe v. Wade established constitutional protection for abortion in the U.S., women often resorted to unsafe methods to induce abortion that resulted in a high death toll. <a href="https://doi.org/10.2307/3419941">Septic abortion wards</a> – or designated areas of hospitals where women were treated for sepsis as a result of illegal abortions – were common. In 1965, 17% of all deaths related to pregnancy were <a href="https://www.guttmacher.org/sites/default/files/article_files/gr060108.pdf">attributed to illegal abortion</a>. </p>
<p>Now that the constitutional right to abortion has been eliminated, more women will inevitably <a href="https://doi.org/10.1016/j.ajog.2022.07.033">die or become seriously ill</a> due to lack of safe access to abortion services. In states with the most restrictions on abortion, whether a woman meets the criteria for an exemption to save the life of the mother may be <a href="https://publichealth.jhu.edu/2023/a-year-without-roe">decided by a hospital committee</a>. This can delay necessary care and increase the risk to the mother.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/rSWwX7lBEGk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Said one: “I didn’t know I was important enough to draw boundaries around what people could and couldn’t do with my body.”</span></figcaption>
</figure>
<h2>Women affected by violence</h2>
<p>In the U.S., more than 25% of women will <a href="https://ncadv.org/STATISTICS">experience physical or sexual violence</a> in their lifetime. Violence from an intimate partner is a <a href="https://www.ansirh.org/research/ongoing/turnaway-study">leading reason for abortion</a>. My research shows that women affected by violence have a <a href="https://doi.org/10.1016/j.contraception.2012.03.005">higher risk of pregnancy</a> and that college women are at increased risk of <a href="https://doi.org/10.1097/jfn.0000000000000086">nonconsensual and forced sexual encounters</a>.</p>
<p>Currently, there are 14 states with abortion bans that contain <a href="https://www.kff.org/womens-health-policy/issue-brief/a-review-of-exceptions-in-state-abortions-bans-implications-for-the-provision-of-abortion-services/">no exception for rape or incest</a> or require that the sexual assault be reported to law enforcement to qualify for exception. </p>
<p>Research has shown that women often <a href="https://doi.org/10.3200/JACH.55.3.157-162">don’t report sexual assault</a> due to stigma, embarrassment or fear of not being believed. Even if women qualify for an abortion as a result of sexual violence, those who have not filed a formal police report lack “proof” that their pregnancy resulted from assault. </p>
<p>While the changes that have occurred since the fall of Roe one year ago are already deeply concerning, the full effect of eliminating the constitutional right to an abortion won’t be known for years. And as laws are enacted and subsequently challenged, uncertainty and confusion regarding women’s reproductive health care will undoubtedly continue for years to come.</p><img src="https://counter.theconversation.com/content/207390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heidi Collins Fantasia has received funding from the National Institutes of Health, National Institute of Child Health and Human Development and Heart, Lung, and Blood Institute. Dr. Fantasia is the editor of Nursing for Women's Health. </span></em></p>Abortion bans and restrictions have numerous downstream effects on health care. For instance, medical students in states where those laws exist will not receive training for some standard procedures.Heidi Collins Fantasia, Associate Professor of Nursing, UMass LowellLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2076482023-06-16T09:41:51Z2023-06-16T09:41:51ZAbortion prison sentence shows the law is focused on foetuses – why that’s dangerous for women<figure><img src="https://images.theconversation.com/files/532234/original/file-20230615-19-y1oe3n.jpg?ixlib=rb-1.1.0&rect=87%2C45%2C2460%2C1849&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-looking-scan-baby-images-589166537">Emituu/Shutterstock</a></span></figcaption></figure><p>The <a href="https://www.theguardian.com/world/2023/jun/12/woman-in-uk-jailed-for-28-months-over-taking-abortion-pills-after-legal-time-limit">imprisonment of a woman</a> in the UK for taking abortion pills at 32-34 weeks of pregnancy has shocked many. Most people are still unaware that abortion at any stage of pregnancy is <a href="https://theconversation.com/woman-jailed-over-abortion-an-expert-on-what-uk-law-actually-says-and-what-needs-to-change-207578">illegal in England and Wales</a>, unless authorised by two doctors. </p>
<p>Any woman who obtains abortion medication from sources other than an official provider faces the prospect of life imprisonment under the <a href="https://www.legislation.gov.uk/ukpga/Vict/24-25/100/contents">Offences Against the Person Act 1861</a>. As does any woman who uses legally obtained medication in any way other than as directed, for example, delaying taking the medication.</p>
<p>Abortion (or “procuring a miscarriage”) was made a criminal offence to <a href="https://books.emeraldinsight.com/page/detail/Criminal-Justice-Responses-to-Maternal-Filicide/?k=9781839096211">protect women from the dangers</a> that backstreet abortion posed in the 1800s. At this time, all abortions were surgical abortions. There were no antibiotics, and few remedies if the procedure caused uncontrollable bleeding. </p>
<p>Today, abortion is incredibly safe when it can be legally accessed – far safer than it is for a woman to <a href="https://www.scientificamerican.com/article/pregnancy-is-far-more-dangerous-to-women-than-abortion/">continue a pregnancy</a> to full-term. Which leads to the question: what is the purpose of the offence today?</p>
<p>Reading the sentencing hearing from this and <a href="https://books.emeraldinsight.com/page/detail/Criminal-Justice-Responses-to-Maternal-Filicide/?k=9781839096211">other cases</a>, it appears the law is being used to protect foetuses. </p>
<p>In his sentencing remarks, the judge focused on the late stage of the woman’s pregnancy. Arguing that this was an aggravating factor of the case, he describes the woman’s “daughter” as “stillborn”. </p>
<p>It is important to note here that the offence of procuring a miscarriage (as detailed in the Offences Against the Person Act) makes no reference to the gestational stage of the pregnancy. The offence is also not dependent on the death of the foetus. </p>
<p>No woman who has illegally ended her pregnancy (for example, by obtaining abortion medication illegally) at an early gestational stage has been prosecuted. This suggests the application of the law is focused on protecting foetuses that could survive if born alive – not on preventing abortion.</p>
<h2>Extreme vulnerability for women</h2>
<p>This case may have further horrified many people due to the stage the woman’s pregnancy had reached at the time she took the abortion medication. </p>
<p>The limited details of the woman’s experience that are outlined in the <a href="https://www.judiciary.uk/wp-content/uploads/2023/06/R-v.-Foster-sentencing-remarks-12.6.23.pdf">sentencing remark</a> indicate that she, like every other <a href="https://books.emeraldinsight.com/page/detail/Criminal-Justice-Responses-to-Maternal-Filicide/?k=9781839096211">woman whose case I have examined</a>, acted from a place of extreme vulnerability and profound crisis. The reality is that no woman wants a late-term abortion. The motivation to seek one comes from a place of desperation.</p>
<p>During the sentencing, the judge noted the woman’s “deep emotional attachment” to her unborn child, a common experience for women in similar situations. These are not simply “unwanted” pregnancies resulting in delayed abortions.</p>
<p>Women who self-abort pregnancies late in gestation do not necessarily want the unborn baby to die. This is the situation of a woman who believes it would be impossible, possibly due to <a href="https://www.thetimes.co.uk/article/lauras-story-jailed-for-having-an-abortion-in-britain-0m06nzrlx">fear of violence or abuse</a>, for her to bring a child into the world.</p>
<h2>The role of the criminal law</h2>
<p>Some may argue that a late-term foetus is no different to a newborn baby, and that both need criminal legal protection. But such application of the criminal law carries significant risks for women, as well as for babies and foetuses.</p>
<p>In the US, many states now explicitly <a href="https://time.com/6191886/fetal-personhood-laws-roe-abortion/">protect the unborn child</a>, resulting in women being arrested, detained and imprisoned following miscarriages and stillbirths, after exerting their right to refuse medical care during pregnancy, and for behaviour that would be legal <a href="https://scholarship.law.upenn.edu/penn_law_review/vol138/iss1/11/">if they were not pregnant</a>. </p>
<p>As with almost all forms of crime control, it is the most vulnerable people – women of colour and those of lower socioeconomic status – who have been <a href="https://www.cambridge.org/gb/universitypress/subjects/law/socio-legal-studies/policing-womb-invisible-women-and-criminalization-motherhood?format=PB">disproportionately criminalised</a>. In addition, a direct line can be drawn between foetal protection laws and the <a href="https://www.pregnancyjusticeus.org/pregnant_drug_users_fetal_persons_and_the_threat_to_roe_v_wade_by_lynn_m_paltrow/">overturning of Roe v Wade</a>, the supreme court case that protected the right to an abortion in the US. Protecting a foetus in law is a direct threat to reproductive rights.</p>
<figure class="align-center ">
<img alt="Black and white photo of a woman with her face in her hands" src="https://images.theconversation.com/files/532163/original/file-20230615-15-mql66x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532163/original/file-20230615-15-mql66x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532163/original/file-20230615-15-mql66x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532163/original/file-20230615-15-mql66x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532163/original/file-20230615-15-mql66x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532163/original/file-20230615-15-mql66x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532163/original/file-20230615-15-mql66x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">No one wants to have a late-term abortion – it comes from a place of deep crisis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-depressed-woman-155806436">Twin Design/Shutterstock</a></span>
</figcaption>
</figure>
<p>The criminalisation of pregnant women has also had disastrous consequences for foetuses and babies. While the aim of foetal protection laws is to prevent harm to unborn babies, the threat of legal sanctions against pregnant women has led many to <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist">actively avoid medical care</a> during their pregnancy due to a fear that they will be reported to the police. Lack of antenatal care is a leading factor in <a href="https://jaapl.org/content/43/2/137">pregnancy complications</a>.</p>
<p>There is also evidence that women in the US have sought abortions to <a href="https://www.repository.law.indiana.edu/ilj/vol89/iss2/8/">escape prosecution</a> under foetal protection laws. For example, one woman who was charged with the reckless endangerment of her foetus after inhaling paint fumes, had the <a href="https://www.pregnancyjusticeus.org/napw-documentation-state-v-greywind/">charges against her dropped</a> after she terminated the pregnancy. </p>
<p>Attempts to “protect” foetuses are, in some instances, resulting in worse health outcomes, or even death, for both foetuses and pregnant women.</p>
<p>Whether the criminal law should protect foetal life is a complex question, but it is a question for parliament alone. The courts and the Crown Prosecution Service, who decide to prosecute women, have interpreted procuring a miscarriage as a crime against a foetus. They have decided that women should be punished if their actions in later pregnancy cause the death of an unborn child. </p>
<p>Their interpretation of the law moves the statute beyond the intentions of parliament when enacted. It is time parliament involves itself in this area of criminal law, conducting a thorough and compassionate review.</p><img src="https://counter.theconversation.com/content/207648/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emma Milne received funding to support this research from the Arts and Humanities Research Council (AH/L503861/), the Socio-Legal Studies Association Research Grants Scheme 2018, and Durham Law School. Emma is a trustee of the Socio-Legal Studies Association, a charitable incorporated organisation (registered charity number 1186333).</span></em></p>Foetal protection laws carry health risks for both mothers and babies.Emma Milne, Associate Professor in Criminal Law and Criminal Justice, Durham UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2047092023-06-01T14:06:22Z2023-06-01T14:06:22ZBlack women are at greater risk of maternal death in the UK – here’s what needs to be done<figure><img src="https://images.theconversation.com/files/529541/original/file-20230601-16-dd836h.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C5760%2C3811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Poorer maternity care may be one explanation.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-deep-thought-looks-out-1565039914">zulufoto/ Shutterstock</a></span></figcaption></figure><p>Black women are <a href="https://www.ndph.ox.ac.uk/news/latest-mbrrace-uk-figures-for-maternal-and-perinatal-mortality-in-the-uk-are-published">four times more likely</a> to die while pregnant or just after childbirth than white women, according to the latest figures published by <a href="https://www.npeu.ox.ac.uk/mbrrace-uk">Mbrrace</a> – a national programme which surveys and investigates the causes of maternal deaths and infant deaths in the UK. Although this report only includes data from 2019-2021, reports from previous years show maternal mortality rates have been largely unchanged for the <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf">last decade or more</a>.</p>
<p>The reason for this racial disparity still isn’t fully understood. It’s likely due to a <a href="https://committees.parliament.uk/publications/38989/documents/191706/default/">combination of many factors</a>, including socioeconomic status and pre-existing health conditions. Numerous reports have also shown that black women receive <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9735204/">poorer maternity care</a> compared with women from other ethnic backgrounds, which may further contribute to poorer health outcomes. </p>
<p>But in order to improve maternal outcomes for black women, work will need to be done at every level of the NHS to fix a root cause of these racial disparities in care – a concept philosophers call <a href="https://academic.oup.com/book/32817">epistemic injustice</a>.</p>
<p>Epistemic injustice is defined as unfairly preventing someone from properly communicating their ideas or making sense of their experiences. This typically happens when someone is biased against a person – for example, due to their race or social class. This leads to them to downplay the other person’s credibility.</p>
<p><a href="https://www.fivexmore.com/blackmereport">Examples of this</a> in maternity care include patients having concerns about their health and their pregnancy dismissed or treated as trivial, being passed off as “dramatic”, questions being brushed aside or not taken seriously, and practitioners not taking patients’ pain seriously. By denying someone credibility, it may make them feel less able to request care and raise worries. </p>
<h2>Racial prejudice</h2>
<p>Numerous studies have highlighted the ways that epistemic injustice is present in real-world healthcare settings. Often, <a href="https://www.pnas.org/doi/10.1073/pnas.1913405117">racial prejudice</a> is a root cause.</p>
<p>For example, research shows that white health workers are more likely to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/">disbelieve reports of pain</a> by black patients and less likely to provide them with proper pain relief, compared with white patients. Reports have also found that when black women raise health concerns, they’re <a href="https://www.birthrights.org.uk/wp-content/uploads/2022/05/Birthrights-inquiry-systemic-racism_exec-summary_May-22-web.pdf">often dismissed</a> – even in severe cases, such as instances where c-section stitches are bleeding and infected. </p>
<p>A <a href="https://blackequityorg.com/state-of-black-britain-report/">2022 report</a> by the Black Equity Organisation, which works to dismantle systemic racism in the UK, found that more than 65% of respondents reported they’d been discriminated against because of their ethnicity by healthcare professionals. The <a href="https://www.nhsrho.org/wp-content/uploads/2022/02/RHO-Rapid-Review-Final-Report_v.7.pdf">NHS Race and Health Observatory</a> has made similar conclusions, showing many black patients experience patronising and judgemental attitudes from healthcare staff.</p>
<figure class="align-center ">
<img alt="An expectant mother cradles her stomach while speaking with her doctor." src="https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Healthcare workers may be more likely to dismiss the health concerns of black mothers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-using-digital-tablet-meeting-pregnant-155727371">Monkey Business Images/Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://www.mayadusenbery.com/book">Knowledge gaps</a> in healthcare research are another example of epistemic injustice. Black people have historically been <a href="http://www.brown.uk.com/teaching/HEST5001/douglas.pdf">underrepresented in research studies</a> and continue to be so.</p>
<p>One reason for this may be their <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0282088">experiences of racism</a> from doctors, which fosters distrust and discourages black people from participating in research studies. But researchers are also slow to engage with black participants and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904098/">close these knowledge gaps</a>. Many justify this lack of engagement on feeble grounds – for instance, by insisting black women are <a href="https://committees.parliament.uk/oralevidence/10072/html/">hard to recruit</a>. </p>
