2009 Book MaternalAndChildHealth PDF

John Ehiri
Editor
Maternal and
Child Health
Global Challenges, Programs, and Policies
1 23
Maternal and Child Health
John Ehiri
Editor

Global Challenges, Programs,
and Policies
Foreword by Paul Garner
13
Editor
John Ehiri, PhD, MPH, MSc (Econ.)
Director, Professor
Division of Health Promotion Sciences
Mel and Enid Zuckerman College
of Public Health
University of Arizona
1295 N. Martin Avenue
Tucson, AZ 85724
USA
[email protected]
ISBN 978-0-387-89244-3 e-ISBN 978-0-387-89245-0

DOI 10.1007/b106524
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2009932149
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Foreword
There has been a crying need for a compendium of teaching and learning
resources dedicated to critical global health issues confronting the most vulner-
able members of our communities, women, infants, children, and adolescents.
This book bridges this gap in literature by taking a global perspective, but
weighting more of the content on the most pressing problems and possible
solutions in middle- and low-income countries. From the outset, the book lays
out the scene, first by respecting history and exploring the foundations of much
of what we see today in the global health arena and then moving on to provide
carefully researched appraisals of some of the most critical issues that the under-
pin achievement of maternal and child health-related Millennium Development
Goals (MDGs) in middle- and low-income countries, including politics and
power, specific disease conditions, programs, policies, and emerging concerns.
Thus, it is right on target as a valuable educational resource for global health
scholars, agencies, and frontline operatives who are striving to reduce global
health inequities. A central theme of the book, among others, is that a systematic
return to basic, evidence-based, cost-effective, and time-proven technologies will
be an integral part of a sustainable response to global maternal and child health
challenges. Revitalizing health systems in less-developed countries based on the
tenets of the Alma Ata Declaration of Primary Healthcare, presented by the
World Health Organization and United Nations Children’s Fund over 30 years
ago as the key to global health improvement, remains essential for attaining the
maternal and child health-related MDGs.
Those who work in health care in developing countries are familiar with
poorly equipped and scantly staffed health facilities that see hundreds of patients
each day. Daily, they see the huge and often fluctuating burden of disease, the
tragedy of infant deaths from infectious diseases, and the gross injustice of young
women dying in childbirth. The result is that each year globally, more than
500,000 women, 99% in less-developed countries, die from pregnancy and child-
birth-related complications. An additional 15–20 million suffer various debilitat-
ing consequences of pregnancy. Also globally, about 10 million children under
the age of 5 die annually, mostly from lower respiratory infections, diarrheal
diseases, malaria, measles, and undernutrition. The irony of this deplorable state
of global maternal and child health is that simple, cost-effective interventions
that can significantly improve survival and quality of life of women, infants, and
children exist. Such interventions include access to clean water and basic
v
vi Foreword
sanitation, immunization, improved nutrition, and access to basic health-care

services. Thus, for the most part, the underlying causes of morbidity and mor-
tality among the maternal and child health population are inequity, poverty,
shortage of health professionals, and dysfunctional health systems that are ill-
equipped to effectively implement and maintain basic health-care services.
The concept of a global community is perhaps idealistic, but it helps interna-
tional health and development agencies, health professionals, and policy plan-
ners to consider commonalities, rather than differences, between nations.
Globalization is a term that is loosely used, but one of the important outcomes
of the discourse is that it has facilitated a convergence of thoughts in that rather
than dichotomizing the world into developing and developed, it fosters the
understanding that we all have problems and solutions – whether in the realms
of policy, public health, or clinical care – that are fundamentally common to all.
Yet, variations exist between nations and even between regions in the same
countries. The burden of ill health and premature death varies dramatically
between countries and within social and economic strata in the same countries.
Respecting these variations is essential to identifying the commonalities. It is thus
noteworthy that the first part of this book is devoted to the issue of heterogeneity
in the world’s resources, systems of care, and health outcomes for women,
infants, and children. Moving on to the second part, readers’ attention is
drawn to the fact that health is always within a context and that maternal and
child health is critically influenced by power and politics within society. To
provide specific examples, the book addresses the challenges posed by wars/
conflicts, globalization, gender equity, harmful traditional practices, and abor-
tion. Adequate understanding of these contexts and their influences on maternal
and child health is central to identifying and appraising priorities for action.
Equally, understanding the main disease burden among women and children
and how interventions can influence health outcomes is core to global health
practice. Selection of the eight diseases (malaria, HIV/AIDS, diarrheal diseases,
malnutrition, tuberculosis, obstetric fistula, disabilities, and injuries) that are
discussed in part three (specific disease concerns) is rational, given their contri-
bution to the global burden of disease among women, infants, and children. The
inclusion of tuberculosis and disabilities as they affect women and children
globally is notable, given the limited focus on women and children in the current
literature on these conditions.
How policies and programs are formulated and organized and who delivers
them is central to the identification of appropriate and sustainable solutions.
This is the focus of the fourth and final section of the book. Key challenges and
emerging concerns in global maternal and child health programming are care-
fully chosen and substantively discussed in this part. Notable among the issues
covered are such factors that have received minimal attention in existing global
health textbooks, including the role of evidence-based policy and practice, chal-
lenges in making pregnancy safer, adolescent health, child maltreatment, chil-
dren in difficult circumstances, and workforce training, deployment, and
maintenance in the face of massive brain drain and health worker migration
from developing countries to the developed world.
What is most exciting about this book is that it represents a global community
of the best people in the field, individuals who understand the issues, have
technical expertise, and can provide the reader with a clear, authoritative steer.
Foreword vii
With all credit to the editor who has the global vision to bring this impressive
array of authors together under a common theme, this book is a real contribution
to help those who want to learn and perhaps become a part of the global
community effort to tackle some of the biggest and most important problems
in global health that face us today.
Paul Garner
Liverpool School of Tropical Medicine, England
Acknowledgments
This book was inspired by Greg R. Alexander, RS, MPH, ScD, Maternal and
Child Health Epidemiologist, and former professor and chair, Department of
Maternal and Child Health, University of Alabama at Birmingham School of
Public Health. Greg, one of the most prominent perinatal epidemiologists
nationally and globally, led groundbreaking studies on gestational age measure-
ment, prenatal care, and racial and ethnic disparities in birth outcomes for nearly
three decades until he passed away in February 2007. He would have been proud
to see a profoundly researched, and well-documented textbook that is truly
global in its authorship and content and, most importantly, that is devoted to
issues of concern to the health of women, children, and adolescents.
This book is a collaborative enterprise. I would like to thank the contributors
and colleagues who have made the completion of this work possible. My special
thanks go to Sarah Windle, MPH, John Ilonze, MD, MPH, Katie Brigham,
MPH, Rebecca Pass, MPA, and Catherine Lem, MPH, for their editorial assis-
tance and for keeping tabs on references in the ever-changing drafts.
Finally, I am deeply indebted to my wife, Bridget, and to our children, Jenifer,
Laurence, Amanda, and Paula, for their love, patience, understanding, and
unflinching support.
ix
Contents
Part I The World’s Heterogeneity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1 A History of International Cooperation in Maternal and Child
Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Allan Rosenfield and Caroline J. Min
2 Global Burden of Disease Among Women, Children,
and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Colin Mathers
3 Promotion of Global Perinatal Health . . . . . . . . . . . . . . . . . . . . . . . . . 43
Victor Y.H. Yu
4 Maternal and Child Health in the Organization for Economic
Cooperation and Development (OECD) Countries. . . . . . . . . . . . . . . . 53
Ian G. Child and John E. Ehiri
5 Health System Impacts on Maternal and Child Health . . . . . . . . . . . . 83
Nancy Gerein, Andrew Green, Tolib Mirzoev,
and Stephen Pearson
6 The Environment and Maternal and Child Health . . . . . . . . . . . . . . . . 99
Mary Ann Pass and Rebecca Pass
Part II Politics, Power, and Maternal and Child Health. . . . . . . . . . . . . . 119

7 Impact of Wars and Conflict on Maternal and Child Health . . . . . . . . 121
Emmanuel d’Harcourt and Susan Purdin
8 The Impact of Globalization on Maternal and Child Health . . . . . . . . 135
Sarah Wamala
9 Gender Equity: Perspectives on Maternal and Child Health. . . . . . . . . 151
Rachel Tolhurst, Joanna Raven, and Sally Theobald
10 Harmful Traditional Practices and Women’s Health: Female
Genital Mutilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Sarah Windle, Chuks Kamanu, Ebere Anyanwu,
and John E. Ehiri
xi
xii Contents
11 Abortion and Postabortion Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Andrzej Kulczycki
Part III Specific Disease Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

12 Malaria in Women and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Martin Meremikwu, Emmanuel Ezedinachi, and John E. Ehiri
13 The Global Burden of Childhood Diarrhea . . . . . . . . . . . . . . . . . . . . . . 225
Cynthia Boschi-Pinto, Claudio F. Lanata, and Robert E. Black
14 Tuberculosis in Childhood and Pregnancy . . . . . . . . . . . . . . . . . . . . . . 245
Krishna Reddy, David Moore, and Robert Gilman
15 Impact of HIV on the Health of Women, Children, and Families
in Less Developed Countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Hoosen M. Coovadia and Nigel C. Rollins
16 Malnutrition and Maternal and Child Health. . . . . . . . . . . . . . . . . . . . 287
Olaf Müller and Albrecht Jahn
17 The Global Burden of Obstetric Fistulas . . . . . . . . . . . . . . . . . . . . . . . 311
L. Lewis Wall
18 Health Challenges for Women, Children, and Adolescents
with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Amy T. Wilson
19 Unintentional Injuries in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
William Pickett, Marianne Nichol, and John E. Ehiri
Part IV Programs, Policies, and Emerging Concerns . . . . . . . . . . . . . . . . 359

20 Evidence-Based Maternal and Child Health . . . . . . . . . . . . . . . . . . . . . 361
Alan Tita and John E. Ehiri
21 A Global Perspective on Teen Pregnancy . . . . . . . . . . . . . . . . . . . . . . . 375
Andrew L. Cherry, Lisa Byers, and Mary Dillon
22 Progress and Challenges in Making Pregnancy Safer: A Global
Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Monir Islam
23 Global Immunization Challenge: Progress and Opportunities . . . . . . . 417
Rebecca Affolder, Michel Zaffran, and Julian Lob-Levyt
24 Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Elizabeth Lule and James Rosen
25 The Global Burden of Child Maltreatment. . . . . . . . . . . . . . . . . . . . . . 463
Andrea Gottsegen Asnes and John M. Leventhal
26 Children in Difficult Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
Nancy Mock and Elke de Buhr
27 Integrated Management of Childhood Illness . . . . . . . . . . . . . . . . . . . . 497
Martin Meremikwu and John E. Ehiri
Contents xiii
28 Planning, Development, and Maintenance of the MCH Workforce . . . 515

Jeffrey M. Smith and Anne Hyre
29 An Agenda for Child Health Policy in Developing Countries . . . . . . . . 533
John E. Ehiri
About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
About the Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Contributors
Rebecca Affolder The GAVI Alliance, Geneva, Switzerland

Ebere Anyanwu Medical Center for Immune and Toxic Disorders, Montgomery
Colleges in Houston Texas, USA
Andrea Gottsegen Asnes Yale University School of Medicine, New Haven,
Connecticut, USA
Robert E. Black Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, Maryland
Cynthia Boschi-Pinto World Health Organization, Geneva, Switzerland
Lisa Byers School of Social Work, University of Oklahoma, Tulsa, OK, USA
Andrew Cherry School of Social Work, University of Oklahoma, Tulsa, OK,
USA
Ian G. Child University of Alabama at Birmingham, USA
Hoosen M. Coovadia Nelson R. Mandela School of Medicine, University of
Natal, South Africa
Elke de Buhr Tulane University, New Orleans, USA
Emmanuel d’Harcourt International Rescue Committee, New York, USA
Mary Dillon School of Social Work, University of Oklahoma, OK, USA
John E. Ehiri Mel and Enid Zuckerman College of Public Health, University of
Arizona, Tucson, Arizona, USA
Emmanuel Ezedinachi University of Calabar Teaching Hospital, Calabar,
Nigeria
Nancy Gerein Nuffield Centre for International Health and Development,
University of Leeds, England
Robert Gilman Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, Maryland, USA
Andrew Green Nuffield Centre for International Health and Development,
University of Leeds, England, UK
xv
xvi Contributors
Anne Hyre Jhpiego, Johns Hopkins University, Baltimore, Maryland, USA

Monir Islam World Health Organization, Geneva, Switzerland
Albrecht Jahn European Commission, Brussels, Belgium
Chuks Kamanu Abia State University Teaching Hospital Aba, Nigeria
Andrzej Kulczycki University of Alabama at Birmingham, USA
Claudio F. Lanata Nutritional Research Institute, Lima, Peru
John M. Leventhal Yale University School of Medicine, Yale University,
New Haven, CT, USA
Julian Lob-Levyt GAVI Alliance, Geneva, Switzerland
Elizabeth Lule World Bank, Washington, DC, USA
Colin Mathers World Health Organization, Geneva, Switzerland
Martin Meremikwu University of Calabar Teaching Hospital (UCTH),
Calabar, Cross River State, Nigeria
Caroline J. Min Mailman School of Public Health, Columbia University,
New York
Tolib Mirzoev Nuffield Centre for International Health and Development,
Nancy Mock Tulane University, New Orleans, LA, USA
David Moore Imperial College London, England
Olaf Müller Ruprecht-Karls-University of Heidelberg, Germany
Marianne Nichol Queens University, Kingston, Canada
Mary Ann Pass University of Alabama at Birmingham, USA
Rebecca Pass United Nations World Food Programme, Dakar, Senegal
Stephen Pearson Nuffield Centre for International Health and Development,
William Pickett Queens University, Kingston, Canada
Susan Purdin International Rescue Committee, New York, USA
Joanna Raven Liverpool School of Tropical Medicine, England
Krishna Reddy Internal Medicine, Massachusetts General Hospital, Boston,
MA, USA
Nigel C. Rollins University of KwaZulu-Natal, South Africa
James Rosen Independent Consultant and Economist, Washington DC, USA
Allan Rosenfield Mailman School of Public Health, Columbia University,
New York, USA
Contributors xvii
Jeffrey M. Smith Jhpiego/Johns Hopkins University, Baltimore, Maryland,

USA
Sally Theobald Liverpool School of Tropical Medicine, Liverpool, England
Alan Tita Obstetrics and Gynecology, University of Alabama, Birmingham,
USA
Rachel Tolhurst Liverpool School of Tropical Medicine, Liverpool, England
L. Lewis Wall Washington University Medical School, St. Louis, Missouri,
USA
Sarah Wamala Swedish National Institute of Public Health, Forskarens väg 3.
SE-831 40 Östersund, Sweden
Amy T. Wilson Gallaudet University, Washington, DC, USA
Sarah Windle University of Alabama at Birmingham, USA
Victor Y.H. Yu Monash University, Australia
Michel Zaffran GAVI Alliance, Geneva, Switzerland
Introduction
Context
With increasing globalization, inequity, and escalating poverty, application of

public health principles to the solution of maternal and child health problems
that transcend national boundaries has become an issue of heightened interest
among scholars and practitioners of public health. The fact that this interest
is shared equally among scholars and practitioners in affluent and poor
countries is noteworthy and well founded. For example, in affluent nations,
there are regions, states, or counties with health outcomes (e.g., infant
mortality rates and child undernutrition) that are comparable to those of
for low-income countries. In addition, globalization, climate change, and the
re-emergence of diseases previously thought to have been conquered in afflu-
ent nations mean that our understanding of the strategies for managing
health conditions in resource-poor settings may have ready application in
counties and neighborhoods in rich countries where poverty and inequity also
abound. Thus, there is acceptance that acquisition of knowledge, skills, and
competencies in addressing issues of global concern to maternal and child
health populations is important for health professionals – whether they are
working or intend to work domestically in rich nations or at foreign sites in
resource-poor countries.
The phrase ‘‘global health’’ has gradually come to replace ‘‘international
health.’’ Global health signifies the commonality of health challenges in both
developed and less-developed countries, while international health often refers
to health issues in other countries, especially in less-developed countries. In
its 1997 report, America’s Vital Interest in Global Health, the Institute of
Medicine defined global health as health problems, issues, and concerns that
transcend national boundaries and may be best addressed by cooperative
actions (IOM 1997). Similarly, as the Global Burden of Disease Report
(Murray and Lopez 1996) noted, health impacts across boundaries of geo-
graphy, finance, and culture include impacts on the global ecosystem and
other health determinants, such as poverty and genetics, a context that
includes the whole world and produces its own institutional complexities.
Global health has become a rallying point for organizations, professionals,
and individuals with a passion for social justice and for alleviating pain and
suffering among human populations, especially the poor and the most vulner-
able members of our communities.
xix
xx Introduction
Maternal and Child Health has been the epicenter of international coopera-
tion in health since the early eighteenth century. As Petersen and Alexander
(2004) assert, much about public health in general is arguably about maternal
and child health, and truly, much about global health is about maternal and child
health. Maternal and child health represents the point at which all the disciplines
of public health converge and operate synergistically in order to achieve public
health goals (Alexander 2004). It has been defined as the professional and
academic field that focuses on the determinants, mechanisms, and systems that
operate and maintain the health, safety, well-being, and appropriate develop-
ment of children and their families in countries and societies in order to enhance
the future health and welfare of society and subsequent generations (Alexander
et al. 2004). In as much as global health policies and programs are rooted in a
social justice philosophy and the protection of vulnerable populations, maternal
and child health embodies the concept of global advocacy for the largest vulner-
able populations in both developed and less-developed countries, notably
women, children, and adolescents.
At the biological level, mothers everywhere conceive, progress through preg-
nancy, and typically deliver a single infant in fundamentally the same way. Yet
unacceptable disparities exist in birth outcomes between women in rich and poor
countries and even between women from rich and poor households in the same
country or region. Each year globally, there are at least 3.2 million stillborn babies,
more than 4 million neonatal deaths, and more than half a million maternal
deaths. The vast majority of these deaths are preventable, and the countries with
the highest burdens of maternal and child morbidity and mortality are those who
currently appear to be making the least progress in reducing these rates.
Concern for the health of every child is paramount for the mother and her
nation because the country’s future ultimately depends upon the achievements of
her child. A healthy child needs a healthy mother, and an environment free from
harmful traditional practices and violence, which provides adequate shelter,
nutrition, clean water, basic school education, preventive, and therapeutic health
services. For maintenance of maternal health, the mother also needs a satisfying
job with adequate pay and a community that acknowledges her rights and
provides equal opportunities for all.
The reality, however, is that our globe is a fundamentally complex and
heterogeneous place with extreme disparities in physical geography, exploitable
resources, honest and skillful governance, education, and promises of income
opportunities that do more than just sustain life. These inequities lead to a wide
range of outcomes and to the tragic fact that in less-developed countries, a child
under 5 years of age died every 3 seconds yesterday, will do so today, and will die
tomorrow and as far as the eyes can see into the future unless pragmatic
preventive actions are taken now, including among other things, the elimination
of global poverty. To paraphrase Wennberg (1998), ‘‘. . .for medical care, geo-
graphy is our destiny,’’ and so is poverty. Causes of mortality that have largely
disappeared in the developed world today, or that are readily and inexpensively
immunizable or treatable, continue to kill millions of women and children for
lack of resources and for simple operational reasons. In many less-developed
countries, if the cure for any major contributor to the burden of disease were an
aspirin and a glass of water given to everyone four times a year by a roving
caregiver with minimal medical training, we could not consistently deliver it.
Rationale and Target Audience for the Book xxi
A significant proportion of the United Nation’s Millennium Development Goals

and Targets have major bearing on the health of women and children. Although
we are halfway to the 2015 target, we already know that in some parts of Asia and
almost all of sub-Saharan Africa, we will likely fail to meet our goals, given a
context in which nearly half of the population is malnourished; millions have
limited access to portable water, and live on less than US $1 a day (World Bank
2004).
In the richest countries, life expectancy is almost double that of the poorest:
infant mortality rates and mortality for children under 5 years of age are over a
hundred times less than the rates in the poorest countries. Maternal mortality is
very rare in the richest nations. Yet, several puzzling situations also persist in
these affluent nations, notably the following: (i) there is a twofold difference in
infant mortality rates between Far Eastern and Scandinavian countries and the
United States; (ii) there is a twofold difference between infant mortality and low-
birth-weight rates of white and black births in the United States, but rates of
white and Hispanic births are almost equal; and (iii) despite all the medical and
technological innovations and the huge resources expended on clinical interven-
tions in the richest nations, none has shown any significant reduction in low-
birth-weight rates over the past 30 years. Thus, these phenomena lend credence to
the widely acknowledged axiom that the causes of health and illness in human
populations do not just lie in biological and genetic factors but also in (i) the
environment (physical, chemical, biological); (ii) personal choices, lifestyles, and
behaviors; (iii) family and community support; (iv) the psychology of inequality;
(v) the social philosophy of government; and (vi) each nation’s health-care
system. This therefore calls for greater policy and programmatic attention to
economic and social determinants of health among the maternal and child health
populations. The challenge ahead is to refocus program content and to balance
the drive for the development of new technologies with establishment of viable
organizational strategies that build health systems and ensure effective and
efficient continuum of services. Strategies for improvement should include revis-
ing the structure, content, and most importantly, implementation of current
maternal and newborn health programs, developing funded national implemen-
tation plans to achieve universal coverage for maternal and newborn health-care
services, and initiating action to muster the political commitment needed to
achieve and sustain these systems and programs. Much of the challenge, in
fact, is to accommodate both programmatic and systemic concerns which are
organizational rather than technical problems.
Rationale and Target Audience for the Book
Although there are many textbooks on the general topic of global health, there
has been a paucity of textbooks or other compendium of training resources that
are specifically dedicated to the field of global maternal and child health, apart
from scattered reports of agencies and professionals working in the field. This
book has been purposefully conceptualized to address this apparent deficit in the
global health literature. It is intended as a reference textbook for graduate and
advanced undergraduate public health students; instructors designing courses on
critical issues in global maternal and child health; frontline professionals seeking
xxii Introduction
information on evidence-based maternal and child programs and policies; and

policy makers sifting through priorities for research and development in this
field. Unlike many textbooks that would require significant additional support
materials to carry students through a full semester course, this book has been
structured to sustain up to two semester courses in global health without the
usual dire need for significant additional reading resources. Nevertheless, all
chapters are adequately referenced, thus providing the opportunity for follow-
up research, analysis, and synthesis. To help guide course instructors, each
chapter has learning objectives, key terms, and discussion questions. Contribu-
tors are some of the world’s most respected experts, carefully selected to repre-
sent different global geographic regions and to ensure complementarity not only
of professional disciplines but most importantly, academic and field practice
perspectives. Authors are individuals who have won teaching, research, and
public health service awards and are internationally recognized as authorities
in global health research, practice, policy, and leadership. They have diverse
qualifications and skills in maternal and child health in addition to prior or
current leadership positions in maternal and child health-related organizations
and programs globally.
Content and Layout
The chapters are grouped into four parts that represent interrelated thematic
areas viz. (i) the world’s heterogeneity; (ii) politics, power, and maternal and
children health; (iii) specific disease concerns; and (iv) programs, policies, and
emerging concerns.
Part I: The World’s Heterogeneity
This part contains six chapters that present an overview of the world’s complex-
ity and macrolevel factors that impact maternal and child health. It deals with the
heterogeneity of the world’s geography and its resources, health systems, living
and working environments, economic strengths, and their impacts on maternal
and child health outcomes.
In Chapter 1, Allan Rosenfield and Caroline Min of Columbia University
present an account of the history of international cooperation in maternal and
child health. They provide an overview of how maternal and child health gained
recognition in industrialized countries and later became a focal point of devel-
opment assistance to low-income countries. They discuss cooperation in mater-
nal and child health within the context of shifting ideologies in global public
health and present a chronology of significant events, policies, and programma-
tic initiatives that demonstrate how the maternal and child health agenda has
evolved over the past 60 years.
The global burden of disease among women, children, and adolescents is
presented in Chapter 2. Colin Mathers, Coordinator for Epidemiology and
Burden of Disease in the Information, Evidence and Research Cluster at the
World Health Organization office in Geneva, presents an analysis of major
diseases and injuries that contribute to morbidity and mortality among children
Part I: The World’s Heterogeneity xxiii
(ages 0–9 years), adolescents (ages 10–19 years), and women (ages 20 and over)
for different World Bank geographic regions (Africa, East Asia and the Pacific,
Europe and Central Asia, Latin America and the Caribbean, Middle East and
North Africa, and South Asia). The chapter highlights how much of the global
mortality among the maternal and child health population is concentrated within
middle- and low-income countries, particularly in South Asia and sub-Saharan
Africa. As he demonstrates, infectious diseases continue to be the major causes of
mortality among children under the age of 5, with five largely preventable
conditions (lower respiratory infections, diarrheal diseases, malaria, HIV/
AIDS, and measles) accounting for 70% of all child deaths in sub-Saharan
Africa. As the chapter shows, morbidity and mortality among the different
maternal and child health subpopulation groups are influenced by different sets
of factors. For children under the age of 10 years, the most important factors are
undernutrition, unsafe water, and sanitation-related conditions. For adolescents
aged 10–19 years, mental disorders (particularly depression, schizophrenia, and
bipolar disorders), injuries (especially road traffic accidents), violence, suicide,
and alcohol use disorders are the most important factors. Among women aged
20–59 years, HIV/AIDS is the leading cause of burden of disease, particularly in
sub-Saharan Africa.
In recognition of the importance of the perinatal period in the field of mater-
nal and child health, Chapter 3 is devoted to an overview of perinatal mortality,
stillbirths, and neonatal mortality. Causes of perinatal mortality as well as low
cost, evidence-based interventions for promoting neonatal survival across the
prenatal, antenatal, intrapartum, and postpartum stages are examined. It is
concluded that strategies which address inequalities both within a country and
between countries are necessary for achievement of improvement in global
perinatal health.
To review progress, challenges, and priorities for future investments in rich
countries, Ian Child and John Ehiri focus on the different ways that maternal and
child health services operate in member states of the Organization for Economic
Cooperation and Development (OECD) in Chapter 4. They present a brief
overview of health and income inequity among the different member nations of
OECD and between OECD and the rest of the world. The chapter includes in-
depth analysis of the structure and financing of health care in OECD countries,
health status indicators, models for delivery of maternal and child health ser-
vices, and the role of social determinants on maternal and child health outcomes.
The chapter highlights the puzzling fact that despite the multiplicity of pre- and
postnatal care approaches, technological improvements, increased expenditure,
and intensity of care over the last 30 years, no significant improvement in the
proportion of infants born with low birth weight has been observed in any high-
income OECD country. The chapter concludes with a call for greater policy and
programmatic attention to economic and social determinants of maternal and
child health.
Nancy Gerein and her colleagues from the Nuffield Centre for International
Health and Development at the University of Leeds, England, analyze the impact
of health systems on maternal and child health in Chapter 5. They begin with a
discussion of the main elements of a health-care system versus a health system,
examining the key differences between the two. They use a conceptual model to
characterize the different elements of the health system from both the biomedical
xxiv Introduction
and the holistic perspectives. The mechanisms by which the elements interact to
influence access, quality, use of health services, and ultimately the health of
mothers and children are analyzed. They discuss major challenges for health-
care systems in improving the health of mothers and children and conclude with
an analysis of the role of the health system in achieving Millennium Development
Goals (MDGs) related to maternal and child health.
Mary Ann Pass, Professor of Maternal and Child Health at the University of
Alabama at Birmingham, and her colleague Rebecca Pass conclude Part I with
their review of the impact of the environment on maternal and child health in
Chapter 6. They highlight disparities in environmental health risks for maternal
and child health populations in different geographic and economic regions of the
world. The chapter analyzes the contributions of unclean water, poor sanitation,
poor hygiene practices, water-, soil-, and air-borne diseases, overcrowding and
pollution to poor maternal and child health outcomes and examines how women
and children in developed and less-developed nations are exposed to ambient
atmospheric pollution from industry and power plants, accidental and deliberate
chemical and petroleum pollution of water tables, asbestos and lead contamina-
tion in older houses, tobacco smoke, radiation, and high risk of traffic accidents.
Part II: Politics, Power, and Maternal and Child Health
While it could be argued that virtually all of the themes covered in this book are
influenced by politics and power at the global, national, and local levels, this part
of the book is devoted to the specific impacts of globalization, wars and conflicts,
gender inequity, harmful traditional practices, and abortion politics on the
health of women and children.
In Chapter 7, Emmanuel D’Harcourt and Susan Purdin of International
Rescue Committee present an analysis of the nature and emerging trends in
modern conflicts, drawing on their vast experiences in frontline emergency rescue
missions in recent and current conflict and emergency situations around the
world. The impact of conflicts is delineated from the perspective of direct trauma
and the indirect effects of malnutrition, displacement, rape, increased vulner-
ability to infectious diseases, and adverse obstetric conditions. They also discuss
the relationship between war and poverty. They present a causal model with
which they analyze the pathways by which conflict affects the health and well-
being of women, children, and adolescents through food insecurity, economic
collapse, decline in habitat, diversion of public spending, destruction of infra-
structure, and loss of qualified personnel. They conclude with an analysis of
strategies for mitigating the impact of conflict on maternal and child health,
including how to respond to immediate needs in acute complex emergencies,
provision of routine care in nonroutine conditions, primary health care, and
postconflict healing and rebuilding.
The impact of globalization on maternal and child health is presented in
Chapter 8. Here, Dr. Sarah Wamala examines how globalization directly affects
the health and well-being of women through changing occupational roles, evolu-
tions in food production, preparation and consumption patterns, and migration.
The indirect effects of privatization and such international policy mechanisms as
the Structural Adjustment Programs (SAPs) on availability of services and
Part III: Specific Disease Concerns xxv
provision of care are also analyzed. The chapter reviews potential public health
practice and policy responses and examines the extent to which the Millennium
Development Goals contribute toward alleviation of the adverse impact of
globalization on the health of women and children.
Sally Theobald and her colleagues in the Gender and Health Research Group
at the Liverpool School of Tropical Medicine, England, introduce the concept of
gender equity and gender power relations in Chapter 9. They begin with defini-
tions of such key concepts as sex, gender, gender roles and relations, women’s
health and gender analysis, gender equity, gender mainstreaming, gender divi-
sions of labor, gender norms and identities, bargaining positions, and access to,
and control over, resources. With specific examples, they illustrate how these
concepts interact to influence and shape maternal, infant, and child health status
and access to health care. They discuss the importance of understanding and
mainstreaming gender into global health at the policy, health provider, and
community levels, using cross-cutting approaches.
Chapter 10 examines the impact of harmful traditional practices on maternal
and child health, using female genital mutilation (FGM) as an example. Begin-
ning with a brief overview of harmful traditional practices, Sarah Windle and her
colleagues at the University of Alabama at Birmingham (UAB) discuss relevant
terms, definitions, and types of FGM. First, the origin and prevalence of FGM
are explored. Second, the health consequences and issues related to care of
victims are discussed, and finally, factors contributing to FGM are critically
analyzed. They examine the policy and practice options for eliminating FGM
and review examples of interventions in order to identify best practices for
prevention. Recognizing that there is no simple solution to the problem, they
argue that interventions for preventing FGM should be nondirective, culturally
sensitive, and multifaceted to be of practical relevance. The authors assert that
such interventions should not only motivate change but should also provide
alternative options and help communities to establish the practical means by
which change can occur. Potentially effective prevention interventions targeted
at local practitioners of FGM, parents, at-risk adolescents, health and social
workers, governments, religious authorities, the civil society, and communities
are presented.
In Chapter 11, Andrzej Kulczycki concludes Part II with a global overview of
abortion, examining its history and incidence, why women have abortions, and
who has abortions. He discusses abortion laws and policies, their implementation
and public health implications, safe and unsafe abortion, abortion-related mor-
tality and morbidity, conditions under which abortions occur around the world,
and the implications for maternal health. He then examines abortion techniques,
safety, and trends toward earlier abortion in countries where abortion is safe and
available. He concludes with a discussion of post-abortion care – its evolution,
current best practices, and examples.
Part III: Specific Disease Concerns
This part contains eight chapters that focus on some of the major diseases
that make the most significant contribution to the global burden of disease
among MCH populations, notably malaria, diarrheal diseases, HIV/AIDS,
xxvi Introduction
tuberculosis, malnutrition, and injuries. It also includes chapters on obstetric

fistula and disabilities, which are less emphasized in global maternal and child
health but nonetheless, are major causes of pain and suffering among women,
children, and adolescents.
In Chapter 12, Martin Meremikwu and his colleagues discuss the global
burden of malaria, its clinical manifestations, and health consequences, including
anemia, splenomegaly, and adverse pregnancy and birth outcomes. They analyze
mechanisms and consequences of HIV and malaria coinfection as well as malaria
treatment and control options. They also discuss the challenges posed by vector
resistance to insecticides, parasite resistance to antimalarials, climate change,
wars/conflicts, and HIV/AIDS which increase susceptibility to malaria and
consume resources available for control and prevention efforts. Also discussed
are social, cultural, and economic limitations associated with community deliv-
ery of malaria treatment through existing primary health-care systems, the pro-
spect of scaling up control and prevention efforts through vaccine development,
and the use of artemisinin-based combination treatments (ACTs). The chapter
concludes with a call for wider use of insecticide-treated bednets and for donors
and governments to develop effective mechanisms to monitor and ensure access
to effective treatment and prevention for children, adolescents, pregnant women,
and children in difficult circumstances. The need to strengthen health systems to
ensure optimization of prevention and treatment efforts for these vulnerable
populations is also emphasized.
While the introduction of oral rehydration solution (ORS) has helped to
significantly reduce global child mortality from diarrhea, morbidity from diar-
rhea has not declined markedly over the past two decades. In Chapter 13, three of
the world’s leading experts on this subject, Cynthia Boschi-Pinto, Claudio
Lanata, and Robert Black provide a comprehensive overview of the current
status of the global burden of childhood diarrhea, highlighting evidence of the
relationship between diarrheal diseases and child health. They begin with defini-
tions and descriptions of clinical manifestations of childhood diarrhea and
provide an exposition on the global burden of childhood diarrheal morbidity
and mortality in different world regions and by age groups. They highlight the
unequal distribution of diarrhea between resource-rich and resource-poor coun-
tries and examine the relative contributions of different diarrheal disease patho-
gens and various hypothesized risk factors. They conclude with an appraisal of
the evidence base of various treatment and prevention options, including promo-
tion of exclusive breastfeeding, hand washing, vaccines, oral rehydration therapy
(ORT), zinc supplementation, and improved access to basic care.
Krishna Reddy (Harvard Medical School), David Moore (Imperial College
London), and Robert Gilman (Hopkins) discuss tuberculosis (TB) in women and
children in Chapter 14. They present a global overview of the prevalence and
trends in tuberculosis among children and the challenges of tracking TB among
children due to the difficulty of diagnosis, lack of commonly used standard case
definitions, inadequate surveillance in less-developed countries, and neglect of
childhood TB control programs. They review risk factors for TB among children,
pathogenesis of the condition, the relationship between HIV and TB as well as
problems posed by multidrug-resistant TB. They examine options for treatment
and prevention of childhood TB and related challenges. Also discussed are the
effects of pregnancy on TB. Here, they examine the historical perspectives of
Part III: Specific Disease Concerns xxvii
research on the topic as well as clinical features and diagnosis of TB among

pregnant and nonpregnant women. They present evidence from research on
perinatal and maternal outcomes of TB in pregnancy and factors that influence
such outcomes. They conclude with an examination of issues around treatment
of both latent and active TB in pregnancy.
In Chapter 15, Hoosen M. (Jerry) Coovadia and Nigel Rollins of the Nelson R.
Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa,
review the global burden of HIV/AIDS with a focus on women, children, and
adolescents. They begin with a discussion of the prevalence of HIV/AIDS among
women, highlighting the factors that increase women’s vulnerability to the disease.
They discuss strategies for prevention of HIV among women, emphasizing the need
for improved antenatal care services with effective counseling on options for preven-
tion of mother-to-child transmission and cervical barrier methods of prevention (e.g.,
diaphragms, microbicides, and HIV vaccine), detection and treatment of sexually
transmitted infections, especially those due to herpes virus 2, and use of female
condoms. Also presented is an overview of the global burden of HIV/AIDS and its
impact on children and adolescents. They discuss strategies for comprehensive
management of children at risk for HIV/AIDS and conclude with an examination
of the impact of HIV/AIDS on the family and community, highlighting the challenge
posed by the increasing scale of AIDS orphans globally. They recommend that
prevention programs targeting women and children be focused on creating social,
political, economic, and cultural environments that empower women, challenge
stigma and discrimination among women, and aggressively combat poverty, gender,
and racial inequalities.
Chapter 16 by Olaf Müller and his colleague Albrecht Jahn presents a global
overview of malnutrition (undernutrition and obesity), its multiple direct and
indirect causes, manifestations, management, and prevention. They examine the
relationship between malnutrition and Millennium Development Goal targets
related to maternal and child health. The chapter concludes with a synthesis of
intervention strategies that could significantly contribute to achievement of the
Millennium Development Goal target of reducing by half of 1990 figures, the
proportion of people who suffer from hunger.
L. Lewis Wall presents an overview of the global burden of obstetric fistula in
Chapter 17. Using the Worldwide Fistula Fund’s pathways to the development
of obstetric fistula, he analyzed the biomedical and sociocultural causes of
obstetric fistula, including the role of obstructed labor, women’s low status in
society, malnutrition, illiteracy, limited access to emergency obstetric services,
early marriage, and traditional harmful practices. He discusses the consequences
(medical and social) of obstetric fistula as well as treatment options and chal-
lenges. He concludes with an appraisal of short- and long-term prevention
strategies as they relate to the provision of appropriate and timely obstetric
services, health systems development, and cultural changes that institutionalize
gender equity from birth through the life course.
The much neglected problem of disabilities among women and children is
presented in Chapter 18. Here, Amy Wilson of Gallaudet University, a world
leader in liberal arts education and career development for deaf and hard-of-
hearing students, discusses the definition and causes of disability, global preva-
lence of disabilities, and the relationship between poverty and disability. She
examines how local concepts and beliefs frame a society’s perspective of disability
xxviii Introduction
and how this perspective affects the status of women and children with disabil-
ities. She reviews the barriers posed by lack of national disability policies or laws,
and the nonenforcement of such policies and laws where they exist. International
and national efforts and strategies to improve inclusion and access to health and
social care for women and children with disabilities are discussed.
Injuries, a major contributor to the burden of disease among children and
adolescents, are presented in Chapter 19 by Wilson Pickett and Marianne
Nichol. They provide a profile of the occurrence of unintentional injuries in
populations of children and analyze their underlying determinants as well as
possible approaches to prevention. They present rates of fatal and traumatic
injury across countries and discuss leading external causes and consequences of
traumatic injuries by age, sex, and other known disparities. Current evidence
surrounding the relative effects of different preventive approaches is reviewed
and a summary of suggested implications for practice, policy, and research is
presented. They conclude with a call for effective prevention strategies to con-
sider engineered changes to the physical environment and legislation, nested
within the framework of education and sustainable behavior change.
Part IV: Programs, Policies, and Emerging Concerns
The fourth and final part of the book contains 10 chapters that address a range
of maternal and child health programmatic and policy issues, including imple-
mentation of evidence-based interventions, teenage pregnancy prevention, the
challenge of making pregnancies safer, progress and challenges related to effec-
tive and efficient application of currently available vaccines, issues related to
integrated management of childhood illnesses, and adolescent health. This part
also addresses the problems of child maltreatment, children in difficult circum-
stances, the challenges of training and deploying the maternal and child health
workforce in the face of increasing brain drain and health worker migration,
and the need for global maternal and child health policy that is underpinned by
the tenets of Alma Ata’s Declaration of primary health care.
Maternal and child health programs in many less-developed countries provide
largely curative and preventive interventions that are already known to be
effective. This means that achievement of quality in maternal and child health
services requires identification of these evidence-based practices and implementing
them according to established standards. In Chapter 20, Alan Tita and John Ehiri
provide a synthesis of the status of evidence-based global maternal and child
health practice and policy, with particular reference to less-developed countries.
They approach the discussion from the perspectives of two main maternal and
child health practice domains (maternal and perinatal health, and infant and
child health) that chronologically relate to the continuum of pregnancy, delivery
and birth, and child development. They examine the meaning of evidence-based
care and discuss its advantages, methods, and limitations. They trace some of the
key historical milestones in the development of evidence-based maternal and
child health and provide an outline of some specific maternal and child health
interventions that are currently considered evidence based.
In Chapter 21, Andrew Cherry his colleagues explore issues related to the
problem of teen pregnancy from a global perspective, examining regional and
Part IV: Programs, Policies, and Emerging Concerns xxix
cross-national themes, trends, progress, and challenges. They highlight the

social, economic, and cultural determinants of teen pregnancy and analyze
programs and policies designed to reduce the health, economic, and social risks
among pregnant teens. Teen pregnancy situation in different regions of the world
is presented, using the United States (North America), United Kingdom and
Russia (Europe and Central Asia), Vietnam and Japan (East Asia and the
Pacific), India (South Asia), Mexico (Central and South America), Nigeria
(Africa), and Egypt (Middle East and North Africa) as examples.
Progress and challenges in making pregnancies safer are discussed in
Chapter 22. Here, Monir Islam of the World Health Organization discusses the
global problem of maternal mortality, highlighting inequities that exist between
and within regions, countries, and populations. Using McCarthy and Maine’s
(1992) framework for analyzing determinants of maternal mortality, he examines
the role of distant factors (e.g., socioeconomic status) and how they interact with
intermediate factors (e.g., access to care and health behavior) as well as indeter-
minate factors to influence maternal and child health outcomes. He reviews
progress made globally in averting maternal mortality and the threats to this
progress, including wars and conflicts, emerging and re-emerging diseases (e.g.,
malaria and HIV/AIDS). He concludes with a synthesis of gaps in programs and
policies and recommends measures for achieving Millennium Development
Goals related to reduction of maternal mortality.
Although significant progress has been made in global immunization cover-
age, immunizable diseases remain the leading causes of maternal and child
mortality in less-developed countries. In Chapter 23, Rebecca Affolder, executive
secretary of GAVI Alliance in Geneva, and her colleagues present a historical
perspective on the emergence of vaccines as a means of disease control and
prevention over the past two centuries. Beginning with the discovery of smallpox
vaccine by Edward Jenner in 1796, they identify and discuss important mile-
stones in widespread use of vaccines in global health. Inequity in access to
vaccines between rich and poor countries and the underpinning factors are
discussed, including lack of safety and quality assurance systems in poor coun-
tries, focus of research and development on rich nations’ priorities, and the
diversion of scarce resources to other emerging global health priorities. They
discuss various innovative options for financing wider access to new and under-
used vaccines in poor countries and conclude with an examination of issues of
sustainability in vaccine development, procurement, management, and integra-
tion into routine care in resource-poor settings.
In Chapter 24, Elizabeth Lule of the World Bank and her colleague James
Rosen present a global demographic profile of adolescents and examine the
rationale for attention to promotion of adolescent health by national govern-
ments and international health agencies. Major health problems confronting
adolescents are analyzed as they vary by region and between developed and
less-developed countries. Specific conditions contributing to the global burden
of disease among adolescents (mental disorders, intentional and unintentional
injuries, malnutrition, tobacco, alcohol and drug use, sexual and reproductive
health concerns) are discussed, and the effectiveness of programs to address these
conditions as well as policy and program gaps are appraised.
Physical and emotional maltreatment, sexual abuse, and negligent treatment
of children, as well as their commercial and other exploitation, constitute a health
xxx Introduction
challenge that prevalent in all parts of the world. While deaths associated with
child maltreatment represent only the tip of iceberg, millions of children are
victims of nonfatal abuse and neglect. Ill-health associated with child abuse
contributes significantly to the global burden of disease among children and
increases their predisposition to serious illnesses in adulthood. An overview of
the global problem of child maltreatment is presented in Chapter 25 by Andrea
Asnes and John Leventhal of Yale University School of Medicine. They begin
with an examination of the challenges in building consensus on a universal
operational definition of child maltreatment. Types of childhood maltreatment
and the scope of the problem are analyzed from a global perspective. The health
and economic consequences of the problem are reviewed as are the concomitant
risk factors, including those related to children, their parents, families, and the
society. They conclude with an appraisal of strategies for prevention, highlight-
ing actions at (i) the societal and community level (e.g., promotion of social,
economic, and cultural rights, reducing income and gender inequalities, and
eradicating cultural acceptance of violent or exploitative behavior toward chil-
dren); (ii) the relationship level (e.g., early and frequent home visiting by trained
providers who are able to establish a relationship with the parent(s) and teach
effective parenting); and (iii) the individual level (e.g., education of children
about how to avoid unsafe situations and protect themselves when confronted
with threatening situations).
In Chapter 26, Nancy Mock and Elke de Buhr of Tulane University present a
review of definitional and methodological difficulties associated with identifying
and enumerating children in difficult circumstances. They examine trends in the
evolution of the problem and its public health impact, and analyze the status of
policies and strategies to protect and promote the health of children in difficult
circumstances.
The integrated management of childhood illnesses (IMCI) initiative was
introduced by the World Health Organization (WHO) and the United Nations
Children’s Fund (UNICEF) in the 1990s in response to the limitations of the
child survival revolution of the 1980s that was based on disparate vertical
programs. Thus, it represents a major policy shift in international approach to
child health management and now represents the guiding principle of many
technical assistance projects in support of child health in less-developed coun-
tries. In Chapter 27, Martin Meremikwu and John Ehiri present a historical
perspective on this initiative and examine its evidence base. They describe field
implementation case studies and conclude with an appraisal of the current status
of the initiative. Prospects for scaling it up to improve child health globally are
also discussed.
The performance of health-care systems depends ultimately on the knowl-
edge, skills, and motivation of the people responsible for delivering services:
health and social care personnel. In Chapter 28, Jeff Smith and Anne Hyre of
Jhpiego, Johns Hopkins University, provide a review of some of the critical
issues in health sector human resource planning, development, and mainte-
nance that underpin the provision of high-quality maternal and child health
services in less-developed countries. They explore elements of successful train-
ing programs as well as issues around the deployment, integration, supervision,
support, and retention of maternal and child health workers. They examine
factors that influence the performance of maternal and child health workers
References xxxi
and discuss gender in relation to maternal and child health workforce capacity
building. They conclude with a review of the relationship between maternal and
child health human resource development and service provision at the local
community level.
In the concluding portion of this book (Chapter 29), John Ehiri determinants
presents a critical review of current strategies for promoting child health in
developing countries and examines the environmental, social, and political fac-
tors that influence child health. The demise of Primary Healthcare, a strategy
that over 20 years, ago was declared the model for achieving the goals of health
for all, is reviewed. He asserts that after several years of investment in disease-
focused vertical interventions, preventable diseases still remain a major challenge
for women, infants, and children. He concludes with a call for return to the tenets
of the Alma Ata Declaration of Primary Health, which emphasizes action on
social, environmental, and economic determinants of health (including poverty
alleviation), a focus on health systems development, and access to basic health
care.
References
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ment. Thousand Oaks, CA: Sage Publications.
Institute of Medicine (1997) America’s vital interest in global health: protecting our people,
enhancing our economy, and advancing our international interests. Washington, DC:
National Academy Press
McCarthy J, Maine D (1992) A framework for analyzing the determinants of maternal
mortality. Studies in Family Planning, 23(1), 23–33
Murray CJL, Lopez AD (Eds.) (1996) The global burden of disease. Vol. 1. Cambridge, MA:
Harvard University Press
Petersen DJ, Alexander GR (2004) Editorial – Charting a future course for the MCH journal.
Maternal and Child Health Journal 8:1; 1–3
Wennberg DE (1998) Variation in the delivery of health care: the stakes are high (editorial).
Annals of Internal Medicine 128:866–868
World Bank (2004) World Development Report 2004: making services work for poor people.
Washington DC: The World Bank
Part I
The World‘s Heterogeneity
Chapter 1
A History of International Cooperation in Maternal
and Child Health
Allan Rosenfield and Caroline J. Min
Learning Objectives After reading this chapter and hospitals were established in growing numbers, but
answering the discussion questions that follow, you by themselves they did not have much influence on
should be able to child mortality rates (Williams et al. 1994).
Toward the late 1800s (Box 1.1), leaders across
Discuss how maternal and child health gained
Europe began to take a keen interest in the health of
recognition in industrialized countries and sub-
children. High rates of infant mortality combined
sequently became a focal point of development
with declining rates of birth aroused fears among
assistance to less developed countries.
politicians that their nations would fall behind in
Identify significant milestones in international
the race for economic and military supremacy,
cooperation in maternal and child health (includ-
which required a robust adult population and,
ing specific programs and initiatives) to illustrate
thus healthy children and healthy mothers to bear
how maternal and child health agenda has
them. Fears of national deterioration were espe-
evolved over the past 60 years.
cially strong among the French in the wake of
Evaluate current international cooperation in
their defeat in the Franco-Prussian War (1870–
maternal and child health within the context of
1871), and later among the British after their poor
shifting ideologies in global health.
showing in the Boer War (1899–1902) and their
difficulties in recruiting able-bodied soldiers
(Dwork 1987).
Introduction Newly established infant welfare programs
quickly attracted the attention of physicians, philan-
Prior to the twentieth century, the health of mothers thropists, and reformers, as well as government offi-
and children was generally considered a domestic cials. In 1892, Pierre Budin at the Charité Hospital in
concern. Childbirth was supervised by midwives, Paris organized the first consultation de nourrissons
traditional birth attendants (TBAs), or relatives, or infant health consultation (Dwork 1987). Mothers
with physicians gradually attending a greater share who gave birth at the hospital were asked to return
of deliveries in industrialized countries. Before the each week to have their babies weighed and exam-
introduction of scientific medicine, care for sick ined. Budin educated mothers on the importance of
children was rudimentary and it was commonly breastfeeding or providing infants with sterilized
accepted that a significant number of children milk, and the basics of infant care. In 1894, Léon
would not survive childhood. The nineteenth cen- Dufour in Fécamp, Normandy, opened a milk sta-
tury brought discoveries in bacteriology and other tion, or goutte de lait, where he distributed sterilized
medical developments, as well as sanitary reforms, milk and provided weekly medical care for infants.
yet infant mortality rates remained high. Pediatric Consultations de nourrissons and goutte de lait clinics
were highly successful in reducing morbidity and
mortality rates for enrolled infants compared to
C.J. Min (*) rates for the general infant population, and they
Columbia University, New York, USA quickly proliferated throughout the country with
J.E. Ehiri (ed.), Maternal and Child Health, DOI 10.1007/b106524_1, 3

Ó Springer ScienceþBusiness Media, LLC 2009
4 A. Rosenfield and C.J. Min
Box 1.1 Milestones in Global Cooperation in MCH
1892 – Pierre Budine organized the first consultation de nourrisons, or infant health consultation.
1894 – Leon Dufour opened the first milk station.
1946 – The United Nations International Children’s Emergency Fund was founded to provide
relief to children and orphans of the world wars.
1948 – The Universal Declaration of Human Rights was adopted by the UN General Assembly.
1948 – The World Health Organization was founded.
1955 – The WHO and UNICEF launch an unsuccessful campaign to eradicate malaria.
1961 – The US Agency for International Development (USAID) was established.
1965 – China develops the ‘‘barefoot doctors’’.
1967 – The World Health Organization launched the smallpox eradication program (January 1)
1974 – The WHO launched Expanded Programme on Immunization (EPI).
1977 – Smallpox certified globally eradicated – marking one of the most successful public health
programs in history.
1978 – The WHO and UNICEF co-sponsor the International Conference on Primary Health Care
in Alma-Ata, Kazakhstan, which leads to the Declaration of Alma-Ata (see Box 1.2).
1982 – The child survival revolution, GOBI-FFF, launched by James P. Grant, then Executive
Director of UNICEF.
1984 – A Task Force on Child Survival and Development established to coordinate immunization
activities of major international agencies.
1987 – The World Bank, the WHO, and the United Nations Population Fund (UNFPA)
sponsored an international conference in Nairobi that became the launching point of the Safe
Motherhood Initiative.
1990 – The World Summit for Children in New York set forth goals to be achieved by 2000,
including a goal to reduce the under-5 mortality rate by one-third or to 70 deaths per 1,000 live
births, whichever is less.
1989 – The UN General Assembly adopted the Convention on the Rights of the Child.
1994 – The International Conference on Population and Development (ICPD) in Cairo led to the
current definition of reproductive health and reproductive rights (see Box 1.4), reaffirmed at the
1995 Fourth World Conference for Women in Beijing.
1996 – The WHO and UNICEF introduced the Integrated Management of Childhood Illness
initiative (IMCI), one of the predominant strategies for addressing child health today.
1997 – A Safe Motherhood Technical Consultation was convened in Colombo, Sri Lanka, and
new strategic priorities were set, including the acknowledgment of maternal mortality as a social
injustice.
1999 – The Bill and Melinda Gates Foundation launched the Global Alliance for Vaccines and
Immunization (GAVI) now known as the GAVI Alliance.
1999 – The Bill and Melinda Gates Foundation funded Columbia’s Mailman School of Public
Health to launch Averting Maternal Death & Disability (AMDD).
2000 – World leaders at the UN Millennium Summit developed the Millennium Development
Goals (MDGs).
2002 – The UNV Secretary-General commissioned the UN Millennium Project to develop a
concrete action plan to achieve the MDGs (see Box 1.5).
2005 – The Partnership for Maternal, Newborn and Child Health was launched to harmonize and
accelerate efforts toward achieving MDG-4 and MDG-5.
1 A History of International Cooperation in Maternal and Child Health 5
both private and public funding (Dwork 1987). Milk The end of the Second World War ushered in
depots were opened in England and the United a new era of international cooperation in health,
States, which soon began using health visitors or within which assistance to mothers and children,
visiting nurses to provide home-based consultations as a moral obligation, would figure prominently.
on infant care. By the early twentieth century, local The United Nations (UN) was established in
authorities were providing infant health services in 1945 and the United Nations International Chil-
one form or another in the industrialized countries of dren’s Emergency Fund (UNICEF) was founded
Europe and in the United States. The loss of lives a year later to provide relief to the thousands of
during the First World War hastened the develop- children and orphans left vulnerable by the war.
ment of more comprehensive infant and child welfare Its earliest programs involved providing aid, in
programs (Dwork 1987). the form of dried milk, to both Western and
Public interest in maternal and child health was Eastern European countries. UNICEF endured
also motivated by other humanitarian concerns. to take on a broader role in protecting children
New and more comprehensive reports on the high all around the world, later changing its name to
levels of infant and maternal mortality in England, the United Nations Children’s Fund (while
the United States, and other countries stimulated retaining its original acronym). The World
action at the local and national levels. Medical asso- Health Organization (WHO), a specialized UN
ciations, charities, women’s groups, and other seg- agency, came into being in 1948 to help all peo-
ments of civil society took an active interest, often as ple attain ‘‘the highest possible level of health’’,
part of social reform movements of that era. For including a function ‘‘to promote maternal and
example, a number of committees and associations, child health and welfare’’ (World Health Organi-
both medical and lay, were formed in various Eur- zation 1948). The Universal Declaration of
opean countries expressly to improve maternal Human Rights, adopted by the United Nations
health. Advocacy was often instrumental in introdu- General Assembly in 1948, included the acknowl-
cing legislation and securing funds to address the edgment that ‘‘motherhood and childhood are
issue (Van Lerberghe and De Brouwere 2001). entitled to special care and assistance’’ (United
MCH was given formal recognition in the United Nations 1948).
States following the emergence of child labor aboli- Maternal and child health had evolved into an
tion and the pressure exerted by progressive reform international priority, but the exact strategies for
movements, leading to the establishment of the Fed- promoting MCH would be debated and trans-
eral Children’s Bureau in 1912 (Lindenmeyer 1997). formed repeatedly in the coming decades. Coop-
During this time, cooperation between nations on eration in MCH has not been limited to the work
matters of health focused on the control of commu- of the UN or other multilateral organizations.
nicable diseases to facilitate trade and commerce. During the first half of the twentieth century,
International Sanitary Conferences, beginning in many of the nations now categorized as develop-
1851, were convened periodically to discuss quaran- ing countries were colonies or protectorates. After
tine and other measures to control cholera, plague, the independence movements of the late 1940s to
and yellow fever (Howard-Jones 1975). International the early 1960s, industrialized nations began to
health bodies, such as the Pan American Sanitary provide aid directly to developing countries on a
Bureau (1902) and the Office International one-to-one basis, a form of assistance known as
d’Hygiène Publique (1907), were created mainly to bilateral aid. The US Agency for International
collect and disseminate new knowledge on infectious Development (USAID), for example, was estab-
diseases. After the First World War, the League of lished in 1961 to provide economic and social
Nations was created along with a subdivision, the development assistance to other nations and has
Health Organization, whose chief activities included funded a number of MCH programs in develop-
the formation of expert committees to study selected ing countries (USAID 2008). Non-governmental
diseases and topics. The League of Nations collapsed organizations (NGOs), or civil society organiza-
after failing to prevent the outbreak of another world tions (CSOs), have also been influential in shap-
war (Simonds 1934). ing the global MCH agenda.
From Vertical, Disease Control Programs improving the economic and social conditions of
to Primary Health Care even the poorest citizens. Under colonial rule,
health services were largely intended for European
The first international programs that were imple- military and civilian populations. They emphasized
mented, beyond war relief efforts, focused on the high technology and curative care in large, urban
control or eradication of specific diseases not only hospitals. Developing countries planned to expand
in Europe but also in Asia, Africa, and Latin Amer- basic curative and preventive health services in rural
ica. Technological breakthroughs, including new areas, where most of the population lived, through a
and cheaper drugs and vaccines, offered a way to network of health posts or health centers staffed by
address epidemic diseases on a grand scale. Mass auxiliary health workers (known as medical assis-
disease campaigns were often ‘‘vertical’’ programs, tants or health assistants). They invested in the
i.e., they utilized financial and logistical resources development of community health workers, who
separate from those of other programs or regular were volunteers, selected by their own communities
health services. This was often at the insistence of and trained to provide health education and basic
donors who preferred having specific objectives and services to their neighbors. The most successful and
who believed that most countries lacked infrastruc- inspiring community-based health initiative was the
tures capable of reaching large segments of the ‘‘barefoot doctors’’ program in China which
population. Tuberculosis, yaws, and other diseases stressed meeting the basic health needs of all people.
came under attack, with generally successful results. Thousands of peasants were trained in basic medi-
Even child malnutrition was addressed as a disease cal practices and preventive medicine including
with protein as its technical solution. During its first proper hygiene, diagnosing infectious disease,
two decades, UNICEF’s efforts to improve child family planning, and maternal and child care.
nutrition consisted of providing milk to children They continued their work alongside other farmers
and pregnant and nursing women (UNICEF in the fields, providing readily accessible health care
2008a). for most peasants, including mothers and children.
However, vertical programs often did little to In reality, however, most developing countries con-
develop existing health systems. The campaign to tinued to spend a large share of health budgets on
eradicate malaria, launched in 1955 by the WHO urban, tertiary hospitals while neglecting care for
and UNICEF, was a noteworthy failure (Brown poor and rural populations.
2002). It demonstrated that not all diseases could The call for an integrated, more equitable
be tamed by the transfer of technology, in this case approach to health care reached a climax in 1978 at
DDT spraying in the absence of well-functioning the International Conference on Primary Health
healthcare infrastructures to support and sustain Care in Alma-Ata, Kazakhstan, co-sponsored by
efforts. The campaign, as well as others like it, the WHO and UNICEF and attended by represen-
ignored the social, economic, and cultural dimen- tatives of over 130 countries and 60 organizations
sions of disease. Nonetheless, disease-specific cam- (WHO/UNICEF 1978). The Declaration of Alma-
paigns continued to be implemented. The smallpox Ata affirmed the goal of health for all by 2000 and
eradication program, concluded in the late 1970s, outlined a strategy for meeting this ambitious goal –
was one of the most successful public health pro- primary health care (PHC) (Box 1.2). More than
grams in history. A global initiative is currently just an organizational strategy, PHC envisioned a
underway to eradicate poliomyelitis which is now process of decision making that valued the commu-
endemic in only a handful of countries. However, nity as a key actor. It recognized the underlying
the need for a more integrated and long-term social, economic, and political dimensions of health
approach to delivering healthcare services has been and, therefore, the need for a multi-sectoral
increasingly acknowledged by international policy- approach. While PHC has often been interpreted
makers and health planners. as merely community-based, preventive health care,
Like their older counterparts, newly independent the declaration recognized the provision of curative
nations sought a different model of health care, part and rehabilitative services to address health pro-
of a broader push for ‘‘development’’ aimed at blems in the community. It stated that PHC should
Box 1.2 Declaration of Alma-Ata
‘‘Primary healthcare is essential healthcare based on practical, scientifically sound and socially
acceptable methods and technology made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and country can afford
to maintain at every stage of their development in the spirit of self-reliance and self-determination. It
forms an integral part both of the country’s health system, of which it is the central function and main
focus, and of the overall social and economic development of the community. It is the first level of
contact of individuals, the family and community with the national health system bringing healthcare
as close as possible to where people live and work, and constitutes the first element of a continuing
healthcare process.’’ (Article VI)
‘‘[Primary healthcare] includes at least: education concerning prevailing health problems and the
methods of preventing and controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and child healthcare, including family
planning [emphasis added]; immunization against the major infectious diseases; prevention and
control of locally endemic diseases; appropriate treatment of common diseases and injuries; and
provision of essential drugs.’’ (Article VII, 3).
Source: WHO/UNICEF (1978)
be sustained by ‘‘functional and mutually suppor- dealt with in more detail in Chapter 8 (Globaliza-
tive referral systems, leading to the progressive tion). PHC helped to bring attention to issues of
improvement of comprehensive healthcare for all’’ community participation, equity, and universal
(WHO/UNICEF 1978). access. But PHC was not widely or consistently
Almost immediately, the concept of primary implemented and soon lost ground.
health care was challenged. It was argued by some
that PHC was too ambitious to be attainable in the
near future. Instead, as an interim measure, a few
conditions responsible for the greatest mortality The Child Survival Revolution
and morbidity and for which efficacious and rela-
tively inexpensive interventions exist should be
prioritized, an idea referred to as selective primary In 1982, James P. Grant, then Executive Director of
health care (Walsh and Warren 1979). A debate on UNICEF, launched an initiative known as the child
comprehensive versus selective primary health care survival revolution (UNICEF 1983). Although
followed. However, UNICEF soon adopted the child mortality rates in low-income countries were
selective approach as the foundation of its child reduced by half between the end of Second World
survival revolution. In the 1980s, developing coun- War and the early 1970s, progress was not main-
tries were suffering from global recession and were tained and almost 15 million children still died each
immersed in foreign debt. In order to receive bail- year from malnutrition and infection. UNICEF
out loans, countries were forced to adopt highly called for massive coverage of four interventions
controversial stabilization and structural adjust- that could significantly reaccelerate progress in
ment programs promoted by the World Bank and child health and nutrition, collectively known by
the International Monetary Fund (IMF). Among the acronym GOBI:
other conditions, these programs required sharp Growth monitoring
cuts in public spending on health, education, and Oral rehydration therapy (ORT) (Box 1.3)
other social sectors. Issues and concerns surround- Breastfeeding
ing structural adjustment programs and MCH are Immunization
Box 1.3 Oral Rehydration Therapy
Oral rehydration therapy (ORT) is a combination of salt water and glucose in the right proportions
that enables the liquid to be absorbed through the intestinal wall. It is used to treat dehydration
caused by diarrheal infections. ORT was discovered in the late 1960s by researchers at the Cholera
Research Laboratory in Dhaka, Bangladesh (later renamed the International Centre for Diarrheal
Disease Research, Bangladesh) and the Infectious Diseases Hospital in Calcutta. During the Ban-
gladesh war of independence in 1971, ORT was applied in refugee camps to combat outbreaks of
cholera and was found to be extremely effective. ORT is considered to be one of the most important
medical breakthroughs of the twentieth century.
These interventions were chosen because they were oral rehydration solution using commonly available
low cost, low risk, effective, and feasible to implement ingredients and simple measurements. Between
(UNICEF 2008b). Food supplementation, family 1980 and 1990, BRAC brought the message of
planning, and female education (GOBI-FFF) were ORT to over 12 million mothers (Chowdhury and
subsequently added to the package in response to Cash 1996).
concerns that GOBI was too narrow in its focus. Before the WHO launched its Expanded Pro-
However, international agencies, donors, and minis- gramme on Immunization (EPI) in 1974, only a
tries of health focused primarily on two components, small proportion of children in developing countries
ORT and immunization, referred to as the ‘‘twin were being immunized (UNICEF 2008c). EPI set
engines’’ of the revolution (UNICEF 2008b). Some out to achieve universal immunization coverage
health professionals and policymakers criticized child against six major diseases: tuberculosis, diphtheria,
survival programs for being top-down, vertical pro- pertussis, tetanus, polio, and measles. In 1984, a
grams, a reversion to the mass disease campaigns of Task Force on Child Survival and Development
the 1950s. Nonetheless, the child survival campaign was established to help develop and coordinate the
generated a great degree of political and popular sup- immunization activities of the major international
port worldwide, and Jim Grant’s energetic leadership agencies, including WHO, UNICEF, the Rockefel-
and personal commitment to the cause was credited ler Foundation, the United Nations Development
with much of its success. Programme (UNDP), and the World Bank. The
The WHO’s Programme for the Control of Diar- scope of the Task Force’s work eventually expanded
rheal Diseases helped countries to develop training to address other aspects of global health. Global
courses for health workers on how to administer immunization coverage increased dramatically to
ORT, while UNICEF supported the production of almost 75% by 1990, helping to avert millions of
packets of oral rehydration salts. Between 1979 and child deaths, but remained level at 70–75% during
1992, the supply of packets increased from 51 to 800 the 1990s with wide variations in coverage between
million. The number of worldwide deaths due to regions (UNICEF 2001). The GAVI Fund (for-
diarrhea among children under 5 years of age fell merly known as the Global Alliance for Vaccines
from 4.6 million in 1980 to 3.3 million in 1990, a and Immunization) was established in 1999 by the
result of the widespread introduction of ORT and Bill & Melinda Gates Foundation to help break the
other complementary activities (Victora et al. 2000). stagnation and widen children’s access to vaccines
Local NGOs were involved in spreading knowledge in poor countries. The GAVI Fund is now a public–
about ORT directly to the village level. Most nota- private partnership made up of national govern-
bly, BRAC (formerly the Bangladesh Rural ments, UNICEF, WHO, the World Bank, the Bill
Advancement Committee) carried out a nationwide & Melinda Gates Foundation, the vaccine industry,
campaign in Bangladesh in the 1980s to educate public health institutions, and NGOs (see Chapter
women in rural areas on how to mix and administer 23 – Immunization).
One of the predominant strategies for addressing reducing child mortality has slowed in many coun-
child health today is the Integrated Management of tries and reversed in some, and the World Summit
Childhood Illness (IMCI) initiative (Chapter 27). goal for reducing child mortality was not achieved.
The introduction of IMCI by the WHO and UNI- The under-5 mortality rate fell from 117 deaths per
CEF in the mid-1990s was a change of course from 1,000 live births in 1980 to 93 per 1,000 in 1990.
other major child health initiatives (Tulloch 1999). However, instead of a one-third reduction, under-5
IMCI integrates disease control programs into a mortality declined by only 11% between 1990 and
package of basic services and now includes house- 2000 to 83 deaths per 1,000 births (UNICEF 2001).
hold- and community-level components. Health More than 10 million children under 5 years of age
workers are trained in comprehensive case manage- still die each year worldwide, and significant chal-
ment skills to accurately diagnose and treat a range lenges remain in particular regions and countries.
of problems as well as promote preventive mea- Members of the international health community
sures. IMCI originally focused on facility-based have called for a renewed commitment to child
interventions for pneumonia, diarrhea, malaria, survival – a second revolution – including increased
and measles, as well as malnutrition. Newer efforts to reduce inequities in child health status and
options, such as early childhood development and strengthen health systems to deliver more coordi-
the treatment of HIV/AIDS, can be included in a nated services for children.
country’s IMCI package. In addition to training
health workers, IMCI aims to strengthen health
systems by developing referral mechanisms for
severely ill children, ensuring the widespread avail- Where Is the ‘‘M’’ in MCH?
ability of drugs and supplies, improving supervision
of staff, and emphasizing monitoring and evalua- Over 500,000 women die each year from pregnancy-
tion. Community-based interventions promote key related causes; almost all maternal deaths occur in
household and community practices linked to the developing regions (World Health Organization
prevention and treatment of common childhood 2004). For every woman who dies, many others
illnesses. The IMCI strategy has been adopted in suffer from debilitating complications, including
more than 100 countries (PAHO 2008). vesico-vaginal fistula and recto-vaginal fistula.
The campaign for child survival reached its poli- While international agencies and donors were
tical peak in 1990 when 71 heads of state and gov- mounting enormous efforts to reduce child mortal-
ernment pledged their support at the World Summit ity, the problem of maternal mortality and morbid-
for Children in New York, one of the largest gather- ity barely registered on the public health agenda. In
ings of world leaders ever assembled at the UN. The 1985, an influential article was published in The
summit set forth goals to be achieved by 2000, Lancet that highlighted the tragedy of maternal
including a goal to reduce the under-5 mortality mortality and called on the World Bank to make
rate by one-third or to 70 deaths per 1,000 live maternity care one of its priorities (Rosenfield and
births, whichever is less. A year earlier, in 1989, Maine 1985). The same year, women’s health and
the UN General Assembly adopted the Convention advocacy groups from around the world gathered
on the Rights of the Child which came into force as together at a conference in Nairobi to mark the end
international law in 1990 and was eventually rati- of the UN Decade for Women, an initiative to help
fied by almost all nations – a remarkable achieve- focus more attention on women’s health and rights.
ment (the United States has yet to ratify the con- The announcement there of the estimated number
vention). The convention outlines the basic human of maternal deaths occurring in developing coun-
rights of children everywhere and protects these tries gave rise to calls for more action to prevent this
rights by setting standards in health care, education, tragedy.
and legal, civil, and social services. There are a number of reasons why maternal
Substantial progress was made in the decade mortality received little attention among politi-
following the launch of the child survival revolu- cians and policymakers. First, the scale of the pro-
tion. However, since the mid-1990s, progress in blem was unclear in most developing countries
until the 1980s because of poor or non-existent vital societies, and women’s contributions to society are
registration systems. In the mid-1980s, the WHO often unrecognized or undervalued. As Halfdan
supported the first community studies on levels of Mahler, former Director-General of WHO, put it,
maternal mortality in developing countries and, with maternal mortality ‘‘has been neglected because
the limited information available from vital registra- those who suffer it are neglected people, with the
tion systems and hospital-based studies, was able to least power and influence over how national
generate global and regional estimates of maternal resources shall be spent; they are the poor, the rural
mortality (World Health Organization 1986). In peasants, and, above all, women’’ (Mahler 1987).
1996, the WHO and UNICEF published revised Allan Rosenfield, former Dean of Columbia’s Mail-
global and regional totals of maternal mortality man School of Public Health, stated on several occa-
and included, for the first time, individual country sions that poor rural women have been ignored and
estimates (World Health Organization 1996). The that they have a basic human right to access to
availability of data, particularly at the country effective maternal health care.
level, was critical in drawing more attention to the
issue. While techniques for measuring maternal mor-
tality have improved somewhat, information is still
extremely difficult to collect and available data con- The Safe Motherhood Initiative
tinue to be rough estimates.
Second, while relatively simple preventive mea- The ‘‘Where is the M in MCH’’ paper, mentioned
sures can substantially reduce mortality among above, strongly recommended that the World Bank
infants and young children, this is not the case with play a major role in this area. A meeting was held at
maternal mortality. The major direct causes of the World Bank which led to consideration of an
maternal death are hemorrhage, infection, eclamp- international conference. In response to mounting
sia, obstructed labor, and complications of unsafe concerns, the World Bank, the WHO, and the Uni-
abortion (Khan and Wojdyla 2006). Women who ted Nations Population Fund (UNFPA) in 1987
develop life-threatening complications during preg- sponsored an international conference in Nairobi
nancy or childbirth need access to the appropriate to raise global awareness of the state of maternal
medical interventions, later referred to as emergency health in developing countries and to mobilize sup-
obstetric care (EmOC). International agencies, port. The conference issued a call to action and
donors, and health professionals believed it was became the launching point of the Safe Motherhood
more feasible to address the problem of child mor- Initiative (Chapter 22 – Making Pregnancy Safer),
tality, which responded relatively quickly and suc- which set a goal to reduce maternal mortality by
cessfully to preventive measures delivered by vertical 50% by the year 2000. UNDP, UNICEF, Interna-
programs. Also, while interpretations of PHC varied, tional Planned Parenthood Federation, and the
the idea of promoting medical treatment found little Population Council joined the three original co-
support at the time. The few measures targeted to sponsors in the formation of a Safe Motherhood
mothers, antenatal consultations and education, had Inter-Agency Group. A series of national and regio-
little impact on maternal mortality and were largely nal safe motherhood meetings followed that helped
aimed at improving infant health (Van Lerberghe to increase global recognition of the problem.
and De Brouwere 2001). Family planning programs In the early years of the Safe Motherhood Initia-
(MCH/FP) were also heavily emphasized in deve- tive, UN bodies, donors, and ministries of health
loping countries beginning in the 1960s. Family continued to support two strategies already being
planning reduces the number of unwanted and implemented: antenatal care with a focus on screen-
unplanned pregnancies and, consequently, the num- ing and the training of traditional birth attendants
ber of maternal deaths, women who are pregnant (TBAs) in safe and hygienic practices. Both interven-
and develop life-threatening complications and tions fit within the perceived ideal of primary health
need access to the appropriate care. care and were also thought to be cost-effective.
Third, discrimination against women is embedded Antenatal screening, an approach supported by the
in the social, economic, and cultural fabric of most first WHO expert committee on motherhood in the
early 1950s (WHO 1952), became accepted wisdom improvements in living standards. Such a broad
despite some evidence of its ineffectiveness. The idea agenda led some policymakers and program man-
was to persuade all women to attend at least one agers to believe that safe motherhood was already a
antenatal visit during their pregnancy. A screening part of their programs (e.g., family planning, antena-
test would be conducted and those women identified tal care, and nutrition), while others considered the
as high risk could then be monitored and treated or agenda too complex and too costly to implement. In
advised to give birth at a health facility. However, contrast, UNICEF provided donors and ministries
many direct obstetric complications can be neither of health with a priority list of interventions – GOBI
predicted nor prevented. Many women who develop – that could prevent childhood deaths from the most
complications have few or no risk factors, and most common causes.
women with risk factors have uneventful pregnancies. Furthermore, fears that targeting maternal mor-
The training of TBAs, which became common in tality would force developing countries to revert to
the 1970s, was considered a rational approach to an emphasis on large, curative hospitals persist.
reducing maternal mortality in countries where there While emergency obstetrical care, such as a cesar-
is a shortage of professional health workers and where ean delivery for obstructed labor, must take place in
the majority of women deliver at home. TBAs live and a properly equipped facility, many life-saving pro-
provide services in rural areas where women have the cedures can be implemented in health centers or the
least access to medical care; they are accepted mem- most peripheral levels of the healthcare system,
bers of the community and they are reimbursed by supported by strong referral mechanisms. In most
women and their families and do not need govern- rural areas in developing countries, there are almost
ment salaries. It was thought that TBAs could be used no obstetricians and very few physicians. To make
to refer women with complications to a facility for emergency obstetrical care available, including
treatment and that they could also be trained to use cesarean sections, Mozambique (and later Tanzania
hygienic practices and avoid harmful ones, such as and Malawi) trained community health workers to
pushing on the abdomen to hasten delivery. However, be able to provide such care (Pereira et al. 2007).
most TBA training programs neither ensured effective This program, which was started about 15 years
supervision nor provided the appropriate linkages to ago, has been highly successful as communities can
referral services. For most of the complications of also play an important role in helping to ensure that
pregnancy and childbirth, there is little that TBAs pregnant women who develop complications
can do to save women’s lives. receive timely care, although distance from ade-
A Safe Motherhood Technical Consultation was quate facilities can still be a barrier in rural areas.
convened in Colombo, Sri Lanka, in 1997 to review It should also be noted that many safe motherhood
key lessons learned from the Initiative’s first 10 years programs gave little attention to the management of
and to develop a consensus on the most effective complications from unsafe abortion because of the
strategies. By this time, it was apparent that little political sensitivities that surround this issue.
progress was being made (Maine and Rosenfield The Sri Lanka meeting focused on a number of
1999). Strategic priorities were not clearly defined key action messages (Starrs 1998). Specific messages
at the outset and some broadened the safe mother- recognized that every pregnancy faces risks and,
hood agenda to include a range of activities aimed at therefore, programs should stop using risk screen-
improving women’s health and social status, including tools as a means to reduce maternal mortality.
ing nutrition and education for young girls. Though Ensuring skilled attendance at delivery was empha-
commendable, these activities cannot substantially sized. The definition of a skilled attendant, a health
reduce levels of maternal mortality. This lack of worker with midwifery skills, excludes TBAs and,
focus was, in part, fueled by the mistaken idea that accordingly, donors and governments have aban-
maternal mortality can be reduced by general socio- doned large-scale TBA training programs. Further-
economic development. However, the experience of more, maternal mortality was framed as a social
countries in Europe and North America has shown injustice. A human rights approach obligates gov-
that levels of maternal mortality are primarily ernments to use all political and legal means avail-
affected by access to medical interventions, not able to provide appropriate health services to all
women. Today, international efforts to reduce one-half by 2015. Operationally, ICPD did not
maternal mortality focus on ensuring a skilled result in any real integration of family planning
attendant at all deliveries and increasing access to and maternal health programs. Reproductive
emergency obstetric care. health programs have focused on family planning
A number of organizations have been involved in and the prevention and management of sexually
maternal health programs over the past 20 years, transmitted diseases. Legal safe abortion services,
including broad-based coalitions and partnerships. post-abortion care, and, to a lesser extent, issues
For example, local NGOs have been involved in pub- such as female genital mutilation and violence
lic education campaigns and other activities. The have also been part of the agenda.
White Ribbon Alliance for Safe Motherhood pro-
motes awareness about maternal mortality and
includes international and local NGOs, UN agencies,
bilateral agencies, and other organizations and indi-
The Millennium Development Goals
viduals. Major donors such as the World Bank, (MDGs)
USAID, and the Department for International Devel-
opment (United Kingdom) have supported intensive In 2000, world leaders gathered at the UN Millen-
maternal health projects in a number of countries. nium Summit to discuss the major development chal-
lenges heading into the twenty-first century. Repre-
sentatives of 189 countries adopted the Millennium
Declaration as a blueprint for action, from which
The International Conference on eight Millennium Development Goals (MDGs)
Population and Development (ICPD) were established (Box 1.5). The MDGs have a target
date of 2015 and synthesize many of the commit-
In the 1960s, fearing the economic and social con- ments made at the international conferences and
sequences of rapid population growth, many coun- summits of the 1990s. Both maternal and child health
tries declared national population policies and estab- are emphasized, while reproductive health is con-
lished family planning programs with the support of spicuously absent from the list. Reproductive health
a variety of donors, particularly USAID. Dismayed advocates have argued, however, that achievement
by the focus on meeting demographic targets, an of the MDGs requires full implementation of the
international women’s health movement emerged ICPD Programme of Action. Nevertheless, the
that sought to shift the rationale for family planning MDGs are currently at the center of the global health
programs from population control to women’s and development agenda and have galvanized an
health and rights. The 1994 International Conference unprecedented level of support. They are being used
on Population and Development (ICPD) in Cairo to reframe the work of UN agencies, governments,
marked the culmination of advocacy efforts and a and organizations, and tracking progress in all parts
significant shift in ideology. The conference was of the world is a priority. MDGs 4 and 5 relate
attended by delegates of over 180 countries as well directly to MCH, while many of the other MDGs,
as representatives of approximately 1,200 NGOs. including MDG 1, are significant. The inclusion of
Both family planning and safe motherhood, along maternal health within the MDG framework was a
with sexual health, were incorporated under the con- highly significant development, although progress
cept of reproductive health (Box 1.4). ICPD was also toward meeting MDG-5 has been slow, particularly
the first major international conference to formally in sub-Saharan Africa and parts of Asia.
articulate a human rights approach to the provision In 2002, the United Nations Secretary-
of reproductive health services. These concepts were General commissioned the UN Millennium Project
reaffirmed at the 1995 Fourth World Conference for to develop a concrete action plan to achieve the
Women in Beijing. MDGs. The project established 10 thematic task-
The ICPD Programme of Action called on coun- forces to conduct extensive research on their respec-
tries to reduce maternal mortality by one-half of tive topics and produce recommendations. The Task
their 1990 levels by the year 2000 and a further Force on Child Health and Maternal Health
Box 1.4 Definition of Reproductive Health and Reproductive Rights
The ICPD Programme of Action defined reproductive health and reproductive rights as follows:
‘‘Reproductive health is a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity, in all matters relating to the reproductive system and to its
functions and processes. Reproductive health therefore implies that people are able to have a
satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide
if, when and how often to do so. Implicit in this last condition are the right of men and women to be
informed and to have access to safe, effective, affordable and acceptable methods of family planning
of their choice, as well as other methods of their choice for regulation of fertility which are not against
the law, and the right of access to appropriate health-care services that will enable women to go safely
through pregnancy and childbirth and provide couples with the best chance of having a healthy infant
[emphasis added]. In line with the above definition of reproductive health, reproductive healthcare is
defined as the constellation of methods, techniques and services that contribute to reproductive
health and well-being by preventing and solving reproductive health problems. It also includes sexual
health, the purpose of which is the enhancement of life and personal relations, and not merely
counseling and care related to reproduction and sexually transmitted diseases.’’ (paragraph 7.2)
‘‘Bearing in mind the above definition, reproductive rights encompass certain human rights that
are already recognized in national laws, international human rights documents and other consensus
documents. These rights rest on the recognition of the basic right of all couples and individuals to
decide freely and responsibly the number, spacing and timing of their children and to have the
information and means to do so, and the right to attain the highest standard of sexual and
reproductive health. It also includes their right to make decisions concerning reproduction free of
discrimination, coercion and violence, as expressed in human rights documents. In the exercise of this
right, they should take into account the needs of their living and future children and their responsi-
bilities towards the community. The promotion of the responsible exercise of these rights for all
people should be the fundamental basis for government- and community-supported policies and
programs in the area of reproductive health, including family planning.’’ (paragraph 7.3)
Source: United Nations (1944)
emphasized the importance of strengthening health within the first month of life or the neonatal period.
systems in developing countries in order to achieve Approximately three quarters of neonatal deaths
meaningful and sustainable progress toward redu- occur in the first week after birth. Four million
cing child and maternal mortality (Freedman and babies are stillborn (Lawn et al. 2005). Effective,
Waldman 2005). The task force recommended the low-cost, feasible interventions do exist and can sig-
rapid scale-up of interventions such as IMCI and nificantly reduce neonatal mortality if universally
the universal provision of emergency obstetric care. implemented. They include tetanus toxoid
vaccination, antibiotics for infections, exclusive
breastfeeding, and kangaroo mother care for low
birth weight babies (a method that encourages skin-
Newborn Survival and the Continuum to-skin contact between mothers and their newborns
of Care to reduce hypothermia, encourage breast feeding,
and prevent infection). Skilled attendants at child-
Until recently, the health of newborns was virtually birth are critical for both mothers and newborns, but
neglected by policymakers and program managers. maternal health programs have focused on bringing
Of the more than 10 million children who die each mothers safely through pregnancy and childbirth. At
year before the age of 5 years, 4 million (38%) die the same time, newborn health has not been
Box 1.5 United Nations Millennium Development Goals
Goal 1: Eradicate extreme poverty and hunger.