<p>This lack of representation can lead to <a href="https://www.tandfonline.com/doi/full/10.1080/15265161.2020.1851811">knowledge gaps</a> at every level – including in the medical guidelines used to identify and diagnose certain diseases. Take the <a href="https://www.hsib.org.uk/news-and-events/new-report-examines-delayed-detection-of-jaundice/">recent case</a> of a black infant who was not diagnosed and treated for jaundice as quickly as she should have been. Although multiple blood tests showed high blood levels of bilirubin (a symptom of jaundice), healthcare staff were still relying on visual signs to detect jaundice – and these aren’t typically as evident in darker-skinned patients. </p>
<p>Although just one example, this highlights the way knowledge gaps make it harder for staff to understand the distinct care needs and experiences of black patients. This may lead to worse health outcomes for these patients, and further <a href="https://www.pnas.org/doi/10.1073/pnas.1913405117">diminish levels of trust</a> the black community has in healthcare practitioners and institutions.</p>
<h2>Making change</h2>
<p>While the negative impacts of epistemic injustice on the maternal healthcare that black women receive is clear, addressing these problems within the NHS will require change at nearly every level.</p>
<p>A report on <a href="https://committees.parliament.uk/publications/38989/documents/191706/default/">black maternal health</a> by the House of Commons’ Women & Equalities Committee, published in March 2023, suggests some measures are already being taken by Health Education England to improve cultural competence and address racism in maternal care. But training staff to improve “cultures of kindness” and to “listen and make sure women are heard” will not be enough to fully address the complex causes of these disparities in black maternal health.</p>
<p>Current NHS strategies such as <a href="https://onlinelibrary.wiley.com/doi/10.1111/1467-9566.13414">hiring more diverse staff</a> and rethinking <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162667/">research priorities</a> are one step in the right direction. By having staff from more diverse backgrounds, there’s a greater likelihood they will be able to sympathise with patients and understand their experiences. Moreover, having more research which has included black patients will help healthcare staff better respond to the specific health needs of these patients.</p>
<p>But such strategies risk falling short if they are not explicitly aimed at <a href="https://www.weahsn.net/news/black-maternity-matters-pilot-evaluation">targeting systemic racism</a> and prejudice in the NHS. </p>
<p>For maternal mortality, midwifery training needs to directly challenge the racist stereotypes that drive some healthcare staff to deny the credibility of others’ testimonies. Gynaecology and obstetric researchers must proactively include black women in their studies to ensure their distinctive needs and concerns are met. This may in turn improve medical care for <a href="https://committees.parliament.uk/publications/38989/documents/191706/default/">women from all backgrounds</a>.</p><img src="https://counter.theconversation.com/content/204709/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian James Kidd does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A recent report found that black women are four times more likely to die while pregnant or just after childbirth, compared with white women.Ian James Kidd, Assistant Professor of Philosophy, University of NottinghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2047852023-05-29T19:50:46Z2023-05-29T19:50:46ZPandemic babies’ developmental milestones: Not as bad as we feared, but not as good as before<figure><img src="https://images.theconversation.com/files/528474/original/file-20230526-23-qh7azn.jpg?ixlib=rb-1.1.0&rect=301%2C760%2C3838%2C2282&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Scientists and physicians raised concerns early in the pandemic that increased parental stress, COVID infections, reduced interactions with other babies and adults, and changes to health care may affect child development.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/pandemic-babies--developmental-milestones--not-as-bad-as-we-feared--but-not-as-good-as-before" width="100%" height="400"></iframe>
<p>The COVID-19 pandemic created conditions that <a href="https://doi.org/10.1017/S2040174420000847">threatened children’s healthy development</a>. </p>
<p>Scientists and physicians raised concerns early in the pandemic, pointing out that increased parental stress, COVID infections, reduced interactions with other babies and adults and changes to health care <a href="https://doi.org/10.1111%2Fcdev.13653">could affect child development</a>. Furthermore, some children could be especially vulnerable to the pandemic circumstances. </p>
<p>With these concerns in mind, we started a <a href="https://doi.org/10.2196/25407">longitudinal study of pregnant Canadians</a> to understand how pandemic stressors might influence later child development. </p>
<p><a href="https://doi.org/10.1016/j.jad.2020.07.126">Our initial findings</a> were alarming: the rates of anxiety and depression among pregnant individuals were two to four times higher during the early phase of the pandemic compared to numerous pregnancy studies prior to the pandemic. This worrisome increase in mental health problems <a href="https://doi.org/10.1016/j.psychres.2021.113912">was seen worldwide</a>. </p>
<h2>Impact on children’s development</h2>
<p>To determine how the pandemic might be affecting children’s development, we measured developmental milestones in 3,742 12-month-old infants born during the first 18 months of the pandemic. We then compared these infants to a similar group of 2,898 Canadian infants born between 2015 and 2018. </p>
<figure class="align-center ">
<img alt="A pregnant woman and a doctor both wearing face masks in the doctor's office" src="https://images.theconversation.com/files/528483/original/file-20230526-27-wmxs0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/528483/original/file-20230526-27-wmxs0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528483/original/file-20230526-27-wmxs0a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528483/original/file-20230526-27-wmxs0a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528483/original/file-20230526-27-wmxs0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528483/original/file-20230526-27-wmxs0a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528483/original/file-20230526-27-wmxs0a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rates of anxiety and depression among pregnant individuals were two to four times higher during the early phase of the pandemic compared to numerous pregnancy studies prior to the pandemic.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The study evaluated developmental milestones using the <a href="https://agesandstages.com/products-pricing/asq3/">Ages and Stages Questionnaire-3</a>. The ASQ-3 is a parent report of child behaviour that can help identify children at risk of developmental delays in five separate domains: Communication, Gross Motor, Fine Motor, Personal-Social and Problem Solving.</p>
<p>In a study to be published in the <em>Journal of Developmental and Behavioral Pediatrics</em>, we found that most children born during the pandemic were doing fine, with almost 90 per cent meeting their key developmental milestones in each area. This should be reassuring for parents, caregivers and communities, because it suggests that most children are developing normally despite adverse early circumstances.</p>
<p>However, a slightly higher proportion of children born during the pandemic were at risk of developmental delay in Communication, Gross Motor and Personal-Social domains, compared to children born before the pandemic. Our findings <a href="https://doi.org/10.1097/jxx.0000000000000653">are consistent</a> with <a href="https://doi.org/10.1101/2021.08.10.21261846">prior smaller studies</a> showing <a href="https://doi.org/10.1001/jamapediatrics.2021.5563">only small increases in the risk</a> for poor verbal, motor and cognitive performance among 12-month-old infants born during the pandemic.</p>
<figure class="align-center ">
<img alt="A woman smiling and playing with her baby in her lap" src="https://images.theconversation.com/files/528494/original/file-20230526-27-cc84m2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/528494/original/file-20230526-27-cc84m2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528494/original/file-20230526-27-cc84m2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528494/original/file-20230526-27-cc84m2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528494/original/file-20230526-27-cc84m2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528494/original/file-20230526-27-cc84m2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528494/original/file-20230526-27-cc84m2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Engaging an infant in conversation or song (even a pre-verbal infant) is a powerful way to encourage language learning.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The largest effects we observed were in the Communication and Personal-Social domains. Infants born during the pandemic were almost twice as likely to score below cutoffs compared to pre-pandemic infants. </p>
<p>This represents an increase of about one to two additional children in 100 who are at risk, but highlights some potentially concerning effects of the pandemic on early child development. Across Canada, this could result in service demands for 20,000-40,000 additional preschool children.</p>
<p>Although small in absolute terms, these increases have important implications, since already limited resources will need to increase to meet the needs of more children. Certainly, it will be important to continue monitoring infants/children born during the pandemic to determine how long-lasting these effects are. </p>
<p>Reassuringly, <a href="https://doi.org/10.1016/S0749-3797(02)00655-4">early interventions</a> can be <a href="https://doi.org/10.1016/j.ehb.2009.01.002">highly effective</a> for children who are struggling. </p>
<h2>Concerns about child development</h2>
<figure class="align-center ">
<img alt="A smiling baby crawling towards the camera in the foreground, and a young man smiling in the background" src="https://images.theconversation.com/files/528624/original/file-20230526-15-805x46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/528624/original/file-20230526-15-805x46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528624/original/file-20230526-15-805x46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528624/original/file-20230526-15-805x46.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528624/original/file-20230526-15-805x46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528624/original/file-20230526-15-805x46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528624/original/file-20230526-15-805x46.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Provide your child with many opportunities for one-on-one interaction with a caring and responsive adult.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Parents should be mostly reassured by these findings. Despite the disruptions to nearly every aspect of life during the pandemic, the majority of children continue to show healthy development. Parents with concerns about their child’s development may find these suggestions helpful:</p>
<ol>
<li><p>Provide your child with many opportunities for one-on-one interaction with a caring and responsive adult. The <a href="https://developingchild.harvard.edu/resourcetag/serve-and-return/">Harvard Center on the Developing Child</a> describes the back-and-forth interactions that form the key processes of child development as “serve and return.” </p></li>
<li><p>Believe in “ordinary magic.” This is the phrase that child development expert <a href="https://doi.org/10.1037//0003-066x.56.3.227">Ann Masten</a> uses to describe how resilience emerges from ordinary, everyday processes and interactions. Children develop resilience when they have access to the right environments, the right relationships and the right chances to be able to safely explore themselves and the world around them.</p></li>
<li><p>Talk and sing with your child. Engaging an infant in conversation or song (even a pre-verbal infant) is a powerful way to encourage <a href="https://doi.org/10.1016/j.dr.2005.11.002">language learning</a>.</p></li>
<li><p>There is a wide range of development that is considered “normal.” It is okay for your child to be at a different stage than other children their age, as long as your child is still showing signs of development. </p></li>
<li><p>If you are concerned about your child’s development after some time of monitoring, discuss your concerns with a qualified health professional to determine if further investigation is needed.</p></li>
</ol>
<p>Overall, the findings of our study (and others) suggest that the effects of the pandemic on infant development (at least to one year of age) have not been as bad as we feared. However, a greater number of children will likely require further evaluation and support compared to pre-pandemic.</p><img src="https://counter.theconversation.com/content/204785/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gerald Giesbrecht receives funding from the Canadian Institutes of Health Research (CIHR) and the Alberta Children's Hospital Foundation. </span></em></p><p class="fine-print"><em><span>Catherine Lebel receives funding from the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council (NSERC), Brain Canada, the Azrieli Foundation, Alberta Children's Hospital Foundation, and the Canada Research Chairs program.</span></em></p><p class="fine-print"><em><span>Lianne Tomfohr-Madsen receives funding from the Canadian Institutes of Health Research (CIHR), the Social Sciences and Humanities Research Council (SSHRC), Brain Canada, Calgary Health Trust, the Alberta Children's Hospital Foundation and the Weston Foundation. </span></em></p>Research findings are mostly reassuring for parents — despite the disruptions to nearly every aspect of life during the COVID-19 pandemic, most children continue to show healthy development.Gerald Giesbrecht, Associate Professor of Pediatrics, University of CalgaryCatherine Lebel, Associate Professor of Radiology, University of CalgaryLianne Tomfohr-Madsen, Associate Professor, Canada Research Chair in Mental Health and Intersectionality, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2056842023-05-23T13:56:37Z2023-05-23T13:56:37ZBuilding a nutrition programme? Understanding how people behave is key<figure><img src="https://images.theconversation.com/files/526560/original/file-20230516-21-r6gzv4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Riccardo Mayer/Shutterstock</span></span></figcaption></figure><p>Undernutrition contributes to up to <a href="https://www.afro.who.int/health-topics/nutrition">45%</a> of child deaths in African countries. At the same time, <a href="https://www.afro.who.int/health-topics/nutrition">child obesity rates have doubled</a> between 2006 and 2016. More than <a href="https://globalnutritionreport.org/resources/nutrition-profiles/africa/">40%</a> of women of reproductive age are anaemic. And <a href="https://globalnutritionreport.org/resources/nutrition-profiles/africa/">13.7%</a> of infants have low weight at birth. Stunting in the African region is <a href="https://globalnutritionreport.org/resources/nutrition-profiles/africa/">30.7%</a> – above the world average of 22%. </p>
<p>In <a href="https://www.fao.org/documents/card/en/c/cb7496en">2020</a>, over a fifth of Africa’s population faced hunger; 346.4 million people experience severe food insecurity; and 452 million experienced moderate food insecurity. </p>
<p>Nutrition programmes have been supporting families in Africa for decades. But many of these programmes have inconclusive results. </p>
<p>As health psychologists and behavioural scientists, we believe this is because the programmes don’t focus on fitting into families’ lives. Doing so would also make nutrition interventions sustainable. Understanding the behaviours of the people being targeted by nutrition programmes could improve their nutrition status. </p>
<p>Our <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000401">recent research</a> looked at the outcomes of studies that had behaviour change embedded within programmes to improve nutrition for mothers and children in sub-Saharan Africa. Our findings show that nutrition programmes that focus on family and community behaviour change have better health outcomes for mothers and children. </p>
<p>The World Health Organization has outlined the importance of <a href="https://apps.who.int/iris/handle/10665/259399">behaviour change</a> to support mother and child health and help address barriers in current nutrition programmes. Our study goes a step further to show how to use behaviour change models to design better nutrition programmes. </p>
<h2>Behavioural science</h2>
<p>Health psychologists and behavioural scientists developed the COM-B model. It suggests that a person’s Capability, Opportunity and Motivation can change their <a href="https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42?report=reader">Behaviour</a>. Our study showed that this model can be used to consider what is happening in the lives of people when designing <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000401">nutrition interventions</a> including what barriers there might be to eating healthy food. </p>
<p>“Capability” from the COM-B model refers to a person’s physical capability, such as their skill sets, and psychological capability, such as knowledge about a behaviour. If a person doesn’t know what foods to be eating to be healthy or doesn’t feel they have the skills to cook healthy foods, they can’t change the behaviour. Programmes need to support people to know what the healthy local foods are and how to cook these foods, potentially through community-led cooking demonstrations. Our findings show that simply educating people isn’t enough. Making lessons interactive and practical in people’s daily lives increases the likelihood of behaviour change.</p>
<p>“Opportunity” from the COM-B model refers to a person’s physical opportunities in their environment, and their social opportunities such as their family and wider community. For example, if communities don’t have apples and bananas growing in their environment, or for sale, then they simply won’t be able access these foods. Programmes therefore need to support the foods that are already available to buy in people’s environment. If possible, they should also support the wider community to grow food. The people around us influence what we do and what we eat. Programmes should try to encourage key community and family figures to support nutrition practices. </p>
<p>“Motivation” from the COM-B model refers to a person’s habits and things they do without realising it (automatic motivation). One of the habits or norms in many communities is to prioritise men, then children, to eat first. Women often get the leftovers, even when they are pregnant. This means that pregnant women don’t get the nutrients they need. Programmes need to work with women, men and wider communities to motivate them to prioritise women’s nutrition, while respecting culture and tradition. This would encourage reflective motivation where people can consciously make decisions about food within social structures.</p>
<h2>Building nutrition programmes</h2>
<p>When designing nutrition programmes, the best way to learn about people’s motivations is to ask them directly about the issues they are facing and the solutions they want. Once you know their issues and potential solutions, you can use behavioural science models such as the COM-B model to categorise the issues and solutions, and start designing programmes to address these gaps. </p>
<p>To go a step further, the same behavioural scientists also developed the Behaviour Change Wheel, which helps us to think of different <a href="https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42?report=reader">methods</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526522/original/file-20230516-17-ml1e3n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Behaviour Change Wheel, with the COM-B at the centre and the intervention functions in the outer circle.</span>
<span class="attribution"><a class="source" href="https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42">Michie et al</a></span>
</figcaption>
</figure>
<p>Our study shows that applying the Behaviour Change Wheel to nutrition programmes may also increase their impact. The wheel suggests:</p>
<ul>
<li><p>giving participants incentives</p></li>
<li><p>using persuasive communication</p></li>
<li><p>modelling healthy diets</p></li>
<li><p>restructuring the environment</p></li>
<li><p>educating on nutrition, in an interactive way</p></li>
<li><p>supplying resources such as tools and seedlings (enablement)</p></li>
<li><p>training communities in cooking or agricultural methods. </p></li>
</ul>
<p>Using simple behavioural science models can help programmes to understand people’s lives and how to design nutrition interventions that directly benefit them, even when the funding ends.</p><img src="https://counter.theconversation.com/content/205684/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniella Watson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Using simple behavioural science models can help programmes to understand people’s lives and how to design nutrition interventions that directly benefit them.Daniella Watson, Postdoctoral Researcher and Health Psychologist, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2029772023-04-19T14:16:04Z2023-04-19T14:16:04ZRahima Moosa: South Africa’s only mother and child hospital is falling apart - a veteran doctor reflects on why<figure><img src="https://images.theconversation.com/files/520758/original/file-20230413-28-483g5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source"> Papi Morake/ Gallo Images via Getty Images</span></span></figcaption></figure><p><em>South Africa’s health ombudsman <a href="https://healthombud.org.za/wp-content/uploads/2023/03/Investigation-Report-into-allegations-against-Rahima-Moosa-Mother-and-Child.pdf">recently published</a> the findings of an investigation into Rahima Moosa Mother and Child Hospital. The investigation followed the publication of a <a href="https://www.news24.com/news24/SouthAfrica/News/watch-pregnant-women-sleeping-on-the-floor-at-joburg-hospital-20220402?s=08">video</a> showing pregnant women lying on the hospital floor, as well as complaints by patients’ family members. The ombudsman’s investigation produced shocking findings, including severe overcrowding and staff shortages at the facility. There haven’t been any substantial upgrades to the hospital since it was built 80 years ago.</em> </p>
<p><em>Laetitia Rispel has been researching health policy and systems for over 20 years. She asked <a href="https://www.thepresidency.gov.za/national-orders/recipient/prof-yosuf-%E2%80%9Cjoe%E2%80%9D-veriava">Professor Emeritus Yosuf “Joe” Veriava</a> – who has been involved in South Africa’s healthcare system for more than half a century and is a recipient of the Order of Luthuli in silver for his contribution to the medical profession in South Africa – about the report.</em></p>
<hr>
<p><strong>Laetitia Rispel:</strong> What did you find most disturbing about the report? Who should be held accountable? </p>
<p><strong>Yosuf Veriava:</strong> I spent most of my student or training years there in the late 1960s. Seeing the problems that are occurring now is very sad. </p>
<p>What I found particularly disturbing is the failure in providing appropriate, effective and efficient leadership. </p>
<p>At first glance I thought the only person to blame was the CEO. But the Gauteng provincial department of health is just as responsible. The department was involved in the appointment of the CEO. It was also the department that gave the CEO permission to work from home. I find this very problematic because the CEO of a hospital cannot work from home. The CEO could be needed at any time during working hours.</p>
<p>The CEO herself should be held responsible. And the Gauteng department of health must take some responsibility.</p>
<p><strong>Laetitia Rispel:</strong> In your opinion, what factors have contributed to the hospital’s current state?</p>
<p><strong>Yosuf Veriava:</strong> There are many. </p>
<p>First of all, it is the heavy patient burden. The hospital has a <a href="https://healthombud.org.za/wp-content/uploads/2023/03/Investigation-Report-into-allegations-against-Rahima-Moosa-Mother-and-Child.pdf#page=18">large catchment area</a>. And within it, many of the people are of a lower social economic group and clearly their disease profile is not of the best. </p>
<p>This is the only mother and child hospital in South Africa, providing care for a very large number of women and children. In theory the hospital should be treasured, but the large patient numbers and high burden of care have a negative impact on the hospital.</p>
<p>Rahima Moosa Hospital delivers around 15,000 babies every year, which is the second highest number of babies in the country after Chris Hani Baragwanath Hospital (which is known as <a href="https://www.chrishanibaragwanathhospital.co.za/">Africa’s biggest hospital</a>). But the total staff complement is 1,200, and health professionals (doctors, nurses, pharmacists and rehabilitation therapists) account for 65% (780). Hence, the staff-to-patient ratio is low, even when compared to hospitals of a similar size. </p>
<p>Another aspect is the age of the hospital. The hospital <a href="https://www.youtube.com/watch?v=OYDhTpC6V-w">is as old</a> as I am – 80.</p>
<p>When I was at Coronation (the hospital’s old name) it was in reasonable shape. Not as good as the hospitals catering for white patients. But it was well kept. </p>
<p>When you have such an old hospital, there is a natural process of decay and this was not catered for. This points to the public works department failing to keep up with the decaying processes, and the maintenance of the hospital. </p>
<p><strong>Laetitia Rispel:</strong> What should be done to turn the situation around?</p>
<p><strong>Yosuf Veriava:</strong> It is the government that should be doing something about sorting this out. There are in fact recommendations that come out of the ombud’s report. These need immediate attention. </p>
<p>There have been concerns about public sector hospitals in general. And there have been various types of interventions.</p>
<p>In 2013, when I was professor emeritus of medicine at the University of the Witwatersrand, I was involved in a legal intervention to make a difference. We wanted to take the then health minister, Dr Aaron Motsoaledi, to court to compel him to take action. </p>
<p>While we were trying to bring the challenge to court, the minister said we should have discussions. These were held with the university as well as the minister’s office. The discussions resulted in an agreement on a turnaround strategy.</p>
<p>While this was positive and helped sort out the university-linked hospitals, it did nothing for the other state hospitals. </p>
<p>The other hospitals have received quite a bit of <a href="https://www.iol.co.za/pretoria-news/news/disturbing-number-of-public-hospital-patients-have-died-due-to-negligence-e623f9b9-4801-446f-af91-51246800ae77">publicity</a>.</p>
<p>There have been other attempts at interventions. One includes the drawing up of the <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-signing-presidential-health-compact-25-jul-2019-0000">Presidential Health Compact</a>. While there was a lot of hype about the meeting with the president and the health compact, nothing much has happened and the hospitals remain the way they were. </p>
<p>So things get raised, but we don’t have any action. </p>
<p><strong>Laetitia Rispel:</strong> What should be done to ensure a capable and functional public healthcare system in South Africa?</p>
<p><strong>Yosuf Veriava:</strong> We can sort out all the hospitals. But the outcomes aren’t just going to improve suddenly.</p>
<p>Without sorting out the marked inequity in our country we will not make any major gains in improving health outcomes. There are many experts who believe that without sorting out various social and economic determinants we won’t have a very healthy society. So that’s the first point to make.</p>
<p>We are sending students to Cuba to try to facilitate the establishment of a health system based on primary healthcare. But our infrastructure here is not conducive to that. Hence, we should improve the primary healthcare system to cater for illnesses that can be seen at that level, which would take some of the extreme load from public sector hospitals.</p>
<p>We can look at improving hospitals but we also need to look at how to improve health outcomes.</p><img src="https://counter.theconversation.com/content/202977/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laetitia Rispel holds a SARChI Chair at Wits University and receives funding from the National Research Foundation.
</span></em></p>Rahima Moosa Hospital caters for a very large number of women and children. The large patient numbers and high burden of care have a negative impact on the hospital.Laetitia Rispel, Professor of Public Health and DST/NRF Research Chair., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1999942023-02-27T13:31:10Z2023-02-27T13:31:10ZWomen’s rights exist only on paper in Nigeria: Five core issues a new president needs to address urgently<figure><img src="https://images.theconversation.com/files/511746/original/file-20230222-26-5mm4xc.jpg?ixlib=rb-1.1.0&rect=0%2C24%2C8256%2C5462&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maternal health is an issue a new government must urgently address in Nigeria. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/midwife-topchin-job-goro-checks-maryam-mohammed-who-is-38-news-photo/1159831601?phrase=maternal%20health%20in%20Nigeria&adppopup=true">Lynsey Addario/Getty Images Reportage</a></span></figcaption></figure><p>Violence against African women and the widespread violation of their basic human rights is shaped by societal and cultural barriers. In Nigeria, women’s rights appear to be protected. The country is a signatory to many international conventions and norms such as the <a href="https://www.un.org/womenwatch/daw/cedaw/">Convention on the Elimination of all forms of Discrimination Against Women</a> and the <a href="https://au.int/sites/default/files/documents/38956-doc-assembly_au_decl_12_iii_e.pdf">Solemn Declaration on Gender Equality in Africa</a>. Yet this protection is mostly on paper.</p>
<p>In a recent <a href="https://link.springer.com/chapter/10.1007/978-3-030-73875-4_10">book chapter</a> about African women in politics, I’ve noted that an African woman is too commonly labelled by her marital position as a wife of an African man. She is seen as an appendage of that man, a mere shadow. </p>
<p>But this has not always been the case. History tells us that there have been many great African women who rose to leadership and pioneered innovation. In Nigeria, activists like <a href="https://en.unesco.org/womeninafrica/funmilayo-ransome-kuti/biography">Funmilayo Ransome Kuti</a> and <a href="https://www.mynigeria.com/person/Margaret-Ekpo-2369">Margaret Ekpo</a> come to mind. History professor <a href="https://ui.edu.ng/uiicons/prof-awe">Bolanle Awe</a> is another.</p>
<p>Yet the subjugation of women’s rights, interests, benefits and endowments is a key issue facing Nigeria. When women have opportunities, a country’s economic productivity and development is enhanced across the board. Therefore Nigeria’s leaders would do well to pay urgent attention to five areas of concern: education for girls, gender-based violence, representation of women in politics, maternal health, and women’s economic empowerment.</p>
<h2>1. Education for girls</h2>
<p>Education enhances the decision-making power of women and imparts the knowledge and skills required to contribute to society. And the right to education is enshrined in section 18 (1) of Nigeria’s Constitution 1999. The provision enjoins the government to direct its policy towards ensuring there are equal and adequate educational opportunities at all levels. Education should be free and compulsory for all children of school age.</p>
<p>But in Nigeria there is a large disparity between the education of boys and that of girls. In 2010, the female adult literacy rate (ages 15 and above) for Nigeria was <a href="https://www.schoolsoftware.com.ng/history-of-girl-child-education-in-nigeria/#:%7E:text=In%20Nigeria%2C%20there%20are%20large,adult%20literacy%20rate%20of%2074.4%25">59.4% while the literacy rate for males was 74.4%</a>. Of more than 10 million children who are out of school or do not have access to adequate education past a certain age, 60% are girls. </p>
<p>Some families, especially in the North East and North West don’t want to expose their girl children to abduction and abuse. Some girls are “given” in marriage at a very young age. About <a href="https://www.girlsnotbrides.org/learning-resources/child-marriage-atlas/atlas/nigeria/#:%7E:text=Nigeria%20has%20the%2011th%20highest,before%20the%20age%20of%2018">43% of girls in Nigeria are married before their 18th birthday</a> and 16% are married before the age of 15. </p>
<p>Nigeria has experienced <a href="https://reliefweb.int/report/nigeria/school-abductions-nigeria">growing abduction and kidnapping of school children</a>, with many girls forced into marriage or impregnated by their kidnappers. At least 1409 students have been kidnapped from their schools in Nigeria since the first incident in the country’s latest school abduction epidemic which started in March 2020.</p>
<h2>2. Gender-based violence</h2>
<p>Women in Nigeria, regardless of demographic factors like age, social status, education, ethnicity, religion, and mental and physical ability, have been subjected to varying <a href="https://standtoendrape.org/a-study-on-violence-against-women-in-the-political-space-part-1/">degrees of violence</a>. </p>
<p>There is a need for the government to enforce the laws that punish offenders. <a href="https://www.wipo.int/edocs/lexdocs/laws/en/ng/ng014en.pdf">Nigeria’s constitution</a> provides that every individual’s dignity should be respected and nobody should be subjected to torture or to inhuman or degrading treatment. The <a href="https://www.ilo.org/dyn/natlex/docs/ELECTRONIC/104156/126946/F-1224509384/NGA104156.pdf">Violence Against Persons Prohibition Act</a> also prohibits all forms of violence in private and public life, while providing maximum protection and effective remedies for victims and punishment for offenders. </p>
<p>States that have not passed this into <a href="https://www.mondaq.com/nigeria/human-rights/1221230/laws-on-domestic-violence-in-nigeria#:%7E:text=The%20law%20limits%20its%20operation,punishable%20by%20imprisonment%20and%20fine'">law</a> should do so. As at June 2021, only <a href="https://nji.gov.ng/wp-content/uploads/2021/12/AN-OVERVIEW-OF-THE-VIOLENCE-AGAINST-PERSONS-PROHIBITION-ACT-2015-By-Prof.-M.-T.-Ladan-Ph.d.pptx">18 out of 36 states</a> of the Federation had passed similar laws. </p>
<h2>3. Women in politics</h2>
<p>In Nigeria, <a href="https://www.iknowpolitics.org/en/news/world-news/only-6-women-active-nigerian-politics-%E2%80%94-report">only 6% of women are active in politics</a>. Of the 109 senators in the parliament, only eight (7.34%) of them are women.</p>
<p>Nigeria is yet to reach the benchmark by the <a href="https://www.un.org/womenwatch/daw/beijing/pdf/BDPfA%20E.pdf">Beijing Declaration Platform for Action</a> endorsed by the Economic and Social Council of having 30% women in positions at decision-making levels by 1995. Quotas would increase the number of <a href="https://rowman.com/ISBN/9781786615213/Promoting-Gender-Equality-in-Political-Participation-New-Perspectives-on-Nigeria">women occupying positions of leadership</a> in governance. This would help to have more women representing their own interests and the interests of the larger society. </p>
<p>Intimidation adds to the low representation of women in governance. In a democracy, all citizens should have an equal say in the governance of the country, and benefit equally from their outcomes. Women have been the targets of violence during elections, to discourage them from vying for positions. They have faced <a href="https://www.ndi.org/files/EXAMPLE_NDI%20Focus%20Group%20Discussion%20Report_Kogi%20State%20Nigeria.docx">physical, sexual, psychological and socio-economic violence</a>. The government must ensure that political parties provide a level playing ground for all and punish any act of violence against women.</p>
<h2>4. Maternal health</h2>
<p>Nigeria accounts for <a href="https://guardian.ng/opinion/addressing-maternal-mortality-in-nigeria/">over 34%</a> of global maternal deaths. The lifetime risk of dying during pregnancy, childbirth, postpartum, or after an abortion for a <a href="https://www.who.int/news/item/25-06-2019-maternal-health-in-nigeria-generating-information-for-action">Nigerian woman is one in 22, compared to one in 4,900 in developed countries</a>.</p>