Goal 2: Achieve universal primary education.
Goal 3: Promote gender equality and empower women.
Goal 4: Reduce child mortality.
Target:
Reduce by two thirds the under-five mortality rate
Indicators:
Under-five mortality rate; Infant mortality rate.
Proportion of 1-year olds immunized against measles.
Goal 5: Improve maternal health
Targets:
Reduce by three quarters the maternal mortality ratio.
Indicators:
Maternal mortality ratio.
Proportion of births attended by skilled health personnel.
Goal 6: Combat HIV/AIDS, malaria and other diseases.
Goal 7: Ensure environmental sustainability.
Goal 8: Develop a Global Partnership for Development.
Source: The United Nations Development Programme (2003)
integrated into conventional child health programs, continuum of care for mothers and children from
which focus on vaccine-preventable diseases, diar- pregnancy to childbirth and the immediate postnatal
rhea, and acute respiratory tract infections. In order period to childhood (World Health Organization
to achieve MDG-4 which aims to reduce child mor- 2005). The turnover between maternal and child
tality by two-thirds by 2015, significant reductions in health services is critical, but there is still no clear
neonatal mortality must be achieved. consensus on who should provide care and where, to
More efforts have been made to incorporate new- newborns, especially during the first week after birth.
born health into MCH programs. For example,
IMCI (Chapter 27) is developing new guidelines
that address the care of sick newborns. In 2005, the
Partnership for Maternal, Newborn and Child
Conclusion – Moving Forward in
Health was launched to harmonize and accelerate International MCH
efforts toward achieving MDG-4 and MDG-5. The
partnership is the result of a merger between three A review of international policies and programs in
existing consortiums on safe motherhood, child MCH reveals a number of significant developments.
survival, and newborn health and consists of more Cooperation has grown to include many different
than 80 members, including governments, UN agen- agents, from UN agencies and governments to local
cies, NGOs, professional associations, bilateral agen- NGOs. A number of partnerships have emerged
cies, foundations, and academic and research institu- that include a broad range of organizations and
tions. The WHO has recently advocated for a interests. Maternal health issues have become pro-
repositioning of MCH to MNCH (maternal, new- minent on the global health agenda, and the
born, and child health) to reflect a more seamless approaches needed to prevent maternal deaths are
better understood. Neonatal mortality is receiving concretely, resources is not necessarily intentional,
due attention as a public health problem. Reducing constrained budgets in developing countries and
maternal and child mortality is no longer merely a inadequate funding levels will continue to make
technical issue but a human rights imperative. The priority setting in MCH difficult. Cooperation in
need to strengthen the capacity of health systems to MCH will, therefore, require more intense advocacy
deliver services is also widely acknowledged. efforts to increase the pool of funding available to
Nonetheless, many issues that have arisen in the address the broad range of problems. All the var-
past remain. The merits of disease-specific versus ious actors will need to address other strategic issues
integrated approaches are still debated, although as well, such as how to develop an adequate health-
the reality is that both will continue to be used to care workforce to handle the myriad of demands
formulate MCH programs and policies. And while and how to scale up and more equitably deliver
competition for global attention and, more effective interventions.
Key Terms
Alma-Ata Declaration International Monetary Fund Integrated Management of

Averting Maternal Death and League of Nations Childhood Illnesses
Disability (AMDD) Midwives (IMCHI)
Barefoot doctor Newborn survival United Nations Children’s
Child survival revolution Pan American Sanitary Bureau Fund (UNICEF)
Emergency Obstetric Care Primary health care United States Agency for
(EmOC) Reproductive rights International Development
Expanded Programme on (USAID)
Safe motherhood
Immunization (EPI) Universal Declaration of
Sanitary reforms
Global Alliance for Vaccines Human Rights
Traditional birth attendants
and Immunization (GAVI) World Bank
(TBAs)
GOBI-FFF World Health Organization
United Nations Decade for
Infant mortality rate Women
Questions for Discussion What were the major reasons why maternal mor-
tality received little attention among politicians
and policy makers until the 1980s?
The end of the Second World War ushered in a
Reducing maternal and child mortality is no
new era of international cooperation in health
longer merely a technical issue but a human
within which assistance to mothers and children
rights imperative. Discuss.
featured prominently as a moral obligation.
Discuss.
Identify and discuss the intervention programs of
the child survival revolution. What were the
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Chapter 2
Global Burden of Disease Among Women, Children,
and Adolescents
Colin Mathers
Learning Objectives After reading this chapter and on attributable disease burden for selected key risk
answering the discussion questions that follow, you factors for children, adolescents, and women in dif-
should be able to ferent geographic regions of the world. As the ana-
lyses reveal, much of the global mortality among
Identify and discuss the conditions that contri-
children is concentrated in middle- and low-income
bute the most significantly to loss of health for
countries, particularly in south Asia and sub-
children (ages 0–9 years), adolescents (ages 10–
Saharan Africa. Infectious diseases are the principal
19 years), and women (ages 20 years and over) in
causes of mortality among children under 5, with
different regions of the world.
five largely preventable conditions (lower respira-
Appraise the burden of disease attributable to
tory infections, diarrheal diseases, malaria, HIV/
key risk factors for children, adolescents, and
AIDS, and measles) accounting for 70% of all
women in different regions of the world.
child deaths in sub-Saharan Africa. A third of the
Discuss the global distribution of mortality
mortality among children under the age of 10 was
among children, women, and adolescents.
attributable to underweight, with unsafe water,
Evaluate the importance of the global burden of
sanitation, and hygiene accounting for another
disease studies and the implications for global
13%. For adolescents aged 10–19, mental disorders
health policy.
(particularly depression, schizophrenia, and bipolar
disorders), injuries (especially road traffic acci-
dents), violence, and suicide were the leading causes
of burden of disease. Alcohol use disorders were
Introduction
the second leading cause of burden of disease in
adolescents in high-income countries. Globally
Using the latest available estimates of mortality and
among women aged 20–59, HIV/AIDS was the
disease burden from World Health Organization’s
leading cause of burden of disease; it is responsible
(WHO) Global Burden of Disease (GBD) study for
for one-half of deaths and disability-adjusted life
the year 2002, this chapter presents an analysis of
years (DALYs) in this age group in sub-Saharan
major diseases and injuries that contribute most
Africa.
significantly to loss of health for children (ages 0–9
Detailed description of the level and distribution
years), adolescents (ages 10–19 years), and women
of diseases, injuries, and their causes are important
(ages 20 and over) for different regions of the world.
inputs to public health policies and programs.
The chapter draws heavily on an extensive WHO
When we are interested in assessing all important
study of risk factors to provide further information
causes of loss of health, the statistics that must be
compared rapidly become large, and we face diffi-
culties in comparing indicators relating to different
health states, mortality risks, or disease events. Such
C. Mathers (*)
Information, Evidence and Research Cluster, World Health statistics also suffer from several other limitations
Organization, Geneva, Switzerland that reduce their practical value for policy making.

20 C. Mathers
First, they are partial and fragmented. Basic infor- were used as the framework for cost-effectiveness
mation on causes of death are not available for all and priority setting analyses carried out for the
important causes in many countries, and mortality Disease Control Priorities Project, a joint project
statistics fail to capture the impact of non-fatal of the World Bank, the World Health Organization,
conditions, such as mental disorders, musculoskele- and the National Institutes of Health, funded by the
tal disorders, blindness, or deafness. Second, ana- Gates Foundation. The GBD results were docu-
lyses of incidence, prevalence, or mortality for single mented in detail, with information on data sources
causes often result in under- or over-estimates, and methods as well as uncertainty and sensitivity
when not constrained to fit within demographically analyses, in a book published as part of the Disease
plausible limits or to be internally consistent. Control Priorities Project (Lopez et al. 2006).
Diseases that cause a large number of deaths are The estimates for 2002 remain the latest available
clear public health priorities, but mortality statistics at the time of writing, although an incremental
alone do not capture the burden of disease caused update which will include 2004 results will soon be
by chronic diseases, injuries, and mental health dis- available.
orders. A substantial body of work in the last two
decades has focused on the quantification of burden
of disease using a summary measure that includes
The Disability-Adjusted Life Year (DALY)
both disability (or loss of full health) and premature
death and gives extra weight to diseases that pri-
marily affect younger people, since mortality at The disability-adjusted life year (DALY) extends
younger ages results in a greater loss of years of life. the concept of potential years of life lost due to
premature death (PYLL) to include equivalent
years of ‘‘healthy’’ life lost from living in states of
poor health or disability. One lost DALY can be
Global Burden of Disease (GBD) Studies thought of as one lost year of ‘‘healthy’’ life (either
through death or illness/disability), and total
The initial Global Burden of Disease (GBD) Study DALYs (the burden of disease) as a measurement
was commissioned by the World Bank to provide a of the gap between the current health of a popula-
comprehensive assessment of disease burden in tion and an ideal situation where everyone in the
1990 from more than 100 diseases and injuries, population lives into old age in full health. DALYs
and from 10 selected risk factors (Murray and for a specific disease or injury cause are calculated
Lopez 1996a, b). As well as generating a compre- as the sum of the years of life lost due to premature
hensive and consistent set of estimates of mortality mortality (YLL) from that cause and the years lost
and morbidity by age, sex, and region for the world, due to disability (YLD) for incident cases of the
the GBD study introduced a new metric – the dis- disease or injury. The YLL are calculated from the
ability-adjusted life year (DALY) – to simulta- number of deaths, dx, at each age x multiplied by a
neously quantify the burden of disease from prema- global standard life expectancy, Lx, which is a func-
ture mortality and the non-fatal consequences of tion of age x:
over 100 diseases and injuries. X
The WHO has undertaken a new assessment of YLLx ¼ dx L x
the global burden of disease for the years 1999– x
2002, with annual assessments published in Annex

Tables to the World Health Reports from 1998 to The loss function Lx was specified in terms of the
2004 (World Health Organization 2004). Addition- life expectancies at various ages in standard life
ally, a major and expanded research program, the tables with life expectancy at birth fixed at 82.5
Comparative Risk Assessment (CRA) project, was years for females and 80.0 years for males, rather
undertaken to quantify the global and regional than using an arbitrary age cutoff such as 70 years.
attributable mortality and burden for 26 major The loss function was specified to be the same for all
risk factors (Ezzati et al. 2004). These assessments deaths of a given age and sex, in all regions of the
2 Global Burden of Disease Among Women, Children, and Adolescents 21
world (Murray and Lopez 1996b). Because YLL the DALY, calculation formulae, and the philoso-
measure the incident stream of lost years of life phy underlying parameter choices is given by
due to deaths, an incidence perspective is taken for Murray (1996).
the calculation of YLD. The YLD for a particular
cause in a particular time period are calculated by
multiplying the number of incident cases ix, at each
Data Sources and Methods
age x in that period by the average duration of the
disease for each age of incidence, lx, and a weight The GBD study developed methods and
factor dwx that reflects the severity of the disease on approaches to make estimates for causes of burden
a scale from 0 (full health) to 1 (dead): for which there was limited data and considerable
X uncertainty, to ensure that causes with limited infor-
YLDx ¼ ix lx dwx mation were not implicitly considered to have zero
x burden and hence ignored by health policy makers
(Murray et al. 2003). The basic philosophy guiding
YLD are calculated either for the average inci- the GBD approach is that there is likely to be useful
dent case of the disease or for one or more disabling information content in many sources of health data,
sequelae of the disease. For example, YLD for dia- provided they are carefully screened for plausibility
betes are calculated by adding the YLD for uncom- and completeness and that internally consistent esti-
plicated cases and the YLD for sequelae such as mates of the global descriptive epidemiology of
diabetic neuropathy, retinopathy, and amputation. major conditions are possible with appropriate
The ‘‘valuation’’ of time lived in non-fatal health tools, investigator commitment, and expert opi-
states formalizes and quantifies social preferences nion. Diseases and injuries are classified in the
for different states of health as disability weights GBD using a tree structure based on the Interna-
(dwx). These weights can also be described as health tional Classification of Diseases. The highest level
state valuations or health state preferences. In the of aggregation consists of three broad cause groups:
formulation of the DALY, the disability weight is Group I (communicable, maternal, perinatal, and
conceived of as quantifying the relative loss of nutritional conditions), Group II (non-communic-
health for different conditions or states and does able diseases), and Group III (injuries). Group I
not carry any implication about quality of life or the causes are those conditions that typically decline at
overall value of a life lived in particular health or a faster pace than all-cause mortality during the
disability states. epidemiological transition and occur largely in
The disability weights used in the GBD for 2002, poor populations (see Table 2.1).
and the methods used to obtain them, are The GBD study produced comprehensive esti-
described elsewhere (Mathers et al. 2006). Murray mates for mortality and YLL by country, cause,
and Lopez chose to apply a 3% time discount rate and sex for 5-year age groups up to age 85 years
to the years of life lost in the future to estimate the and over. For incidence, prevalence, and YLD, esti-
net present value of years of life lost in calculating mates were made for 17 geographic regions and for
DALYs. Based on a number of studies that suggest 8 age groups: 0–4, 5–14, 15–29, 30–44, 45–59, 60–69,
the existence of a broad social preference to value a 70–79, and 80+. For the purposes of this chapter,
year lived by a young adult more highly than a year the YLD estimates were imputed to the age groups
lived by a young child or an older person, Murray 0–4, 5–9, 10–19, and 20–29 as follows: For cause–
incorporated non-uniform age weights. When dis- age–sex groups where the YLD/YLL ratio was less
counting and age weighting are both applied, a than 5, YLD were imputed to 5-year age groups
death in infancy corresponds to 33 DALYs, using the YLL estimates for the 5-year age groups
while deaths at ages 5–20 equate to around 36 and the YLD/YLL ratio for the relevant broader
DALYs. Discounting and age weighting essen- age group. For other cause–age–sex groups where
tially modify the loss function, Lx, in the calcula- the DALY was dominated by non-fatal loss of
tion of YLL and the average duration, lx, in the health, the YLD rate per capita was assumed to be
calculation of YLD. A more complete account of constant for the 5-year age groups within the
22
Table 2.1 Estimated global deaths and burden of disease by cause for children, adolescents, and women, 2002. Within each major group, disease and injury causes resulting
in greater than 1% of total deaths or DALYs for all ages combined are shown, ranked within each group by global DALYs
Children aged 0–9 Adolescents aged 10–19 Women aged 20 and over All ages, both sexes
Deaths DALYs Deaths DALYs Deaths DALYs Deaths DALYs
All causes (’000) (’000) (’000) (’000) (’000) (’000) (’000) (’000)
Total number (thousands) 11,401 501,067 1,380 116,331 21,035 413,737 57,243 1,490,168
Rate per 1,000 population 9.3 409.9 1.2 98.1 10.9 215.2 9.2 239.4
Selected cause groups – Number (thousands) —
I. Communicable, maternal, perinatal, and nutritional conditions
Group I total 9,905 388,643 533 31,656 3,920 104,146 18,538 612,185
Perinatal conditions* 2,462 97,300 0 2 0 1 2,462 97,303
Lower respiratory infections 1,986 71,410 155 6,315 918 7,847 3,947 93,617
HIV/AIDS 434 15,244 54 2,171 1,127 33,036 2,919 85,581
Diarrheal diseases 1,686 59,378 4 1,137 87 1,781 1,869 64,368
Malaria 827 31,634 11 991 36 1,037 908 34,604
Tuberculosis 62 2,460 55 2,447 479 10,405 1,566 34,726
Maternal conditions 0 113 66 7,787 444 25,698 510 33,599
Measles 599 21,004 9 346 0 1 607 21,352
Protein-energy malnutrition 166 15,537 18 661 39 335 260 16,883
II. Non-communicable diseases
Group II total 961 76,144 300 56,402 15,848 273,930 33,537 696,298
Unipolar depressive disorders 0 3,003 0 11,775 7 32,347 13 67,052
Ischemic heart disease 8 420 14 863 3,395 23,691 7,208 58,632
Cerebrovascular disease 17 582 14 502 2,946 23,298 5,509 49,169
Chronic obstructive pulmonary 4 154 1 149 1,333 12,268 2,748 27,721
disease
Hearing loss, adult onset – – – 447 – 12,465 – 25,948
Cataracts – 152 – 721 – 13,751 – 25,152
Alcohol use disorders 0 126 0 3,424 13 2,493 91 20,258
Diabetes mellitus 4 199 5 423 542 8,244 988 16,161
C. Mathers
2
Table 2.1 (continued)

Children aged 0–9 Adolescents aged 10–19 Women aged 20 and over All ages, both sexes
All causes (’000) (’000) (’000) (’000) (’000) (’000) (’000) (’000)
Schizophrenia 0 803 0 5,241 12 5,298 23 16,090
Asthma 6 4,049 12 4,108 110 3,086 240 15,285
Osteoarthritis 0 5 0 485 3 8,730 5 14,809
Congenital heart anomalies 230 14,401 11 408 11 256 262 15,309
Vision disorders, age related – 54 – 296 – 7,686 – 14,102
Bipolar disorder 0 356 0 4,613 1 4,450 1 13,903
Cirrhosis of the liver 30 1,206 14 669 256 4,158 786 13,973
Lung cancer 1 34 1 35 353 3,226 1,243 11,228
Nephritis and nephrosis 22 997 15 745 315 3,133 677 8,393
Stomach cancer 0 14 2 57 326 3,016 850 8,094
Hypertensive heart disease 2 84 2 72 490 3,714 911 7,643
Liver cancer 2 83 4 139 188 1,981 618 7,135
Global Burden of Disease Among Women, Children, and Adolescents
Colon and rectum cancer 0 3 1 37 299 2,684 622 5,817

III. Injuries
Group III total 535 34,507 547 33,890 1,268 33,267 5,168 181,685
Road traffic accidents 136 7,207 138 7,066 229 5,915 1,192 38,630
Violence 20 1,074 66 3,981 90 2,636 559 21,372
Self-inflicted injuries 2 149 83 3,700 286 6,373 873 20,765
Falls 30 4,342 19 3,376 137 2,834 392 16,158
* Includes ‘‘causes arising in the perinatal period’’ as defined in the International Classification of Diseases and does not include all causes of deaths occurring in the
perinatal period.
Source: World Health Organization (2004)
23
24 C. Mathers
broader YLD age range. Results are presented data available from different studies. Data sources
using World Bank geographic regions to group included disease registers, epidemiological studies,
low- and middle-income countries. High-income health surveys, and health facility data (where rele-
countries in all regions are separately grouped as a vant). Two key tools in dealing with limited or
single ‘‘high-income’’ group. Definitions of these missing data were to carefully screen sources of
regions are given by Lopez et al. (2006). health data for plausibility and completeness, draw-
ing on expert opinion and on cross-population com-
parisons, and to explicitly ensure the internal con-
sistency of estimates of incidence, prevalence, case
Estimation of Mortality Levels and fatality, and mortality for each specific disease
Causes of Death cause. A software tool called DisMod was devel-
oped for the GBD study to help model the incidence
For the most recent GBD estimates at the WHO, and duration parameters needed for YLD calcula-
life tables specifying mortality rates by age and sex tions from available data, to incorporate expert
for 192 WHO Member States were developed for knowledge, and to check the consistency of different
2002 from available death registration data (112 epidemiological estimates and ensure that the esti-
member states), sample registration systems mates used were internally consistent (Barendregt
(India, China), and data on child and adult mortal- et al. 2003).
ity from censuses and surveys such as the Demogra- Epidemiological estimates for incidence, preva-
phy and Health Surveys (DHS) and UNICEF’s lence, and YLD were first developed for 17 group-
Multiple Indicator Cluster Surveys (MICS). Death ings of countries, and then imputed to country
registration data containing usable information on populations using available country-level informa-
cause of death distributions were available for 107 tion and methods to ensure consistency with the
countries, the majority of these in the high-income country-specific mortality estimates. The resulting
group, Latin America and the Caribbean, and Eur- country-level estimates were then used to prepare
ope and central Asia. Population-based epidemio- regional estimates for the World Bank country
logical studies, disease registers, and notification groups. Around 8,700 data sets were used to quan-
systems (in excess of 2,700 data sets) contributed tify the YLD estimates for GBD 2000–2002, of
to the estimation of mortality due to 21 specific which more than 7,000 related to Group I causes.
communicable causes of death, including HIV/ One-quarter of the data sets relate to populations in
AIDS, malaria, tuberculosis, childhood immuniz- sub-Saharan Africa and around one-fifth to popu-
able diseases, schistosomiasis, trypanosomiasis, lations in high-income countries. Together with the
and Chagas disease. Almost one-third of these more than 1,370 additional data sets used for the
data sets related to sub-Saharan Africa. In order estimation of YLL, the 2000–2002 GBD Study
to address information gaps relating to other causes incorporated information from over 10,000 data
of death for populations without useable death sets relating to population health and mortality.
registration data, models for estimating broad This almost certainly represents the largest synth-
cause-of-death patterns based on GDP and overall esis of global information on population health ever
mortality levels were used (Mathers et al. 2006). carried out. Cause-specific data sources and meth-
ods are documented in more detail by Mathers et al.
(2006).
Calculating Years Lived with Disability
(YLD)
Disease Burden from Risk Factors
Estimating YLD requires systematic assessments of
the available evidence on incidence, prevalence, There are many published analyses of disease and
duration, and severity of a wide range of conditions, mortality attributable to individual risk factors such
often based on inconsistent, fragmented, and partial as tobacco smoking or unsafe water and sanitation,
usually for specific populations. It is usually diffi- x: risk factor exposure level
cult to compare such estimates across risk factors P(x): population distribution of exposure
due to different definitions and treatments of P0 (x): counterfactual distribution of exposure
‘‘hazardous exposure’’ and to differences in health RR(x): relative risk of mortality from site-
outcome measures used. As part of the Global Bur- specific cancer at exposure level x
den of Disease project, a unified framework for m: maximum exposure level
Comparative Risk Assessment (CRA) was devel-
For risk factors with discrete exposure levels, a
oped using a systematic and consistent approach
similar equation can be written with summation over
to the assessment of the changes in population
the discrete levels, rather than integration. Because
health (deaths or DALYs) which would result
most diseases are caused by multiple risk factors
from modifying the population distribution of
acting together, and because some risk factors act
exposure to a risk factor or a group of risk factors
through others, PAFs for multiple risk factors for
(Ezzati et al. 2003). In the CRA framework, the
the same disease can add to more than 100% (Mur-
burden of disease due to the observed exposure
ray and Lopez 1999). In other words, the joint attri-
distribution in a population is compared with the
butable burden of several risk factors combined may
burden from an alternative ‘‘theoretical minimum
be less than the sum of the individual attributable
risk’’ distribution which is defined consistently for
burdens. For this reason, attributable burden esti-
different risk factors.
mates for individual risk factors presented below
The CRA project included 26 selected risk fac-
should not be added across risk factors. For each
tors presented in Table 2.3. The criteria for selection
risk factor, between 1999 and 2002, an expert group
of risk factors included that they were not too spe-
conducted a comprehensive review of published lit-
cific or broad, that the likelihood of causality was
erature as well as sources such as government
high based on scientific knowledge, that sufficient
reports, international databases to obtain data on
data on exposure levels and relative risks of health
risk factor exposure and the magnitude of hazardous
outcomes were available, and that they were poten-
effects (relative risk, RR, or absolute hazard size
tially modifiable. For many of these risk factors, the
when appropriate) (Ezzati et al. 2004). This chapter
counterfactual distribution is zero exposure (e.g.,
presents some summary results for the mortality and
100% of the population being never smokers). For
burden of disease in the year 2002 attributable to the
some risk factors, where zero exposure is an inap-
26 selected risk factors. This measures the reduction
propriate choice [e.g., body mass index (BMI), high
in the current (2002) disease or death if the current
blood pressure, or outdoor air pollution (where
and past exposure to the risk factor had been equal to
there is a physical lower limit to particulate matter
a counterfactual distribution. The results presented
concentration)], the lowest levels observed in speci-
here are based on the analyses carried out for the year
fic low-risk populations and epidemiological studies
2000 for the CRA project. Age–sex–cause-specific
were used to choose the theoretical minimum risk
PAFs calculated for the year 2000 for 14 subregions
distribution. The counterfactual exposure distribu-
of the 6 WHO regions were applied to country-
tions are specified elsewhere (Ezzati et al. 2002).
specific estimates of mortality and burden of disease
The proportional reduction in disease or death
for the year 2002 for each country in each of the 14
that would occur if exposure to a risk factor or
subregions. The results were aggregated for high-,
group of risk factors were reduced to the counter-
low-, and middle-income countries.
factual distribution is referred to as the population
attributable fraction (PAF) and is given by the fol-
lowing relationship:
Global Burden of Disease – An Overview
Rm Rm
RRðxÞPðxÞ dx RRðxÞP0 ðxÞ dx
PAF ¼ x¼0 x¼0 Just over 57 million people died in 2002, 10.4 mil-
Rm lion (or nearly 20%) of whom were children less
RRðxÞPðxÞ dx
x¼0 than 5 years of age. Of these child deaths, 99%
26 C. Mathers
occurred in low- and middle-income countries. DALYs, 21% of total disease and injury burden
Child and adolescent deaths under age 20 comprise for the world in 2002 was in children aged less than
just 1.5% of deaths in high-income countries, but 10 years, 7.5% in adolescents aged 10–19 years,
more than 25% in low- and middle-income coun- and 34% in women aged 20 years and over. The
tries (Fig. 2.1). About 70% of deaths in high- global disease burden for children fell almost
income countries occurred beyond 70 years of entirely in low- and middle-income countries
age, compared to 30% in other countries. A key (Fig. 2.2). Table 2.1 summarizes estimated num-
point is the comparatively high number of deaths bers of deaths and DALYs in 2002 for diseases and
in low- and middle-income countries at young and injuries which caused more than 1% of global
middle adult ages. The causes of death at these deaths or DALYs.
ages, as well as in childhood, are thus important
in assessing public health priorities. Measured in
Low and middle income countries High income countries

49.4 million deaths in 2002 7.9 million deaths in 2002
1%
0%
1%
21%
39%
2%
3% 49% 49%
35%
Child 0–4 years Child 5–9 years Adolescent 10–19 years
Women 20 years and over Men 20 years and over
Low and middle income countries High income countries

1,372 million DALYs in 2002 119 million DALYs in 2002
4% 2%
7%
29% 31%
46%
5% 41%
8%
27%
Fig. 2.1 Age–sex distribution of total deaths in low- and middle-income countries and in high-income countries, 2002
High income
Measles, pertussis and tetanus
Diarrhoeal diseases
Europe and Central Asia Respiratory infections

Other infectious and parasitic
Perinatal causes
Latin America and Caribbean
Nutritional deficiencies
Noncommunicable
Middle East and North Africa Injuries
East Asia and Pacific
South Asia
Sub-Saharan Africa
0 500 1000 1500 2000 2500 3000 3500

Death rate per 100,000 children aged 0–4
Fig. 2.2 Death rates by disease group and region for children shown as a single group at the top of the graph. Source:
aged 0–4 years, 2002. For all the World Bank geographical World Health Organization (2004)
regions, high-income countries have been excluded and are
The Burden of Disease in Children achieved in certain areas (e.g., polio), communicable
diseases still represent 7 out of the top 10 causes and
Of the estimated 11.4 million deaths of children cause about 60% of all child deaths. Overall, the 10
under age 10 in 2002, over 90% (or 10.4 million) leading causes represent 83% of all child deaths
were among children aged 0–4 years and 99% of under age 5. In contrast, in high-income countries
these deaths occurred in low- and middle-income perinatal conditions and congenital anomalies are
countries. The risk of a child dying before age 5 the leading causes of child death (Table 2.2).
ranged from 17% in sub-Saharan Africa to 0.7% About 90% of all HIV/AIDS and malaria deaths
in high-income countries in 2002. Globally, condi- in children in developing countries occurred in sub-
tions arising in the perinatal period such as prema- Saharan Africa, where 23% of the world’s births and
turity, birth asphyxia, and severe neonatal infec- 43% of the world’s child deaths are found. The
tions were the leading cause of death under age 5, immense surge of HIV/AIDS mortality in children
responsible for 2.5 million deaths (Table 2.1). in recent years means that HIV/AIDS is now respon-
Lower respiratory infections, principally pneumo- sible for around 300,000 child deaths annually in
nia, diarrheal diseases, malaria, HIV/AIDS, and sub-Saharan Africa and nearly 7% of all child deaths
measles were the next leading causes. Collectively in the region. Some progress has been observed
these five largely preventable causes were responsi- against diarrheal diseases and measles. While inci-
ble for 70% of all child deaths. dence is thought to have remained stable, mortality
Infectious and parasitic diseases remain the major from diarrheal diseases has fallen from 2.5 million
killers of children in the developing world (Fig. 2.2 deaths in 1990 to about 1.7 million deaths in 2002,
and Table 2.1). Although notable success has been accounting for 15% of all child deaths under age 10.
28 C. Mathers
Table 2.2 Leading causes of mortality by income group among children aged 0–4 years, 2002
Low- and middle-income countries High-income countries
Deaths Percent of total Deaths Percent of total
Cause (thousands) deaths Cause (thousands) deaths
1 Perinatal 2,431 23.4 1 Perinatal 30.7 43.9
conditionsa conditionsa
2 Lower respiratory 1,803 17.3 2 Congenital 16.9 24.2
infections anomalies
3 Diarrheal diseases 1,681 16.2 3 Road traffic 1.7 2.4
accidents
4 Malaria 822 7.9 4 Lower respiratory 1.5 2.2
infections
5 Measles 537 5.2 5 Endocrine 1.5 2.2
disorders
6 Congenital 408 3.9 6 Drownings 1.2 1.7
anomalies
7 HIV/AIDS 340 3.3 7 Violence 1.0 1.5
8 Whooping cough 294 2.8 8 Meningitis 0.8 1.1
9 Tetanus 198 1.9 9 Leukemia 0.6 0.8
10 Protein-energy 148 1.4 10 Inflammatory 0.6 0.8
malnutrition heart diseases
a
Includes ‘‘causes arising in the perinatal period’’ as defined in the International Classification of Diseases and does not include
all causes of deaths occurring in the perinatal period.
There has also been a significant decline in deaths leading cause because of the considerable disability
from measles, although more than half a million associated with lifelong stunting and, for many cases
children under 5 years were killed by measles in of severe stunting, associated cognitive impairment.
2002. Malaria deaths are thought to have increased Malnutrition (resulting in underweight) is also a risk
during the 1990 s to around 820,000 deaths among factor for deaths from infectious causes as discussed
children under 5 years of age in 2002, nearly 8% of all in the following section. More than 85% of the bur-
under-5 deaths. den of disease among children aged 0–9 is concen-
Many Latin American and some Asian and Middle- trated in children aged 0–4. Because DALYs are
Eastern countries have partly shifted toward the cause- calculated using an incidence perspective, this
of-death pattern observed in high-income countries. means that 85% of lost years of healthy life are due
Here, conditions arising in the perinatal period, includ- to incident disease, injury, and mortality below age 5.
ing birth asphyxia, birth trauma, and low birth weight, However, there will be prevalent disability among
have replaced infectious diseases as the leading causes children aged 5–9 years due to infectious diseases,
of death and are now responsible for 21–36% of deaths. nutritional deficiencies, congenital malformations,
Such a shift in the cause-of-death pattern has not etc., present at birth or incident in the first 5 years.
occurred in sub-Saharan Africa, where perinatal con- Almost 50% of the burden of disease in children aged
ditions rank in fourth place. 0–4 years is attributable to just seven infectious dis-
eases: lower respiratory infections, diarrheal dis-
eases, malaria, measles, whooping cough, HIV/
The Burden of Diseases and Injuries AIDS, and tetanus. Injuries become relatively more
in Children important for children aged 5–9 years. Among the
top 10 causes of DALYs for this age group are road
The leading causes of burden of disease in children traffic accidents, falls, and fires. Although injuries
aged 0–9 years, as measured in DALYs, are almost become more important for boys beyond infancy,
the same as for mortality, except that protein-energy the causes of burden of disease are broadly similar
malnutrition ranks somewhat higher as the seventh for boys and girls.
Fig. 2.3 Mortality Per cent of total global deaths

attributable to 10 leading 0 5 10 15 20 25 30 35
global risk factors for
children aged 0–9 years, as a Childhood and maternal underweight
percent of global deaths for
children aged 0–9 years. The Unsafe water, sanitation, and hygiene
figure shows the estimated
mortality and disease burden Indoor smoke from solid fuels
attributable to each risk
Zinc deficiency
factor considered
individually. Source: World
Vitamin A deficiency
Health Organization (2004)
Unsafe sex
Iron deficiency
Contaminated injections in
health care settings
Global climate change
Alcohol
Leading Risk Factors for Mortality and adolescents are very similar in all developing
Burden of Disease in Children regions at just under 1 per 1,000 population except
for south Asia, where the rate is twice as high, and
One-third of child deaths under age 10 in 2002 were sub-Saharan Africa, where it is almost three times as
attributable to underweight (primarily due to pro- high. HIV/AIDS, tuberculosis, and maternal deaths
tein-energy malnutrition). Micronutrient deficien- explain much of the excess death rate in sub-
cies were also among the leading risk factors for Saharan Africa, along with higher rates from other
child mortality (e.g., vitamin A deficiency [6.3%], infectious diseases and violence and war. For south
zinc deficiency [6.7%], and iron deficiency [3.6%]) Asia, the excess death rate is associated with high
(Fig. 2.3 and Table 2.3). Unsafe water, sanitation, infectious disease death rates and with high injury
and hygiene was the second leading risk factor death rates. Globally, lower respiratory infections
responsible for child deaths through diarrheal dis- and road traffic accidents were the leading causes of
eases primarily [13.0%] followed by indoor smoke death in adolescents (Table 2.1). These were fol-
from household use of solid fuels [7.5%] and unsafe lowed by suicide (6%), drownings (6%), and inter-
sex [4.3%]. The mortality and burden of disease personal violence (5%) (WHO 2004).
attributable to all these risks was primarily concen- Road traffic accidents were the second leading
trated in south Asia and sub-Saharan Africa. cause of burden of disease in this age group, after
unipolar major depression (Table 2.4). Injuries
comprised four out of the ten leading causes of
DALYs for adolescents as well. Several mental dis-
The Burden of Disease in Adolescents orders also appear in the top 10 causes of burden
including depression, schizophrenia, bipolar disor-
While death rates and burden of disease rates are der, and alcohol use disorders (dependence and
lower for adolescents than for children or adults problem use of alcohol). Alcohol use disorders
aged 20 years and over, many of these deaths are were the second leading cause of burden of disease
preventable and strong regional differences remain in adolescents in high-income countries; in low- and
(Fig. 2.4). The regional differentials are lower than middle-income countries they were only the 11th
for child deaths, and total death rates for leading cause.
30 C. Mathers
Table 2.3 Attributable global deaths (000) and DALYs (000) by risk factor – for children, adolescents, and women, 2002. The
combined effects of any group of risk factors in this table will often be less than the sum of their separate effects
Adolescents aged 10– Women aged 20 and
Children aged 0–9 19 over All ages, both sexes
All causes (’000) (’000) (’000) (’000) (’000) (’000) (’000) (’000)
Childhood and maternal
under-nutrition
Childhood and maternal 3,778 139,272 – – – – 3,778 139,272
underweight
Iron deficiency 410 16,046 16 2,697 144 6,090 603 27,489
Vitamin A deficiency 718 25,018 15 551 90 2,599 823 28,177
Zinc deficiency 762 27,160 – – – – 762 27,160
Other diet-related risks
and physical
inactivity
High blood pressure – – – – 4,250 29,202 7,984 61,746
High cholesterol – – – – 2,077 16,200 4,018 36,495
Overweight and obesity – – – – 1,227 15,782 2,225 29,065
Low fruit and vegetable – – 5 241 1,165 10,434 2,526 24,855
intake
Physical inactivity – – 3 188 980 8,942 1,981 19,560
Sexual and reproductive
health risks
Unsafe sex 492 18,217 55 4,014 1,380 39,367 3,162 95,005
Lack of contraception – – 13 1,551 149 7,501 162 9,052
Addictive substances
Tobacco – – – – 1,029 11,545 5,039 61,284
Alcohol 25 1,338 85 7,600 379 8,410 2,199 61,557
Illicit drugs 0 87 6 1,740 50 2,410 247 12,336
Environmental risks
Unsafe water, 1,483 52,213 4 992 76 1,547 1,643 56,554
sanitation, and
hygiene
Urban outdoor air 22 735 – – 359 2,339 769 6,079
pollution
Indoor smoke from solid 851 29,948 – – 549 4,522 1,592 36,430
fuels
Lead 2 9,793 2 85 80 1,058 246 13,172
Global climate change 62 2,494 1 105 3 111 70 2,808
Occupational risks
Occupational airborne – – 1 363 95 1,091 377 5,092
particulates
Occupational – – 1 21 21 218 121 1,181
carcinogens
Occupational ergonomic – – 0 96 0 312 1 854
stressors
Occupational noise – – – 111 – 1,341 – 4,278
Occupational risk – – 27 1,518 17 636 315 10,767
factors for injuries
Other selected risks to
health
Unsafe healthcare 66 2,356 12 506 153 2,789 543 10,908
injections
Childhood sexual abuse – – 6 1,362 38 4,563 82 8,595
High income HIV/AIDS and TB

Respiratory infections
Europe and Central Asia
Maternal conditions
Cancers
Latin America and Caribbean Neuropsychiatric conditions
Other noncommunicable diseases
Road traffic accidents
Middle East and North Africa Other unintentional injuries
Suicide
Violence and war
South Asia
Sub-Saharan Africa
0 50 100 150 200 250 300

Death rate per 100,000 adolescents aged 10–19 years
Fig. 2.4 Death rates by disease group and region for adolescents aged 10–19 years, 2002. For all the World Bank geographical
regions, high-income countries have been excluded and are shown as a single group at the top of the graph. Source: World
Table 2.4 Leading causes of disease burden by income group among adolescents aged 10–19 years, 2002
DALYs Percent of total DALYs Percent of total
Cause (thousands) DALYs Cause (thousands) DALYs
1 Unipolar 10,316 9.6 1 Unipolar 1,458 17.4
depressive depressive
disorders disorders
2 Road traffic 6,443 6.0 2 Alcohol use 820 9.8
accidents disorders
3 Lower respiratory 6,294 5.8 3 Road traffic 623 7.4
infections accidents
4 Schizophrenia 4,766 4.4 4 Asthma 521 6.2
5 Bipolar disorder 4,193 3.9 5 Schizophrenia 474 5.7
6 Violence 3,856 3.6 6 Migraine 468 5.6
7 Asthma 3,587 3.3 7 Bipolar disorder 420 5.0
8 Self-inflicted 3,489 3.2 8 Drug use disorders 295 3.5
injuries
9 Falls 3,226 3.0 9 Panic disorder 228 2.7
10 Drownings 2,977 2.8 10 Self-inflicted 211 2.5
injuries
32 C. Mathers
High income HIV/AIDS and TB

Maternal conditions
Cancers
Latin America and Caribbean Neuropsychiatric conditions
Other noncommunicable
diseases
Middle East and North Africa Road traffic accidents
Other unintentional injuries
Suicide
Violence and war
South Asia
Sub-Saharan Africa
0 20 40 60 80 100 120 140 160

DALYs per 1,000 adolescents aged 10–19 years
Fig. 2.5 DALYs per 1,000 population, by region and cause excluded and are shown as a single group at the top of the
group, adolescents aged 10–19 years, 2002. For all the World graph. Source: World Health Organization (2004)
Bank geographical regions, high-income countries have been
Interpersonal violence and war are disproportio- This was followed by unsafe sex (4% of deaths) and
nately large contributors to adolescent burden of selected occupational risks (totaling 2% of deaths).
disease in Latin America and the Caribbean and in Alcohol was also the leading risk factor for burden
sub-Saharan Africa (Fig. 2.5). In sub-Saharan of disease, responsible for an estimated 6.5% of
Africa, where there were significant conflict levels DALYs in ages 10–19 (Fig. 2.6). These DALYs
in a number of large countries, war and civil conflict include the direct burden of alcohol dependence
were responsible for almost as much burden of dis- and problem use, as well as the attributable
ease as interpersonal violence. In Latin America, DALYs from causes such as road traffic accidents,
interpersonal violence is far more important, which were estimated to already be responsible for
responsible for twice as many DALYs as road traf- increased burden of disease among this population
fic accidents in the age group 10–19 years. Uninten- group. Other important risk factors in this age
tional injuries other than road traffic accidents are range include unsafe sex, iron deficiency, occupa-
also responsible for a much higher burden of disease tional risks, illicit drugs, and lack of contraception.
in south Asia than in other regions.
The Burden of Disease in Women

Leading Risk Factors for Mortality and
Burden of Disease in Adolescents Table 2.5 shows the 20 leading causes of deaths and
DALYs among women aged 20–59 years worldwide
Among the selected 26 risk factors quantified in the for 2002. Despite a global trend of declining com-
CRA project, the leading attributable cause of mor- municable disease burden in adults, HIV/AIDS has
tality in adolescents was alcohol, responsible for become the leading cause of mortality and the single
around 6% of deaths in the age group 10–19 years. most important contributor to the burden of disease
Fig. 2.6 DALYs Per cent of total DALYs

attributable to 10 leading 0 1 2 3 4 5 6 7
adolescents aged 10–19 Alcohol
years, as a percent of global
DALYs for adolescents. The Unsafe sex
figure shows the estimated
disease burden attributable Iron deficiency
to each risk factor
considered individually. Occupational risks
Source: World Health
Organization (2004) Illicit drugs
Lack of contraception
Childhood sexual abuse
Unsafe water, sanitation,

and hygiene
Unsafe health care injections
among women aged 20–59. Nearly 90% of the 1.1 also a greater cause of death, as they were in south
million adult female deaths from HIV/AIDS glob- India. Maternal conditions, associated with preg-
ally in 2002 occurred in sub-Saharan Africa. In this nancy and childbirth, were also important in south
region, HIV/AIDS accounted for almost half of Asia and Africa. Cardiovascular diseases were an
deaths of adult women (aged 20–59). Owing to the important cause of death in all middle- and low-
impact of HIV/AIDS, there has been a reversal in income regions of the world, but highest rates were
mortality trends among women in this region and in Europe and central Asia, reflecting the high rates
life expectancies for many countries have declined of cardiovascular disease in former Soviet and East-
since 1990. ern European countries.
Injuries were also an important cause of death In developing countries, non-communicable dis-
and burden of disease (Table 2.6). Road traffic eases were responsible for more than 60% of deaths
accidents and self-inflicted injuries (suicide) were in women aged 20–59 in all regions except south
among the 10 leading causes of death, and fires Asia and sub-Saharan Africa, where Group I
and violence were also in the top 20 causes. Sui- causes including HIV/AIDS remained responsible
cide was the fifth leading cause of death for for two-fifths and three-quarters of deaths, respec-
women in this age group, after HIV/AIDS, tively (Fig. 2.7). In other words, the epidemiologic
ischemic heart disease, stroke, and tuberculosis. transition is already well established in most devel-
Other chronic diseases in the top 10 causes of oping countries. Maternal conditions were esti-
death included breast cancer and chronic obstruc- mated to be responsible for 2.9% of deaths world-
tive lung disease. wide in females aged 20 and older in 2005 or
The overall death rate from all causes varied 444,000 deaths. Among reproductive-age women
greatly across the regional groupings of low- and aged 20–44, these conditions were responsible for
middle-income countries (Fig. 2.7) and between 13.1% of deaths. The most common causes of
them and high-income countries. HIV/AIDS was maternal mortality include post-partum hemorrhage
largely responsible for the very high death rate in (25%), eclampsia (12%), unsafe abortions (13%),
sub-Saharan Africa relative to other low-income infections (15%), and obstructed labor (8%)
countries, although other infectious diseases were (World Health Organization 2005).
34 C. Mathers
Table 2.5 Twenty leading causes of mortality and disease burden in the world among women aged 20–59 years, 2002
Mortality Burden of disease
Deaths Percent of DALYs Percent of total
Cause (thousands) total deaths Cause (thousands) DALYs
1 HIV/AIDS 1,112 17.7 1 HIV/AIDS 32,871 10.8
2 Ischemic heart 416 6.6 2 Unipolar depressive 30,086 9.9
disease disorders
3 Tuberculosis 325 5.2 3 Cataracts 9,295 3.1
4 Cerebrovascular 321 5.1 4 Tuberculosis 9,163 3.0
disease
5 Self-inflicted 214 3.4 5 Hearing loss, adult 9,028 3.0
injuries onset
6 Breast cancer 205 3.3 6 Ischemic heart 8,508 2.8
disease
7 Lower respiratory 174 2.8 7 Cerebrovascular 7,812 2.6
infections disease
8 Road traffic 163 2.6 8 Osteoarthritis 6,189 2.0
accidents
9 COPD 145 2.3 9 Self-inflicted 5,877 1.9
injuries
10 Maternal 130 2.1 10 COPD 5,631 1.9
hemorrhage
11 Cirrhosis of the 112 1.8 11 Road traffic 5,403 1.8
liver accidents
12 Diabetes mellitusa 107 1.7 12 Schizophrenia 5,238 1.7
13 Cervix uteri cancer 105 1.7 13 Maternal sepsis 5,120 1.7
14 Fires 104 1.7 14 Vision disorders, 4,851 1.6
age related
15 Nephritis and 90 1.4 15 Diabetes mellitusa 4,808 1.6
nephrosis
16 Lung cancer 87 1.4 16 Bipolar disorder 4,444 1.5
17 Stomach cancer 85 1.4 17 Lower respiratory 4,423 1.5
infections
18 Hypertensive heart 72 1.1 18 Breast cancer 4,278 1.4
disease
19 Violence 72 1.1 19 Maternal 3,907 1.3
hemorrhage
20 Rheumatic heart 71 1.1 20 Anemia 3,659 1.2
disease
a
Does not include renal failure deaths attributable to diabetic nephropathy or cardiovascular disease deaths attributable to
diabetes mellitus as a risk factor.
Diabetes caused around 550,000 deaths in (9%), and stomach cancers (9%), but there are sig-
women aged 20 years and over. Diabetes increases nificant regional variations in the prevalence of
the risk of cardiovascular disease and the total attri- cancer by site.
butable deaths are likely to be more than double the
direct deaths. Together, cardiovascular disease and
diabetes were responsible for more than two in five
deaths among women aged 20 years and over. Just Disability and Burden of Disease
fewer than 1 million women aged 20–59 died of
cancer in 2002. The most common cancers were Among the 10 leading causes of burden of disease
breast cancer (22% of cancer deaths in women for adult women aged 20–59 are four non-fatal
aged 20-59), cervical cancer (11%), lung cancers conditions: unipolar depressive disorders,
Table 2.6 Leading causes of disease burden among women aged 60+ years in the world, 2002
DALYs Percent of total DALYs Percent of total
Cause (thousands) DALYs Cause (thousands) DALYs
1 Ischemic heart 2,979 20.2 1 Cerebrovascular 15,486 14.0
disease disease
2 Cerebrovascular 2,625 17.8 2 Ischemic heart 15,183 13.7
disease disease
3 COPD 1,188 8.0 3 COPD 6,637 6.0
4 Lower respiratory 744 5.0 4 Alzheimer and 5,468 4.9
infections other dementias
5 Diabetes mellitusa 436 3.0 5 Cataracts 4,456 4.0
6 Hypertensive heart 418 2.8 6 Hearing loss, adult 3,437 3.1
disease onset
7 Breast cancer 270 1.8 7 Diabetes mellitusa 3,437 3.1
8 Lung cancer 265 1.8 8 Lower respiratory 3,424 3.1
infections
9 Alzheimer and 244 1.7 9 Vision disorders, 2,835 2.6
other dementias age related
10 Stomach cancer 240 1.6 10 Osteoarthritis 2,541 2.3
a
Does not include renal failure deaths attributable to diabetic nephropathy or cardiovascular disease deaths attributable to
diabetes mellitus as a risk factor.
High income
HIV/AIDS
Maternal conditions
Cardiovascular disease
Cancers
Neuropsychiatric conditions
Sense organ disorders
Middle East and North Africa Other noncommunicable diseases
Unintentional injuries
Intentional injuries
South Asia
Sub-Saharan Africa
0 200 400 600 800 1000 1200

Death rate per 100,000 women aged 20 years and over
Fig. 2.7 Death rates by disease group and region for women shown as a single group at the top of the graph. Source:
aged 20–59 years, 2002. For all the World Bank geographical World Health Organization (2004)
regions, high-income countries have been excluded and are
36 C. Mathers
Fig. 2.8 Global YLD, YLL,

HIV/AIDS, TB and malaria
and DALYs for major
disease groups, women aged Other infectious and parasitic
20–59 years, 2002. DALYs diseases
are the sum of years of life Respiratory infections
lost due to premature
mortality (YLL) and years Maternal conditions
lived with disability (YLD).
Source: World Health Nutritional deficiencies
Organization (2004)
Malignant neoplasms
Sense organ diseases

Cardiovascular diseases
and diabetes
Respiratory diseases
Digestive diseases
Musculoskeletal diseases
Other Group II conditions

YLL
Unintentional injuries YLD
0 10 20 30 40 50 60 70
DALYs (millions)
cataracts, adult-onset hearing loss, and osteoar- over one-half of the global burden of disease for
thritis. Figure 2.8 summarizes the contributions women aged 20–59 in 2002, and close to one-
of premature mortality (YLL) and disability third of the non-communicable disease burden
(YLD) to the burden of disease for the various was due to neuropsychiatric conditions (Fig. 2.9).
major cause groups. In all regions, neuropsychia-
tric conditions are the most important causes of
disability, accounting for over 37% of YLDs
among women aged 20–59 years. While depres-
Mortality and Burden of Disease for
sion is the leading cause of disability for both Adult Women Aged 60 Years and Over
males and females, the burden of depression is
50% higher for females than males, and females The risk of death rises rapidly with age among
also have higher burden from anxiety disorders, women aged 60 and over in all regions. Globally,
migraine, and senile dementias. In contrast, the 60-year-old women have an 18% chance of dying
male burden for alcohol and drug use disorders is before their 70th birthday. Regional variations in
nearly six times higher than that for females, and risk of death at older ages are smaller than at
accounts for one-quarter of the male neuropsy- younger ages, although death rates at older ages
chiatric burden. Vision disorders, hearing loss, are significantly lower in high-income countries
and musculoskeletal disorders are also important where a 60-year-old woman has on average, a 9%
causes of YLD, particularly for women, in both chance of dying before age 70. Historical data
developed and developing countries. The burden from countries such as Australia and Sweden
of non-communicable diseases accounted for just show that life expectancy at age 60 changed slowly
High income
HIV/AIDS
Maternal conditions
Cardiovascular disease
Cancers
Sense organ disorders
Middle East and North Africa
Other noncommunicable diseases
Unintentional injuries
South Asia
Sub-Saharan Africa
0 50 100 150 200 250 300 350 400 450

DALYs per 1,000 women aged 20 years and over
Fig. 2.9 DALYs per 1,000 population, by disease group and excluded and are shown as a single group at the top of the
region for women aged 20–59 years, 2002. For all the World graph. Source: World Health Organization 2004
Bank geographical regions, high-income countries have been
during the first six to seven decades of the 20th The primary risk factor for COPD is tobacco use,
century but since around 1970 has started to and as more females smoke, the prevalence of
increase substantially. Life expectancy at age 60 COPD will increase.
has now reached 27 years in Japan. In Eastern While Alzheimer disease and other dementias
Europe from 1990 onward, Poland and Hungary were the leading cause of YLD for older females,
have started to experience similar improvements sight and hearing loss disorders accounted for four
in mortality for older women, but Russia has not. of the ten leading causes of disability. Other impor-
Female deaths at ages 60 years and over are tant causes included cerebrovascular disease, dia-
predominantly due to chronic (non-communicable betes, and chronic lung disease. YLD rates were
diseases) and globally the leading causes of death in higher in low- and middle-income countries than
2002 were ischemic heart disease, cerebrovascular in high-income countries in 2002 although their
disease, and chronic respiratory disease. Together variation across regions was much lower than for
with diabetes mellitus, these causes were responsible YLL rates. The prevalence of disabling conditions
for just under one-half of all female deaths at ages such as dementia and musculoskeletal disease was
60 and greater. Other leading causes of death higher in high-income countries due to the higher
included acute lower respiratory infections (pneu- proportions of older women in their populations
monia and influenza), breast cancer, lung cancer, and, for dementia, to higher age-specific prevalence
stomach cancer, and senile dementia. Chronic rates than in low- and middle-income countries.
obstructive pulmonary disease (COPD) was respon- This was offset by lower contributions to disability
sible for about 1.3 million female deaths in 2002. in high-income countries from conditions such as
38 C. Mathers
cardiovascular and chronic respiratory diseases, the highest, making it the leading cause of burden of
and long-term sequelae of communicable diseases disease in these countries. In high-income countries,
and nutritional deficiencies. In other words, women smoking (9%), high blood pressure (8%), high BMI
living in developing countries not only face shorter (7%), high cholesterol (4.6%), and alcohol use
life expectancies than those in developed countries (4.2%) were consistently the leading causes of loss
but also live a higher proportion of their lives in of healthy life, contributing mainly to non-commu-
poor health. nicable diseases and, to a lesser extent, injuries.
In terms of overall DALYs for women aged 60
years and older, ischemic heart disease, cerebrovas-
cular disease, and chronic obstructive pulmonary
disease were the three leading causes (together Discussion and Conclusions
responsible for one-third of all DALYs in this age
group), followed by Alzheimer and other demen- The analysis presented here has confirmed some of
tias, and cataracts. Vision disorders, including cat- the conclusions of the original GBD study about the
aracts and age-related vision disorders, were importance of including non-fatal outcomes in a
responsible for 7% of the total DALYs, around comprehensive assessment of global population
double the burden of hearing loss. health and has confirmed the growing importance
of non-communicable diseases for women in low-
and middle-income countries, but has also docu-
mented some dramatic changes in women’s health
Burden of Disease Attributable to in some regions since 1990. Among the key findings
Selected Risk Factors for Women Aged are the following:
20 Years and Over The vast majority of child deaths are concen-
trated in middle- and low-income countries,
The leading global causes of mortality and disease particularly in south Asia and sub-Saharan
burden for women aged 20 years and over included Africa. Infectious diseases remain the principal
risk factors for communicable, maternal, perinatal, killers of children under 5. Just five largely pre-
and nutritional conditions (e.g., unsafe sex; indoor ventable conditions were responsible for 70% of
smoke from household use of solid fuels; and iron all child deaths in 2002: lower respiratory infec-
deficiency), whose burden is primarily concentrated tions, diarrheal diseases, malaria, HIV/AIDS,
in the low-income and high-mortality regions of and measles.
sub-Saharan Africa and east Asia, as well as risk One-third of child deaths under age 10 in 2002
factors for non-communicable diseases (e.g., high were attributable to underweight, and another
blood pressure and cholesterol, tobacco and alcohol 13% to unsafe water, sanitation, and hygiene.
use, and overweight and obesity) which affect most Mental disorders, particularly depression, schi-
regions. High blood pressure was the single leading zophrenia, and bipolar disorders, and injuries,
global cause of mortality for adult women, respon- particularly road traffic accidents, violence, and
sible for 20% of all deaths, although most of these suicide, were the leading causes of burden of
are at older ages. In terms of DALYs, which mea- disease in adolescents aged 10–19 in 2002. Alco-
sure lost years of full health, high blood pressure is hol use disorders were the second leading cause
second behind unsafe sex (Fig. 2.10a, b) of burden of disease in adolescents in high-
Leading causes of burden of disease in low- and income countries.
middle-income countries were unsafe sex (10%), HIV/AIDS is now the leading cause of burden of
high blood pressure (7%), high serum cholesterol disease among women aged 20–59 years globally,
(3.8%), and high body mass index – or overweight and responsible for one-half of deaths and
and obesity (3.2%). The relative contribution of DALYs in this group in sub-Saharan Africa.
unsafe sex was disproportionately larger (40%) in The epidemiological transition in low- and mid-
sub-Saharan Africa where HIV/AIDS prevalence is dle-income countries has resulted in a 20%
Fig. 2.10a, b Mortality a Per cent of global total deaths

attributable to 10 leading 0 5 10 15 20 25
women aged 20 years and High blood pressure
over, as a percent of global
deaths for women aged 20 High cholesterol
years and over. The figure Unsafe sex
shows the estimated
mortality and disease burden High BMI
attributable to each risk
factor considered Low fruit and vegetable intake
individually. Source: World
Tobacco
Physical inactivity
Indoor smoke from solid fuels
Alcohol High income countries

Low and middle income countries
Urban outdoor air pollution
b Per cent of global total DALYs

0 1 2 3 4 5 6 7 8 9 10
Unsafe sex
High blood pressure
High cholesterol
High BMI
Tobacco
Low fruit and vegetable intake
Physical inactivity
Alcohol
Lack of contraception High income countries

Low and middle income countries
Iron deficiency
reduction since 1990 in the per capita disease 1990, so that women in this region now have
burden due to Group I causes (communicable, similar levels of health to other low- and middle-
maternal, perinatal, and nutritional conditions). income countries of the world apart from those
Without the HIV/AIDS epidemic, this reduction in south Asia and sub-Saharan Africa.
would have been substantially greater, at 30% Women aged 20–59 in low- and middle-income
over the last 11 years. Several of the ‘‘traditional’’ countries have substantially greater mortal-
infectious diseases such as tuberculosis and ity risks and disease burden from non-
malaria have not declined, in part because of communicable diseases than those in high-
weak public health services and the increased income countries.
numbers of women with immune systems wea- Injury deaths are noticeably higher for women in
kened by HIV/AIDS. some parts of Asia and the Middle East and
The per capita disease burden in Europe and North Africa, in part due to high levels of suicide
central Asian countries has increased since and violence. This higher burden of injury deaths
40 C. Mathers
in combination with higher rates of infant and of techniques depending on the type and quality of
child mortality for girls result in the narrowest evidence.
differential between male and female healthy life While methodological and data developments
expectancy for any of the low- and middle- over the past decade have improved the empirical
income regions. base for disease burden assessment, there are still
High blood pressure is the leading risk factor for very substantial data gaps and uncertainties, parti-
attributable mortality for women aged 20 years cularly for causes of death and levels of adult mor-
and over, responsible for an estimated 20% of tality in Africa and parts of Asia. Improving the
deaths in 2002. In terms of burden of disease, population-level information on causes of death
unsafe sex was the leading risk factor, responsi- and on the incidence, prevalence, and health states
ble for 10% of DALYs. associated with major disease and injury causes
Sense organ disorders, principally hearing and remains a major priority for national and interna-
sight loss, contribute significantly to disability tional health and statistical agencies. At the time of
among older women in all regions of the world. writing, the Gates Foundation has decided to pro-
Levels of non-fatal health loss are proportionately vide substantial funding for an international colla-
greater in lower income countries than in high- borative effort, led by Chris Murray and with the
income countries, contrary to the perception that WHO collaboration, to carry out a complete revi-
disability is associated with older populations. sion and update of the Global Burden of Disease
over the next 3 years, taking advantage of recent
The GBD analyses have been criticised for mak-
developments in data collection and analysis meth-
ing estimates of mortality and burden of disease for
ods. Despite the uncertainties in the 2002 estimates,
regions with limited, incomplete, and uncertain data
the results summarized here suggest that further
(Cooper et al. 1998). Murray and colleagues have
gains in health for children, adolescents, and
argued that health planning based on uncertain
women in developing countries could be achieved.
assessments of the available evidence, which
Intervention choices and priorities can be better
attempt to synthesize it while ensuring consistency
guided by information about potential costs and
and adjustment for known biases, will almost
gains, including a comprehensive understanding of
always be more informed than planning based on
disease burden. More rational application of the
ideology (Murray et al. 2003). The GBD analytic
available information and knowledge in this area
approach has been strongly influenced by demo-
would accelerate progress toward millennium devel-
graphic and economic traditions of making the
opment goals and reduce the persistent differentials
best possible estimates of quantities of interest for
in health that show little tendency to narrow under
populations from the available data, using a range
current health policies.
Key Terms
Age weighting Global descriptive Observed exposure distribution

Alcohol epidemiology Plausibility
Attributable mortality Hazardous exposure Population attributable
Bipolar disorders High-income countries fraction (PAF)
Body mass index (BMI) HIV/AIDS Population distribution of
Burden of disease Hygiene exposure
Causality Incidence Potential years of life lost to
Cause-of-death patterns Individual attributable burden premature death (PYLL)
Central America Infectious diseases Premature death
Chronic diseases Injuries Prevalence
Comparative Risk Assessment Internally consistent estimates Quality of life
(CRA) International Classification of Relative loss of health
Counterfactual distribution Diseases (ICD) Relative risk
Death registration Latin America and the Retinopathy
Demography and Health Caribbean Risk factor exposure level
Surveys Life expectancy Risk factors
Depression Low-income countries Sanitation
Diabetic neuropathy Lower respiratory tract Schizophrenia
Diarrheal diseases infections Sensitivity analysis
Disability Malaria Standard life table
Disability-adjusted life years Maximum exposure level Sub-Saharan Africa
(DALYs) Measles Suicide
Disability weights Mental disorders Theoretical minimum risk
Discounting Middle-income countries Theoretical minimum risk
Discrete exposure levels Multiple Indicator Cluster distribution
Disease control priority Survey Underweight
Disease notification systems Musculoskeletal disorders Unsafe water
DisMod Non-fatal conditions Valuation
Epidemiological transition Non-uniform age weights Violence
Global Burden of Disease North Africa and the Middle Years of life lost to premature
Study East mortality (YLL)
Questions for Discussion 2 In what ways can information on global burden

of disease aid global health policy? What are the
limitations of global burden of disease estimates?
1 Write short explanatory notes to summarize your
3 Identify the major causes of global burden of
understanding of the following terms:
morbidity and mortality for the following age
a. Disability-adjusted life years groups:
b. Epidemiological transition
a. Children aged 0–9 years
c. Population attributable fraction (PAF)
b. Adolescents aged 10–19 years
d. Comparative Risk Assessment (CRA)
c. Women aged 20 years and older
42 C. Mathers
4 Discuss the major features of disease burden and Mathers CD, Lopez AD, Murray CJL (2006) The burden of
risk factors in low-income countries compared to disease and mortality by condition: data, methods and
results for 2001. In Global Burden of Disease and Risk
high-income countries. Factors, Lopez AD et al. (eds.). Oxford University Press,
New York, pp. 45–240
Murray CJL (1996) Rethinking DALYs. In The Global Bur-
den of Disease, vol. 1 Murray CJL, Lopez AD (eds.).
Harvard University Press, Cambridge, pp. 1–98
References Murray CJL, Lopez AD (1996a) Global Health Statistics.
Harvard University Press, Cambridge
Murray CJL, Lopez AD (1996b) The Global Burden of Dis-
Barendregt J, van Oortmarssen GJ et al. (2003) A generic ease: A Comprehensive Assessment of Mortality and Dis-
model for the assessment of disease epidemiology: the ability from Diseases, Injuries and Risk Factors in 1990
computational basis of DisMod II. Population Health and projected to 2020. Harvard University Press,
Metrics, 1, 4 Cambridge
Cooper RS, Osotimehin B et al. (1998) Disease burden in sub- Murray CJL, Lopez AD (1999) On the comparable quantifi-
Saharan Africa: what should we conclude in the absence cation of health risks: lessons from the global burden of
of data? The Lancet, 351(9097), 208–210 disease study. Epidemiology 10(5), 594–605
Ezzati M, Vander Hoom S, Rodgers A et al. (2002) Com- Murray CJL, Mathers CD, Salomon JA (2003) Towards evi-
parative Risk Assessment Collaborative Group. Selected dence-based public health. In Health Systems Performance
major risk factors and global and regional burden of Assessment: Debates, Methods and Empiricism. Murray
disease. Lancet, 360(9343), 1347–1360 CJL, Evans D (eds.). World Health Organization, Geneva
Ezzati M, Vander Hoom S, Rodgers A et al. (2003) Com- World Bank (1993) World Development Report 1993.
parative Risk Factors Collaborating Group. Estimates of Investing in Health. Oxford University Press for the
global and regional potential health gains from reducing World Bank, New York, http://files.dcp2.org/pdf/World-
multiple major risk factors. The Lancet, 362, 271–280 DevelopmentReport1993.pdf, cited 7 July 2008
Ezzati M, Lopez AD, Rodgers A, et al. (2004) Comparative World Health Organization (2004) World Health Report 2004:
Quantification of Health Risks: Global and Regional Changing History. World Health Organization, Geneva,
Burden of Disease Attributable to Selected Major Risk. http://www.who.int/whr/2004/en/, cited 7 July 2008
World Health Organization, Geneva World Health Organization (2005) World Health Report
Lopez AD, Mathers CD, Ezziati M et al. (2006) Global 2005: Make Every Mother and Child Count. World
Burden of Disease and Risk Factors. Oxford University Health Organization, Geneva, http://www.who.int/whr/
Press, New York 2005/en/index.html, cited 7 July 2008
Chapter 3
Promotion of Global Perinatal Health
Victor Y.H. Yu
Learning Objectives After reading this chapter and are exacerbated by lack of health-care and poorly
answering the discussion questions that follow, you distributed health-care access and funding. Discre-
should be able to pancies in data collection and measurement in some
regions and the resulting lack of comparable data
Present an overview of perinatal mortality rates,
pose challenges to assessment and response to peri-
stillbirth rates, and neonatal mortality rates in
natal mortality. Sixteen low-cost, community-based
different geographical and economic regions of
interventions with proven efficacy for neonatal sur-
the world.
vival have been identified across the prenatal,
Identify and discuss factors that influence peri-
antenatal, intrapartum, and postpartum stages.
natal survival from a global perspective.
Standardizing and improving available data and
Identify and evaluate the evidence base of speci-
directing more funding to prevention of perinatal
fic low-cost interventions to improve perinatal
mortality are key factors in reducing mortality
health.
rates. Strategies that address inequalities both
within a country, and between countries are neces-
sary if there is going to be further improvement in
global perinatal health.
Introduction
Perinatal mortality refers to death in the perinatal
period that includes late pregnancy, birth, and the
Globally, there are 141 million annual live births;
neonatal period. By avoiding the difficult judgment
127 million (90%) of which occur in developing
of whether a fetus exhibits signs of life or not at
countries. These regions also have a higher rate of
birth, it is a useful measure for comparison of repro-
contribution to the 7.5 million annual perinatal
ductive loss and perinatal health between countries.
deaths and 5.1 million neonatal deaths. The perina-
Although the global perinatal mortality rate (PMR)
tal mortality rate (PMR) and the neonatal mortality
has fallen by about 10% in the last decade, the total
rate (NMR) have often been used as indicators of
number of perinatal deaths has remained unchanged
the standard of a country’s social, educational, and
because the number of births has increased in the
health-care systems. Developing regions of the
same period. No systematic global estimates of still-
world, and particularly rural areas, where there are
births exist, and any statistical modeling used to
few skilled birth attendants experience dispropor-
predict stillbirth number and stillbirth rate (SBR)
tionately high perinatal mortality rates. This chap-
probably underestimates both figures. Epidemiolo-
ter presents an overview of perinatal health, provid-
gical data on the estimated 450 neonatal deaths every
ing data on perinatal mortality rates, stillbirth rates,
hour around the world remain sparse, but most of
and neonatal mortality rates across the globe.
these deaths are considered preventable and, halving
Underlying causes of stillbirths and neonatal deaths
of the global neonatal mortality rate (NMR) is an
achievable goal. In this chapter, published data on
Victor Y.H. Yu (*) perinatal outcomes (including available estimates
Monash University, Australia of global and regional PMR, SBR, and NMR) are