<p>Government must provide free and adequate healthcare for expectant mothers and their babies. </p>
<h2>5. Economic empowerment</h2>
<p>More than <a href="https://www.nigerianstat.gov.ng/elibrary/read/1123">18% of households</a> in Nigeria are headed by women. But they often lack access to, and control over, productive resources, and are not recognised as fully participating economic actors. With limited income, it’s <a href="https://www.pasgr.org/wp-content/uploads/2021/02/IDS_Working_Paper_548.pdf">difficult to provide for their households</a>. </p>
<p>Training, networking and mentoring, orientation and enlightenment, legislative and value changes, financial support and empowerment can contribute to changing this.</p>
<h2>Equality and trust</h2>
<p>Nigeria’s leaders should not relegate women to the background and treat them like second class citizens. Giving everyone equal opportunities enhances trust in government and brings about good governance in the long run.</p><img src="https://counter.theconversation.com/content/199994/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Damilola Agbalajobi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When women have opportunities, a country’s economic productivity and development is enhanced.Damilola Agbalajobi, Lecturer, Political Science, Obafemi Awolowo UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1988872023-02-07T15:28:05Z2023-02-07T15:28:05ZSurgery risks are disproportionately high for women in Africa - new study<figure><img src="https://images.theconversation.com/files/508290/original/file-20230206-21-p6o6gc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Improving surgical care for women in low- and middle-income countries is a global health priority. It’s also <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60497-4/fulltext">critical for sustainable development</a> because of the critical role women play in macro-economic growth, community well-being, and as part of the healthcare workforce.</p>
<p>When the inequities and disparities in obstetric outcomes between world regions came to the attention of governments and multinational organisations, maternal health initiatives were started in regions with <a href="https://theconversation.com/increasing-caesarean-sections-in-africa-could-save-more-mothers-lives-75879">the highest maternal mortality rates, including sub-Saharan Africa</a>. This has contributed to an almost <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">40% reduction</a> in maternal deaths in sub-Saharan Africa in the last two decades.</p>
<p>But the outcomes of other kinds of surgery for women in Africa have remained under-examined. Women need equitable surgical care <a href="https://pubmed.ncbi.nlm.nih.gov/26606703/">throughout their lives</a> – not just during childbirth. </p>
<p>In our <a href="https://www.sciencedirect.com/science/article/pii/S2772609622000995#!">recent study</a> we compared the outcomes of non-obstetric surgery for women in African countries with the outcomes for women in countries outside Africa. We wanted to bring attention to the outcomes and establish whether there was a large disparity between the groups. At the surface the outcomes seemed similar: 2.9% of the African patients and 2.3% of the international group experienced severe complications after surgery. But when we adjusted for risk profile, African women were twice as likely to experience severe complications (including death) after surgery compared with the international incidence. </p>
<p>Our <a href="https://www.sciencedirect.com/science/article/pii/S2772609622000995#!">study</a> reveals an important and addressable health equity issue and makes a case for expanding funding and resources for women’s health and global surgery. The findings point to the urgent need to improve healthcare and surgical care for women in Africa.</p>
<h2>Comparing surgery outcomes</h2>
<p><a href="https://www.sciencedirect.com/science/article/pii/S2772609622000995#!">The study</a> was an analysis of data from two large, similar studies: the African Surgical Outcomes Study (<a href="https://www.asos.org.za/ASOS%20Lancet%20publication.pdf">ASOS</a> and the International Surgical Outcomes Study (<a href="https://isos.org.uk/isos.php">ISOS</a>. There were 1,671 women in the African cohort and 18,449 in the international cohort (from low-, middle- and high-income countries elsewhere in the world).</p>
<p>We focused on the outcomes of operations such as orthopaedic and bowel surgery. We excluded obstetric and gynaecological surgeries such as caesarean sections and hysterectomies.</p>
<p>At first glance, the rates of severe complications appeared to be similar: 2.9% of women in the African cohort developed a severe complication and 2.3% of women in the international cohort did. </p>
<p>But the African cohort was almost a decade younger. The African women also had significantly fewer comorbidities such as diabetes and hypertension. And they typically underwent more minor and fewer major surgeries. One would therefore expect their outcomes to be significantly better. This means the African outcomes were disproportionately worse.</p>
<p>Our analysis then adjusted for these differences in health status and type of surgical procedure. The analysis confirmed that, if the risk profiles were equal, women in the African cohort would have twice the odds of dying or having a severe complication after surgery. </p>
<p>This indicates that health system factors, such as staffing and infrastructure, are severely affecting women’s surgical care and health in Africa. This not only affects the patients, but has ripple effects for their families, communities and the macroeconomic development of their countries.</p>
<p>Almost half – 48% – of the women who developed severe complications in the African cohort died while in hospital (versus 18% in the international cohort). This is a particular cause for concern.</p>
<p>The percentage of severe complications that result in death is known as the “<a href="https://academic.oup.com/bja/article/119/2/258/3939718">failure-to-rescue</a>” rate. It’s largely determined and prevented by the early detection of potentially serious postoperative complications in hospital – and fast and effective clinical action in response. Where there are staff shortages, high patient loads and limited funding, doctors and nurses are stretched. Many hospitals in these settings don’t have the resources and warning systems to pick up these complications and act early enough. This is currently a <a href="https://blogs.worldbank.org/opendata/why-are-people-dying-following-surgery-africa">major issue</a> in African health systems.</p>
<h2>Future steps</h2>
<p>Women at all life stages and from all backgrounds deserve access to safe and comprehensive surgical care. Our study highlights the need for further research and investment into women’s surgical care in African countries.</p>
<p><a href="https://www.thecairoreview.com/essays/more-than-a-monolith/">Africa is not a monolith</a>. There are vast differences between and within African countries’ health systems. Therefore there’s a need for country-specific and condition-specific research into women’s surgical care and ways to improve these outcomes on the African continent.</p><img src="https://counter.theconversation.com/content/198887/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Salome Maswime receives funding from the South African Medical Research Council, UNICEF and the National Institites of Health. </span></em></p><p class="fine-print"><em><span>Amy Paterson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The outcomes of obstetric operations has improved in the past decades. But women need equitable surgical care throughout their lives - not just during childbirth.Amy Paterson, DPHIL STUDENT, University of OxfordSalome Maswime, Professor of Global Surgery, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1946432022-12-01T02:46:43Z2022-12-01T02:46:43ZWhy do nurse home visits stop a few weeks after giving birth? Extending them to 2 years benefits the whole family<figure><img src="https://images.theconversation.com/files/498167/original/file-20221130-26-xgedg.jpg?ixlib=rb-1.1.0&rect=35%2C17%2C5955%2C3970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/mother-with-baby-in-arms-7282407/">Pexels/Sarah Chai</a></span></figcaption></figure><p>Bringing home a new baby can be one of the most exciting and stressful times in your life. A nurse might visit a couple of times, then other than routine check-ups at the nurse’s office, you’re largely on your own. </p>
<p>Some people have a particularly hard time with a new baby because the challenges of parenting come on top of existing adversity, such as financial hardship, or poor physical or mental health. </p>
<p>Experiencing adversity from when a baby is conceived can affect the child’s <a href="https://www.rch.org.au/uploadedFiles/Main/Content/ccchdev/CCCH-The-First-Thousand-Days-An-Evidence-Paper-Summary-September-2017.pdf">health and development</a> as they grow older. So rather than stopping nurse visits a week or two after bringing a new baby home, we investigated whether extending these visits from pregnancy until children turned two made a difference. </p>
<p>The nurse visits focused on areas fundamental for children’s development: how a parent cares for and responds to their child, and their home environment. </p>
<p>We found home visits with nurses helps parenting and family relationships, and women’s mental health, wellbeing and confidence.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1380610832485154816"}"></div></p>
<h2>What happens when the nurse visits?</h2>
<p>Sustained nurse home visiting provides intensive services in a family’s home during pregnancy and the first two years of the child’s life. During this time, the child’s brain develops more rapidly than any other time in their life. </p>
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Read more:
<a href="https://theconversation.com/how-do-i-know-if-my-child-is-developing-normally-129137">How do I know if my child is developing normally?</a>
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<p>International studies of sustained nurse home visiting programs show <a href="https://onlinelibrary.wiley.com/doi/10.1111/jan.14576">they can help families</a> with parenting, children’s behaviour and academic skills. However, most have only measured impacts up to when children turn three. </p>
<p>Programs differ depending on how they work to support families. They generally engage highly-trained nurses who can listen without judgement, offer practical, evidence-informed advice, and remind parents they’re doing a good job.</p>
<h2>Our study</h2>
<p>Our randomised controlled trial of <a href="https://www.rch.org.au/ccch/research-projects/right-at-home/">right@home</a> is Australia’s longest and largest trial of nurse home-visiting, starting in 2013. </p>
<p>The program supports parents with evidence-based techniques that promote parenting that responds to the child’s needs, safe homes, regular routines, and children’s learning and language development. The program starts in pregnancy and offers 25 home visits (60-90 minutes each) with a specially trained nurse until the children turn two. </p>
<p>The right@home program was designed for delivery through Australia’s existing child and family health nursing services, which are free for families with children from birth to school age. These existing services typically offer a handful of appointments (of around 20-40 minutes) that mostly take place in local clinics. Some also offer more intensive services.</p>
<figure class="align-center ">
<img alt="Toddler reads from a board book" src="https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Existing nurse services only offer a handful of appointments from birth to school age.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/u0zTce7KNlY">Unsplash/Stephen Andrews</a></span>
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<p>We invited women into the right@home study if they were experiencing two or more factors that can make it more difficult to parent. These include having low social support, poor physical or emotional health, or no household employment. We found <a href="https://onlinelibrary.wiley.com/doi/10.1111/jpc.13860">almost 40%</a> of pregnant women experienced at least two of these factors. </p>
<p>In total, 722 women and families living across Victoria and Tasmania took part in the study. Half were randomly allocated (like tossing a coin) to receive the right@home program and half received their local child and family health nursing service. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/parents-have-the-biggest-influence-over-their-childs-language-and-emotional-development-55823">Parents have the biggest influence over their child's language and emotional development</a>
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<h2>What did we find?</h2>
<p>Researchers who were separate to the nurse teams interviewed the families twice a year (one at home and one by phone) until children started school. </p>
<p>When the right@home program ended (at children’s second birthdays), the evaluation showed it <a href="https://doi.org/10.1542/peds.2018-1206">offered benefits</a> over and above the usual services. Parents had more confidence and skills in caring for their children, responding sensitively and providing a nurturing and stimulating home. </p>
<p>This pattern <a href="https://publications.aap.org/pediatrics/article/147/2/e2020025361/77055/Nurse-Home-Visiting-and-Maternal-Mental-Health-3">continued</a>. At three years, parents who received the right@home program reported benefits to their mental health, wellbeing, and self-confidence. </p>
<figure class="align-center ">
<img alt="Parents snuggle their newborn baby" src="https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Nurses can remind new parents they’re doing a good job.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/cheerful-young-multiethnic-parents-admiring-sleeping-baby-on-bed-6392952/">Pexels/William Fortunato</a></span>
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<p>Our latest paper, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0277773">published in PLOS ONE</a>, shows that right@home offered lasting impacts to four and five years, which is two and three years after the program ended. </p>
<p>Some 5-10% more families had regular mealtimes, bedtimes and bedtime routines by the time the children turned five.</p>
<p>Around 9% more women reported very good health and parenting confidence. The proportions of women experiencing stress, and emotional abuse from an intimate partner were 7% and 11% lower, respectively. </p>
<p>There were additional benefits for children’s and women’s mental health, parenting, and women’s wellbeing, quality of life and relationship with their child. These impacts were evident for families regardless of where they lived across the seven regional and metropolitan areas in the two states.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/having-problems-with-your-kids-tantrums-bed-wetting-or-withdrawal-heres-when-to-get-help-125299">Having problems with your kid's tantrums, bed-wetting or withdrawal? Here's when to get help</a>
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</p>
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<h2>Levelling the playing field for kids</h2>
<p>A goal of the program is to address the challenging circumstances that disrupt parenting and affect children’s health and development.</p>
<p>If Australia did this, and provided support according to need, we could reduce children’s poor developmental outcomes by <a href="https://doi.org/10.1093/ije/dyy087">50%-70%</a>.</p>
<p>Providing equitable support is especially important as we <a href="https://bmjpaedsopen.bmj.com/content/6/1/e001390">emerge from the COVID pandemic</a>, which has <a href="https://doi.org/10.5694/mja2.51368">disproportionately affected</a> families already experiencing adversity. </p>
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<img alt="Mother wipes ice cream from her daughter's chin" src="https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Greater early support boosts mothers’ mental wellbeing.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/attentive-asian-mother-cleaning-face-of-cute-daughter-5094378/">Kamaji Ogino/Pexels</a></span>
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<p>Almost no other public health program delivered during the early years has evidence of such a broad range of gains. </p>
<p><a href="https://bmjopen.bmj.com/content/11/12/e052156">Our economic evaluation</a> of right@home at three years showed delivering these benefits through the right@home program costs A$7,700 extra per family compared with the usual service.</p>
<p>Research from the US shows the benefits of <a href="http://www.wsipp.wa.gov/BenefitCost/Program/35">similar programs</a> accrue for families and taxpayers over a child’s lifetime, producing positive returns on investment, from improved mental health and more employment, among other benefits.</p>
<p>Australia is fortunate to have nationwide child and family health nursing services. These are the perfect platform for delivering an extended program like right@home. When so few programs make a difference for families experiencing adversity, we should maximise the reach of those that do.</p>
<p><em>Diana Harris, Lead for Knowledge Translation at the Australian Research Alliance for Children & Youth, coauthored this article.</em></p>
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Read more:
<a href="https://theconversation.com/stressed-about-managing-your-childs-behaviour-here-are-four-things-every-parent-should-know-104481">Stressed about managing your child's behaviour? Here are four things every parent should know</a>
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<img src="https://counter.theconversation.com/content/194643/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>right@home is supported by the state governments of Victoria and Tasmania, the Ian Potter Foundation, Sabemo Trust, Sidney Myer fund, the Vincent Fairfax Family Foundation, and the National Health and Medical Research Council (NHMRC, 1079148). The MCRI administered the research grant for the study and provided infrastructural support to its staff but played no role in the conduct or analysis of the trial. Research at the MCRI is supported by the Victorian Government's Operational Infrastructure Support Program. SG was supported by NHMRC Practitioner Fellowship (1155290).
The “right@home” sustained nurse home visiting trial is a research collaboration between the Australian Research Alliance for Children and Youth (ARACY); the Translational Research and Social Innovation (TReSI) Group at Western Sydney University; and the Centre for Community Child Health (CCCH), which is a department of The Royal Children's Hospital and a research group of Murdoch Children’s Research Institute. Ownership of the right@home implementation and support license, which is purchased by Australian state governments for roll out for fidelity support, is shared between institutes.</span></em></p><p class="fine-print"><em><span>The MECSH home visiting program upon which right@home is based is trademarked and licenced by Western Sydney University and was developed by UNSW Australia. Western Sydney University is a member of the right@home consortium that receives funding from Australian state governments to support the implementation of the program. Western Sydney University also licenses the MECSH program to government and non-government providers of home visiting services in the UK and USA. </span></em></p><p class="fine-print"><em><span>Sharon Goldfeld receives funding from ARC and NHMRC.</span></em></p>Extending visits from nurses who can listen without judgement and offer practical, evidence-informed advice helps new parents who are experiencing adversity.Anna Price, The Erdi Foundation Child Health Equity (COVID-19) Scholar, Centre for Community Child Health | Honorary, Department of Paediatrics, University of Melbourne | Team Leader / Senior Research Officer, Murdoch Children's Research InstituteLynn Kemp, Director of the Translational Research and Social Innovation group, School of Nursing and Midwifery, Western Sydney UniversitySharon Goldfeld, Director, Center for Community Child Health Royal Children's Hospital; Professor, Department of Paediatrics, University of Melbourne; Theme Director Population Health, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1939092022-11-30T13:35:39Z2022-11-30T13:35:39ZMore than 4 in 5 pregnancy-related deaths are preventable in the US, and mental health is the leading cause<figure><img src="https://images.theconversation.com/files/498087/original/file-20221129-14-ezp753.jpg?ixlib=rb-1.1.0&rect=27%2C27%2C4524%2C3064&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">According to the CDC's latest numbers, 65% of pregancy-related deaths occur in the first year following childbirth.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/a-young-woman-holds-her-newborn-baby-in-a-safety-royalty-free-image/834822152">Petri Oeschger/Moment via Getty Images</a></span></figcaption></figure><p>Preventable failures in U.S. maternal health care result in far too many pregnancy-related deaths. Each year, approximately <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths.html#">700 parents die from pregnancy and childbirth complications</a>. As such, the U.S. maternal mortality rate is <a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries">more than double </a> that of most other developed countries.</p>
<p>The Department of Health and Human Services declared maternal deaths a <a href="https://www.hhs.gov/sites/default/files/call-to-action-maternal-health.pdf">public health crisis</a> in December 2020. Such calls to action by the U.S. Surgeon General are reserved for only the most serious of public health crises.</p>
<p>In October 2022, the Centers for Disease Control and Prevention released new data <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html">gathered between 2017 and 2019</a> that further paints an alarming picture of maternal health in the U.S. The report concluded that a staggering <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">84% of pregnancy-related deaths are preventable</a>. </p>
<p>However, these numbers don’t even reflect how widespread this problem could be. At present, only 39 states have <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">dedicated committees in place</a> to review maternal deaths and determine whether they were preventable; of those, 36 states were included in the latest CDC data.</p>
<p>I am a <a href="https://www.adler.edu/programs/rachel-diamond/">therapist and scholar</a> specializing in mental health during the perinatal period, the time during pregnancy and postpartum. Research has long demonstrated <a href="https://www.mmhla.org/wp-content/uploads/2020/07/MMHLA-Main-Fact-Sheet.pdf">significant mental health risks</a> associated with pregnancy, childbirth and the year following childbirth. The CDC’s report now makes it clear that mental health conditions are an important factor in many of these preventable deaths.</p>
<h2>A closer look at the numbers</h2>
<p>The staggering number of preventable maternal deaths – 84% – from the CDC’s most recent report represents a 27% increase from the agency’s previous report, <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief_2019-h.pdf">from 2008 to 2017</a>. Of these pregnancy-related deaths, 22% occur during pregnancy, 13% during childbirth and 65% during the year following childbirth.</p>
<p>This raises the obvious question: Why are so many preventable pregnancy-related deaths occurring in the U.S., and why is the number rising?</p>
<p>For a pregnancy-related death to be <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">categorized as preventable</a>, a maternal mortality review committee must conclude there was some chance the death could have been avoided by at least one reasonable change related to the patient, community, provider, facility or systems of care. </p>
<p>The <a href="https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf">most commonly identified factors</a> in these preventable deaths have been those directly related to the patient or their support networks, followed next by providers and systems of care. While patient factors may be most frequently identified, they are often dependent on providers and systems of care.</p>
<p>Take, for instance, the example of a new mother dying by suicide from a mental health condition, such as depression. Patient factors could include her lack of awareness about the warning signs of clinical depression, which she may have mistaken for difficulties with the transition to parenthood and perceived personal failures as a new parent. </p>
<p>As is often the case, these factors would have directly related to the inaction of health care providers, such as a failure to screen for mental health concerns, delays in diagnosis and ineffective treatment. This type of breakdown – which is common – would have been made worse by poor coordination of care between providers across the health care system.</p>
<p>This example illustrates the complexities of the failures and preventable outcomes in the maternal health care system. </p>
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<figcaption><span class="caption">The U.S. has a far higher rate of pregnancy-related deaths than other developed nations.</span></figcaption>
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<h2>The role of mental health</h2>
<p>In the CDC’s latest report, mental health conditions are the overall <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html">most frequent cause of pregnancy-related death</a>. Approximately 23% of deaths are attributed to suicide, substance use disorder or are otherwise associated with a mental health condition. The next two leading causes are hemorrhage and cardiac conditions, which combined contribute to only slightly more deaths than mental health conditions, at about 14 and 13%, respectively.</p>
<p>Research has long shown that <a href="https://doi.org/10.1001/jamapsychiatry.2013.87">1 in 5 women</a> suffer from mental health conditions during pregnancy and the postpartum period, and that this is also a time of <a href="https://doi.org/10.1016/j.ajog.2016.03.040">increased risk for suicide</a>. Yet, mental illness – <a href="https://doi.org/10.1542/peds.2010-2348">namely, depression</a> – is the most underdiagnosed obstetric complication in America. Despite some promising reductions in U.S. suicide rates in the general population over the last decade, <a href="https://doi.org/10.1001/jamapsychiatry.2020.3550">maternal suicide has tripled</a> during this same time period.</p>
<p>As it relates to maternal substance use, this issue is also worsening. In recent years, almost all deaths from drug overdose during pregnancy and the postpartum period involved opioids. A review from 2007 to 2016 found that pregnancy-related deaths <a href="https://doi.org/10.1016/j.ajog.2018.09.028">involving opioids more than doubled</a>. </p>
<p>Many of these issues stem from the fact that up to 80% of women with maternal mental health concerns are <a href="https://www.themotherhoodcenter.com/blogindex/2022/6/23/what-are-perinatal-mood-and-anxiety-disorders-pmads#">undiagnosed or untreated</a>. </p>
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<h2>Barriers to care</h2>
<p>In 2021, the first national data set of its kind showed that <a href="https://www.2020mom.org/blog/2022/11/14/us-maternal-depression-screening-rates-released-for-the-first-time?emci=d266ca19-ae66-ed11-ade6-14cb65342cd2&emdi=726c140a-d666-ed11-ade6-14cb65342cd2&ceid=8668229">less than 20% </a> of prenatal and postpartum patients were screened for depression. Only half of those who screened positive received follow-up care.</p>
<p>Research has long demonstrated widespread <a href="https://www.issuelab.org/resources/40013/40013.pdf">barriers and gaps</a> in maternal mental health care. Many health care providers do not screen for mental health concerns because they do not know where to refer a patient or how to treat the condition. In addition, only about <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care">40% of new mothers</a> even attend their postpartum visit to have the opportunity for detection. Non-attendance is more common among <a href="https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=0&sid=aa757e01-7bbb-4387-9f50-ee7cfd726f00%40redis">higher-risk populations of postpartum women</a>, such as those who are socially and economically vulnerable and whose births are covered by Medicaid. </p>
<p>Medicaid covers around <a href="https://www.cdc.gov/nchs/products/databriefs/db387.htm#section_3">4 in 10 births</a>. Through <a href="https://americanpregnancy.org/healthy-pregnancy/planning/medicaid-for-pregnant-women/">Medicaid benefits</a>, pregnant women are covered for care related to pregnancy, birth and associated complications, but only up to 60 days postpartum. Not until 2021 did the <a href="https://www.kff.org/policy-watch/postpartum-coverage-extension-in-the-american-rescue-plan-act-of-2021/">American Rescue Plan Act</a> begin extending Medicaid coverage up to one year postpartum. </p>
<p>But as of November 2022, only <a href="https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/">27 states</a> have adopted the Medicaid extension. In the other states, new mothers lose postpartum coverage after just 60 days. This matters a great deal because low-income mothers are at a <a href="https://doi.org/10.1542/peds.2010-2348">greater risk for postpartum depression</a>, with reported rates as high as 40% to 60%. </p>
<p>In addition, the recent CDC report showed that 30% of preventable pregnancy-related deaths happened between 43 and 365 days postpartum – which is also the time frame <a href="https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf">suicide most commonly occurs</a>. Continued Medicaid expansion would reduce the number of uninsured new parents and <a href="https://ccf.georgetown.edu/wp-content/uploads/2021/09/maternal-health-and-medex-final.pdf">rates of maternal mortality</a>. </p>
<p>Another challenging barrier to addressing maternal mental health is the criminalization of substance use during pregnancy. If seeking care exposes a pregnant person to the <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist">possibility of criminal or civil pentalties</a> – including incarceration, involvement with child protective services and the prospect of separation from their baby – it will naturally dissuade them from seeking treatment. </p>
<p>At this time, 24 states consider <a href="https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy">substance use during pregnancy to be child abuse</a>, and 25 states require health care professionals to report suspected prenatal drug use. Likewise, there are also tremendous barriers in the postpartum period for mothers seeking substance use treatment, due in part to the lack of <a href="https://doi.org/10.1111/famp.12501">family-centered options</a>. </p>
<p>With all these barriers, many pregnant and new mothers may make the difficult decision to not engage in treatment during a critical window for intervention.</p>
<h2>Looking ahead</h2>
<p>While the information described above already paints a dire picture, the CDC data was collected prior to two major events: the COVID-19 pandemic and the <a href="https://theconversation.com/roe-overturned-what-you-need-to-know-about-the-supreme-court-abortion-decision-184692">fall of Roe v. Wade</a>, which overturned nearly 50 years of abortion rights. Both of these events have <a href="https://www.axios.com/2022/07/05/maternal-mortality-death-abortion-ban-roe">exacerbated existing cracks</a> in the health care system and, subsequently, worsened the <a href="https://www.gao.gov/assets/730/723432.pdf">maternal health in the U.S.</a> </p>
<p>In my view, without radical changes to maternal health care in the U.S., starting with how mental health is treated throughout pregnancy and postpartum, it’s likely parents will continue to die from causes that could otherwise be prevented.</p><img src="https://counter.theconversation.com/content/193909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Diamond does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many of the preventable pregnancy-related deaths documented by the CDC are directly attributable to failures and barriers in the maternal care system.Rachel Diamond, Clinical Training DIrector and Assistant Professor of Couple and Family Therapy, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1923442022-10-13T14:22:00Z2022-10-13T14:22:00ZTigray’s healthcare workers haven’t been paid in over a year – and bear the brunt of the war<figure><img src="https://images.theconversation.com/files/489388/original/file-20221012-5607-61pmb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The unfolding crisis will only worsen the situation in Tigray.</span> <span class="attribution"><span class="source">Eduardo Soteras/AFP via Getty Images</span></span></figcaption></figure><p>Tragic stories of suffering and death have emerged from Tigray since 2020, when civil war erupted between the central Ethiopian government and the regional Tigrayan government.</p>
<p>In just one example, a professor who headed Ayder Hospital’s oncology department in Mekelle, the capital city of Tigray, <a href="https://www.theguardian.com/global-development/2022/may/25/i-saw-an-oncologist-cry-tigray-cancer-patients-sent-home-to-die-for-lack-of-drugs">spoke</a> of women’s malnutrition and resulting childbirth complications and deaths.</p>
<p>It’s not only the patients who are suffering. Despite being <a href="https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/INTRO/365?OpenDocument">protected</a> by <a href="https://www.icrc.org/en/doc/assets/files/publications/icrc-002-0173.pdf">international laws</a>, healthcare workers and health facilities in the region are extremely vulnerable. Since the war broke out, healthcare workers have <a href="https://pubmed.ncbi.nlm.nih.gov/34815244/">lost their jobs</a>, been <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00115-8/fulltext">displaced</a>, and been wounded, threatened or <a href="https://tigrayeao.info/tigray-health-bureau-tigray-health-sector-annual-bulletin-2021-january-2022/">killed</a>.</p>
<p>There have been <a href="https://www.state.gov/air-strike-on-village-market-in-tigray/">reports</a> of ambulances being obstructed and health workers being <a href="https://www.doctorswithoutborders.org/latest/widespread-destruction-health-facilities-ethiopias-tigray-region">prevented</a> from treating civilians. </p>
<p>There’s a lack of <a href="https://www.theguardian.com/global-development/2022/may/25/i-saw-an-oncologist-cry-tigray-cancer-patients-sent-home-to-die-for-lack-of-drugs">medical supplies</a>. Patients and healthcare workers have resorted to unusual measures. At one hospital, healthcare workers were <a href="https://apnews.com/article/health-ethiopia-africa-united-nations-dialysis-f9c2c16ba1ee9704fa3799d1846d7ee5">reusing gloves</a> and asking patients to bring white clothes that could be repurposed as gauze.</p>
<p>Tigray’s healthcare systems were already <a href="https://ligsuniversity.com/blog/assessment-of-hr-standards-in-private-and-public-hospitals-in-tigray-region-ethiopia">under pressure</a> before the war. The unfolding crisis will only worsen the situation. Action is crucial: the international community must recognise and acknowledge that accepted global norms related to healthcare workers’ safety are being violated. They must condemn the situation in the strongest terms. Tigray’s health sector needs support – both now and when the war ends.</p>
<h2>Trying circumstances</h2>