44 Victor Y.H. Yu
reviewed, problems and obstacles associated with the perinatal health in the future are suggested. Box 3.1
promotion of perinatal health are described, and presents definitions of common terminologies used
strategies that are potentially effective in improving in the field of perinatology.
Box 3.1 Definition of Terms
Live birth: Live birth is the complete expulsion or extraction from its mother, of a product of
conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or
shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or
definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the
placenta is attached; each product of such a birth is considered live-born.
Fetal death: Fetal death is death prior to the complete expulsion or extraction from its mother of a
product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that
after such separation the fetus does not breathe or show any other evidence of life, such as beating of
the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.
Birth weight: The first weight of the fetus or newborn obtained immediately after birth.
Low birth weight: Less than 2500 g (up to, and including 2499 g).
Very low birth weight: Less than 1500 g (up to, and including 1499 g).
Extremely low birth weight: Less than 1000 g (up to, and including 999 g).
Gestational age: The duration of gestation is measured from the first day of the last normal
menstrual period.
Pre-term: Less than 37 completed weeks (less than 259 days) of gestation.
Term: From 37 completed weeks to less than 42 completed weeks (259–293 days) of gestation.
Post-term: Forty-two completed weeks or more (294 days or more) of gestation.
Perinatal period: The perinatal period commences at 22 completed weeks (154 days) of gestation
(the time when birth weight is normally 500 g), and ends seven completed days after birth.
Neonatal period: The neonatal period commences at birth and ends 28 completed days after birth.
Neonatal deaths: Deaths among live-births during the first 28 completed days of life; may be
subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal
deaths, occurring after the seventh day but before 28 completed days of life.
Fetal death ratio
Fetal deaths
—————————————— 1000
Live-births
Fetal death rate
Fetal deaths
—————————————— 1000
Total births
Fetal death rate, weight-specific
Fetal deaths weighing 1000 g and over
———————————————————————— 1000
Total births weighing 1000 g and over
3 Promotion of Global Perinatal Health 45
Early neonatal mortality rate

Early neonatal deaths
———————————————————————— 1000
Live-births
Early neonatal mortality rate, weight-specific
Early neonatal deaths of infants weighing 1000 g and over at birth
———————————————————————— 1000
Live-births weighing 1000 g and over
Perinatal mortality ratio
Fetal deaths and early neonatal deaths
———————————————————————— 1000
Live-births
Perinatal mortality rate
Fetal deaths and early neonatal deaths
———————————————————————— 1000
Total births
Perinatal mortality rate, weight-specific
Fetal deaths weighing 1000 g and over, plus early neonatal
deaths of infants weighing 1000 g and over at birth
———————————————————————— 1000
Total births weighing 1000 g and over
Neonatal mortality rate
Neonatal deaths
———————————————————————— 1000
Live-births
Neonatal mortality rate, weight-specific
Neonatal deaths of infants weighing 1000 g and over at birth
———————————————————————— 1000
Live-births weighing 1000 g and over
Infant mortality rate
Deaths under one year of age
———————————————————————— 1000
Live-births
Infant mortality rate, weight-specific
Infant deaths among live-births weighing 1000 g and over at birth
———————————————————————— 1000
Live-births weighing 1,000 g and over
46 Victor Y.H. Yu
Perinatal Outcome group with the highest PMRs included Yemen, Tur-
key, Syria, and Iraq (40–70 per 1,000). The second
group with medium-high PMRs included Iran, Jor-
Perinatal Deaths dan, Oman, and Saudi Arabia (30 per 1,000). The
third group with medium-low PMRs included Bah-
The Maternal and Safe Motherhood Program of rain, Kuwait, and United Arab Emirates (20 per
the World Health Organization (WHO) gave an 1,000). The sub-region of east Asia has always been
estimate of 7.5 million annual perinatal deaths and dominated by China with over twenty million annual
a global PMR of 53 per 1,000 births (WHO 1996). births and an estimated PMR of 45 per 1,000. Exclud-
Great disparities were reported to exist in PMR ing Hong Kong and Japan, South Korea has the best
between the five world regions: Africa (75 per PMR in east Asia (15 per 1,000). Countries in the sub-
1,000), Asia–Oceania (53 per 1,000), Central and region of Southeast Asia have a relatively wide range
South America (39 per 1,000), Europe (13 per of estimated PMRs. The highest was found in Laos
1,000), and North America (9 per 1,000). The differ- and Cambodia (65–90 per 1,000), medium high in
ences in PMR could partly be explained by the Indonesia and Myanmar (45–55 per 1,000), and med-
proportion of developed and developing countries ium low in Vietnam, Philippines, and Thailand (20–25
in these world regions. The PMR in developing per 1,000). Excluding Australia, New Zealand, and
countries was estimated to be 5.2 times higher than Singapore, Malaysia has the best PMR in Southeast
that, in developed countries. This discrepancy has Asia (20 per 1,000).
progressively worsened in recent years, because over
a period, when a 35% reduction in PMR was
observed in developed countries, developing coun-
tries saw only an 11% reduction in PMR (Yu 2003). Stillbirths
The world region with the largest number of
annual births is the Asia–Oceania region. There- The most recently published global estimate of 3.2
fore, although its PMR is not the highest but second million stillbirths (uncertainty interval 2.5–4.1 mil-
to that of Africa, it has the greatest number of lion) is similar to the WHO estimate of 3.3 million in
perinatal deaths among the five regions. Further 2005, which is less than the previous WHO esti-
analysis of the five sub-regions within the Asia– mates of 4 million in 1999 and 5.3 million in 1995
Oceania region has shown that south Asia has the (Stanton et al. 2006). The SBR was estimated to be
highest estimated PMR (66 per 1,000) followed by 23.9 per 1,000 (uncertainty interval 18.8–30.5 per
west Asia and Oceania (44 per 1,000), east Asia (41 1,000). There was a fivefold difference in the SBRs
per 1,000), and Southeast Asia (37 per 1,000). between developing countries (25.5 per 1,000;
Within the Asia–Oceania region, there are only uncertainty interval 20.1–32.5 per 1,000) and, devel-
five places that have a PMR below 10 per 1,000: oped countries (5.3 per 1,000, uncertainty interval
Australia, Hong Kong, Japan, New Zealand and 4.2–6.8 per 1,000). Estimated SBRs were reported
Singapore. However, the number of births in these for different parts of the world, although the world
places with a more favorable PMR was relatively regions used in this analysis are not identical to
low: Australia (260,000), Hong Kong (300,000), those used in the PMR report: sub-Saharan Africa
Japan (1.3 million), New Zealand (60,000), and Sin- (32.2 per 1,000), south Asia (31.9 per 1,000), east
gapore (40,000). In total, less than 1.7 million or just Asia (23.2 per 1,000), west Asia (18.9 per 1,000),
over 2% of the annual births in the Asia–Oceania North Africa (18.6 per 1,000), Oceania (15.8 per
region were from these five places. In contrast to 1,000), Latin America/Caribbean (13.2 per 1,000),
these low PMR settings, countries in the sub-region Southeast Asia (12.7 per 1,000), and Eurasia (12.2
of south Asia such as Bangladesh, Pakistan, Nepal, per 1,000). The two world regions with the highest
and India have an estimated PMR of 65–85 per 1,000. SBRs combined were responsible for two-thirds of
Sri Lanka was the one exception with a relatively low the world’s stillbirths: 28% from sub-Saharan
PMR of 25 per 1,000. Countries in the sub-region of Africa and 40% from south Asia. Ninety-nine per-
west Asia could be divided into three groups. The first cent of stillbirths occurred in developing regions,
and, 51% occurred in the four countries of India, of intrapartum complications leading to asphyxia, con-
China, Pakistan, and Bangladesh. tributing to the fact that three-quarters of all neonatal
deaths occurred in the first week.
Neonatal Deaths
Problems and Obstacles
Four million infants out of the 130 million annual
births die in the neonatal period (first 4 weeks after
birth), giving a global NMR of 30 per 1,000 live Perinatal Deaths
births (Lawn et al. 2005). An eightfold difference
in NMR between developing countries (33 per The availability of healthcare resources is a major
1,000) and developed countries (4 per 1,000) has problem. A 10-fold difference in PMR between
been reported. Consequently, 99% of neonatal developing and developed countries is frequently
deaths were estimated to occur in developing coun- associated with a 10-fold difference in healthcare
tries. The NMR and percentage of global neonatal expenditure per capita. For example in the Asia–
deaths in six world regions have been reported as Oceania region, countries with the lowest PMR
follows: Africa (44 per 1,000), Eastern Mediterra- were also reported to have the highest ranking for
nean (40 per 1,000), Southeast Asia (38 per 1,000), healthcare expenditure per capita: Japan (US $1760),
Western Pacific (19 per 1,000), Americas (12 per Australia (US $1600), New Zealand (US $1390),
1,000), and Europe (11 per 1,000). Two-thirds of South Korea (US $860), and Singapore (US $750).
neonatal deaths occurred in two regions: Africa In contrast, countries with the highest PMR were
and Southeast Asia. Countries in sub-Saharan among the lowest ranking for healthcare expenditure
Africa have the highest NMRs (majority over 45 per per capita: India (US $84), China (US $74), Pakistan
1,000) especially in those countries plagued by civil (US $71), Indonesia (US $56), and Nepal (US $41).
war. However, countries in Southeast Asia have the Lack of healthcare resources in a country is
greatest absolute number of neonatal deaths. The aggravated by the problem of maldistribution
NMR and percentage of global neonatal deaths in within the same country, especially in developing
the top 10 countries accounting for two-thirds of the countries with already scarce resources. A large
world’s neonatal deaths were as follows: India (43 per proportion of the limited healthcare budget reaches
1,000), China (21 per 1,000), Pakistan (57 per 1,000), only the more privileged members of the commu-
Nigeria (53 per 1,000), Ethiopia (51 per 1,000), Ban- nity. It is not uncommon to find that 80% of the
gladesh (36 per 1,000), Congo (47 per 100), Afghani- country’s healthcare workers are serving 20% of the
stan (60 per 100), Tanzania (43 per 1,000), and Indo- population who reside in relatively affluent urban
nesia (18 per 1,000). areas. Conversely, only 20% of healthcare resources
The four major causes of neonatal death globally are available to 80% of the population who reside
were estimated to be infections (sepsis, pneumonia, teta- in impoverished rural areas. Even in emerging
nus, and diarrhea, 36%), prematurity (28%), asphyxia economies where the socioeconomic condition is
(23%), and congenital abnormalities (7%) (Lawn et al. rapidly improving, the gap between the rich and
2006). Infection accounted for over 50% of neonatal poor continues to widen. The ‘‘inverse care law’’
deaths in countries with a high NMR of above 45 per which states that the availability of good medical
1,000, compared to 20% in countries with a low NMR care tends to vary inversely with the need for it in the
of below 20 per 1,000, where tetanus and diarrheal population served, is also the ‘‘inverse information
illnesses were almost never a cause of neonatal death. law’’ when applied to the fetal and neonatal popula-
The risk of neonatal death in high-NMR countries tion. The communities with the highest PMR and
compared to that in low-NMR countries was estimated number of perinatal deaths have also the least basic
to be 11-fold for infection, 8-fold for asphyxia, and clinical information on these deaths, and the least
3-fold for prematurity. The highest risk of death was research investment to evaluate cost-effective stra-
reported on the first day after birth, primarily as a result tegies to lower their PMR.
48 Victor Y.H. Yu
Stillbirths perinatal services were judged to be substandard,

there would have been a public outcry. In contrast,
Most population-based surveys and even WHO there is a lack of basic epidemiological data on causes
publications have not routinely included reports of neonatal death in 98% of deaths that occur in
on stillbirths. Neither did the Millennium Develop- developing countries because of their inadequate
ment Goals and estimates of the global burden of vital registration coverage. Furthermore, most med-
disease feature stillbirths. Counting stillbirths is ical research projects, including randomized clinical
particularly problematic. On the one hand, they controlled trials of perinatal–neonatal interventions,
are unlikely to be registered in many parts of the were conducted in developed countries where the
world. On the other hand, live births that died early smallest number of neonatal deaths occur. The
might be recorded as stillbirths for reasons such as work of identifying and implementing cost-effective
failing to accurately assess the signs of life, avoiding interventions within developing countries with the
blame in the review of the birth attendant’s perfor- highest burden of neonatal deaths has therefore
mance, reducing administrative work or funeral been an extremely slow process.
costs, or minimizing emotional trauma of the loss Eighteen million newborn infants or 14% of
for the family. No uniformity exists in the definition births were estimated to be low birth weight, but
of stillbirths, and fetal deaths from 20, 22, 23, 24, or they accounted for 60–80% of neonatal deaths.
28 weeks of gestation have been used in surveys. Most deaths in low birth weight infants, either in
Recent advances in perinatal–neonatal care have those who are moderately preterm or those born at
lowered fetal viability to 22 weeks in developed term but who are growth-restricted in utero, are pre-
countries, prompting changes in the definition of ventable without expensive high-technology inter-
fetal death. However, this phenomenon of increas- ventions, but simply through extra attention to
ing neonatal survival at 22–28 weeks of gestation is warmth, feeding, and prevention of sepsis. In spite
largely irrelevant in the majority of countries in the of the known biological survival advantage of girls
developing world. For the purpose of international over boys in the neonatal period, there is no epide-
comparison, the WHO has recommended the use of miological evidence of this especially in south Asia
fetal death occurring from 28 weeks of gestation or and China where the practices of sex-selective abor-
from 1,000 g birth weight as the definition of still- tion, female infanticide, and reduced care seeking for
birth, that is, late fetal death during the last trime- girls have been reported. The intrapartum risk fac-
ster of pregnancy. tors of obstructed labor and malpresentation have
been identified to carry the highest risk for early
neonatal death. Unfortunately, 44% of women glob-
ally were estimated to deliver without a skilled atten-
Neonatal Deaths dant, and this figure might be up to 95% in the
poorest of developing countries. More than 50% of
The inequity between developing and developed neonatal deaths were reported to be associated with
countries has continued to worsen in recent years. home birth in the absence of skilled care. The target
The already lower NMRs in developed countries to totally eliminate neonatal tetanus globally has
have been reducing at a faster rate compared to been missed, and although it is now only responsible
that in developing countries. Between 1996 and for 6% of neonatal deaths, it is a disease that is
2005, the percentage reduction in NMR was 29% almost exclusively found within poor communities.
in developed countries compared to only 8% in
developing countries. Reduction in the global
NMR is only possible when there is high coverage
of perinatal services in high-mortality developing Strategies for the Future
countries where the poorest people with the greatest
risk live. Although only 2% of neonatal deaths Strategies that address inequalities within indivi-
occurred in developed countries, they have been the dual countries and between developing and devel-
subject of extensive confidential audits and, if oped countries are necessary before we can see a
significant improvement in global perinatal health below 5 years by two-thirds between 1990 and
in this century. Currently, developed countries give 2015 – will be impossible to meet without halving
less than half a percent of their gross national the NMR. Because childhood mortality after the
product (GNP) as foreign aid to developing coun- neonatal period has been falling faster than neona-
tries. A target for governments of affluent countries tal mortality, an increasing proportion of early
facing up to their global responsibilities is to con- childhood deaths is now in the first month. It has
tribute at least 1% of their GNP to developing been estimated that in the year 2000, 38% of all
countries. under-5 child deaths happened in the neonatal
The paucity of accurate vital registration data period.
from many countries, especially those from the There is a wrong perception that only expensive
developing world with high SBRs, poses the pri- high-technology and facility-based neonatal inten-
mary difficulty in estimating stillbirth numbers sive care can reduce NMR. Many neonatal deaths
and their underlying causes. With continued are preventable with low-level, low-cost commu-
advances in obstetric care, the SBR might improve, nity-based health care. Historically, the fall in
especially with intrapartum stillbirths, and this NMR in England from 30 per 1,000 in 1940 to 10
could lead to an increase in early neonatal deaths. per 1,000 by 1975 was associated with the introduc-
Therefore it is mandatory to count both stillbirths tion of free antenatal care, skilled attendance at
and neonatal deaths in routine perinatal audits. childbirth, and availability of antibiotics. To pre-
Otherwise, our assessment would be incomplete vent the 4 million annual neonatal deaths, it is
and decision making and priority setting for the necessary to first be able to accurately count them
development of maternal and neonatal healthcare and second to know what is causing them in those
programs might be misguided. Most of the still- settings where most neonatal deaths occur. An evi-
births in developing countries are avoidable, as evidence-based review has been carried out on the
denced by the low SBRs of 4 per 1,000 seen in some efficacy and effectiveness of cost-effective interven-
developed countries, compared to the high SBRs of tions to reduce the global NMR from its existing
40 per 1,000 in the worst of the developing coun- level of 30 per 1,000 (Darmstadt et al. 2005). Sixteen
tries. Better counting of stillbirths and having infor- interventions with proven efficacy for neonatal sur-
mation on the causes of stillbirths are important as a vival were identified: preconception (folic acid sup-
means to advocate for action and to prioritize pre- plementation), antenatal (tetanus toxoid immuniza-
ventive healthcare strategies. For example, some tion, syphilis screening and treatment, pre-
definable causes of stillbirths, such as syphilis in eclampsia and eclampsia prevention, malaria treat-
at-risk regions or communities, could be identified ment, detection and treatment of asymptomatic
and effective preventive measures taken. However, bacteriuria), intrapartum (antibiotics for premature
experience in developed countries, has shown that rupture of membranes, corticosteroids for preterm
even when extensive resources are available to labor, detection and management of breech, labor
investigate stillbirths, the cause of death might not surveillance for early diagnosis of complications,
be established in up to one-third of stillbirths. Ulti- clean delivery practices), and postnatal (resuscita-
mately, political will and financial investment in tion of newborn infant, breastfeeding, prevention
registering stillbirths and documenting their causes and management of hypothermia, kangaroo
are required. This would facilitate development of mother care, community-based pneumonia case
maternal–fetal interventions targeted to reduce the management). These interventions have been com-
SBR in that region or community. To complete the bined into packages for scaling up in healthcare
loop, systematic assessments could then be devised systems according to the three service delivery
to monitor the effectiveness, equity, and costs of any modes of outreach, community–family, and facil-
perinatal initiatives, especially if they have been ity-based clinical care. The total cost of a package of
introduced in low-income countries with the weak- maternal or neonatal interventions has been esti-
est healthcare systems. mated to be less than the sum of the costs of each
The Millennium Development Goal (MDGs) for component evaluated separately. Furthermore,
child survival – to reduce mortality in children aged because of this synergy of costs, packages of
50 Victor Y.H. Yu
interventions are more cost-effective than indivi- innovative approaches to retain trained staff in poor
dual interventions. Therefore, it is important to rural communities. In many of the world’s poorest
implement maternal and neonatal interventions in countries, even without developing expensive high
parallel and to have effective integration of the technology, there is a need to double or triple the
different components of perinatal services. The healthcare budget in order to halve the NMR. The
development of regionalization of perinatal services cost per neonatal death averted has been estimated at
that integrate primary, secondary, and tertiary about US $2000 (Martines et al. 2005). Although
levels of care has been shown to be effective in more than 10,000 newborn infants die every day in
improving both the quality and the availability of developing countries, estimates have suggested that
essential services to a geographically defined region up to three-quarters of these deaths could be pre-
(Yu and Dunn 2004). vented with low-technology interventions at an addi-
If 99% coverage of these 16 interventions could be tional cost of less than US $1 per capita in these
achieved, an estimated 41–72% of neonatal deaths countries where the highest NMRs were seen.
worldwide could be averted. Reliance on outreach
and community–family services alone would achieve
an 18–27% reduction in neonatal deaths, and the
addition of facility-based clinical care would achieve Conclusion
reductions of over 50%. The aim to halve the global
NMR is therefore an achievable goal using the Under-reporting of stillbirths remains a major
three basic intervention packages. This target NMR challenge, especially in regions where most of the
of 15 per 1,000 would be similar to the NMR in stillbirths occur. Improving the global database on
today’s developed countries back in the era immedi- stillbirths is an essential first step toward effective
ately before the introduction of neonatal intensive preventive action. There is a lack of reliable cause-
care in these countries. In developing countries with of-death data for both stillbirths and neonatal deaths
weak healthcare systems and high NMRs, the especially in developing countries with the highest
emphasis must initially be on antenatal and postnatal mortality rates. Evidence-based reviews have shown
care through family–community interventions that that population-oriented outreach and community-
include health education to improve domiciliary neo- oriented and family-oriented healthcare interven-
natal care practices and care seeking for illness tions are highly cost-effective for the promotion of
(Bhutta et al. 2005). Because effective, yet simple perinatal health, but their current coverage is insuf-
interventions are not reaching those most in need, ficient. When individual-oriented facility-based clin-
there needs to be a systematic scaling up of neonatal ical services are added to these primary care services,
care in countries where the coverage of interventions is up to 70% of neonatal deaths could be prevented
low and inequity is high (Knippenberg et al. 2005). provided they are implemented with high coverage
Reduction in NMR is less dependent on technology where they are needed most. Governments need an
and commodities than on people with skills. Increased overall strategy to promote perinatal health, and to
coverage depends on a commitment to increase the work with donors to invest in well-integrated pro-
number of midwives and doctors, together with grams for maternal, neonatal, and child care.
Key Terms
Antibiotics Intrapartum complications Pre-eclampsia

Breastfeeding Kangaroo mother care Premature rupture of
Congenital abnormalities Low birth weight membrane
Cost-effective interventions Malaria Prematurity
Disparities Millennium Development Pre-term birth
Female infanticide Goals (MDGs) Reproductive loss
Folic acid supplementation Neonatal mortality rate Sex selection abortion
Gestational age Newborn Stillbirth rate
Gross national product Obstetric care Syphilis screening
Healthcare system Perinatal mortality rate Uncertainty interval
Infant mortality rate Perinatology
International comparison Preconception
health outcomes in developed countries: a review of the

Questions for Discussion evidence. Pediatrics 115:519–617
Darmstadt GL, Bhutta ZA, Cousens S et al. (2005) for the
1 Define the following terms: Lancet Neonatal Survival Steering Team. Evidence-
based, cost-effective interventions: how many newborn
a. Infant mortality babies can we save? Lancet 365:977–988
Knippenberg R, Lawn JE, Darmstadt GL et al. (2005) Lancet
b. Neonatal mortality rate Neonatal Survival Steering Team. Systematic scaling up of
c. Perinatal mortality rate neonatal care in countries. Lancet 365:1087–1098
d. Gestational age Lawn JE, Cousens S, Zupan J (2005) Lancet Neonatal
e. Live births Survival Steering Team. Neonatal survival 1. 4 million
neonatal deaths: when? Where? Why? Lancet 365:891–900
f. Low birth weight Lawn JE, Wilczynska-Ketende K, Cousens SN (2006) Esti-
g. Pre-term birth mating the causes of 4 million neonatal deaths in the year
2000. Int J Epidemiol 35:706–718
2 Briefly discuss the major risk factors for perinatal Martines J, Paul VK, Bhutta ZA et al. (2005) for the Lancet
mortality. Neonatal Survival Steering Team. Neonatal survival: A
3 What factors account for the wide disparity in call for action. Lancet 365:1189–1197
perinatal outcomes between high-income and Stanton C, Lawn JE, Rahman H et al. (2006) Stillbirth
rates: delivering estimates in 190 countries. Lancet 367:
low-income countries? 1487–1494
4 Sixteen interventions with proven efficacy for pre- World Health Organization (WHO) (1996) Perinatal mortality.
venting neonatal survival have been identified in Maternal Health and Safe Motherhood Programme.
the literature. List any five of these and discuss in Geneva: WHO/FRH/MSM/96.7
World Health Organization (2006) Neonatal and perinatal
about 200 words, the challenges of implementing mortality – country, regional and global estimates.
them in one low-income country of your choice. Geneva: World Health Organization. http://www.who.
int/making_pregnancy_safer/publications/neonatal.pdf,
cited 27 July 2008
References Yu VYH (2003) Global, regional and national perinatal and
neonatal mortality. J Perinatal Med 31:376–379
Yu VYH, Dunn PM (2004) Development of regionalized
Bhutta ZA, Darmstadt GL, Hasan BS et al. (2005) Community- perinatal care. Sem Neonatol 9:89–97
based interventions for improving perinatal and neonatal
Chapter 4
Maternal and Child Health in the Organization for Economic
Cooperation and Development (OECD) Countries
Ian G. Child and John E. Ehiri
Learning Objectives After reading this chapter and

answering the discussion questions that follow, you Box 4.1 OECD Member Countries
should be able to
North America: Canada, the United States,
Discuss health and income inequality among the
and Mexico.
different member countries of the OECD and
Western Europe: Austria, Belgium, Den-
between OECD as a whole, and the rest of the
mark, Finland, France, Germany, Greece,
world.
Iceland, Ireland, Italy, Luxembourg, the
Evaluate MCH issues in OECD countries in rela-
Netherlands, Norway, Portugal, Spain, Swe-
tion to structure and financing of health care,
den, Switzerland, Turkey, and the United
health status indicators, service delivery models,
Kingdom.
and social determinants.
Former USSR members: Czech Republic,
Analyze the different ways that maternal and
Hungary, Poland, and the Slovak Republic.
child health services are organized and delivered
Asia and Australasia: Japan, The Republic of
in OECD member countries.
Korea, Australia, and New Zealand.
Structure and financing of health care: This

Introduction
section examines the typology and different
healthcare financing mechanisms in OECD
This chapter focuses on MCH practices in countries
member nations, analyzing the relative impor-
that are members of the 30-nation Organization for
tance of public funding, social programs,
Economic Cooperation and Development (OECD)
employer-supported health insurance, private
with its headquarters in Paris, France (Box 4.1). It
insurance, and out-of-pocket payments in the
examines the different ways that maternal and child
various member nations. This section also
health services operate in member states of the
examines the influence of different national
OECD. The chapter begins with a brief overview
social philosophies on the predominance of par-
of health and income inequity among the different
ticular financing mechanisms as well as differ-
member nations of OECD and between OECD as a
ences in healthcare expenditures and human
whole and the rest of the world. It then discusses
resource capacities in the various member
MCH issues in OECD countries from four perspec-
nations.
tives, namely
Health status indicators: This section presents a
comparative overview of maternal, infant, and
child health indices, contrasting high performing
nations with those that have poorer indices, and
I.G. Child (*) examining the role of differing economic and
University of Alabama at Birmingham, USA social factors.

54 I.G. Child and J.E. Ehiri
MCH service delivery models: This section United Kingdom, and the United States) – with aver-
examines variations in national approaches to age annual per capita national incomes which, in
antenatal care, using the United Kingdom, 2005, ranged from US $30,000 to US $44,000. The
Germany, France, Australia, Sweden, Canada, 11% of the world’s population that live in the G8
and Japan as examples. nations produces 64% of the world’s economic out-
Social determinants: This concluding section of put. The World Bank classifies 29 nations with popu-
the chapter discusses the relationships between lations over 1 million as ‘‘high-income’’ countries
biological and genetic causation, and the com- (per capita gross national income (PC GNI) >US
plex network of social, environmental, and beha- $10,066 in 2004). Twenty-three are OECD members.
vioral determinants of health. The six high-income, non-OECD members are Hong
Kong, Singapore, Israel, and the oil-rich nations of
The authors highlight the puzzling fact that
Kuwait, Saudi Arabia, and the United Arab Emi-
despite the multiplicity of prenatal and postnatal
rates. Membership in the OECD is expanding. In
care approaches, technological improvements, and
the past 7 years, four former USSR nations, plus
increased expenditure and intensity of care over the
Mexico, Turkey, and South Korea became OECD
last 30 years, no significant improvement in the
members. Their 2005 per capita GDPs ranged from
proportion of infants born with low birth weight
$4,700 in Turkey to $16,000 in South Korea. Five
has been observed in any high-income OECD coun-
prospective members are Chile, Estonia, Israel,
try. The need for greater policy and programmatic
Russia, and Slovenia, and discussions are underway
attention to economic and social determinants of
with the highly populated but middle-income nations
maternal and child health is emphasized.
of Brazil, China, India, Indonesia, and South Africa.
Within the OECD, healthcare systems reflect a
The OECD is a forum where member nations com-
wide range of social philosophies and economic and
pare policy experiences and address the economic,
political systems. Together, the OECD countries are
social, and governance challenges of globalization.
home to 18% of the world’s population but produce
For example, within the OECD, the 23-nation Devel-
80% of the world’s economic output. Thirty-nine
opment Assistance Committee (DAC) is the principal
and fifty-one percent of the world’s doctors and
body through which, if all countries honored promises
nurses, respectively, practice in OECD countries
to give 0.7% of their GDPs annually as aid for the
(WHO 2006). The United States is the only high-
poorest developing nations, approximately US $245
income nation that does not recognize universal
billion (109 in the US terminology) in aid would have
health care as a right of citizenship and permits
been donated in 2007 (UNICEF 2007). In 2005, five
critical provider and insurance sectors to profit.
countries, Denmark, Luxembourg, the Netherlands,
The US healthcare expenditures are double the
Norway, and Sweden exceeded the promised 0.7% of
OECD average, yet fewer services are delivered to
GDP; at the opposite end of the scale, Italy, Greece,
a younger population; 47 million persons are left
and the United States are ranked 20th–22nd in gener-
uninsured, and life expectancy, infant mortality,
osity with donations of slightly less than 0.2% of GDP
and low birth weight outcomes are worse.
(UNICEF 2007).
OECD grew out of the Organization for European
In many ways, this chapter is about the hetero-
Economic Cooperation (OEEC) created in 1948 with
geneity among high-income countries. The diverse
the support of the United States and Canada to con-
ways in which different OECD nations’ healthcare
solidate the Marshall Plan for reconstruction of
systems are structured, financed, and delivered
Europe after World War II (OECD 2008). As a coun-
reflect each member’s unique history, culture,
terpart to NATO, OECD took over from OEEC in
industry, social welfare, and political philosophies.
1961 with the mission of helping member govern-
It is not possible here to describe all members’
ments to achieve sustainable economic growth while
health systems in detail and we, therefore, have
maintaining financial stability and contributing to the
selected seven to illustrate the different healthcare
development of the world economy (OECD 2008).
structures as they relate to MCH processes of care
The OECD includes seven of the powerful G8 nations
and outcomes. We address issues related to the pre-
(Canada, France, Germany, Italy, Japan, Russia, the
natal period, infancy, childhood, and adolescence,
4 Maternal and Child Health 55
where young people and families are considerably countries. It is thus germane to explore MCH prac-
influenced by the social infrastructure and environ- tices within the OECD to determine whether there
mental determinants of health. OECD members are lessons to be learned.
have relatively better functioning healthcare sys- Several references are made in this chapter to
tems and better health outcomes for their MCH commonly used economic and developmental
populations than many middle- and low-income terms, defined briefly in Box 4.2.
Gross Domestic Product (GDP): The total final value of all goods and services produced by a nation in
a given year.
Gross National Income (GNI): GDP plus income received from abroad such as a proportion of wages
sent home, known as remittances, by foreign workers.
Purchasing Power Parity (PPP): A widely used conversion of GDP or GNI to compensate for recent
exchange rate changes and for the equivalent purchasing power of a common market basket of
household items in the nation.
Gini Coefficient (World Bank 2008): A measure of income inequality within each nation, where a
value of 0 indicates perfect equality and a value of 1 indicates total inequality. Among OECD
members, the United States has the biggest gap between the haves and the have-nots. The countries
with the highest degrees of equality in 2004 were Sweden, Denmark, Finland, and Germany.
Freedom Index (Heritage Foundation 2008): Issued by Freedom House, it measures the relative
degree of social and political rights and freedom of choice in 190 countries. Its annual report is widely
relied upon by international policy makers in organizations such as the World Bank and IMF. Forty-
seven countries were listed as ‘‘most free’’ and they included all OECD nations except Greece, Japan,
and the Republic of Korea.
Corruption Index (Transparency International 2002): A widely referenced product of the Berlin-
based company called Transparency International. It measures the degree to which corruption in the
actions of local politicians and public officials is perceived in 12 surveys of businesspersons, interna-
tional policy experts, and others. The index is a scale from 1 (most corrupt) to 10 (least corrupt)
nations. Nordic countries, Australia, New Zealand, Singapore, and Switzerland are rated as the least
corrupt. The United States was ranked 20th.
Human Development Index (HDI) (UNDP 2008): This covers 175 countries and is published annually
by the United Nations. HDI is sometimes referred to as the ‘‘livability index’’ and is based on a
composite measure of life expectancy, literacy, and standard of living. The five most livable OECD
countries based on 2004 data were Norway, Iceland, Australia, Ireland, and Sweden.
Human Poverty Index (HPI) (United Nations 2005): There are two HPI indices. HPI-1 is designed for
developing nations and is a composite measure of life expectancy, literacy, access to clean water, and
proportion of appropriate weight children. HPI-2 is designed for high-income nations and is a
composite of the probability of not surviving to 60 years of age, percent of adults lacking functional
literacy skills, population in poverty (50% of median adjusted household income), and percent of
population unemployed longer than 12 months. OECD countries with the lowest poverty index are
Sweden, Norway, the Netherlands, Finland, and Denmark.
International Classification of Diseases (ICD): Endorsed by the WHO, this is the world’s international
standard diagnostic classification scheme. It is very widely used by governments for vital statistics
recording, by healthcare providers for medical records and financial and billing systems, and by
policy makers. Diseases, signs and symptoms, accidents and many other health problems are coded.
The latest revision ICD-10 was released in 1994.
OECD in an Unequal World neighboring countries. To explore the context,

delivery, and status of MCH in OECD nations,
In 2007, the world’s population was 6.6 billion and the remainder of this chapter has been structured
produced a total income (GNI) of US $49 trillion into the following sections: (i) structure and
(UNICEF 2007). The world is extremely heteroge- financing of healthcare systems; (ii) health status
neous and income is unevenly spread among, or indicators – outcomes, processes, and resources;
within, nations (see Tables 4.1 and 4.2). The following (iii) specific processes of MCH care in six coun-
key facts illustrate the degree of international inequal- tries; (iv) the relationships between biological and
ity that exists: (a) 61% of the world’s people live in the genetic causation, and the complex network of
11 largest countries (China, India, the United States, social, environmental, and behavioral determi-
Indonesia, Brazil, Pakistan, Russia, Bangladesh, nants of health.
Nigeria, Japan, and Mexico), each of which has a
population greater than 100 million residents (UNI-
CEF 2007). Two of these countries, the United States
and Japan, together are home to 6.6% of world’s Structure and Financing of Health Care
population but produce 42% of its income; (b) the
10 countries (the United States, Japan, Germany, the
Table 4.3 presents a summary of healthcare finan-
United Kingdom, France, Italy, Spain, Canada, Mex-
cing mechanisms in selected OECD countries. The
ico, and South Korea) with the largest economies (all
five dominant financing mechanisms include the
of whom are members of the OECD) have 70% of the
following:
world’s economy but only 14% of the world’s popu-
Public taxation: Federal, state, county, or muni-
lation; (c) 34% of the world’s population resides in the
cipality government income taxation that creates a
44 poorest nations (of the 44 poorest nations: 31 are in
pool of cash (often called a general fund) out of
sub-Saharan Africa, 9 are in south/Southeast Asia,
which amounts to pay for services such as health,
and 4 are in Central Asia) and have per capita
education, pensions, law and order, roads are allo-
incomes of less than US $2 per day and produce
cated. Government has funding flexibility, typically
only 3% of its economic output. In 2004, China and
defined by an annual budget, to direct general taxa-
India, respectively, had 20 and 17% of world’s popu-
tion funds toward these specific purposes and to
lation and 4.8 and 1.7% of the world’s economy.
place them under federal or state control. This
Tables 4.1 and 4.2 show key indicators for all 142
approach is primarily used in Australia (state con-
countries with populations of 1 million or more that
trol), Canada (federal and provincial control), New
publish data. Table 4.1 divides the countries into eight
Zealand (federal), Spain (federal and private),
income groups: the first two rows correspond with the
Sweden (counties), the United Kingdom (federal
World Bank (WB) category of low-income nations;
and regional), and the United States (States’ control
the third and fourth rows correspond with the WB
of Medicaid). These countries typically use a system
low middle-income nations, the fifth and sixth rows
of delegation of some authority and flexibility to
with WB upper middle-income nations, and the
define the ‘‘right’’ coverage for the populations of its
seventh and eighth rows with WB’s high-income cate-
regions together with strictly held global budgets to
gory. Table 4.2 subdivides the countries by geo-
control operating and capital expenditure in each
graphic area.
region.
Life expectancy in Western Europe is approxi-
Social programs: Federal, state, county, or muni-
mately double that of the poorest countries in the
cipality government taxes are specifically designated
world, where infant mortality rates are 20 times
for health care and cannot be used for other purposes
higher and maternal mortality rates are 75 times
such as welfare, social security, subsidized housing,
higher (OECD 2006). But economic and social
education, roads. This approach is primarily used in
inequality between nations is not the end of the
France, Italy, Japan, and the Netherlands. Some
story. There is sometimes more difference
countries such as France have complex authority
between MCH outcomes in different regions of
and control structures.
the same country than there is between
4
Table 4.1 Distribution of countries by per capita GNI groups (2004 data unless otherwise stated)
WB # Per Cap Popn % Cum Average GNI/Cap GNI % Cum % Life Inf mort / <5 mort Matern MDs Corrup Hum Dev
terminol countries income range millions Pop % GNI/Cap PPP IMF $trillion GNI GNI exp 000 bths /000 mortal /000 GINI 2006 Index
LI 25 <$400 406 6.4 6.4 $226 $1,188 92 0.2 0.2 48 100 160 975 0.12 0.347 2.4 0.420
LI 23 $400 - $825 1,810 28.4 34.8 $579 $2,812 1,049 2.6 2.8 61 66 95 536 0.56 0.359 2.5 0.531
LMI 14 $826 - $1,499 516 8.1 42.9 $1,153 $4,629 $595 1.5 4.3 68 31 41 218 0.73 0.346 2.7 0.710
LMI 24 $1,500 - 1,880 29.5 72.5 $1,814 $7,316 $3,411 8.5 12.8 71 27 31 91 1.06 0.404 3.2 0.715
$3,255
UMI 14 $3,256 - 374 5.9 78.3 $3,680 $10,482 $1,376 3.4 16.2 66 23 28 92 2.57 0.385 3.9 0.763
$4,999
UMI 14 $5,000 - 201 3.2 81.9 $6,724 $11,945 $1,352 3.4 19.5 75 16 19 55 2.23 0.284 4.3 0.782
$10,065
HI 14 $10,066 - 277 4.4 85.8 $20,974 $25,681 $5,810 14.4 34.0 79 6 7 11 2.73 0.309 7.1 0.973
$29,999
HI 14 $30,000 + 694 10.9 96.7 $37,222 $35,274 $25,832 64.1 98.1 79 5 6 13 2.68 0.305 8.4 0.947
142 Countries 6,158 96.7 96.7 $6,417 $39,516 98.1
pop >1mill
36 Pop <1 mill c 11 0.2 99.5 $7,233 80 0.2 98.3
GNI
30 Pop < 1 or no 174 2.7 99.7 Unk Unk
GNI
208 Total above 6,343 99.7 $6,242 39,596 98.3
WB Grand 6,365 100 $6,329 $40,282 100.0 67 54 79 400
total
LI = low income; LMI = lower middle income; UMI = upper middle income; HI = high income
57
58
Table 4.2 Distribution of countries by geographic region (2004 data unless otherwise stated)
Cum <5 Hum
# Popn % Cum GNI/ GNI/cap GNI % % Life Inf mort mort/ Matern MDs Corrup Dev
countries Region 000,000’s Pop % cap PPP IMF $trillion GNI GNI exp /000 bths 000 mortal /000 GINI 2006 Index
16 Europe 395 6.2 6.2 $29,613 $29,459 $11,697 29.0 29.0 79 4 5 9 3.35 0.315 7.8 0.941
27 E. Central 467 7.3 13.5 $3,358 $9,246 $1,568 3.9 32.9 69 23 27 54 2.92 0.291 3.5 0.766
Asia
4 E. Asia 187 2.9 16.5 $30,482 $28,101 $5,700 14.2 47.1 81 4 4 13 1.87 0.356 7.6 0.926
(high inc)
10 E. Asia 1,796 28.2 44.7 $1,457 $6,590 $2,618 6.5 53.6 70 26 32 92 0.86 0.410 2.9 0.680
(low/mod
inc)
5 S. Asia 1,417 22.3 67.0 $598 $3,103 $848 2.1 55.7 63 63 85 518 0.57 0.351 2.6 0.592
9 Caribbean 51 0.8 67.8 $2,392 $5,497 $122 0.3 56.0 70 26 33 162 0.78 0.490 3.2 0.746
10 S. America 371 5.8 73.6 $2,952 $8,422 $1,095 2.7 58.7 72 26 28 211 1.45 0.532 3.7 0.792
3 N. America 430 6.8 80.3 $32,082 $33,320 $13,795 34.2 93.0 77 11 13 32 2.39 0.410 6.4 0.906
(NAFTA)
15 N. Africa & 306 4.8 85.2 $3,336 $7,276 $1,021 2.5 95.5 71 31 38 132 0.89 0.379 3.8 0.719
Mid East
41 Sub- 714 11.2 96.4 $603 $2,119 $431 1.1 96.6 46 96 161 889 0.18 0.355 2.6 0.452
Saharan
Africa
2 Australasia 24 0.4 96.7 $25,890 $29,880 $621 1.5 98.1 80 5 6 8 2.45 0.357 9.2 0.947
142 Countries 6,158 96.7 96.7 $6,417 $39,516 98.1
pop >1
mill
36 Pop <1 mill 11 0.2 96.9 $7,233 80 0.2 98.3
c GNI
30 Pop < 1 mill 174 2.7 99.7 Unk Unk 98.3
or no
GNI
208 Total above 6,343 99.7 $6,242 $39,596 98.3
WB grand 6,365 100 $6,329 $40,282 100.0 67 54 79 400
total
I.G. Child and J.E. Ehiri
Table 4.3 Healthcare financing mechanisms in OECD countries

Financing Providers
Public taxation Primary care provider
Social National Regional Private Public Private
Australia Yes Yes
Canada Yes Yes Yes
Denmark Yes Yes
France Yes Yes Yes
Germany Yes Yes Yes
Italy Yes Yes Yes
Japan Yes Yes Yes
The Netherlands Yes Yes Yes
NZ Yes Yes Yes
Norway Yes Yes
Spain Yes Yes
Sweden Yes Yes Yes
Swiss Yes Yes
The United Kingdom Yes Yes
The United States Yes Yes Yes Yes
Source: OECD (2006)
Health insurance: Direct payments by employees Other US federal government plans include
to health insurance funds that are largely indepen- TRICARE (ex-military persons) and the excellent
dent of government and are typically negotiated by coverage for congresspersons and federal govern-
employers or unions. Examples are the sickness ment staff. Coverage and purchasing is centrally
funds in Germany and the insurance companies in regulated in similar ways to some European sys-
the United States. tems. Medicaid (for low-income populations) is
Private insurance: Little government control of jointly funded from state income taxes plus a vary-
payments. In some countries, private insurance can ing proportion of matching financing by the federal
offer full coverage. In others it may be used for government. The US state governments define the
comfort and convenience items such as hospital range of available treatment coverage and eligibility
single rooms, or dental, ophthalmic, prescriptions, based on the patient’s personal financial status.
and long-term care. In Canada, private insurance Individual states differ markedly in their eligibility
may be used only for services not provided by and coverage criteria. Employers and employees
government. pay a proportion of wages for health insurance
Out of pocket: Direct patient usage payments coverage for themselves and, typically at an addi-
either as co-payments, deductibles, or entire charges tional premium, for their families. Employers and
for certain services are widely used in the United unions choose from a number of competitive for-
States but are not used in most high-income coun- profit health insurance management companies or
tries with strong social support philosophies. Out- self-insure. In the United States, it is not mandatory
of-pocket payments are sometimes sub-classified that employers provide health insurance and many
according to necessity, such as different classes of do not, particularly for part-time workers. The
drugs in France. United States is the only country in the OECD
In most countries, more than one financing that does not have a philosophy of universal health
mechanism is used. For example in the United insurance as a fundamental right of citizenship and,
States, Medicare (which covers citizens over 65 in 2007, 47 million residents had no insurance and a
years of age and others of any age with long-term further 25 million had inadequate insurance for at
disabilities) funding is collected as a separate wage least a part of the year. It should be noted that some
tax plus funds from general federal income tax. young and healthy employees in the United States
prefer not to be insured and not to pay a proportion burden (the percentage that a nation’s taxes are of
of their income for services they believe they will that country’s GDP) in selected OECD nations.
never need. OECD healthcare expenditures and processes:
Different national cultures and social philoso- Fig. 4.2 compares the per capita expenditure on
phies play a role in general citizen welfare in ways health care (in US $ PPP) in a cross section of
that go well beyond health and cover pensions, OECD nations. The US expenditure of $6,000 per
housing, food subsidies, and education – including capita is approximately double the OECD average
higher education. However, when we comment on but serves a comparatively younger population (on
the ‘‘generosity’’ of a country like Sweden, whose average, 15% fewer citizens over 65 years of age
government pays directly for health and social wel- than some nations have), provides fewer services
fare programs, and has almost eliminated child pov- such as prescriptions (the data predate the Medicare
erty, it should be noted that this ‘‘generosity’’ is Part D prescription plan), long-term care, dental
made possible by higher taxation and a culture in and ophthalmic care (some, but not all, OECD
which it is a core value that the richer members of countries provide these), and delivers fewer physi-
society should contribute to the well-being of the cian visits and bed-days per capita. This is accom-
poorer members. Fig. 4.1 presents the relative tax panied by worse outcomes such as life expectancy,
Fig. 4.1 Tax burden in

selected OECD countries
(2004). Source: OECD
(2006)
$7,000
$6,000
Per capita expenditures
$5,000
$4,000
$3,000
$2,000
$1,000
Fig. 4.2 Per capita $0

expenditure on health care in
Ze al
Fi n
d
n
Ki taly
Sw d
D den
he rk
G nds
Au ny
Au a
ria
C ce
N a
U zer y
d nd
es
a
an
ai
an
li
ad
ew rtug
do
ra
a
an
Sw orw
at
p
la
st
a
Sp
N nm
I
rla
m
al
nl
Ja
an
l
Ire
st
St
ng
2004 US $PPP, OECD

Fr
er
Po
it
te
et
members. Source: OECD

d
ni
te
N
ni
(2006)
U
infant mortality, and low birth weight. Some however, residents with annual salaries over a
researchers question whether these statistics accu- specified level have a choice of opting out of
rately and comparably represent the true situation. public health insurance if they purchase private
Some draw attention to possible problems with insurance that gives at least equivalent coverage.
equivalent definition and rigor in the collection of Approximately 10% of Germans opt for this. In
comparative outcomes data in all countries (Howell the Netherlands, it is mandatory that the approxi-
and Blondel 1994). In 2000, the WHO ranked the mately 20–25% of residents earning more than a
US healthcare system in the 37th place but ‘‘infor- certain annual threshold level each year leave public
mal opinion’’ ranks the United States between 15th health coverage and subscribe to private insurance.
and 20th among 30 OECD nations (WHO 2000). No system is wholly accepted as perfect, and
Countries (with populations > 1 million persons) most countries have individual and common con-
that led the WHO ranking were France, Italy, Sin- cerns. In general, annual healthcare expenditures in
gapore, Spain, Austria, Japan, and Norway, and OECD members have grown at more than double
some question that order. A 2006 survey compar- the rate of GDP growth (111%) over the past 5
ing adult healthcare experiences in seven nations years. This ranges from 3% increase in Greece to
(Australia, Canada, Germany, the Netherlands, >120% in France and Norway (OECD 2006)
New Zealand, the United Kingdom, and the Uni- (Table 4.4). Two major population transitions that
ted States) found wide national differences in are common to most high-income countries may
access, after-hours care, coordination, and medical provide some explanation for this. First, fertility
errors (particularly when patients saw multiple rates have slowed to or are below the replacement
doctors; Schoen et al. 2006). The ‘‘United States rate, and second, in general, populations live longer.
stands out for its cost-related access barriers and As medical costs increase, the working population,
less-efficient care’’ and ‘‘practices least use of elec- who make contributions through wage and salary
tronic medical records’’ (Schoen et al. 2006). The deductions, whether in general taxation or specific
United States ranked lowest in patient satisfaction health and welfare contributions, will have an
but together with the German system was ranked increasing load placed on them to support health
highest in speedy access. Similarly, results from the care for the elderly and unemployed sectors of the
Commonwealth Fund’s National Scorecard report population that do not pay for health care.
show that the US health system continues to fall Health systems’ human resources in OECD
short of what is attainable based on a survey of 19 countries: Table 4.5 shows numbers of physicians,
industrialized nations (The Commonwealth Fund nurses, and nurse midwives per 1,000 population
Commission on a High Performance Health Sys- (WHO 2006). The number of physicians per 1,000
tem 2008). Across 37 core indicators of perfor- population is a useful but incomplete measure. Of
mance, the United States achieved an overall at least equal importance are the following: (a) the
score of 65 out of a possible 100. Overall perfor- average time (‘‘face time’’) that patients spend in
mance did not improve from 2006 to 2008. Access discussion with their physicians, (b) the content
to health care significantly declined, while health and quality of the information imparted, (c) the
system efficiency remained low (The Common- proportion of that time devoted to prevention, and
wealth Fund Commission on a High Performance (d) the written materials or web sources given to
Health System 2008). the patient. A study in the British Medical Journal
A nation’s population health status is dependent compared the ‘‘face time’’ of patients in the United
on a complex web of interconnected factors, of States, Australia, and New Zealand and found that
which the healthcare system is only one factor (see Australian and New Zealand patients, respec-
Chapter 5 on Health systems and MCH). Different tively, had double and 50% more ‘‘face time’’
countries have different philosophies regarding than the US patients (Bindman et al. 2007). The
responsibility for, and provision of, health care for amount of time a patient spends with other care-
their citizens. Except the United States, all high- givers in the practice (e.g., a prevention nurse) is
income OECD countries have had universal health clearly also important but was not included in this
insurance coverage for decades. In Germany, study.
62
Table 4.4 OECD gross domestic product (PPP) and health expenditure
Year 2004 – all PPP 2000–2004 Other comparisons
PC Health
GDP Tot. exp Health Annual Annual Health Gini
Per cap Index Health index expend GDP health Difference empl coef
WHO GDP USA = expend USA = as % PPP exp % of GDP wage (diff Livability Corruption
rank Country US$ 100 per cap 100 GDP growth growth growth Index years) rank 2005 index 2006
21 countries with a per capita GDP PPP >US $20,000
24 Australia $32,573 82 $3,120 51 9.6 4.4% 6.8% 55 65 0.352 3 8.7
5 Austria $32,519 82 $3,124 51 9.6 3.5% 4.0% 14 71 0.291 14 8.6
14 Belgium $31,381 79 $3,260 53 10.4 4.2% 9.4% 124 72 0.330 13 7.3
22 Canada $31,828 80 $3,165 52 9.9 3.3% 6.0% 82 72 0.326 6 8.5
26 Denmark $32,304 81 $2,881 47 8.9 2.9% 4.9% 69 77 0.254 15 9.5
23 Finland $29,778 75 $2,235 37 7.5 3.6% 6.8% 89 64 0.269 11 9.6
1 France $29,945 75 $3,159 52 10.5 2.9% 6.6% 128 71 0.327 16 7.4
17 Germany $28,816 72 $3,043 50 10.6 3.1% 3.7% 19 66 0.283 21 8.0
9 Greece $21,586 54 $2,162 35 10.0 7.3% 7.5% 3 31 0.343 23 4.4
12 Ireland $36,479 92 $2,596 43 7.1 6.0% 9.4% 57 61 0.343 4 7.4
2 Italy $28,352 71 $2,467 40 8.7 2.4% 4.3% 79 51 0.360 17 4.9
6 Japan $29,567 74 $2,340 38 7.9 3.2% 4.4% 38 69 0.249 7 7.6
43 Korea, Rep $20,668 52 $1,149 19 5.6 6.0% 10.0% 67 39 0.316 25 5.1
10 The $32,978 83 $3,041 50 9.2 3.7% 7.8% 111 74 0.309 10 8.7
Netherlands
31 New Zealand $24,744 62 $2,083 34 8.4 3.2% 6.8% 113 46 0.362 20 9.6
7 Norway $40,715 102 $3,966 65 9.7 2.9% 6.5% 124 79 0.258 1 8.8
4 Spain $25,875 65 $2,094 34 8.1 5.3% 8.4% 58 55 0.347 19 6.8
16 Sweden $31,139 78 $2,825 46 9.1 3.5% 5.6% 60 77 0.250 5 9.2
3 Switzerland $35,149 88 $4,077 67 11.6 3.6% 6.4% 78 102 0.337 9 9.1
11 UK $30,822 77 $2,508 41 8.1 4.8% 7.8% 63 76 0.360 18 8.6
28 USA $39,772 100 $6,102 100 15.3 3.5% 7.4% 111 100 0.408 8 7.3
4

Year 2004 – all PPP 2000–2004 Other comparisons
PC Health
GDP Tot. exp Health Annual Annual Health Gini
Per cap Index Health index expend GDP health Difference empl coef
WHO GDP USA = expend USA = as % PPP exp % of GDP wage (diff Livability Corruption
rank Country US$ 100 per cap 100 GDP growth growth growth Index years) rank 2005 index 2006
7 countries with a per capita GDP PPP <US $20,000
35 Czech Rep $18,634 47 $1,361 22 7.3 6.4% 8.5% 33 35 0.254 6.5 4.8
51 Hungary $15,948 40 $1,276 21 8.0 7.2% 10.5% 46 32 0.269 5.9 5.2
46 Mexico $10,242 26 $662 11 6.5 3.0% 6.8% 127 14 0.495 n/a 3.3
37 Poland $12,409 31 $805 13 6.5 4.6% 8.0% 74 22 0.345 n/a 3.7
8 Portugal $18,125 46 $1,824 30 10.1 1.1% 3.0% 173 41 0.385 27 6.6
47 Slovak Rep $14,060 35 $855 14 6.1 6.7% 9.4% 40 24 0.258 n/a 4.7
52 Turkey $7,562 19 $580 10 7.7 2.8% 6.3% 125 8 0.436 n/a 3.8
Source: OECD 2006
63
64
Table 4.5 OECD resources and processes of care

Acute Tot %
MDs/ Nurses/ NMWs/ MD bed- Ac beds/ Ac bed % Ac bed beds/ measles % DPT % >65
WHO 000 000 000 consults/ days/ 000 pop. occup ’03 ALOS 000 immune immune Flu vacc CTs/ MRIs/
rank1 Country popn. popn. popn. capita capita ’03 or ’04 or ’04 ’03 or ’04 2003 2004 2004 03 or 04 000,000 000,000
21 countries with a per capita GDP PPP >US $20,000
24 Australia 2.38 9.35 n/a 6.0 1.0 3.6 70.6 6.1 3.8 94.0 92.3 79.1 n/a 3.7
5 Austria 3.34 9.29 0.20 6.7 1.8 6.6 79.0 6.2 8.3 88.0 83.0 n/a 28.5 14.9
14 Belgium 4.45 5.78 0.63 7.6 1.2 4.8 n/a 7.3 6.8 97.0 95.0 65.0 29.8 6.8
22 Canada 2.09 9.70 n/a 6.1 1.0 3.0 91.0 7.3 3.4 82.0 n/a 63.0 10.8 4.9
26 Denmark 2.90 10.26 0.22 7.5 n/a 3.3 85.0 3.6 4.0 96.9 95.0 50.8 14.6 10.2
23 Finland 3.16 14.32 0.76 4.2 0.9 3.0 n/a 4.8 n/a 81.0 n/a 46.0 14.2 14.0
1 France 3.38 7.27 0.26 6.7 1.0 3.8 74.9 5.6 7.7 97.3 98.0 68.0 7.5 3.2
17 Germany 3.37 9.72 0.10 n/a 1.8 6.6 75.5 8.9 8.7 88.0 97.7 48.0 15.4 6.6
9 Greece 4.32 3.80 0.17 n/a n/a 3.8 n/a n/a 4.7 93.3 88.0 n/a n/a n/a
12 Ireland 2.79 15.19 4.12 n/a 0.9 2.9 85.3 6.5 4.3 74.0 89.0 61.4 n/a n/a
2 Italy 4.18 5.42 0.29 n/a 1.0 3.7 75.8 6.8 4.2 93.5 92.7 66.6 20.6 10.2
6 Japan 1.97 7.78 0.19 13.8 2.1 8.5 79.3 20.7 14.3 95.8 100.0 43.0 92.6 36.0
43 Korea, Rep 1.56 1.73 0.18 n/a n/a 5.9 71.6 10.6 7.1 100.0 97.0 75.7 31.5 11.0
10 The 3.12 13.61 0.12 5.3 n/a 2.8 68.0 7.4 4.8 95.0 98.0 73.0 n/a n/a
Netherlands
31 New Zealand 2.20 7.59 0.52 3.2 n/a n/a n/a n/a n/a 87.1 n/a 49.2 12.1 3.7
7 Norway 3.09 14.62 0.49 n/a 0.9 3.1 86.4 5.2 3.8 96.0 91.0 n/a n/a n/a
4 Spain 3.17 7.38 0.15 9.5 0.8 2.8 79.2 6.9 3.4 99.9 96.6 68.6 13.3 7.7
16 Sweden 3.24 10.08 0.69 n/a n/a 2.2 n/a 4.7 n/a 99.6 99.0 n/a n/a n/a
3 Switzerland 3.50 10.42 0.27 n/a 1.2 3.9 86.3 8.7 3.9 n/a 95.0 57.0 17.9 14.3
11 UK 2.23 11.78 0.61 5.3 1.1 3.7 84.4 6.6 4.1 96.4 91.5 71.0 7.0 5.0
28 USA 2.49 9.09 0.02 3.9 0.7 2.8 66.9 5.6 3.3 81.0 85.5 64.6 32.2 26.6
4

Acute Tot %
MDs/ Nurses/ NMWs/ MD bed- Ac beds/ Ac bed % Ac bed beds/ measles % DPT % >65
WHO 000 000 000 consults/ days/ 000 pop. occup ’03 ALOS 000 immune immune Flu vacc CTs/ MRIs/
rank1 Country popn. popn. popn. capita capita ’03 or ’04 or ’04 ’03 or ’04 2003 2004 2004 03 or 04 000,000 000,000
7 countries with a per capita GDP PPP <US $20,000
35 Czech Rep 3.53 9.74 0.47 13.1 1.8 6.4 74.7 8.1 8.7 85.5 97.9 n/a 12.6 2.8
51 Hungary 3.26 8.65 0.20 12.6 1.7 5.9 76.6 6.5 7.8 82.0 99.8 37.9 6.8 2.6
46 Mexico 1.88 0.85 n/a 2.5 0.4 1.0 62.2 3.9 1.9 96.0 98.1 29.1 3.1 1.7
37 Poland 2.49 4.94 0.58 6.2 n/a 4.8 77.0 6.6 n/a 80.7 99.0 n/a 6.9 1.9
8 Portugal 3.28 4.18 0.08 3.8 0.8 3.0 70.5 7.0 3.6 97.0 97.8 n/a 12.8 3.9
47 Slovak Rep 3.18 6.77 0.27 11.9 1.4 5.9 69.1 7.7 7.2 85.0 99.3 22.9 8.7 2.0
52 Turkey 1.34 1.69 n/a 3.1 n/a 2.4 64.9 5.2 2.6 93.0 85.0 n/a 7.3 3.0
Source: Outcomes – OECD 2006. Personnel – WHO.
Key: AC = acute; ALOS = average length of stay
CT = computed tomography (CT) scan
MRI= Multiple Resonance Imaging
65
The number of nurse midwives is low in the to the general populations of Malaysia, Costa Rica,
United States, Germany, the Netherlands, and Sri Lanka, Bosnia Herzegovina, and Mauritius
Spain. This has implications for pregnancy manage- (World Bank 2008).
ment and child care. Numbers of physician visits per Pregnancy termination: In interpreting and com-
capita are lowest in New Zealand, the United States, paring adverse pregnancy outcomes across OECD
and Finland. Acute bed-days in the United States countries, one question that merits research is
and Finland are low. Occupancy is lowest in the whether pregnancy termination and abortion
United States (67%, suggesting an oversupply of regulations and practices have an impact on
hospital beds); length of stay is lowest in Denmark, national pregnancy outcome statistics. Abortion is
Sweden, and Finland. legal in all European countries except Ireland and
Switzerland (unless the mother’s life is in danger)
but the regulations of individual nations vary mark-
edly. For example, the gestational age limit for on-
Health Status Indicators demand or unreviewed abortion in Belgium,
Denmark, France, Germany, and Italy is 12 weeks
Maternal, infant, and child mortality in OECD but in Finland and the United Kingdom it is 24
countries: Table 4.6 shows a ranking of OECD weeks. In the Netherlands, abortion is available
countries based on a composite, unweighted index under 14 weeks free of charge under their federal
of life expectancy, infant mortality, under 5-year insurance plan. The Scandinavian countries have
mortality, and maternal mortality. the lowest infant mortality rates in Europe. These
The countries with the best indices are Sweden, nations have the most open acceptance of abortion
Norway, and Finland. The bottom ranked coun- as a rightful choice for women. However, a study in
tries are the United States, Mexico, and Turkey. 1999 showed that abortion rates in Scandinavia,
Infant mortality rates fell steadily in all countries Finland, the Netherlands, and England are slightly
until the mid-end of the 1990s when they began to lower than the United States. Use of abortion in
flatten (Fig. 4.3). In 1970, infant mortality rates Southern European countries varies (Bindman et al.
ranged from the lowest rate of 11 per thousand 2007). France and Italy have moderate use but
births in Sweden to the highest rate of 28–29 per Spain’s use is lower. There is no indication (as
thousand births in Italy and Spain. By 2004, this there was not when oral contraceptives were intro-
range had declined in all countries from a low of 4 duced in the 1960s) of a strong tendency to follow
per thousand births in Sweden and Japan to a high the Catholic Church that condemns the practice.
of 7 per thousand births in the United States where For example, abortion is available on demand in
rates also vary considerably according to race Italy where 99% of the population is Roman Catho-
(UNICEF 2007). lic. In the United States approximately 20% of
Table 4.7 ranks major causes of infant mortality pregnancies are ended by surgical or drug-induced
in the United States. We may now be approaching a abortion (Henshaw et al. 1999). In some Northern
natural limitation where only slight reductions in European OECD countries as many as 60% of
infant mortality rates can be anticipated in the pregnancies where a high risk of congenital
future. Four Asian high-income countries (Hong abnormalities has been detected are terminated,
Kong, Japan, Republic of Korea, and Singapore) and clearly, this would have significant impact on
and several North European countries have the infant mortality rates in those countries (OECD
world’s lowest infant mortality rates of 3–4 per 2006).
thousand births. Infant mortality rates in the Pregnancy outcomes: In comparison with low-
United States still remain double the level of those and middle-income nations, maternal mortality
countries. Infant mortality rates among African- and death of children between ages 1 and 4 years
American births (13.5 per thousand) are 2.4 times have a much lower incidence in high-income coun-
higher than among Caucasian births (5.7 per thou- tries. Low numbers and statistical significance may
sand) (Shen et al. 2005; CDC 2007). The US infant limit their value as a comparative measure of MCH
mortality rate among African-Americans is similar status among OECD nations. The percentage of
4
Table 4.6 OECD life expectancy & maternal and child outcomes, 2004 (ordered by the composite outcomes index)
Inf <5
WHO Popn. HE index Hum dev Life exp at mort/ mort/ Mat mort1/ LBW C-sect % Composite
rank Country 000,000s USA=100 index birth 000 000 00,000 bth % of bths outcome index2
16 Sweden 9.0 46 0.951 80.6 3.1 4 3 4.2 17.2 3.70
7 Norway 4.6 65 0.965 79.9 3.2 4 4 4.8 15.6 4.03
23 Finland 5.2 37 0.947 78.8 3.3 4 5 4.2 16.3 4.10
14 Belgium 10.4 53 0.945 78.9 4.3 5 n/a n/a n/a 4.65

2 Italy 57.6 40 0.940 80.0 4.1 5 3 6.7 37.0 4.66
35 Czech Rep 10.2 22 0.885 75.8 3.7 4 4 6.8 16.0 4.70
12 Ireland 4.0 43 0.956 78.5 4.9 6 3 5.0 21.8 4.74
4 Spain 42.7 34 0.938 80.5 3.5 5 4 7.1 23.6 4.87
9 Greece 11.1 35 0.921 79.0 4.1 5 2 8.6 n/a 4.91
17 Germany 82.5 50 0.932 78.6 4.1 5 4 6.9 26.0 4.97
3 Switzerland 7.4 67 0.947 81.2 4.2 5 4 6.3 25.7 4.98
5 Austria 8.2 51 0.944 79.3 4.5 6 4 6.8 22.1 5.24
24 Australia 20.1 51 0.957 80.6 4.7 6 5 6.3 29.7 5.39
8 Portugal 10.5 30 0.904 77.6 4.0 5 5 7.6 29.2 5.52
6 Japan 127.7 38 0.949 82.1 2.8 4 6 9.4 n/a 5.60
10 The 16.3 50 0.947 79.2 4.1 6 7 5.4 13.6 5.61
Netherlands
22 Canada 31.9 52 0.950 80.0 5.3 6 6 5.8 24.7 5.70
1 France 60.2 52 0.942 80.3 3.9 5 8 6.8 17.8 5.81
26 Denmark 5.4 47 0.943 77.6 4.4 5 10 5.3 19.9 6.25
11 UK 59.8 41 0.940 78.7 5.1 6 7 7.5 21.9 6.45
37 Poland 38.2 13 0.862 75.0 6.8 8 5 6.1 n/a 6.53
31 New Zealand 4.1 34 0.936 79.2 5.0 7 10 6.1 22.2 6.93
51 Hungary 10.1 21 0.869 72.8 6.6 7 7 8.3 27.9 7.23
47 Slovak Rep 5.4 14 0.856 74.1 6.8 9 7 7.2 19.2 7.49
43 Korea, Rep 48.1 19 0.912 77.3 5.3 6 15 4.2 35.2 7.71
28 USA 293.7 100 0.948 77.7 7.0 8 10 8.1 29.1 8.32
46 Mexico 104.0 11 0.821 75.2 19.7 28 67 9.1 37.9 28.10
52 Turkey 71.8 10 0.757 71.2 24.6 32 n/a n/a n/a 28.30
Source: Outcomes — OECD 2006.
1. Maternal mortality = average of 2000–2004.
2. Based on 4 pregnancy outcome columns IM through LBW.
67
Fig. 4.3 Trend in infant

mortality, OECD, 1970–
2004. Source: OECD (2006)
Table 4.7 Causes of infant mortality in the United States, 2003

R% of % of
Rank 18,893 neonatal deaths total 9,132 post-neonatal deaths total
1 Short gestational and/or low birth weight 25.2 Sudden infant death syndrome 21.6
2 Congenital and chromosomal abnormality 21.2 Congenital malformation 17.7
chromosome abnormality
3 Maternal complication of pregnancy 9.0 Unintended injuries 9.1
4 Newborn affected by complications of placenta, 5.7 Disease of circulatory system 4.5
chord, or membranes
5 Newborn respiratory distress 4.1 Influenza or pneumonia 3.2
6 Bacterial sepsis of newborn 3.9 Homicide 3.2
7 Neonatal hemorrhage 3.4 Gastritis, duodenitis, non-infective 3.1
enteritis, or colitis
8 Intra-uterine hypoxia or asphyxia 2.7 Septicemia 3.0
9 Atelectasis 2.3 Chronic respiratory disease 2.4
10 Necrotizing enterocolitis 1.9 Short gestational and/or low birth wt 1.1
All other 20.7 All other 31.1
Source: CDC (2007). Note that 34% of the US post-neonatal deaths were as a result of SIDS, injuries, or homicide
babies born prematurely or with low birth weight In France, Germany, Italy, and the United
provides a better comparative measure. A measure of States, rates of low birth weight have increased
appropriate weight for gestational age together with a slightly and in Japan and Spain, they have increased
national fetal growth curve is perhaps the best method significantly (Fig. 4.5). Ironically, Japan, the coun-
of all. Low birth weight rates have not decreased try with the lowest infant mortality rates, has the
significantly across OECD countries in spite of the highest rate of increase in low birth weight and in
advances in technology, clinical and social welfare 2004 had the highest absolute rate (9.5%) (OECD
interventions over the past three decades (US Depart- 2006).
ment of Health and Human Services 2006). In eight The above findings suggest a need for research to
countries (Australia, Canada, Denmark, Finland, determine (a) why, despite the clinical and social
New Zealand, Norway, Sweden, and the United interventions of the past 30 years, low birth weight
Kingdom), low birth weight rates have remained flat rates have not been reduced in any OECD nation,
or increased very slightly from 1970 to 2002 (Fig. 4.4) (b) whether the data are real or are an offsetting
(OECD 2006). combination of a decrease in real mortality and an
Fig. 4.4 Low birth weight,

OECD, 1970–2003. Source:
OECD (2006)
Fig. 4.5 Increasing rates of

low birth weight, selected
OECD countries. Source:
OECD (2006)
improvement in more complete and better defined what should be the standard content of prenatal
data collection and reporting, and (c) whether the care testing and advice and how can quality be
data represent the role of a mix of as yet unidentified monitored; (iv) which countries have national clin-
social influences. ical guidelines and what are they? The approaches
taken by many OECD countries are discussed
below.
Delivery of MCH Services (i) Who should deliver prenatal care: Before describ-
ing some of the contrasting processes of prenatal
Provision of prenatal care services: There are four care utilized in individual OECD nations, it is
fundamental issues relating to the provision of evi- useful to have an overall sense of the relative
dence-based prenatal care (also known in some numbers of healthcare professionals in each
countries as antenatal care). These are as follows: country. As shown in Table 4.5, midwives play
(i) who should deliver it to the patient – general a major role in Belgium, Finland, New Zealand,
practitioner physicians, specialist obstetricians, Norway, Sweden, and the United Kingdom.
nurse midwives, or a team of caregivers including The lowest numbers of midwives are in the
both physicians and midwives; (ii) is there an United States (only 5,000 in the country as a
accepted standard number of prenatal care visits a whole), followed by Portugal, Germany, the
woman with a normal pregnancy should attend; (iii) Netherlands, and Spain.
(ii) Standard number of prenatal care visits: In the fibronectin, and only three recommended placental
1990s, the WHO published a general guideline for hormones or hemoglobinopathies. Nations with
prenatal care and updated it in 2003 (OECD lower national incomes tend to recommend more
2006). The WHO guideline recommends 12–16 tests than those with higher national incomes
prenatal care visits, which seems to have become (OECD 2006).
the standard in a number of countries. However in
the United Kingdom, the National Institute for
Health and Clinical Excellence (NICE), an inde-
pendent organization responsible within the
Variations in National Approaches
National Health Service for providing evidence- to Antenatal Care
based guidance, recommends 10 prenatal care vis-
its for uncomplicated, first pregnancies and seven It should be noted that in the future within Europe,
visits for second and subsequent pregnancies. greater standardization is likely to take place as a
(iii) Content of prenatal care visits: As described result of increasingly open borders and the overall
below, some countries are very specific about European Union’s basic aim of free movement of
recommended prenatal care content. Bernloehr persons, capital, and goods, and services between
and colleagues (2007) concluded that countries. Nine countries no longer require passports
to be shown for passage between them of residents of
. . . there are sufficient differences in national guidelines
to produce gaps or an unnecessary, expensive and possi- each country; inter-nation employment is encour-
bly harmful multiplication of tests for pregnant women. aged; and freedoms for patients of country X to
obtain medical care from a physician or hospital in
Thirty-seven tests were reported by 25 nations,
country Y are growing (Bernloehr et al. 2007). In the
and of these, 23 are recommended by more than 12
following pages, comparisons of national practices
countries (Table 4.8). are described for six countries (the United Kingdom,
Only three tests were recommended by all 20
Germany, France, Australia, Canada, and Sweden)
nations (maternal BP, blood group, and rhesus fac-
that have different structures and different attitudes
tor). Only one country recommended routine fetal toward the dissemination of national guidelines.
Table 4.8 Most frequently mentioned tests (23 tests men-
tioned by at least 50% of countries)
Physical Technical Laboratory
Blood pressure Fetal heart Alpha-fetoprotein The United Kingdom
auscultation (triple)
Body mass Abdominal Red cell antibodies
index ultrasound
The philosophy that health care is a right of all
Fetal position Transvaginal Blood group citizens is fundamental and the British National
ultrasound Health Service (NHS), formed in 1948, covers all
Formal risk Gestational legal residents. Care costs are paid from general
scoring diabetes taxes and cover a wide range of medical, ophthal-
Fundal height Hemoglobin
mic, dental, psychiatric, long-term, and other ser-
Maternal Hepatitis B
height vices. Independent contractor general practitioners
Maternal HIV serve as gatekeepers and are paid a capitation fee for
weight each patient on their ‘‘list’’ plus additional fees for
Vaginal Lues preventive or other activities that are deemed bene-
examination
ficial. Patients choose their own physician and list
Rhesus factor
sizes are limited to 2–2,500 patients except in unu-
Rubella titer
Bacteria in urine sual circumstances. Evidence-based guidelines exist
Glucose in urine for a wide range of clinical conditions and the one for
Protein in urine management of pregnancy is described below. Hos-
Source: OECD (2006) pitals, owned by National Trusts, are controlled by
the central government via strictly enforced regional National Institute for Health and Clinical Excellence
authority and individual hospital global budgets. (NICE) published, in October 2003, a very detailed
Hospital physicians and specialists are salaried – as guideline entitled ‘‘Antenatal Care: routine care for
they are in most of Europe. Central purchasing of the healthy pregnancy woman’’ which has been
drugs, supplies, and equipment ensures the bargain- updated in 2008 (National Collaborating Centre for
ing power of the entire country and prices for the Women’s and Children’s Health 2008). Like many
same item are, for example, lower than in the United OECD nations over the past decade, this guideline
States. Total healthcare system costs per capita are emphasized a focus on ‘‘Woman Centered Care.’’
less than half of those in the United States and British NICE guidelines stress the need to inform and sup-
outcomes are somewhat better. Approximately 10– port pregnant women, explain their choices (includ-
15% of residents are privately insured. Waiting list ing termination), communicate in written and elec-
problems for elective surgery exist and some hospital tronic forms, set up a schedule of prenatal visits and
facilities are in need of renovation. In the late 1990s procedures, and explain the woman’s right to accept
and early 2000s the English parliament recognized or refuse diagnostic testing or treatment. Parallel evi-
that its cost control measures had been too severe dence-based guidelines for healthcare professionals
and that NHS services were suffering. Hospital and explain the clinical thinking behind these recommen-
clinic building programs were increased and waiting dations. Women in the United Kingdom receive 6–9
times reduced. However, ironically during the period months paid maternity leave and this is soon to be
of discontent, some outcomes improved slightly increased to 1 year.
(early data). This may be similar to a recent report NICE recommends 10 prenatal care visits for
in the United States that shows that as a result of a uncomplicated first pregnancies and seven visits
large, on-going geographical study, the best out- for second and subsequent pregnancies. Screening
comes were not necessarily linked to the areas recommendations and non-recommendations are
where most funds were spent. given in Table 4.9. The specific processes of care
Approximately 10–15% of British citizens are cov- recommended at each visit are described and several
ered by private insurance. One company, BUPA, is a processes carried out in the past are specifically
global health and care organization, with members in discouraged. Screening for Down’s syndrome that
nearly 190 countries worldwide. Nurse midwives play gives a detection rate over 60% and a false-negative
a significant role and several home visits both prior to rate less than 5% (nuchal translucency integrated
and after delivery are a key component of the care with serum tests at 11–20 weeks) is specifically
plan (BUPA 2008). In the United Kingdom, the recommended. An early ultrasound scan is
Table 4.9 Recommended prenatal screenings in the United Kingdom

Recommended Not recommended
Gestational age (ultrasound) Asymptomatic bacterial vaginosis
Anemia (first appointment and 28 weeks) Cytomegalovirus
Proteinuria Hepatitis C
Blood group and red cell alloantibodies Streptococcus group B
Sickle cell and thalassemia Toxoplasmosis
Structural abnormalities Gestational diabetes mellitus
Down’s syndrome Cervical exam to predict preterm birth
Hepatitis B Fetal fibronectin
HIV Transabdominal scan at 36 weeks unless placenta extends over the os
Rubella Fetal movement counting
Syphilis Cardiotocography
Pre-eclampsia risk level Routine ultrasound after 24 weeks
Fetal presentation at 36+ weeks Umbilical artery Doppler ultrasound
Symphysis-fundal distance Fetal heart auscultation unless requested by the patient
Source: National Collaborating Centre for Women’s and Children’s Health (2008)
recommended to determine gestational age [as taxes, and social security contributions. It was
opposed to the last menstrual period (LMP)] and ranked number 1 by the 2000 WHO multi-national
to detect multiple pregnancies. Screening for gesta- comparison report (United Nations 2005). France is
tional diabetes is discouraged. one of the only countries where a key part of their
Recommended appointment schedules are as medical payment philosophy is to make the patient
follows: aware of the cost of treatment in a belief that this
will reduce the ‘‘moral hazard’’ problem. This is
Nulliparous women: <12 weeks, 16, 18–20, 25,
accomplished by making the patient directly
28, 31, 34, 36, 38, 40.
responsible for paying the provider bill, and then
Parous women: <12 weeks, 16, 18–20, 28, 34,
having the patient reimbursed, almost in full and
36, 38.
fairly quickly, by the private or government payer.
Any concerns the patient may have about the care
received can be directly addressed to the physician
Germany at this time.
In 1971 a pregnancy management program
change was made at a national level following a
Germany was the first country to introduce universal
cost–benefit analysis that suggested that both
health care in 1883 (Murray 2006; WHO 2004). All
short- and long-term cost savings would be realized
citizens are covered but those with a salary over a
if the incidence of preterm and low birth weight
certain moderate level can opt out and cover them-
births could be reduced. The program involved a
selves – via private insurance. Approximately 5% of
combination of (a) improvements in social welfare,
Germans do that (Murray 2006). Another 5% are
(b) greater involvement of the patient in her own
government employees covered by a separate plan.
care planning, and (c) implementation of a clinical
Employers and employees make equal contributions
protocol for management of high-risk pregnancies
from wages into a ‘‘social insurance fund.’’ The fund
and certain lifestyle changes. Nurse midwives do
is administered by approximately 200 not-for-profit
not play as significant a role in France as in other
‘‘sickness funds’’ (down from 1300 in the 1990s),
countries except for some home visits and commu-
based on region and occupation, that contract with
nity maternity clinics, particularly in economically
physicians and hospitals. The federal government
disadvantaged areas. Whereas the focus of British
pays fees for the unemployed or retired persons and
policy has been on clinical guideline aspects of care
retains oversight control of funds and providers.
specifically during pregnancy, the French approach,
Satisfaction levels are high and waiting lists are
begun in 1971, was an ambitious national scale
among the lowest in Europe. Patients are free to
pregnancy management program focused on redu-
choose general practitioners, specialists, and hospi-
cing social and work-related risk factors.
tals. There are approximately 50% more physicians
The French pregnancy management program
per resident in Germany than in the United States or
concentrated on four coordinated interventions:
the United Kingdom and approximately 50% work
(i) risk scoring, e.g., previous preterm birth or still-
from solo practices. Public health is not an important
birth (internationally, this is one of the few significant
part of German health care.
predictors of a future adverse pregnancy outcome), (ii)
patient education about risk, (iii) reduction of physical
activity and workplace stress, and (iv) self-assessment
France and self-management.
Simultaneously, some changes in the healthcare
The French healthcare system structure has chan- system were made. Since 1945, pregnant women had
ged little over the past two decades because gener- been financially induced to begin prenatal care dur-
ally there is a high degree of public satisfaction ing the first trimester under the care of a general
coupled with the circularity that it is structured to practitioner. However the physicians were less than
be resistant to change. Funding is a combination of enthusiastic to participate and tended to refer
employee and employer payroll taxes, property women to out-patient maternity clinics where they
either were seen by an obstetrician or by a midwife. evidence-based medicine and guidelines is well
The financial incentive to a woman was unaffected accepted. Low infant mortality and low birth weight
by whether she was seen by a physician or a mid- levels have placed Australia in the middle of the
wife. This policy was instituted nationally in 1992 OECD ranking. A study published in 2002 showed
and a 12-year intervention measurement study that major hospitals that delivered more than 200
known as the Haguenau Project was implemented births/year vary as follows in their practices of six
in a fairly self-contained area in northeast France. protocols (Hunt and Lumley 2002):
In reports published in 1985 (Papiernik et al.
1. Number of prenatal care visits: Most hospitals
1985) and 1986 (Papiernik et al. 1986), reductions
(90%) seemed to have based their policies on a
in both preterm birth and low birth weight levels
1929 recommendation from the United King-
were reported over a period of 12 years (1971–1982)
dom. This policy recommended 13 prenatal care
divided into three 4-year periods. In these three
visits (every 4 weeks up to the 28th, every 2 weeks
periods, low birth weight rates decreased from 4.6
from 29 to 36 weeks, every week from 37 to 40).
to 4.0 to 3.8%, and preterm birth levels fell from 5.4
2. Gestational diabetes mellitus screening: Although
to 4.1 to 3.7%. Unfortunately, the OECD database
widely known to be of questionable value, 90%
used extensively in this chapter did not publish pre-
of hospitals still recommended glucose challenge,
term birth rates or show low birth weight levels until
glucose tolerance, HbA1c, and random blood
1982 (5.2%), then 1986 (5.3%), and annually there-
sugar tests.
after. These OECD data show that low birth weight
3. Syphilis screening: Ninety-two percent of hospi-
levels increased from 1988 (5.0%) to 1998 (6.8%).
tals recommended screening at the first visit.
The results for the last period of the Haguenau
4. HIV: Only 55% of hospitals recommended
Study and the OECD figures are not compatible
screening. Half of hospitals screen at-risk
and the reasons for this remain unknown at this
women and half screen all women.
time.
5. Hepatitis C: Fifty percent of hospitals recom-
The French healthcare system is strongly con-
mended screening even though evidence-based
nected with school health programs from age 5,
research questions the value. Two-thirds of
and there is also a very active preschool health
women tested were ‘‘selected’’ as being at risk.
program. For many years, the French have used
The policy for hepatitis B is not known.
an adjunct to their medical records system called
6. Smoking cessation counseling: Ninety percent of
the carnet de sante´ which is an 80 page notebook
hospitals had no written guidelines.
issued at birth in which parents and physicians
make notes on care, immunizations, treatments,
developmental, and clinical observations so that a
child’s entire medical history is immediately avail-
able to the next caregiver. Confidentiality con- Sweden
cerns have made the French slow to introduce
electronic medical records. The carnet de santé Nurse midwives play a significant role via geogra-
is well accepted by both physicians and parents. phically closely spaced community care centers. The
The Japanese and Russian systems have a similar centers were specifically designed to promote team-
parent-held record. work between different types of caregivers. Physi-
cians were required to locate their offices in these
centers. Much attention was devoted to restructur-
ing the entire healthcare system during the 1990s
Australia following serious public and staff discontent with
services, waiting times for surgery, escalating costs,
The Australian prenatal care system is currently dissatisfaction with global budgeting, lack of incen-
undergoing change. Until recently, there have been tives for quality care, and poor morale among rela-
no comprehensive and nationally promoted prena- tively low paid personnel. Note: the discontent took
tal care protocols. However, the concept of place at the same time that outcomes were improving
and Sweden consistently ranks in the top three Canada

nations in indicators such as life expectancy, infant
mortality, and low birth weight. The Swedish The Canadian healthcare system is based on a combi-
healthcare system is based on a fundamental pol- nation of funding by the Federal government and each
icy of decentralization of management and control of the 10 provinces and 4 territories. The provinces and
to 23 counties and 3 large municipalities. Numbers territories have considerable freedom to set their own
of physicians are a little higher than the often- priorities. The Federal Prevention of Low Birth
quoted ideal of 3 physicians per 1,000 citizens Weight in Canada Report (Stewart et al. 1998)
and there are a high proportion of primary care declared that ‘‘the prevention of low birth weight is
physicians. Physicians are well trained, paid by the most important perinatal issue in Canada.’’ Exten-
government, work in community teams, and are sive guidelines are published for both patients and care
willing to share responsibilities with nurses and givers. Most care is initially delivered by a primary care
other caregivers. School-based health services are physician (PCP) who acts as a gatekeeper for specialist
an important component of child care. Hospitals referral. Patients can elect to go directly to a specialist
are well equipped. Because the proportion of resi- of their choice but must pay a small additional charge.
dents aged 65 and above (19%) is high in compar- A central component of the federal guideline is
ison with some other European countries and with extensive patient education in written and electronic
the United States (13%) the average cost per media. Canada began its ‘‘E-health Program’’ in
patient is relatively high. 1997 and now has at its core, a nationally common
Swedish guidelines for prenatal care include a electronic patient medical record (Health Canada-
higher number of tests than the European aver- Santé Canada 1999). Some parts of Canada are
age. In addition, special emphasis is now placed extremely remote and E-health permits patients to
on offering women a choice of extensive genetic contact physicians and other caregivers from any
screening. All pregnant women must be given home PC or hand-held device. For decades, Canada
information on genetic screening and particular has had a stronger sense of the importance of social
care is taken to be sure that women are made determinants and the concept of ‘‘population
aware of their choices. Additional emphasis on health.’’ Extensive guidelines are available for phy-
screening is given to women aged 35 and over, sicians and also for patients. High emphasis is
and to women who have previously given birth to placed on ‘‘the fully informed patient and family.’’
children with some impairment or who are known Health Canada–Santé Canada (HC-SC) boasts sev-
to be carriers of a hereditary disease. Screening eral general guidelines produced as a joint effort
for phenylketonuria (PKU), galactosemia, between the federal government and the Society of
hyperthyroidism, and the adrenogenital syndrome Obstetricians and Gynecologists. In addition they
is recommended. reference 27 specific guidelines on separate topics
Traditionally, for patients of all ages, screening such as morning sickness, breech delivery, SIDS.
has not been emphasized in Sweden. Decisions They refer physicians to the Cochrane Library.
about the health of all members of a family are
based more on family-centered observation aris-
ing from the close relationship between the entire
family and community health centers staff. Swe- Japan
den is a country with very advanced social and
welfare programs – and a high taxation burden to Japan has the highest life expectancy in the world
pay for them. Child poverty has almost been and the lowest infant mortality. Its healthcare sys-
eliminated. Per capita incomes are high and the tem covers everyone, and the very strong philoso-
Gini coefficient indicates low-income inequality – phy that an employer has a responsibility to its
similar to Denmark, Finland, Japan, and employees dominates the type of system. Typically,
Norway. The nations with the highest income a doctor visit requires a 25–30% co-pay (the
inequality are Italy, Mexico, Turkey, and the employer wants the employee to know the value of
United States. the services) and this usually is reimbursed. Many
Japanese hospitals are private but are contracted to numbers are not subject to ridicule when they
employers who negotiate rates. Hospitals can seem do attend school.
to be an odd mix of older buildings and very modern b. Fostering socialization with peers and adults.
equipment. Few ambulatory care physicians have Respect for the rules of society, and the rights
appointment systems (first come, first seen). Until and duties of individuals. Discourage gang
recently there were few pharmacies. Therefore, phy- memberships and initiation ceremonies that
sicians dispensed medications and patients returned are often a child’s introduction to illegal sub-
for refills. The average length of stay in hospitals in stances or crime.
Japan is longer than in Europe and North America c. Early detection, counseling, or treatment of
because often, patients live in small houses in which clinical, social, and behavioral problems that
living rooms become bedrooms at night, making it impair personal learning and development
difficult to accommodate a recuperating patient at and that disrupt the learning opportunities of
home. Paradoxically, Japan, which has the lowest peers and the dedication of teachers.
infant mortality rate among OECD nations (better
than half the US rates), has the highest rate of Several recent reviews have reconsidered how
increase in low birth weight levels. well-child care is delivered (Schor 2004). The ways
in which these goals are implemented vary consid-
erably and three conceptual differences emerge
(Kuo et al. 2006). First, some countries do not for-
Child Care in OECD Countries mally take steps to link the care given to an indivi-
dual child by different providers. Second, some
The available evidence shows that the objectives of countries do foster collaborative teamwork among
child care are fewer than two general headings, each the caregivers. And third, some countries, particu-
with three components that, although perhaps larly in Northern Europe, encourage entire families
worded differently, are common to most OECD to use the same primary care physician or commu-
nations (American Academy of Pediatrics 2000): nity nurse, so that a holistic family picture plays a
role in assessment of a child’s health. Clearly the
1. Clinical health:
development of electronic medical records could
(a) Ensuring adequacy of nutrition, sleep, and have a major impact. The French do not discourage
exercise, in a safe, loving and caring, stress multiple physician care for the same child but back
free, dual parent family, and immediate that up by the individual record called the carnet de
neighborhood environment. sante´ described earlier. Electronic medical record
(b) Immunization and vaccination, recreational systems that are increasingly widely used in some
safety and injury prevention. Early, age- Northern European countries fill the same role. The
appropriate health education about risks of United States lags behind Europe in its use of
alcohol, drugs, sexual behaviors, and contra- patient management computer systems.
ception. Collaboration with law enforcement The following comments illustrate the wide range
to prevent sale and distribution of harmful of approaches adopted within the OECD. Some
substances to minors. countries such as Germany, the Netherlands, and
(c) Early detection and clinical treatment of the United States rely heavily on physicians (general
acute or chronic diagnoses and hearing or practitioners and/or pediatricians) operating from a
eyesight problems. clinical setting to treat the child as an individual.
(d) Milestones against which to continuously Child care in Denmark and Sweden is based on the
measure every child’s physical, clinical, aca- concept of the same physician for the entire family.
demic, behavioral, and social development. These countries feel that the relationship of a child
within the context of the total family is important,
2. Mental, behavioral, and psychosocial health:
while other countries such as Germany and the
a. Special attention to ensure that children who Netherlands do not. Physicians in Sweden tend to
fall behind in learning the basics of letters and be opposed to routine screening and feel that the
same results will be obtained by frequent observa- with peers and with persons outside what might be
tion of the whole family. Swedish physicians must the usual age group for friends. If asked, law enfor-
be located in the same premises as other members of cement and truancy officers can carefully add their
the healthcare team to encourage information shar- comments in a spirit that is more aimed at preven-
ing. Other systems in Europe and Australasia rely on tion than punishment.
treatment by a range of typically well-coordinated
community and school personnel, including
physicians, nurses, and home visitors. Some nations
combine sick child care (referral to hospital in- or Social Determinants of Health
out-patient facilities, psychologist or psychiatrist
care, or specialist pediatricians) with well-child care, Finally, in order to design cost-effective prevention,
some do not. Some are closely linked with schools, early detection, and treatment interventions for any
others are not. Some are based on clinics and others disease, we must first comprehend the deepest and
on numerous, geographically close, shared commu- most fundamental layers of causation. For example,
nity centers. Some report to local or regional autho- race, widely accepted to primarily be a social rather
rities: others to federal management. In Sweden, than a biological construct, and poverty are often
France, and Australia, well-child care, immuniza- blamed. But what layers of causality lie beneath
tions, prevention, and psychosocial counseling is lar- these phenomena? Pregnancy is a healthy condition
gely the responsibility of public health or defined that occasionally results in an adverse outcome. Our
child health nurses. In France, home visits are not understanding of the etiology of adverse pregnancy
unusual and there are close health contacts with outcomes is incomplete and more research into
public pre-schools (beginning when a child reaches causes hidden in our external environments is
age 4). In Sweden, these functions come under much needed. In a 1998 study of low birth weight
county or municipality control. In Canada, Austra- and preterm birth in the United States, Goldenberg
lia, and Denmark control flows from the region. In (1998) made the following statement, which sadly is
the United Kingdom and Spain, control is national as true today as it was then: ‘‘Unfortunately, despite
where there is a federal, single payer, and a powerful the utilization of ever increasing amounts of
drugs/supplies purchasing authority. In the United research and clinical care resources . . . there is very
Kingdom and Holland, patients typically have a little evidence that any intervention or practice has
single, primary care provider, often for life, who had a major impact on prevention of low birth
acts as a gatekeeper making specialist recommenda- weight. Neither medical/obstetric strategies, nor
tions when appropriate. In Germany, patients often behavioral approaches have had a significant
retain the same primary care doctor but chose from impact on the rate of preterm birth.’’
many specialists. German pediatricians typically see Our lack of complete knowledge is illustrated by
children only up to age 6. There are complex arrange- two puzzling situations that raise fundamental
ments for patient and service sharing between hospi- questions for further research. First, in spite of the
tals and ambulatory physicians. All give universal application of advanced technology, improvements
access with no co-pay or cost sharing. in patient care, and increased resources spent on a
We have earlier drawn attention to the extent of wide range of public health and social welfare inter-
use of nurse midwives in Belgium, Finland, ventions over the past three decades, there has been
Norway, Sweden, and the United Kingdom, and no significant reduction in the rates of low birth
for disadvantaged persons in France. The geogra- weight in all of the world’s richest nations. Second,
phical areas served by these community centers are the United States has infant mortality and low birth
often located within walking distance of small con- weight rates that are twice as high among African-
centrations of residents. All caregivers are encour- American women as among Caucasian women, but
aged to share impressions, even though they may with no disparity observed between Caucasian and
not be fully formed, about a child’s health, eye sight, Hispanic women. Black/white disparities in these
hearing, dental needs, physical coordination, play two important outcomes have persisted in the
patterns, and particularly his/her social interaction United States in spite of medical and social efforts
to reduce the gaps. Research into racial and ethnic 2002), the United States (Institute of Medicine
differences in health care in Europe is scarce. 2003), and undoubtedly many more in European
It is widely argued that the causes of health and Asian publications hidden from many of us
and illness among individuals, communities, by language barriers are powerful reminders. We
regions/states, and entire countries go beyond must never forget these factors that are so often
biological and genetic factors and lie in a mix of ignored because they lie outside the daily
(a) working, living, and psychosocial environ- practice of medicine. And we must always dig
ments, (b) personal choices, life styles, and beha- more deeply into the layers of causality until we
viors, (c) family and community support, (d) the find, as Marmot states, the ‘‘causes of the
psychology of inequality, (e) the social philosophy causes’’ (Marmot 2007). Finally, we should
of government, and (f) each nation’s healthcare heed Strobino et al.’s (1995) admonition that
system. In her paper on the complex web of ‘‘Public policy is frequently based on simplistic
causation, Krieger (1994) asks the key question solutions to complex problems, often leading to
‘‘Has anyone seen the spider?’’ What is the failure and the belief that these problems are
response to this question within MCH? Is the intractable.’’
response the same in all developed nations? It
may well be that effective strategies for significant
improvements in MCH indicators would benefit
more from attention to the social determinants of Conclusion
health than from any specific clinical services. In
a remarkably prescient report to the Canadian Everywhere except in the United States, uni-
Parliament in 1967 (Lalande 1967), the Hon. versal health care (equal access to basic care
Mark Lalande observed ‘‘. . .changes in lifestyles for all citizens and legal residents based solely
or social and physical environments would likely on clinical need and not on ability to pay, and
lead to more improvements in health than would funded by all) is considered to be a fundamen-
be achieved by spending more money on existing tal societal right. This philosophy has a redis-
healthcare delivery systems.’’ tributive cost to some; consequently, taxation
The impact on health of a broad range of levels in most countries are higher than in the
social, economic, living and working environ- United States. For-profit insurance companies,
ments, and lifestyle choice determinants is consid- so dominant in the US healthcare system, play
erable and has been recognized since ancient a considerably smaller role in the rest of the
Greek, Roman, and Chinese times. The current developed world.
impetus was rekindled in the last quarter of the There is considerable variation among nations in
20th century. McKeown (1979) in ‘‘The Role of the ways that health care is financed and deliv-
Medicine: Dream, Nemesis or Mirage’’ proposed ered. The mechanisms used are of five types:
that social changes, improvements in housing, (a) payment of providers by central or regional
sanitation, nutrition, work conditions, and prac- government out of a general fund from income
tices had greater effect on health status in Europe taxes; (b) payment of providers by central or
since the 1900s than specific medical interven- regional governments out of a fund specifically
tions. Reports to the UK government such as collected for health purposes; (c) payment of pro-
the 1980 Black Report (Black et al. 1980) and viders by independent health funds; (d) direct
the 1998 Acheson Report recognized the impor- payment as premiums to private insurance com-
tance of social determinants and concluded that panies; and (e) direct, out-of-pocket payment of
the traditional assumption that biology and providers by patients for all or part (co-payments)
genetics are the primary cause of disease in of services received. Some countries utilize several
high-income economies is not correct. These of these mechanisms for different sectors of
major contributions all brought the relationship society.
between socioeconomics and health into the poli- No country’s healthcare system is considered by
tical debate. Other reports in Canada (Romanow its residents to be ideal in all respects and most
countries continually strive for improvement. GDP or $5,700 per capita even though it has
Typical, macrolevel concerns are as follows: fewer residents aged over 65 years, offers fewer
(a) increasing annual costs; (b) the cost of new services (doctor visits, bed-days, and prescrip-
technology; (c) the aging population and the tion coverage in 2003), leaves more than 45
corresponding decline in numbers of supporting million without health insurance coverage,
workers. Fertility has declined in many countries and has poorer outcomes. The ‘‘face’’ time
in Europe to at or below replacement rates; between a patient and physician is twice as
(d) immigration and growing problems of social long in Australia and 50% as long in New
inclusion of minorities, many of whom do not Zealand as in the United States.
speak the language of their adopted countries; Total taxation levels as a percentage of GDP
(e) need to be responsive to the increasing expec- are on average 15% higher in Europe than in
tations of patients; (f) uneven access and quality the United States, with Scandinavian countries
of care in different parts of the same country; and Finland being the highest. Generally,
(g) waiting lines for less urgent care; (h) maximiz- higher paid persons bear a proportionately
ing the use of information technology; and higher taxation load in Europe than in the
(i) some countries are concerned that the balance United States and welfare and other national
between specialist and primary care physicians, goals such as higher education are heavily
and between urban and rural providers, is mov- subsidized.
ing in the wrong direction. Hospital physicians are often salaried and global
The highest life expectancy is attained in budgets are widely used in Europe. The personal
Japan, Switzerland, Sweden, Australia, France, cost of medical education and the probability
and Spain. The lowest infant mortality rates of litigation are lower everywhere than in the
are found in Japan, Finland, and Sweden and United States.
the lowest low birth weight rates in Finland, Most European, Canadian, and Australian prac-
Sweden, and Norway. The rate of increase of tices make greater use of computer technology
low birth weight rates in Japan and Spain is such as universally accessible medical records
puzzling. The fact that the United States is an and shared responsibility for care 24 h per day,
outlier, with generally worse outcomes and 7 days per week.
higher costs may not so much be an indict- Some countries have very well-developed evi-
ment of the US healthcare system as it is a dence-based guidelines for prenatal and early
reflection of poverty, social, and behavioral child care, others have not. Realization of the
determinants. importance of behavioral and social determi-
The highest numbers of physicians per thou- nants of health is better developed in some
sand population are in Belgium, Italy, and countries than others. The importance of pre-
Greece, the highest proportions of nurses/ vention and early detection, and the concepts
1,000 are in Ireland, Norway, and Finland, of population health are well established in
and of midwives are in Finland, Norway, Canada, Europe, and Australasia. Countries
New Zealand, Belgium, Sweden, and the differ widely in their use of nurse midwives in
United Kingdom. The highest numbers of community pregnancy management teams. In
acute hospital beds per thousand population some countries, child care is closely integrated
are in Japan, which has longer average length with schools.
of stay (ALOS). Austria and Germany have In the United States there is a twofold gap
the shortest surgery waiting times. between infant mortality and low birth weight
Among countries other than the United States, levels for Caucasian and African-American
there was little difference in percentage of pregnancies.
GDP devoted to health care (9.2%), or the In Eastern Europe and Central Asia, falling out-
national healthcare expenditures per capita comes of care, such as a drop in life expectancy,
($2,650). The United States spent 15.3% of are a cause for concern.
Key Terms
Abortion Gross national product (GNP) Well-child care

Acute bed-days Growth curve Women-centered care
African-Americans Haguenau project World War II
After-hours care Healthcare expenditure Last menstrual period (LMP)
Antenatal care Health insurance Low birth weight
Asia Health system Low-income countries
Average length of stay Healthcare systems Marshall Plan
Behavioral determinants Hemoglobinopathies Maternal mortality
Behavioral health Hepatitis C Medicaid
Capitation fees HIV Medical errors
Caregivers Human Development Index Medicare
Carnet de santé Human Poverty Index Mental health
Caucasians Immunization Middle-income country
Causality Incidence National scoreboard
Child health nurse Income inequality North Atlantic Treaty
Child mortality Inequality Organization (NATO)
Corruption Index Infant mortality Northern European countries
Cost per capita Insurance plan Nulliparous
Development Assistance International Classification of Nurse midwife
Committee (DAC), G8 Diseases (ICD) Occupancy rate
nations Scandinavian countries Out-of-pocket payment
Down’s syndrome School health programs Out-patient maternity clinic
Economically disadvantaged Smoking cessation Parous
areas Social influence Patient satisfaction
E-Health Program Social philosophies Per capita income
Environmental; determinant Social welfare interventions Placental hormones
Evidence-based guidelines South European countries Political systems
Fertility rate Specialist obstetricians Postnatal care
Fetal fibronectin Stillbirth, patient education Pregnancy outcomes
Fetal growth curve Sub-Saharan Africa Prenatal care
Freedom Index Sustainable economic growth Prenatal care visits
Fundamental human rights Syphilis screening Pre-school
General practitioner physicians TRICARE Preterm birth
Gestational age Trimester Private insurance
Gestational diabetes Under-5 mortality Psychological health
Gini coefficient Uninsured Purchasing power parity (PPP)
Globalization The United States of America
GNP per capita Weight for gestational age
Gross national income (GNI)
Questions for Discussion analysis of results from three national surveys. British
Medical Journal 334(7606), 1261–1263
Black D, Morris JN, Townsend P (1980) Inequalities in
1. (a) What is the OECD? (b) How did the OECD health. London, UK: Penguin Books
originate? (c) What was its mission? BUPA (2008) Health insurance tailored for you. London,
2. It is said that healthcare systems in the different England: British Provident Association (BUPA). http://
OECD countries are a reflection of each coun- www.bupa.co.uk/, cited 13 July 2008
Centers for Disease Control and Prevention (2007) News
try’s social, economic, and political philosophies. report shows decline in stillbirths: racial disparities per-
What does this mean? sist. http://www.cdc.gov/media/pressrel/2007/r070221.
3. What are social determinants of health? Using htm?s_cid=mediarel_r070221_x, cited 16 July 2008
specific examples in relation to any OECD coun- Goldenberg R (1998) Low birth weight PORT – Patient Out-
comes Research Team. Low birth weight in minority and
try, explain how social, environmental, eco- high risk women. Agency for Healthcare Policy and
nomic, political, and lifestyle factors influence Research, Washington, DC
any four MCH indicators of your choice. Henshaw SK, Singh S, Haas T (1999) The incidence of abor-
4. Despite the plethora of pre- and postnatal care tion worldwide. International Family Planning Perspec-
tives 25 (suppl), S30–S38
approaches, technological improvements, increased Heritage Foundation (2008) Index of economic freedom.
expenditure and intensity of care over the past three http://www.heritage.org/Index/, cited 14 July 2008
decades, no significant improvements have been Howell EM, Blondel B (1994) International infant mortality
recorded for the proportion of infants born with rates: bias from reporting differences. American Journal
of Public Health 84(5), 850–852
low birth weight in any high-income OECD coun- Hunt JM, Lumley J (2002) Are recommendations about
try. Why is this so? What are the implications of this routine antenatal care in Australia consistent and evi-
phenomenon to low-income countries? dence-based? Medical Journal of Australia 176(6),
5. Define the following terms: 255–259
Institute of Medicine (2003) The future of the public’s health
a. Capitation in the 21st century. Washington, USA: National Acade-
mies Press
b. Gross domestic product (GDP)
Krieger N (1994) Epidemiology and the web of causation:
c. Gross national product (GNP) has anyone seen the spider? Social Science and Medicine
d. Gross national income (GNI) 39(7), 887–903
e. Gini coefficient Kuo AA, Inkelas M, Lotstein et al. (2006) Rethinking well-
child care in the United States: An international compar-
f. Human Development Index (HDI)
ison. Pediatrics 118(4), 1692–1702
g. Human Poverty Index (HPI) Lalande M (1967) A new perspective on the health of Cana-
h. Life expectancy dians. Ottawa, Canada: Health Canada Publications
i. Per capita income Marmot M (2007) Achieving health equity: from root causes
to fair outcomes. Lancet 370(9593), 1153–1163
j. Per capita expenditure
McKeown T (1979) The role of medicine: dream, mirage, or
k. Purchasing power parity (PPP) nemesis? Nuffield Provincial Hospitals Trust, London,
UK
Murray JE (2006) The persistence of the health insurance
dilemma. Social Science History 30(4), 465–477
National Collaborating Centre for Women’s and Chil-
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Chapter 5
Health System Impacts on Maternal and Child Health
Nancy Gerein, Andrew Green, Tolib Mirzoev, and Stephen Pearson
Learning objectives After reading this chapter and home after half an hour. However, the health centre
answering the discussion questions that follow, you had run out of the drugs required to help Margaret,
should be able to who was by now bleeding heavily. Margaret and her
husband traveled to the hospital in the nearest town,
Discuss elements of a health system and identify
where they were asked to find a suitable blood donor.
key differences between a health system and a
This took another hour, by which time Margaret and
healthcare system.
her baby were dead. The cause of death was listed as
Appraise the mechanisms by which the various
obstructed labor and hemorrhage. But was that the
elements of the health system interact to influence
real reason the mother and child died?
access, quality, and use of health services, and
Technical (or medical) knowledge exists to pre-
ultimately the health of mothers and children.
vent the death of Margaret and her child. In fact,
Identify and analyze major challenges for the health
technical knowledge exists to provide health ser-
systems in improving maternal and child health.
vices that could respond to many, if not most, of
Describe the role of the health system in achiev-
the serious health problems affecting mothers and
ing the Millennium Development Goals (MDGs)
children. Often, however, barriers prevent those
related to maternal and child health.
who need these effective health services, like Mar-
garet, from receiving them. The responsibility for
removing these barriers lies with the health system.
Introduction This chapter focuses not on specific aspects of
maternal and child health (MCH) but on the critical
A story: One evening, Margaret went into labor with contribution that the wider healthcare system
her first child at her home, and summoned help from the makes to MCH. It discusses the main elements of
traditional birth attendant in the village. By the next a healthcare system and examines key differences
evening, no progress had been made, and Margaret’s between a health system and a healthcare system.
husband decided to take her to the health centre. He To present the contribution of the health system to
went to his relatives to borrow money and then spent maternal and child health in proper context, the
an hour trying to hire a private car to travel to the chapter uses a conceptual model to characterize
health centre. When Margaret and her husband the different elements of the health system from
arrived at the health centre in the middle of the both the biomedical and holistic perspectives. Com-
night, no doctor was on duty (he was away for train- ponents of the model including the healthcare sys-
ing) but they were able to find the midwife at her tem (health services delivery, resources and support
systems, and governance), community inputs, and
health-related services (e.g., water and sanitation,
N. Gerein (*)
Nuffield Centre for International Health and Development, education and literacy, social services) are deli-
University of Leeds, England neated. The mechanisms by which these various

84 N. Gerein et al.
facets interact to influence access, quality, and use of the major components of a healthcare system,
of health services and ultimately the health of and how the healthcare system should work effec-
mothers and children are analyzed. Major chal- tively to maintain and improve MCH.
lenges for healthcare systems in improving the
health of mothers and children are discussed. The
chapter concludes with a discussion of the role of
the health system in achieving Millennium Devel- Conceptual Framework
opment Goals (MDGs) related to maternal and
child health and an examination of future policy
Fig. 5.1 presents a framework that illustrates the
and practice directions.
relationships between MCH and the components
The healthcare system is the structure which sup-
of the health system. It differentiates between the
ports the provision of necessary health services. It
healthcare system and the wider health system. The
ensures that the right staff and materials are avail-
main differences between these two concepts origi-
able in the appropriate place at the right time to
nate from two broad interpretations of health:
allow utilization of health services by those in need.
When working well, the healthcare system’s pre- A biomedical or clinical interpretation, which
sence is often largely ignored by health profes- refers mostly to physiological processes of an
sionals. However, when the healthcare system fails individual and delivery of health services.
to perform adequately, the consequences for the A wider holistic interpretation, which includes
provision of MCH services can be severe. It is there- social determinants of health such as water sup-
fore important that health professionals are aware ply, education, and social services.
WIDER CONTEXT
Social, Cultural, Economic, Political, Genetic, Others
HEALTH SYSTEM
OTHER HEALTH-
RELATED
SERVICES HEALTH CARE SYSTEM
• Water supply
• Education and
literacy
• Social services HEALTH SERVICE
• Others DELIVERY
• Level
• Type GOVERNANCE
• Relationships
• Location
• Ownership • Policy
MATERNAL • Quality • Planning
• Regulation
AND CHILD
HEALTH
Management
Decentralization
COMMUNITY RESOURCES & SUPPORT
INPUTS SYSTEMS
• Individual • Human resources
• Family • Finance
Fig 5.1 Relationships • Social groups • Infrastructure & transport
between MCH and the • Medical supplies
health system. • Information
Source: Adapted from WHO
(2000)
5 Health System Impacts on Maternal and Child Health 85
According to the World Health Organization (WHO), affect both health and the way the healthcare system
the health system comprises the following: operates. Although these factors may be outside the
direct influence of the health system and wider pub-
. . . all organizations, institutions and resources
. . .whose primary purpose is to improve health lic system, it is essential to recognize and, where
(WHO 2000). possible, to respond to these factors. This chapter
recognizes the importance of the wider health sys-
The health system, therefore, reflects the wider hol- tem, but focuses more on the biomedical interpreta-
istic interpretation of health, which goes beyond the tion of health to describe the impacts of the health-
boundaries of the health sector to include other care system on MCH.
health-related services. Female literacy, for example,
is a critical determinant of MCH, and indeed, of
uptake of health care. While action on such factors
is not usually the direct responsibility of the health Elements of the Healthcare System
sector, health professionals should be aware of these
factors’ importance in affecting the health of their Fig. 5.1 shows three broad components of the
patients and in seeking ways to get appropriate healthcare system: health service delivery (which is
responses from the relevant sectors. deliberately placed in the center of the framework),
The biomedical interpretation of health fits per- governance, resources, and support systems. These
fectly within the boundaries of the healthcare sec- components broadly correspond to the conven-
tor, which is often referred to as the healthcare tional interpretation of the functions of the health-
system or a system for health service delivery. The care system, which are described by the WHO
overarching aim of the healthcare system is to (2000) as follows: delivery of services (health-
improve health. This is done primarily by expand- care system), stewardship (governance), and finan-
ing and improving the delivery of health services. cing and creating resources (resources and support
Community inputs have an important role in systems) (Fig. 5.2).
improving and maintaining maternal and child As shown on the right side of Fig. 5.2, the main
health in many ways – including through the life- objective of the health system is to produce good
styles that individuals adopt, through provision of health. Another objective is to ensure the fair finan-
informal care in the home, and through participa- cial contribution for health. Health services should
tion (either as individuals or as a community) in also be ‘‘responsive’’ to the public’s demands for
decisions about healthcare provision. quality in the non-medical aspects of health care,
Also, MCH exists within a wider context. Social, such as promptness in receiving care, privacy, and
cultural, economic, and political factors inevitably respectful communication. All of the components in
Functions the system performs Objectives of the system
Stewardship
(oversight) Responsiveness
(to people’s non-
medical expectations)
Creating resources Delivering

(investment and services HEALTH
training) (provision)
Fig. 5.2 Relationships Fair (financial)

between the functions and Financing contribution
objectives of a health system. (collecting, pooling
Source: WHO (2000) and purchasing)
86 N. Gerein et al.
Fig. 5.1 and their constituent elements combine in health service delivery at the PHC level includes
complex ways to meet the objectives of the health facility-based out-patient services and outreach
system. The next sections provide a broad overview services performed at the community level. For
of key elements and components from the system MCH, such services should include antenatal
perspective. and postnatal care, family planning services,
child immunizations, treatment of common
childhood illnesses (such as malaria, diarrhea,
and upper respiratory infections), and health
Health Service Delivery education around child care. Some PHC facil-
ities may offer MCH in-patient services includ-
The purpose of the healthcare system is to deliver ing normal deliveries, newborn care, and treat-
health services in the most effective and efficient ment for child malnutrition and severe
way to address priority health needs. As such, the infections. Basic diagnostic facilities such as
delivery of health services should be the centerpiece laboratory facilities for diagnosing anemia and
of the healthcare system. Health service delivery is a malaria should be part of such services. Health
complex issue, requiring consideration of: professionals working at the PHC level have gen-
eral skills (such as community nurses, medical
a) What types of health services are needed and at assistants, or general medical practitioners). In
what level? some health systems, the health centers or health
b) What relationships should exist between health posts which offer PHC also act as a ‘‘gateway’’ to
services? secondary levels of care.
c) Where should health services be provided? Secondary Health Care includes more specialist
d) Who should own the health service institutions? diagnostic facilities and expertise, available on
e) What level of quality should health services an out-patient and in-patient basis. Such facil-
maintain? ities are usually provided at district hospitals
Each question describes a characteristic of health which may have a supervisory and support role
services, which are discussed in the following sec- for PHC services. In addition to the MCH ser-
tions. Remember, however, that these characteris- vices offered at PHC, secondary health facilities
tics are closely related. should offer in-patient services for complicated
deliveries and specialist newborn care.
Tertiary Health Care is the most sophisticated
level of health services where, for example, treat-
Types and Levels of Health Services ment for infertility takes place. Tertiary health-
care facilities are normally located at a regional
Within the healthcare system, a hierarchy of differ- or country level. This is the level where narrow
ent levels of services exists, which is normally specialization takes place, as well as training of
divided into three broad levels: primary, secondary, health professionals. Tertiary health care is the
and tertiary. most resource-intensive level of health services
(both in terms of cost of health services and
Primary Health Care (PHC) comprises a basic human resources).
‘‘package’’ of health services aimed at provision
of essential health services at the community The boundaries between the three levels can be
level. The term PHC is also used to refer to the fuzzy. For example, PHC services may be provided
philosophy that underpinned the Alma Ata from the out-patient department of the district hos-
Declaration of 1978 (WHO/UNICEF 1978) pital. The examples of MCH services given above
which sets out a series of principles for a health can be classified into three types:
system. These principles were equity, community Promotive services include health education on
participation, appropriate technology, health topics to enable people to protect their health,
promotion, and multi-sectoralism. Normally, e.g., practicing safe sex, avoiding smoking,
feeding nutritious weaning foods to infants, and healthcare system, and lost opportunities for main-
screening for diseases such as vitamin A defi- taining and improving health by not adopting a hol-
ciency and cervical cancer. istic interpretation of health.
Preventive services are provided to prevent health Vertical integration is referral between different
problems, e.g., family planning, immunization, levels of health services, e.g., primary to secondary
clean water and sanitation to reduce diarrheal care (Murray and Frenk 2000). A well-functioning
disease, and provision of vitamin and mineral referral system is needed when health services are
supplements. provided at more than one level. Effective referral is
Curative services are provided to treat existing particularly important for emergency health care, as
illness, such as anemia and skin infections. in the care of children with life-threatening malaria,
or for women with obstetric complications (as shown
The PHC level is supposed to take a major role in
in the story of Margaret). A well-functioning referral
providing promotive and preventive services, along
system should include a clear and effective distribu-
with basic curative care. Secondary and tertiary
tion of roles and responsibilities (in this case, types of
levels tend to focus on curative services, but increas-
health services at each level), clear lines of commu-
ingly it is recognized that secondary and tertiary
nication (both between different levels of health ser-
levels should provide promotive and preventive ser-
vices and between patients and healthcare providers),
vices alongside their traditional curative services.
and adequate transportation for moving patients
In many health systems, vertical disease control
between levels. The referral system should also
programs (e.g., voluntary counseling and testing
include feedback systems between the levels to ensure
centers for HIV/AIDS) will operate alongside the
appropriate follow-up care for patients.
primary, secondary, and tertiary levels of service.
Relationships Between Health Services Location of Health Services
How services relate to each other is a critical feature of The geographical location of health services clearly
a health system. An integrated approach, where plan- affects the ease of access for a population, and deci-
ning, financing, and provision of all health services sions should be based on factors including health
occur together, will benefit both patients and staff. needs, population densities, the transportation infra-
Patients need to be able to move easily between types structure, and the relative costs of services.
and levels of services according to their particular Some healthcare systems have norms for the provi-
needs. For example, a pregnant mother might prefer sion of different types of health services, reflected
to receive, in one visit to one facility, a combination of either in terms of time–distance (e.g., 2 h travel)
antenatal care, sexually transmitted infection testing, or physical distance (e.g., 10 km). Historically, health
and immunization for her infant, rather than having services have tended to cluster in urban centers,
to move to another facility or return another day. This leaving rural populations underserved. As urbaniza-
type of referral is called horizontal integration (referral tion becomes a growing phenomenon in populous
at the same level and between different programs). countries such as China, India, and Nigeria, the
Non-integrated services (e.g., a clinic providing only peri-urban dwellers who often live in illegal shanty
HIV/AIDS treatment and care) may result from sepa- areas become the new underserved. One mechanism
rately managed services which give priority to a parti- for providing care to remote or underserved popula-
cular program, with earmarked budgets, clear targets, tions is through outreach services. A common
and independent management structures. Such pro- outreach service involves health staff traveling
grams have advantages of having a clear technical through villages to provide immunization to chil-
focus to improve quality and ensure priority to parti- dren. Outreach has been shown to improve immuni-
cular health problems through earmarked resources. zation coverage, particularly to rural and poor
Disadvantages, however, include a greater manage- populations (Bryce et al. 2003; Azubuike and
ment and administrative burden for the whole Ehiri 1998).
88 N. Gerein et al.
Ownership of Health Service Institutions willingness of the public to use available health
services. Therefore, a vital element of a health
Health care can be provided by either the public or system should focus on assuring that there is
private sector. The relative merits of these two sectors adequate quality. Donabedian’s (1980) structure/
for MCH are subject to great debate. One argument process/outcome model is a conventionally
is that the public sector is more likely to respond to accepted framework for assessing and improving
patient need, whereas the private-for-profit sector’s the quality of health services. According to this
focus on income generation and profits may lead to model
inappropriate services, and a focus on better-off peo-
Structure refers to the professional and organiza-
ple in urban areas. In South Africa, for example,
tional resources associated with the provision of
75% of obstetric specialists work in the private sector
care, such as staff qualifications, and infrastruc-
(in which only 9% of women give birth) resulting in
ture, equipment, and supplies.
poorer quality services in the public sector for the
Process refers to the things that are done to, and
other 91% of women giving birth (Parkhurst et al.
for, patients by practitioners in the course of
2005). An alternative argument is that the private
treatment.
sector has greater flexibility to manage MCH ser-
Outcome refers to the desired results from service
vices and is therefore more responsive and attractive
delivery processes, which may include reductions
to patients.
in morbidity, disability, and improvements in the
These arguments are further complicated first by
quality of life.
the extensive presence of non-governmental organi-
zations (NGOs) who can be described as having Quality assurance systems are an important ele-
motivations similar to the public sector, but with ment in the governance (stewardship) of health sys-
the ability to operate in a private manner. NGOs tems; they provide a systematic way of focusing on
often operate in geographically remote areas and the quality of services and on the structure–process–
work on politically sensitive issues, for example, outcome factors that produce quality. A quality
HIV/AIDS education for commercial sex workers assurance system includes the development of
and drug users. NGOs have also been important objectives for quality, setting, and communicating
advocates for policy change for important issues standards to staff and the public, developing indi-
such as reproductive rights. Second, the public and cators, collecting data to monitor compliance with
private sectors are becoming increasingly ‘‘mixed’’ the standards, and applying solutions to improve
and the boundaries between them are therefore health care. Returning to the debate over public and
blurred. For example, health professionals may private ownership of MCH services, what evidence
work in both public and private services, and ser- is available on the quality of these two sectors?
vices may be contracted to the private sector by the Patients may perceive quality as being high in the
public sector. Indeed, no ‘‘pure’’ public or private private sector, for example, due to the flexibility of
models of healthcare systems exist, and the relative opening hours, short waiting times, and increased
involvement of both sectors is dependent on the personal attention from the healthcare provider.
wider political and economic context. However, some studies have found that the quality
of care from private-for-profit practitioners is tech-
nically worse, with poorer prescribing practices
(over-medication, use of expensive rather than
Quality of Health Services cheaper generic drugs), over-use of diagnostic
tests, and neglect of preventive care. In maternal
Low-quality health services are unlikely to be care, medically unnecessary (but lucrative) cesarean
effective. Services may suffer from a lack of or sections increasingly are common in Latin America
poorly trained and managed staff; from a lack and urban areas of Asia, even though they carry
of appropriate medical supplies or equipment or greater health risks to women and newborns, and
an inadequate physical environment. Perceived may incur catastrophic expenditures for clients
quality of services is a key driver behind the (Ravindran et al. 2005).
Governance The importance of health policy, health planning

and management, and the effects of decentraliza-
Governance (and the related term ‘‘stewardship’’) tion are described below.
emerged in the late 1990s as a key concept for
improving health systems. It refers to how decisions
are made and how the health sector is regulated. Key
questions around governance include the following:
Health Policy, Planning, and
Management
What are the underlying values of the healthcare
system?
Health policy is a statement of intent by the central
Who makes decisions and to whom are the deci-
government as to the development of the health
sion makers accountable?
system. For example, a child health policy could
How transparent and inclusive is the decision-
include the following:
making process?
How effective and efficient are the management Guidance for the planning, implementation,
and planning processes in identifying and monitoring, and evaluation of health services
responding to needs? for children, including goals and targets for chil-
How are different entities (individuals or institu- dren’s health status and services
tions associated with the health system) brought Strategic approaches to achieve these goals and
together? targets
What should the appropriate balance be between The types of services to be provided
regulations in the form of control versus Human and financial resources needed
incentives? Management and coordination of the services
Research and information systems support
One of the key values within the healthcare sys-
needed
tem is equity of access to healthcare services. This is
The roles of the government, private sector, and
particularly important for MCH as mothers and
communities in promoting and protecting child
children are one of the most vulnerable groups of
health
population:
The development of policy can be thought of as a
In Afghanistan, the differences [in the Maternal Mor-
tality Ratio] were. . .striking, with mortality being 418 series of inter-related stages in the form of a cycle or
maternal deaths per 100,000 live births in the capital a spiral (emphasizing an iterative nature). Being
city of Kabul compared with 6,507 maternal deaths closely linked to politics, health policy making
per 100,000 live births in the remote district of Ragh. therefore involves complex power interactions
. . . . In sub-Saharan Africa, the pooled estimate for
urban areas is 447 maternal deaths per 100,000 live between different individuals and groups with dis-
births compared with 640 maternal deaths per 100,000 tinct values, ideologies, agendas, and practices
live births in rural areas. Differences in physical access (Buse et al. 2005). To be meaningful, health policy
to obstetric care are likely to explain at least part of needs to be translated into services through the
this variation. Other mechanisms might be involved,
such as high prevalence of HIV or of unsafe abortion, setting of plans and ultimately, the allocation of
or the poor quality of emergency obstetric care in appropriate resources and budgets.
hospitals (Ronsmans and Graham 2006). Health planning can be defined as follows:
During the 1990s, many countries reformed their . . .a systematic method of trying to attain explicit
health systems with particular emphasis on decen- objectives for the future, through the efficient and
tralization of management and greater roles for the appropriate use of resources, available now and in
the future (Green 2007).
private sector in service provision. This has raised
other governance issues, for example, changing the Health planning includes strategic and opera-
role of national ministries of health from operational planning. Strategic planning, which is often
tional aspects of health services management to a seen as an integral part of health policy making,
more strategic policy making and regulatory role. focuses on the priority direction for the development
90 N. Gerein et al.
of a sector or a program. Operational planning the public sector, it means the passing of these from
focuses more on the shorter term technicalities of central government authorities to such bodies in the
periphery as local government, field administration,
the planning process (such as the construction of subordinate units of government, specialized authori-
new buildings or the provision of staff training pro- ties and semi-autonomous public corporations
grams) and should link into the regular recurrent (Collins 1994).
budget.
Different forms of decentralization have been
Approaches to planning are often described as
tried, with varying implications for health services.
top-down or bottom-up. For top-down, the plan-
Two key forms are as follows:
ning process occurs at the highest level (e.g., central
government) with decisions (plans) being commu- Devolution – the transfer of authority from the
nicated to lower levels. The bottom-up approach center to a multi-functional authority which may
emphasizes the involvement in the planning process, be seen as a separate lower level of government
of actors at the local levels through assessment of with its own legitimacy, authority, and sources of
health needs, identification of priorities and partici- revenue.
pation in decision making. As health policy making Deconcentration – the transfer of resources,
and planning should involve different actors to responsibilities, and authority to a lower level
achieve the desired objectives, a balance between with main line management control being
technical and political dimensions is needed. How maintained.
this balance is achieved is critical to the success of
Decentralization can affect the provision of
the MCH system, and can be aided by ensuring that
MCH services through different elements of the
key stakeholders are consulted and feel ‘‘ownership’’
health system. On the plus side, decentralization
of policy-making and planning processes.
can allow for better planning for local needs and
Health management is concerned with the best
greater financial allocation to these needs, improved
possible use of available resources to achieve health
availability of drugs and transport, more flexible
goals through the implementation of plans (Green
and appropriate deployment of staff, and the gen-
and Collins 2006). Health management can be both
eration of local funds. However, decentralization
general (managing an overall system) or related to
can also produce the opposite of these results,
specific resources used within the health system, in
greater inequity between local districts, a reduction
particular human resources, financial resources,
in the quality of services because of loss of the most
infrastructure, and medical supplies. The decision-
experienced staff and other effects. Decentralization
making processes involved in setting MCH policies
is a continual process, and with effective monitoring
and plans, and managing MCH services often have
and decision-making systems and processes, and
been neglected in healthcare systems. Such neglect
sufficient capacity within the healthcare system,
results in poor policies, strategies, and services.
improvements can be made.
Strengthening decision-making processes requires
Under a decentralized health system, therefore,
the active involvement of relevant actors from the
local health managers could have greater influence
health system, patients, communities, the appropri-
over local health planning. With an effective Health
ate use of evidence, and transparent and effective
Management Information System (HMIS) and evi-
decision-making processes.
dence on the likely effectiveness of different inter-
vention options, spending could be more closely
matched to health needs. Ideally, local health man-
Decentralization
agers could also receive inputs from local commu-
nities to make healthcare delivery more appropriate
Decentralization has become a popular policy in and strengthen community ‘‘ownership’’ of the
many healthcare systems, but with varying results. healthcare system. But could such an approach
Decentralization can be defined as follows: work in practice? The Tanzania Essential Health
A transfer of authority to make decisions, to carry out Interventions Project applied such a package of
management functions and use resources. Focusing on affordable interventions in two districts in Tanzania
in the late 1990s (de Savigny et al. 2004). This was mortality). Progress toward the Millennium Devel-
credited to have resulted in a 40% reduction in child opment Goal (MDG) (United Nations Develop-
mortality over 5 years. This successful intervention ment Programme 2003) to improve maternal health
is now being scaled up to the whole of Tanzania. is monitored by the percentage of women whose
delivery is managed by skilled personnel (midwives
and doctors with appropriate training). For devel-
oping countries, the indicator increased from an
Resources and Support Systems estimated 43% in 1990 to 57% in 2005 (United
Nations 2007).
Resources and support systems are vital in under- As well as being available in sufficient numbers,
pinning the delivery of MCH services. For ‘‘front- human resources require skills, supplies, motivation,
line’’ professionals providing health services, and good management, in order to provide health-
resources and support systems may be taken for improving services. What are the important consid-
granted but is critical to the professionals’ abilities erations in planning and managing health staff?
to work effectively. As described in the next sec- First, as initial training of health professionals takes
tions, crucial resources and support systems for several years, a long time is required to achieve shifts
MCH services include human and financial in professional staffing. Second, as priorities and
resources, infrastructure and transportation, medi- services change, staff should be retrained periodically
cal supplies and information. and equipped for new challenges. Integrated man-
agement of childhood illness (IMCI), for example, is
a promising strategy for delivering essential child
health interventions as discussed in Chapter 27.
Human Resources Consistent and high-quality implementation of
IMCI has been hampered, however, due to very few
The healthcare system is very labor intensive and is health workers being trained in IMCI, lack of IMCI-
dependent on a rich variety of professionals and trained supervisors, and high staff turnover (Bryce
other staff. A shortage of key staff may critically et al. 2003).
compromise the provision of quality MCH services. Third, being human, staff are very different to
Staff shortages may reflect an overall national other ‘‘resources’’. They have personal circum-
shortage or a geographical imbalance. In many stances, needs, and ambitions which have to be
countries, health professionals are concentrated in considered alongside the needs of the healthcare
urban centers and in the private sector. In India, for system. Unlike equipment, for example, staff can-
example, the availability of midwives in rural areas not easily be redeployed elsewhere in the health
was between 6 and 27% of the national norm sector. Furthermore, changes in priorities and
(Koblinsky et al. 2006). Opportunities for MCH health service approaches (for example, allowing
staff to emigrate to work in richer countries are midwives to provide safe abortions, instead of only
increasingly attractive, leading to a current or doctors) may be resisted by professionals, and yet
impending crisis for the health system, especially their agreement is critical to the success of any
in sub-Saharan Africa. High levels of HIV infection change in an MCH program.
among health personnel also contribute, in some The planning and management of human
countries, to loss of health workers. For example, resources may be the most critical responsibility
of all nurses lost from the public sector in Malawi for planners and managers and yet has strangely
and Zambia (two countries with high HIV preva- been neglected by many healthcare systems. Issues
lence rates) in the late 1990s, 40% were due to involved in planning, developing and maintaining
deaths (Schneider et al. 2006). the maternal, newborn, and child health workforce
Staffing is an especially critical issue in maternal are explored in greater detail in Chapter 28.
care. Delivery by a skilled attendant is argued to be The growing crisis in health human resources was
one of the best ways to reduce maternal mortality also the focus of WHO’s (2006) World Health
(and it would also substantially reduce neonatal Report.
92 N. Gerein et al.
Finance reduced their use of MCH services (WHO 2006).

When the South African public health system
Finance is, of course, the underpinning resource for removed fees for services for pregnant women
all health services. All health systems have less and children under 6, service use surged (Gilson
finance than they would like, hence the need for and McIntyre 2005). This surge, however, resulted
clear priority setting. Health systems need to con- in health workers complaining of overwork
sider two broad issues related to health financing – and inadequate supplies and medicines, showing
how finance is raised (resource generation) and how how elements of health systems are related. In
it is allocated. China, diminished financial support from the gov-
There are five broad approaches to generating ernment encouraged professionals to earn more
resources (Green 2007): income through curative medicine, over-use of
diagnostic tests and technology (e.g., cesarean sec-
(a) User fees collect a payment from the patient at
tions), and selling of medicines (Ravindran et al.
the point of service delivery. Different types of
2005).
user fees are possible: the main types being per
In theory, the social insurance approach to gen-
case treated/ diagnosis; per duration (e.g., per
erating revenue encompasses the principles of
bed-day); and per type of services (e.g., per con-
equity (richer groups of the population pay
sultation/prescription).
more, thus covering some costs for the poorer
(b) Private insurance is a complement to user fees
groups). In practice, however, social insurance
and provides a mechanism for pooling risk
schemes involve a substantial management bur-
among a group. A fixed sum is prepaid to a
den. A scheme needs a critical mass of employed
private insurance company, which then covers
individuals to be able to generate enough revenue;
all, or part, of any subsequent health costs.
a reliable registration system; and willingness of
(c) Social insurance is a public insurance system
employers to contribute toward the scheme. Com-
with risk pooling similar to private insurance.
munity-based financing is argued to empower
The key difference, however, is that the contri-
local communities to be involved in health-related
butions by the employee and the employer are
decisions. In theory, risks are pooled and every
related to the level of income of the employee.
community member has access to the services
(d) Taxation generates revenue through a govern-
that are financed by the community-generated
ment system of taxes on income, goods, and
funds. In practice, many communities have mar-
businesses. The strength of general taxation is
ginal groups (such as women and children) for
that it is compulsory and is usually not the
whom health-related decisions are made by more
responsibility of the health sector to administer.
‘‘powerful’’ members of the family or community
(e) Community-based financing is increasingly pop-
(such as husbands or elders).
ular and includes several of the above
approaches, but implemented at the community
level. A well-known example is the Bamako
Initiative (Ridde 2003) which involves Revol- Infrastructure and Transportation
ving Drug Funds and is a variation of user
fees with revenue retained at the community
Appropriate physical structures and equipment,
level.
together with a functioning transport system, are
Each approach has its advantages and disad- essential for the provision of high-quality MCH
vantages for MCH. Two important considerations services. It is important to tailor these features to
are how the approach affects equity through the patterns of service delivery (e.g., transportation
affecting the accessibility of services by poorer requirements for facility-based care are different
groups and the risk of services being provided to from those of outreach services) as well as to the
raise income rather than to meet health needs. In health needs of the local population. Transporta-
most countries that have introduced user fees, tion arrangements are particularly important for
the poorest population groups subsequently have emergency health situations such as obstetric health
care. An adequate communication system between Data are lacking in accuracy and reliability,
patients and health facilities and between different which are related to the HMIS’ capacity for
levels of the healthcare system is paramount to data collection and processing.
making the referral system work effectively. Information is not used at the appropriate level
of the healthcare system, which is related to the
system’s organizational structure.
Medical Supplies Feedback mechanisms within and across the
levels of the healthcare system are poor, which
is related to the inter-relationships between the
An adequate supply of appropriate medicines is
different levels.
needed for MCH care systems. Preventive (e.g.,
immunization) and curative (e.g., treatment of How important is it to have a good HMIS, med-
infections with antibiotics) interventions require a ical supplies, and a transportation system? In Arua
reliable supply of in-date and good-quality medi- District in Uganda in the 1990s, cases of childhood
cines. Medical supplies, however, can absorb a size- measles were increasing, despite an existing immu-
able amount of a health service’s operating budget. nization program. District health managers identi-
Good planning and management is therefore criti- fied and prompted improvements in the HMIS and
cal, with health system issues including cold chain (the system for maintaining a tempera-
ture controlled supply of vaccines). As a result, the
(a) The choice of medicines (selection of generic
number of measles cases reduced by three-quarters
versus branded medicines)
(Bryce et al. 2003).
(b) The use of an essential drug list which limits the
use of medicines to an agreed list
(c) The purchase, distribution, and storage of
medicines
Other Health-Related Services
(d) Rational prescribing practices by health providers
Referring back to Fig. 5.1, health-related services

provided in other sectors are equally important for
Information MCH when taking the wider holistic interpretation
of health. This has also been acknowledged in one
How can policy be informed, and resources and of the key international policy statements, the
delivery of health services planned and monitored, MDGs, where health is included in non-health
without relevant and up-to-date information? goals such as those related to poverty eradication
Within the health system, different types of informa- and environmental sustainability (United Nations
tion could be collected, including data on inputs, Development Programme 2003). Examples of
processes, and service delivery, and on the health health-related services include improving the
status of the population. A Health Management socio-economic status of the population (e.g., pov-
Information System (HMIS) is concerned with rou- erty reduction initiatives) and interventions tar-
tine collection, transmission, processing, analysis, geted at a particular group (e.g., female literacy).
and storage of health and health service-related For example, in India, one study showed that
data within the healthcare system. Some programs deaths due to domestic violence were the second
such as maternal health also establish their own ver- largest cause of death in pregnancy (16%), requir-
tical information systems to generate evidence for ing a response from the police and judicial system,
their own planning and decision making. The overall as well as health and social services (Ronsmans and
aim of an HMIS is to generate information to sup- Graham 2006). In child health, diarrhea is a leading
port decision-making processes, including monitor- cause of morbidity and mortality. Safe water sup-
ing and evaluation of health service delivery. This is ply, adequate sanitation, sufficient food supply, and
easier said than done, however. Why do most HMISs personal and household hygienic practices all help
in developing countries under-perform? to prevent childhood diarrhea, yet require work by
94 N. Gerein et al.
many sectors of society outside of the healthcare employment and domestic activities through attend-
system. Effective responses to multi-sectoral issues ing health services, to household decision processes
need to establish and maintain partnerships and wider cultural norms and beliefs about health
between the sectors, each of which has its own prio- and its determinants. In the story at the beginning of
rities and practices. this chapter, for example, why did the husband make
the decision that Margaret should attend the health
center? In most societies, men have greater power
than women in making decisions around family
Community Inputs members’ health behaviors, spending on health
care, and accessing health care. Other factors that
If health systems focus entirely on the provision of can affect a person’s status, power, and access to
services to people, this dangerously ignores the cri- resources within a society include age, social class,
tical roles that these people have in the process of ethnicity, poverty status, and sexuality. Health sys-
promoting and maintaining good health. These tems often are ill-informed about these wider influ-
roles can be seen at several levels (Fig. 5.1). First, ences and yet they can be critical in ensuring that
individual and family behaviors are vital in ensuring MCH services are used in a timely and appropriate
the survival, healthy growth, and development of way by all groups in society.
children, through, for example, decisions to breast- Communities also have the potential (if the pro-
feed babies, sleeping under bed-nets to prevent cess is managed appropriately) to be involved in the
malaria, and drinking safe water. It is estimated planning and delivery of services in response to the
that combining family–community care and out- communities’ own perceived needs. For example,
reach care at 90% coverage could avert 18–37% community members can be involved in local man-
of neonatal deaths in low-income countries agement of staff or facilities or give views on how to
(Darmstadt et al. 2005). Most of these deaths improve the provision of services. The community
would be averted through care such as keeping new- members can also help health staff with immuniza-
borns warm, exclusive breastfeeding, aseptic cord tion days and organizing well-baby clinics, or set up
care, and ‘‘kangaroo mother care’’ (a system of care a system to transport emergency obstetric cases to
for ‘‘particularly premature’’ newborns, focusing on hospital.
skin-to-skin contact, exclusive breastfeeding, and
support for the mother and infant) for low birth
weight infants.
Much health care is provided informally within Conclusion
families through the purchase and administration of
over-the-counter medicines. If the health service The MDGs are important international targets for
recognizes and values this home-based care, real development, particularly for the least developed
opportunities are presented for support and countries of the world. Reaching the MDGs for
improvement, while concurrently ensuring that indi- MCH crucially depends on the performance of
viduals are able to access formal care when neces- health systems. This is especially true of maternal
sary. Up to 80% of deaths of children under 5 are and neonatal health which is particularly affected
estimated to occur at home without contact with by health systems’ attributes of access, quality, and
health providers (Olumole et al. 2000), underscoring responsiveness of care, and high utilization of key
the importance of family and community care, as services such as antenatal care, routine and emer-
well as strengthened linkages between health services gency delivery care, safe abortion care, family plan-
and communities. Second, decisions on using health- ning services, and immunization. The research lit-
care services are made by individuals and families in erature has many examples of disease-specific MCH
the wider social, cultural, and economic contexts interventions with some evidence of effectiveness
(Fig. 5.1). The influences of these contexts vary for small target groups (see Chapter 20 on Evi-
from the availability of cash to pay for health services dence-based MCH). Ensuring that interventions
or transport, the implications of time lost from are sustainable, however, and have equitable public
health benefits beyond a relatively small group, health system are needed so that optimal health
requires working with a robust, cost-effective, and practices become widespread, and services become
responsive health system. available to and used by families. The value placed
For maternal health, encouraging women to on motherhood and child bearing in many cultures
have their babies in facilities rather than at home, means that families can be motivated to ensure that
with the help of teams of skilled midwives and assis- mothers and children do receive high-quality
tants, has been cited as the single largest measure to treatment.
reduce maternal and neonatal mortality (Ronsmans The private sector is very important in providing
and Graham 2006). This goal can conflict with cul- MCH services in some countries – it needs to be
tural norms around birthing in the family home, regulated and supported to ensure that high quality
and would require families to have easy access to is maintained. However, the private sector (both
health services offering (what families perceive as) for-profit and NGOs) is very diverse, dynamic,
high-quality and responsive delivery services. An and not well understood. Understandably, govern-
effective referral system is needed to connect the ments traditionally have focused on the public
different levels of the healthcare system, so that health sector. A clear need exists for research-
emergency obstetric care is available promptly. based evidence on how to develop and sustain part-
New communication technologies and commu- nerships between health and other government sec-
nity-run transport schemes potentially can improve tors, and between the public and private health
the referral system, but the greatest challenge will sectors.
always be the short time available between detecting A major bottleneck in scaling up the availability of
and recognizing symptoms of an obstetric emer- health services, especially for maternity care, is the
gency and receiving appropriate treatment. lack of adequate human resources. Training, deploy-
Child health (especially communicable and para- ing, and retraining skilled health workers, at primary,
sitic diseases, such as diarrhea, malaria, and worms) secondary, and tertiary levels, are key and are dis-
is also affected by elements of the health system such cussed elsewhere in this book (see Chapter 28).
as access, quality, and use of healthcare services. To work effectively, staff need adequate financing,
After the neonatal period, however, other non- medical supplies, equipment, and supportive and
health system factors become more important, and efficient management systems. All of these are critical
child health is reduced by poverty, unclean environ- areas for research aiming to identify and evaluate
ments, poor nutrition, low parental education, dis- locally feasible ways to improve the availability and
empowered mothers, etc. These factors can hinder quality of MCH services. With regard to financing,
appropriate use of curative care. Scaling-up PHC cost-sharing approaches may be necessary to sustain
along with a more multi-sectoral approach to deal and expand MCH programs, but the impacts on
with issues of poverty, environment, nutrition, and equity need to be compared to the resources gener-
education underpins a sustainable improvement in ated. Much more research and experience with insur-
child health. As discussed earlier, however, multi- ance schemes is needed, now that user fees have
sectoral work has its own challenge of involving all demonstrated such clear negative effects on equity
sectors effectively. Also, scaling up of any health of access to MCH services.
intervention is a process with its own challenges. A Monitoring of progress toward the MDGs is
small, focused intervention usually receives lots of faced with several methodological challenges
attention, support, and can more easily identify, including unavailability, unreliability, and inconsis-
involve, and encourage community participation. tency of information from different contexts (Anon-
A few motivated managers and staff can play key ymous 2007). Furthermore, the development of
roles in ensuring the intervention works and is tai- new methods for measuring progress, especially
lored to one, local context. All these enabling fac- in maternal health, is needed. Across all the top-
tors can easily dissipate when the intervention is ics identified for further research, involving policy
scaled up to the regional or national level. makers and health managers in the research
Strategies for the effective involvement of families, process, and ensuring that findings are commu-
communities, and civil society organizations in the nicated effectively, will help to ensure that research
96 N. Gerein et al.
findings are used to inform improvements in MCH evidence to inform the development of policy. How-
services. Researchers often state their desire to see ever, policy making has historically been cited in the
their findings used to improve health services, but domain of central government, and government
the researchers’ working environments and capacity (central and local) and other actors need to develop
in knowledge transfer limit their abilities to make new ways of thinking, capacity, and confidence to
this happen. ensure an inclusive policy-making process.
In order to ensure all of the above, effective and Finally, it is important to note that good health
inclusive decision-making processes for health pol- care for mothers and their children will help to eradi-
icy making and planning are needed. Good govern- cate poverty. Many governments in developing coun-
ance of the health system should bring together tries face great difficulties in investing in the health
professional, community, and management per- sector to provide even the minimum packages of care
spectives to seek solutions to the problems identi- at reasonable standards. Therefore, substantial long-
fied and to develop effective and sustainable MCH term global support from other sources is needed to
policies and plans. Evidence from communities, enable governments in developing countries to
patient groups, and civil society organizations sug- improve the performance of their health systems and
gests they do want to be involved and have valuable make services available to all those in need.
Key Terms
Alma-Ata Declaration Health education Over-medication

Health system Community nurses Generic drugs
Healthcare system Secondary health care Monitoring and evaluation
Biomedical model Tertiary health care Health Information
Holistic model Healthcare financing Management System
Female literacy Horizontal integration (HIMS)
Antenatal care Vertical integration Private-for-profit providers
Postnatal care Earmarked budget Strategic planning
Family planning Immunization coverage Top-down
Child immunization Referral system Bottom-up
Newborn care Emergency health care Community ownership
Voluntary counseling and Obstetric complications Staff shortage
testing Underserved Sub-Saharan Africa
Integrated approach Outreach services Safe abortion
Decentralization Feedback system Children in difficult
Deconcentration Follow-up care circumstances
Devolution Public sector, private sector Bamako Initiative
Recurrent budget Non-governmental Taxation
Skilled attendant organization User fees
Human resources Quality of health service Private insurance
Financial resources Ethnicity Social insurance
Cesarean section Poverty Revolving Drug Fund
Low birth weight Sexuality Community-based financing
Regulation Infrastructure Social class
Social services Social groups
Questions for Discussion Gilson L, McIntyre D (2005) Removing user fees for primary
care in Africa: the need for careful action. British Medical
Journal, 331(7519), 762–765
1. Distinguish between a health system and a Green A (2007) An Introduction to Health Planning for
healthcare system. Developing Health Systems. 3rd Edition, Oxford Univer-
2. Through what mechanisms can a health system sity Press, Oxford
influence maternal and child health status? Green A, Collins C (2006) Management and planning. In:
Merson M, Black R, Mills A (Eds.), International Public
3. How does a holistic model of the health system Health (553–594). Jones and Bartlet, Boston, MA
differ from the medical/clinical model? Koblinsky M, Matthews Z, Hussein J et al. (2006) Going to
4. Distinguish between horizontal and vertical scale with professional skilled care. Maternal Survival
integration. Series 3. Lancet, 368, 1377–1386
Murray C, Frenk J (2000) A framework for assessing the
5. Using one MCH service as an example, e.g., performance of health systems. Bulletin of World Health
infant and child healthcare services, describe Organization, 78(6), 717–731
Donabedian’s Framework for quality of health Olumole D, Mason E, Costello A (2000) Management of
services. childhood illness in Africa. British Medical Journal, 320,
594–595
6. Discuss ‘‘governance’’ in relation to health sys- Parkhurst JO, Penn-Kekana L, Blaauw D et al. (2005) Health
tems management. systems factors influencing maternal health services: a
7. Write short explanatory notes (not more than a four-country comparison. Health Policy, 73(2), 127–138
quarter of a page) to demonstrate your under- Ravindran TKS, Weller S, Moorman J et al. (2005) Public-
private interactions in health. In: Ravindran TKS, de
standing of the meaning of health policy, health Pinho H (Eds.), The Right Reforms? Health Sector
planning, health management, decentralization, Reform and Sexual and Reproductive Health. Women’s
devolution, and deconcentration. Health Project, University of the Witwatersrand, School
8. List four common mechanisms for financing of Public Health, Johannesburg, South Africa
Ridde V (2003) Fees-for-services, cost recovery, and equity in
healthcare systems and discuss the advantages a district of Burkina Faso operating the Bamako Initia-
and disadvantages of each. tive. Bulletin of the World Health Organization, 81(7),
532–538
Ronsmans C, Graham WJ, Lancet Maternal Survival Series
Steering Group (2006) Maternal mortality: who, when,
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20010827_1, cited 13 July 2008
Chapter 6
The Environment and Maternal and Child Health
Mary Ann Pass and Rebecca Pass
Learning Objectives After reading this chapter and built environment, and the degree of development
answering the discussion questions that follow, you lead to profoundly different environmental risks
should be able to across geographic and economic regions of the
world. In the poorest nations, environmental risks
Discuss the characteristics of children that pre-
stem from unclean water, poor sanitation and
dispose them to greater risks of exposure to
human waste disposal, poor hygiene practices,
environmental hazards and to more lasting
water-, soil-, and air-borne diseases, crowded
damage from such exposures.
homes, and smoke from biomass cooking and heat-
Identify and describe differences in environmen-
ing fuels. In developed and developing nations, risks
tal risks and outcomes for children in high- and
include atmospheric pollution from industry and
low-income countries.
power plants, chemical or petroleum pollution of
Appraise the benefits of monitoring environmen-
groundwater, asbestos or lead contamination in
tal health indicator data at the national, regional,
houses, tobacco smoke, and injury from traffic acci-
and global levels.
dents. This chapter will identify key contaminants
Discuss strategies for reducing environmental
and environmental risk factors that impact the
health threats to children at different levels –
health of women, children and adolescents.
home, community, national, and global.
The concept of environmental health in children
encompasses all the external conditions, influ-
ences, and interactions between children and their
environment as well as the effects of these interac-
Introduction
tions on their health. This broad view of environ-
mental health includes the chemical, physical, and
In affluent as well as in deprived populations, the most
biological risks that cause or influence diseases in
compelling socio-medical problems have their origin
in the lasting and often irreversible effects of early women and children. While environmental risk
environmental influences (Rene Dubos et al. 1966). factors vary across regions of the world, children
have characteristics that make them particularly
Our environment is a critical determinant of the
susceptible to environmental hazards in all
health status of individuals and populations.
regions. The scope of environmental health is
Broadly defined, our environment includes both
immense and the field of environmental health
the Earth’s thin layer of land, water, atmosphere
has profound implications for both human health
and the man-made structures or modifications to
and the sustainability of our ecosystem. As J.P.
the natural world in which humans live, work, and
Grant, Executive Director of UNICEF (1992),
play. Differences in environmental resources, the
asserted eloquently at the United Nations (UN)
Conference on Environment and Development,
‘‘We must preserve our planet in order to nurture
M.A. Pass (*) our children; equally, we must nurture our children
University of Alabama at Birmingham, USA if we are to preserve our planet.’’