<p>Healthcare workers in Tigray were last paid in <a href="https://www.devex.com/news/opinion-in-tigray-we-are-demanding-food-and-medicine-not-bombs-102621">May 2021</a>. In July 2021, <a href="https://pubmed.ncbi.nlm.nih.gov/34815244/">50%</a> of the region’s roughly 20,000 healthcare workers did not report for normal duty. This figure includes all 741 <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-12-352">health extension workers</a> employed in posts across Tigray to provide primary healthcare services, including crucial maternal and child health services.</p>
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Read more:
<a href="https://theconversation.com/what-people-from-war-torn-tigray-told-us-about-the-state-of-their-lives-amid-the-war-180594">What people from war-torn Tigray told us about the state of their lives amid the war</a>
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<p>The economic meltdown and the ongoing violence have prompted many healthcare workers to flee. Some have remained in the area, seeking refuge in camps for internally displaced people. Researchers found about <a href="https://pubmed.ncbi.nlm.nih.gov/34815244/">2,000 healthcare workers</a> living in one such camp in Mekelle. Others <a href="https://www.unhcr.org/news/stories/2021/2/6033e61d4/working-commitment.html">have fled</a> to neighbouring countries like Sudan.</p>
<p>During an interview with the BBC on 3 October 2021, the head of the Tigray region Health Bureau, Dr Hagos Godefay, reported that <a href="https://gh.bmj.com/content/7/4/e008475">22,000</a> health workers were displaced. </p>
<p>Those who have continued to work, along with international aid workers providing healthcare support, are extremely vulnerable. The regional Health Bureau reports that <a href="https://www.devex.com/news/opinion-in-tigray-we-are-demanding-food-and-medicine-not-bombs-102621">37 healthcare workers have been killed and 78 wounded</a> since the start of the war. The UN says <a href="https://reliefweb.int/report/ethiopia/hc-ai-statement-killing-23-aid-workers-tigray-region-start-crisis">23 aid workers</a> have died. </p>
<h2>Fears for the future</h2>
<p>Healthcare infrastructure has not been spared in this conflict. Seventy-eight percent of health posts (primary healthcare structures), 72% of health centres, and 80% of hospitals have been <a href="https://www.ethiopia-insight.com/2022/01/26/data-shows-siege-and-destruction-of-health-system-are-causing-preventable-deaths-in-tigray/">destroyed</a>. </p>
<p><a href="https://www.researchgate.net/publication/349750000_Status_of_the_Tigray_universities_Ethiopia_after_nine_months_of_war">Educational facilities</a>, including medical colleges, have also repeatedly come under attack. The resulting disruptions bode ill for the future – Tigray may experience a significant gap in the supply of skilled health professionals in the coming years.</p>
<p>Some students from the medical colleges have stepped up to provide services, despite not yet being qualified. This unfortunate situation imposes a responsibility beyond their capacity. It’s also likely to cause extreme stress in their lives and may drive them out of the profession after the war.</p>
<p>The extreme and blatant disregard of healthcare
workers’ neutrality (which is guaranteed in numerous international agreements), the <a href="https://globalhealthnow.org/2022-04/tigray-and-its-health-care-system-under-siege">denial</a> of access to basic services for civilians and wounded combatants, and the destruction of healthcare infrastructure in the Tigray war cannot be justified. </p>
<h2>Looking ahead</h2>
<p>It is a painful paradox. At a time when Tigray’s citizens need it most, they cannot access good, reliable, safe healthcare. We fear that the situation won’t improve.</p>
<p>We expect that Tigray’s post-conflict period will be characterised by poor health outcomes due to the limited availability of healthcare workers and complete collapse of its healthcare system. The brain drain of health workers and collapse of the healthcare system, and sustained negative health outcomes in the population after the conflict, have been seen in several conflict areas such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947047/">Sierra Leone</a> and <a href="https://www.sciencedirect.com/science/article/pii/S0277953621000836">Yemen</a>. </p>
<p>Here’s what’s needed to address the situation:</p>
<ul>
<li><p>global advocacy and a show of solidarity from the international community</p></li>
<li><p>mobilisation and financial commitment to rebuild the health workforce </p></li>
<li><p>demanding accountability from those who have flagrantly violated international law and ignored global norms around protecting healthcare workers even in times of conflict.</p></li>
</ul><img src="https://counter.theconversation.com/content/192344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fisaha Tesfay works as humanitarian coordinator for Tigrean diasporas living in Australia, New Zealand and East Asia to ease the humanitarian crisis in Tigray </span></em></p><p class="fine-print"><em><span>Fasika Amdesellassie and Hailay Gesesew do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Since the war broke out, some healthcare workers have lost their jobs, others have been displaced, wounded, threatened or killed.Hailay Gesesew, NHMRC Research Fellow (Public Health), Flinders UniversityFasika Amdesellassie, Surgeon, Ayder Hospital, Mekelle UniversityFisaha Tesfay, Postdoctoral Research Fellow, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1891152022-10-06T13:44:06Z2022-10-06T13:44:06ZNigerian newborns weigh less if their mothers use biomass fuel - a major health risk<figure><img src="https://images.theconversation.com/files/487412/original/file-20220929-21-m1469e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Low birth weight is the primary cause of infant morbidity and mortality in Nigeria. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/young-babies-sleep-together-under-a-heat-lamp-at-the-lagos-news-photo/81924722?adppopup=true">Bennett Raglin/WireImage</a></span></figcaption></figure><p>Babies should ideally weigh <a href="https://www.medicalnewstoday.com/articles/325630#average-weights">about 2,500g or more at birth</a>. Birth weight is a <a href="https://academic.oup.com/ije/article/30/6/1233/651751">vital indicator</a> of foetal and neonatal health. If a newborn weighs less than 2,500g – because they are preterm or their growth in the womb was restricted for some reason – they are <a href="https://reliefweb.int/report/nigeria/nigeria-profile-preterm-and-low-birth-weight-prevention-and-care">more at risk</a> of death, disability and noncommunicable diseases. </p>
<p>The low birth weight infant’s tiny body is not as strong as it should be. The baby might struggle to gain weight and fight infection. And with so little body fat, these babies often have difficulty staying warm in normal temperatures.</p>
<p>Low birth weight is <a href="https://www.tandfonline.com/doi/full/10.3402/gha.v9.28822">the primary cause</a> of infant morbidity and mortality in Nigeria.</p>
<p>The factors that are known to influence a baby’s weight at birth <a href="https://www.panafrican-med-journal.com/content/article/20/108/full/">include</a> duration of pregnancy, and maternal characteristics like age, parity (the number of times a woman has given birth) and illness, as well as adverse environmental exposures.</p>
<p>One factor that hasn’t been studied much in Nigeria is the type of cooking fuel that the baby’s mother uses or is exposed to during pregnancy. My research group suspected this might be a significant factor because of the high prevalence of low birth weight in Nigeria and the fact that biomass fuel is <a href="https://ng.boell.org/en/clean-cooking-energy">commonly used</a>.</p>
<p>Nigeria <a href="https://pubmed.ncbi.nlm.nih.gov/25103583/#:%7E:text=Two%2Dthirds%20of%20small%2Dfor,Pakistan%2C%20Nigeria%2C%20and%20Bangladesh.">is among the five countries</a> where most preterm and small-for-gestational-age infants are born. <a href="https://www.countdown2015mnch.org/documents/2012Report/Nigeria_Report_ExecSum.pdf">About 5.9 million babies are born in Nigeria each year</a>, and 15% of these newborns have a low birth weight accounting for 25% of infant mortality. </p>
<p>Our <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000419">study</a> explored the association between biomass cooking fuel and birth weight among full term births in Kaduna, northwestern Nigeria. We found there was a link – and this was supported by <a href="https://dhsprogram.com/pubs/pdf/SR264/SR264.pdf">data from the nationally representative Demographic and Health Survey</a>. Mothers in Kaduna who were exposed to biomass fuel gave birth to infants who were on average 113g lighter than those using liquefied petroleum gas, which is <a href="https://group.met.com/en/media/energy-insight/what-is-lpg-liquefied-petroleum-gas#:%7E:text=LPG%20is%20a%20cleaner%20energy,use%20natural%20gas%20as%20fuel.">a cleaner fuel</a>. Nationally, mothers using biomass had infants weighing 50g lower at birth than those using clean fuel.</p>
<p>Exposure to biomass fuel combustion during pregnancy <a href="https://pubmed.ncbi.nlm.nih.gov/18639310/">could adversely affect</a> foetal growth or increase preterm birth risk, resulting in a child born early or small for gestational age and thus creating further health risks for the child. </p>
<p>Biomass fuel includes wood, animal dung, charcoal and crop residues. It is used worldwide for cooking, heating and lighting. Biomass fuels and <a href="https://onlinelibrary.wiley.com/doi/10.1111/1467-8268.12348">kerosene</a> are still widely used in urban and rural Nigeria due to supply and demand issues driving household energy choices. </p>
<p>The study results show the importance of efforts to make safer fuel choices available.</p>
<h2>Kaduna and national Nigerian data</h2>
<p>Our study focused only on term infants because <a href="https://pubmed.ncbi.nlm.nih.gov/1536353/">duration of pregnancy independently affects</a> birth weight, and multiple factors influence preterm birth. </p>
<p>We conducted the primary analysis based on a study of 1,514 mother-child pairs in Kaduna, northwestern Nigeria. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9278217/">Kaduna</a> is the fourth largest city in Nigeria, with a population of 1.6 million. </p>
<p>To validate the primary analysis, we repeated it using data from 6,975 mother-child pairs in the most recent <a href="https://www.dhsprogram.com/publications/publication-fr359-dhs-final-reports.cfm">Nigeria Demographic and Health Survey 2018</a>.</p>
<p>The primary analysis classified cooking fuel types as liquefied petroleum gas, kerosene and biomass fuel (including charcoal, wood, crops or straw, and animal dung). In the survey, cooking fuels were categorised into low pollution fuel (electricity, liquefied petroleum gas and natural gas), kerosene and biomass fuel.</p>
<p>In both analyses, we observed that the impact of biomass use on birth weight was greater than the impact of liquefied petroleum gas or kerosene.</p>
<p>The results highlight the need for public health intervention. Reducing adverse birth outcomes like low birth weight will depend on addressing regional disparities in the key determinants. </p>
<p>Our results showed that birth order, household size, and socio-economic status influenced cooking fuel choice, which is consistent with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7995525/">existing literature</a>. It is reasonable that the women least able to use clean cooking fuels will be those who:</p>
<ul>
<li><p>live in households of five or more people</p></li>
<li><p>live in poorer households</p></li>
<li><p>have given birth at least once before. </p></li>
</ul>
<p>This could be due to cost and unreliable fuel supply. Women with more children or living in larger households might also cook with bigger pots, requiring longer cooking times, which increases their exposure to indoor air pollution from biomass fuel use.</p>
<h2>Recommendations</h2>
<p>We recommend that pregnant women attending antenatal care be asked about cooking fuels and given help to minimise prenatal biomass exposure. Some recent intervention trials conducted in low- and middle-income countries, including Nigeria, have shown that transition from biomass fuel to cleaner fuels reduces air pollution and <a href="https://www.sciencedirect.com/science/article/pii/S0160412016306018">improves outcomes like birth weight</a>. </p>
<p>Interventions to reduce indoor air pollution could include a stove subsidy, fuel subsidy, fuel ban and behaviour change communication. </p>
<p>It’s important first to understand why a household uses a particular cooking fuel.</p>
<p>It is also vital to <a href="https://pubmed.ncbi.nlm.nih.gov/28055947/">learn</a> from other household health interventions, such as sanitation and nutrition. These can enhance an understanding of what bars or enables adoption of a new method.</p><img src="https://counter.theconversation.com/content/189115/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Musa Kana does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pregnant women attending antenatal care should be asked about cooking fuels and given help to minimise prenatal biomass exposure to reduce low birth weight in Nigeria.Musa Kana, Perinatal Epidemiologist, Kaduna State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1883612022-08-11T03:00:19Z2022-08-11T03:00:19ZSepsis is serious during pregnancy, but thankfully it is still rare<figure><img src="https://images.theconversation.com/files/478470/original/file-20220810-14-z1zgd6.jpg?ixlib=rb-1.1.0&rect=23%2C46%2C5152%2C3399&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/asian-pregnant-woman-patient-on-600w-454486129.jpg">Shutterstock</a></span></figcaption></figure><p>The tragic case of <a href="https://www.theage.com.au/national/victoria/a-cascade-of-failures-how-annie-moylan-lost-her-child-and-her-life-in-melbourne-s-private-hospitals-20220802-p5b6je.html">Annie Moylan</a>, who died in Melbourne in 2017 from sepsis, when 18 weeks pregnant, has put a spotlight on this life-threatening condition. </p>
<p>Delay in receiving blood results, admission to a private hospital that did not provide obstetric care, and communication breakdown when Annie transferred to another private hospital all seem to have played a role in what has been described as a “cascade of failures”. A <a href="https://www.theage.com.au/national/victoria/a-cascade-of-failures-how-annie-moylan-lost-her-child-and-her-life-in-melbourne-s-private-hospitals-20220802-p5b6je.html">coronial inquest</a> into her death begins on Monday. </p>
<p>Sepsis can also happen after birth, as was seen in the devastating loss of <a href="https://www.abc.net.au/news/2018-02-27/michaela-perrin-coroner-findings-say-inadequate-care-given/9489790">Michaela Perrin</a> who died in 2014, six days having a healthy baby girl via caesarean section.</p>
<p>Women who are currently pregnant may worry about how cases such as these can happen in a country like Australia with an excellent health system. </p>
<p>Sepsis is a serious health condition for anyone, and pregnant women are no exception to this. Thankfully it is still rare for young women to die from the condition. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sepsis-still-kills-1-in-5-people-worldwide-two-icu-physicians-offer-a-new-approach-to-stopping-it-175650">Sepsis still kills 1 in 5 people worldwide – two ICU physicians offer a new approach to stopping it</a>
</strong>
</em>
</p>
<hr>
<h2>When the body fights itself</h2>
<p><a href="https://www.cdc.gov/sepsis/what-is-sepsis.html">Sepsis</a> is syndrome (or group of symptoms) mostly caused by a bacterial infection. It results when the body is trying to fight an infection and begins to damage its own tissues. This can lead to a serious drop in blood pressure, and organ damage. </p>
<p>In Australia, <a href="https://www.safetyandquality.gov.au/sites/default/files/2020-05/epidemiology_of_sepsis_-_february_2020_002.pdf">around 12%</a> of people hospitalised with sepsis will die from it. Very young (less than 12 months) and older people (over 85 years) are most vulnerable. The death rate for pregnant women with sepsis worldwide is estimated to be <a href="https://www.ajog.org/article/S0002-9378(19)30246-7/fulltext">between 1% and 4.6%</a>. </p>
<p>Treatment relies on early identification, antibiotics, intravenous fluids (fluid through a drip) and skilful medical care. For those who survive, there can be lifelong damage, both <a href="https://www.sepsis.org/sepsisand/amputations/">physically</a> and <a href="https://www.sepsis.org/sepsisand/post-traumatic-stress-disorder-ptsd/">psychologically</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1556227148683296768"}"></div></p>
<h2>What causes sepsis during pregnancy, or after birth?</h2>
<p>When sepsis happens during pregnancy, it is sometimes called maternal sepsis. After birth it is called postpartum or puerperal sepsis. </p>
<p>The syndrome can result from an infection anywhere in the body (such as pneumonia or a urinary tract infection) or it can be introduced during medical procedures like a caesarean section. </p>
<p>For this reason, all women who have a caesarean section are given intravenous antibiotics in the operating theatre to prevent sepsis. </p>
<p>For around <a href="https://www.ajog.org/article/S0002-9378(19)30246-7/fulltext">30% of cases</a>, no source of infection is found. </p>