100 M.A. Pass and R. Pass
In less developed countries, environmental diseases. Children in the poorest regions die
health risks are particularly profound. Social, from the ‘‘usual’’ conditions of childhood, but at
economic, and environmental risks combine to higher rates than seen elsewhere in more devel-
create a triple burden for mothers and children. oped or protected environments.
Poverty, poor nutrition, environmental pres-
sures, and displacement caused by such forces
as climate change or conflict precipitate more
exposure to environmental health threats. These
International Recognition of Children’s
threats also erode household stability and
weaken public health infrastructure, thereby
Environmental Health
exacerbating health outcomes. While health
workers have made dramatic progress in control Increased understanding of the linkages between
of vaccine preventable diseases and diarrhea, diseases in children and their underlying environ-
their work has uncovered the need for even mental risk factors has fostered international recog-
more attention to the control of the underlying nition of children’s environmental health issues over
social and environmental contributors to these the past decades (Box 6.1).
Box 6.1 A Chronology of Children’s Environmental Health
1776 Percival Pott, a London doctor, notes incidence of scrotal cancer in young chimney sweeps, in
what is generally considered to be the first linking of cancer to environmental hazards.
1904 J.L. Gibson of Queensland, Australia is the first to recognize paint as the source of lead
poisoning among children.
1953 Mercury Linked to Nervous System Damage in Developing Fetus. Grain contamination in
Sweden in 1953 demonstrates the devastating effect of high-dose prenatal exposure to mercury and its
derivative methyl mercury to the developing nervous system. Other historic incidents of mercury
poisoning include: contaminated fish in Minimata, Japan in 1958; pollution in Nugota, Japan in
1965; grain contamination in Iraq in 1971; and grain contamination in New Mexico in 1972. These
incidents illustrate the extreme vulnerability and susceptibility of the fetus to mercury.
1970 The enacting of the Clean Air Act in the US eliminates the worst sources of air pollution and
leads to health-based standards. Similar legislation is adopted across the developed world.
1970s Regulations to reduce lead in motor fuel in Europe and the US.
1984 First evidence of long-term effects of low-level lead exposure (Needleman et al. 1984).
1990 US Environmental Protection Agency (EPA) and International Life Sciences Institute (ILSI)
sponsor conference on Similarities and Differences Between Children and Adults: Implications for
risk assessment, one of the first scientific symposia on children’s health issues (ILSI 1992).
1993 National Academy of Sciences (NAS) report highlights the pesticide exposure of infants and
children through food and food consumption (NAS 1993). Report points to large gaps in our
knowledge.
1996 Food Quality Protection Act passed in the US, partly in response to the NAS report. Act
requires that children’s special needs be taken into account in setting pesticide standards.
1997 President Clinton issues Executive Order on Children’s Environmental Health and Safety
(US Environmental Protection Agency 1997a). EPA sets up Office of Children’s Health Protection
(US Environmental Protection Agency 1997b). The G8 issues a Declaration on Children’s Environ-
mental Health (G8-Group 1997).
2000 EPA publishes a strategy for future research and a first set of indicators on children’s
environmental health issues (EPA 2000).
6 The Environment and Maternal and Child Health 101
2002 International Conference on Environmental Threats to the Health of Children, held in

Bangkok; Major reviews of scientific literature published by European Environment Agency
(WHO 2002a,b) and Danish Environmental Protection Agency (2002). Children’s health a key
issue at Johannesburg World Summit (United Nations 2002).
Source: Children’s Environmental Health Network (2008); Sharpe (2002)
In 1989, the UN Convention on the Rights of the conditions. Integral to the MDGs is an understand-
Child declared that children have universal rights to ing that the health of the environment and environ-
safe, healthy, and clean environments that are fun- mental sustainability is intrinsically linked to
damental to their ability to thrive. The International human health. Progress on environmental health is
Network on Children’s Health, Environment and required for attainment of many of the UN Millen-
Safety (INCHES – http://www.inchesnetwork.net/) nium Development Goals, particularly Goal # 1 to
– a global network of people and organizations eradicate extreme poverty and hunger, Goal # 4 to
interested in promoting the protection of children reduce child mortality, and Goal # 6 to combat
from environmental and safety hazards – was estab- HIV/AIDS, malaria, and other diseases. Consider-
lished in 1998 as a coordinating structure for orga- able interaction exists between progress toward
nizations and individuals involved with children’s these MDGs and Goal # 7 to ensure environmental
environmental health. Members include national sustainability, access to safe water, improved sani-
and international professional associations, tation and waste disposal, and reduction in the use
research and policy institutes, advocacy organiza- of solid fuels. In turn, progress toward additional
tions, universities, parents’ and children’s organiza- goals will facilitate progress on environmental
tions, national and intergovernmental agencies, and health, for example, Goal # 2 – targeting universal
individuals (INCHES 2008; Bistrup and van den primary education for both girls and boys is critical
Hazel 2008). The First International Conference for successful health promotion, improved hygiene,
on Children’s Environmental Health held in Bang- and community development. Goal # 3 which tar-
kok in 2002 strongly affirmed ‘‘that all children gets reduction in gender disparities and empower-
should have the right to safe, clean and supportive ment of women will allow women to become
environments that ensure their survival, growth, involved in making healthy choices regarding their
development, healthy life and well-being’’ (Suk environment and that of their children. Their
2002). Delegates at this conference recognized achievement depends on the ability of the MDGs
both the traditional risks from poor housing and to spawn research-based policies that recognize the
insanitary conditions and the ‘‘new’’ environmental unique susceptibility of children to environmental
exposures from chemicals and byproducts of devel- health threats and engender action to improve
opment. They realized that these ‘‘new’’ exposures environmental sustainability.
present increasing risks to children and that these
risks are exacerbated by poverty, poor education,
and malnutrition. The conference recommended
stronger programs for recognition, assessment, The Unique Vulnerability of Children
and understanding of environmental influences on
children’s health. Participants pledged ‘‘to collabo- The statement that ‘‘children are not little adults’’ is
rate in promoting children’s health through protec- the fundamental principle behind the need for more
tion from environmental threats’’ (Suk 2002). attention to, and better understanding of, children’s
Currently, the Millennium Development Goals environmental exposure. Developmentally, physi-
(MDGs) provide the overarching international pol- cally, and behaviorally, children are at higher risk
icy and development framework that addresses the from environmental hazards. Children’s bodies
threats to health from adverse environmental develop rapidly both physically and intellectually.
These spurts may be compromised by undernutri- AIDS, and malaria, perhaps coupled with prema-
tion – a lack of macro- and micro-nutrients often turity or low birth weight, could lead to stunting,
exacerbated by diarrheal diseases – or exposure to poor developmental outcomes, or death. A child’s
harmful substances. Children have higher metabolic distinct developmental stage at the time of expo-
rates; they eat more, drink more, and breathe more sure, along with the intensity of the exposure, and
in relation to their body size, increasing the expo- the toxicity of a substance shape the severity of the
sure to harmful substances when reported as a pro- environmental health impact and may be pivotal to
portion to body mass. In addition, elements char- the outcome of the illness.
acteristic of children’s body composition (the The World Health Organization (WHO) used the
proportion of water, fat, protein, and mineral) Delphi method to quantify global environmental
further intensifies the toxicity of some environmen- risk and published results from a panel of experts
tal hazards on their systems compared with those of in its 2006 report Preventing Disease through
adults. Yet, a child’s immature organs and systems Healthy Environments. The report found that 23%
lack competence to detoxify and excrete potentially of global deaths and 24% of the global burden of
hazardous compounds. Children have smaller air- disease in disability-adjusted life years (DALYs) are
ways, increasing the hazardous effect of agents that attributable to environmental exposures and risks
cause mucosal irritation and airway narrowing. related to climate change (Prüss-Üstün and Corva-
Finally, children’s behaviors and relation to their lán 2006). While experts acknowledge that different
physical surroundings can expose them to greater methods exist for calculating exposure and risks,
transmission risks – from the hand-to-mouth con- they agreed that the risks are highest among chil-
duct of toddlers that carries infections to dust inha- dren 0–14 where the proportion of deaths attributed
lation while crawling and exploring. With neither to modifiable environmental factors reached 36%
the life experience to identify and avoid potential by some estimates. Among children, those under the
risks nor the ability to alter their surroundings, age of 5 years are most vulnerable to environmental
children are vulnerable to danger and dependent conditions. This subgroup of children is estimated
on the knowledge and habits of caregivers and the to bear 40% of global environmental disease risk
customs and beliefs of their family and community although it represents only 10% of the total popula-
(Louis et al. 2006). tion (Prüss-Üstün and Corvalán 2006).
Children not only bear a disproportionate share
of the disease burden from environmental hazards,
but also experience more profound, lasting damage
from environmental exposure. ‘‘Windows of sus-
Environmental Risks – Different Risks,
ceptibility’’ exist during periods of a child’s life, Different Outcomes
when a brief exposure to a toxicant can permanently
alter the structure and function of an organ. Dis- Communities, states, and regions of the world vary
tinct life stages have been defined by dynamic pro- markedly in environmental risks and associated
cesses at the molecular, cellular, organ, system, and health outcomes, creating huge disparities in child
organism level (Louis et al. 2006). Exposures to health. Pneumonia, diarrheal diseases, and malaria,
hazards prenatally can contribute to complications the top three causes of child death worldwide, all
of pregnancy, stillbirth, and birth defects. However, have underlying environmental causes and dispro-
the potential result of an insult prenatally or even in portionately impact children in developing coun-
early childhood may not become apparent until tries. In the cases of diarrheal disease and lower
years later in the course of a child’s development, respiratory infection, the poorest WHO regions
particularly the development of his neurological experience a level of disease attributable to the
system (Landrigan et al. 2004; Louis et al. 2006; environment 120–150 times higher than the weal-
Gauderman et al. 2004). Simultaneous exposures thier regions (Prüss-Üstün and Corvalán 2006). The
to environmental threats may combine to further total number of healthy life years lost per capita as a
exacerbate health outcomes. Co-morbidities, such result of environmental factors was 15 times higher
as upper respiratory tract infections, diarrhea, HIV/ in developing countries than in the more developed
countries (Prüss-Üstün and Corvalán 2006). By con- these household chemicals. Nevertheless some items
trast, studies have found little overall difference commonly found around the house have serious
between developed and developing countries in the toxicity. These items include household cleaners,
fraction of non-communicable disease attributable to solvents, glues, fragrances, cosmetics, certain plas-
the environment (Prüss-Üstün and Corvalán 2006). tics, paints, auto products, and yard and garden
Infants, young children, and their mothers often products. In the United States the National Insti-
share risks because they inhabit the same environ- tute of Health has a web site for consumer informa-
mental spaces for most of the day, particularly in tion on household products, http://householdpro-
resource-poor countries. In most high-income ducts.nlm.nih.gov/index.htm. Unfortunately, even
countries, mothers tend to be separated earlier where risks are known, lack of global product safety
from their children. In these situations, the environ- standards may insufficiently protect households
ments of both mothers and children may be influ- from toxic exposure. Product recalls of items from
enced more by income level, residential location, toys to candles with lead added to candlewicks are
parental education, occupation, and community common. Labels required in developed regions may
exposures to smoke, heavy metal toxins (arsenic, not be present in developing countries, may not be
lead, and mercury), or industrial chemicals. Specific translated into local languages or, because of the
environmental risks to children include household literacy levels in the local population, may not be
and industrial chemicals, air pollution, lack of clean understood (Gordon et al. 2004).
water, and insanitation (Prüss-Üstün et al. 2008). Industrial chemicals also commonly impact chil-
dren’s health. Some fat-soluble chemicals are of
particular concern because they persist in the envir-
onment and accumulate in the food chain through a
Use of Chemicals process called bioaccumulation. These chemicals
are called persistent organic pollutants or POPs.
Industrial and agricultural byproducts of develop- Studies in toxicology, a field of health concerned
ment and increased food production may enable with the effects of chemicals on living organisms,
development but also pose health threats to chil- have linked the fire retardant polybrominated
dren. Agricultural chemicals are the major source diphenyl ethers (PBDEs) to poor health outcomes.
of poisoning among children and highly dangerous Other POP chemicals are industrial byproducts
when used without knowledge of safe handling such as dioxins, furans, and polychlorinated biphe-
practices (Gordon et al. 2004). Children may be nyls (PCBs). Known as endocrine disrupters, PCBs,
exposed to agricultural chemicals directly or plastics and additives to plastic including phtha-
through their parents. Parents may of necessity lates, polyvinyl chloride (PVC), and bisphenyl A
take children with them to work into the fields (BPA) are also of increasing concern because of
where they may be directly exposed to agricultural their potential effects on children’s development
chemicals through work or play. Outside of homes (Rogan and Ragan 2007).
in poorer countries, women carry out a major role in The European Union (EU) currently has the
non-mechanized, subsistence farming. As a result, most stringent chemical regulatory programs.
they have an increased likelihood of physical con- Under the policy, Registration, Evaluation, and
tact with pesticide or chemical effluent. Whether Authorization of Chemicals (REACH), chemical
contaminated from agricultural exposure to pesti- producers have the responsibility for safety testing
cides and herbicides or from mining, smelting, or (Foth and Hayes 2008). Unfortunately, storage and
lead industries, clothing worn by parents poses con- manufacturing of chemicals are increasingly being
tamination risks to children. shifted to the regions of the world that are less likely
In high-income countries, children may not have to develop, implement, and enforce environmental
direct or indirect contact with agricultural chemi- regulation. The Organization for Economic Co-
cals. However, many chemicals are marketed for operation and Development (OECD 2001) esti-
use in the home despite inadequate safety data. mated that by the year 2020, nearly one-third of
Families often have choices regarding their use of the world chemical production will take place in
non-OECD countries and that global output will be childhood to air pollution and widely distributed
85% higher than it was in 1995. In 2006, the Inter- environmental contaminants are increasingly linked
national Conference on Chemical Management to pediatric morbidity from asthma, cancers, obe-
finalized a Strategic Approach to International sity, and earlier age of onset of diabetes, endocrine
Chemicals Management or SAICM and urged and sexual disorders, and neuro-developmental dis-
member states to take action on chemical safety orders such as autism (Woodruff et al. 2004).
and build the capacity for dealing with chemical Inhabitants of large cities throughout the world
incidents. They partnered with OECD to make che- deal with the highest levels of air pollution. An
mical safety information available through the estimated 1.1 billion people worldwide breathe air
OECD’s electronic ‘‘chemportal’’ (http://webne- that is considered unhealthy, and those in develop-
t3.oecd.org/echemportal/). ing countries are exposed to a much greater concen-
tration of small particulates (UNEP 2002). Indus-
try, transportation, and household fuels are major
pollution sources. Burning of trash as a means to
Air Pollution dispose of waste in urban environments in less
developed countries is another significant source
Both indoor and outdoor air pollution cause of air pollution with dioxins, furans, and heavy
respiratory illnesses in children. As many as 60% metals. In high-income countries, pollution from
of acute respiratory infections (ARI) are related to transportation and industry remains a problem.
environmental conditions including air pollution Children riding on school buses are exposed to tox-
(Prüss-Üstün and Corvalán 2006). Indoors, expo- ins and particulate counts 5–10 times higher than
sure to air pollutants can be 60 times greater than levels outside the bus (Behrentz et al. 2005). School
exposure outdoors. In homes in less developed bus diesel exhaust is associated with a host of
countries, poor indoor air quality is among the respiratory problems and is classified as a likely
greatest risks to child health. Biomass fuels or coal carcinogen. Despite clean air regulatory activities
may be the cheapest or only fuels available to in high-income countries, it is estimated that 24%
families. Because women and children spend more of the US children live in counties where one or
time in the home, they are disproportionately more air pollutants exceed standards (EPA 2006).
affected by poor indoor air quality. However, all In Europe, air pollution is second to injury as an
homes using biomass fuels do not have the same environmental burden of disease (Valent et al.
level of particulate matter. Dasgupta et al. (2006) 2004). In both high- and low-income countries,
reported significant variation in the quality of there is consistent association between long-term
indoor air and particulates among households in exposure to smoke and particulate matter and
Bangladesh. Household exposure is strongly poor respiratory health in children. Ironically,
affected by structural arrangements: cooking loca- many of these exposures to unhealthy air derive
tions, construction materials, and ventilation meth- from the rapid expansion of industry and technol-
ods. The poorest, least educated households had ogy that developing regions seek.
twice the pollution levels of relatively high-income
households.
By contrast, regions with reliable electricity, nat-
ural gas, or kerosene have comparatively low levels Lack of Clean Water and Sanitation
of childhood respiratory disease. However, expo-
sure to tobacco smoke in homes is still a significant Diarrheal disease is the second most important
threat. In families where an adult smokes tobacco, cause of child mortality worldwide. Approximately
children are exposed to increased risks for otitis 80–90% of diarrhea cases are related to environ-
media, respiratory infection, worsened asthma, sud- mental conditions, specifically to contaminated
den infant death, fires, burns, childhood behavioral water and food, and to inadequate sanitation.
problems, and impaired physical and intellectual Childhood diarrheal diseases can stem from lack
development (Prüss-Üstün 2006). Exposures in of clean water for drinking, cooking, and
preparation of weaning foods. Sewage runoff, likely follow temperature bands both latitudinally
inadequate wastewater treatment, and inadequate and altitudinally, as conditions conducive to their
sanitation all contaminate water supplies. In transmission spread. Poor regions where people’s
resource-poor countries, mothers who work in sub- livelihoods depend on subsistence farming, particu-
sistence farming have a high likelihood of contact larly in areas of sub-Saharan Africa, are considered
with unclean water in streams and irrigation ditches the most vulnerable to climate change with least
or exposure to animal feces. Women and girls are adaptive capacity (UNEP GEO 2007). Poor chil-
often disproportionately responsible for collecting dren and families may lack access to the resources
clean water. Often traveling long distances, they are necessary to adapt to their environment or to move.
exposed to potential environmental contaminants Those families that do move may face environmen-
and may pay the opportunity cost of attending tal risks associated with large population migra-
school. Lack of education regarding basic hygiene tions. The 0–4 years age group bears the heaviest
and sanitation threatens both mothers and children burden of death from factors related to drought,
in their care. flooding, and changing disease patterns accompa-
Pathogens in water supply include viruses, bac- nying global climate change (Prüss-Üstün and
teria, intestinal parasites, and parasitic protozoan. Corvalán 2006).
While diarrheal diseases claim the largest number of
children’s lives among the water-related environ-
mental health threats, schistosomiasis, dengue
fever [http://www.cdc.gov/ncidod/dvbid/dengue/ Environmental Health Indicators
index.htm#history], malaria, and West Nile Virus
[http://www.cdc.gov/ncidod/dvbid/westnile/] are Environmental health indicators enable health pro-
also serious health hazards. Mostly affecting parts fessionals and policy makers to quantify environ-
of Africa and South America, schistosomiasis is mental health status of the population and gauge
contracted from swimming or bathing in lakes, riv- the impact of environmental risks discussed above.
ers, and ponds contaminated by freshwater snails Indicators are essential to identifying the most cri-
that carry the Schistosoma parasite [http:// tical problems, establishing a baseline by which to
www.dpd.cdc.gov/dpdx/html/schistosomiasis.htm]. measure trends, and assessing the efficacy of inter-
Malaria, dengue fever, and West Nile Virus all ventions. The development, tracking, and monitor-
involve disease cycles dependent on mosquitoes for ing of regional indicators for children’s environ-
transmission. An estimated 90% of malaria cases in mental health also assist in focusing attention on
children occur in sub-Saharan Africa where ineffec- specific regional needs and comparing health status
tive water resource management, irrigation, or sani- across regions.
tation strategies, along with environmental degra- Through conferences, workshops, and publica-
dation that increases runoff and produces standing tions, the WHO (2008) has promoted the develop-
water, amplify the transmission of these vector- ment of region-specific environmental health indi-
borne diseases (UNEP 2002). cators for children (Briggs 2003). Each region is to
Expected to aggravate existing environmental define their critical exposures and to identify their
threats and usher in new environmental health specific needs for the measurement of the environ-
threats, climate change will place further burden of mental conditions that lead to health disparities.
disease on those areas of the world least able to The indicators can be compared and used for track-
adapt to new conditions. Deforestation can cause ing progress in each region. Kyle et al. (2006) sug-
further depletion of water resources, erosion, and gested that indicators include both measures of
flooding due to runoff, as soils are no longer able to environmental contamination, studies of the body
absorb the same amount of rainfall. The expected burden, and the morbidity from specific diseases.
incidences of extreme drought and flooding that Gordon et al. (2004) developed an atlas to display
threaten fragile ecosystems will likely create habitat selected environmental challenges for each region.
suited to the pathogens that cause water-borne dis- The WHO web site for the indicators is given below.
eases. Disease vectors of water-borne diseases will Some examples of regional exposure indicators are
and its effect is limited, and combinations of envir-

Box 6.2 Environmental Health Indicators onmental exposures are particularly difficult to
study. Animal studies are expensive and may not
Sample Environmental Health Exposure be reliable as conditions are difficult to reproduce in
Indicators a laboratory. Children can respond in only so many
– Households without basic services for ways to whatever mix of toxins presented. Effects
water supply, sanitation, and hygiene from co-exposure may be additive or interactive.
– Households using biomass fuels or coal as Community risk assessment must factor in the com-
the main source of heating and cooking plex web of environmental risks, the health threats
– Households in which at least one adult resulting from these risks, and their potential effect
smokes tobacco on a regular basis on children.
– Mean annual exposure of children aged 0–4 Briggs used the multiple exposures multiple
to atmospheric particulate pollution effects (MEME) (Fig. 6.1) model to show that
– Living in proximity to heavily trafficked health effects in children can be traced back to
roads many different environmental exposures and any
– Living in homes with a source of lead one particular environmental risk can often lead
exposure to a wide range of health effects. In this model,
Sample Environmental Health Outcome the relationship between environmental exposure
Indicators and health outcome is rarely based on simple
direct relationships. Instead, complex interrela-
– Mortality rate for children aged 0–4 years tionships between both exposures and health
of age due to acute respiratory illness outcomes are affected by contextual conditions
– Diarrhea mortality rate in children aged 0– such as social, economic, or demographic factors
4 years (Briggs 2003).
Sample Environmental Health Policy Historically, community risk assessment has
Indicators been based on a population-oriented exposure
model. In this model, risk was traced back to an
– Attributable change in the number of identified exposure ‘‘source’’ and quantified based
households lacking basic services on the variables related to that source. For example,
– Attributable change in atmospheric pollu- risk from a smokestack or factory might be based
tant concentrations on its geographical location, toxin produced, release
– Attributable change in numbers of house- rate of toxin, rate of dispersion, and other measures
hold relying on biomass fuels or coal as the that are time and place bound. Children move
main source of heating and cooking. through different communities over their course of
development. More recently, the US EPA devel-
oped a framework to guide risk assessment for chil-
shown in Box 6.2 (http://www.who.int/ceh/indica dren that considers children’s critical developmen-
tors/indicators2003/en/index.html). tal stages and discussed the complexities of the
The goal is to use indicators to craft policy inter- exposure assessment and data collection. A change
ventions to both improve access to basic environ- from prior EPA risk assessment, their so-called
mental health measures and reduce disparities in person-oriented model recognizes the existence of
health, particularly differences seen between urban multiple independent sources, all of which could
and rural health in all countries. Such interventions contribute to total exposure to a chemical or mix-
must start at the community level. In communities, ture of chemicals. Kyle et al. (2006) reviewed these
in contrast to what is seen in a controlled scientific efforts and concluded that the person-oriented
or laboratory setting, complex combinations of exposure for children better characterizes the indi-
exposures are the norm rather than the exception. vidual and life stage of interest along with the
Because biological processes are complex, symp- applicable exposure sources than population-
toms may be variable, knowledge of the exposure oriented exposure assessment.
Fig. 6.1 Multiple exposures Contexts

multiple effects (MEME)
model. Source: Briggs (2003) Social conditions
Economic conditions
Demographic conditions
Exposures Health Outcomes

Distal
Ambient Causes
environment Well-being
Community Morbidity
Home Mortality
Attributable to
Proximal
Preventive Remedial
actions actions
Processes
Prevention – Policy Action an appropriate opportunity to participate in decisions

about a proposed activity that will affect their environ-
ment and/or health; (2) the public’s contribution can
In both high- and low-income countries, environ- influence the regulatory agency’s decision; (3) the con-
mental health policy frameworks must be linked to cerns of all participants involved will be considered in
an assessment of pertinent environmental health the decision making process; and (4) the decision
threats and the social, economic, and political con- makers seek out and facilitate the involvement of
those potentially.
ditions that enable these threats to persist. Children
from the most disadvantaged families are at greatest Environmental injustice recognizes that commu-
risk from environmental hazards; yet, it is precisely nities with the least resources bear the biggest bur-
these families that may be least able to afford safe den of health disparities. Poor families need assis-
environments. Environmental injustice is a term tance in working with local authorities and the
used for targeted placement of environmental risks private sector in order to participate in decision
in resource-poor communities. The US Environ- making and ensure development and implementa-
mental Protection Agency (2005) defines Environ- tion of prevention and intervention programs. Coa-
mental Justice as follows: litions of family, community, government, and aid
groups are crucial to promote adoption of rules,
The fair treatment and meaningful involvement of all
people regardless of race, color, national origin, or minimum safety standards, and policies and prac-
income with respect to the development, implementa- tices that value child health and empower families.
tion, and enforcement of environmental laws, regula-
tions, and policies. Fair treatment means that no group
of people, including a racial, ethnic, or a socioeconomic
group, should bear a disproportionate share of the
negative environmental consequences resulting from At Home
industrial, municipal, and commercial operations or
the execution of federal, state, local, and tribal pro-
grams and policies. Meaningful involvement means A safe environment for children starts at home
that: (1) potentially affected community residents have where they typically spend the bulk of their time.
Basic measures such as improved housing, avoid- promote development of curricula to identify
ance of biomass fuel smoke, breastfeeding, safe region-specific environmental health-related pro-
food and water, oral rehydration, and hand wash- blems and list strategies to involve children in the
ing protect children, enhance health and delay expo- solutions. Schools can also serve as sites for com-
sure to potentially toxic compounds. Access to safe munity education on key issues of community
water is often listed first in importance among envir- development, safe water and sanitation facilities,
onmental indicators for children, particularly dur- waste management, air quality and ventilation,
ing weaning. Promoting breastfeeding practices is safety, vector control, and personal hygiene. Health
crucial for early childhood survival. Extended and development specialists can help communities
breastfeeding delays the risk of disease from to launch focused actions that are key to recogni-
unclean water and offers the infant a critical period tion of problems, development of strategies to
of protection for growth and development. The address specific problems, and implementation of
survival benefit of breastfeeding is most pro- policy and programmatic changes to protect chil-
nounced in poor environments (Ehiri and Prowse dren. The WHO has promoted basic preventive
1999). Education of mothers and families can strategies in their Integrated Management of Child-
improve child health and survival. Educational hood Illness (IMCI), details of which can be found
materials should reflect the practical and cultural in Chapter 27. IMCI includes a community compo-
needs of the community. The incidence of diarrhea nent that focuses on preventive health services and
can be reduced when mothers boil water for drink- community-based strategies that can shift the focus
ing and supplemental food preparation for their toward primary prevention.
babies. In situations where fuel for cooking is in
short supply, households may, in a bid to save
energy, prepare large quantities of food in advance
and then store it until needed (Ehiri et al. 2001). The National Concerns
potential for microbial contamination and growth
of pathogens (and thus diarrhea) increases in the Children’s environmental health cannot be just a
absence of facilities for monitoring food tempera- concern of health agencies. Multi-sectoral involve-
ture and for properly storing leftover foods as is ment is critical for sustainable action to reduce
often the case in many low-income countries. environmental threats to the health of women and
Hand washing is a simple but effective way of block- children. Research studies and best practices need
ing fecal–oral disease transmissions (Ejemot et al. to be made available to policy makers within and
2008; Clasen et al. 2007). Williams et al. (1994) outside of governments. Most important would be
identified time-honored health promotion strategies policies to improve air and water quality, regulate
for families including hygiene in the home, how to and control chemicals, remove lead from gasoline,
build homes and keep them clean, proper ventila- paints, water pipes, and ceramics, and to provide
tion, the water supply, the kitchen, the latrine, and smoke-free environments in all public buildings.
the elimination of stagnant water. Unfortunately, as Non-governmental groups and the media can give
reported by Carpenter et al. (2006), prevention stra- high priority to efforts to safeguard children’s
tegies often take a back seat to more fundamental health, and disseminate information on environ-
issues of safe food. mental health issues and potential solutions.
Policies must also map the environmental health
risks of a particular country or region. In low-
income countries, access to clean water, provision
In the Community of adequate sanitation, and improvement of air
quality are critical. In places without access to
Schools and daycare centers can also provide par- basic health care and sufficient food, these efforts
ents with culturally relevant information about the must be linked with measures to achieve food secur-
special vulnerability of children to environmental ity and further access to primary health care. Con-
threats. The WHO (Pond et al. 2007) guidelines trol of water resources to combat breeding grounds
of vector-borne diseases must also be implemented. Extreme drought may cause resource, food, and
Since a 2002 meeting of the WHO Regional Com- water scarcity, while rise in sea level could cause
mittee for Africa, African countries have been flooding in heavily populated low-lying regions of
developing national strategic plans to address nega- the world. Both of these changes could lead to
tive health outcomes and environmental degrada- intensified conflict over environmental resources
tion, ‘‘inter alia.’’ National Environmental and and population migration, both of which could
Health Action Plans, or NEHAPS, are country- have a serious impact on maternal and child health.
by-country collaborations between governments, In addition, global climate change and natural dis-
NGOs, and technical experts to propose solutions asters can contribute to undernutrition and the
to environmental health problems, as a component spread of infectious disease, and quickly wipe out
of national development agendas. Implementing hard-earned health gains. Deforestation and envir-
interventions in an integrated fashion will assist onmental degradation cause soil erosion, pollute
efforts toward better health care and environmental streams with sediment and debris, reduce biodiver-
sustainability (UNEP 2008). sity, change patterns of vector-borne disease trans-
Access to safe water in high-income countries is mission, and alter host–pathogen interactions. In
complex as public water supplies face costly regula- today’s context of transportation and global trade,
tion and testing requirements. For example, in the infectious diseases can travel quickly from low-
United States under the Safe Drinking Water Act, income countries and impact the health of people
the EPA defines maximum contaminant levels for in high-income countries. There have also been
90 pollutants out of some 700 organic, inorganic, instances of high-income countries dumping toxic
biological, and radiological contaminants detected waste in low-income countries that cause cata-
in public water supplies around the country. Com- strophic health damages to vulnerable populations,
munity water treatment is a multiple-step and costly including women and children. Participation by all
process of physical treatment, including sedimenta- nations is crucial for early warning systems, disease
tion, coagulation, and filtration, and disinfection or surveillance networks, and global problem solving.
chlorination with continuous monitoring of quality. To be successful, action must take place at the com-
Contaminant occurrence in public drinking water munity, national, and international levels and
systems is highly variable depending on water recommendations of scientific research must be
source, surface or ground water, and well depth reflected in political decision making. Increasingly,
(Barnes et al. 2008). In low-income countries, policies of Corporate Social Responsibility call for
where piped water is available, routine testing for polluting parties to manage the impact of their own
water safety is costly and not feasible for many externalities – pollution and potential hazardous
communities where bacterial contamination, byproducts – on communities (BPH 2007).
increased salinity, and products of agricultural run- Table 6.1 describes the sources, exposures, and pub-
off are common. lic health impacts of nine key pollutants.
Global Concerns Priorities for Research
Some environmental threats to human health truly Specific research priorities include the impact of
transcend political boundaries. While some air pol- multiple exposures, the impact of chemicals specifi-
lution concentrates relatively close to the source, cally on children, and the health effects from an
greenhouse gases emitted through polluting activ- ever-increasing number of chemical compounds.
ities affect climate globally. Atmospheric concen- Policy responses to chemical threats in high-income
trations of carbon dioxide from increased energy countries too often are late responses to identified
production and unsustainable global consumption toxicity in children and fragmented across different
are at historically high levels and are considered a countries. Australia was among the first countries
major contributor to global climate change. to ban lead from paint following an epidemic of lead
Table 6.1 Common environmental exposures

Air pollution: Indoor Air pollution: Outdoor Arsenic
Overview: Crowded, poorly built or Overview: Very large urban areas Overview: Some regions have high
poorly ventilated homes increase commonly struggle with poor air concentrations of arsenic in soil,
risk of chronic exposure to smoke quality. Specific chemical mixtures water, and food – particularly
from biomass fuel, tobacco, dust, vary by proximity to industrial seafood. Arsenic can be released by
and animal allergens sources and automobile exhausts, mining and smelting, from
geography, wind patterns, hazardous waste sites, and during
temperature, and time of day volcanic activity
Source: Combustion products contain Source: The US EPA monitors outdoor Source: Drinking water is the most
thousands of health-damaging air for six ‘‘criteria’’ pollutants common source of arsenic risk,
substances and particles. The including ozone (O3), a potent particularly in Asian regions such as
smallest particles are the most irritant present in urban smog, sulfur Bangladesh and China. Tube wells
dangerous because they can carry dioxide (SO2), carbon monoxide bored into naturally occurring ore
other pollutants on their surface (CO), several nitrogen oxides (NOx), such as arsenopyrite lead to
and penetrate to the deepest levels lead, and particulates. In addition, mobilization of arsenic. The WHO
of the lung. The smoke from cured 188 ‘‘air toxic’’ substances are has set a standard for arsenic in
tobacco contains up to 4,000 recognized. This group contains water of less than 10 ppb and
different chemicals, some of which volatile hydrocarbons, heavy metals, recommends that all wells be tested
are carcinogenic. Other noxious solvents, and combustion byproducts for arsenic. In other regions, arsenic
agents such as lead, arsenic, carbon such as dioxin. Exhaust from has been used as a pesticide. Copper
monoxide, cadmium, automobiles or diesel engines is chromium arsenate has been used as
formaldehyde, nitrogen and sulfur major hazards. Fuel vapors contain a wood preservative and in the
oxides, pesticides, nitrosamines, volatile organic compounds (VOCs) industrial production of
hydrocarbons, molds, or cleaning that react with sun to produce ozone. semiconductors and other
fluids can accumulate in indoor air Most cities in the developing world electronic components
lack regulation of outdoor air quality
Exposure: An estimated 50% of the Exposure: Children are exposed to air Exposure: Arsenic is ingested through
world’s population and 70% of pollutants during outdoor play and water, food, or inhaled. Where
population of Africa, south and in transportation. Ambient lead water levels are known to be high,
Southeast Asia uses biomass fuels levels are highest near urban water for drinking can be purified
for cooking and heating. Use of roadways. Toxins in smog can through special filtration systems. A
solid fuels is still prevalent in poorer accumulate in airway secretions and major concern for children is
regions within developed countries become ingested outside play in contaminated soil
Toxicity: Smoke irritates the mucous Toxicity: Outdoor air pollution is a Toxicity: Children are less able than
membranes of the eyes, nose, throat, respiratory system irritant, adults to detoxify arsenic.
and respiratory tract. It contributes increasing risks of asthma, Symptoms differ with acute or
to allergies, asthma, lower respiratory respiratory infection, and certain chronic exposure and impact almost
disease, chronic obstructive cancers. Health impacts from acute every organ. Arsenic is associated
pulmonary disease, and cancers exposures may be reversible, but with hyperpigmentation and sores
extended exposure is associated of the skin, kidney, and liver, and
with long-term reduction in lung respiratory effects, cancers of the
function and increased risk of skin, bladder, liver and lung
chronic obstructive lung disease
Public Health Implications: Even in Public Health Implications: Smog Public Health implications: In addition
developed nations, mean 24-h reduction is a critical priority in all to toxicity listed above, the cancer
concentrations of particulates in countries, rich and poor. Despite risk from arsenic at this level
indoor air may exceed by a factor of regulation in the United States, exceeds 1 in 10,000, leading to calls
2–60 health and safety standards for 58% of children reside in counties for even lower standards.
air pollution levels defined by that exceed limits for ozone. In Developing countries may lack the
OECD nations. Improved stoves, addition, 19% of the US children regulatory structures in place for
chimneys, housing, and education reside in counties that exceed testing and detoxification (Gordon
are beneficial (Gordon et al. 2004) particulate standards (EPA 2005) et al. 2004)
Endocrine disruptors Fluoride Lead
Overview: Endocrine disruptors are a Overview: Fluoride is beneficial for Overview: Lead has many uses and has
diverse group of chemicals that prevention of oral health cavities been recognized as a toxin for
mimic or modify the action of and is added to water supplies in centuries, but only recently has the
endogenous hormones. They are small amounts in the developed special vulnerability of children to

typically slow to degrade in the world. Unfortunately, when the neuro-developmental toxicity at
environment and accumulate in humans are exposed to the element very low doses been accepted
biological tissues. They are toxic to through coal ores or ground water
plants, fish, animals, and humans in excessive amounts, it is toxic
Source: This group of toxins includes Source: Fluoride exists naturally in soil Source: Lead is still used in pipes,
well-known pollutants like DDT, and groundwater in some regions. It batteries, ceramics, and some
dioxins, furans, and PCBs. Other is added to water in small amounts paints. It is still used as an additive
group members include certain to prevent dental disease in some fuels despite being phased
pesticides such as Aldrin, out in the developed countries for
Chlordane, Dieldrin, Endrin, automobiles. It is also found in
Heptachlor, Hexachlorobenzene, some jewelry and toys in excessive
Mirex, and Toxaphene; compounds concentrations
in fire retardants such as
polybrominated diphenyl ethers
(PBDEs) and phthalates which are
used in plastics
Exposure: These compounds are most Exposure: Children can be exposed to Exposure: Children are most often
commonly ingested through fatty excessive amounts of fluoride exposed through inadvertent
food and milk, including breast through drinking water contamination of paint from old
milk. These agents are of special contamination. In China, the houses, food, natural medicines,
concern in developing countries burning of fluoride-rich coal glazed ceramics, battery recycling,
where children can be increases fluoride exposure through lead pipes for water supply and in
simultaneously exposed to both air pollution emissions from smelters. Proximity
pesticides and infectious pathogens to traffic is a risk in areas where
when their immune systems are leaded gas is still used
already compromised by other
factors such as malnutrition
Toxicity: In very small doses disrupters Toxicity: At higher exposures fluoride Toxicity: Acute exposure causes life-
may mimic or block hormones, produces a condition known as threatening encephalitis with
interfere with normal growth and fluorosis. It destroys teeth, irreversible neurological sequelae.
development, cause sterility, lower accumulates in developing bones, Low lead levels can reduce IQ, cause
sperm counts, impair nervous and can lead to crippling skeletal learning disabilities, poor school
system development, lower damage. Fluorosis is endemic in 25 performance and violent behaviors.
intelligence, and contribute to countries. Toxicity is related to Lead use is still prevalent in many
behavioral abnormalities, levels of exposure and nutrition parts of the world
childhood leukemia, lymphoma, status, particularly intakes of
CNS cancers, breast cancer, and calcium, vitamins A and C
compromised immune function
(Rogan and Ragan 2007)
Public Health Implications: Reduction Public Health Implications: There is a Public Health Implications: Reducing
of these chemicals is critical. The need for resources and improved exposure depends primarily on
Stockholm Convention (UNEP technology to monitor fluoride and governmental action restricting lead
2001) seeks the elimination or to remove it from water where levels in gasoline and paint, and vigilance
restriction of production and use of are excessive, and reduce childhood in monitoring of consumer
industrial chemicals, pesticides, and fluoride exposures (Gordon et al. products. The urban poor remain at
unintentionally produced POPs, 2004) greatest risk for exposure (Gordon
such as dioxins and furans et al. 2004)
Mercury Nitrates Pesticides (or agrochemicals)
Overview: Mercury exists in certain Overview: Nitrogen is an atmospheric Overview: Over 900 insecticides,
ores and fossil fuels. Elemental component essential for biological herbicides, fumigants, and
mercury is less toxic than organic processes. It requires ‘‘fixation’’ repellents are in use worldwide.
mercury compounds like methyl before use by plants as ammonium. Important classes include
mercury. Mercury is used in Used globally for improved crop organophosphates, carbamates,
fluorescent lights, thermostats, and yields, nitrogen fertilizer can pyrethrums, glyphosate (Roundup),
thermometers, in science and contaminate water supplies through organochlorines (Lindane), and
chemistry lab equipment and runoff. Sodium nitrite is added to insect repellents N, N-diethyl-3-
electrical systems cured meats as a preservative methylbenzamide (DEET).

Source:Levels of mercury in air, land, Source: Children are exposed to Source: Agriculturally, pesticides are
and water increase with excessive nitrates from food or used to increase crop yields and
industrialization. Contamination drinking water. Infants less than 4 decrease pests. Domestically, they
occurs with mining, smelting, months of age are at particular risk are used in insect control products,
industrial discharges, or waste from nitrates in regions where pet shampoos, lice shampoos, and
incineration. Coal-fired power contaminated water is used to community mosquito abatement
plants are significant sources of prepare formula. Shallow and products. While potentially toxic,
emissions. Mercury is released into poorly constructed wells in rural pesticides are of critical importance
the air, falls to the ground in rain, areas are at great risk of nitrate in control of mosquitoes and other
becomes deposited in rivers, contamination and are unlikely to disease-carrying vectors
lakes, and streams, and then is be adequately monitored
converted to harmful forms by
bacteria
Exposure: The most common exposure Exposure: Nitrate levels in drinking Exposure: Absorption is through the
is from eating contaminated fish. water increase with the increase in skin or through ingestion of
Methyl mercury, the most toxic use of nitrogenous fertilizers, contaminated food. Farm workers
form, accumulates in biological intensive livestock operations that and their families are particularly at
tissues, particularly fish or animals produce large amounts of animal risk. In poor rural populations
at the top of the food chain. waste, substandard human septic where men, women, and children all
Concern exists for island systems, and municipal waste work and live in close proximity to
communities dependent on fish for streams fields and orchards where chemicals
subsistence are applied and stored, safe use
policies may be most needed and
most lacking
Toxicity: Methyl mercury is a potent Toxicity: Nitrates can be converted to Toxicity: Each pesticide class has
neurotoxin that can cause brain nitrites in the intestinal tract. The differing symptoms. Whereas acute
damage and developmental nitrites react with iron to produce a exposure can lead to death or
disorders in fetuses and children. condition in infants called ‘‘blue serious illness, long-term exposure
Childbearing women in the United baby syndrome’’ or increases disorders of development
States are warned against eating methemoglobinemia where the and the reproductive system,
too much of certain types of hemoglobin is incapable of carrying disrupts the immune and endocrine
fish. Chronic exposure oxygen systems, impairs nervous system
to methyl mercury may function, and leads to certain
cause cancer or damage other cancers
organs
Public Health Implications: Some Public Health Implications: Adequate Public Health Implications: Two-thirds
nations have taken steps to regulate monitoring of intensive agricultural of pesticide deaths occur in the
the inadvertent release of mercury production systems, such as feed developing world where excessive
and to reduce the production and lots and chicken and hog farms is exposure is related to inappropriate
uses of mercury (Gordon et al. 2004) needed to ensure better disposal of use, poor environmental
production waste management, and lack of policies
for education and regulation
(Gordon et al. 2004)
poisoning in children in Queensland. Limits on and expressed concern regarding the special vulner-
release of mercury from factories developed in part ability of children to environmental toxins. They
because of the devastating effects of methyl mercury noted that acceptable tolerance levels for pesticides
poisoning in Japan. In their report on pesticides, the were developed based on the residual amounts that
National Research Council in the United States might exist safely in food for general adult
(NRC 1993) identified inadequate safeguards consumption. Prior guidelines did not consider the
against exposure to pesticides in children’s diets particular vulnerabilities of children and their
greater risk of negative health effects. Furthermore, (de Burbure et al. 2006). The bioaccumulation of
tolerances did not address inadvertent exposure persistent pollutants and the impact on children’s
unrelated to food. The NRC report recommen- neurodevelopment are particularly troublesome
ded that a new approach to risk assessment be and only partly understood.
developed for the unique effects of the toxins in Children might be exposed to multiple agents
children. that have a common toxic effect, and estimates of
However, research on the vulnerability of chil- exposure and of risk could be improved by allow-
dren to toxins and risk assessment regarding the ing and accounting for simultaneous exposures.
effects of toxins in children is still insufficient. Likewise information is needed on the differences
While pesticides have received some degree of in acute and chronic effects of specific agents. In
public health attention, other chemicals have 2000, the United States initiated a longitudinal
never been studied for toxicity. In the last cen- study, the National Children’s Study, to deter-
tury’s chemical revolution, over 80,000 chemicals mine the environmental influences on children’s
were produced for various industrial and consu- health and development from birth until age 21.
mer uses. In the report, Toxic Ignorance, Roe et al. Approximately 100,000 children are to be fol-
(1997) identified gaps in the most basic testing lowed with measures of certain biological, chemi-
data available for more than 70% of the top- cal, physical, genetic, social, psychological, cul-
volume commercial use chemicals in the United tural, and geographical factors. There is great
States. Following this report, the US Environmen- hope that this will provide a valuable resource in
tal Protection Agency (EPA) in 1998 identified the field (NRC and IOM 2008).
almost 3,000 high production volume chemicals
(HPV) representing 3% of all industrial chemicals.
Only 7% of the HPV chemicals had a full set of
basic toxicity data, while 43% of HPV chemicals Precautionary Principle
had no test data. EPA developed a voluntary test-
ing program, the results of which have been sum- Advocates for children believe that when the health
marized by Dennison (2007). Despite industry and safety of children is potentially at risk, public
sponsorship of approximately 2000 chemicals, health personnel must take action to investigate, to
many chemicals remain without sponsors and intervene, and to reduce potential risk following the
without adequate testing data. The chemicals precautionary principles approach. This precaution-
without sponsors have been referred to as ary principle requires that scientific uncertainty
‘‘orphans’’ and continue to be produced in high should not postpone preventive measures. Suppor-
volume amounts without complete, publicly avail- ters say a precautionary approach is comparable to
able safety data. New chemicals are added to the the action of John Snow in 1854 who removed the
HPV list every year. Broad Street pump handle in London to slow a
In many instances, the scientific community cholera epidemic, when the exact cause of the out-
lacks tools, resources, and biological markers to break was still being debated. Key components of
clearly define safety for children as a specific the precautionary principle include (i) taking pre-
population subgroup. Despite the attempt of new ventive action in the face of uncertainty, (ii) shifting
models to understand multiple exposures in chil- the burden of proof to the proponents of an activity,
dren, scientific studies on multiple exposures and (iii) exploring a wide range of alternatives to possi-
their impact on children’s environmental health ble harmful actions, and (iv) increasing public par-
remain limited. A study in Eastern Europe fol- ticipation in decision making. Past failures to take
lowed children living near historical non-ferrous adequate action in a timely manner are chronicled
smelters and found evidence of subtle effects on in a report of the European Environmental Agency,
children’s renal and nervous systems from expo- Late Lessons from Early Warnings (Harromoës
sure to a mixture of heavy metals even though et al. 2001). The report documents delays in recog-
there was no clear evidence of a threshold effect nition of health and environmental toxicity from
use of benzene, asbestos, endocrine disruptors such pollution, accidental and deliberate release of
as polychlorinated biphenyls (PCBs), diethylstilbes- industrial waste, petroleum and chemical efflu-
trol (DES), organochlorine compounds, and the ent pollution of water tables are major concerns
impact of halocarbons on the ozone layer. in urban areas. Agricultural chemical pollution
from fertilizer, insecticides, and herbicides
leaching into streams and rivers particularly
affects rural areas. In the poorer countries,
Appraisal of Relevant Themes crowded homes with indoor air polluted by
smoke from biomass cooking and heating
The poorest children aged 0–4 with their com- fuels are difficult to change as improvements
pounded risks from poverty, undernutrition, and in the environment may be limited by socio-
socioeconomic disadvantage are almost always economic and cultural factors.
the group most vulnerable to environmental Children are uniquely vulnerable as a result of
hazard. Improvements in housing for poor their early physical and intellectual develop-
families, basic environmental hygiene measures mental processes and their immature immune
such as safe water, adequate sanitation, and systems. Children are not small adults. As our
safe air are measures to significantly reduce mor- future, they deserve our protection and
bidity and mortality among the most vulnerable. investment.
However, newer risks, such as our lack of under- Community health workers and peer groups can
standing of risk from chemicals and toxins in advise families, neighborhoods, and commu-
our increasingly technological world, threaten nities about hazards to children and work to
all children. Our clinical and public health develop resources, infrastructure, and to pro-
knowledge has lagged far behind the develop- mote policies to protect and to improve condi-
ment, distribution, and regulation of the chemi- tions. Where resources are limited, wise invest-
cals. The long latent period between exposure, ments are most crucial.
intervention, and recognition of a child’s devel- The use of global and regional indicators and
opmental outcome complicates study of the measures such as the MDG’s promotes aware-
effect of environmental hazards on children. ness and allows the monitoring of progress in
Our collective actions toward environmental sus- meeting specific environmental goals to reduce
tainability will determine the survival of all of disparities and provide safer communities for
our children. women and children.
More research is needed to improve our under-
standing of the levels at which environmental
chemicals and toxins interact to impact chil-
Conclusions dren’s growth and development. Safer and sus-
tainable development strategies that acknowl-
Mothers and children living in different edge and address health and developmental
regions, urban or rural, very underdeveloped concerns are critical to our future.
or highly developed communities, are exposed Global health leaders and the international
to vastly different environmental risks. The business communities in nations with weak reg-
environmental risks in the developing regions ulations must recognize the risks posed when
from unclean water, sanitation, and human industries are located close to residential neigh-
waste disposal are well described in the litera- borhoods and emit chemical and radiological
ture (Genser et al. 2008; Ezzati et al. 2005). The pollutants and accept social responsibility.
man-made pollutants and other environmental Environmental pollution is a global issue as it
determinants of health present new challenges. does not recognize geographical, political, or
In high and low-income countries alike, air economic boundaries.
Key Terms
Air pollution Environmental Protection Natural disasters

Arsenic Agency National environment and
Asbestos Environmental resources health plans (NEHAPs)
Asthma Environmental risk factors Neuro-developmental disorders
Autism Environmental pressures Non-communicable diseases
Benzene Environmental sustainability Obesity
Biodiversity Environmental threats Outdoor air pollution
Biphenyl A (BPA) Exposure Paints
Breastfeeding Extreme poverty Persistent organic pollutants
Cancers Fragrances (POPs)
Carbon dioxide Freshwater snails Person-oriented model
Chemical effluent Furans Pesticides
Chemical revolution Glues Phthalates
Climate change Greenhouse gases Plastics
Community risk assessment Groundwater Pneumonia
Contaminants Heavy metals Pollution
Convention on the rights of Herbicides Polybrominated diphenyl
children cooking and heating High-income countries ethers (PBDEs)
fuels High production volume Polychlorinated biphenyls
Corporate social responsibility chemicals (HPV) (PCBs)
Deforestation HIV/AIDS Polyvinyl chloride (PVC)
Deforestations Household cleaners Population-oriented
Dengue fever Hygiene practices exposure
Diabetes Indoor air pollution Precautionary principle
Diarrhea Industrial chemicals Sanitary conditions
Diethylstilbestrol (DES) International Network on Sanitation
Dioxins Children’s Environmental Schistosomiasis
Drought and Safety (INCHES) Sewage
Early warning systems Lead Solvents
Ecosystem Low-income countries Tobacco
Empowerment Lower respiratory tract Toxicant
Endocrine disruptors infection Unclean water
Environmental degradation Malaria Vector-borne diseases
Environmental hazards Mercury Ventilation
Environmental health Millennium Development Water-borne diseases
Environmental health impact Goals West Nile Virus
Environmental influences Multiple exposures multiple
Environmental justice effects (MEME)
Questions for Discussion Clasen T, Roberts I, Rabie T et al. (2007) Interventions to

improve water quality for preventing diarrhea, The
Cochran Collaboration, http://www.cochrane.org/
1. Distinguish between leading environmental health reviews/en/ab004794.html, cited 31 August 2008
risk factors for children in low income countries, Committee on Pesticides in the Diets of Infants and Children
and children in high income countries. (1993) Pesticides in the Diets of Infants and Children,
2. Why are children at greater risk of exposure to National Research Council (NRC). Washington, D.C.:
National Academies Press, http://www.nap.edu/open-
environmental health risks and to more damaging book.php?isbn=0309048753, cited 31 August 2008
effects of environmental hazards than adults? Danish Environmental Protection Agency (2002) Children
3. What are environmental health indicators? and the Unborn Child: Exposure and susceptibility to
Give examples of any five of such indicators. chemical substances – an evaluation, Environmental Pro-
ject 589, Danish Environmental Protection Agency. www.
Of what value are environmental health indi- mst.dk/udgiv/publications/2001/87-7909-574-7/html
cators in ensuring a safe environment for Dasgupta S, Huq M, Khaliquzzaman M et al. (2006) Who
children? suffers from indoor air pollution? Evidence from
4. Define the following terms: Bangladesh. Health Policy and Planning, 21(6), 444–458
de Burbure C, Buchet J, Leroyer A et al. (2006) Renal and
a. Environmental justice. neurologic effects of cadmium, lead, mercury, and arsenic
in children: Evidence of early effects and multiple inter-
b. Precautionary principle.
actions at environmental exposure levels. Environmental
5. What are the implications of environmental Health Perspectives, 114(4), 584–590
Dennison RA (2007) High Hopes, Low Marks: a final report
justice and the precautionary principle for card on the high production volume chemical challenge.
the promotion of children’s environmental New York: Environmental Defense. http://www.edf.org/
health? documents/6653_HighHopesLowMarks.pdf, cited 31
August 2008
Dubos R, Savage D, Schaedler R (1966) Biological Freudian-
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Oxford University Press
Part II
Politics, Power, and Maternal and
Child Health
Chapter 7
Impact of Wars and Conflict on Maternal and Child Health
Emmanuel d’Harcourt and Susan Purdin
Learning Objectives After reading this chapter and diversion of public spending, destruction of infrastruc-
answering the discussion questions that follow, you ture, and loss of qualified personnel. Strategies for
should be able to mitigating the impact of conflict on maternal and
child health are discussed, including how to respond
Analyze the nature of modern conflicts, and
to immediate needs in acute, complex emergencies,
emerging trends.
provision of routine care in non-routine conditions,
Summarize the impact of conflicts on the health and
primary health care, and post-conflict healing and
well-being of women, children, and adolescents.
rebuilding.
Develop a causal model to explain the pathways by
It is impossible to improve global maternal and
which conflicts affect maternal and child health.
child health without addressing the issue of violent
Discuss the relationship between war and
conflict. Modern conflict – including war between
poverty.
states, civil war, and insurgencies – has had a devastat-
Identify and discuss strategies for mitigating the
ing impact on the health of women and children, and is
impact of wars on women, children, and
getting worse. The civilian share of war deaths has
adolescents.
gone from an estimated 53% in World War I and
60% in World War II (Keegan 1999, 1997) to more
than 98% in the 1998–2004 war in the Democratic
Republic of Congo (Coghlan et al. 2006, 2008). Con-
Introduction
flict can cause an immediate and extreme rise in the
crude mortality rate, and in many modern conflicts,
This chapter presents an overview of the nature and
mortality remains elevated for years after the official
emerging trends in modern conflicts. With examples of
end of the war (Coghlan et al. 2006, 2008). Unfortu-
recent and current conflicts around the world, the
nately, most of the civilian victims of modern conflict
chapter examines the impact of conflict on the health
are women and children. In Congo, for example, an
and well-being of women, children, and adolescents,
estimated 45% of all excess deaths during the conflict
including direct trauma, malnutrition, displacement,
period were of children under the age of 5 (Coghlan
rape, increased vulnerability to infectious diseases,
et al. 2006, 2008). Worldwide, war is strongly asso-
and adverse obstetric conditions. The relationship
ciated with poor maternal and child health. Of the 20
between war and poverty is examined. Using a causal
countries with the world’s highest child and maternal
model, the chapter analyzes the pathways by which
mortality, 13 have recently emerged from violent con-
conflict affects maternal and child health, including
flict or are still experiencing conflict (Table 7.1).
food insecurity, economic collapse, decline in habitat,
These countries represent a tiny proportion of the
world’s population, but account for one-fifth of the 10
E. d’Harcourt (*) million preventable child deaths annually (Fig. 7.1).
International Rescue Committee, New York, USA Another 2 million preventable child deaths occur in
122 E. d’Harcourt and S. Purdin
Table 7.1 Countries with the highest child mortality and conflict status
Conflict status Mortality
Country Recent Current Children <5* Maternal**
1 Sierra Leone a 282 2,000
2 Angola a 260 1,700
3 Afghanistan a 257 1,900
4 Niger 256 1,600
5 Liberia a 235 760
6 Somalia a 225 1,100
7 Mali 218 1,200
8 Chad a 208 1,100
9 DR Congo a 205 990
10 Equatorial Guinea 205 880
11 Rwanda a 203 1,400
12 Guinea-Bissau a 200 1,100
13 Côte d’Ivoire a 195 690
14 Nigeria 194 800
15 Central African Republic a 193 1,100
16 Burkina Faso 191 1,000
17 Burundi a 190 1,000
18 Zambia 182 750
19 Ethiopia a 164 850
20 Swaziland 160 370
*Deaths per 1,000 live births;
**Pregnancy-related deaths per 100,000 live births
a
Countries with recent or current conflict are shaded
Source: UNICEF (2006)
increased by 25% during, and in the aftermath of the

Countries with genocide, but 10 years later, it improved back to base-
localized line. In Sierra Leone, there was no recorded spike in
conflict,
Non-conflict 1,956,000 child mortality. However, one of the hallmarks of
countries, maternal and child deaths in conflict-affected coun-
5,699,000
Countries
tries is that they are rarely recorded; over a decade of
affected by civil war, child mortality remained stagnant when
large-scale other equally poor but more peaceful countries, such
war, 2,003,000 as Mali, experienced a continuing improvement in
child survival. Within countries, regions in which con-
Fig. 7.1 Total annual child deaths in conflict and non-conflict
countries. Source: Zwi et al. (2006)
flict is most intense have much higher mortality than
peaceful areas. This was documented most clearly in a
countries such as Nigeria, which have not had war 2004 mortality survey in the Democratic Republic of
recently, but have substantial localized conflicts. The Congo (Coghlan et al. 2006). The Congo survey, con-
impact of war on maternal and child health goes ducted by the International Rescue Committee and
beyond the deaths of women and children. Stunted the Burnett Institute (Coghlan et al. 2006), sampled
growth, chronic infection, and obstetric fistula are just 19,500 households in an effort to understand the
some of the serious but non-fatal consequences of impact of conflict on mortality.
conflict on women and children worldwide (Coghlan The results showed the effect the Congo war had
et al. 2006, 2008). on overall mortality (Fig. 7.3), and specifically on
Conflict can impact maternal and child health to children. Areas with violence had a rate of 6.4 deaths
different degrees (Fig. 7.2). In Rwanda, the impact was per month, per 1,000 under-5 children, as compared
dramatic but relatively short-lived: child mortality to 3.1 in zones in which no violence was reported. This
7 Impact of Wars and Conflict on Maternal and Child Health 123
Fig. 7.2 Child mortality 300

rate, 1960–2002, in three sub-
Saharan African countries
200
100
0
1960 1970 1980 1990 2000
Mali Rwanda Sierra Leone
between, nation states. Many wars today, even if they

are about resources, are cast as identity conflicts, in
which warring factions are divided by personal char-
acteristics such as religion and ethnicity (Smyth 2002).
One dramatic effect of identity conflict is the deliberate
targeting of civilians. Propaganda and other forms of
hate speech fuel ethnic or religious hatred. This hatred,
coupled with the breakdown in social fabric and col-
lective trust, pushes combatants to inflict harm, not on
an opposing army but on a despised people – including
women and children, who form more than half of the
population.
In some cases, such as the genocides in Rwanda
and the former Yugoslavia, children and women were
deliberately targeted so that the hated group could not
reproduce itself. Strategies that were traditionally used
Fig. 7.3 Mortality and conflict in DR Congo. Numbers to attack a military opponent, such as infrastructure
represent crude mortality rates, expressed in deaths per destruction, are now used primarily to hurt civilians.
month per 1,000 people. Numbers in parenthesis represent Combatants inflict physical damage not only on air
confidence intervals. Source: Coghlan et al. (2006)
bases, but on civilian infrastructure such as clinics,
schools, and family homes, with the deliberate intent
survey was not designed to examine the impact of war
of harming a group of people, rather than crippling a
on women specifically, but other reports have docu-
military opponent. In Bosnia, the religion and ethni-
mented widespread violence against women, as well
city of a family could be determined by the distinct
as high rates of fistulas attributed to trauma and to
construction of their home. Opposing forces used this
inadequate obstetric care, in the eastern zones of DR
knowledge to attack ‘‘enemy’’ houses (Purdin 1996).
Congo where fighting had been most intense (USAID
Increasingly, even wars begun by states are becom-
2006).
ing complicated by identity conflicts. In Afghanistan,
the invasion by the Soviet Union eventually evolved
into a civil war between Pashtun- and Farsi-speaking
The Changing Nature of Conflict tribes; in Iraq, the collapse of the regime as a result of
war between nation states, has led to a civil conflict
The nature of conflict in the world has changed sig- based on religious differences.
nificantly since the end of the Cold War. In the past Unfortunately, identity conflicts are challenging
1000 years, nearly all wars were conducted by, and to resolve. Negotiation and compromise are more
difficult when enmity is linked to personal character- Many years of intense identity conflict in Somalia
istics. Furthermore, many such conflicts are led not by have devolved it into a country that is more a collec-
one government but by a variety of groups, which may tion of feudal fiefdoms than a nation state.
fight each other as well as a common enemy. In Bur- Sudan: The Sudanese people endured a long-run-
undi, for example, a peace agreement was delayed by ning civil war between the mostly Muslim north and
several years because, although the war was ostensibly the predominantly Christian south of the country.
between two ethnic groups, each group was divided The war had a religious dimension, but many obser-
into many smaller factions and militias, each with its vers felt the root of the conflict was the systematic
own agenda and geographic base. hostility of a regime that views itself as Arab toward
Other trends have also contributed to making compatriots who saw themselves and were seen as
war more deadly for women and children. The ‘‘black Africans.’’ This explanation has been but-
surge in the global small arms trade has made weap- tressed by the current conflict in Darfur, where the
ons such as semi-automatic rifles much cheaper – in Sudanese government has led a proxy war primarily
some cases as little as $20 a piece – allowing groups targeting civilians who are both Muslim and black
such as ethnic militias to equip combatants in ways African. In both cases, the government, in waging
that, in the past, only states could. A militia member ethnic war against its own citizens, has used local
can now, in minutes, wipe out a family with a ethnic divisions: in South Sudan, the government
machine gun and destroy a clinic with a couple of took advantage of hostility between the Dinka and
grenades. In some areas, such as the Karamoja other southern tribes, and within Dinka sub-tribes;
region in Uganda, the flood of small arms has in Darfur, the government has armed and financed
turned traditional conflict with spears into a much local Janjawid militias against the Fur and other
deadlier operation. tribes.
Another devastating trend has been the recruit- Afghanistan: In the past, the conflict in Afghani-
ment of children for combat and other combat- stan took place in the context of the Cold War
related duties. Children are easier to recruit and between the United States and the Soviet Union,
more expendable if they die; they are easier to then against the surge of Islamic fundamentalism.
train, condition, and more defenseless. Children Today, the conflict in Afghanistan is primarily
are used as combatants, porters, domestic workers, internal, between different warlords that are all
and sexual objects. There has been some outcry, but Afghan and Muslim. Many of the hostilities have
little effective action by the United Nations or by its an ethnic undertone, with loyalty to one or another
member states to stop the practice. The enrollment warlord based on ethnic background.
of children in conflict has many negative conse-
quences for maternal and child health, including
direct harm to the children themselves through
combat injury, sexual assault, psychological Conflict and Maternal and Child Health
trauma, HIV infection, the harm that the children
are forced to inflict on civilians, including their own Understanding the exact mechanism by which con-
communities, high risk of pregnancy for recruited flicts affect maternal and child health is no academic
girls, and high rates of infant mortality for the exercise. It is an essential step for the public health
children they bear. Some examples of recent con- and human rights community as we try to protect
flicts that illustrate this phenomenon are presented women and children affected by conflict and to
hereunder. prevent the conflicts in the first place. There are in
Somalia: In Somalia, the saying goes: ‘‘Myself fact, not one but many links. These are summarized
against my family, my family against other families in Fig. 7.4 and in the following paragraphs.
of my clan, my clan against all other clans, and all Direct injury: First, and most obviously, comba-
the Somalis against the rest of the world.’’ In prac- tants target children and women, killing and injur-
tice, as in many other civil conflicts around the ing them intentionally. Rape in particular has
world, it is the first two or three components of become a systematic weapon of war in places such
this saying which best describe the daily reality. as Congo and the former Yugoslavia. In Rwanda,
Less food
availability Household
Economic
collapse
Poverty
Malnutrition
Flight; decline
in habitat
Armed
Increased exposure to
conflict
disease
Diversion of
public
spending Death and disability
No curative or
of women and
preventive health
Destruction of children
services
infrastructure available
Loss of qualified
personnel
Country Direct
violence
Points of
intervention
Fig. 7.4 A causal model for the impact of conflict on maternal and child health
militias deliberately targeted children, so that ‘‘they agricultural self-sufficiency in the process. In many
don’t grow up to be rebels and fight us.’’ (Human places, such as Congo, combatants – both rebels
Rights Watch 1999a). These direct injuries to and regular army – loot civilian fields and food
women and children, while devastating and by no stores for their own survival. In Sierra Leone, the
means rare, represent a small portion of the burden population reported that during the war, most of
of conflict. Of the millions of deaths for Eastern their rice was harvested and eaten by soldiers
Congo recorded in the International Rescue Com- (Human Rights Watch 1999b). To compound
mittee’s 2004 mortality survey (Coghlan et al. 2006), these problems, relief agencies often cannot deliver
only 1.3% were from direct violence. Over two- food aid to conflict areas. Children and women,
thirds of these victims were men. Adult men were who in many areas already have much higher rates
almost 5 times more likely than women and 16 times of malnutrition prior to conflict, suffer the brunt of
more likely than children to die of direct violence. the added malnutrition and the attendant morbidity
Impaired food availability: War affects food and mortality.
availability in different ways. In agricultural socie- Economic collapse: Even in non-agricultural
ties, insecurity stops farmers from going to their areas, economic activity plummets in times of con-
fields to tend crops. Traders stop bringing necessary flict, leading to a decline in the standard of living.
inputs, such as seeds and tools. Many families move Traders flee, markets close; there is a sudden stop in
closer to population centers for protection (as mili- outside investments. On a national level, govern-
tias maneuver through less populated areas), losing ments in conflict zones often spend less to build
their economies, diverting resources to military pur- spending too little on health services, divert public
poses, a loss made more acute by the accompanying spending away from health to finance weapons and
reduction in international aid. To make matters ammunition. Second, the service infrastructure is
worse, governments often lose their ability to collect destroyed as health centers are razed by bombard-
taxes and other revenue in conflict zones, as in ments or grenades, hospitals are looted or used for
Liberia and Sierra Leone, where the near totality housing by displaced people, and equipment dete-
of the diamond trade went underground during the riorates beyond repair. Third, qualified health
peak war years (United Nations 2001). As with food workers become rare as nurses, doctors, and other
availability, poor economic performance translates agents flee for their lives, migrate to more stable
into impaired maternal and child health status, as areas in which they can provide for their families,
families lose the ability to buy food, live in more or are killed. In Cambodia, for example, educated
precarious and disease-prone environments, and personnel were especially targeted for death and
can no longer afford medical care. imprisonment. Whatever the reason, in areas
Displacement: Displacement is the most immedi- where diarrhea, pneumonia, malaria, and obstetric
ate consequence of conflict for millions of refugees complications kill many women and children even
and internally displaced people and has a dramatic in peacetime, losing access to medical care inevita-
impact on health. Children separated from their bly means that more women and children die. This
parents are much more likely to die. Even when effect is compounded by the concurrent loss of pre-
families can stay together, children and women are ventive health services. In times of conflict, preven-
at high risk as the normal community networks that tive interventions that have saved millions of lives,
provide safety and care are disrupted. Sometimes such as immunizations, vitamin A supplementation,
the passage itself, on foot over long distances, and insecticide-treated bednets, become less avail-
endangers the health of women and children, expos- able, leaving women and particularly children more
ing them to physical exhaustion, extreme tempera- vulnerable.
tures (both heat and cold), disease vectors, and Of the three factors discussed above, economic
malnutrition. In Eastern Congo, many children suf- collapse and the loss of health services are particu-
fered broken bones when they fell while running, at larly devastating because their impact is felt for
night and over uneven terrain, from looting militias. years after the end of hostilities. In South Sudan
Children and pregnant women sleeping outside are for example, 3 years after a peace accord was signed,
particularly vulnerable to malaria. The lost boys of the absence of roads and clinics, an economy still in
Sudan (United Nations High Commission for Refu- a battered shape, and the near-total absence of qua-
gees [UNHCR] 2001), a group of South Sudanese lified health workers meant that most of the popu-
children (mostly, though not exclusively, boys), lation did not have access to any health services; an
were decimated as they walked across East Africa, obstetric complication in this setting could be a
vulnerable to malnutrition, exposure, wild animals, death sentence. In Eastern Sierra Leone, 6 years
and their worst enemy – armed human beings. Dis- after the end of the war, the diamond trade has
placement can also cause devastating psychological fully resumed, but public clinics are still not ade-
trauma. Even when displaced people reach the com- quately funded, and there have been no systematic
parative safety of a refugee camp – where mortality efforts to distribute mosquito nets. As a result,
rates are relatively low – they are vulnerable to infectious diseases which would have been pre-
abuse, particularly women and children. vented or treated in a non-conflict setting kill thou-
Loss of health services: Health services in conflict sands of children. Likewise, obstetric complications
areas decline precipitously. In some cases, as in such as hemorrhage or obstructed labor, which
Eastern Sierra Leone in the 1990s, they disappear would have been dealt with in a clinic or hospital,
altogether. In others, such as Eastern Congo, ser- become deadly. For example, in Sierra Leone thou-
vices continue but are provided on a strictly cash- sands of children die each year of malaria that could
for-service basis, excluding many women and chil- have been saved by a net costing less than $10; this is
dren. Services decline for three major reasons. First, in sharp contrast to nearby Senegal, which has been
governments, which in many cases were already largely at peace and has made great strides in the
fight against malaria (United Nations 2007a). In an identify and respond to specific threats in a given
indirect but very real way, a pregnant woman dying context. In 1994 for example, in the space of a few
of postpartum hemorrhage in South Sudan or a days, a million Rwandese refugees fleeing the
child dying of cerebral malaria in Sierra Leone are genocide crossed the border into Goma, in Eastern
victims of conflict – the most common face, in fact, Democratic Republic of Congo (then Zaire), settling
of suffering in twenty first century conflicts. on the shores of Lake Kivu, a seasonal reservoir of
cholera. In the absence of any other option, the
refugees used the lake for all their water needs.
Within days, over 50,000 people had died in a blazing
Mitigating the Impact of Conflict cholera epidemic (CDC 1996; Goma Epidemiology
Group 1995). In retrospect, public health practi-
When conflict occurs, as it sadly continues to do, tioners have recognized that the most effective way
there is much that can be done to reduce the enor- to prevent and mitigate the epidemic would have
mous burden it imposes on women and children. been to add chlorine to water collection containers
Over the last decade, the maternal and child health at lakeside until adequate amounts of clean water
response in acute emergencies has improved consid- could be transported throughout the refugee settle-
erably as agencies have learned from past failures ments. Because speed is so important in acute emer-
and successes. Measles was the leading cause of gencies, the United Nations and private organiza-
mortality in humanitarian emergencies in the tions working in emergencies pre-stock emergency
1980s, but is now much less common thanks to kits in warehouses strategically located near places
early and widespread immunization (CDC 1992). where emergencies are likely to occur. These kits
There is a growing body of best practices and writ- include basic supplies and medicines to meet the
ten standards. Elements of an effective response to needs of people for days to weeks.
the impact of violent conflict include the following: Unfortunately, even with pre-packaged kits and
Acute complex emergencies: responding to immedi- efforts to prepare for and anticipate conflict crises,
ate needs: Where people are displaced, governments, timely access is often a difficult issue. Emergency
agencies, and other parties can work quickly to aid groups were able to provide some shelter and
establish safe camps with essential services, including health care within days to refugees fleeing from
curative and preventive health care. To be effective, Darfur into neighboring Chad, for example, but
relief needs to follow the best practices outlined in the were much more limited in their ability to provide
Sphere Guidelines [http://www.humanitarianinfo. basic services to people displaced from their villages
org/darfur/uploads/sphere/Sphere%20Handbook_ within Darfur itself.
full.pdf] which include standards on the provision Chronic complex emergencies: providing routine
of water, food, shelter, and health services in emer- care in non-routine conditions: Many violent con-
gencies (The Sphere Project 2004). For children in flicts last months or years. Some of the affected
developing countries where the vast majority of population is displaced, many are not. Some of the
conflicts occur and where most of the maternal displaced cross an international border and are
and child mortalities from conflict occur, this will recognized as refugees (United Nations 1951);
include systematic vaccination for measles. For others stay within their country and are described
women, immediate needs are outlined in the Mini- as internally displaced persons (United Nations
mum Initial Service Package (MISP), which includes 1998). Some displaced persons are in camps; most
prevention of HIV transmission, assuring access to are not. In some cases, conflict is nearly continuous.
emergency obstetric care, preventing and managing South Sudan experienced fighting for most of the
the consequences of sexual violence, and planning second half of the twentieth century; the Demo-
for more comprehensive reproductive health services cratic Republic of Congo, the Darfur region of
as the crisis situation becomes more stable. Sudan, and Northern Uganda are areas in which
In addition to these universal actions applicable fighting has become chronic. Humanitarian work-
to nearly all emergencies, Sphere Guidelines man- ers have a choice of alternative strategies to improve
date that public health workers in acute emergencies maternal and child care in these contexts. One
approach is to continue the type of programming mothers and children, such as zinc for diarrhea or
implemented in acute conflicts, accessing short- ergometrine to stop postpartum hemorrhage, are
term funding, focusing on providing basic inputs less likely to interest looters.
such as medicine, with many services performed by In some cases, approaches considered ‘‘develop-
expatriate and other outside providers, and concen- mental,’’ such as the use of community health
trating on traditional emergency interventions such workers to provide care, may actually be well
as mass immunization campaigns and feeding cen- adapted for conflict areas. In Northern Uganda,
ters for malnourished children. for example, community-based workers stocked
Increasingly, however, humanitarian agencies are with several months of medicines have been able
taking a different approach, with programming that to continue to provide basic care even when clinics
combines some features of acute emergencies, such were destroyed.
as the provision of key supplies and the elimination Primary health-care provision in camps: Maternal
of user fees, with attention to some of the longer- and child health programming in camps, as in
term needs of the population, such as training and chronic emergencies, combines features of emer-
other forms of capacity building. In the Democratic gency actions with those of long-term development.
Republic of Congo, for example, non-governmental New arrivals often need services for acute needs:
organizations (NGOs) have begun to address family young children, for example, may need therapeutic
planning. Family planning may not be a needed life- feeding for malnutrition and almost always need
saving activity in an acute emergency, but it is an catch-up immunizations. At the same time many
appropriate focus for chronic emergencies. First, in people, whether refugees or internally displaced
conflict as in non-conflict periods, thousands of people, remain in camps for months and years. As
women wish to exercise their right to make repro- their situation stabilizes, agencies offer longer-term
ductive choices, including the choice to not become programming, including training, household-level
pregnant; second, family planning is a highly effec- health education, and prevention. For this reason,
tive way to decrease both maternal and child mor- camps often have much lower mortality than sur-
tality; last, but not least, family planning services are rounding areas or the areas from which camp resi-
feasible in chronic emergencies and can be offered in dents fled.
many of the same channels through which other Post-conflict healing and rebuilding: The impact of
health interventions are offered, including clinics conflict on women and children is felt for years after
and community-based providers. hostilities cease. There is much that can be done to
Even when they are addressing longer-term mitigate that impact. In the early post-conflict period,
needs and using more development approaches, governments and NGOs should rebuild the infrastruc-
maternal and child health workers operating in ture, such as health clinics, and replace equipment or
chronic emergencies may need to adapt their meth- supplies that have been destroyed or looted. At this
ods. In the Democratic Republic of Congo, for time, it may also be helpful to provide salary support,
example, humanitarian agencies took a more devel- either directly or through institutions, to attract health
opment approach to supporting health clinics, workers into what are often remote places with harsh
including training providers and setting up revol- working conditions. The early post-conflict period is
ving drug funds, but have had to make provisions also a time to begin thinking about rebuilding not only
for re-stocking health centers that were looted by clinics but also systems – reporting systems, human
combatants. To the extent possible, humanitarian resource systems, and logistics systems. Although this
organizations and other external actors should work is less glamorous and harder to explain to
bring low-value assets rather than lootable assets. donors and the public than direct provision of ser-
This can often be achieved in maternal and health vices, it ultimately will have more impact on the health
programs without compromising impact. Activities of women and children.
such as vaccination programs or preventive health Even in this early period, it is important to work
education can achieve concrete results without with local institutions, such as district-level Minis-
exposing centers to looting. Even when drugs are try of Health offices or local NGOs, building their
provided, the drugs most effective in helping capacity to manage and provide services. This can
be difficult, in part because these institutions can be basic human rights. For example, some NGOs are
extremely short-staffed and have limited financial working with local leaders and women’s groups to
and organizational capacity and in part because raise awareness about gender-based violence and to
NGOs may have been used to the flexibility of implement locally designed solutions (IRC 2004).
working on their own in the acute emergency Humanitarian workers can shine a spotlight on the
phase. In the long term, however, work done to abuses they see firsthand and work to decrease the
build local institutions, from the very start, is likely impunity which is a major factor in the epidemics of
to help as much or more than the direct provision of sexual abuse and other human rights violations. In
supplies and services. some cases, testimony on the abuse of human rights
The late post-conflict period starts months after they have witnessed is the most powerful action
the end of hostilities and can last more than a dec- humanitarian workers can take.
ade. In some cases, NGOs may no longer need to Conflict-sensitive and ‘‘do-no-harm’’ programming:
supply all the necessary inputs; in others, such direct Even with the best of intentions, combatants or civi-
support may be necessary for years. In all cases, lians may perceive humanitarian work as helping one
donors and agencies should be developing ways to side of the conflict or having other negative effects.
sustain primary care services. In this period, NGOs Health program managers need to analyze the conflict
and donors should be working with local institu- situation in which they operate and the implications of
tions to develop and improve the systems they have their projects on fighting factions, politicized commu-
begun to work on in the immediate post-conflict nities, and the dynamics of conflicts in their areas.
phase. Health services may play a crucial role in For example, an NGO may open a health center
the late post-conflict period. A functioning health near an army base. If the center is used – or looted
system and the availability of high-quality basic regularly – by soldiers, the NGO may be seen, by
health services at little or no cost can create goodwill outsiders as well as by a resentful local population, as
and help legitimize a new government by showing in fact supporting continued conflict. Where possible,
evidence of its competence. Although this is still a the workers and beneficiaries of development projects
hypothesis, and there are little hard data on whether should be drawn from across conflict lines. In some
health services in practice do help to stabilize a situations there may be a case for bypassing govern-
country, the possibility is credible enough that ments, in particular when operating through govern-
donors are increasingly willing to support basic ments which lend support to abusive regimes.
health-care provision as an element of their ‘‘fragile
states’’ policy (USAID 2005).
It is important to note, however, that even in
post-conflict settings, or in more developmentally Preventing Conflict
oriented chronic conflict programming, there may
be important differences between work in conflict The surest way to protect women and children from
and non-conflict countries. In conflict countries, conflict is to prevent the conflict from ever happening
rebuilding health services requires direct investment, in the first place. Prevention is difficult, because it
a form of assistance that cannot be easily diverted, requires attention to the complex problems of remote
and a higher ratio of external project financing. countries, and the news media rarely cover wars that
The rights-based approach: Conflict in the twenty have not yet happened. There is little reward to the
first century is marked by massive violations of effort – few Nobel Prizes have been given for prevent-
human rights. Humanitarian aid workers, whether ing wars. It is, however, clearly the best way to care for
working in maternal and child health or in other the millions of women and children who live in areas of
areas, need to respond to these violations. They can the world where conflict might flare up again. Prevent-
do so at various levels. Most immediately, they can ing conflict means promoting the conditions that
redress the violation of the right to health by helping make conflict less likely, including good governance,
to provide health services. They can work with com- economic development, and equity. When conflict
munity-based institutions, building the capacity of is brewing, advocacy can help to bring attention
local groups to monitor and improve respect for from outside nations and put pressure on potential
combatants. Public health workers can play an impor- to occur most often in poor and slowly growing
tant role, because they often work in countries before countries. And, as demonstrated in the foregoing
conflict breaks out and because they work at the field discussion, when they do occur they inflict enor-
level and may have learned to understand the complex mous hardship. World Bank models (Djankov
realities of rural and urban communities in potential and Reynal-Querol 2007) show a profound rela-
conflict countries. To be effective, however, it is essen- tionship between the poverty of a nation and its
tial that they share their unique perspective and knowl- chances of having a civil war. A country where
edge with others, including political advocates, human the average person survives on less than $1 per
rights lobbyists, and journalists. In conflict prevention day has a predicted probability of war (at some
as in maternal and child health, foresight and team- point over the next 5 years) of 15%, even if it is
work are essential to success. otherwise considered an ‘‘average’’ country
(Gagain 2006). This probability of war reduces
by half for a country with GDP of $600 per
person; and countries with per person income
Advocacy over $5,000 have a less than 1% chance of experi-
encing civil conflict (Gagain 2006). Although
Advocacy is a powerful tool and often the most power- none of the Millennium Development Goals
ful way for humanitarian aid workers and other con- (MDGs) specifically addressed conflict, goals 3–5
cerned citizens to help women and children in conflict (promote gender equality and empower women;
areas. There are several ways to advocate. NGO per- reduce child mortality; improve maternal health)
sonnel who work directly in conflict sites can witness, deal with maternal and child health. Indeed,
to the media, decision-makers in their countries or countries in conflict are more likely to be poor
others about the abuses they have seen. Advocates and to stay poor, which is an obstacle to reaching
can also participate in decisions about how aid is any of the MDGs. They are particularly less
given out and other policy decisions that affect conflict likely to reach the MCH-related MDGs because
countries. Such policy issues can range from export of the profound negative impact of war on
bans for conflict diamonds and fair-trade laws to women and children. Countries at war will need
structuring economic reform packages that are sensi- more resources if they are to achieve the MDGs.
tive to the needs of conflict-affected populations. Eco- Countries which have experienced protracted con-
nomic reform packages that include major cutbacks in flict such as Afghanistan or the Democratic
government spending may have devastating humani- Republic of Congo will require particularly large
tarian impacts – and be economically ill-advised, espe- assistance to achieve parity among non-conflict
cially in immediate post-conflict areas where public states when aiming to achieve the Millennium
investment is needed after years of neglect. Whatever Development Goals – whether economic or health
the issue, real progress on a large scale will only be indicators are measured.
possible if the voices and interests of women and In weak states, evaluation of progress toward the
children in conflict areas are heard and taken into MDGs should take account of progress toward
account in national and international policy decisions. achieving the goals at a provincial or smaller level
Thus advocacy is an important element of maternal rather than at a national level only. In states where
and child health work. ethnic, regional, or religious divisions run deep,
MDG reports should take note of the ways in
which MDG policies address the concerns of these
different groups and not simply the national attain-
Millennium Development Goals (MDGs) ment of the goals. Countries emerging from conflict
and Countries in Conflict such as Liberia have established MDG teams and
produced interim reports (United Nations 2007b).
Conflict-affected countries are more likely to stay Such reports from post-conflict settings illustrate
poor, and poor countries are more likely to the distance yet to be traveled by some of the
experience conflict. Civil wars have been shown world’s poorest countries.
Conclusion within affected countries, has adapted its response

and become more effective at mitigating the effect
Conflict is a significant cause of maternal and of conflict on the health of women and children.
child morbidity and mortality. As conflict has This response has included more effective huma-
evolved, combatants deliberately target civilians, nitarian action, adapted to the varied contexts in
both through direct violence and through the which conflict occurs, as well as advocacy, to help
destruction of essential services. Women and chil- avoid conflict in the first place. The international
dren, whose well-being depends on health ser- public health community is increasingly recogniz-
vices, particularly in pregnancy and early child- ing that mitigating and preventing conflict is
hood, have felt the greatest impact. Concurrently, essential to achieving the Millennium Develop-
the public community, both internationally and ment Goals.
Key Terms
Abuse Conflict-sensitive Humanitarian emergencies

Acute complex emergencies programming Identify conflict
Acute emergencies Darfur Immunization
Adverse obstetric condition Democratic Republic of Congo Insecticide-treated bednets
Advocacy Destruction of infrastructure Insurgencies
Afghanistan Diamond trade Insurgents
Airbase Dinka tribes Internally displaced people
Arab Direct injury International Rescue
Black Africans Displacement Commission
Bombardment Do-no-harm programming Iraq
Bosnia East Congo Islamic fundamentalism
Burnett Institute Economic collapse Janjawid militias
Burundi Enemy Lake Kivu
Cambodia Ethnic divisions Loot
Camps Ethnicity Loyalty
Catch-up immunization Family planning Machine guns
Child mortality Farsi-speaking tribes Malaria
Chlorine Feudal fiefdoms Mali
Cholera Food aid Malnutrition
Christian Food insecurity Maneuver
Chronic emergencies Fur tribes Maternal mortality
Civil war Genocide Militia
Civilian victims Goma Millennium Development
Clan Grenades Goals (MDGs)
Cold war Hate speech Minimum Initial Service
Combat injury Hatred Package (MISP)
Combatants Hemorrhage Muslim
Conflict HIV infection Nation state
Conflict zones Hostilities Obstetric care
Conflict-affected countries Human rights Obstetric complications
Obstetric fistula Semi-automatic rifles United Nations High

Obstructed labor Sexual assault Commission for Refugees
Pashtun-speaking tribes Sierra Leone (UNHCR)
Post-conflict period Small arms United States
Post-conflicts rebuilding Soldiers Violence against women
Postpartum hemorrhage Somalia Vitamin supplementation
Propaganda Soviet Union Vulnerability
Proxy war Sphere Guidelines War
Psychological trauma Standard of living Warlords
Rape Sudan Weapon of war
Rebels Surge Weapons
Refugees Trauma World War I
Regular army Uganda World War II
Relief agencies United Nations Yugoslavia
Religion Zaire
Coghlan B, Brennan RJ, Ngoy P et al. (2006) Mortality in the

Questions for Discussion Democratic Republic of Congo: a nationwide survey.
Lancet, 367(95040), 44–51
1. The nature of conflicts in the world has changed Coghlan B, Ngoy P, Mulumba F et al. (2008) Mortality in the
Democratic Republic of Congo: an ongoing crisis. http://
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explain what you understand by this statement. urvey.pdf, cited 22 January 2008
What are some of the consequences of identity con- Djankov S, Reynal-Querol M (2007) The Causes of Civil
flicts? Why are they difficult to resolve? War. World Bank Policy Research Working Paper 4254
(WPS4254), June 2007. The World Bank, Washington
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3. Discuss some of the maternal and child health 0615144341/Rendered/PDF/wps4254.pdf, cited 22 January
implications of recruiting children for combat 2008
Gagain JR (2006) Millennium Development Watch: The
and combat-related duties. Dominican Republic as a pilot project. United Nations
4. Draw a causal diagram to illustrate the pathways Chronicle 4(XLIV). http://www.un.org/Pubs/chronicle/
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being of women, children, and adolescents. Goma Epidemiology Group (1995) Public health impact of
Rwandan refugee crisis: what happened in Goma, Zaire,
5. What are chronic complex emergencies? Sum- in July, 1994? Lancet, 345(8946), 339–344
marize key strategies for addressing them. Human Rights Watch (1999a) Leave none to tell the story:
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cited 22 January 2008 conflict: time to rethink. Lancet, 367(9526), 1886–1888
Chapter 8
The Impact of Globalization on Maternal and Child Health
Sarah Wamala
Learning Objectives After reading this chapter and which many writers believe has deepened poverty
answering the discussion questions that follow, you around the world. It then examines how globa-
should be able to lization directly affects the health and livelihoods
of women through changing occupational roles,
Discuss the meaning and features of
evolution in food production, preparation and
globalization.
consumption patterns, and migration. It con-
Evaluate how globalization directly affects
cludes with the investigation of possible public
maternal and child health through changing
health and policy responses and examines the
occupational roles of women, evolution of food
extent to which the Millennium Development
production, preparation, and consumption pat-
Goals contribute to the alleviation of the adverse
terns, and migration (including migration of
impacts of globalization on the health of women
health professionals).
and children.
Analyze how globalization indirectly affects
Contrary to popular opinion, globalization is
maternal and child health through limitations
not a new phenomenon (Frenk and Gómez-
in the provision of care as a consequence of
Dantés 2002). The forces of trade, migration,
such economic policies as privatization, interna-
war, and conquest have historically bound people
tional trade agreements, and structural adjust-
from distant places together. As Frenk and
ment policies (SAPs).
Gómez-Dantés (2002) observed, the expression
Propose potential public health policies and mea-
‘‘citizen of the world’’ was coined by the Greek
sures to reduce the impact of globalization on the
philosopher Diogenes in the 4th century BC.
health of women, children, and adolescents.
There is consensus however, that the pace, range,
and depth of integration have intensified over the
past two decades. As never before, the conse-
quences of actions that take place far away show
Introduction up, literally at our doorsteps (Frenk and Gómez-
Dantés 2002). Globalization is a term with multi-
This chapter presents an overview of how globa- ple, contested meanings. For the purposes of this
lization and our increasingly interlinked world chapter, it is defined as ‘‘a process of greater inte-
affect the lives and health of women and chil- gration within the world’s economy through
dren. It begins with an analysis of globalization’s movements of goods and services, capital, tech-
impact on the provision of care through privati- nology and labor, which increasingly leads
zation and such international policy mechanisms to economic decisions being influenced by global
as the Structural Adjustment Programs (SAPs), conditions’’ (Jenkins 2004). Thus, the concept
of globalization is linked to the rise of transna-
tional corporations (TNCs) and the associated
S. Wamala (*)
Swedish National Institute of Public Health, Forskarens väg 3., internationalization of production, distribution,
SE-831 40 Östersund, Sweden and consumption of goods and services. It is
136 S. Wamala
the process whereby national and international reproductive technologies, such as contraception.
policy-makers promote domestic deregulation The close integration of societies, particularly
and external liberalization (Cornia 2001). Globa- through telecommunications and the Internet, has
lization gained momentum as a policy paradigm in mobilized the international women’s movement. In
the 1980s with the adoption of domestic deregula- arguing the case for the health benefits of globaliza-
tion, trade liberalization, and privatization poli- tion, Dollar (2001) also observes that the economic
cies that allow cross-border acquisitions by multi- integration made possible by globalization is a
national firms (Cornia 2001; Dollar 2001). The powerful force for raising the incomes of poor coun-
process intensified in the 1990s with the removal tries. Within the past two decades, several large
of barriers to international trade, foreign direct developing countries have opened up to interna-
investments (i.e., investments by foreign compa- tional trade and foreign direct investment (e.g.,
nies, such as construction of production facilities, China, India, and Vietnam). They have recorded
buildings, machinery, and equipment), and short- more impressive economic growth rates than some
term financial flows (Cornia 2001). Foreign direct rich countries. Dollar (2001) also observed that
investment (FDI) has been on the rise around the there is a tendency for income equity to increase in
world since the 1970s. Table 8.1 presents informa- countries that have embraced trade liberalization
tion on FDI in developing economies from 1990 to and foreign direct investments. Dollar and Kraay
2006. In India, for example, incoming FDI has (2001) attribute the increasing income equity to ris-
grown from 1.705 billion in the 1990s to 16.881 ing average incomes in, for example, China and
billion in 2006 and from 1.9% of the GDP to India. The perception is that economic growth,
8.7%. There is debate regarding the impact of brought about by globalization, contributes directly
globalization on health and the quality of life of to improvements in the health status of the poor in
people. However, empirical results on links less developed countries (especially women and chil-
between globalization and specific health out- dren) through improvements in nutrition (Hawkes
comes are limited (Kawachi and Wamala 2006a). 2005), increased education of females, better mater-
The impact of globalization has been debated nal health, and lower child mortality (Filmer and
in terms of both its positive (Dollar 2001; Pritchett 1999).
2004) and its negative impacts (Rabbani et al. Magnussen et al. (2004) argue that pro-growth
2006). macroeconomic, labor, and social policies widen
Proponents of globalization believe that it cre- income inequity and significantly disadvantage the
ates new jobs and can lead to transfer and infusion poor and less privileged, particularly women and
of innovative technologies, management strategies, children. Such policies have the tendency to provide
and workforce practices. Foreign direct investment better opportunities to those with resources and
is also argued to have expanded women’s employ- high levels of education, while large segments of
ment opportunities and hence, their economic the population without these assets are unlikely to
autonomy (Dollar 2004). Globalization is belie- benefit and may in fact become casualties of the
ved to have aided the international transfer of economic transition. As Lee (2004) argues, the
Table 8.1 FDI flows

As a percentage of gross fixed capital
FDI flows (millions of dollars) Developing economies formation
1990–2000 2003 2004 2005 2006 1990–2000 2004 2005 2006
Inward flow 130,722 178,699 283,030 314,316 379,070 9.3 12.9 12.6 13.8
Outward flow 52,836 45,372 877,301 837,194 1,215,789 7.9 10.1 92. 11.8
World economy
Inward flow 495,399 564,078 742,143 945,795 1,035,852 7.8 8.5 10.4 12.6
Outward flow 492,622 560,087 877,301 837,194 1,215,789 7.9 10.1 9.2 11.8
Source: UNCTAD (2007)
8 The Impact of Globalization on Maternal and Child Health 137
health impacts of globalization are simultaneously globalization impacts health in relation to context,
positive and negative and vary according to factors social structure, history, and politics. A number of
such as geographical location, sex, age, ethnic ori- conceptual frameworks have been suggested
gin, education level, and socioeconomic status. (Huynen et al. 2005; Woodward et al. 2001;
Labonte and Torgerson 2002). In one example,
Huynen et al. (2005) proposed a framework that
identifies the main determinants of population
Effect of Globalization on Maternal health (Table 8.2) and relates them to main features
and Child Health of the globalization process (Table 8.3).
Figure 8.1 provides an example to aid in under-
The relationship between globalization and health standing the interaction of these mechanisms.
is complex. The analyses require conceptual frame- Pinpointing the effects of globalization at the
works that define links and mechanisms by which institutional, economic, sociocultural, and ecological
Table 8.2 Determinants of population health

Level/Nature General Determinants More Detailed Determinants
Contextual level
Institutional Institutional Governance structure
Infrastructure Political environment
System of law
Regulation
Economic Economic infrastructure Occupational structure
Tax system
Markets
Sociocultural Culture Religion
Ideology
Customs
Population Population size
Structure
Geographical distribution
Social infrastructure Social organization
Knowledge development
Social security
Insurance system
Mobility and communication
Environmental Ecological settings Ecosystems
Climate
Distal level
Institutional Health policy Effective public health policy
Sufficient public health budget
Health-related policies Effective food policy
Effective water policy
Effective social policy
Effective environmental policy
Economic Economic development Income/wealth
Economic equity
Trade Trade in goods and services
Marketing
Sociocultural Knowledge Education and literacy
Health education
Technology
Social interactions Social equity
Conflicts
(continued )
138 S. Wamala

Level/Nature General Determinants More Detailed Determinants
Travel and migration
Environmental Ecosystem goods and Habitat
services Information
Production
Regulation
Proximal level
Institutional Health services Provision of and access to health services
Economic – –
Sociocultural Lifestyle Healthy food consumption patterns
Alcohol and tobacco use
Drug abuse
Unsafe sexual behavior
Physical activity
Stress coping
Child care
Lifestyle-related endogenous factors (blood pressure, obesity, cholesterol
levels)
Social environment Social support and informal care
Intended injuries and abuse/violence
Environmental Food and water Sufficient quality
Sufficient quantity
Sanitation
Physical environment Quality of the living environment (biotic, physical and chemical factors)
Unintended injuries
Source: Huynen et al. (2005)
Table 8.3 Features of globalization

Feature Characteristics
New global governance structure Globalization influences the interdependence among nations as well as the nation
state’s sovereignty leading to (a need for) new global governance structures
Global markets Globalization is characterized by worldwide changes in economic infrastructures and
the emergence of global markets and a global trading system
Global communication and Globalization makes the sharing of information and the exchange of experiences
diffusion of information around common problems possible
Global mobility Global mobility is characterized by a major increase in the extensity, intensity, and
velocity of movement and by a wide variety in ‘‘types’’ of mobility
Cross-cultural interaction Globalizing cultural flows result in interactions between global and local cultural
elements
Global environmental changes Global environmental threats to ecosystems include global climate change, loss of
biodiversity, global ozone depletion, and the global decline in natural areas
determinants of population health, the model the national, community, and individual levels.
demonstrates that the globalization process mainly Figure 8.3 demonstrates how globalization impacts
operates at the contextual level, while influencing health-related policies, agriculture, social spheres,
health through its more distal and proximal determi- and the provision and funding of healthcare services
nants (Fig. 8.2). at a national level. These national factors, in turn,
The effects of globalization on the health of influence capabilities, cohesiveness, social fragmen-
women and children can also be characterized at tation, entitlements, endowments, resources, and
Fig.8.1 Conceptual framework for globalization and population health. Source: Huynen et al. (2005)
services at the community level. These influences at The Uruguay Round of Multilateral Trade Negotia-
national and community levels consequently impact tions (1986–1994) led to the Marrakech Agreements,
women’s occupational roles and household food which established the World Trade Organization
and nutrition security, ultimately affecting maternal (WTO) and extended the rules governing commercial
and child health. relations between trading partners to several new
Several trends affected by an increasingly global areas that were previously excluded from trade liber-
economy demonstrate the convergence of globaliza- alization. These include agriculture, services, invest-
tion and MCH: the privatization of healthcare and ment measures, and the protection of intellectual
public services, Structural Adjustment Programs property rights (Supakankunti et al. 2001). Thus,
(SAPs and public health services), changing occu- the WTO is one of the major features of globaliza-
pational roles, food production, preparation and tion. It exerts its influence on the globalization pro-
consumption, and migration. These are examined cess through health and health-related policies (Figs.
in more detail in the following paragraphs. 8.11 and 8.22). Its aim is economic growth and sta-
bility based on free markets and minimum govern-
mental interference. It deals with the rules of trade
between nations at a global or near-global level. It
Globalization and Commercialization of describes itself as an organization for liberalizing
Healthcare and Public Services trade – a forum for governments to negotiate trade
agreements and a place for them to settle trade dis-
The objective of the General Agreement on Tariffs putes. Where countries have faced trade barriers and
and Trade (GATT) signed by 23 nations in 1947 was wanted them lowered, these negotiations have helped
to promote and regulate the liberalization of inter- to liberalize trade (World Trade Organization 2008).
national trade through rounds of trade negotiations. WTO’s membership includes 151 nation states (as of
140 S. Wamala
Fig.8.2 Conceptual framework for globalization and population health: the role of contextual, distal, and proximal factors.
Fig.8.3 Effects of Global National Community Individual Outcomes

globalization on maternal Household
and child health: a G Maternal
Health care
conceptual framework L Capabilities health
services and
O Cohesiveness Women’s
B related policies
Fragmentation occupational
A
L Agricultural Entitlements roles
I Sphere Endowments Food and
S
A nutrition
T Resources
I Social Services Child
O sphere health
N
July 27, 2007) and voting is based on democratic committees in the presence of these transnational
terms. However, the transnational corporations corporations that desire expanded private enterprise
that are represented on all significant advisory com- involvement in the increasingly important service
mittees decide detailed policies and set the WTO’s sectors. These sectors include telecommunications,
agenda. Low-income developing countries who transport, distribution, postal, insurance, environ-
constitute two-thirds of the organization’s member- ment, tourism, entertainment, and leisure services.
ship, have a weak bargaining position at the WTO The main problematic services are those managed
by the public health sector namely healthcare, social drugs, but implementation of TRIPS without
services, education, and housing. The WTO’s focus regard to the technological and financial limitations
on the service industry reflects the sector’s growing of resource-poor countries has had the following
commercial importance. As such, WTO trade agree- negative implications for public health in these
ments have been described as a bill of rights for countries (Correa 2001) and on the health of the
corporate business, not for nations (AFSC 2006). poor, especially women and children:
In 1994, a comprehensive new treaty on intellec-
Patent holders, usually large pharmaceutical
tual property rights known as the Agreement on
firms in industrialized nations, can exclude direct
Trade-Related Aspects of Intellectual Property
competition and charge higher prices for
Rights (TRIPS), was established within the frame-
patented medicines than would have been
work of the WTO. Later, this would have signifi-
expected in a competitive market.
cant impact on global health. The treaty established
Life-saving drugs can become unaffordable (e.g.,
minimum universal standards in all areas of intel-
the cost of antiretroviral drugs is above the reach
lectual property with the intention of implementing
of most individuals and families in sub-Saharan
these standards globally through a strong enforce-
Africa where HIV/AIDS poses a significant chal-
ment mechanism. The treaty requires all WTO
lenge to health and development).
member countries to adopt minimum standards of
Poor countries are excluded from the benefits of
protection for patents, trademarks, copyrights, and
protection for inventions because they lack the
other intellectual property rights in their laws. Any
scientific infrastructure and the capital needed
member country failing to bring its patent law into
for research and development since the high
conformity with the TRIPS agreement, if chal-
costs and the need for economies of scale place
lenged by another member country, is subject to
the development of patentable pharmaceuticals
WTO’s dispute settlement system, and sanctions
beyond their reach.
can be imposed in accordance with WTO proce-
Pharmaceutical companies that invest in
dures. TRIPS requires universal patent protection
research and development focus mainly on dis-
for any invention in any field of technology. Accord-
eases likely to yield the highest return for their
ingly, this affects pharmaceuticals, which many coun-
shareholders. Such diseases of the poor that have
tries had previously excluded from patent protection
more debilitating consequences for women and
in order to produce drugs at reduced prices. Although
children, e.g., malaria and tuberculosis, are not
TRIPS has significant implications for public health,
considered priorities.
it was negotiated with little or no participation from
public health authorities (Ehiri and Anyanwu 2004). The application of TRIPS has caused serious pro-
As part of its obligations, it sets forth to protect blems to developing country producers of generic
inventions including the following: drugs such as India and Brazil and to importers of
these drugs such as South Africa and Kenya. In Côte
recognizing patents for pharmaceuticals without
d’Ivoire, one of West Africa’s wealthiest countries,
distinction between imported and locally pro-
only about 500 of the estimated 1,000,000 people
duced products;
infected with HIV/AIDS receive drug treatment.
granting patent protection for at least 20 years
Even though the Ivorian and French governments
from the date of application;
subsidize over half of the cost, the drug regime still
limiting the scope of exemptions from patent
costs $1–$10 a month on average while the average
rights;
monthly wage is only about $50 (Pompey 1999).
enforcing patent rights through administrative
Various regional trade zones of the world (e.g.,
and judicial mechanisms;
North Atlantic Free Trade Agreement (NAFTA)
compulsory protection against unfair commer-
and the European Union (EU)) have rules which
cial use of data submitted for the marketing
can facilitate privatization in relation to service pro-
approval of new pharmaceutical products.
vision and insurance schemes. In addition, national
Patents are supposed to contribute to the genera- government leaders in a number of developed and
tion of funds for research and development of new developing countries frequently use privatization as
142 S. Wamala
a policy instrument to reduce the financial burden The implications for public health are clear.
of the public sector. Their decisions are encouraged Improved access to basic public services such as
by global institutions such as the World Bank safe water and energy is the key to improved child
and International Monetary Fund (IMF) through health in poor regions of the world. A large number
mechanisms such as Structural Adjustment Pro- of women and children in many poor countries walk
grams (SAPs) discussed in the next section. several miles in search of water and firewood. Sub-
stantial research literature describes the effects of
the Structural Adjustment Programs (SAPs) that
integrated African countries into the global econ-
Structural Adjustment Programs (SAPs) omy in the 1980s (De Vogli and Birbeck 2005). SAP
and Public Services measures such as domestic deregulation, privatiza-
tion, fiscal austerity, and marketization of social
Another marked feature of globalization is the pri- services, combined with deeper liberalization and
vatization of public services. This was initiated with integration in specific sites such as Export Proces-
the argument of improving effectiveness and effi- sing Zones (EPZs), reflected and reinforced the
ciency of publicly managed institutions and agen- more fundamental changes in the organization of
cies – e.g., electricity corporations, water corpora- production and the distribution of wealth and risk
tions, financial institutions, factories. Structural under globalization (UNCTAD 1993).
Adjustment refers to a set of policy advice that is After two decades of field studies and contests
given to developing countries by international agen- concerning the impacts, it is now accepted that the
cies, mainly the World Bank and the International overall effects of these policies in Africa, in relation
Monetary Fund, in order to enhance economic to social development and poverty, has been nega-
growth through macroeconomic stability and elim- tive (Mkandawire 2005). There is evidence for nega-
ination of market distortions. The World Bank and tive health outcomes of deepening liberalization,
IMF recommend SAPs to indebted poor countries commercialization, cost recovery in health and
as a means of achieving economic recovery. Devel- essential services, weakening community and public
oping countries, who implement the recommended sector authority in health, increased food insecurity
policies, receive grants or loans from donor agencies associated with changes in trade, and increased con-
for this purpose. trol of food markets by a limited number of buyers
While national governments have a social (FAO 2004a). An equally substantial body of
responsibility to ensure access to basic amenities research literature demonstrates that globaliza-
such as water, energy, and essential services, many tion’s negative health effects have not been gender-
opt to promote privatization with the belief that neutral and that women have experienced some of
it facilitates market competition and efficiency the greatest negative consequences in health and
(Gleick 2000). Private owners of public sector ser- caring burdens (Afshar and Barrientos 1998).
vices are often dominated by transnational corpora-
tions (TNCs) with long-term contracts (even up to
50 years) and limited knowledge of local conditions.
TNCs may set price policies that do not match local
Globalization and Changing
demands and capabilities. As a result, privatization Occupational Roles
of energy and water in sub-Saharan Africa, Latin
America, and Central and Eastern Europe (Olivera In spite of the fact that women’s participation in
and Lewis 2004; Gleick 2000) has resulted in limited the labor force increased particularly in the era of
access for local populations due to prohibitively globalization (1980s and 1990s), a large proportion
high prices. In this example, the government of women’s unpaid work still goes unnoticed (Uni-
does not provide services, the population cannot ted Nations 2005a). In many cases, while women’s
afford services provided by the private sector, participation has increased, men’s has fallen.
and there is a resulting lack of access to basic Thus a phenomenon of ‘‘masculinization of unem-
infrastructure. ployment’’ has occurred. An increasingly large
underclass of younger men who cannot find work is for food. About 90% of the developing world’s
observed in many poor countries. High unemploy- poor live in Asia and sub-Saharan Africa and
ment rates and redundancy among men have con- about 75% of those live in rural areas. These people
tributed to increased alcohol consumption, unrest, depend on agriculture for their daily existence. Yet,
and drug abuse which accelerate violence against more than two-thirds of total exports from poor
women and children (UN 2005a). developing countries are agro-based commodities.
‘‘Feminization of employment’’ has occurred due Agricultural growth is therefore crucial to their
to a number of explanations. One explanation is livelihood. The globalization of agricultural mar-
that the global labor force has become more female kets brought about by trade liberalization and
due to a greater demand for women workers in worldwide changes in markets and marketing chan-
sectors of the economy related to globalization, nels poses special challenges for small-scale farmers
such as export sectors (UN 2005b). Notable exam- and poor areas of developing countries.
ples are low-skilled manufacturing, such as gar- It is known that women are responsible for 80% of
ments, footwear, and electronic products. These food production in Africa, including the most labor-
new export processing industries depend heavily intensive work, such as planting, fertilizing, irrigating,
on women workers, many of whom are young, weeding, harvesting, and marketing (FAO 2004b).
rural immigrants. In fact, in countries where SAPs However, changes in the agricultural sector wrought
were introduced there are higher women’s partici- by globalization are widening gender inequalities. The
pation rates (Cagatay and Ozler 1995). Another focus of support on export production can include a
explanation is that more women must now work bias toward larger scale farms, at the expense of sup-
to ensure family survival due to declining real port for small holders. These small holders are often
wages and the increased monetary cost of subsis- women farmers, many of whom produce food for
tence, resulting from the SAP cutbacks in public local, domestic markets. Women may become cheap
services and subsidies. It should be noted that laborers for more export-orientated commercial farm-
women’s increased participation in the labor force ing concerns. The only alternative for rural women is
brings increased opportunities to women, but the to migrate to urban centers to seek employment.
effects have not all been positive. Women’s employ- The attainment of food security and subsequent
ment is associated with seasonal, unpaid, casual food consumption and nutrition patterns here take
wage labor, long working hours, and generally on another dimension (Hawkes 2005; McMichael
poor working conditions (Loewenson 1999). 2005). Poor nutrition (under- or overnutrition) has
substantial impacts on health. In Africa, this is
marked in the context of poverty and HIV/AIDS,
where the household workforce is decreased (Cho-
Changes in Food Production, pra 2004). Globalization has led to global expansion
Preparation, and Consumption of agricultural trade and finance. It can also prevent
fluctuations in food supply, by enabling developing
Globalization has an impact on healthcare through countries to import food at adequate and stable
changes to livelihoods of small-scale farmers, an prices. Improved market access for these countries
anticipated rural–urban migration, and changes to can increase agricultural exports, thereby increasing
nutrition and food security. Globalization in the foreign exchange. Raising the level of income and
form of trade liberalization, increased economic employment among low-income rural families
growth, improved communication, improved infor- increases the amount of food poor people can
mation flows, and technology is expected to afford and protects them from higher food prices
increase access to better food and cheap food sup- in the event of domestic market shortages.
plies (FAO 2004b). Forces of globalization on the Globalization has accelerated urbanization and
other hand can endanger food production and changes in food preparation, choices, and con-
security (Hawkes 2005). It should be noted that in sumption. It has created a shift in the structure of
spite of the changes in the manufacturing sphere, a diets from traditional, low-cost diets rich in fiber
majority of the population depends on agriculture and grain to high-cost diets that include greater
144 S. Wamala
proportions of sugars, oils, and animal fats (FAO their families. The United Nations estimates that
2004a). The local staple foods with rich nutrients women accounted for 48% of migration. How-
have been replaced by high-carbohydrate foodstuffs ever, the ratio of women to men migrating may
from fast food restaurants. These include fried be even larger in some parts of the world, for
chicken, beef burgers, pizzas, potato chips, and soft example, in sub-Saharan Africa and some Asian
drinks, among others. All of these foods have high countries. Globalization has contributed to
proportions of oil, salt, and sugar that are higher in ‘‘feminization of migration’’ resulting in more
calories than other foods. Because higher socioeco- women from poorer developing countries migrat-
nomic status (SES) in many low-income countries is ing to find paid employment. This can cause
often associated with western lifestyle including food these women to be economically and socially
choices and behaviors, high SES individuals buy independent of their own cultures. This cultural
food from westernized fast food restaurants. In isolation is detrimental to their health and that
fact, a large number of people with high SES in the of their children. While the increased availability
developing countries are overrepresented among of affordable migrant providers of care for
people who suffer from obesity, hypertension, and young children, elderly parents, and disabled
type 2 diabetes. This is an epidemiological transition relatives has enabled women in wealthier coun-
which many western industrialized countries tries to join or remain in the workforce (Ehren-
bypassed in the beginning of the 19th century. reich and Hochschild 2004), migrant women
In many poor countries, a phenomenon of ‘‘street themselves are often exposed to poor employ-
foods’’ in a takeaway style has also risen due to ment conditions. The poor conditions for a
increased urbanization, coupled with low wages. large domestic workforce of women from poor
Street foods account for 70% of the total calorie to wealthy countries have been well documented
intake of the urban low- and middle-income groups. (Loewenson 1999; UNCTAD 1993; Ghosh
The choice of food depends mainly on SES. Many 2003).
low- and middle-income households buy food from Migrant women often lack knowledge about
vendors to save on the cost of food ingredients and their rights and entitlements and about healthcare
cooking fuel, save preparation time, and try new access. This often negatively influences health.
foods. The type of foods served by street food ven- Poor health is intertwined with adverse social, eco-
dors include rice, stiff porridge from maize flour, nomic, and institutional factors (e.g., sexually
plantains, maize cooked with beans, fried potato, transmitted infections and being subject to gen-
cassava, sweet potato, chips, roast and fried der-based violence) that affect low-wage earners
chicken, and roast meat. There is often a lack of and their families. These conditions have major
hygiene and proper handling methods associated policy implications in the host countries. In addi-
with the preparation of street foods. This results in tion, the migration of women for work results in
microbial contaminants that contribute to diarrhea the fragmentation of the household structure,
and intensify other diseases, particularly among family dynamics, and social support mechanisms
children and pregnant women. As many households (Afshar and Barrientos 1998). In many poor coun-
adapt to street foods, wisdom and knowledge about tries women have the primary role in child
traditional food preparation is forgotten between upbringing. Thus, their migration leaves a vacuum
generations. This could lead toward worse nutri- in child care. Women’s absence may create a care
tional problems in the future. deficit for their children and disabled or elderly
relatives. A common scenario is that women
migrate from poor to rich countries to work as
nannies and leave their children in their home-
Globalization and Migration towns to be taken care of by another nanny
(often a young girl) from a poorer family in a
Globalization has led to an increased number of nearby rural area.
women who migrate as potential participants in Thus, a large number of children grow up with-
the labor market and principal breadwinners for out the care of their parents. Wisdom of women is
not passed on to their children. This leads to frag- Policy Responses and Achieving the
mented culture and lack of traditions which may Millennium Development Goals (MDGs)
have negative consequences on children’s self-
esteem, sense of coherence, and well-being. Because A global response to the world’s main development
of fragmentation in household support and care challenges and to the calls of civil society, the
mechanisms, more girls practice sex at earlier ages. MDGs promote poverty reduction, education,
Economic hardships force many women and girls maternal health, gender equality and aim to combat
into commercial sex work or transactional sex child mortality, HIV/AIDS, and other diseases. The
(entering into relationships with older and wealthier World Health Organization (WHO) plays an
men in exchange for money). This increases their important role in reaching the MDG targets and
risk and vulnerability to HIV/AIDS and other the global health governance (Bonita et al. 2006).
infectious diseases, teenage pregnancies, poverty, However, other global institutions such as the
and deteriorated maternal and child health (UNI- WTO, the World Bank, and the IMF have the
CEF 2005). Nearly 60% of HIV-infected indivi- potential to influence global health through eco-
duals in sub-Saharan Africa are women, and the nomic policies (Fidler 2002). The MDGs have now
proportion rises to 75% among young people 15– become the central focus of development policy
24 years of age in the region. This process continues nationally and internationally and are regarded as
in a vicious cycle as the breakdown of their families a potentially powerful policy tool to further the
further provides the motivation for family members agenda of improving maternal health and reducing
to emigrate. child mortality. Thus, the relationship between glo-
balization and the MDGs, especially goals 4 (reduce
child mortality) and 5 (improve maternal health),
gives key insight into the relationship between exist-
Migration of Healthcare Professionals ing and changing economies and MCH.
There is evidence that health workers are emigrating

from Africa at an increasing rate to areas like
Western Europe, North America, New Zealand, Goal 4: Reduce Child Mortality
and Australia (Kuehn 2007; Connell et al. 2007;
Stilwell et al. 2004). For instance in 2001 Zimbabwe Target: To reduce by two-thirds the mortality rate
lost about 30% of its newly graduated nurses to the among children under 5 years between 1990 and
UK and other countries. Within the European 2015.
Union, marked migration of health workers from Indicators:
eastern and central Europe has been observed.
(i) Under-5 mortality rate
Migration of health professionals has been attribu-
(ii) Infant mortality rate
ted to low salaries, poor facilities, poor working
(iii) Proportion of 1-year-old children immunized
conditions, and limited career development oppor-
against measles
tunities. Consequently, health service provision
has been adversely affected, especially in remote The MDG report (2005) has shown small improve-
regions. There is a global phenomenon of shortage ments in child survival. For example, in 1960, more
of healthcare professionals. In spite of this fact, than 1 in 5 children in the developing regions died
migrant health workers do not often end up work- before age 5. By 1990, the rate was down to 1 in
ing in healthcare in destination countries. Even those 10 children. Such progress gave hope that child
who succeed to do so often take lower-level mortality could be cut by a further two-thirds by
jobs, such as medical assistants instead of 2015. But advances slowed in the 1990s. Only
working as physicians. This is an enormous waste Northern Africa, Latin America, the Caribbean,
of both national economic resources and individual and South-East Asia have maintained a rapid pace
resources that are put into training health toward progress. The progress has been attributed
professionals. to increased economic growth, better nutrition,
146 S. Wamala
and access to healthcare services. However, unequal individuals to consume sufficient quantity and qual-
progress toward the MDGs by country and by ity of food to meet their daily needs) has deterio-
region underscores variations in socioeconomic rated in many households in Africa, particularly
conditions and other local social policies. Africa those that are headed by females. Improving nutri-
has been highlighted in the monitoring of MDGs tion will continue to be a challenge. If the MDG of
for several reasons. Almost half of all deaths among reducing child mortality is to be achieved, other
children under the age of 5 occur in sub-Saharan major determinants, particularly access to basic
Africa. This increased mortality has been associated public health services, should be met. For example,
with weak health systems, conflicts, and AIDS. The public services should not be included in General
same region has not benefited from the positive Agreement on Trade in Services (GATS) and
effects of globalization in relation to increased eco- national governments should be given more space
nomic growth and decreased poverty. In fact, sub- for policy actions.
Saharan Africa is the only region in the world where
the number of poor people (living on less than $1
per day) has increased since 1990 (Melanovic 2002).
In Africa and elsewhere, poverty is a substantial Goal 5: Improve Maternal Health
determinant of child mortality and survival. There
is a close link between a country’s Gross Domestic Target: To reduce the maternal mortality ratio by
Product (GDP) and child survival. Countries with three-quarters between 1990 and 2015.
high GDP have lower child mortality and vice versa. Indicators:
Basic public health services such as safe water, bet-
(i) Maternal mortality ratio
ter sanitation, and good nutrition are major deter-
(ii) Proportion of births attended to by skilled
minants. Other determinants such as education for
health personnel
girls and mothers are also of great importance and
save children’s lives. Having said this, in the light of The chances of dying during pregnancy or child-
the globalization era, privatization of basic services birth over a lifetime are as high as 1 in 16 in sub-
such as water and energy may not enhance child Saharan Africa, compared with 1 in 3,800 in the
health. Children in developing countries suffer and developed regions of the world. This lifetime risk
die from a comorbidity of disease and adverse con- could substantially be reduced if women had the
ditions. Just five diseases (pneumonia, diarrhea, family planning services they need. Once a woman
malaria, measles, and AIDS) account for half of is pregnant, it is essential that she has good medical
all deaths in children under the age of 5. In spite of care and access to emergency obstetric care facilities
the fact that preventive and treatment measures for in the case of unexpected complications.
these diseases are inexpensive and feasible, there are The MDG report 2005 shows that countries with
no committed efforts to combat these diseases. The already low levels of maternal mortality have made
question is ‘‘Why?’’ Local governments are unwill- further progress, but reductions in the worst
ing or unable to make political commitments to affected regions require additional resources to
social and public health policies that combat these ensure that the majority of births are attended to
diseases. On the other hand, globalization and its by doctors, nurses, or midwives. These medical per-
features leave limited space for national policies and sonnel might be able to prevent, detect, and/or
political decisions (Labonte 2003). manage obstetric complications. However, globali-
In terms of undernutrition and hunger, however, zation has resulted in migration of health profes-
globalization can play either a positive or a negative sionals from low- to high-income countries. This
role. Of the world’s 6 billion people, about 800 means that the majority of women are less likely to
million do not have enough to eat. Africa has the be attended to by trained healthcare personnel. The
largest number of chronically hungry people – hun- issue of migration of health professionals calls for a
ger and undernutrition have worsened, despite global partnership to agree on common actions for
improvements in other regions (FAO 2004b). In policies and guidelines for ethical recruitment of
addition, food security (which is the ability of health professionals. Thus, MDG 8 (develop a
global partnership for development) provides a earning power, but also exposes them to the threat
good opportunity for such common policies (Lee of exploitation and discrimination (Ehrenreich and
et al. 2004). In addition, features of globalization Hochschild 2004). While some forms of reproduc-
can be used to develop immigration policies of tive technology, such as antenatal ultrasound, have
developed countries that facilitate movement at contributed to improved maternal and child health
the same time as incorporating mechanisms to in relation to early detection of illnesses, they are
enhance economic growth in developing countries. prone to abuse, such as when they are used to assist
For example, this could be done by establishing sex-selective abortion (Kohli 2005). These positive
bilateral agreements and standardizing GATS and negative impacts of globalization must be con-
commitments. sidered within their specific contexts: globaliza-
In addition, universal and equitable access to tion’s benefits and drawbacks are unequally distrib-
reproductive healthcare is essential for improved uted among different regions, countries, and
maternal health. However, this improvement is communities (Kawachi and Wamala 2006b). For
hampered by privatization of healthcare services, instance, the declines in extreme poverty in East
which limits access as a result of high costs. This Asia are offset by large increases in poverty in sub-
limitation occurs particularly among the most vul- Saharan Africa, Eastern Europe, and Central Asia,
nerable poor populations, most of which are women as well as a pattern of stagnation in Latin America
and children. and the Caribbean (Kawachi and Wamala 2006a).
Women constitute a large proportion (70%) of poor
people and there is a large proportion of children
Conclusion living in poverty (Gakidou et al. 2007). It remains to
be seen whether the MDGs, including the global
Many features of globalization pose a threat to commitment and partnership, will contribute to
women’s health. For example, economic migration improved maternal and child health in the era of
from poor to richer countries enhances women’s globalization.
Key Terms
Agriculture Foreign direct investment International Monetary Fund

Bill of rights (FDI) (IMF)
Citizens of the world Gender International trade
Contextual determinants of Gender inequality Internet
health Gender-based violence Marrakech Agreements
Copyrights General Agreement on Trade in Migrants
Cross border acquisition Services (GATS) Migration
Deregulation General Agreements on Millennium Development
Distal determinants of health Tariffs and Trade (GATT) Goals
Economic growth rate Globalization Multinational firms
Economic integration Gross Domestic Product North Atlantic Trade
Economic transition (GDP) Agreement (NAFTA)
Employment Hunger Patent
Export Import Patents
Export processing zones (EPZs) Indebted poor countries Pharmaceuticals
Feminization Intellectual property rights Privatization
Pro-growth policies
148 S. Wamala
Proximal determinants of Trade liberalization United Nations Conference on

health Trademarks Trade and Development
Small-scale farmers Trade-Related Aspects of (UNCTAD)
Social fragmentation Intellectual Property Rights Uruguay Round of Multilateral
Street foods (TRIPS) Trade Negotiations
Structural Adjustment Policy Transnational corporation World Bank
(SAP) (TNCs) World Trade Organization
Telecommunications Undernutrition
Cornia GA (2001) Globalization and health: results and

Questions for Discussion options. Bulletin of the World Health Organization
79(9), 834–841
1. What is globalization? List six features of globa- Correa CM (2001) Health and intellectual property rights.
Bulletin of the World Health Organization 79(5), 381
lization and their characteristics. De Vogli R, Birbeck GL (2005) Potential impact of adjust-
2. Using the framework proposed by Huynen et al. ment policies on vulnerability of women and children to
(2005), discuss the determinants of population HIV/AIDS in Sub-Saharan Africa. Journal of Health
health at the contextual, distal, and primal levels. Population Nutrition 23(2), 105–120
Dollar D (2001) Is globalization good for your health? Bulle-
3. List any two global macroeconomic policies tin of the World Health Organization 79(9), 827–833
associated with globalization and discuss how Dollar D (2004) Globalization, Poverty, and Inequality Since
their implementation indirectly impacts on 1980. Washington DC: World Bank Policy Research
maternal and child health. Working Paper 3333 (June 2004)
Dollar D, Kraay A (2001) Trade, Growth and Poverty.
4. Discuss any three pathways by which globaliza- Finance and Development. 8:3. http://www.imf.org/
tion directly effects maternal and child health. external/pubs/ft/fandd/2001/09/dollar.htm Washington,
5. In what ways can the Millennium Development DC: International Monetary Fund (IMF), cited 14 April
Goal targets serve as a tool for monitoring and 2008
Ehiri JE, Anyanwu E (2004) The role of international agen-
addressing the impact of globalization on mater- cies in health policy and practice in less developed coun-
nal and child health? tries. In: Kamel R, Lumley J (Eds.) Textbook of Tropical
Surgery, pp. 85–88. London: Westminster Publishing Ltd.
Ehrenreich B, Hochschild A (Eds.) (2004) Global Woman:
Nannies, Maids, and Sex Workers in the New Economy.
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Chapter 9
Gender Equity: Perspectives on Maternal and Child Health
Rachel Tolhurst, Joanna Raven, and Sally Theobald
Learning Objectives After reading this chapter and infant, and child health status and access to health
answering the discussion questions that follow, you care. The chapter presents an exposition on the
should be able to importance of understanding and mainstreaming
gender into global health policies and programs,
Explain terminologies commonly used in the
using cross-cutting approaches that consider the
gender and health literature, including sex, gen-
role of socioeconomic determinants, effectiveness,
der, gender roles and relations, women’s health
sustainability, participation, accountability, and
gender analysis, gender equity, gender main-
multisectoral approaches. The importance of gen-
streaming, gender divisions of labor, gender
der mainstreaming at the policy, health provider,
norms, gender identity, and bargaining
and community levels is discussed. The chapter con-
positions.
cludes with an examination of current gaps in
Use specific examples to illustrate how gender
knowledge and priorities for future research and
influences maternal, infant, and child health sta-
practice.
tus and access to health care.
A number of key concepts are integral to the
Analyze the importance of mainstreaming gen-
concept of gender inequities in maternal and child
der into global health at the policy, health provi-
health (MCH) (Box 9.1), and these must be under-
der, and community levels.
stood in the context of place and time. Though they
Identify current gaps in knowledge and priorities
may appear to be ‘‘natural,’’ gender roles are
for future research and practice.
socially constructed rather than biologically deter-
mined. Because societies are different, and because
every society develops and changes its practices
and norms over time, gender roles and relations
Introduction
are neither fixed nor universal. In general, how-
ever, the social, economic, and cultural ramifica-
This chapter introduces the concepts of gender
tions of gender roles and relations have significant
equity and gender power relations. It begins with
impacts on the health status of women, infants,
definitions of such key concepts as sex, gender,
and children as well as on their access to care.
gender roles and relations, women’s health and gen-
While gender roles and responsibilities vary across
der analysis, gender equity, gender mainstreaming,
societies, they are rarely equally balanced. Women
gender divisions of labor, gender norms and identi-
and men generally do not have equal access to
ties, bargaining positions, as well as access to and
money, information, power, and influence. In
control over resources. It then illustrates how these
almost all societies, what is perceived to be mascu-
concepts interact to influence and shape maternal,
line is more highly valued than what is perceived to
be feminine, and families and communities treat
R. Tolhurst (*)
women, men, girls, and boys differently. Gender
International Health Research Group, Liverpool School of
Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, roles and relations therefore involve the exercise
England, UK of power.
152 R. Tolhurst et al.
Box 9.1 Key Concepts and Definitions in Gender and Maternal and Child Health
Sex: Biological differences between women and men.

Gender: Characteristics of women and men that are socially and culturally determined.
Gender roles: Activities and responsibilities assigned to women and men.
Gender relations: Interactions between women and men and their underlying structural and institu-
tional influences.
Women’s health: Historically, a discipline that focused on biomedically defined health needs, specific
to women’s biological or sexual makeup.
Gender analysis: Contemporary approach to studying gender that looks at all health issues in order to
understand the ways in which gender roles and relations impact every aspect of women’s and men’s,
girls’ and boys’ health, and to promote gender equity.
Gender equity: Allocation of fair shares between the genders, rather than ‘‘equality’’ which implies
allocation of equal shares.
Gender mainstreaming: Policy response to gender inequities that integrates a consideration of gender
at every stage of health-care planning and provision.
Gender-sensitive policies: Policies that consider and meet the priorities and needs of different groups
of women and men.
Gender division of labor: Different activities assigned by society to women and men at home and at
work.
Productive roles: Paid work or the production of goods for subsistence or sale.
Reproductive roles: Domestic tasks including cooking, cleaning, and caring for children and sick
people.
Community management roles: Participation in various tasks associated with managing community
organizations or maintaining community services.
Gender norms: Implicit guidelines for the capacities, characteristics, roles, and social behavior for
men and women, including their expected social and spatial mobility, their sexual behavior and open-
ness about sexuality, their parental roles, and the acceptability of violent behavior.
Bargaining Power: The extent to which women and men can act in order to protect their own and their
children’s best interests in the case of a conflict with another’s interests.
Access to and control over resources: Women’s and men’s ability to use and control resources such as
money, transport, time, information, political power, and influence.
Sexual and reproductive health rights: Women’s rights to control their fertility and sexual interactions,
rights to safe abortion services, and freedom from sexual coercion and violence for women, men, girls,
and boys.
Triple burden: Term used when women bear the responsibility of productive, reproductive, and
community management roles.
Unequal gender roles and relations influence inequity and such other forms of social disadvan-
many aspects of women’s and men’s health, includ- tage as class, race and ethnicity, not all women or
ing relative health status, vulnerability to illness, men experience gender-related health inequity in the
access to preventative and curative measures, qual- same way. Consequently, the impact of gender roles
ity of services received, and burden of ill-health on and relations on individuals’ health status and
family members. It is important to note that gender health-care access varies.
inequalities work mostly to the disadvantage of Historically, the discipline of women’s health
women, but also sometimes to the disadvantage of focused on biomedically defined health needs, such
men. Because of the interaction between gender as those related to pregnancy. In contrast, the
9 Gender Equity: Perspectives on Maternal and Child Health 153
contemporary ‘‘gender analysis’’ approach seeks to often in a poorer negotiating position because of
understand the ways in which gender roles and rela- their greater social and economic vulnerability if
tions impact on every aspect of health, in order to their relationships break down. Education, control
address related inequities and promote gender over resources, and other socioeconomic factors can
equity. In a health context, equity is concerned with increase women’s bargaining power. Women’s
achieving a system that gives everyone a fair and agency or enhanced bargaining power is positively
equal opportunity to attain their fullest health poten- correlated with many aspects of women’s and chil-
tial. The goal of health equity is to raise the health dren’s health (Lule et al. 2005).
status of the population as a whole and minimize
differentials in health status throughout the popula-
tion. This requires actively recognizing and addres- Gender Perspectives on Maternal
sing the structures and processes that give rise to and Child Health
health differentials and gender inequities. Gender
mainstreaming is the main policy response to gender
inequities agreed to in global health. It is a commit- Social norms and behaviors based on gender affect
maternal and child health throughout the life cycle,
ment toward ensuring gender sensitivity in health
from preconception through old age. Figure 9.1
systems, by integrating a consideration of gender at
every stage of health-care planning and provision. illustrates some of the negative health impacts of
gender inequities in the specific context of South
Gender analysis considers aspects of gender roles
Asia.
and relations in any given context. A key aspect of
gender roles is ‘‘gender division of labor,’’ or the Inequity in nutrition: Much of the inequity at the
various levels shown in Fig. 9.1 can be attributed to
work roles that societies assign to women and
the low value placed on girls’ and women’s well-
men. These include ‘‘productive,’’ ‘‘reproductive,’’
and ‘‘community management’’ roles (Gender and being. This low value may have several dimensions,
including the perceived burden of girls to their par-
Health Group LSTM 1999). Generally, productive
ents and traditional beliefs that differentiate
work is done by both women and men, but it is seen
as men’s work. Though women produce goods and between the needs of boys and girls. The undervalu-
ing of girls often leads to lower access to key
services and often earn money, men usually have
resources such as food and health care. In some
preferential access to such productive resources as
land, tools, capital, and jobs and can earn higher contexts, girls may receive less food or even less
nutritious food than boys and boys may also be
wages. On the other hand, reproductive work is
given better treatment for illnesses. Malnutrition
mainly done by women. Women may work less
hours in ‘‘productive work’’ due to their ‘‘reproduc- during childhood can have severe consequences in
later life. Maternal undernutrition is prevalent in
tive’’ work. ‘‘Community management’’ roles are
many regions. For example, in south-central Asia,
often sex segregated. Men may be more involved
in decision making about the use of community more than 10% of women aged between 15 and 49
years are of short stature (shorter than 145 cm); and
resources, while women are more likely to be
in most countries of sub-Saharan Africa, south-cen-
involved in the day-to-day management of the
tral and south-eastern Asia, more than 20% of
resources. In many societies, women fill parts of all
women have very low body mass index (Black
three roles, while men are involved in one or two.
et al. 2008).
This tendency has led to the concept of the ‘‘triple
In adolescence, increased biological need may
burden’’ borne by women.
interact with low nutritional status to produce par-
Women often have less ‘‘bargaining power’’ than
ticular risks for anemia and malnutrition. Girls’
men to act to protect their own interests or those of
nutritional needs increase in early adolescence
their children in the case of a conflict, including the
because of the growth spurt associated with puberty
ability to make decisions, command resources and,
and the onset of menstruation. The status of girls
at times, influence the behavior of others. This is
within the family and community may also be at its
partly because of gender norms that recognize men
lowest during adolescence. Inadequate diet during
as decision makers, but also because women are
Fig. 9.1 Gender influences on women’s health across the life cycle. Source: Fikree et al. (2004)
this period can jeopardize girls’ health and physical Marriage, Pregnancy, and Sexuality
development, with lifelong consequences. For in Adolescence
example, skeletal growth is delayed by malnutri-
tion, and since a smaller pelvis can prolong labor Pregnancy in adolescence is common in many con-
and obstruct deliver, this can pose serious risks texts. Because of its significant health considerations,
during childbirth. Adolescence sets the stage for a chapter (21) has been dedicated to it in this book.
health and nutritional status in the later years. Here, we will discuss those dimensions of gender
Once pregnant, women are particularly vulnerable relations that contribute to high instance of preg-
to anemia. This may result both from a lack of nancy in adolescence. In some societies, the low
access to resources, and the unequal allocation of value accorded to daughters and the perception
resources between genders, or cultural practices spe- that they are a financial burden to parents supports
cific to one gender. In some contexts, there are the gender norm of early marriage and pregnancy.
taboos against pregnant women eating certain The equation of female status with marriage and
foods, such as animal protein, that could reduce motherhood puts pressure on adolescent girls to
the risk of anemia. Maternal short stature and iron prove their fertility as early as possible in some
deficiency anemia increase the risk of death of the contexts. Girls’ education is often not seen as a
mother at delivery and account for at least 20% of priority because of the perception that a role as a
maternal mortality (Black et al. 2008). wife and mother does not require education, or
that a daughter will marry into another family so when they have children. In many societies, there is
that her family of birth will not gain from the strong pressure on women to bear children, as
investment. In addition, girls are often withdrawn motherhood secures social and economic status.
from school to care for sick family members. Women are often vulnerable to divorce, abandon-
The lower educational status of girls lowers ment, or are forced to put up with a polygamous
opportunities for independence, leaving girls to marriage if they are perceived as infertile. In addi-
look for economic and social support from men. tion, women may not be the decision makers in
Girls who become pregnant while in school often having children. However, high fertility is asso-
lose the opportunity to continue their education. ciated with high levels of maternal mortality,
Girls may seek abortions from informal providers both because more pregnancies mean more chance
in order to avoid expulsion. Adolescent girls are of pregnancy-related death and because preg-
also vulnerable to coerced sex, rape, and abuse, nancy-related risks increase after the third child
often lacking the power and confidence to refuse or (Aliyu et al. 2005). Women who cannot choose
resist unwanted advances. A study in Central African whether to have children are denied a level of con-
Republic found that 22% of women reported that trol over their own health.
their first sexual experience was rape (Chapko et al. Lack of power over sexual interactions and ferti-
1999). Early marriage may also be seen as a practice lity can lead to unwanted pregnancy, and a propor-
that helps maintain the gender norm of male control tion of women will seek abortions. For an in-depth
over female sexuality. The gender norm that unmar- discussion of abortion, refer to Chapter 11 of this
ried women, and particularly adolescents, should not book. Gender norms that deny rights to safe abor-
be sexually active, limits girls’ access to information tion services are a contributor to maternal mortality.
and services that would help them protect their Even when pregnancy termination is permitted,
reproductive health. services are often not available to the full extent
permitted by the law or are not accessible to certain
women, such as young, unmarried women. Under
such circumstances, women may resort to unsafe
Gender and Sexual Relations abortions. Each year, there are an estimated 19
in Adulthood million unsafe abortions worldwide, most in low-
income countries. As a result, around 68,000
Gender identities, norms, roles, and relations at women die each year, making unsafe abortion a sig-
household, community, national, and interna- nificant cause of maternal mortality (Singh et al.
tional levels all influence women’s ability to pro- 2007). The consequences of unsafe abortion are
tect their own sexual and reproductive health. greater in Africa, with nearly half of all deaths due
Many women lack the bargaining power necessary to unsafe abortion.
to negotiate safe sex because they rely on sexual
relationships for social and economic security or
survival. This reduces their ability to choose
whether, when, and how they have sex or use con-
Gender, Health Promotion, and Health-
traceptives, posing the risks of unwanted preg- Seeking Behavior in Pregnancy
nancy, sexually transmitted infections, and vulner-
ability to sexual violence. Gender norms for men Gender norms and identities, divisions of labor
often emphasize risk taking, placing pressure on and control over resources all influence women’s
men to seek multiple partnerships, and reducing willingness and ability to protect their own health
their interest in safe sex. These gender-based norms and seek preventive and curative health care in
around sex are also key factors in family planning pregnancy. In many countries, women continue
decisions and the use of contraceptives, particu- with their full heavy workload right up until
larly of male-controlled methods. Religious and labor and resume work shortly after giving birth.
cultural prescriptions around fertility control can Women’s low control over work burdens prevents
also reduce women’s rights to decide whether and them from taking sufficient rest pre- and post-
labor. This often leads to delays in seeking health that at least one in five women has been physically or
care for themselves and their children (Azubuike sexually abused by a man at some stage in her life
and Ehiri 1998). Women’s low control over house- (DFID 1999). Present throughout the life cycle, from
hold resources often translates into low decision- sex-selective abortion of female fetuses and female
making power to seek health care. Where resources infanticide due to son preference, through child mar-
for care seeking are controlled by men, women may riage and coerced sexual initiation, gender-based vio-
need to convince others of the seriousness of their lence persists in adulthood through rape and physical
illness to seek care. In some settings, men have little and psychological abuse (DFID 1999). The abuse of
understanding of the risks associated with preg- women has an impact on many aspects of their lives,
nancy and delivery but have decision-making including their psychological well-being, bodily
power over the use of household resources for integrity, public participation, autonomy, sexual
health services. In addition, women are often pleasure, and the well-being of their children
socialized to regard their own discomfort as (DFID 1999). Rape, the threat of violence, and sex-
unworthy of complaint, so may not seek care for ual coercion can lead to unwanted pregnancies and
danger signs in pregnancy. unsafe abortions, and sexually transmitted diseases,
Social restrictions on women’s movement may including HIV infection, with consequent effects on
also reduce their autonomy to seek care. For exam- maternal and child health (DFID 1999).
ple, in Northern Nigeria, the purdah system may Gender-based violence is a significant and over-
mean that a husband has to accompany his wife to looked cause of maternal death (Heise 1993). A
use services and she may not be able to access ser- study in the United States found that one in six
vices in his absence (Oxaal and Baden 1996). Gen- pregnant women experienced violence (Oxaal and
dered attitudes toward maternity-related problems Baden 1996). Women beaten during pregnancy are
in some communities may also limit access to care. four times more likely to have a low birth-weight
For example, in some African societies, prolonged baby and twice as likely to miscarry. Fatal injuries
labor may be ascribed to marital infidelity and assis- may also be inflicted on the mother (DFID 1999).
tance may be withheld until the woman confesses to Young unmarried mothers may be particularly vul-
this (Oxaal and Baden 1996). If women do seek nerable to violence and even murder in some socie-
health care, they must give up time that they ties. One abiding problem related to gender-based
would normally spend on household chores such violence is the practice of female genital mutilation
as caring for children, collecting water and fuel, (FGM) (see Chapter 10). Often referred to as
cooking, doing agricultural work, and engaging in ‘‘female circumcision,’’ FGM comprises all proce-
other employment. A study in Zaire showed that 13 dures involving partial or total removal of the exter-
out of 20 maternal deaths occurred during the first 5 nal female genitalia or other injury to the female
months of planting and harvest, when women were genital organs whether for cultural, religious, or
reluctant to go to the hospital because of the need other nontherapeutic reasons (Jones et al. 2004).
for them to work in the fields (Oxaal and Baden This practice affects an estimated 80 million
1996). women worldwide. It doubles the maternal death
rate and increases the risk of stillbirth several times.
FGM can cause obstructed labor and intense dis-
tress during labor (Jones et al. 2004).
Gender-Based Violence
Widespread physical violence and abuse against

women results from a range of aspects of gender
Impact of Gender on Maternal Health
inequality, including women’s limited bargaining Care
positions in the family and broader community,
men’s perceived right to dominate women and gen- Gender affects maternal health care from the com-
der norms that define masculinity as physically tough munity level or ‘‘demand side’’ and from the health
(Oxaal and Baden 1996). Available evidence shows services or ‘‘supply side’’. At the community level,
several factors already mentioned limit women’s planning services (Oxaal and Baden 1996). Conver-
access to health care. Gender divisions of labor, sely, the gender norm that family planning is a
gender norms and identities, access to and control woman’s responsibility means that family planning
over resources, and limited autonomy and bargain- services in many countries are focused on female-
ing positions within the family and community limit targeted methods such as intrauterine devices,
poor women’s ability to use health-care services injectables, contraceptive pills, and female steriliza-
including during pregnancy or delivery (Afsana tion. Services rarely target male decision makers or
et al. 2007). The amount of time, money, informa- support women to negotiate the use of these
tion, and authority for decision making that women methods.
have determines their opportunities to use preven- Some providers may show judgmental and nega-
tive and curative services during pregnancy, deliv- tive attitudes toward women, and especially toward
ery, and the postnatal period. Women often do not poorer, more vulnerable groups of service users
have access to adequate transportation to health (Kim and Motshei 2002). A study of health-seeking
facilities or the cash to pay for it. They have to behavior by pregnant women in southern Malawi
negotiate for transportation with men, other family found that the attitudes and behavior of providers
members, or elders in the community. Lack of were barriers to many women using services due to
transportation can cause delays in emergency situa- the real risk they posed to women’s lives (Tolhurst
tions (see Margaret’s story in Chapter 5). Absolute et al. 2008). Acute human resource shortages and
and relative poverty can pose a serious barrier to poor conditions of service for health workers are
women’s demand for and access to health care. contributory factors toward ill-treatment of clients
On the health system services, or ‘‘supply side,’’ by health providers. The availability of female
obstetric, abortion, and family planning services health professionals may have a strong influence
often do not respond to client’s needs and rights over whether women use services in some contexts.
(Kim and Motshei 2002). Patterns of social and In some cultures, the custom that women should not
gender discrimination that shape society as a be seen by males except for close relatives after
whole influence the rights of women and men in puberty translates into unwillingness to see a male
the health system and shape the maltreatment of doctor. In Northern Nigeria, for example, both
patients and their families (Freedman 2003). Gen- women and men were opposed to female patients
der norms in national and international policies being treated by male physicians (Prevention of
may exacerbate the effect of gender norms within Maternal Mortality Network 1992). In contrast, in
the household. Politically, at international and Ghana, there is a perception that older male physi-
national levels, women’s rights to control their cians were more competent than younger or female
bodies remain a battleground between religious doctors (Prevention of Maternal Mortality Net-
conservative alliances and the radical vision of work 1992).
social change laid out at the landmark conferences Often, services that could address poor women’s
on population policy in Cairo (1994) and women in gendered needs are not provided, such as confiden-
Beijing (1995). tial and quality counseling and testing services, pro-
The goal of access to reproductive health services vision of antiretroviral therapy, STI screening and
for all individuals of appropriate ages was removed treatment, abortion and postabortion services
in development of the Millennium Development (Mayhew 1996). Health systems seldom include
Goals (MDGs), due to pressure from a US-led alli- women in making decisions about health service
ance of social conservatives. In some countries, provision, and there are limited opportunities for
legal or regulatory restrictions prevent groups of women (especially poor women and their families)
women, such as adolescents and unmarried women to influence the way that health services are pro-
from using family planning services (Oxaal and vided. In addition, women’s demand for health care
Baden 1996). In Northern Nigeria, policy requires is likely to be affected more than men’s by rising
men’s consent for women to obtain contraceptives, costs, including user fees and under the table pay-
and in Lesotho, women’s husbands and families ments. In Nigeria, user-fee introduction reduced use
have a ‘‘legal and cultural right’’ to deny them family of maternity care, with hospital deliveries falling by
46% over 5 years and maternal mortality increasing buy appropriate medicines, or seek formal health
by 56% (Tinker and Koblinsky 1993). care. In addition, studies have noted that fathers
have more decision-making power than mothers
about where and when their children should be
treated. However, such dynamics vary subtly in
the degrees and types of decision-making power
Impact of Gender on Child Health Status available to women and cannot be seen as universal.
and Health-Care Access Other factors such as women’s educational status
and position within the household structure may
Gender roles and relations impact directly on chil- interact to influence their decision-making power.
dren’s health and indirectly through the position
and power of their mothers and fathers. Even before
birth, the availability of new technology for deter- Interaction Between Gender Equity and
mining the sex of fetuses may lead to sex-selective Other Socioeconomic Determinants
abortion and risk for female fetuses due to strong
gender norms that value sons. In many countries in
Asia, the male to female birth ratio has increased, As discussed in the introduction, gender differences
with far-reaching social implications. Maternal and inequalities interact with other forms of social
mortality can be affected by health system responses disadvantage or socioeconomic determinants such
to sex selection. To respond to the practice of sex- as age, class, ethnicity, and education status to
selective abortion, a hospital in Gujarat, India, affect health experiences and health outcomes.
stopped providing abortion services. Some women
sought abortions from traditional birth attendants.
Consequently, maternal deaths due to complica- Ethnicity
tions increased (Oxaal and Baden 1996).
Women are the principal providers of care and Ethnicity and caste affect women’s maternal health
nourishment during the most crucial periods of in both resource-poor and resource-rich contexts.
childhood development. However, low resources For example, a study in the United States found
are allocated to childcare in most societies because that from 1940 to 1990 maternal mortality was
it is associated with women’s work. Health services consistently higher for black women than for white
perpetuate this association by targeting women as women (Oxaal and Baden 1996). Black women were
caregivers of children. Health promotion cam- three times more likely than their white counter-
paigns are directed toward women, ignoring other parts to die from maternal causes. Possible explana-
potential caregivers in the household such as tions for this difference include unequal access to
fathers. The gender division of labor and the result- and use of health-care services and disparities in the
ing labor burdens for women also potentially content and quality of care. Studies indicate that
decrease the efficacy of interventions for child sur- black and white pregnant women may be given
vival. Women may not have the time to utilize life- different advice and differential access to technol-
saving technologies and child-care approaches ogy. In Nepal, the utilization of emergency obstetric
(Leslie 1989). Difficulty in taking time off work care varies by caste. One study found that in moun-
was one of the main reasons given by women for tainous areas, high-caste men were unwilling to
not attending a vaccination clinic in Nigeria (Azu- transport Dalit (lowest caste) women to hospital
buike and Ehiri 1998). (Neupane 2004). A study in Ghana showed that
Women’s relatively low ability to control women preferred to travel further, and face higher
resources reduces their opportunity to prevent and opportunity costs, to see providers who were the
treat illness for their children. Women tend to allot a same ethnic group as them (Prevention of Maternal
larger proportion of their income than men to the Mortality Network 1992). This preference was
basic needs of the family but they may not have related to the concept of ‘‘social distance’’ between
access to resources to provide sufficient nutrition, providers and clients which in West Africa consists
of differences in language, behavior, and expecta- disabilities worldwide (see Chapter 18 for discussion
tions. Hence a provider from the same ethnic group on disabilities and MCH populations). Women with
was perceived as having a smaller ‘‘social distance’’ disabilities comprise 10% of all women worldwide,
and worth traveling the extra distance for. and yet, their reproductive health and rights are all
too often neglected (Center for Reproductive
Rights 2002). The sexuality and reproductive rights
Geographic/Regional Variations of women with disabilities and the basic rights of
children with disability are rarely recognized by
society or health policy (Smith et al. 2004). A gen-
The extent of discrimination against girls may vary
eralized assumption that women with disabilities
significantly within one country or region. For
will not be sexually active, and not require repro-
example, in some parts of India, there is evidence
ductive health services, leads to increased vulner-
of greater malnutrition among girls whereas this is
ability to sexually transmitted infection including
not observed in other regions. Cultural and reli-
HIV (Smith et al. 2004). Health professionals are
gious practices and levels of poverty influence dis-
often ill-trained to counsel women with disabilities
crimination. Gender, poverty, and geography also
regarding contraception or pregnancy (WHO
intersect to affect women’s birth experiences with
2001). Women with disabilities are also likely to
direct implications for maternal and child morbidity
encounter various financial, logistical, and physical
and mortality. In Malawi, poorer, less educated and
barriers to accessing safe motherhood and repro-
rural women are more likely to die in childbirth
ductive health services, including the lack of assis-
because of lack of access to services and a skilled
tive devices and suitable and affordable transporta-
attendant (Mann et al. 2006). The poorest 10% of
tion (Smith et al. 2004). Women with disability are
women are nearly twice as likely as the richest 10%
more likely to be concentrated in the poorer sections
to deliver at home or be assisted by a TBA; rural
of society due to a lack of socioeconomic opportu-
women with no school education are nearly four
nities, and are therefore, likely to have low financial
times as likely to be assisted in delivery by a TBA
access to care.
(Mann et al. 2006).
Factors that cause poorer and rural women to
have less access to skilled attendant at delivery can
be categorized as follows (Thaddeus and Maine
1994): Advocacy for Gendered Approaches
Delays in the decision to seek care;
Delays in arrival at point of care; Much of the literature on gender and maternal and
Delays in provision of adequate care. child health comes from a gender equity or rights-
based perspective. The central argument is that gen-
In each type of delay, gender roles and relations der and power shape vulnerability to disease and
intersect with poverty to affect access to resources access to health care, and that women, regardless of
and bargaining power. In rural areas, large distances economic position, age, residence, religion, etc.,
that women must travel to seek care and the relative have a right to good maternal health services. How-
lack of skilled staff in rural health centers make delay ever, advocacy efforts must also link these rights-
in arrival at point of care and delay in provision of based arguments to practical concepts used in pol-
adequate care particularly problematic. icy, such as effectiveness and sustainability. For
example, it could be argued that if gender roles
and relations at community and health service levels
Disability are ignored, maternal health services will remain
inaccessible to poor rural women, undermining
Disadvantage and discrimination due to disability both the effectiveness and sustainability of service
interact with gender relations to produce particular provision. Likewise, both the effectiveness and sus-
vulnerabilities for women and children living with tainability of maternal health services are brought
into question if service provision does not reflect the women’s opportunities to carry out satisfying pro-
needs of different groups of women. ductive work also reduce the chances of improved
Advocacy efforts also benefit from linking argu- maternal health. Partnerships with the Ministry of
ments for better service provision for women to key Education and other stakeholders should strengthen
frameworks or goals at international and national a focus on sexual, reproductive, and maternal health
levels. For instance, Poverty Reduction Strategy Papers in educational curricula and offer increased training
frame debates in many resource-poor contexts and and employment opportunities for women.
often highlight the need for better maternal and child
health. It can be argued that ignoring gender inequities
and power differentials leads to ineffective health poli-
Gender Mainstreaming in Policy
cies and programs and reduces the likelihood of achiev- and Practice
ing MCH-related MDGs. For example, it is widely
recognized that improvements in maternal education From the above analysis, we conclude that many
and women’s control over income will be important in different but interrelated dimensions of gender roles
efforts to reach MDG Goal number 4, which aims to and relations impact on maternal and child health,
reduce, by two-thirds, between 1990 and 2015, the including gender divisions of labor, gender norms
under-five mortality rate (World Bank 2003). and identities, women’s bargaining positions, and
access to and control over resources. These dimen-
sions impact women’s health status over their life
Multisectoral Approaches cycle as well as the quality of health care they are
able to access for themselves and for their children.
Gender impacts on maternal and child health are Ignoring these issues in the design and delivery of
problems to be addressed both within and beyond maternal and child health services is a problematic
the health sector. A more holistic approach to and dangerous oversight. Gender mainstreaming is
women’s general and reproductive health-care needs the agreed approach to addressing gender issues in
may be necessary to create the kind of quality of care in policy and practice. The following sections explore
health services necessary to increase women’s access the main components of a gender mainstreaming
(Oxaal and Baden 1996). For example, there is a need approach in maternal and child health policy and
to strengthen partnerships with the transport sector to practice within and beyond the health sector, at
address maternal health. Multisectoral action, includ- policy, health service, and community levels.
ing public–private partnerships and NGO involve- Gender mainstreaming is the strategic policy
ment to alleviate transportation barriers to maternal approach to promoting gender equity agreed upon
and child health care, has the potential to raise the in the Platform for Action published by the Beijing
status of maternal, infant, and child health in resource- Conference on Women in 1995. The Beijing Plat-
limited settings. Recognition of this challenge is the form for Action states that ‘‘Governments and
impetus behind the work of ‘‘Riders for Health’’ a non- other actors should promote an active and visible
governmental organization (NGOs) whose mission is policy of mainstreaming a gender perspective in all
to ensure that health workers in Africa have access to policies and programs so that, before decisions are
reliable transportation so they can reach the most taken, an analysis is made of the effects on women
isolated people with regular and predictable health and men, respectively’’ (Beijing Platform for Action
care (http://www.riders.org/about.aspx) 1995). As the policy of gender mainstreaming is
Working with education and employment sectors interpreted in practice, implementation strategies
is also important. Low access to education for girls is have been varied. However, there are some com-
a pathway to low maternal status and poor health. monly identifiable elements. First, the approach
Employment that provides status and fulfillment is a should focus on gender equity as a goal and include
factor encouraging the limitation of family size. Low a range of complementary initiatives. A focus on
paid, informal, and insecure work does not demon- gender generally implies working with men as well
strate the same effect (Oxaal and Baden 1996). Thus, as women as beneficiaries of change and as cata-
gender norms and divisions of labor that limit lysts for change. Secondly, gender mainstreaming
generally focuses on organizations as well as their gender differences and patterns in who becomes ill
work, including attention to gender equality within and asks why this may be. The second question
the structure, culture, and staffing of organizations. stimulates a consideration of how women and men
Women as well as men should participate in deci- respond to ill-health – for example, how easily they
sion making at all levels, so that the interests of can utilize health services. To answer these questions,
women as well as men can be integrated into main- we need to consider the various aspects of gender
stream priorities, policies, and programs. Finally, roles and relations, including women’s and men’s
‘‘mainstreaming’’ implies emphasizing the responsi- interactions with the environment, their activities
bility of all staff in organizations such as the health (gender division of labor), their bargaining positions,
sector to ensure a gender equity perspective, rather and access to, and control over, resources, and gen-
than designating this responsibility to ‘‘women’s der norms. We also need to consider these at several
units’’ (Theobald et al. 2005). levels, including the household, community, health
A gender analysis of the specific inequities in rela- services, and national/international levels. Finally we
tion to maternal and child health in any given context need to consider interactions with other social divi-
should form the basis of a gender mainstreaming sions and inequalities, including ethnicity, class, age,
approach. Gender analysis frameworks can stimu- and religion.
late those involved in health policy and planning or Gender analysis should be used to develop poli-
community development to identify how gender cies and interventions appropriate to gender roles
roles and relations may affect planned projects or and relations in a specific context. However,
interventions. An example of a gender analysis fra- there are some key goals that are agreed to inter-
mework focusing on health is given in Fig. 9.2. The nationally. Following the conferences on popula-
first key question in the framework aims to identify tion policy in Cairo of 1994 and on women in
Fig. 9.2 Gender analysis Key questions Aspects of gender