<p>When identified, the <a href="https://www.somanz.org/content/uploads/2020/07/2017SepsisGuidelines.pdf">most common causes</a> of sepsis during and after pregnancy are <em>Escherichia coli</em> (<em>E. coli</em>) and group B <em>Streptococcus</em>. As mixed infections are also possible with sepsis, broad-spectrum antibiotics are given as soon as possible.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaginal-birth-after-caesarean-increases-the-risk-of-serious-perineal-tear-by-20-our-large-scale-review-shows-173249">Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows</a>
</strong>
</em>
</p>
<hr>
<h2>Sepsis was a major cause of women dying after birth</h2>
<p>Puerperal sepsis was once one of the main causes of women dying following childbirth. As knowledge about hygiene practices advanced and then antibiotics were introduced, this declined rapidly. However, sepsis has never been eliminated.</p>
<p>The work of Viennese physician <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2009.185363">Ignaz Philipp Semmelweis</a> in the mid-1800s led to the discovery that health provider hand-washing could reduce infection rates in women. </p>
<p>Semmelweis observed there was a much lower rate of women dying when cared for by midwives than doctors in two clinics and realised the midwives were not involved in autopsies and hence not carrying bacteria from the autopsy rooms into the maternity ward. </p>
<p>Semmelweis told anyone attending autopsies to scrub their hands with chloride and lime before entering the maternity ward. Soon after this, the rate of maternal deaths in the doctors’ clinics fell. </p>
<p>It took nearly another 30 years for Semmelweis’s ideas to be fully embraced. He <a href="https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives">suffered a tragic death</a> in an asylum and ironically succumbed to sepsis from a gangrenous wound to his hand.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="doctors washing hands" src="https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478471/original/file-20220810-4975-i1fx4v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Rates of maternal sepsis improved with the advent of better clinical hygiene.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/couple-surgeons-washing-hands-before-600w-633363035.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<p>It has been estimated nearly a half of all maternal deaths in the pre-antibiotic era (before the 1930s) were due to <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2009.185363">infection</a>. </p>
<p>“<a href="https://fivethirtyeight.com/features/what-the-history-of-back-alley-abortions-can-teach-us-about-a-future-without-roe/">Back-alley abortions</a>” were once another major cause of sepsis and death in women before better access to proper medical care for abortions was legislated in many countries. </p>
<p>Today, around <a href="https://msf.org.au/article/project-news/unsafe-abortion-forgotten-emergency">one in 12 maternal deaths</a> are from lack of access to safe abortion care and infection remains a big part of this. This is one reason why there is such grave concern over the recent overturning of <a href="https://www.ajog.org/article/S0002-9378(19)30246-7/fulltext">Roe vs Wade</a> in the United States.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-can-be-transmitted-to-babies-during-and-after-pregnancy-we-should-be-watchful-but-not-alarmed-188283">Monkeypox can be transmitted to babies during and after pregnancy. We should be watchful but not alarmed</a>
</strong>
</em>
</p>
<hr>
<h2>Rates of maternal sepsis today</h2>
<p>While sepsis is considered to be a <a href="https://www.ajog.org/article/S0002-9378(19)30246-7/fulltext">preventable cause</a> of maternal death, it continues to be a major cause of women dying during or after childbirth, even in high resource countries such as Australia. </p>
<p>Sepsis was the <a href="https://www.aihw.gov.au/reports/mothers-babies/maternal-deaths-australia#maternal-deaths">second most common cause</a> of maternal death between 2010 and 2019 in Australia (22 deaths). </p>
<p>According to the <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpregnancy-mortality-surveillance-system.htm">Centres for Disease Control and Prevention</a> sepsis is the second leading cause of pregnancy related deaths in the US, leading to around 14% of pregnancy-related deaths. </p>
<p>Investigations into sepsis cases during pregnancy and following birth in the United Kingdom <a href="https://www.ogmagazine.org.au/21/4-21/managing-the-septic-patient-in-labour/">found</a> 63% of deaths were associated with substandard care, such as delays in recognising or managing sepsis.</p>
<p>Delays in diagnosing sepsis or misdiagnosis of sepsis in childbearing women is made more complicated due to the physical changes in women’s bodies during pregnancy, labour and the postnatal period. Sepsis can also <a href="https://www.ogmagazine.org.au/21/4-21/managing-the-septic-patient-in-labour/">progress more rapidly</a> in pregnant women. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"968383732620189696"}"></div></p>
<h2>We should all be alert</h2>
<p>If you are unwell during pregnancy or following birth let your health care provider know and persist in seeking care if you are not satisfied. </p>
<p>Most of the time everything will be fine but there are signs of sepsis that can be detected by health providers, such as low blood pressure, temperature or via blood tests.</p>
<p>Health providers have processes for <a href="https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0008/292193/Maternal-Sepsis-Pathway-December-2016.pdf">suspected maternal sepsis</a>, <a href="https://www.somanz.org/content/uploads/2020/07/2017SepsisGuidelines.pdf">guidelines</a> to follow and regular training on this important health emergency. </p>
<p>Health providers need to listen to women and take them seriously when they are unwell, and have the possibility of sepsis in mind. </p>
<p>The brave and persistent actions of <a href="https://www.theage.com.au/national/victoria/a-cascade-of-failures-how-annie-moylan-lost-her-child-and-her-life-in-melbourne-s-private-hospitals-20220802-p5b6je.html">Annie Moylan</a>’s parents in seeking answers about their daughter’s death from sepsis will make care safer for other women.</p><img src="https://counter.theconversation.com/content/188361/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While sepsis is considered to be a preventable cause of maternal death, it continues to be a major cause of women dying during or after childbirth, even in Australia.Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1828672022-07-24T15:48:27Z2022-07-24T15:48:27ZLifesaving maternal health services are so close, yet so far for pregnant women living in sub-Saharan Africa’s largest metropolis<figure><img src="https://images.theconversation.com/files/475138/original/file-20220720-26-4561hm.jpg?ixlib=rb-1.1.0&rect=0%2C9%2C3035%2C1847&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A pregnant woman arrives at Lagos Island Maternity Hospital, Nigeria.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>Every year around the world, <a href="https://www.unfpa.org/sites/default/files/pub-pdf/Maternal_mortality_report.pdf">295,000 women die</a> due to complications of pregnancy and childbirth. Seven in 10 of these maternal deaths occur in sub-Saharan Africa. These deaths are usually caused by excessive bleeding, infection, high blood pressure, obstructed labour and abortion. Many are preventable, especially when pregnant women can get prompt access to critical maternal health services, otherwise known as <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2004.11.026">emergency obstetric care</a>.</p>
<p>When complications arise, pregnant women need to travel to health facilities that can provide emergency obstetric care. Any delays in travelling to such health facilities affects pregnancy outcomes for them and their unborn child. However, some women need to travel <a href="https://doi.org/10.1093/heapol/czab099">long distances</a> from outskirts of town to large hospitals or over a <a href="https://gh.bmj.com/content/6/1/e004318">prolonged time due to traffic congestion</a> in urban areas.</p>
<p>There is a misconception that women living in rural areas experience more challenges in travelling to care compared to those in urban areas. However, research has shown that there are <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-020-00996-7">significant challenges with geographical access</a> even for women living in urban areas.</p>
<p>The past few decades has been characterised by the emergence of many large, densely populated, sprawling cities in sub-Saharan Africa. By 2050, two-thirds of the world’s population is expected to live in urban areas and 40% of the projected additional 2.5 billion urban residents are likely to concentrate in Africa. As such, it is imperative to fully gather evidence on care outcomes in sub-Saharan African urban areas.</p>
<h2>Some pregnant women live close but…</h2>
<p>In an <a href="https://gh.bmj.com/content/7/4/e008604.full">April 2022 study</a> published in the journal <em>BMJ Global Health</em>, we mapped journeys of pregnant women who had an emergency to public hospitals in sub-Saharan Africa’s largest metropolis, Lagos. To do this, we extracted data from patient records reflecting their journeys to reach health facilities while in an emergency. These data were inputted into Google Maps, which had been shown to be able to provide <a href="https://gh.bmj.com/content/6/1/e004318">closer-to-reality travel time and distance estimates</a> for journeys of pregnant women to care.</p>
<p>Results from the study showed that almost two-thirds of maternal deaths occurred among pregnant women who travelled 10 kilometres or less directly from home and arrived at the hospital in 30 minutes.</p>
<p>Also, there was a higher likelihood of maternal deaths with a 10 to 15 kilometre distance from home. Travel of pregnant women to a hospital located in the suburbs was almost four times more likely to result in a maternal death compared to those in the city. On the other hand, travel to a hospital located in the outskirt towns was more than two times more likely to lead to a maternal death compared to those in the city. For pregnant women who were referred, the likelihood of maternal death was significantly higher even when travel of 10 to 29 minutes was required.</p>
<h2>Addressing inequalities in care access</h2>
<p>Indeed, the so-called “urban advantage” might be disappearing in sub-Saharan Africa. As such, there is a need to consider geographical access to health facilities with an urban versus rural lens in the region.</p>
<p>In citing services, it is not enough for governments to say health facilities have been <a href="https://www.publichealthinafrica.org/index.php/jphia/article/view/717">“strategically located”</a>. Functional health facilities within 10km of every woman, supported by robust referral systems that can transfer women promptly if care elsewhere is deemed more beneficial must be available. Furthermore, pre-hospital services have to be able to support pregnant women in crisis, as was the case for a pregnant women who <a href="https://www.vanguardngr.com/2022/04/how-lagos-health-officials-rescued-stranded-pregnant-woman-in-labour/">fell into labour while in public transport</a>.</p>
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<p>
<em>
<strong>
À lire aussi :
<a href="https://theconversation.com/geographic-access-to-critical-maternal-health-services-in-an-african-megacity-142607">Geographic access to critical maternal health services in an African megacity</a>
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</em>
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<p>As part of birth preparedness planning, pregnant women along with their care companions need to be proactively encouraged to commence journeys to the hospital early in the event of an obstetric emergency. If an emergency occurs, structures need to be in place to support her access to a hospital. This needs to be done while making consideration for <a href="https://link.springer.com/article/10.1186/s12939-020-1123-y">pregnant women who are poor and those who live far from hospitals</a>.</p>
<p>At a global level, the World Health Organization has long recommended that health facilities with capacity to provide emergency obstetric care should be <a href="https://apps.who.int/iris/bitstream/handle/10665/44121/9789241547734_eng.pdf">“available within two to three hours of travel for most women”</a>. Evidence from our research suggests that this two-hour access benchmark warrants careful review, with many maternal deaths involving women who travelled less than an hour. These global guidelines also need to reflect delays permissible at referring facilities, recognising that some women still face additional delays even if they make it to hospitals that can provide the care needed.</p>
<p>In conclusion, pregnant women living in urban areas (city or suburb) and even next to a hospital are not precluded from the risk of poor adverse outcomes in pregnancy. Priority needs to be given to fixing areas of access inequalities, especially in the suburbs. This will be crucial for efforts geared toward the realisation of the “leave no one behind” mantra of the sustainable development goals.</p>
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<p><em>Created in 2007 to help accelerate and share scientific knowledge on key societal issues, the AXA Research Fund has been supporting nearly 700 projects around the world conducted by researchers from 38 countries. To learn more, visit the site of the <a href="https://www.axa-research.org">Axa Research Fund</a> or follow on Twitter <a href="https://twitter.com/axaresearchfund?lang=fr">@AXAResearchFund</a>.</em></p><img src="https://counter.theconversation.com/content/182867/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aduragbemi Banke-Thomas ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>Every year, seven in ten maternal deaths occur in sub-Saharan Africa. A study examining sub-Saharan Africa’s largest metropolis find that inequalities in access play a key role.Aduragbemi Banke-Thomas, Senior lecturer, University of GreenwichLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1865742022-07-18T13:49:42Z2022-07-18T13:49:42ZNigeria’s large, youthful population could be an asset or a burden<figure><img src="https://images.theconversation.com/files/473194/original/file-20220708-21-ts9vsb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nigeria's large population of young people may become a burden if not healthy and well educated.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vendor-carries-nigerian-national-flags-on-october-1-2015-as-news-photo/490811636?adppopup=true">Pius Utomi Ekpei/AFP via Getty Images </a></span></figcaption></figure><p>With a population estimated at <a href="https://guardian.ng/business-services/industry/nigerias-population-now-206m-says-npc/">206 million in 2020</a>, Nigeria is the most populous country in Africa and <a href="https://www.worldometers.info/world-population/">seventh in the world</a>.</p>
<p>The country’s <a href="https://drive.google.com/file/d/1_LqDbc249sq_bo_Cmpa8VSZBmk8fHJSj/view">population is growing at 2.6% a year</a>, one of the fastest rates globally. At this rate, Nigeria’s population could double within the next 25 to 30 years. </p>
<p>Nigeria’s population structure is potentially an economic asset. The country has the largest <a href="https://www.worldometers.info/world-population/nigeria-population/">population of youth</a> in the world, with a median age of 18.1 years. <a href="https://www.worldometers.info/world-population/nigeria-population/">About</a> 70% of the population are under 30, and 42% are under the age of 15. </p>
<p>The size and youthfulness of the population offer great potential to expand Nigeria’s capacity as the regional economic hub of Africa and globally. A young, large population could be an economic asset because population growth and urbanisation go together and <a href="https://blogs.worldbank.org/africacan/can-rapid-population-growth-be-good-for-economic-development">economic development is closely correlated with urbanisation</a>. Population growth increases density and, together with rural-urban migration, creates higher urban agglomeration. This can help companies in producing goods in larger numbers and more cheaply, serving a larger number of low-income customers. </p>
<p>But the potential needs to be properly harnessed. Leaders must invest (through health and education) and adopt strong policies to create an environment where this human resource is used optimally. Such was the case among the Asian Tiger countries, which invested massively in technology, infrastructure and education.</p>
<p>Nigeria is, by every measure of socioeconomic progress, failing to develop its endowment of young people. Millions of young people have a poor quality of life, including a lack of education, low living standards and poor health outcomes. </p>
<p>Nigeria is not reaping the benefits of its current population structure and must do more to mitigate the negatives. A large population of unskilled, economically unproductive, unhealthy and poorly educated young people is also a burden to society.</p>
<h2>Poor human development</h2>