framework. Source: Gender Levels of analysis and
and Health group, Liverpool interactions with other
School of Tropical Medicine socio-economic factors
(1999)
Why do different groups of How does the Households
men and women suffer ENVIRONMENT influence
from ill-health? who becomes ill?
Communities
How do the ACTIVITIES of
How are men and women’s men and women influence
responses to ill-health their health and responses to Available health services
influenced by gender? illness?
Influence of states/markets/
How do the relative
BARGAINING POSITIONS international relations
of men and women influence
their health and responses to Consider how the situation of
illness? women and men may differ
across different social
How does access to and groupings (e.g. race, class,
control over RESOURCES age, religion)
influence the health of men
and women and their
responses to illness?
How do GENDER NORMS

influence health and
responses to illness?
Beijing of 1995, the international consensus on (Oxaal and Baden 1996). At the level of health
population and reproductive rights has shifted sector practice, an important approach to improv-
from an emphasis on reducing fertility through ing the quality and gender sensitivity of maternal
improving women’s status, advocating female edu- and child health-care services is working together in
cation and employment, to the promotion of gender partnership with health workers. Participatory gen-
equality and women’s empowerment (Oxaal and der sensitivity training for health workers has the
Baden 1996). This approach takes a more holistic potential to enable them to drive change from the
view of women’s health and well-being rather than bottom up. An example is the Health Workers for
providing for women only in terms of potential or Change program, which aimed to address the inter-
actual motherhood. Key to this strategic approach personal aspects of quality of care through a series
are the concepts of sexual and reproductive health of workshops (Fonn and Xaba 2001). The work-
and rights. Sexual and reproductive rights include shops included sessions that enabled health workers
women’s rights to control their fertility and sexual to critically analyze provider–client relations, to
interactions, rights to safe abortion services, and become sensitized about how gender relations may
freedom from sexual coercion and violence for impact on health and on provider–client relations,
women, men, girls, and boys. and to assess whether interventions to improve this
A key component of a gender mainstreaming aspect of quality could be developed by health-care
approach is advocacy for policies, services, and workers themselves. Research shows that the work-
resource allocations to establish the sexual and shops enabled health workers to reflect on women’s
reproductive rights of women, men, boys, and girls disadvantage and the impact this has on their
and to ensure that they are met. This goal requires experiences of health care and to identify training
intersectoral collaboration to improve women’s needs to enable them to respond to this more posi-
bargaining power and access to and control over tively (Fonn and Xaba 2001). Training health work-
resources. Policies must aim to improve maternity ers in a participatory approach can enable services
rights, increase girls’ access to education, improve to become more client and gender sensitive and
women’s equitable access to productive resources, therefore more effective (Khanna et al. 2002). How-
and encourage men’s increased contribution to ever, such ‘‘bottom-up’’ approaches are likely to
reproductive work, including caring for children. require resource allocation and a supportive policy
Ensuring sufficient resource allocation nationally to create sustainable change.
and internationally to guarantee the availability It is also important to promote gender equity in
and accessibility of good quality, patient-centered maternal and child health at the community level, or
maternal and child health care, including obstetric ‘‘demand side.’’ At this level, two important strate-
services, requires committed advocacy for improv- gic approaches are (1) involving men in reproduc-
ing geographically equitable provision of services. tive and child health in ways that support women’s
Policy-level approaches to improve access to ser- rights and preferences and (2) encouraging broader
vices include removing user charges, including gender-sensitive community participation in mater-
services in social- or community-based health insur- nal and child health programs. The past decade has
ance schemes, and providing free emergency trans- seen the emergence of programs to encourage men
port to services. to take a more active role in reproductive health
The activity of organized women’s groups is services. Most have focused on involving men in
important for realizing reproductive health and family planning services, but there are examples of
rights worldwide. Involving such groups in policy initiatives focusing on broader maternal and child
and its implementation is a key strategy for improv- health issues such as those aiming to encourage men
ing both participation of, and accountability to, to accompany their pregnant wives to antenatal
different groups of women. Such groups can lobby care appointments, or to improve their parenting
for relevant legal changes, greater commitment and skills (de Koning et al. 2005). By raising awareness
resources to be given to safe motherhood, and they of male partners about obstetric issues, these pro-
can engage in dialogue with health service providers grams aim to improve maternal health outcomes.
over quality of care issues on behalf of patients There is evidence that educating male partners and
increasing male involvement in women’s maternal Research Priorities

health can lead to improved antenatal care atten-
dance and discourage home deliveries (Nanda et al. Despite widespread recognition that gender inequal-
2005). ities are an important influence on maternal and
There is also some experience of the involvement child health, there are surprisingly few published
of men in programs for the prevention of mother to studies examining the influence of gender on mater-
child transmission (PMTCT) of HIV/AIDS and nal and child health and health services. To date,
joint couple approaches to HIV voluntary counsel- there is an insufficient evidence base for many poten-
ing and testing (VCT). In pilot projects for PMTCT, tial approaches to addressing gender inequities. For
male involvement was found to be important for the example, there is insufficient research conducted on
acceptance and uptake of antiretroviral treatment ways to enhance the role of men in improving mater-
(de Koning et al. 2005). VCT programs that counsel nal and child health, as well as a lack of assessment of
couples in which one person is HIV positive have gender sensitivity of existing programs for the invol-
been shown to be significantly more effective than vement of men. There is a clear need to further
individual counseling in preventing transmission develop participative and accountable maternal and
between partners (The Voluntary HIV-1 Counseling child health services. Gendered approaches to parti-
and Testing Study Efficacy Group 2000). However, cipation and accountability that aim to recognize
involvement of men can threaten women’s rights and and address the multiple needs of different groups
autonomy if it is not conducted with a focus on of women and men and power relations in ‘‘commu-
gender. Relatively few programs take into account nities’’ and health systems will arguably lead to more
gender equity when addressing men’s involvement in gender equitable, efficient, and sustainable services.
reproductive health services and even fewer have Additional future research should both incorpo-
been evaluated (de Koning et al. 2005). Consulting rate a context-specific gender analysis of maternal and
and involving women in shaping interventions to child health and services and then evaluate the process
improve male involvement is likely to be an impor- and outcome of approaches to improve gender equity
tant approach to prevent inadvertently threatening in different contexts. Research must address gender-
women’s interests or positions. related barriers to the delivery of quality maternal and
Gender-sensitive community participation in child health care. Researchers must assess approaches
programs that may improve maternal and child to improve the gender sensitivity of providers and
health outcomes includes involving women and evaluate ways to provide incentives for change. In
men in the development of ‘‘birth preparedness addition, further research is needed on the gender
plans,’’ holding advocacy workshops and health division of labor imbalance and decision-making
forums and creating women’s action groups. Some inequities, in order to propose successful gender-sen-
studies have successfully employed behavior sitive approaches for involving men in reproductive
change strategies to mobilize both women and and child health. Finally, there is an urgent need to
men in communities to improve ‘‘birth prepared- improve access to reproductive and maternal and
ness,’’ including awareness of signs of emergency child health services for the most vulnerable groups
obstetric complications and motivating families to of women, including the very poor, unmarried
seek services. Behavior change communication women, HIV positive women, and adolescents. Both
strategies use various reinforcing messages process and outcome evaluation of approaches will
through multiple channels to target both enable researchers to grasp the broader impacts of
men and women (Afsana et al. 2007). When com- interventions on gender equity in society.
bined with ‘‘top-down’’ action to improve obste-
tric care services, facilitating women’s groups
to take action can improve resources and support
Conclusion
available to women. Supporting local women
to influence decision-making processes may lead In order to improve the gender equity, sustainabil-
to increased prioritization of women’s health ity, and efficiency of MCH services, there is an
needs. urgent need to pay greater attention to the multiple
ways in which gender roles and relations affect and regional contexts to address gendered barriers
maternal and child health. This means gender main- to access of quality services at both the health ser-
streaming in policy and practice, and innovative vice (provider side) and community (demand side)
action, grounded in the reality of different country levels.
Key Terms
Access to and control over Gender identity Psychological abuse

resources Gender norms Purdah
Advocacy Gender relations Rape
Autonomy Gender role Religious practices
Bargaining positions Gender-sensitive policies Reproductive roles
Beijing conference Gender-based violence Safe sex
Birth preparedness plans Gendered attitudes Sex determination
Cairo conference on population Intrauterine device Sex-selective abortion
policy Male-controlled family Sexual and reproductive
Caste planning methods rights
Community management roles Male–female birth ratio Sexual coercion
Contraceptive pills Marital infidelity Sexuality
Cultural practices Marriage Social change
Dalit Masculine Social distance
Educational status Maternal mortality Stillbirth
Female genital mutilation Maternity care Traditional beliefs
Female sterilization Millennium development goals Traditional birth
Feminine Motherhood attendants
Fertility control Multisectoral approaches Triple burden
Gender Polygamous marriage Undervaluing
Gender analysis Poverty Unsafe abortion
Gender analysis framework Power relations Vulnerability
Gender discrimination Productive roles Women’s health
Gender division of labor Prolonged labor Women’s rights
Gender equity
Questions for Discussion access to, and quality of, care and the burden of
ill-health on family members. In a short essay of
not more than 200 words, discuss what you
1. Discuss how the traditional women’s health
understand by this statement.
approach differs from the more contemporary
4. Discuss the impact of gender on maternal health
gender analysis approach.
care from the perspective of the community
2. Using specific examples, distinguish between
(‘‘demand side’’) and the health system (‘‘supply
gender analysis and gender mainstreaming.
side’’).
3. It is said that unequal gender roles and relations
5. Using specific examples, discuss the importance
influence many aspects of women’s and men’s
of involving men in health-care program for
relative health status, vulnerability to illness,
women, infants, and children.
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Chapter 10
Harmful Traditional Practices and Women’s Health: Female
Genital Mutilation
Sarah Windle, Chuks Kamanu, Ebere Anyanwu, and John E. Ehiri
Learning Objectives After reading this chapter and interventions in order to identify the best practices
answering the discussion questions that follow, you for prevention. Recognizing that there is no simple
should be able to solution to the problem, the chapter argues that
interventions for preventing FGM should be non-
Identify and discuss the origin, types, and pre-
directive, culturally sensitive, and multifaceted to be
valence of female genital mutilation (FGM).
of practical relevance. Such interventions should not
Critically appraise factors that help to perpetuate
only motivate change but should also provide alter-
the practice of FGM globally.
native options and help communities to establish the
Review the immediate and long-term conse-
practical means by which change can occur. Poten-
quences of FGM and discuss the various
tially effective prevention interventions targeted at
approaches for caring for victims.
local practitioners of FGM, parents, at-risk adoles-
Analyze opportunities for prevention activities
cents, health and social workers, governments, reli-
targeted at local practitioners of FGM, parents,
gious authorities, the civil society, and communities
at-risk adolescents, health and social workers,
are presented. According to the United Nations
governments, religious authorities, the civil
(2008), harmful traditional practices are those prac-
society, and the community.
tices that are based on cultural values and beliefs, but
which are harmful to a specific group within the
culture (typically women and/or children). These
traditional practices are often longstanding and ben-
Introduction
efit some, or all, of the community, but violate the
rights of vulnerable populations. They include
This chapter examines the impact of harmful tradi-
FGM, forced feeding of women, early marriage,
tional practices on maternal and child health, using
early pregnancy, taboos or practices that prevent
female genital mutilation (FGM) as a case study.
women from controlling their own fertility, nutri-
Beginning with a brief overview of harmful tradi-
tional taboos and traditional birth practices, son
tional practices, the chapter discusses relevant
preference and its implications for the girl child (Uni-
terms, definitions, and types of FGM. First, the
ted Nations 2006), and female infanticide. Males are
origin and prevalence of FGM are explored.
typically the main beneficiaries of harmful tradi-
Second, the health consequences and issues related
tional practices, as these practices often lead to loss
to care of victims are discussed, and finally, factors
of female control over sexuality, economic depen-
contributing to FGM are critically analyzed. The
dence, and political subordination.
chapter examines the policy and practice options
Harmful traditional practices have been very
for eliminating FGM and reviews examples of
slow to change over time, particularly given
past national and international reluctance to con-
front problems that are ‘‘cultural’’ in nature (Uni-
S. Windle (*)
Department of Maternal and Child Health, University of ted Nations 2008). In addition, longstanding prac-
Alabama at Birmingham, USA tices are often continued by custom and social
168 S. Windle et al.
reinforcement, perpetuated even by those who human rights of women and girls, and thereby
have themselves been victimized. In this chapter, helps promote national and international advocacy
FGM is used as a case study in order to examine toward its abandonment (UNICEF 2005b). In
the history, causes, prevalence, consequences, and 1990, this term was adopted at the third conference
prevention of a harmful traditional practice. FGM of the Inter-African Committee on Traditional
encompasses all procedures involving partial or Practices Affecting the Health of Women and Chil-
total removal of external female genitalia or other dren (IAC) in Addis Ababa (Shell-Duncan and
injury to the female genital organs for cultural, Hernlund 2000). In 1991, the World Health Orga-
religious, or other non-medical reasons (WHO nization recommended that the United Nations UN
1995). The term FGM does not refer to sex reas- adopt this terminology and it has subsequently been
signment surgery or genital modification of widely used in UN documents (United Nations
intersexuals. 2002). In communities where this practice is
Different terms are interchangeably used to entrenched, the term FGM is viewed as judgmental
describe the act of female genital mutilation. Oppo- with the intention of demonizing certain cultures,
nents of this practice use the term FGM, while religions, and communities. Against this back-
groups who support and practice this ritual tend to ground, the term female genital cutting (FGC) has
use the term female circumcision (FC). Some autho- increasingly been used to avoid alienating commu-
rities argue that the term female circumcision results nities and to show more sensitivity toward indivi-
in an unwanted association between male and duals who have undergone some form of genital
female circumcision (UNICEF 2005a). Some Uni- excision (WHO 1996). FGM is the preferred term
ted Nations agencies use the term ‘‘female genital for policy makers and human rights advocates
mutilation/cutting’’ wherein the additional term working to protect girls and women from the prac-
‘‘cutting’’ is intended to reflect the importance of tice (WHO 1998).
using non-judgmental terminology with practicing FGM was first subdivided into four types in 1995
communities. Both terms emphasize the fact that when it became apparent that classification was
the practice is a violation of girls’ and women’s necessary for measurement, medical management,
human rights (WHO 2008a). and research. The WHO further classified FGM
The term mutilation not only establishes a clear into seven subtypes in 2007 in order to better cap-
distinction from male circumcision but also empha- ture clinically significant variations within types
sizes the gravity of the act as a violation of the (Table. 10.1). The extent of genital cutting typically
Table 10.1 Classification of FGM

WHO modified typology (2007) WHO typology (1995)
Type I: Partial or total removal of the clitoris and/or the Type I: Excision of the prepuce, with or without excision of
prepuce (clitoridectomy) part or the entire clitoris.
When it is important to distinguish between the major
variations of Type I mutation, the following subdivisions
are proposed: Type Ia, removal of the clitoral hood or
prepuce only; Type Ib, removal of the clitoris with the
prepuce.
Type II: Partial or total removal of the clitoris and the labia Type II: Excision of the clitoris with partial or total excision
minora, with or without the excision of the labia majora of the labia minora.
(excision).
When it is important to distinguish between the major
variations that have been documented, the following
subdivisions are proposed: Type IIa, removal of the labia
minora only; Type IIb, partial or total removal of the clitoris
and the labia minora; Type IIc, partial or total removal of
the clitoris, the labia minora, and the labia majora.
(continued )
10 Harmful Traditional Practices and Women’s Health 169

WHO modified typology (2007) WHO typology (1995)
Note also that, in French, the term ‘‘excision’’ is often used as
a general term covering all types of female genital
mutilation.
Type III: Narrowing of the vaginal orifice with creation of a Type III: Excision of part or all of the external genitalia and
covering seal by cutting and appositioning the labia stitching/narrowing of the vaginal opening (infibulation).
minora and/or the labia majora, with or without excision
of the clitoris (infibulation).
When it is important to distinguish between variations in
infibulations, the following subdivisions are proposed:
Type IIIa, removal and apposition of the labia minora;
Type IIIb, removal and apposition of the labia majora.
Type IV: Unclassified: all other harmful procedures to the Type IV: Unclassified: pricking, piercing, or incising of the
female genitalia for non-medical purposes, for example, clitoris and/or labia; stretching of the clitoris or labia;
pricking, incising, scraping, and cauterization. cauterization by burning of the clitoris and surrounding
tissue; scraping of tissue surrounding the vaginal orifice
(angurya cuts) or cutting of the vagina (gishiri cuts);
introduction of corrosive substances or herbs into the
vagina to cause bleeding or for the purpose of tightening
or narrowing it; and any other procedure that falls under
the broad definition of female genital mutilation.
Source: WHO (2008)
increases from Types I to III, with Type IV repre- with the creation of a covering seal by cutting and
senting unclassified varieties of FGM. Type I (cli- appositioning the labia minor and/or labia majora
toridectomy) is the partial or total removal of the with or without excision of the clitoris (Fig. 10.4).
clitoris and/or the prepuce (Figs. 10.1 and 10.2). Type IV (unclassified) is all other harmful proce-
Type II (excision) is partial or total removal of the dures done to the female genitalia for non-medical
clitoris and the labia minora, with or without exci- purposes, for example, pricking, piercing, incising,
sion of the labia majora (Fig. 10.3). Type III (infi- scraping, or cauterization (Fig. 10.5) (WHO
bulation) is the narrowing of the vaginal orifice 2008b).
Fig. 10.1 Clitoridectomy (Type 1a). Source: WHO (2001a) Fig. 10.2 Clitoridectomy (Type 1b). Source: WHO (2001a)
Fig. 10.3 Excision (Type IIb). Source: WHO (2001a)
Fig. 10.5 Stretching of the Labia Minora (Type IV - Unclas-

sified). Source: WHO (2001a)
Egyptian mummies dating from 200 BC (Hathout

1963; Barstow 1999; Skaine 2005). The custom was
then presumably retained and spread throughout
Mesopotamia and the Islamic countries. The pre-
sence of FGM in other regions is also recorded. For
instance, in Europe, some Russian and Romanian
religious sects kept the ritual in order to ensure
perpetual virginity (Worseley 1938). Clitoridectomy
was practiced fairly extensively in the English-
speaking world during the 19th century for the
treatment of diverse medical conditions like nym-
phomania, prevention of masturbation, hysteria,
epilepsy, melancholia, and insanity (Sanderson
Fig. 10.4 Infibulation (Type III). Source: WHO (2001a)
1981).
Origin and Prevalence The WHO (2008) estimates that between 100 and
140 million women and girls have undergone FGM
FGM probably has multiple origins (Odoi 2005; (Types I, II, and III) worldwide. Annually, 3 million
Hathout 1963; Hosken 1992). However, the best girls (mostly under 15 years old) undergo genital
documentation suggests that this practice began in mutilation (WHO 2006). Most women with FGM
ancient Egypt where the people believed in bisexu- live in one of the 28 African or Middle Eastern
ality of the external genitalia (Fourcroy 1983; countries where FGM is practiced (Fig. 10.6).
Skaine 2005). FGM has been discovered on ancient FGM is also practiced in some areas of Asia and
Fig. 10.6 FGM prevalence by country. Source: WHO (2001a)
South America (WHO 2006, 2008a). As shown in predictor of risk for FGM is ethnicity (WHO
Tables 10.1 and 10.2, the prevalence of FGM varies 2008b), which explains how FGM can occur in iso-
greatly within and between countries, although two lated groups in non-practicing regions. For
countries (Egypt and Ethiopia) account for nearly instance, in Indonesia and Malaysia, FGM is fairly
half of all women who undergo FGM worldwide common among the country’s Muslim women (U.S.
(WHO 2006). Department of State 2001), while overall prevalence
The characteristics of girls and women who are is low. It also explains the increase in the practice of
subjected to FGM vary greatly. The strongest FGM in the United States, Canada, Australia, and
Table 10.2 Countries where FGM has been documented

Estimated Prevalence
of Female Genital Mutilation
in girls and women ages
Country Year 15–49 years (%)
Benin 2001 16.8
Burkina Faso 2005 72.5
Cameroon 2004 1.4
Central African Republic 2005 25.7
Chad 2004 44.9
Cote d’Ivoire 2005 41.7
Dijbouti 2006 93.1
Egypt 2005 95.8
Eritrea 2002 88.7
Ethiopia 2005 74.3
Gambia 2005 78.3
Ghana 2005 3.8
Guinea 2005 95.6
Guinea-Bissau 2005 44.5
Kenya 2003 32.2
Liberia* 45.0
Mali 2001 91.6
Mauritania 2001 71.3
Niger 2006 2.2
Nigeria 2003 19.0
Senegal 2005 28.2
Sierra Leone 2005 94.0
Somalia 2005 97.9
Sudan, northern 2000 90.0
(approximately 80%
of total population
in survey)
Togo 2005 5.8
Uganda 2006 0.6
United Republic 2004 14.6
of Tanzania
Yemen 1997 22.6
*The estimate is derived from a variety of local and sub-national studies (Yoder and Khan 2007)
Source: WHO (2008)
Europe as a result of international migration. In 79% respectively), Sudan and Senegal differ by
particular, France has migrant populations from type. Type III accounts for 86% of FGM in the
Benin, Chad, Guinea, Mali, Niger, and Senegal, Sudan, while in Senegal, the majority of FGM
and the United Kingdom often receives immigrants (68%) is Type II, with the prevalence of Type III
from Kenya, Nigeria, and Ghana. In the 1970s, at only 1% (Table 10.3). Age at FGM also differs
refugees from Eritrea, Ethiopia, and Somalia car- significantly among countries (WHO Study Group
ried the practice of FGM into Norway, Sweden, and 2006). In Egypt 90% of FGM is performed between
Switzerland (WHO 2006). ages 5 and 14. In Ethiopia, Mali, and Mauritania,
Ethnicity also affects the type and timing of 50% of FGM is performed on those under 5 years
FGM. Worldwide, approximately 90% of FGM is old and in Yemen, 76% of FGM is performed on
of Types I, II, or IV, with the remaining 10% being those less than 2 weeks old (WHO 2006). FGM may
Type III. Country-level comparisons show wide also be performed on women at significant life
variation in the extent of tissue cut. For example, stages, such as at the time of marriage, pregnancy,
despite having a similar prevalence of FGM (82 and or childbirth (WHO 2006).
Table 10.3 Distribution of FGM status and total FGM by country

No FGM FGM I FGM II FGM III Total
No (%)
Burkina Faso 938 (19%) 1097 (23%) 2172 (45%) 609 (13%) 4816
Ghana 1841 (60%) 353 (11%) 867 (28%) 33 (1%) 3094
Kenya 1681 (40%) 865 (21%) 1201 (29%) 420 (10%) 4167
Nigeria 646 (12%) 3369 (63%) 1310 (24%) 41 (1%) 5366
Senegal 733 (21%) 837 (24%) 1850 (54%) 29 (1%) 3449
Sudan 1332 (18%) 335 (5%) 371 (5%) 5463 (73%) 7501
Total 7171 (25%) 6856 (24%) 7771 (27%) 6595 (23%) 28393
Source: WHO Study Group (2006)
There are also additional distinctions between the than women with secondary or higher school edu-
practice of FGM in urban versus rural areas. How- cation, although this is reversed in some countries
ever, this finding may be partly attributable to the (Burkina Faso, Sudan, and Yemen). This is not to
distribution of certain ethnic populations. In general, suggest that the education of a woman decreases her
the prevalence of FGM is lower in urban areas. The likelihood of undergoing FGM, because FGM in
Population Reference Bureau (PRB 2001) found this the vast majority of cases occurs before school age.
to be true in all countries surveyed except Sudan and Education is correlated with a family’s socioeco-
Burkina Faso (Fig. 10.7). Other than patterns of nomic status, and higher SES may lessen the societal
ethnic settlement, this may be due to higher general influence on the family’s perception of the necessity
education and greater availability of information of FGM (for instance, in order for their daughters
about the practice in urban areas (PRB 2001). In all to find husbands). Urban and more educated
countries, approval of FGM was lower in urban women are less likely to believe that men prefer
compared with rural areas (Fig. 10.8). women who have undergone FGM or that FGM
The Population Reference Bureau (RPB 2001) is an important part of religious practice. Religion
also found that education status directly correlates alone does not affect the prevalence of FGM, as
with the likelihood of a woman undergoing FGM prevalence varies by religion and country together,
(Fig. 10.9). Women with primary or no school edu- likely pointing again to the cultural origins of the
cation are more likely to have experienced FGM practice (Table 10.4).
Fig. 10.7 Prevalence of FGM by urban or rural residence. Source: PRB (2001)
Fig. 10.8 Women who support FGM, by urban or rural residence. Source: PRB (2001)
Fig. 10.9 Prevalence of

FGM by education level.
Source: PRB (2001)
Table 10.4 Prevalence of FGM by religion and country

Muslim Christian Traditional/Other
Country % Surveyed % Circumcised % Surveyed % Circumcised % Surveyed % Circumcised
Burkina Faso 56 78 27 66 17 61
Central African 9 50 90 43 2 42
Republic
Egypt 95 98 5 88 - -
Eritrea 38 99 62 92 - -
Kenya 5 28 92 38 3 31
Mali 91 94 3 85 6 90
Sudan 98 90 2 47 - -
Tanzania 31 14 57 19 12 22
Source: Special tabulations of Demographic and Health Survey data for 1989–2000 by Principia International, Inc. and
published data from ORC Macro. Data for Yemen are not available.
Source: PRB (2001)
Health Consequences of the clitoris may grow as large as 18 cm in dia-

meter (Hathout 1963; Agugua and Egwuata 1982).
Numerous negative health outcomes have been Chronic pelvic infection may result from the pro-
attributed to FGM. These include the immediate gression of acute infection at the time of performing
physical consequences as well as urinary, gyneco- FGM (Rushwan 1980) or the accumulation of vagi-
logical, psychological, and obstetrical complica- nal secretions and urine, especially after Type III
tions (WHO 2000a). Given the dubious legality FGM. Other pelvic infections include recurrent
and sensitive nature of FGM, incidence of these vaginal candidiasis, trichomoniasis, and bacterial
complications is likely to be under-reported. Sur- vaginosis (Larson and Okonofua 1999; De Silva
geons may be motivated to hide complications 1989). FGM was found to be the most common
originating from it and, in communities where cause of gynatresia (obstruction of part of the geni-
FGM is practiced, discussion about genital condi- tal tract) in eastern Nigeria (Ozumba 1992). Such
tions may be embarrassing to the woman (Odoi gynatresia have resulted in the formation of calculi
2005). in the vulva and posterior vaginal fornix (Ozumba
Acute complications are those that occur at the 1992; Shandall 1967; Verzin 1975).
time of FGM. Performance of the procedure in Sexual dysfunction in the form of dyspareunia
unsterile conditions may cause cellulitis, clitoral gang- (pain during intercourse) or even apareunia (inabil-
rene, and sepsis (Nour 2004; Dirie and Lindmark ity to have intercourse) following Type III FGM
1992). Other acute complications include severe has been reported by several authors (Odoi 2005;
pain, hemorrhage, acute urinary retention, and death Hathout 1963; Shandall 1967). Urethral coitus
(Odoi 2005; Dirie and Lindmark 1992; Jones et al. resulting from apareunia and misdirected efforts at
2004). FGM performed during pregnancy may result sexual intercourse has also been reported (Lawson
in the formation of fistulae, as well as pregnancy 1967). Other sexual complications that can occur
complications from hemorrhage or infection (WHO include anorgasmia and coital bleeding. An associa-
2000a). tion between primary infertility and Type III FGM
FGM may result in recurrent urinary tract infec- has recently been established. The likely mechanism
tions. For women with Type I or Type II FGM, is via ascending infections occurring after the pro-
injury may affect the urethral meatus at the time of cedure, causing damage (inflammation and scar-
the procedure or subsequently during labor and ring) to the fallopian tubes which leads to infertility
delivery. Meatal stricture, obstruction, or periure- later in life (Larson and Okonofua 1999; Almroth
thral tears may result from such trauma. For et al. 2005).
women with Type III FGM, the urethral meatus FGM may also put women at increased risk for
may be blocked by the infibulated scar, which can contracting HIV (Brady 1999). The WHO and the
lead to accumulation of urine and menstrual blood, International Federation of Gynecologists and
thereby creating a favorable environment for Obstetricians (FIGO) have hypothesized reasons
ascending bacterial infection into the urinary tract for this presumed link (Kun 1997), including the
(Nour 2004; Dirie and Lindmark 1992; Eke and increased risk of inflammation and bleeding at coi-
Nkanginieme 2006). Signs and symptoms may tus in genitally mutilated women and subsequent
include slow urinary stream, straining, and urinary disruption to the genital epithelium and exposure
retention. Relief may be obtained by surgical open- to blood, abrasions in men attempting vaginal pene-
ing of a urethral stricture or defibulation (Odoi tration, increased risk of hemorrhage in childbirth
2005; Agugua and Egwuata 1982). Urinary reten- due to obstructed labor and tearing of vaginal and
tion during labor appears to be particularly com- perineal scar tissue and the consequent increased
mon in women with Type III FGM and catheteriza- need for blood transfusion, use of unsterilized
tion often cannot occur without defibulation (WHO instruments in the performance of FGM, and the
2000a). practice of the more risky anal intercourse as a
Gynecological complications include the forma- substitute for painful vaginal intercourse (Kun
tion of cysts, chronic pelvic infection, and gynatre- 1997; Rushwan 2000; Jones et al. 2004; Braddy
sia. Epidermal inclusion cysts at the site of excision and Files 2007).
Some authors have suggested that the most

serious adverse effect of FGM is the mental and Box 9.1 Complications of FGM
psychological agony that the victim goes through
(De Silva 1989; Lightfoot-Klein and Shaw 1991). 1. Medical
This is in part because these complications do not Acute urinary tract infections
manifest outwardly as the physical complications Recurrent urinary tract infections
do and are hardly addressed (Odoi 2005). Given Local sepsis at site of operation
the wide variation in age at which FGM is per- Septicemia
formed (WHO 2006), it is likely that psychologi- Transmission of viral infections (HIV,
cal effects from the initial act of FGM will vary HBV)
among women. These may include fear of having 2. Surgical
sexual intercourse, posttraumatic stress disorder, Keloids
chronic anxiety, and depression. These complica- Epidermal inclusion cysts
tions are a consequence of the procedure and the Injury to the urethral meatus
short- and long-term physical complications that Injury to the rectum
follow (Odoi 2005; Braddy and Files 2007; Morris Hemorrhage and shock
2006). During pregnancy, women may have fear
of pain from pelvic examinations, tearing of the 3. Gynecological
infibulation scar, of delivery due to the small size Vulval adhesion
of the vaginal opening, and of incorrect suturing Gynatresia
following birth (WHO 2000a). Immigrants to Hematocolpos
countries with low prevalence of FGM may have Vulval/vaginal calculi
concerns about the knowledgeability of the Acute/chronic PID
healthcare provider with respect to FGM and Primary infertility
fear of cesarean section, episiotomy, or perineal Vesicovaginal fistula (VVF)
repairs because of lack of provider knowledge Rectovaginal fistula (RVF)
(WHO 2000a). 4. Sexual
A recent perspective study by the WHO has Dyspareunia
highlighted a substantial contribution of FGM Apareunia
to morbidity and mortality in women of repro- Anorgasmia
ductive age (Box 9.1). This study revealed that Coital bleeding
women who undergo FGM are at substantially Urethral coitus
higher risk for cesarean section, postpartum
hemorrhage, episiotomy, extended hospital stay, 5. Obstetric
resuscitation of the infant, and inpatient perinatal Increased risk of cesarean section
death compared with women who have not under- Postpartum hemorrhage
gone FGM (WHO Study Group 2006; Morris Increased risk of perineal laceration and
2006). anterior episiotomy
Women who were subjected to FGM as neo- Increased risk of prolonged/obstructed
nates, children, at puberty, or at marriage (as labor
opposed to during the pregnancy) are more likely Increased perinatal morbidity
than women who did not have FGM earlier in life to Increased inpatient perinatal death
experience obstructed labor. Obstructed labor can Increased risk of puerperal sepsis
be severe and directly relates to maternal and fetal 6. Mental and psychological
mortality (WHO 2000a). Type III FGM clearly Posttraumatic stress disorder
presents a mechanical barrier to delivery, but even Chronic anxiety
Types I, II, and IV FGM can result in scarring and Chronic depression
stenosis of the vaginal and vulval tissue from pre-
vious infection, inflammation, or the formation of
vulval adhesions that can obstruct labor (WHO second stage as the fetal head distends the vulva.
2000a). A reduced vaginal opening may make Defibulation at this time has several advantages –
assessment difficult, complicating antenatal and minimal blood loss and reduced risk of trauma to
intrapartum care (WHO 2000a). the urethral meatus as the external urethral meatus
Sequelae to obstructed labor from FGM include tends to be displaced away from the fusion by the
fetal distress and death (WHO Study Group 2006; fetal head. Also the line of fusion of the vulva is
WHO 2000a). Episiotomy and perineal tears are highlighted following full stretching by the fetal
common and these may lead to an increased inci- head (Odoi 2005; Braddy and Files 2007; RCOG
dence of postpartum hemorrhage (WHO 2000a). 2002). A woman who previously had Type III FGM
Obstructed labor may require the use of instruments may request for reinfibulation after vaginal deliv-
or cesarean section for delivery (WHO Study Group ery. This should be discouraged because of the long-
2006; WHO 2000a). Maternal death from impro- term complications associated with infibulation.
perly treated obstructed labor, postnatal infec- Counseling and advice against reinfibulation
tion, and vesicovaginal/rectovaginal fistulae should be offered (Odoi 2005; Nour 2004; Braddy
(from prolonged pressure of the fetal head dur- and Files 2007).
ing delivery) is of particular significance for
women who have had Type III FGM (Verzin
1975; Laycock 1950; Kelly and Hillard 2005;
WHO 2000a).
Factors Contributing to the Practice
of FGM
There are numerous factors that contribute to the

Caring for FGM Patients perpetuation of FGM. The WHO (1999) created a
‘‘mental map’’ highlighting the broad basis for
Women who have undergone FGM should be treated FGM within communities, including some of the
with sympathy, kindness, and in a non-judgmental social, religious, and aesthetic reasons for continua-
way in order to avoid barriers to effective commu- tion of the practice and community enforcement
nication (Odoi 2005; Braddy and Files 2007). Prior mechanisms (Fig. 10.10). These reasons vary in pre-
knowledge of type of FGM, complications, or any valence and strength across regions. Common
previous pelvic examination will be of help in antici- themes include attitudes and beliefs regarding gen-
pating and managing complications in labor. Outside der roles and ethnic identity, religion as justifica-
pregnancy, tight vaginal orifice resulting from Type tion, the perceived necessity of FGM for marriage
III FGM may hinder proper pelvic examination and and chastity, and the economic dependence of
sexual intercourse. Defibulation should be performed women.
anytime on patients’ request, anytime infibulation is FGM practices are deeply entwined with ethnic
detected, after counseling and consent from the identity. This constitutes an important obstacle to
patient, or when she marries. During pregnancy, change (Jones et al. 2004). In many communities
elective defibulation after counseling and obtaining FGM is so entrenched that it is the social norm
consent should be done. This permits a proper pelvic rather than the exception (Jones et al. 2004). In
examination anytime during pregnancy should some instances, one must be physically altered to
the need arise and also a proper assessment of probe perceived as a true woman (Gruenbaum 2001).
gress in labor. It also reduces the risk of prolonged FGM may mark the transition from girlhood to
labor. womanhood. In such communities, elaborate cere-
Defibulation should be done early in the second monies and lessons on the role of a wife and mother
trimester so as to allow for wound healing before are often part of the procedure. However, it is
labor. For pregnant women who present late in the important to remember that in most cultures
third trimester, partial defibulation should be done FGM is performed at such an early age that it
early in labor in order to permit proper pelvic exam- cannot be defined as a transition into womanhood
ination. Full defibulation should be deferred to late (Gruenbaum 2001).
Fig. 10.10 Why the practice of FGM continues: a mental map. Source: WHO (1999)
While religion itself does not influence the pre- Gruenbaum 2001; Balk 2000). In a society where
valence of FGM (PRB 2001), the interaction of mutilation is perceived to protect virginity and vir-
religion and culture may lead to religious justifica- ginity is directly linked to marriageability, we can
tion of FGM. For example, ‘‘Sunna’’ refers to what begin to understand why mutilation might be
the prophet Mohammed has said or done. In some viewed as an important step to realize future mar-
Islamic communities where FGM is prevalent, the riage (Gruenbaum 2001). Such communities also
practice of excision of the prepuce of the clitoris believe that excision of the clitoris or its prepuce
(Type I) is referred to as ‘‘Sunna.’’ This has led to (Type I) helps to curb sexual desire in the woman
the erroneous perception that FGM is closely tied to which ensures chastity after marriage. Furthermore,
Islam. However, FGM is not a religious practice as infibulation (Type III) is thought to increase sexual
it predates the arrival of both Christianity and Islam pleasure for the man by creating a tight vaginal
in Africa and FGM is not known in many Muslim orifice (Odoi 2005; Worseley 1938; Jones et al.
countries (Jones et al. 2004; Gruenbaum 2001; 2004; Gruenbaum 2001; Toubia and Sharief 2003;
Shell-Duncan and Hernlund 2000; Elmusharaf Toubia 1994).
et al. 2006; Lockhat 2004; Rahman and Toubia FGM is common in communities where mar-
2000; Henrieka and Dhar 2003). riage and motherhood are essential to the social
Virginity at the time of marriage and fidelity after and economic security of women. In such settings,
marriage are vitally important in many cultures that a decision to forgo FGM can have negative conse-
practice FGM. In these cultures, FGM is clearly quences (Braddy and Files 2007). Women must rely
associated with chastity (Jones et al. 2004; on their husbands to provide for them in their
reproductive years and their children to care for program credibility and increases its effectiveness.
them in their old age (Jones et al. 2004). As a result, According to the WHO (De Silva 1989), ‘‘commu-
women themselves are often the strongest advocates nities need to play a central role in any initiative’’
of the practice because they believe it will ensure targeting FGM. The alternative ritual program
important benefits (marriage and security) for their implemented by the Mandeleo Ya Wanawake
female children (Braddy and Files 2007; Jones et al. organization (MYWO) in Kenya is an example of
2004; Gruenbaum 2001; Dorkenoo 1996; Gerais a highly successful intervention that involved the
and Bayoumi 2001). community in the planning and implementation of
the intervention. MYWO involved the community
by seeking their help in developing a conceptual
framework for the problem in their community,
Implications for Policy and Practice designing and exploring the feasibility of the
program, and implementing the program (De
Interest in curtailing the practice of FGM has Silva 1989).
increased in the past 20 years. Although the political It is important for FGM prevention programs to
and legal environment toward the practice has be non-directive. While education about the harm-
become more hostile, this awareness has yet to ful effects of FGM is important, the program
translate into measurable changes in prevalence should not seek to force communities to end the
(Jones et al. 2004). Identifying the most effective practice. Past directive approaches have been seen,
and appropriate strategies for eliminating FGM is with good reason, as imperialist attempts by ‘‘out-
among one of the most bitterly contested issues siders’’ to meddle in cultural issues they do not fully
surrounding the practice (Larson and Okonofua understand (Dirie and Lindmark 1992). These pro-
1999). Simple educational campaigns dealing with grams have not only failed to eliminate the practice
the health consequences of genital mutilation have but may also have actually created more resistance
not been as effective as was once expected (De Silva to change among some groups (Dirie and Lind-
1989). Program planners assumed that once people mark 1992; De Silva 1989). A more appropriate
realized the dangers associated with FGM, the prac- goal for intervention programs is to seek to educate
tice would be immediately abandoned; unfortu- people about human rights and the health conse-
nately, this has not been the case. Although educa- quences of FGM and to be available to help the
tion about health risks is an important component communities change when they determine they are
of change, intervention programs that do not ready to do so (Nour 2004; De Silva 1989). The
address the causes of FGM will not be effective in history of FGM among the Sabiny people in the
ending the practice (Dirie and Lindmark 1992; De Kapchowra district of Uganda illustrates the
Silva 1989). importance of a non-directive approach. Efforts
Since female genital mutilation is a highly sensi- to stop the practice among the Sabiny began with
tive and culturally embedded practice, it is critical the arrival of Christian missionaries in the district
for program strategies to be based on community in the 1930s and 1940s. Sixty years of education,
values, customs, and roles of interaction (De Silva health risk communication, and awareness-raising
1989). Those introducing prevention interventions campaigns yielded little success (De Silva 1989). In
must be familiar with the settings in which their fact, the Sabiny community was so offended with
programs will be implemented (Verzin 1975). Sig- arrogant ‘‘outsiders’’ passing judgment on their cul-
nificant formative research should be done not ture and traditions that one campaign program was
only on the prevalence and type of FGM practiced actually linked to a dramatic increase in the num-
in the area but also on the community perceptions ber of girls who underwent FGM (De Silva 1989).
and relevant importance of the practice within the This disturbing increase led to the creation of the
culture. Better understanding of the practice Reproductive, Education and Community Health
within the community and culture where the pro- (REACH) project, which was designed with invol-
gram is being implemented makes the intervention vement from the local community. REACH’s fra-
more salient to the target audience. This gives the mework allows the Sabiny people to determine the
process by which they will change harmful prac- Practitioners of FGM

tices, and at what pace and how the changes will
occur (De Silva 1989). Despite the fact that the number of urbanized
The success of this type of non-directive strat- parents who take their daughters to healthcare
egy, termed a ‘‘sensitive persuasive’’ approach by providers to undergo FGM is increasing, the
the WHO (De Silva 1989), has been highlighted practice is still being performed predominantly
in a program in Senegal, in which communities by ‘‘traditional female excisors’’ (De Silva 1989).
were involved in a year-long educational inter- The performance of FGM is considered a skill
vention that taught human rights and women’s and the women who perform it are paid for their
health with emphasis on the risks and dangers of work. Educational programs teaching these
FGM (Lawson 1967). The results have been women the health risks associated with FGM
impressive. In Senegal, 708 villages, representing are needed. After having the opportunity to
13% of the country’s population that observed learn about the harmful effects of mutilation,
the practice, have made public declarations these women should be offered the opportunity
abandoning FGM. The remarkable thing about to be trained in an alternative skill. Without
the results, as the program planners noted, was offering retraining to circumcisers, the women
that the program never asked people to stop would have no way to financially support them-
FGM. ‘‘Usually, participants come to the deci- selves and it would be unlikely that they would
sion to abandon the practice on their own’’ stop practicing their trade. While retraining
(Lawson 1967). The decision to end the practice efforts would vary slightly depending on the
must be made by the people of practicing cul- local infrastructure and needs, these women
tures themselves if there is to be real and lasting could be retrained as village health workers or
change. birth attendants. The retrained women could
Given that FGM is a problem with many then begin to work toward solving the most
causes, programs addressing the issue must pressing problems facing their communities, such
have many facets to be effective. Eradication of as communicable diseases and malnutrition. In
a deeply entrenched practice like FGM cannot addition to providing skilled workers to combat
be accomplished through a singular approach growing health problems, many of which are of
(Almroth et al. 2005). Program implementers greater immediate concern than FGM, retraining
must focus their strategies on understanding traditional circumcisers would allow these women
and addressing the core values, myths, and to retain their place of importance and respect in
enforcement mechanisms that support the prac- the society without continuing the practice of
tice (De Silva 1989). A successful program must FGM (De Silva 1989).
not only motivate the community to change, but More than a third of responding agencies sur-
it must also provide alternative options and the veyed during a WHO program evaluation
means through which the anticipated change can thought that alternative income and retraining
occur. Intervention efforts should target several programs for excisors were very effective strate-
different groups, including practitioners of gies (De Silva 1989). Programs such as the one in
FGM, parents, at-risk adolescents, heath and Ghana that retrained circumcisers to become
social welfare professionals, religious leaders birth attendants initially yielded positive results
and other authoritative figures, relevant govern- (Laycock 1950). Other programs utilizing this
ment institutions, and the civil society. These strategy have resulted in a large percentage of
preventive approaches are described in the circumcisers stopping the practice temporarily
following sections. More details regarding best or, in some cases, permanently (Jones et al.
practices in FGM prevention can be found 2004). However, used in isolation, this approach
in the World Health Organization’s (1999) has proven ineffective since it does not reduce the
publication entitled ‘‘FGM programmes to demand for FGM in the community (Jones et al.
date: what works and what doesn’t: a review.’’ 2004; De Silva 1989; Laycock 1950). Retraining
of circumcisers must be done in conjunction with
community education if retraining efforts are to their daughters’ feet bound and not to let their
foster lasting change. sons marry young women with bound feet (Larson
and Okonofua 1999; Kelly and Hillard 2005).
Pledge societies operate on the principle that
change is desired, but not carried out because of the
Parents social consequences associated with it. Applied to the
issue of female genital mutilation, this means that
Parents of children and adolescents are a second some parents have their daughters undergo FGM
important target audience for change efforts. not because they support the practice but because
Among this group, the motivation to continue the they fear other families will not allow their sons to
practice of FGM is predominantly social confor- marry a young woman who has not undergone the
mity. Parents fear that if they do not follow the procedure. Parents of daughters joining the pledge
status quo, their daughters will suffer because they society would vow not to have their daughters
are considered unmarriageable. Parents do not have undergo FGM; parents of sons joining the society
their daughters undergo FGM because they do not would pledge to allow their sons to marry these girls.
love them; they have them undergo the practice This creates a new ‘‘marriage market’’ for those who
because they love them. They may perceive this to choose not to practice genital mutilation. Parents of
be the best way to ensure their daughters’ future daughters are guaranteed that their children will have
safety and happiness (Rushwan 1980). Successful marriage opportunities if they do not undergo FGM
programs must help provide a system where the and what seems to be the greatest perceived barrier of
prospect of marriage exists for girls who have not ending the practice is eliminated (Rushwan 1980).
undergone FGM. Programming for parents should The Population Reference Bureau (Shandall
provide education about the health consequences 1967) attributed much of the success of the Sene-
and human rights aspects of FGM. Parents should gal-based Tostan program to this type of approach
be introduced to the idea that not all cultures prac- which ‘‘enables people to agree collectively to stop
tice genital mutilation. At the end of the educational the practice so that no one family stands out or no
phase, families who are ready to embrace change one person becomes socially stigmatized and thus
should be encouraged to form a pledge society unmarriageable.’’ Public declaration programs
(Kelly and Hillard 2005). appear to have been responsible for the rapid and
The value of the pledge society approach has total abandonment of FGM in several villages in
been demonstrated through its success in ending Senegal (Laycock 1950). The pledge society
foot binding in China in the early 1900s (Kelly and approach has proven successful because it takes
Hillard 2005). Foot binding involved tightly wrap- into account the fact that ‘‘discontinuation of
ping the feet of young girls after bending the toes FGM is largely a matter of social rather than indi-
under the feet, forcing the sole of the foot to the vidual change’’ (De Silva 1989).
heel. Girls who underwent foot binding matured
with tiny feet, perhaps only 5 in. in length. Although
foot binding was painful and caused lasting health
problems for women, its practice was perpetuated At-Risk Adolescents
with the belief that it ensured the honor of the
family and the virtue and marriageability of the Another target group for intervention should be
young woman (Kelly and Hillard 2005). Like children and adolescents considered ‘‘at risk’’ for
FGM, foot binding was an entrenched cultural female genital mutilation practices. Young people
practice that had existed for thousands of years are an important target for intervention because
when intervention programs began (Rushwan they tend to be less attached to cultural traditions
1980). Foot binding eradication efforts included and more easily influenced with sound arguments
not only education about negative health conse- about the harmful effects of FGM than older mem-
quences of the practice but also the formation of bers of the same community (De Silva 1989). Inter-
associations of parents who pledged not to have ventions geared toward reaching adolescents are of
especially critical importance in cultures and com- This is a ceremony that includes a week-long pro-
munities that closely link initiation with FGM (Lar- gram of counseling, training, and provision of
son and Okonofua 1999). Programs for adolescents information to young women. It ends with a ‘‘com-
should be intensely culturally sensitive and should ing of age’’ celebration that involves music, dan-
offer education while incorporating cultural prac- cing, presents, and feasting (Lightfoot-Klein and
tices and values whenever possible. For example, in Shaw 1991; Braddy and Files 2007). This program
a society where group seclusion during and after is reported to have prevented over 1000 FGM pro-
FGM is common, the alternative transition ritual cedures in its 8 years of operation (Larson and
might involve the girls leaving their community to Okonofua 1999). Although the long-term success
participate in the educational program. If commu- of the alternative ritual approach has not been
nity or family celebrations are part of the FGM fully evaluated, recent reports from Kenya suggest
tradition, these celebrations could be held when that it is a promising strategy, especially when used
the young woman finishes the alternative program. in conjunction with other approaches (De Silva
Although the details of this type of intervention 1989; Lightfoot-Klein and Shaw 1991). An impor-
will vary from culture to culture, the girls should be tant aspect of Ntanira Na Mugambo is the flex-
provided with information not only about FGM ibility that arises from the ability to stress various
practices and health consequences but also practical components in response to community character-
knowledge of basic health care. Family planning, istics. The success of this program has also been
reproductive rights, HIV/STDs, and child health linked to the involvement of the entire family,
practices would be possible topics to address. A community, and the inclusion of a male motivation
second part of the educational program should pro- component.
vide the young women with knowledge of relevant
cultural practices and traditions, such as what is
expected of a wife and mother within the commu-
nity. Ideally, the FGM alternative program pro- Health, Social, and Economic Sectors
vides a way for communities to keep cultural ideals
and values without keeping the harmful practice of The increasing medicalization of FGM mandates
FGM. While help from cultural outsiders might be further research and creation of sensitization and
needed in the planning stages, this program should training programs for nurses, midwives, and other
be implemented entirely by people inside the com- health professionals (WHO 2001). Exploration of
munity. ‘‘Wise women’’ of the culture trained in the use of religious leaders and other authoritative
basic health care should become the instructors for figures in the society, including law enforcement offi-
the educational program. The alternative teaching cials, as agents of change for harmful traditional
ritual has the potential to empower the older women practices like FGM is needed. It is also important
by emphasizing their status and authority while that governments utilize many strategies, including
empowering the young women by emphasizing the establishing government departments or ministries
importance of the role they are taking in their cul- to look after women’s issues, strengthening safe
ture, as well as the importance of the culture itself. motherhood initiatives, improving the knowledge
Girls initiated into similar programs report that the and skills of health and social workers, and collabor-
training raised their self-esteem (Laycock 1950). ating with non-governmental organizations (NGOs)
The young women also develop a support system and the private sector (RCOG 2002). The World
through the program that strengthens and helps Health Organization has produced several training
them adjust to the changing roles they are expected materials (WHO 2000b, 2000a, b) that would serve
to fill in their communities (Laycock 1950). as a useful resource for programs that seek to enhance
The most well-known example of an alternative the skills of health workers in addressing FGM.
ritual program currently in progress is a project Health, social, and economic sectors should coop-
based in Meru, Kenya, in which several commu- erate and collaborate in order to empower women
nities have organized events which they call ‘‘Nta- in the areas of education, social status, and technol-
nira na Mugambo’’ (circumcision through words). ogy. Many governments have already made
commitments at the UN Special Session on Children the practice of FGM was long-standing and the
(Gruenbaum 2001) to end FGM in their countries. prevalence of FGM among girls aged 15–19 years
What is urgently needed is for these governments to was 34%. Although FGM had been illegal since
establish the foundation for change recommended by 1994, the practice was still socially condoned as a
the WHO (De Silva 1989) which includes the estab- rite of passage ritual for adolescent girls. Interven-
lishment of strong and capable institutions that imple- tions involving a community participation
ment anti-FGM programs at the national, regional, approach were used in three communities with a
and local levels; support for FGM elimination with fourth community as a comparison group. One
positive policies, laws, and resources; mainstreaming intervention community participated in FGM edu-
of FGM prevention issues into national reproductive cation activities including group discussions,
women’s health and literacy development programs; videos, clinic and school-based education, anti-
training of staff who can recognize and manage the FGM song and drama competitions, and radio pro-
complications of FGM; coordination with non-gov- grams. Another intervention community partici-
ernmental agencies; and support for advocacy that pated in livelihood and development activities
fosters a positive policy and legal environment, including learning skills such as crafts and market-
increased support for programs, and public education ing, reproductive health education, and culturally
(De Silva 1989). This foundation will not only ensure relevant skills such as preparation of traditional
cross-cultural feasibility of the public health actions dishes. The third intervention community partici-
proposed in this chapter but will also result in mean- pated in a combination of both programs.
ingful reduction of the practice of FGM and thus its Controlling for age, marital status, religion, and
impact on women in these nations. education, the community participation and educa-
In addition, governments should demonstrate tion intervention compared with the control group
political commitment through policies that address was associated with a 93% decrease in the incidence
poverty, nutrition, adolescent health, violence of FGM and the combined community participa-
against women, and sexual abuse. Strategies to tion/education/skills intervention was associated
foster active dialogue and engagement of national with a 94% decrease in the incidence of FGM. The
institutions, including the media, religious institu- community participation and development activ-
tions, and the civil society, to openly confront ities showed a decrease in the incidence of FGM
FGM and to ensure that women and families who that was not significant. Survival analysis deter-
choose not to undergo FGM are not discriminated mined the percentage of girls who had not under-
against must be identified and utilized. Teachers, gone FGM at age 15 at the start of the study and still
social workers, and community groups that inter- had not at age 19. The incidence of FGM was found
act with families must be encouraged to play sig- to be similar in all three intervention groups and
nificant roles in preventing FGM through active nearly 4% higher in the control group (Fig. 10.11).
education and advocacy. The following are Reported challenges were that the baseline preva-
abridged versions of the case studies selected by lence of FGM was lower than expected (necessitat-
the Population Reference Bureau (2006) to repre- ing expansion of the study area) and that some girls
sent examples of successful interventions for who had initially reported having undergone FGM
FGM. denied it in future surveys. Reversal of FGM status
was determined to not bias the results, as it occurred
similarly across all groups.
The Navrongo FGM Experiment
Between 1999 and 2003, efforts were made to hasten Intrahealth International in Ethiopia
the elimination of FGM in a portion of the Kas-
sena-Nankana district of northern Ghana and to This intervention’s objectives were to identify current
determine which strategies were the most effective knowledge, attitudes, and practices regarding FGM,
in reducing the practice. This is a rural area where develop the capacity of community leaders to
Fig. 10.11 Survival analysis: the probability of not undergoing FGM over time. Source: PRB (2006)
advocate against FGM, increase knowledge and occurred before age 10. The practice is supported with
change attitudes of community members about religious justification, a belief that FGM makes
FGM, and to monitor and evaluate the impact of women better wives, by the idea that it protects a
the interventions. The prevalence of FGM in Ethiopia daughter’s reputation and marital prospects, and
in 1998 was 73% and a study in 2003 indicated a trend even by the idea that it is necessary to stop the clitoris
toward less extreme forms of FGM. Of girls under- from growing. Three areas were selected for interven-
going FGM, 50% occurred before age 1 and 88% tion because of their higher than average prevalence
Fig. 10.12 A 5-dimensional approach to eliminating FGM in Ethiopia. Source: PRB (2006)
rates: Oromia (90%), Somali (99%), and Harari community participation, coverage of FGM in
(94%). multiple dimensions, transfer of the project to
This intervention took a five-dimensional local stakeholders, multimedia training aids,
approach to reducing FGM (Fig. 10.12). These focus on ending demand for FGM, encouraging
dimensions were health, gender, religion, human community discussion and bridging gaps between
rights/law, and information. Activities included social groups, respecting the social–cultural con-
engaging and empowering community leaders with text of the practice, and working with local per-
education, advocacy, communication skills, mobili- sonnel and knowledge bases as well as other
zation of the community through reducing knowl- organizations.
edge gaps, initiating discussion, and formulating
grassroots action plans. Activities resulting from
community mobilization included
Tostan Community Empowerment
public demonstrations; Program
anti-FGM arts (drama, music, etc.);
traditional ceremonies such as the slaughtering
Tostan is an NGO in Senegal and Guinea, where
of sheep; and
the overall prevalence of FGM in women (15–49)
anti-FGM declarations.
in 2005 was 28.2 and 95.6%, respectively. The
Multimedia were used in the form of pamph- areas in Senegal in which Tostan worked often
lets, televised drama, and radio announcements. A had prevalence rates above 90%. Over the past
forum of religious leaders was held to discuss decade, it is estimated that Tostan had 60 partici-
FGM and reach consensus on public banning of pants in each of 2,000 villages. The Tostan
the practice. Project successes were measured approach is based on the social convention theory
through qualitative data only. They include legis- of FGM which argues that FGM is practiced
lation that made FGM illegal, a consensus of 83 mainly to ensure community membership. On
national and religious leaders to criminalize and this basis, abandonment of the practice would be
ban FGM, the participation of 4,200 community fairly rapid if it were a collective decision. Tostan
members in the intervention, public promises to conducted over 200 education sessions over a 2- to
stop performing FGM by 7 well-known practi- 3-year period. These sessions covered democracy,
tioners in the community, and 2,252 community human rights, responsibilities, problem-solving
members publicly agreeing to ban FGM. Addi- methods, hygiene and health (including discus-
tional successes include the support of various sions on early marriage, childbearing, sexually
religious leaders, continued coverage of the inter- transmitted infections, FGM), literacy, math,
vention by the media, and adoption of the project and management skills. The approach emphasized
dimensions by local organizations. Feedback the underlying essential components of credibility
from the project suggests that its strengths were of information, belief that people will make good
Table 10.5 Attitudes of men and women toward FGM

Intervention Group Comparison Group
Endline
Baseline Participant Non-participant Baseline Endline
Women (n) 576 333 200 199 200
h Approve of FGC 72 16* 28* 89 60*
h Will cut daughters in the future 71 12* 23* 89 54*
Men (n) 373 82 185 184 198
h Will cut daughters in the future 66 13* 32* 78 56*
h Prefer a woman who has been cut – 20 40 – 63
*p<0.05
Source: PRB (2006)
decisions when they are informed, learner-cen- (33% of communities that practiced FGM in
tered, holistic, practical, and respectful of cultural Senegal in 1997).
learning practices. It also used an ‘‘organized dif-
fusion’’ strategy, whereby participants shared
what they had learned by choosing another person
to teach.
Conclusion
The Tostan intervention was unique in that it
did not explicitly target FGM. The inclusion of a
session on FGM explicitly was only done after Many observers of the FGM controversy have
participants requested it. When two communities asked whether such a complicated and entrenched
initially decided in 1997 to end FGM, the spread cultural practice can ever be successfully changed.
of the movement was largely due to the efforts of The answer to this question is a resounding ‘‘Yes’’
an Iman (an Islamic religious leader) who was (Dirie and Lindmark 1992; Jones et al. 2004;
concerned that girls from these villages would Rushwan 1980). However, evidence shows that
not be able to intermarry with other areas that this can only be achieved through gradual persua-
had not abandoned FGM. He took it upon him- sion, sensitization, and community education on
self to speak with members of the surrounding human rights and health aspects of FGM, as well
communities also about ending the practice. This as efforts to change socioeconomic factors that
resulted in the first public declaration of FGM perpetuate the practice. Women need to be pro-
abandonment in 1998. vided with avenues for the expression of their
The Tostan approach has been evaluated by social status approval and respectability, other
outside organizations a number of times. One than FGM. Mere repression through legislation
evaluation found that the intervention resulted in has not been successful (Morris 2006) since people
increased knowledge of FGM, decreased the pro- will only stop practicing FGM when they are pre-
portion of girls under age 10 who were undergoing sented with a safe alternative that preserves their
FGM, and decreased approval of FGM and intent culture and protects the welfare of their daughters
to subject daughters to the practice (Table 10.5). (Rushwan 1980). Even now, individuals and
Another evaluation concluded that FGM and families are challenging laws banning FGM prac-
forced/child marriages had been abandoned in tices in spite of the great risks (Dirie and Lind-
83% of communities visited (22 of 24), and lit- mark 1992; Rushwan 1980). Societies have proven
eracy/education classes were well attended. Other to be open to interventions to end FGM when the
evaluations confirmed positive changes in atti- community is included in program planning and
tudes, knowledge, and health practices, abandon- implementation (Jones et al. 2004; De Silva 1989).
ment of FGM in project villages, and greater dis- Change has already begun. The ancient practice of
cussion about FGM in non-project villages. As of FGM, which currently undermines the health of
July 2006, Tostan estimated that as a result of its millions of the world’s women, will eventually
work, FGM was ended in 1,748 communities come to an end.
Key Terms
Acute urinary retention Female genital mutilation Perineal repairs

Adolescent health Female genitalia Periurethral tear
Alternative ritual Female infanticide Piercing
Anorgasmia Fertility Pledge societies
Anti-FGM songs Fistula Postpartum hemorrhage
Apareunia Foot binding Posttraumatic stress disorder
Ascending bacterial infection Forced feeding Prepuce labia minora
At-risk adolescents Gender Pricking
Bacterial vaginosis Genital excision Public declaration programs
Beliefs Genital modification Recurrent urinary tract
Calculi Female circumcision infection
Catheterization Girl child Reinfibulation
Cauterization Gynatresia Religious leaders
Cellulitis Harmful traditional practice Sensitive persuasive
Cesarean section Hemorrhage approach
Christianity Human rights Sepsis
Chronic anxiety Hysteria Septicemia
Chronic pelvic infection Infection Sex reassignment surgery
Circumcisers Infibulated scar Sexual abuse
Clitoral gangrene Infibulation Sexual dysfunction
Clitoridectomy Infibulations scar Sunna
Clitoris Insanity Tostan program
Coital bleeding Islam Traditional birth practices
Coming of age Keloids Traditional female excisors
Cultural outsiders Labia majora Trichomoniasis
Cultural values Male circumcision Unsterilized instruments
Custom Marriageability Urethral coitus
Defibulation Masturbation Urethral meatus
Depression Meatal stricture Urinary retention
Dyspareunia Melancholia Urinary tract infection
Early marriage Menstrual blood Vaginal candidiasis
Early pregnancy Ntanira na Mugambo Vaginal orifice
Epidermal inclusion cysts Nutritional taboos Violence against women
Episiotomy Nymphomania Virginity
Ethnicity Obstetric complications Vulnerable populations
Fallopian tubes Organized diffusion Vulval adhesion
Female control over sexuality Painful vaginal intercourse Wise women
Female genital cutting Perineal laceration Ya Wanawake
Questions for Discussion Elmusharaf S, Elhadi N, Almroth L (2006) Reliability of self

reported form of female genital mutilation and WHO
classification: cross sectional study. British Medical Jour-
1. Identify and describe the four types of FGM. nal, 333, 124
2. Discuss any two factors that influence the prac- Fourcroy JL (1983) Review of female circumcision. Urology,
tice and type of FGM in developed and less XX11(4), 458–461
developed countries. Gerais AS, Bayoumi A (2001) Female Genital Mutilation
(FGM) in the Sudan: A Community Based Study. Uni-
3. Distinguish between acute and gynecological versity Press Khartoum
complications of FGM. Gruenbaum E (2001) The Female Circumcision Contro-
4. It is said that educational campaigns that provide versy. Philadelphia: University of Pennsylvania Press
information on the health consequences of FGM Hathout HM (1963) Some aspects of female circumcision.
Journal of Obstetrics and Gynecology of the British
have not been effective. In an essay of about 250 Empire, 70, 505–507
words, discuss reasons for the failure of such Henrieka E, Dhar J (2003) Female genital mutilation in the
programs. Sudan: survey of the attitude of Khartoum University
5. Using a table to structure your response, produce at students towards this practice. Sexually Transmitted
Infections, 79, 220–223
least one strategy for preventing the practice of Hosken FP (1992) Genital and sexual mutilation of females.
FGM at the following levels – local practitioners The Hosken Report. Third Review Edition. Women’s
of FGM, parents, at-risk adolescents, health and International Network News (WINN), 18, 4
social workers, governments, religious authorities, Jones SD, Ehiri JE, Anyanwu EC (2004) Female genital
mutilation in developing countries: an agenda for public
the civil society, and communities. Cite the evidence health response. European Journal of Obstetrics and
base of each preventive recommendation you Gynecology and Reproductive Biology, 116, 144–151
identify. Kelly E, Hillard PJ (2005) Female genital mutilation. Current
Opinion in Obstetrics and Gynecology, 17, 490–494
Kun KE (1997) Female genital mutilation: the potential for
increased risk of HIV infection. International Journal of
Gynecology and Obstetrics, 59(2), 153–155
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Chapter 11
Abortion and Postabortion Care
Andrzej Kulczycki
Learning Objectives After reading this chapter and where abortion is safe and available. The
answering the discussion questions that follow, you chapter concludes with a discussion on postabor-
should be able to tion care – its evolution, current best practices,
and examples. We begin with some historical
Critically analyze the history, incidence, and rea-
perspective.
sons for abortion from a global perspective.
Abortion has been with us since time imme-
Identify and discuss differences in implementa-
morial. Spontaneous abortions, or miscarriages,
tion of abortion laws and policies across
occur in approximately 15% of clinically recog-
different countries, and the public health impli-
nized pregnancies. Induced abortion, more com-
cations with particular attention to unsafe
monly referred to as abortion, is the deliberate
abortion and abortion-related mortality and
termination of pregnancy before viability (the
morbidity.
point at which a fetus can survive independently
Explain abortion techniques and safety and
outside the womb). Abortion is invariably a
appraise the emerging trend toward earlier abor-
response to unwanted pregnancy and reflects a
tion in countries where abortion is safe and
decision that may be due to a range of circum-
available.
stances. Abortion may also have consequences
Discuss postabortion care – its evolution, current
for women’s health if not performed under safe
best practices, and examples.
and hygienic conditions. Estimates suggest that
approximately 68,000 deaths, or 13% of all
maternal deaths, can be attributed to unsafe
Introduction abortion. This is defined as the termination of
an unwanted pregnancy either by persons lack-
This chapter presents a global overview of abor- ing the necessary skills or in an environment
tion, examining its history and incidence, why lacking the minimal medical standards, or both
women have abortions, and who has abortions. (WHO 2003).
Abortion laws and policies, their implementa- Due to the centrality of abortion in birth
tion, and public health implications are dis- control and in women’s lives, the contribution
cussed. Safe and unsafe abortion as well as abor- of unsafe abortion to maternal mortality and
tion-related mortality and morbidity, conditions morbidity, the importance of efforts to reduce
under which abortion occurs around the world abortion and make it safer, and the immense
and their health implications are presented. Also passions associated with the topic, it is critical
discussed are abortion techniques, safety and that we review why, how many, and under what
trend toward earlier abortion in countries conditions women around the world have abor-
tions. It is also vital that we review efforts to
reduce the incidence of abortion and to make it
A. Kulczycki (*) safer.
University of Alabama at Birmingham, USA
192 A. Kulczycki
Historical Perspective or lower its incidence. This is because it does not