<p>Nigeria was ranked 158 of 185 countries in the <a href="https://hdr.undp.org/sites/default/files/Country-Profiles/NGA.pdf">2019 Human Development Index</a>. A <a href="https://www.worldbank.org/en/news/press-release/2022/03/21/afw-deep-structural-reforms-guided-by-evidence-are-urgently-needed-to-lift-millions-of-nigerians-out-of-poverty#:%7E:text=According%20to%20the%20report%2C%20which,below%20the%20national%20poverty%20line.">2022 World Bank report</a> also says about 40% of Nigerians live below the national poverty line of U$1.90 per day and about 95.2 million are in poverty. About <a href="https://www.premiumtimesng.com/agriculture/agric-news/516720-19-4-million-nigerians-to-face-food-insecurity-by-august-2022-fao.html">19.4 million Nigerians</a> are likely to face food insecurity in 2022. </p>
<p>According to <a href="https://www.unicef.org/nigeria/education">UNICEF</a>, Nigeria accounts for 20% of the world’s children who are out of school. In absolute terms, about 10.5 million children, the majority of whom are girls, do not have access to education in Nigeria.</p>
<p><a href="https://nigerianstat.gov.ng/elibrary/read/856">Unemployment is high at 33.3%</a>. Most of those who are unemployed are women and young people. Of those with jobs, over 20% are underemployed as they don’t earn enough.</p>
<h2>Health indicators</h2>
<p>Most of the health indicators in Nigeria are disturbing. Health is key for human development and this means that Nigeria is lagging behind in development.</p>
<p>Health facilities are at sub-optimal levels. Nigerians <a href="https://www.thelancet.com/action/showPdf?pii=S0140-6736%2821%2902488-0">currently</a> have a lower life expectancy (54 years) than many of their neighbours. The country’s burden of chronic and infectious diseases is high. While infectious diseases remain the primary causes of death in the country, <a href="https://www.afro.who.int/news/nigeria-fulfils-commitment-launches-plan-prevention-and-control-non-communicable-diseases">non-communicable diseases account for 3 out of every 10 deaths</a>.</p>
<p>While Nigeria is failing to develop her human capital, Nigerians are making more babies, adding to the potential burden.</p>
<h2>Fertility</h2>
<p>The national fertility rate stands at <a href="https://dhsprogram.com/pubs/pdf/SR264/SR264.pdf">about</a> 5 children per woman. There are regional variations. It is also lower in urban areas (4.5) than in rural areas (5.9); lower in the Southwest (3.9) than in the Northwest (6.6). In other words, poorer households are worse off, particularly those in the rural areas. Also, poor women and those with no or low education are disproportionately affected.</p>
<p>There were <a href="https://www.dhsprogram.com/pubs/pdf/FR359/FR359.pdf">20 adolescent mothers (aged 15-19) among every 100 adolescent girls </a> in Nigeria, with <a href="https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-022-00789-3">wide variations</a> across states and regions. This is <a href="https://www.tandfonline.com/doi/full/10.3402/gha.v8.29745">among the highest in the world</a> and is associated with high risk births, adverse social-economic consequences, limited opportunities and a likely pathway to <a href="http://www.ghheadlines.com/agency/ghana-news-agency/20191112/132518617/adolescent-parenthood-escalates-generational-poverty-nigerian-professor">intergenerational poverty</a>. </p>
<p>The unmet need for modern contraception has been estimated at <a href="https://dhsprogram.com/pubs/pdf/SR264/SR264.pdf">over 20%</a>. Modern contraceptives help to prevent unwanted pregnancy. This is imperative for improving maternal and child health. A lack of access to contraception perpetuates the high maternal and infant mortality, and high fertility in the country.</p>
<p>Currently, the infant mortality <a href="https://data.unicef.org/country/nga/#/">is 72 deaths per 1,000 live births</a>. Maternal mortality is estimated at 512 maternal deaths per 100,000 live births. The national target is to reduce maternal mortality to 72 per 100,000 live births and zero deaths by 2030. </p>
<h2>High dependency</h2>
<p>Nigeria has a relatively high and growing population of dependants. This could put a strain on those who provide for them. Young people account for a bigger share of the dependants, a situation which will get worse unless there is a deliberate public policy to address high fertility.</p>
<p>The age structure of the population suggests that for every 100 people in the economically active age group (15-64), there are 86 dependants (under 15 and over 64). This compares with the <a href="https://www.worldeconomics.com/Country-Data/">78.1 average</a> for the African continent, 52 for South Africa.</p>
<p>There are <a href="https://data.worldbank.org/indicator/SP.POP.65UP.TO?end=2021&locations=NG&start=2021&view=bar">about 6 million people aged over 65</a>. Though this equates to only 3% of population, it is numerically larger than the population of some states in Nigeria. In 2020, <a href="https://www.statista.com/statistics/1203462/dependency-ratio-in-nigeria/#:%7E:text=In%202020%2C%20the%20elderly%20dependency,(15%20to%2064%20years).">the elderly dependency ratio in Nigeria stood at 5.1</a>. This means that there were about five people aged 65 years and older that depend on every 100 people of working age (15 to 64 years). This number of dependants, in addition to children, can reduce the capacity of the working age population to save and invest. </p>
<p>Other groups with high dependency in Nigeria are those with disabilities and the displaced. </p>
<p>The percentage of disabled Nigerians stands at <a href="https://drive.google.com/file/d/1_LqDbc249sq_bo_Cmpa8VSZBmk8fHJSj/view">about</a> 2.3%, comparable to <a href="https://www.tandfonline.com/doi/full/10.1080/09687599.2018.1556491">Ghana’s 3%</a>, but far less than <a href="https://www.google.com/search?q=percentage+of+disability+in+south+africa+population&oq=percentage+of+disability+in+south+africa+population&aqs=chrome..69i57.13625j0j7&sourceid=chrome&ie=UTF-8">South Africa’s 7.5%</a>. But Nigeria <a href="https://www.scidev.net/sub-saharan-africa/features/facts-figures-disabilities-in-developing-countries-1/">doesn’t have plans</a> for addressing the needs of its disabled.</p>
<p>The country is also home to <a href="https://data.unhcr.org/en/country/nga#_ga=2.105709184.2034587582.1657237059-239904064.1657237059">over 3 million internally displaced people</a> and <a href="https://data.unhcr.org/en/country/nga#_ga=2.105709184.2034587582.1657237059-239904064.1657237059">over 82,000 international refugees</a>, mostly from neighbouring countries.</p>
<h2>Demographic dividend</h2>
<p>Nigeria needs to balance population growth with economic prosperity. This makes it possible to achieve a demographic dividend – faster economic growth arising from a favourable population age structure and favourable social and economic policies. </p>
<p>Some countries in Asia including <a href="https://www.un.org/en/development/desa/population/events/pdf/expert/9/wang.pdf">China</a>, <a href="https://www.cgdev.org/blog/what-comes-after-demographic-dividend-east-asia-finding-out">Hong Kong</a>, <a href="https://www.files.ethz.ch/isn/99030/2005_06_East_Asian_Economic.pdf">South Korea</a> and <a href="https://www.files.ethz.ch/isn/99030/2005_06_East_Asian_Economic.pdf">Singapore</a> have benefited substantially from this. Nigeria should aim to make a transition to low birth and death rates. Government at all levels must invest towards addressing high fertility and mortality. </p>
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Read more:
<a href="https://theconversation.com/nigerias-2022-census-is-overdue-but-preparation-is-in-doubt-177781">Nigeria's 2022 census is overdue but preparation is in doubt</a>
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<p>Nigerians need to embrace family planning and address some of the root causes of high fertility, including sociocultural factors. A reduction in fertility by one child per childbearing woman <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)60827-7.pdf">would lead to a 13% increase</a> in Nigeria’s GDP per capita in 20 years or a 25% increase over 50 years.</p>
<p>As stated in the <a href="https://drive.google.com/file/d/1_LqDbc249sq_bo_Cmpa8VSZBmk8fHJSj/view">population policy document</a>, Nigeria should aim to reduce fertility from the current 5.3% to 4.3% by 2030. Family planning should be available to all and there should be no maternal deaths by 2030.</p>
<p>Education is key to good health, empowerment, employment and peaceful societies. It offers the best return on investment. Graduates in sub-Saharan Africa earn <a href="https://documents1.worldbank.org/curated/en/442521523465644318/pdf/WPS8402.pdf">21% more than</a> those without tertiary education.</p>
<p>Nigeria must prioritise investment in education, health and infrastructure to harness the opportunities of its huge population. But Nigerians have a role to play too. They must make rational decisions and choices. These include choices about investment in quality of life, healthy living, fertility reduction and the empowerment of young people.</p><img src="https://counter.theconversation.com/content/186574/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>There is nothing to disclose.</span></em></p><p class="fine-print"><em><span>Akanni Ibukun Akinyemi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nigeria must prioritise investment in education, health and infrastructure to harness the opportunities of its huge population.Akanni Ibukun Akinyemi, Professor of Demography and Social Statistics., Obafemi Awolowo UniversityJacob Wale Mobolaji, Lecturer, Demography and Social Statistics, Obafemi Awolowo UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1840822022-06-29T14:34:56Z2022-06-29T14:34:56Z‘Gain a child, lose a tooth’: old saying holds true for women in northern Nigeria<figure><img src="https://images.theconversation.com/files/470962/original/file-20220626-19-mjscln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women who have children over a long time lose more teeth. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/mothers-wait-to-have-their-children-immunized-against-a-news-photo/50989067?adppopup=true">Jacob Silberberg/Getty Images</a></span></figcaption></figure><p>Childbearing has an impact on the health of women, and the <a href="https://patient.info/doctor/gravidity-and-parity-definitions-and-their-implications-in-risk-assessment#:%7E:text=Parity%20is%20defined%20as%20the,born%20alive%20or%20was%20stillborn">impact</a> grows with the number of times a woman has been pregnant for longer than 24 weeks. Pregnancy and breastfeeding put energy demands on a woman and can cause permanent changes to a mother’s health.</p>
<p>What’s less well known is the relationship between parity and oral health. That’s despite a widespread customary belief that having an increasing number of children results in tooth loss. <a href="https://pubmed.ncbi.nlm.nih.gov/9683217/">“Gain a child, lose a tooth”</a>, or “for every child, a tooth is lost” are common proverbs in many societies. The biological basis of these beliefs is still questioned.</p>
<p>There are few studies on parity and tooth loss. In addition, the available results are inconsistent. Nevertheless, increasing number of children in women has been associated with tooth loss in some populations, as seen in studies in <a href="https://bmcoralhealth.biomedcentral.com/articles/10.1186/1472-6831-9-18">Uganda</a> and the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424105/">US</a>. </p>
<p>We decided to <a href="https://pubmed.ncbi.nlm.nih.gov/33340105/#affiliation-2">study</a> this relationship to add to the evidence. Our study of rural women in northern Nigeria looked at how age, reproductive and socioeconomic factors and oral health practices contributed to tooth loss.</p>
<p>We found that women with more than five children lost more teeth than women of the same age who’d had fewer children.</p>
<p>Tooth loss matters because teeth are important for both functional and aesthetic roles. The loss of a tooth affects an individual socially, functionally and psychologically, negatively affecting their quality of life. Tooth loss can affect beauty, self-esteem, mastication, speech and social interaction. </p>
<h2>Tooth loss</h2>
<p>Our study involved 612 women who live in rural northern Nigeria. They were between the ages of 13-65. They all identified as Hausa. We decided on this cohort because women in this area have very high <a href="https://pubmed.ncbi.nlm.nih.gov/33340105/#affiliation-2">fertility</a> rates. Nigeria has a <a href="https://dhsprogram.com/pubs/pdf/FR148/04Chapter04.pdf">total fertility rate</a> of 5.7 children per woman. However, in the northwest zone where Hausa and closely related Fulani populations are predominant, <a href="https://dhsprogram.com/pubs/pdf/fr222/fr222.pdf">the rate is 7.3</a>. </p>
<p>Sociodemographic status and oral health practices were collected using a questionnaire. All teeth present (excluding third molars) and missing teeth were noted. </p>
<p>Generally, tooth loss experience in the participants was low: an overall prevalence of 14.1%. This means that 14% of women had lost some teeth. The presence of tooth loss in the women differed based on how many children they’d carried beyond 24 weeks, with more tooth loss experienced among women who had had more children. </p>
<p>There was no discernible pattern between tooth loss and number of children among those with fewer than five children. </p>
<p>At five children and above, tooth loss increased with each additional child.</p>
<p>The participants in the study displayed generally similar socio-economic statuses and dental service usage. This reduced the potential effects of other factors such as dietary quality and oral health status that can result in tooth loss. </p>
<p>The results showing a relationship between child bearing and tooth loss were as we had expected. Importantly, the duration of reproduction (the span of reproductive years) was found to be a critical contributor. Women who had children over a longer period of time lost significantly more teeth. </p>
<p>Also, socio-economic status contributed significantly to tooth loss, as women of middle socio-economic experienced significantly greater tooth loss. This was age related, most women in the middle socio-economic class were older while those in the low socio-economic status were younger. </p>
<p>Age played a significant role more generally too. Our study found that age was strongly associated with tooth loss. Tooth loss is typically the culmination of degenerative biological processes rather than an event. The longer the tooth is in the oral cavity, the greater the probability that it is exposed to the factors leading to tooth loss. In addition to the effects of increasing age, women face heightened risks stemming from their reproductive histories. </p>
<h2>Hormones and tooth decay</h2>
<p>Tooth loss is the result of multiple processes involving infection and weakening of the tooth structure or supportive tissues. Diet, hormonal changes, oral hygiene and dental treatment all play a part. In addition, teeth can be lost to trauma and cosmetic cultural practices. Gum disease following tooth decay is a major cause of tooth loss. </p>
<p>Gender-based differences exist in oral health, with more tooth loss in females than males. This is <a href="https://pubmed.ncbi.nlm.nih.gov/20652339/">largely attributed</a> to the role of female sex hormones, pregnancy and reproductive history. Estrogen levels are <a href="https://pubmed.ncbi.nlm.nih.gov/2637066/">higher during pregnancy</a> than during any other period in the life cycle. <a href="https://pubmed.ncbi.nlm.nih.gov/16788889/">Pregnancy reduces</a> the buffering capacity of saliva and promotes growth of bacteria that cause tooth decay. </p>
<p>Estrogen and progesterone are known, among others, to inhibit a body’s ability to produce a normal immune response. This is known as <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/immunocompetent">immunocompetence</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/6103927/">The result</a> is faster tooth decay. </p>
<h2>Way forward</h2>
<p>This study highlights the need to give more attention to the oral health of women during the reproductive years, in particular those who have many children. </p>
<p>Generally in Nigeria, the use of dental care service is poor due to limited availability and accessibility of oral health clinics. This affects early treatment of dental problems, which contributes to more tooth loss. Furthermore, dental problems are not considered as life threatening, thus low priority is given to dental care.</p>
<p>We found in our study that pregnancy and maternity made women even less likely to use oral healthcare service. </p>
<p>Oral health should be incorporated into the general healthcare. Dental care should also be made available and accessible to the general public, especially to those in the rural communities. And women’s oral health should be monitored as part of pregnancy support too. </p>
<p>There is need for oral health awareness and education too to identify barriers to dental care services.</p><img src="https://counter.theconversation.com/content/184082/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Oziegbe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More attention should be given to the oral health of women during the reproductive years, in particular those who have many children.Elizabeth Oziegbe, Associate Professor of Dentistry, Obafemi Awolowo UniversityLicensed as Creative Commons – attribution, no derivatives.