reduce unintended pregnancy, the underlying cause
Until the twentieth century, abortion was deemed of abortion. Instead, outlawing abortion impacts
unfit for public discussion in every country of the the circumstances under which abortion occurs
world. Women undergoing clandestine abortions and is associated with adverse public health conse-
were at high risk of being maimed and dying a lonely, quences for the woman, her family, and society.
gruesome death. This situation changed slowly with This is a major reason why many countries legalized
improvements in family planning, as abortion proce- abortion in the twentieth century.
dures became much safer, and as efforts to legalize
abortion gained momentum. However, the topic
remained largely off-limits in most countries and
avoided at the international level until several high-
Abortion Laws and Public Health
profile UN conferences accorded greater attention to Implications
abortion. These included, in particular, the 1994 Inter-
national Conference on Population and Development Laws determine the official availability of abortion
held in Cairo, and the 1995 Fourth World Conference services. Nearly all Western democracies permit
on Women in Beijing. The Cairo conference was the abortion under broad social and health grounds,
first such intergovernmental meeting to deal with enabling women to obtain a medically supervised
abortion as a public health issue, generating much and extremely safe abortion early in pregnancy. In
acrimonious debate in the process (Kulczycki 1999). contrast, Latin American, sub-Saharan African,
Most countries criminalized abortion during the and Arab countries have the most restrictive laws,
nineteenth century. Women’s health, medical, legal, generally allowing abortion only to save the life of a
and religious leaders later took up the cause of mother. South and South East Asian countries tend
legalizing abortion so as to reduce the toll of abor- to restrict abortion, but India permitted abortion on
tion-related mortality and morbidity. In the United broad grounds in 1971. Despite formal prohibitions
States, for example, 201 deaths were officially on the procedure, Indonesia allows abortions to be
attributed to abortion as late as 1965, 8 years before performed in teaching hospitals as part of medical
the procedure was legalized. This total accounted training and, along with Bangladesh, permits men-
for 17 % of all reported maternal deaths that year, strual regulation before a pregnancy is confirmed.
despite gains in the safety of abortion and adequacy In East Asia, China and Vietnam have likewise
of postabortion care over time. The true figure was allowed abortion under broad circumstances for
undoubtedly higher because many deaths were several decades and have also promoted it as a
ascribed to other causes so as to protect the name means to reduce population growth.
of women, their families, and those performing the On average, 6 in 10 women live in countries
abortions. Low-income women were disproportio- where early abortion is legally available to women
nately affected because they lacked the financial on broad grounds, with 40% able to obtain the
means to access safe abortion. Similarly today, procedure on request, that is, without being
poor women in countries where abortion is out- required to specify a reason. One in four of the
lawed sometimes resort to self-induced abortion world’s population reside in countries where abor-
or, more often, seek dangerous, illegal abortion. tion is allowed only to save a woman’s life or is
Those with more resources typically manage to prohibited altogether; 10% of women have legal
obtain a better quality procedure. They may also access to abortion only when deemed necessary to
seek abortions in other jurisdictions, although this protect a woman’s physical health or life, and 4%
may result in a later-stage abortion and onward have access also if needed to protect a woman’s
travel shortly afterward. This may prevent adequate mental health (United Nations 2002). Nevertheless,
rest and postabortion care if it is required, thereby abortion is frequently performed in most countries
increasing the risk of complications. that prohibit the procedure under almost all circum-
Historical and contemporary evidence demon- stances; about 41% of all procedures worldwide are
strates that outlawing abortion does not eliminate illegal (WHO 2004). Those who live in extreme
11 Abortion and Postabortion Care 193
poverty are least likely to get a safe clandestine primary health centers. Consequently, India has
procedure performed by a physician under sanitary more abortion-related deaths than any other coun-
conditions. Those who are both poor and living in try. India’s experience shows that legal abortion
rural areas, without access to hospital care for the does not guarantee safety in an environment where
complications that may follow an abortion using broad access to services under sanitary conditions is
crude procedures in unsanitary conditions, are at impeded or where providers are not trained.
high risk of death.
England liberalized its abortion law in 1967, an
action followed by many countries that had inherited
English legal and parliamentary procedures. The US
Abortion-Related Mortality and
Supreme Court ruled in 1973 that restrictive state Morbidity
abortion laws were unconstitutional, thereby legaliz-
ing abortion throughout the country. As in other coun- Each year, about 19 million women undergo unsafe
tries, decriminalization of abortion led to an initial abortions; 18.4 million of these women live in the
increase in abortion rates that subsequently declined economically less-developed countries and the rest
as contraceptive practice improved. The public health live primarily in Eastern Europe (Table 11.1). One
gains realized through reducing mortality and morbid- third of these women will suffer serious complica-
ity far exceed any demographic effect associated with a tions, but fewer than half will obtain the hospital
temporary reduction in the number of births. Evidence treatment they need. About 68,000 deaths can be
points to a strong correlation between less-restrictive attributed to unsafe abortion, and still others to
abortion laws and policies, safer abortion, and lower spontaneous abortion. If no new actions are taken,
maternal mortality. When Romania recriminalized almost 100 million women alive today will experi-
abortion and banned contraceptives in 1966, maternal ence the risk and trauma of an unsafe abortion
deaths soared, but after the procedure was legalized during their lifetimes. Younger women are most
again in 1990, they fell sharply down from 159 to 83 affected, as two of every three unsafe abortions are
deaths/100,000 live births within a year and continued experienced by 15–30-year-olds and one in seven,
to fall thereafter. This fall coincided with a rapid gain in occur among women below age 20.
contraceptive use as access to modern contraceptives In parts of sub-Saharan Africa, perhaps one in
improved. Hospital admissions for septic and incom- three maternal deaths is due to abortion. African
plete abortion also fell sharply after South Africa lega- women experience the greatest risk of death from
lized abortion in 1997. unsafe abortions, with a ratio of 1 in 150 compared
Access to abortion is further conditioned by the to Asia’s 1 in 250, Latin America’s 1 in 800, and
actual implementation of laws and by societal and Northern countries’ 1 in 3,700 (WHO 2004). Com-
cultural views on sexuality and reproduction. In plications of spontaneous and induced abortion
nearly all Latin American countries, abortion is include sepsis, hemorrhage, toxic shock, damage to
only permitted in the event of a threat to a woman’s internal organs, and long-term conditions such as
life and is generally severely stigmatized, yet safe chronic pelvic pain and infertility. The consequences
abortion services are readily accessible for those are especially serious for poor, young, and unedu-
able to pay for them. In India, which closely fol- cated women. In many African countries, nonmar-
lowed the United Kingdom in allowing abortion on ital adolescent pregnancies lead to expulsion from
public health grounds, many women are driven to school, abandonment by the family, and sharply
clandestine procedures, often performed by diminished life chances. Many such women will
untrained persons in unhygienic conditions at sites seek an abortion as a way out, but all too often lack
other than registered government institutions. This the resources to obtain a safe abortion. In cultures
is because women are not aware of the legal status of where a woman’s status still depends on her ability to
abortion and because services are insufficient to give birth to many children, infertility arising from
meet the demand. Service availability in rural pregnancy termination may be devastating.
areas remains largely limited to community health Morbidity from unsafe abortion is a huge public
centers and rural hospitals, with few providers in health problem. For decades, complications of illegal
194 A. Kulczycki
Table 11.1 Global and regional estimates of incidence and mortality due to unsafe abortions
Unsafe Mortality from
Number of abortions per Number of unsafe abortions Percent of
safe abortions 1,000 women deaths from per 100,000 live maternal
Region (1,000s) aged 15–44 unsafe abortions births deaths
World total 19,000 14 67,900 50 13
‘‘More’’ 500 2 300 3 14
developed
countries
‘‘Less’’ 18,400 16 67,500 60 13
developed
countries
Africa 42,000 24 29,800 100 12
Asia y 10,500 13 34,000 40 13
Europe 500 3 300 5 20
Latin America* 3,700 29 3,700 30 17
Oceana y 30 17 <100 20 7
y
Excludes Australia, Japan, and New Zealand, although these countries are included in the total for developed countries
*Includes Caribbean states
Source: WHO (2004). Note that figures may not add to totals due to rounding
and unsafe abortion have been known to take up most Surgeon General C. Everett Koop, a vocal opponent
maternity beds and obstetrics and gynecology budgets of abortion whose office spent 15 months reviewing all
at the large urban hospitals of manydeveloping coun- published studies on the topic (Kulczycki 1999). Evi-
tries. The cost of providing safe abortion services dence also indicates that abortion does not affect
would be many times lower. Moreover, many women’s future fertility and birth outcomes, assuming
women will not seek treatment, leading to lifelong it is performed safely.
suffering. Abortion-related mortality and morbidity
are preventable. The glaring disparity between rich
and poor countries in terms of abortion-related mor-
tality and morbidity shows that it is the circumstances Demography of Abortion
in which abortion takes place, including the presence
or absence of legal and safe abortion care that deter- Estimates derived from a range of demographic tech-
mines the health consequences for women, rather than niques and pooled from an array of sources suggest
an abortion per se. that each year, approximately 46 million abortions
In more affluent countries that provide good access occur worldwide (WHO 2004). Put another way,
to safe abortion services, the procedure is far less likely about one in four pregnancies end in abortion.
than an injection of penicillin to cause death. Abortion While the incidence, distribution, and quality of
is considerably safer than carrying a pregnancy to term abortions vary, there is no country in which abortion
(Cates et al. 2003). Although it is often asserted by does not occur. The incidence of abortion is only
those opposed to abortion that the procedure may be known in detail for those countries in which abortion
dangerous to other aspects of women’s health, the is legally permitted with few restrictions and the
body of accumulated evidence indicates that there is number of procedures is counted with a strong
no link between abortion and breast cancer. There is degree of completeness by an official government
no evidence to suggest a causal relationship between department. For many years, the lowest abortion
abortion and mental health problems. Any psycholo- rates in the world have been in the Netherlands,
gical impacts are likely associated with having an Belgium, and Scandinavia, now joined by Germany.
unwanted pregnancy to begin with or, if present, These countries have some of the world’s most liberal
may be due to factors unrelated to either the preg- abortion laws, with services legal, free, and widely
nancy or abortion, such as being in an abusive rela- available; they also have a culture of contraceptive
tionship. This was acknowledged by former US responsibility. In the United States, 1.3 million
abortions occurred in 2002 and each year, 2 out of As fertility preferences fall, there is initially an
every 100 women aged 15–44 have an abortion. At increase in both contraceptive use and abortion.
the current rate, over one third of US women will Evidence from a diverse set of countries shows
have had an abortion by the time they reach age 45. that over time, abortion rates fall as levels of contra-
These levels are higher than anywhere in Western ceptive use rise. In South Korea, average family size
Europe, Australia, or New Zealand, where contra- fell by over half between the 1960s and 1980s. Both
ceptive practice is more widespread and effective. contraceptive prevalence and abortion rates
The highest abortion rates in the world are found in increased alongside the sharp decrease in desired
many former Soviet Bloc republics. A 1999 survey family size. After some 20 years, the birth rate
documented that in Georgia, a woman would have began to stabilize, the abortion rate plateaued, and
about 3.7 abortions during her lifetime (Westoff contraceptive prevalence continued to rise (Mar-
2005). A follow-up survey in 2005 indicated that the ston and Cleland 2003). Russia has historically
abortion rate had declined by 16%, but at 3.1 abor- had one of the world’s highest abortion rates, lar-
tions per woman, it is still high even by regional gely due to the poor accessibility and quality of the
standards. limited available contraceptive options, and the
The incidence of abortion is primarily a function ready availability of abortion (legalized in 1955).
of the incidence of unintended pregnancy rather Sexually active women tended to rely more on abor-
than of the legal status of abortion. Unintended tion rather than contraception to limit their family
pregnancies are those not wanted at the time con- size. Many Russian women who wanted only two
ception occurred, regardless of whether or not con- children had multiple abortions in their lifetimes,
traception was being used. Unintended pregnancy is and as late as 1990, the abortion rate was well over
a function of the level of sexual activity, the age at 100 per 1,000 women of childbearing age. The situa-
which women marry, desired family size, and con- tion finally changed in the early 1990s when the
traceptive knowledge and use. It follows that abor- government began to promote contraceptive use.
tion rates will be higher where desired family size Family planning programs started to be subsidized,
and effective contraceptive use are low, regardless free contraceptives were distributed, and free mar-
of the legal status of abortion, or cultural and reli- ket reforms opened the door to better quality, for-
gious sanctions against the practice. Thus, com- eign-made modern contraceptives. As a result,
pared to Western Europe, abortion rates tend to modern contraceptive use experienced an 80%
be several times higher in Latin America and the increase over 1988–1998, while the abortion rate
Caribbean, in many sub-Saharan African countries, fell by 53%.
and in many Asian countries where contraceptive
prevalence is low and abortion is heavily restricted.
The US abortion rate is higher than that found in
other Western nations because 49% of pregnancies Why Do Women Have Abortions?
are unintended, and about half of which are
aborted. Women have abortions for many reasons. Most
A major cause of unintended pregnancy is lack women who terminate their pregnancies do so
of use or access to contraceptives. In the economic- because doing otherwise would limit their ability
ally less-developed countries, over half of all sexu- to meet their current responsibilities and because
ally active women are at risk of an unintended they cannot afford the index child at that time.
pregnancy because they are using no contraceptive Even if it is dangerous or forbidden, many
method at all, they are using a traditional method women will resort to abortion in order to protect
with high failure rates, or they are using a rever- their family from poverty or to conceal an ille-
sible method that demands regular resupply. How- gitimate pregnancy where it is stigmatized. When
ever, even widespread modern contraceptive use asked for their reasons to have an abortion, 74%
will not entirely eliminate the need for recourse to of recent US abortion patients cited concern for
abortion because no contraceptive works perfectly or responsibility to other individuals. Almost as
every time. many (73%) said they could not afford a baby
196 A. Kulczycki
then. In addition, 69% said that having a baby family support they believe their children deserve.
would interfere with their education, employ- With improved availability and new technologies
ment, or ability to care for dependents; almost for performing abortions, including medication
half said they were having relationship problems abortion and vacuum aspiration with ultrasound,
or would have to raise the child as a single women are increasingly able to obtain an early-term
parent; and 38% did not wish to have another abortion when it is safer and less traumatic. Within
child because they had already completed their the United States, nine out of ten of all abortions are
childbearing (Finer et al. 2005). performed at or before 12 weeks’ gestation, and
three in five abortions occur at or before eight
weeks’ gestation. The proportion carried out at or
before 6 weeks’ gestation increased from 14% of all
Characteristics of Women Who Obtain abortions in 1992 to 25% in 2001. Less than 1% of
Abortions women who have had an abortion did so at, or after
21 weeks’ gestation (Jones et al. 2002).
Both unintended pregnancy and abortion rates are
higher among some groups of women. These typi-
cally include women under age 30 (especially those
aged 20–24), unmarried women, those in poverty, New Technologies and Earlier Abortion
and those with more disadvantaged racial/ethnic
minority status. In the United States, women in Orthodox surgical methods of abortion include use
their 20s account for over half of abortions and of transcervical procedures such as vacuum aspira-
almost two-thirds of all abortions are to never- tion, manual vacuum aspiration (MVA), and dila-
married women. Women living below the federal tation and curettage (D&C). Vacuum aspiration
poverty level are four times as likely to have an uses a plastic cannula or tube attached to either a
abortion as women living above 300% of the pov- hand-held vacuum syringe (MVA) or to an electric
erty level (44 vs. 10 per 1,000 women). US Hispanic pump so as to evacuate the contents of the uterus.
and Asian women have slightly higher than aver- Although D&C is less safe, it remains widely used in
age abortion rates, and Afro-American women are developing countries. Medical methods involve the
over twice as likely as women overall to have an use of pharmacological drugs which are limited to
abortion. Thus, 5% of Afro-American women nine weeks’ gestation. Other technological improve-
have an abortion each year, compared to 3% of ments, including increased use of highly sensitive
Hispanic women, 3% of Asian women, and 1% of at-home urine pregnancy tests and the use of trans-
Caucasian women. The abortion rate for Protes- vaginal ultrasonography, have also enabled a shift
tant women is slightly lower than for Catholic toward earlier abortions, which reduce the risk of
women (18 vs. 22 per 1,000), and for both groups complications.
it is lower than for those who do not identify with Mifepristone remains limited to high-income
any religion (30 per 1,000). countries where abortion is legal. It permits an
It is often assumed that women who have abor- alternative to surgical abortion in the first 9
tions and women who have children are different, weeks of pregnancy and is given under the super-
but in fact, they are the same women, at different vision of a physician with the resulting abortion
points in their lives. In the United States, 6 in 10 completed in the privacy of one’s own home.
women who have an abortion are already a parent Mifepristone, more commonly referred to as the
(Jones et al. 2002) and over half of women who have abortion pill or by its earlier acronym, RU-486,
an abortion intend to have children or more was first approved in France in 1988 and then in
children in the future. These findings also indicate other countries. A decade later, it accounted for
that most women who choose to have an abortion over half of eligible early abortions in France,
do so because they feel unable in their current Scotland, and Sweden. With this new medication,
circumstances to fulfill their parental responsibil- a higher fraction of European women are now
ities as they would like, or to provide the kind of having abortions at or before 9 weeks than did so
before the drug’s introduction, which has not been education, screening, diagnosis, treatment, screen-
associated with any increase in the overall abortion ing for sexual and/or domestic violence (with treat-
rate. In the United States, use of mifepristone has ment as needed), and referral for medical, social,
steadily increased since the drug’s approval in and economic services and support. Effective con-
2000, but mostly at sites that also provide surgical traceptive methods should be initiated immediately
abortion. Integration of the procedure into the postabortion or no later than 7 days, in order to
health-care system has been slow. prevent another unwanted pregnancy. Primary care
facilities with limited health-care capacity can sta-
bilize and refer clients with postabortion complica-
tions to hospitals for treatment, provide referrals
Postabortion Care for reproductive and other health services to other
accessible facilities in providers’ networks, and
Postabortion care (PAC) is a critical health-care serve as a site for follow-up and provision of family
service that can save women’s lives in settings planning counseling and methods to better space or
where abortion is performed unsafely. At mini- prevent subsequent pregnancies.
mum, PAC services should provide treatment for International health organizations providing
complications of spontaneous or induced abor- PAC assistance emphasize MVA as the preferred
tion and strengthened family planning counseling procedure for treating incomplete abortions.
and contraceptive method provision, both imme- Although D&C is still widely used by hospitals
diately after a procedure and in subsequent fol- in many countries for uterine evacuation, it
low-up, to prevent unintended pregnancies that requires general anesthesia and therefore a longer
can lead to repeat abortions. Attempts to institute hospital stay, and is more costly. MVA is safer,
PAC services only gained momentum in the wake less expensive, and can be performed effectively in
of the 1994 Cairo conference. International health low-resource settings. It can be provided using
organizations and donors then began providing local anesthesia, enabling clients to safely leave
technical and financial support for PAC pro- the hospital within hours. Turkey and several
grams. Several PAC models were introduced Latin American countries have succeeded in insti-
with links slowly developed between emergency tutionalizing the provision of the main elements
abortion treatment services and comprehensive of PAC (Billings and Benson 2005; Senlet et al.
reproductive health care, focused primarily on 2001). But in general, PAC programs have rarely
clinical and related facility-based services from a been scaled up throughout the national health
health-care provider perspective. Attention was system and few postabortion care pilot projects
given to improving both technical competence in have been expanded successfully. Numerous
medical treatment of incomplete abortion and obstacles are frequently encountered in program
interpersonal communication with patients implementation, typically due to political rather
(Winkler et al. 1995). This also led to an than technical reasons. In many countries, the
increased stress on the holistic treatment of the political and cultural sensitivity of abortion
patient as opposed to improving a single aspect makes even PAC programs vulnerable to political
of services, such as the use of MVA instruments. changes and charges, inadequate funding, and
Current best practices in PAC programming, like changes in hospital personnel. Since 2001, the
those in safe motherhood programming, show the U S government has instituted a ‘‘Global Gag
importance of minimizing delays in receiving care. Rule’’ that restricts non-governmental organiza-
At the facility level, at least three types of services tions (NGOs) in poor countries that receive
are needed. These include emergency treatment of USAID family planning funding from engaging
postabortion complications, counseling on PAC in abortion-related activities, even with their own
treatment and family planning, including direct funds. This policy has prevented institutionaliza-
provision of contraceptives or referral, and referral tion of PAC services. Moreover, it has almost
for other reproductive health services. These might certainly increased the number of abortions
include, for example, STI/HIV prevention through its disruption of family planning services.
198 A. Kulczycki
Where emergency treatment for postabortion stigma attached to abortion. Such barriers
complications has been provided, it has tradi- could be potentially reduced through working
tionally been without family planning, counsel- at the community level. An expanded and
ing, and often contraceptive methods are not updated ‘‘Essential Elements of PAC’’ model
available on the OB/GYN ward where PAC ser- has been proposed by family planning and
vices are provided. Integration between such ser- reproductive health agencies, NGOs and donors
vices is often lacking because many family plan- (Post-abortion Care Consortium 2002). This
ning clinics in hospitals may be closed when adds the community and counseling as essential
women are discharged from the hospital after elements (Table 11.2).
receiving treatment in a 24-h emergency setting. Partnerships are increasingly emphasized with
The development of integrated postabortion ser- community members, community health work-
vices within a family planning and reproductive ers, and formally trained service providers to
health-care program has also been impeded in improve and ensure the accessibility, acceptabil-
many countries by women’s low socioeconomic ity, and use of quality PAC services. Under this
status and normative restrictions on abortion. model, counseling is not limited to family plan-
All these obstacles conspire to make the health- ning and contraceptive education and services.
care concerns of women who need PAC care a Rather, it should cover the full range of repro-
low priority for governments and for many med- ductive health, and other health and emotional
ical professionals. Additionally, legal and admin- needs, and concerns that arise for women in
istrative constraints may force women to seek these circumstances. The revised PAC model
clandestine procedures from providers who can- has been extended in practice by the CATA-
not offer related reproductive health-care LYST Consortium of reproductive health and
services. family planning agencies initiated by the US
The international health community has only Agency for International Development (USAID).
recently begun to address some of the many There are three core components to this promising
sociocultural barriers that prevent women from initiative: (1) emergency treatment, (2) family
seeking PAC services. For example, women may planning counseling and provision, STI evaluation
delay seeking care or not seek care at all if they and treatment, and HIV counseling and/or referral
are not the main family decision makers and for testing, and (3) community empowerment
cannot seek services autonomously, or if they through community awareness and mobilization.
do not recognize the urgency of a situation of Since 2003, CATALYST programs have
postabortion complications. Facilities may also been implemented and successfully scaled-up
discriminate against PAC clients due to the in Bolivia, Egypt and Peru (CATALYST
Table 11. 2 Essential elements of postabortion care

Community and service provider partnerships
Prevent unwanted pregnancies and unsafe abortion
Mobilize resources to help women receive appropriate and timely care for complications from abortion
Ensure that health services reflect and meet community expectations and needs
Counseling
Identify and respond to women’s emotional and physical health needs and other concerns
Treatment
Treat incomplete and unsafe abortions and potentially life-threatening complications
Contraceptive and family planning services
Help women practice birth spacing or prevent an unwanted pregnancy
Reproductive and other health services
Preferably provided on-site to ensure women’s needs are met, or via referrals to other accessible facilities in providers’
networks
Source: Postabortion Care Consortium (2002)
Consortium 2005). Several common elements have problem. The CATALYST Consortium has also
been identified: started to help local NGOs in Romania, Nepal,
and Cambodia to identify community needs
(1) Provision of PAC training tailored to the regarding PAC and to provide solutions that
type of facility in which the provider works are socially and culturally adapted to their spe-
and sensitizing providers to the situations of cific situations. The goal is to build awareness of
women who experience complications of PAC issues among communities and stake-
abortion. For example, providers at primary holders and improve provider skills and PAC
care facilities were trained to recognize dan- programming at all levels of facilities. By
ger signs, stabilize, and refer clients to a expanding from facility-based, clinical services
higher level facility for emergency treatment. to a more comprehensive public health model,
These providers were also trained to provide PAC programs are increasingly providing pre-
follow-up care, including family planning vention, treatment, counseling, and services to
counseling and contraceptive methods to respond to women’s reproductive health needs
PAC clients. and concerns following an incomplete or unsafe
(2) Community mobilization at all sites, whereby abortion.
community participants (women, men, and
adolescents) were provided with the tools
and technical support needed to identify
Conclusion
community problems and resources related
to PAC, to develop and implement action
plans, and to collaborate with local hospital Abortion is an essential aspect of fertility regula-
authorities, in order to increase knowledge tion. Pregnancy is not always planned or wel-
of, access to, and quality of PAC services. comed, an awkward truth for some workers and
Community awareness sessions included, for researchers in the MCH field, as well as public
example, disseminating information about health practitioners and policymakers. Some
safe behaviors for preventing unintended women conceive when they do not want to and
pregnancies, seeking immediate care in the pregnancy is not always trouble-free. Programs
event of complications of abortion and wait- must address such problems. The role of
ing at least 6 months before getting pregnant improved contraceptive practice, particularly the
again. Community leaders and organizations use of more effective, long-acting methods, is
were also engaged in this effort and commu- critical to reducing the incidence of abortion.
nities involved in ongoing monitoring and New technologies allow women to obtain earlier
evaluation. and safer, abortions. Laws and policies should
(3) Creation and maintenance of a supportive reflect health concerns and access to safe abortion
policy environment at local, regional, and services. Laws and policies can be improved by
national levels, to facilitate integration of decreasing the administrative obstacles to legal
PAC services. services (abortions performed under the indica-
tions allowed by a country’s law) and by increas-
These steps have helped ensure political commit- ing the availability of legal services for safe abor-
ment and community empowerment, with trans- tion in public sector facilities.
fer of responsibility to local communities and Morbidity and mortality due to unsafe abor-
local governments. They are also facilitating pro- tion continue to pose a serious global threat to
gram sustainability and scale-up. In Bolivia and women’s health and lives. The costs of treating
Peru, community members additionally identi- these complications are a major economic burden
fied gender-based violence as an important on limited health-care budgets, particularly in
cause of unintended pregnancy, miscarriage and resource-poor settings. PAC programs are being
induced abortion, underscoring the need to implemented in a growing number of countries
address another neglected community health and increasingly recognize the need to build
200 A. Kulczycki
partnerships with communities. In addition to needed in this vital area to prevent unsafe abor-
providing treatment for incomplete and unsafe tion, reduce morbidity and mortality from incom-
abortion, such programs increasingly stress a con- plete and unsafe abortion, and improve the lives
tinuum of postabortion care. Much more work is of women and their families.
Key Terms
Abortion Fourth World Conference on Miscarriage

Abortion-related mortality and Women Postabortion care
morbidity Hemorrhage Postabortion care consortium
Birth control Illegal abortion Pregnancy termination
CATALYST Consortium Infertility Safe motherhood
Chronic pelvic pain International Conference on Self-induced abortion
Contraceptive knowledge Population and Sepsis
Contraceptive responsibility Development Spontaneous abortion
Contraceptive use Late-stage abortion Toxic shock
Dilatation and curettage Manual vacuum aspiration Unintended pregnancy
(D&C) (MVA) Unsafe abortion
Family planning counseling Maternal death
Fetus Mifepristone
Questions for Discussion References

Billings DL, Benson J (2005) Post-abortion care in Latin
1 Briefly summarize the reasons why women have America: policy and service recommendations from a
abortion. decade of operations research. Health Policy and Plan-
2 What factors account for the disparity in abor- ning, 20(3): 158–166
tion-related morbidity and mortality between CATALYST Consortium (2005) PAC Compilation Docu-
ment. www.pathfind.org/site/DocServer/PAC_Compila-
rich and poor countries? tion_Document.pdf?docID=5585 Cited 2 August 2008
3 Historical and contemporary evidence shows that Cates W, Grimes DA, Schulz KF (2003) The public health
outlawing abortion does not eliminate or reduce impact of legal abortion: 30 years later. Perspectives on
its incidence. Using specific country examples, Sexual and Reproductive Health, 35(1): 25–28
Finer LB, Frohwirth LF, Dauphinee LA et al. (2005) Rea-
discuss why this is the case. sons U.S. women have abortions: quantitative and quali-
4 Evidence shows that there is a strong correlation tative perspectives. Perspectives in Sexual and Reproduc-
between less-restrictive abortion laws and poli- tive Health, 37(3): 110–118
cies, safer abortion, and low maternal mortality. Jones RK, Darroch JE, Henshaw SK (2002) Patterns in the
socioeconomic characteristics of women obtaining abor-
However, experts say that for many less-devel- tions in 2000–20001. Perspectives on Sexual and Repro-
oped countries, legalization of abortion may not ductive Health, 34(5): 226–235
guarantee safe abortion. Explain the rationale for Kulczycki A (1999) The Abortion Debate in the World
this observation. Arena. London: Macmillan and New York: Routledge
Marston C, Cleland J (2003) Relationships between contra-
5 List the three elements of an effective postabor- ception and abortion: a review of the evidence. Interna-
tion care model. What factors hinder the imple- tional Family Planning Perspectives, 29(1): 6–13
mentation of effective postabortion services in Postabortion Care Consortium (2002) Essential elements of
less-developed countries? postabortion care: an expanded and updated model. Post-
abortion Care Consortium, PAC in Action, no. 2, special
supplement. www.pac-consortium.org/site/PageServer? Winkler J, Oliveras E, McIntosh N (eds.) (1995) Postabor-

pagename=PAC_Model Cited 2 August 2008 tion Care: A Reference Manual for Improving Quality of
Senlet P, Cagatay L, Ergin J et al. (2001) Bridging the gap: Care. Baltimore, MD: Postabortion Care Consortium
integrating family planning with abortion services in Turkey. World Health Organization (WHO) (2003) Safe Abortion:
International Family Planning Perspectives, 27(2): 90–95 Technical and Policy Guidance for Health Systems. Gen-
United Nations (2002) Abortion Policies: A Global Review. eva: World Health Organization
Vols. 1–3. New York: United Nations World Health Organization (WHO) (2004) Unsafe Abortion:
Westoff, C (2005) Recent Trends in Abortion and Contra- Global and Regional Estimates of the Incidence of Unsafe
ception in 12 Countries. DHS Analytical Studies no. 8. Abortion and Associated Mortality in 2000, 4th ed. Gen-
Calverton, MD: ORC Macro eva: World Health Organization
Part III
Specific Disease Concerns
Chapter 12
Malaria in Women and Children
Martin Meremikwu, Emmanuel Ezedinachi and John E. Ehiri
Learning Objectives After reading this chapter and prevalent in Asia and is rarely associated with
answering the discussion questions that follow, you acute complications of malaria or fatality. Box
should be able to 12.1 presents definitions of some of the most com-
monly used terms in malaria epidemiology.
Explain the global burden of malaria, discuss its
Figure 12.1 shows the global distribution of
clinical manifestations, and appraise its health
malaria transmission risk. Malaria transmission
impact on women and children.
occurs in Africa, Asia, and the Americas, but sub-
Analyze the mechanisms and consequences of
Saharan Africa bears over 80% of the global bur-
malaria and HIV co-infection and discuss current
den of malaria mortality (Ehiri et al. 2004). Malaria
treatment, control and prevention strategies.
is still a major public health problem in parts of
Describe the challenges posed by vector resis-
Southeast Asia with foci of high P. falciparum
tance to insecticides, parasite resistance to anti-
transmission and high incidence of multidrug
malarials, climate change, wars/conflicts, and
resistance.
HIV/AIDS to malaria control and prevention
More than 40 species of Anopheles mosquitoes
efforts.
transmit malaria. Anopheles gambiae, which is the
Evaluate social, cultural, and economic limita-
most efficient and resilient vector, is the predomi-
tions of community-based programs for malaria
nant vector in most parts of tropical Africa, where it
control and prevention.
finds adequate rainfall, temperature, and humidity
to support its breeding. Figure 12.2 provides an
illustration of the life cycle of Plasmodium in the
Introduction human and in the mosquito vector.
Spleen rates (percentage of the population with
Malaria is caused by Plasmodium, a protozoan palpably enlarged spleen at any given time) and
parasite transmitted through the bite of infected parasite rates (percentage of the population with
female anopheline mosquitoes. The four species of malaria parasites in peripheral blood film at any
Plasmodium known to cause malaria in humans are given time) are traditionally used as malario-
P. falciparum, P. malariae, P. ovale, and P. vivax. metric indices to determine whether or not
Plasmodium falciparum is the most virulent of these malaria is endemic in a given area. The entomo-
species and is responsible for most cases of malaria logic inoculation rate (EIR) is believed to be a
infections and malaria deaths in sub-Saharan better measure of malaria transmission and risk
Africa. Plasmodium vivax, the second most com- of infection than spleen or parasite rates. How-
mon species of the malaria parasite, is more ever, it is more difficult to assess. EIR is the
product of human biting rates (the number of
mosquitoes biting a person over a given period
M. Meremikwu (*)
of time) and the sporozoite rate (the proportion
Department of Pediatrics Institute for Tropical Disease
Reasearch, University of Calabar, Calabar, Cross River of vectors with sporozoites in the salivary glands)
State, Nigeria (Snow et al. 2004).
206 M. Meremikwu et al.
Anemia: A reduction in the number of circulating red blood cells or in the quantity of
hemoglobin.
Anopheles: A genus of mosquito, some species of which can transmit human malaria.
Artemisinin: A drug used against malaria, derived from the Qinghao plant, Artemisia annua L.
Cerebral Malaria: A complication of Plasmodium falciparum malaria in which infected red blood
cells obstruct blood circulation in the small blood vessels in the brain. When cerebral malaria is
present, the disease is classified as severe malaria.
Chemoprophylaxis: Taking antimalarial drugs to prevent the disease.
Chloroquine: A drug used against malaria. A very safe and inexpensive drug, its value has been
compromised by the emergence of chloroquine-resistant malaria parasites.
Drug Resistance: Drug resistance is the result of microbes changing in ways that reduce or
eliminate the effectiveness of drugs, chemicals, or other agents to cure or prevent infections.
Endemic Malaria: Constant incidence over a period of many successive years in an area.
Epidemic: The occurrence of more cases of disease than expected in a given area or among a specific
group of people over a particular period of time.
Erythrocyte: A red blood cell.
Erythrocytic Stage: A stage in the life cycle of the malaria parasite found in the red blood cells.
Erythrocytic stage parasites cause the symptoms of malaria.
Gametocyte: The sexual stage of malaria parasites. Male gametocytes (microgametocytes) and
female gametocytes (macrogametocytes) are inside red blood cells in the circulation. If they are
ingested by a female Anopheles mosquito, they undergo sexual reproduction which starts the extrinsic
(sporogonic) cycle of the parasite in the mosquito. Gametocytes of Plasmodium falciparum are
typically banana- or crescent-shaped (from the latin falcis = sickle).
Hemoglobin: The red, oxygen-carrying protein found in red blood cells.
Hemolysis: Destruction of red blood cells. Malaria causes hemolysis when the parasites rupture the
red blood cells in which they have grown.
Hyperreactive Malarial Splenomegaly (also called ‘‘tropical splenomegaly syndrome’’): occurs
infrequently and is attributed to an abnormal immune response to repeated malarial infections.
The disease is marked by a very enlarged spleen and liver, anemia, and a susceptibility to other
infections (such as skin or respiratory infections).
Hypoglycemia: Low blood glucose. Hypoglycemia can occur in malaria. In addition, treatment
with quinine and quinidine stimulate insulin secretion, reducing blood glucose.
Immunity: Protection generated by the body’s immune system, in response to previous malaria
attacks, resulting in ability to control or lessen a malaria attack.
Leukocyte: White blood cell.
Lymphocyte: Leukocyte with a large round nucleus and usually a small cytoplasm. Specialized
types of lymphocytes have enlarged cytoplasms and produce antibodies.
Merozoites: A daughter cell formed by asexual development in the life cycle of malaria parasites.
Liver stage and blood stage malaria parasites develop into schizonts which contain many merozoites.
When the schizonts are mature, they (and their host cells) rupture; the merozoites are released and
infect red blood cells.
Monocyte: Leukocyte with a large, usually kidney-shaped nucleus. Within tissues, monocytes
develop into macrophages which ingest bacteria, dead cells, and other debris.
Oocyst: A stage in the life cycle of malaria parasites, oocysts are rounded cysts located in the outer
wall of the stomach of mosquitoes. Sporozoites develop inside the oocysts. When mature, the oocysts
12 Malaria in Women and Children 207
rupture and release the sporozoites, which then migrate into the mosquito’s salivary glands, ready for
injection into the human host.
Parasitemia: The presence of parasites in the blood. The term can also be used to express the
quantity of parasites in the blood (e.g., ‘a parasitemia of 2%’’).
Phagocyte: A type of white blood cell that can engulf and destroy foreign organisms, cells and
particles.
Platelets: Small, irregularly-shaped bodies in the blood that contain granules. These cells are
important components of the blood coagulation (clotting) system.
Presumptive Treatment: Treatment of clinically suspected cases without, or prior to, results from
confirmatory laboratory tests.
Protozoan: Single-celled organism that can perform all necessary functions of metabolism and
reproduction. Some protozoa are free-living, while others, including malaria parasites, parasitize
other organisms for their nutrients and life cycle.
Residual insecticide spraying: Treatment of houses by spraying insecticides that have residual
efficacy (i.e., that continue to affect mosquitoes for several months). Residual insecticide spraying
aims to kills mosquitoes when they come to rest on the walls, usually after a blood meal.
Resistance: The ability of an organism to develop strains that are impervious to specific threats to
their existence.
Schizogony: Asexual reproductive stage of malaria parasites. In red blood cells, schizogony entails
development of a single trophozoite into numerous merozoites. A similar process happens in infected
liver cells.
Schizont: A developmental form of the malaria parasite that contains many merozoites. Schizonts
are seen in the liver-stage and blood-stage parasites.
Sequelae: Morbid conditions following as a consequence of a disease.
Severe Malaria: occurs when P. falciparum infections (often in persons who have no immunity
to malaria or whose immunity has decreased) are complicated by serious organ failures or
abnormalities in the patient’s blood or metabolism, resulting in cerebral malaria, with abnor-
mal behavior, impairment of consciousness, seizures, coma, or other neurologic abnormalities,
severe anemia due to hemolysis (destruction of the red blood cells), hemoglobinuria (hemoglo-
bin in the urine) due to hemolysis, pulmonary edema (fluid buildup in the lungs) or acute
respiratory distress syndrome (ARDS), which may occur even after the parasite counts have
decreased in response to treatment, abnormalities in blood coagulation and thrombocytopenia
(decrease in blood platelets), cardiovascular collapse, shock, acute kidney failure, hyperparasi-
temia, where more than 5% of the red blood cells are infected by malaria parasites, metabolic
acidosis (excessive acidity in the blood and tissue fluids), often in association with hypoglyce-
mia (low blood glucose).
Splenomegaly: Enlargement of the spleen, found in some malaria patients. Splenomegaly
can be used to measure malaria endemicity during surveys (e.g., in communities or in school
children).
Sporozoite Rate: The proportion of female anopheline mosquitoes of a particular species that have
sporozoites in their salivary glands (as seen by dissection), or that are positive in immunologic tests to
detect sporozoite antigens.
Sporozoite: A stage in the life cycle of the malaria parasite. Sporozoites are produced in the
mosquito and migrate to the mosquito’s salivary glands. They can be inoculated into a human host
when the mosquito takes a blood meal on the human. In the human, the sporozoites enter liver cells
where they develop into the next stage of the malaria parasite life cycle (the liver stage or exo-
erythrocytic stage).
Stable Malaria: A situation where the rate of malaria transmission is high without any marked
fluctuation over years though seasonal fluctuations occur.
Strain: A genetic variant within a species.
Sulfadoxine–pyrimethamine: A drug used against malaria.
Trophozoite: A developmental form during the blood stage of malaria parasites. After merozoites
have invaded the red blood cell, they develop into trophozoites (sometimes, early trophozoites are
called ‘‘rings’’ or ‘‘ring stage parasites’’); trophozoites develop into schizonts.
Uncomplicated Malaria: The classical, (but rarely observed) uncomplicated malaria attack that
lasts 6–10 hours. It consists of a cold stage (sensation of cold, shivering), a hot stage (fever, headaches,
vomiting, seizures in young children), and finally a sweating stage (sweats, return to normal tem-
perature, tiredness).
The classical (but infrequently observed) uncomplicated malaria attacks occur every second day
with the ‘‘tertian’’ parasites (P. falciparum, P. vivax, and P. ovale) and every third day with the
‘‘quartan’’ parasite (P. malariae). More commonly, the patient presents with a combination of
symptoms that include fever, chills, sweats, headaches, nausea and vomiting, body aches, general
malaise.
Unstable Malaria: A situation where the rate of malaria transmission changes from year to year.
Vaccine: A preparation that stimulates an immune response that can prevent an infection or create
resistance to an infection.
Vector: An organism (e.g., Anopheles mosquitoes) that transmits an infectious agent (e.g. malaria
parasites) from one host to the other (e.g., humans).
Source: Malaria Glossary – Centers for Disease Control and prevention
http://www.cdc.gov/malaria/glossary.htm
Malaria transmission can be perennial (occur- Burden of Malaria

ring throughout the year), high, intense, and/or
stable, low, unstable, and seasonal. High stable Figure 12.3 illustrates the various pathways by
transmission of mostly P. falciparum associated which malaria contributes to poverty, under-devel-
with high incidence of severe illness and mortality opment, malnutrition, and maternal and infant
among preschool children is the predominant pat- mortality. Some 300–500 million malaria episodes
tern of malaria in most of sub-Saharan Africa. occur annually. Children under 5 years of age in
The average malaria incidence rates across several sub-Saharan Africa and women who are pregnant
parts of Africa with high transmission are esti- for the first or second time bear the heaviest burden
mated at 1.4 per persons per year, 0.59 per persons of malaria morbidity and mortality. An estimated
per year, and 0.11 persons per year for age groups 250 million episodes of clinical malaria occur in
<5 years, 5–14 years, and 15 years, respectively young sub-Saharan African children annually.
(Snow et al. 2003). In low transmission areas, About 1 million cases are cerebral malaria, 4 million
incidence rates of malaria are much lower, and cases are severe anemia, and approximately 1 mil-
differ only marginally between the young and lion result in death. Estimates of malaria mortality
older age groups. Malaria epidemics are more show wide variation. A review of the literature on
likely to occur in areas with seasonal and unstable this subject shows that the number of deaths due to
transmission. malaria in African children aged less than 5 years
Fig. 12.1 Global distribution of malaria transmission risk, 2003. Source: WHO (2007)
could be between 625,000 and 1,824,000 annually years to be 0.252 attacks per adolescent per year
(Breman et al. 2004). (Lalloo et al. 2006). Results of analyses based on
About 250,000 of those that survive develop rainfall and temperature data and geographic infor-
sequelae from neurological complications of P. fal- mation system (GIS) population databases in areas
ciparum malaria. Pregnant women are more vulner- with high and stable malaria transmission put the
able to adverse consequences of malaria than other yearly estimate of the number of malaria attacks in
adults. An estimated 10 million infections occur in children aged 0–4 years, 5–9 years, and 10–14 years
pregnant women annually, resulting in 500,000 at 81.3 million, 16.0 million, and 13.4 million,
cases of severe maternal anemia and 500,000 low respectively.
birth weight babies (Greenwood et al. 2005). In
malaria-endemic countries of Africa, up to 40% of
all outpatient clinic visits and between 20 and 50%
of all hospital admissions are due to malaria (WHO Clinical Manifestation of Malaria
2003). Although the incidence of uncomplicated
malaria is lower in adolescents aged 10–19 years The clinical pattern and deleterious consequences
than younger school aged and preschool children, of malaria infection vary, depending on the level
the burden of malaria in this age group could be of acquired malaria immunity of the individual
substantial in areas with high and stable transmis- and the pattern of malaria transmission in an
sion. A recent review of the epidemiology and pat- area. In areas with high and stable malaria
tern of malaria in adolescents estimates the clinical transmission, resident adults and older children
malaria rate in African adolescents aged 10–20 acquire sufficient partial immunity to reduce the
Fig. 12.2: Life cycle of Plasmodium parasite. Key: (A) Mosquito infected with the malaria parasite bites human, passing cells
called sporozoites into the human’s bloodstream. (B) Sporozoites travel to the liver. Each sporozoite undergoes asexual
reproduction, in which its nucleus splits to form two new cells called merozoites. (C) Merozoites enter the bloodstream and
infect red blood cells. (D) In red blood cells, merozoites grow and divide to produce more merozoites, eventually causing the
red blood cells to rupture. Some of the newly released merozoites go on to infect other red blood cells. (E) Some merozoites
develop into sex cells known as male and female gametocytes. (F) Another mosquito bites the infected human, ingesting the
gametocytes. (G) In the mosquito’s stomach, the gametocytes mature. Male and female gametocytes undergo sexual
reproduction, uniting to form a zygote. The zygote multiplies to form sporozoites, which travel to the mosquito’s salivary
glands. (H) If this mosquito bites another human, the cycle begins again. Source: Microsoft Encarta (2008), http://encar-
ta.msn.com/media_461541582_761566151_-1_1/life_cycle_of_the_malaria_parasite.html
Fig. 12.3 Pathways by School absenteeism Poverty

which malaria contributes to Poor cognition Underdevelopment
morbidity, mortality, and Poor productivity
Uncomplicated
under-development. Source: malaria
Adapted from Breman
Hypoglycemia
(2004) Infected
Mosquito Anemia
Acute
febrile Severe Death
Respiratory distress
illness Illness
Cerebral malaria
Anemia
Chronic Impaired
Infected Neurologic/ growth and Malnutrition
Human effects cognitive
development
Developmental
Low birth Infant

Fetus weight/
mortality
Pregnancy Preterm
Maternal Acute Impaired productivity

illness
Maternal mortality
Anemia
risk of severe and fatal malaria but younger within 6 months but about 2% persist for longer
children and pregnant women remain vulnerable periods of time causing varying degrees of disability
to severe and complicated malaria. Malaria and impaired intellectual development (Murphy
infection may be asymptomatic or symptomatic. and Breman 2001).
The majority of malaria infections in areas
where transmission is high and stable are asymp-
tomatic. Even when malaria infection is asymp-
tomatic, it is believed that the high prevalence of Consequences of Malaria in Children and
low parasitemic and asymptomatic malaria infec-
tions contribute to the high prevalence of mild
Adolescents
and moderate childhood anemia. In these set-
tings, young children who are less immune to Anemia
the disease are more likely to have clinical
malaria following infections. Childhood anemia in low-income countries is
The common symptoms of uncomplicated caused by multiple factors including poor nutrition,
malaria are fever, poor appetite, aches, malaise, malaria, intestinal parasites, HIV/AIDS, and inher-
nausea, and vomiting. Uncomplicated malaria is ited blood disorders (e.g., glucose-6-phosphate
the most common reason for which children and dehydrogenase (G-6-P-D) deficiency and sickle cell
adults use the health service in sub-Saharan Africa. disease). In areas with high transmission, malaria is
Uncomplicated malaria accounts for about 40 and the leading etiological factor for anemia. The pro-
30% of outpatient attendance and hospital admis- cesses by which malaria causes anemia are not yet
sions, respectively. Malaria is also a leading cause of fully understood; however, malaria-related toxins
absenteeism and poor performance at work and and immunological factors are believed to cause
school. Uncomplicated malaria is rarely fatal when increased hemolysis, increased splenic clearance of
treated promptly with effective antimalarial drugs. infected and uninfected red blood cells, and
In preschool children, delayed treatment or failure impaired production of red blood cells in the bone
to treat uncomplicated falciparum malaria could marrow (dyserythropoeisis). In areas of Africa with
lead to rapid disease progression to severe and high malaria transmission, surveys have shown high
potentially fatal malaria within a period often less prevalence rates of anemia (hemoglobin <11 g/dL)
than 48 h from onset of illness. Plasmodium falci- among infants and children under 5 years of age (as
parum causes severe malaria through complex pro- high as 50–80% in several areas). Most of these
cesses that involve immunological substances cases of anemia go unnoticed and untreated because
known as cytokines (John et al. 2000) leading to they are mild and cause no symptoms. Although
impaired perfusion and damage to tissues and children with mild and chronic anemia do not feel
organs. These pathological changes lead to clinical distinct symptoms of illness, mild anemia is asso-
and laboratory features that are characteristic of ciated with chronic debility. It can cause such
severe and complicated malaria, namely cerebral adverse effects as reduced activity and impaired
malaria that is associated with impaired conscious- cognition and learning. These chronic effects of
ness, repeated convulsions, severe malarial anemia, malarial anemia in concert with malaria-related
hypoglycemia, respiratory distress, and circulatory school absenteeism and neurological complications
collapse. Children that die from malaria would have from cerebral malaria, adversely affect childhood
one or more of these signs. The risk of death is development and education in sub-Saharan Africa
higher in patients with multiple signs (Schellenberg (Mung’Ala-Odera et al. 2004).
et al. 1999). Case fatality rate of complicated falci- Severe anemia (hemoglobin <5 g/dL) is a com-
parum malaria is 10–50%. About 10–17% of those mon acute complication of falciparum malaria. It is
that survive cerebral malaria have residual neurolo- responsible for high case fatality and often follows
gical problems such as dyskinesia, cortical blind- massive hemolysis from a single episode of falci-
ness, seizures, and learning disorders (Meremikwu parum malaria. Repeated episodes or poorly trea-
et al.1997). Most of these disorders are resolved ted episodes of uncomplicated malaria are fairly
common pathways to severe anemia in infants and Malaria Nephropathy and Splenomegaly
young children who are residents of areas with high
and stable malaria transmission. In many commu- Two other notable chronic effects of malaria in
nities in Africa where there are high levels of P. children and adolescents include malarial nephro-
falciparum resistance to chloroquine and sulpha- pathy and hyperactive malarial splenomegaly.
doxine–pyrimethamine, the continued use of failed Malarial nephropathy results from gradual damage
drugs has resulted in an increase in the incidence of of kidney cells by an antigen–antibody complex that
severe malarial anemia. Case fatality from severe is caused by previous malarial infection. There are
malarial anemia varies from 1% in treated cases to no reliable data on the magnitude of renal morbid-
over 30% when associated with other complications ity which are caused by this malaria-induced pathol-
of falciparum malaria, especially respiratory dis- ogy. However, it is believed that the problem is
tress and deep coma (John et al. 2000). Many substantial. Hyperactive malarial splenomegaly
more children with life-threatening severe malaria (also called tropical splenomegaly syndrome) is
anemia do not have access to formal health care another chronic, but less common presentation of
where adequate treatment and blood transfusion malaria among children and adolescents in the tro-
are possible. This indicates that overall case fatality pics. This condition is characterized by an enlarged
from severe malarial anemia is likely to be much spleen, high levels of malarial immunoglobulin
higher than reported. Blood transfusion for severe (IgM), sinusoidal lymphocyte infiltration, and reso-
malaria-related anemia accounts for a remarkable lution with prolonged antimalarial therapy.
proportion of new pediatric HIV infections in
Africa (Crawley and Nahlen 2004).
Given the multifactorial nature of the etiology of
childhood anemia, interventions to prevent or treat Malaria in Pregnancy
it should involve several approaches. For instance,
mass de-worming of children and micronutrient Plasmodium falciparum and P. vivax are known to
supplementation programs are interventions that cause significant effects on maternal and child
have the potential to reduce the burden of child- health during pregnancy. Plasmodium falciparum
hood anemia in developing countries (Briand et al. exerts the worst effects among all the species of
2007). Insecticide-treated nets, chemoprophylaxis, malaria parasite. In sub-Saharan Africa, the trans-
and intermittent preventive treatment are malaria- mission of P. falciparum is predominantly high and
specific interventions that have been shown to sig- intense with high levels of morbidity and mortality
nificantly reduce morbidity and mortality from among infants and pregnant women. The major
malaria-related anemia (Briand et al. 2007). consequences of malaria infection during pregnancy
Malaria is a leading cause of hemolytic and vaso- are clinical episodes of malaria, maternal anemia
occlusive crisis in African children and adolescents (hemoglobin concentration <11 g/dL), or severe
with sickle cell disease. Sickle cell disease is the anemia (hemoglobin concentration <8 g/dL), pla-
most common inherited hematological disease cental parasitemia, intrauterine growth retardation,
among Africans. The prevalence of the sickle cell preterm births, and low birth weight.
trait (heterozygous inheritance on an abnormal Table 12.1 shows the contribution of malaria to
and a normal gene) can be as high as 25–40% in adverse maternal and child health outcomes.
some parts of Africa with 1–3% affected by the Malaria in pregnancy is estimated to account for
disorder (inheritance of a pair of abnormal gene). up to 25% of cases of severe anemia, 10–20% of
A paradoxical relationship exists between the babies born with low birth weight, and 5–10% of
sickle cell gene and malaria. The sickle gene is neonatal and infant deaths are due to malaria-
believed to confer some measure of protection induced LBW (Greenwood et al. 2005). The effect
against malaria to those with the trait (one abnor- of malaria in pregnancy is influenced by the level of
mal gene); however, it is a leading cause of mor- malaria immunity acquired by the mother before
bidity and mortality among those with the disorder pregnancy. This depends on the pattern and inten-
(two abnormal genes). sity of malaria transmission. The parasite species,
Table 12.1 Contribution of malaria to anemia, negative participants, the incidence of malaria was
low birth weight, and infant deaths almost twice as high in the HIV-positive group (6.2
Adverse health events % of total per 100 women-months) than in the HIV- negative
group (3.5 per 100 women-months) (Ladner et al.
Maternal anemia 2–15
Low birth weight 8–14
2002). A review of studies on malaria and HIV co-
Preterm birth 8–36 infection shows that HIV infection in pregnancy
Intrauterine growth retardation 13–70 significantly increases the risk of peripheral and pla-
Infant death 3–8 cental malaria parasitemia. Malaria in pregnant
Source: WHO-AFRO (2004)
women infected by HIV is more likely to cause
higher parasite densities, febrile illness, severe ane-
mia, and low birth weight than malaria in those
the number of previous pregnancies, and the pre- without HIV infection (Snow et al. 2003). In the
sence of human immunodeficiency virus (HIV) also absence of HIV infection, the deleterious effects of
remarkably impact malaria morbidity and mortality malaria in pregnancy, notably low birth weight and
during pregnancy. In areas with high and stable maternal anemia, were significantly worse in those
malaria transmission, the prevalence and intensity pregnant for the first or second time than in those
of P. falciparum parasitemia are higher in pregnant who have been pregnant for three or more times (Ter
women than in non-pregnant women. The majority Kuile et al. 2004). With HIV co-infection, the pat-
of malaria infections in pregnant women living in tern of malaria morbidity is similar across all cate-
high transmission areas are asymptomatic because gories of pregnant women (Ter Kuile et al. 2004).
of immunity acquired from repeated exposure to A review of studies in areas of sub-Saharan Africa
malaria before pregnancy. The adverse conse- with high and stable malaria transmission shows
quences of malaria during pregnancy in areas of that HIV-1 infection and clinically diagnosed AIDS
high transmission are anemia, placental malaria, increased the incidence of malaria 1.2-fold and 2-
intrauterine growth retardation, and low birth fold, respectively (Korenromp et al. 2005). In these
weight. In areas of low or unstable transmission, high transmission areas, HIV-1 infection in children
acquired malaria immunity is low in all age groups. increased hospitalization for malaria and malaria
Pregnant women with malaria in this area are vul- case fatality 6-fold and 9.8-fold, respectively. At the
nerable to severe manifestation of the disease includ- same time in low transmission areas, the incidence of
ing cerebral malaria. severe malaria and malaria case fatality increased
2.7-fold and 3.6-fold, respectively. The effect of
HIV on malaria incidence is worse in HIV patients
HIV and Malaria Co-infection with lower CD4 counts. In adult patients living in
high malaria transmission areas, HIV increased the
The evidence that malaria and HIV co-infection malaria incidence 1.2-fold, 3-fold, and 5-fold when
increases morbidity associated with both conditions CD4 counts were 500, 200–499, and <200/mL,
has been confirmed by several studies (Snow et al. respectively (Korenromp et al. 2005).
2003). Impact of the complex interaction between The increase in morbidity and mortality asso-
malaria and HIV appears to be most profound in ciated with HIV and malaria co-infection, both of
pregnancy and children. HIV infection in pregnancy which are highly prevalent in most parts of sub-
is known to increase the risk of malaria infection Saharan Africa, calls for more focused research in
(population attributable risk (PAR), 10–27%), this area and for integration of service delivery. One
maternal anemia (PAR, 12–15%), and low birth way of achieving greater impact is the integration of
weight (PAR, 11–38%) (Steketee et al. 2001). The malaria and HIV/AIDS control activities within
mechanism by which HIV infection alters malaria maternal and child health programs. Achieving
morbidity is not well understood. It is believed to be high coverage of insecticide-treated bed nets (ITNs)
due to systemic and placental immunologic changes use and prompt access to treatment with artemisinin-
that are induced by HIV. In a Rwandan cohort based combination treatments (ACTs) would con-
study that included 228 HIV-positive and 229 HIV- tribute to the reduction in the morbidity and
mortality attributable to HIV co-infection with ITNs by poor women and children who need to be
malaria in high transmission areas. In areas of low protected from severe and fatal malaria. The Global
intensity and unstable transmission, widespread and Fund for Tuberculosis AIDS and Malaria is provid-
effective indoor residual spraying combined with ing funding to countries in endemic low and middle-
effective treatment using artemisinin-based combi- income countries to support this intervention. A
nation therapy (ACT) is cost-effective and has been systematic review of randomized controlled trials
shown to significantly reduce malaria morbidity and conducted in Africa showed that ITNs used in preg-
mortality (Snow et al. 2003). nancy compared to ‘‘no nets’’ significantly reduced
the risk of placental malaria in all pregnancies (rela-
tive risk 0.79, 95% confidence interval 0.63–0.98).
Strategies for Global Malaria Control The review also showed that ITNs significantly
reduced the risk of low birth weight (relative risk
The following section provides a summary of the 0.77, 95% CI 0.61–0.98) and fetal loss in the first to
three-pronged approach to malaria control recom- fourth pregnancy (relative risk 0.67, 95% CI 0.47–
mended by the World Health Organization’s 0.97). However, this was not the case in women with
malaria control program (WHO 2005). more than four previous pregnancies (Gamble et al.
2006). In a large randomized controlled trial in
communities with intense and perennial malaria
Vector Control transmission, ITN use significantly reduced the
risk of severe malaria anemia, placental malaria,
Indoor residual spraying, environmental manage- and low birth weight among those pregnant for
ment to eliminate mosquito breeding sites, and use the first to fourth time, but not in those pregnant
of larvicides are known to be effective in reducing for five or more times (Ter Kuile et al. 2003). The
malaria when used in combination. Aerial and ter- adherence to ITN use in pregnancy was shown to be
restrial spraying of insecticides is used in parts of significantly lower in adolescent and young women,
South America and Asia to control malaria. This who are most at risk for the deleterious conse-
intervention strategy is cost intensive and low in quences of malaria (Browne et al. 2001). This obser-
effectiveness. It is therefore, not an appropriate vation and the known risk of higher malaria
control measure for sub-Saharan Africa given morbidity associated with first pregnancy (invol-
the complex terrains and weak economies of these ving mostly adolescent women) make it necessary
malaria-endemic countries. to specially target this age group for intervention.
In summary, the limited risk assessments under-
taken so far with regard to the safety of ITNs suggest
that they are relatively safe. However, a cautionary
Prevention of Human–Vector Contact note regarding the need to monitor the health effects
of long-term exposure to insecticides in resource-
Insecticide-treated bed nets (ITN) have been shown poor settings has been presented by Ehiri et al.
by studies in a variety of settings to be effective in (2004). Although the use of mosquito nets is not
reducing the incidence of clinical malaria by half new, mass use of ITNs as a population-based malaria
and fatalities by about a third (Snow et al. 2003). control tool is a relatively new technology, and some
Population coverage for ITN in most parts of uncertainty remains about the potential for problems
Africa remains low (<20%). The low re-treatment as their use expands (Hirsch et al. 2002).
rate at the expiration of the usual period of potency
(6 months) was a major challenge, even in areas that
achieved high ITN coverage. The development and Treatment and Prevention with Drugs
widespread deployment of factory-treated nets with
lifelong protective effects (LLINs) has eliminated Prompt treatment of malaria with efficacious and
the need to re-treat insecticide-treated nets. The affordable antimalarials is a key component of the
persisting challenge is how to improve access to Global Malaria Control Strategy. The emergence
and spread of malaria parasites (especially P. falci- these drugs to the people that need them. Imple-
parum) resistant to the commonly used affordable mentation of this policy would put significant cost
antimalarials, like chloroquine (CQ) and sulpha- burdens on national malaria control programs.
doxine–pyrimethamine (SP), hampered malaria However, the costs of failing to change, such as an
control in Africa and has deteriorated the malaria increase in childhood deaths and high cost of hos-
situation on the continent. The emergence of these pitalization, make it a necessary and cost-effective
multidrug-resistant malaria parasites led to the program.
adoption of combination treatment options as Affordability of ACTs is a major issue affecting
the gold standards for treating malaria. The WHO their effective deployment in malaria control pro-
(2006) recommends that the ideal drug combination grams in sub-Saharan Africa. ACTs are generally
should contain two drugs that are individually effec- too expensive for most people in low-income set-
tive against the blood stages of the parasite and use tings where malaria is endemic. While drugs such as
completely different mechanisms to kill the parasite. chloroquine and sulphadoxine–pyrimethamine
Based on results from several well-conducted stu- (SP), which were previously used for treating
dies, the WHO recommended that combinations uncomplicated malaria, cost only a few US cents,
that contain artemisinin (a drug derived from the the new ACTs cost about $2–$3.5 and even higher
Chinese plant A. annua L.) or its derivatives and when not discounted. International efforts to
another structurally unrelated and more slowly act- address this issue championed by the Roll Back
ing drug provide the best therapeutic effects and are Malaria (RBM) partnership have yielded some posi-
safe. This category of drug combinations is collective results, especially through the Global Fund for
tively known as artemisinin-based combination Tuberculosis, AIDS and Malaria (Brundtland
treatments (ACTs). 2002). However, huge gaps still exist. Unfortunately
The advantages of artemisinin-based combina- access to prompt treatment with effective antima-
tion treatments (ACTs) have been outlined by the larial drugs remains very low in many sub-Saharan
WHO to include the following (WHO 2006): countries, leading to the persistence of high malaria
mortality rates. The reasons for poor access to treat-
Rapid substantial reduction of parasite biomass
ment are mainly due to weak health systems that are
Rapid resolution of clinical symptoms
poorly patronized by the populace and a lack of
Effective action against multidrug-resistant
funds to procure and effectively deliver expensive
P. falciparum
artemisinin-based combination treatment (ACTs).
Reduction of gametocyte carriage, which may
ACTs are necessary since high levels of P. falci-
reduce malaria transmission
parum resistance have rendered chloroquine and
No parasite resistance documented as yet with
sulphadoxine–pyrimethamine ineffective. These
the use of artemisinin and its derivatives
were the cheaper treatment options that have been
Few reported adverse clinical effects (note that
used for several decades. Most children who
pre-clinical data on artemisinin derivatives are
become ill with malaria in these areas are usually
limited)
treated at home with poor quality or inappropri-
Monotherapy with artemisinin derivatives ately administered medicines that were purchased
requires multiple doses given for 7 days due to from local, often untrained drug vendors.
their characteristic short half-life. The other key Antimalarial treatment policies, adopted by each
advantage of artemisinin containing combination country, depend on the epidemiology of the disease,
treatments (ACTs) is the shortened duration of including patterns of transmission, drug resistance,
treatment (3 days), with expected improvement in political environment, and economic context. The
patient compliance to treatment. If the partner drug adoption of ACTs in sub-Saharan Africa was pre-
is effective, ACTs ensure prompt recovery and high ceded by establishment of local evidence on the
cure rates. They are generally well tolerated. Repla- effectiveness of existing first- and second-line
cing the older failing or failed monotherapies with drugs which have demonstrated consistently high
effective drugs will reduce morbidity and mortality. treatment failure rates due to parasite resistance
The challenge, however, remains how to deliver (Snow et al. 2003). The WHO (2006) also
Box 12.2 Challenges of Community Delivery of Malaria Chemotherapy Through the Primary
Healthcare System
Limitation of outreach capacity to geographically remote areas, and particularly to nomadic

populations
Inability to make efficient use of community resources (both human and material)
Difficulty in achieving full community acceptance of chemotherapy
Insufficient training of local health workers
Lack of understanding of health problems and their solutions
Potential ineffectiveness of the curative drug or drug dosage used, usually through the emergence
of parasite resistance to the drug
Undesirable side-effects of the drug
Source: Jeffery (1984)
recommends that countries developing antimalarial Box 12.2. A careful appraisal of these factors in the
treatment policies should strive to ensure that context of the current situation of malaria control
efforts in most endemic countries in sub-Saharan
all populations at risk have access to prompt
Africa shows situations that are as pertinent today
treatment with safe, good quality, effective,
as they were over two decades ago when they were
affordable, and acceptable antimalarial drugs
highlighted by Jeffery (1984).
and
Home management of malaria (HMM), the
there is rational use of antimalarial drugs in
strategy currently recommended by the WHO
order to prevent the emergence and spread of
(Mendie et al. 2003) as an effective community
drug resistance induced by unduly high selec-
delivery mechanism for antimalarial treatment, is
tion drug pressure on mutant malaria
likely to address some of the limitations highlighted
parasites.
in Box 12.2. The HMM strategy entails educating
Delivery of effective and safe antimalarial treat- community health workers, volunteers, mothers,
ment to poor rural populations and those in diffi- and caregivers to recognize symptoms of malaria
cult, hard-to-reach settings poses enormous and treat with appropriate antimalarial drugs
challenges to malaria control programs in Africa. (Mendie et al. 2003). Its goal is to ensure early
In many endemic countries, the formal health sys- recognition and prompt and appropriate response
tem is weak. Often the health system consists of a to malarial illness in under-5 children in the home
few ill-equipped health facilities run by inade- and community by enabling health workers,
quately trained and/or poorly motivated health mothers, and caregivers to recognize malarial illness
personnel. The proportion of the people that early and take appropriate action. The WHO
access these services is so low that successful HMM strategy consists of four strategic
malaria treatment programs in Africa would be components:
impossible without community-based delivery
1. Ensure access to effective and good-quality anti-
mechanisms including adequately trained and
malarial drugs (preferably pre-packed) at com-
equipped informal community-based providers
munity level.
and caregivers who provide treatment and preven-
tive services as close as possible to where people 2. Ensure that community drug or service providers
live and work. Delivering community health care (e.g., patent medicine vendors, volunteer village
such as malaria treatment services through pri- health workers, community health extension
mary healthcare centers has long been identified a workers) have necessary skills and knowledge
big challenge by Jeffery (1984) as summarized in to manage malaria.
3. Ensure an effective communication strategy to risk 0.58, 95% CI 0.43–0.78; 1,399 participants) in
enable caregivers to recognize malarial illness women who were pregnant for the first or second
early and take appropriate action. time (Garner and Gülmezoglu 2006).
4. Ensure good mechanisms for supervision, mon- IPT with sulphadoxine–pyrimethamine (SP)
itoring, and communication activities. along with consistent use of ITNS are currently
recommended as cost-effective and evidence-based
As shown in Chapter 27, integrated management
interventions to prevent the deleterious effects of
of childhood illness (community IMCI) also
malaria in pregnancy and to reduce the associated
addresses both preventive and curative aspects of
maternal and infant morbidity and mortality.
malaria control by seeking to improve community
Almost all the 35 countries in Africa with stable
and family practices.
malaria transmission are already implementing
intermittent preventive treatment in pregnancy
(IPTp) with SP (Vallely et al. 2007). One of the key
challenges with implementation of IPT is the high
Using Drugs to Prevent Malaria rate of parasite resistance to SP, and the lack of a
safe and effective alternative to this antimalarial. In
Giving prophylactic antimalarial drugs to prevent most parts of Africa SP failure exceeds 20% and
malaria is a routine practice for non-immune per- surveillance data on the trends are lacking in most
sons visiting malaria-endemic areas. Malaria pro- cases. The effectiveness of this intervention in areas
phylaxis refers to daily or weekly administration of with high SP failure rates is yet to be adequately
antimalarial drugs at a dose that is usually smaller studied. The suggestion that two and three doses of
than the therapeutic doses with a view to prevent- SP, respectively, should be used in areas with SP
ing clinical malaria. Intermittent preventive treat- resistance <30 and 30–50% remains to be validated
ment (IPT) refers to full therapeutic doses of an by robust research data. The continued use of IPT
antimalarial given at specified time points to with SP in areas where SP resistance exceeds 50%
presumptively cure asymptomatic malaria and pre- also needs to be justified by research.
vent clinical malaria or such other adverse conse- There is also the problem of how to handle
quences as anemia or placental malaria. Usually, malaria co-infection with HIV in areas with high
sulphadoxine–pyrimethamine (SP) is used for IPT prevalence of HIV. A third dose of SP for IPT has
as it requires a single dose and has a long half-life. been recommended for areas with high HIV pre-
The rationale is that intermittent treatment is likely valence but there is a need to monitor impact
to have fewer adverse events than prophylaxis on such outcomes as severe anemia and low
because it is taken less often, and it is easier to birth weight, and to study possible drug interac-
deliver through clinics, reducing poor adherence tions in those receiving anti-retroviral treatment.
with self-administration. In malaria-endemic communities, use of antima-
Chloroquine was the most widely used drug for larial drugs for prophylaxis or intermittent
malaria prophylaxis in pregnancy. The high preva- preventive treatment (IPT) is recommended for
lence of resistant strains, and the fact that most only pregnant women and special vulnerable
women adhered poorly to the weekly regimen groups such as children with sickle cell disease.
required to achieve beneficial effects, rendered Several randomized controlled trials in malaria-
chloroquine chemoprophylaxis ineffective for endemic communities have shown consistently
malaria control in pregnancy. Meta-analysis that malaria prophylaxis and intermittent preven-
included in a Cochrane systematic review of rando- tive treatment of infants (IPTi) and young
mized controlled trials showed that IPT with sul- children are effective. A Cochrane systematic
phadoxine–pyrimethamine significantly reduced review and meta-analysis (Meremikwu et al.
the risk of severe maternal anemia (relative risk 2005) showed that receiving antimalarial drugs as
0.60, 95% CI 0.50–0.78; 2,243 participants), placen- prophylaxis or intermittent treatment reduced the
tal malaria (relative risk 0.35, 95% CI 0.27–0.47; incidence of clinical malaria episodes and severe
1,232 participants), and low birth weight (relative anemia by about 50% in preschool children living
in malaria-endemic communities. Two main rea- poses a complex challenge. Researchers involved
sons are commonly given for discouraging wide- in development of malaria vaccine devote their
spread use of malaria chemoprophylaxis in pre- efforts to three key strategies that target the pre-
school children in endemic communities. The first erythrocytic and erythrocytic stages of the life cycle
reason is the concern that giving malaria prophy- in humans (Fig. 12.2), and vaccines that induce
laxis to infants and young children living in antibodies in humans that can kill or prevent devel-
malaria-endemic areas will delay or minimize opment of viable sexual forms ingested by the mos-
their chances to acquire protective immunity and quito vectors. The pre-erythrocytic stage vaccines
result in a rebound rise in the incidence of severe aim to prevent sporozoites (the stage of plasmo-
morbidity and mortality later in life. dium that mosquitoes pass to humans) from invad-
The second reason is that poor compliance to ing and developing in the liver, while an asexual
weekly antimalarial drug prophylaxis could induce erythrocytic stage vaccine limits the invasion of
drug pressure and selection of mutant resistant erythrocytes or prevents their multiplication in the
strains of P. falciparum. Intermittent preventive erythrocytes.
treatment of infants (IPTi) with treatment doses of The complete mapping of the P. falciparum
SP under direct observation at the time of routine genome with a better understanding of the organ-
immunization offers a better programmatic option, ism at sub-cellular and molecular levels coupled
since it eliminates the problem of non-compliance with recent advances in genomic and proteomic
and is expected to have little or no adverse effect or science has led to a remarkable increase in the
interfere with the child’s ability to acquire malarial number of candidate malaria vaccines. There is
immunity. A major challenge to implementation of no time better than the present to scale up sup-
IPTi, among others, is the rising incidence of SP port for malaria vaccine research and develop-
resistance which is the principal drug currently used ment. The goal of most of the initial efforts of
for this intervention. There has also been a concern malaria vaccine development is complete preven-
about the possible interaction between SP and the tion of the disease with the hope of eliminating
routine infant vaccines but this has not been sup- malaria. The disappointing results of early
ported by any strong evidence. malaria vaccine trials appear to have diminished
this enthusiasm. Should efforts to develop a
malaria vaccine capable of completely preventing
clinical malaria fail, most public health experts
Malaria Vaccines and vaccine researchers advocate the goal of
making malaria vaccines that ameliorate the
Timely and efficient deployment of efficacious vac- severity of the disease and reduce the level of
cines is widely accepted as an effective child survival fatality. In Africa, where pregnant women and
strategy. The development of a successful malaria children bear the greatest burden of severe
vaccine especially against P. falciparum would con- malaria, such a vaccine will be a significant addi-
tribute remarkably to reduction of the unacceptably tion to maternal and child health services and will
high childhood death from malaria. Unfortunately help to reduce the burden of childhood disability
decades of efforts at vaccine development have yet attributable to cerebral malaria. The opportu-
to meet this expected public health success. Devel- nities provided by better research tools and a
oping vaccines against parasitic infections poses better understanding of the Plasmodium and Ano-
greater challenges than developing vaccines for pheles genome make the prospects and possibili-
virus and bacterial infections because of their more ties of a malaria vaccine better today than ever
complex nature and larger genomes. The multiple before. Funding for malaria vaccine development
stages of the malaria parasite and the different pro- and field trials has increased in recent years.
teins they express pose additional challenges to the However, it is still far short of the expected
development of a potent malaria vaccine. An all- investment, given its huge potential for improving
stage malaria vaccine capable of inhibiting growth child survival and contributing to achievement of
or killing all of these different stages of malaria the millennium development goals (MDG).
Progress and Challenges of the Global have contributed to the deterioration of the global
Malaria Control Strategy malaria situation in Box 12.3.
While the discovery of additional malaria control
The inadequacies of health information systems and measures such as a highly effective malaria vaccine
vital registration processes in most parts of sub- should be expected to increase the gains of malaria
Saharan Africa make it difficult to obtain reliable control efforts, several appraisals and overviews of
records of malaria mortality. Facility-based records global malaria control efforts agree that the key rea-
of deaths, when available, are not representative of sons for the recent decline in the gains of malaria
the situation in the larger population given that the control efforts have not been the lack of effective
majority of sick children do not use health facilities malaria control measures. There is consensus that
and most deaths occur outside the formal health the four technical elements of the global malaria con-
facilities. Most of the available mortality data from trol strategy (Box 12.4) affirmed by the international
malaria-endemic areas are estimates and prospective ministerial conference held in Amsterdam under the
mortality data from demographic surveillance sys- auspices of the World Health Organization in 1992
tems validated by verbal autopsies (Snow et al. have been essentially effective in the years preceding
2004). The inefficiency of health information systems and succeeding the Amsterdam conference.
and vital registration processes in sub-Saharan Afri- Careful study of malaria control scenarios
can countries makes it difficult to obtain sufficient (mostly in sub-Saharan Africa) that have failed, or
and timely information to track the performance of achieved only minimal success with these same stra-
malaria control programs. The malaria situation tegies, shows that these control programs lacked the
globally deteriorated in the past three decades. This pre-conditions for effectiveness of the global strat-
resulted in increased malaria-related morbidity and egy (Box 12.5) as also outlined in the Amsterdam
mortality, especially in sub-Saharan Africa where Ministerial Conference on Malaria.
emergence and spread of multidrug-resistant malaria When the RBM strategy was established in
parasites and breakdown of malaria control pro- 1998, it was in response to these deficiencies.
grams were the leading reasons, among others (Kor- The RBM is a partnership between the WHO,
enromp et al. 2003). Greenwood et al. (2005) have other UN agencies, bilateral aid agencies, non-
given an elaborate summary of the factors believed to governmental organizations, and governments of
Box 12.3 Factors Contributing to Deterioration of the Malaria Situation
Climate instability: drought and floods increased malaria transmission in different epidemiologi-
cal circumstances
Global warming may have led to increased malaria transmission especially in some highland areas
Civil disturbances and unrest have resulted in the collapse of malaria control programs and
refugee situations with attendant effects on malaria transmission across epidemiological areas
and increased risk of epidemics
Changes and increase in travel patterns within endemic areas and from non-endemic areas to
endemic areas putting many non-immune people at risk
HIV increases susceptibility to malaria and increases the burden on the health service
Emergence and spread of drug resistant P. falciparum has been a key reason for deterioration of
malaria situation in especially Africa and Southeast Asia
Insecticide resistance: resistance to pyrethroids used for treated bed-nets has emerged in Anopheles
gambiae (in West Africa) and Anopheles funestus (in southern Africa). High vector resistance to
Anopheles funestus diminished the use of DDT for household spraying in southern Africa.
Source: Greenwood et al. (2005)
Box 12.4 Basic Technical Elements of the Malaria Control Strategy
To provide early diagnosis and treatment

To plan and implement selective, multiple and sustainable preventive measures: including vector
control; personal protection (notably insecticide treated nets); and chemoprophylaxis/intermittent
preventive treatment.
To detect early, contain or prevent epidemics;
To conduct focused research, and to regularly assess the country’s malaria situation, including
ecological, social and economic determinants of the disease.
Source: WHO (1992)
Box 12.5 Conditions for Effective Implementation of the Global Malaria Control Strategy
Political Will: sustained political commitment from all levels and sectors of government
Integration: malaria control should be an integral part of health systems, and be coordinated with
relevant development programs in non-health sectors
Community participation: communities should be full partners in malaria control activities
Resource mobilization: adequate human and financial resources should be mobilized
Source: WHO (1992)
malaria-endemic countries. The RBM has a long- (DALY)) is similar to most childhood vaccines
term goal of reducing malaria morbidity and mor- (WHO 2003). When community coverage is high,
tality by at least half by 2010. RBM was not meant ITNs not only protect those who sleep under them,
to be a new malaria control strategy but rather an but also those in the same dwelling (the home effect)
organized global effort to facilitate the effective and those living nearby (the community effect)
implementation of the global control strategy. (Snow et al. 2003).
The year 2005 marked the end of the target set by
African Heads of State to achieve at least 60%
Conclusion access to prompt and effective treatment of malaria
and 60% ITN coverage for under-5 children and
The evidence that large-scale and effective use of pregnant women. However, most countries in sub-
ITNs can reduce the incidence of malaria and Saharan Africa fell far short of these targets. It was
malaria-related deaths is both strong and consistent also in the same year that RBM set the landmark
(Lengeler 2000). Insecticide-treated mosquito nets target of halving malaria mortality by 2010. Apprai-
(ITNs) can reduce all-cause childhood mortality by sal of malaria control efforts at the end of 2005
about a fifth; with about 6 lives saved for every uniformly indicated that resources available for
1,000 preschool children protected with ITN procurement of malaria control commodities
(Lengeler 2000). It is estimated that full ITN cover- (ACTs, ITN, and diagnostic kits) were grossly
age in sub-Saharan Africa could prevent 370,000 inadequate. The appraisal also showed that malaria
child deaths per year (Lengeler 2000). Insecticide- control personnel at national and regional levels
treated nets are cost-effective, but endemic poverty was inadequately equipped.
and inadequate sensitization of people in malaria- Donors and governments should develop effec-
endemic areas remain the major reasons for low use tive mechanisms to monitor the access that
(Snow et al. 2003). The cost-effectiveness of ITNs children, adolescents, pregnant women, and children
(US $19–85 per disability-adjusted life year in difficult circumstances have to evidence-based
treatment and preventive interventions for malaria. grossly impeded by weak health systems in malaria-
Donor funds specifically tagged to providing endemic countries. Funds meant for providing ade-
resources and infrastructure for effective manage- quate infrastructure and personnel for managing
ment of severe and complicated malaria have severe malaria should be tagged to bilateral and
been grossly inadequate. Supportive care for multilateral health system support grants.
women and children with severe malaria is
Key Terms
Acquired malaria immunity Impaired consciousness Plasmodium malariae

Anemia Infant mortality Plasmodium ovale
Anopheles funestus Insecticide-treated bed nets Plasmodium vivax
Anopheles gambiense (ITNs) Poor appetite
Artemisia annua Integrated management of Population attributable risk
Artemisinin-based combination childhood illnesses (IMCI) (PAR)
therapy (ACT) Intermittent preventive Poverty
Artemisinin-based combination treatment (IPT) Pregnancy
treatments (ACTs) Intermittent preventive Preterm births
Blood transfusion treatment of infants (IPTi) Relative risk
Case fatality rate Intrauterine growth retardation Repeated convulsions
Cerebral malaria (IUGR) Residual spraying
Chloroquine Learning disorders Respiratory distress
Circulatory collapse Lifelong protective effects Roll Back Malaria (RBM)
Cortical blindness (LLINs)
Seizures
Cytokines Low birth weight
Severe anemia
Dyserythropoeisis Malaise
Severe malaria
Dyskinesia Malaria-endemic countries
Sickle cell disease
Entomologic inoculation rate Malaria vaccine
Sinusoidal lymphocyte
(EIR) Malarial nephropathy infiltration
Fetal loss Malariometric indices Splenomegaly
Fever Maternal malaria Sporozoite
Global Malaria Control Maternal mortality Sporozoite rate
Strategy Monotherapy Stable malaria transmission
Glucose-6-phosphate Mosquito Sulphadoxine–pyrimethamine
dehydrogenase (G6PD) Multidrug-resistant malaria (SP)
deficiency parasites Tropical splenomegaly
Hemoglobin Nausea syndrome
Hemolytic crisis Parasite resistance Uncomplicated malaria
Home management of malaria Parasitemia Under-development
(HMM) Perennial malaria Vaso-occlusive crisis
Hyperactive malarial Placental malaria Vector control
splenomegaly Plasmodium falciparum
Hypoglycemia
Questions for Discussion Ehiri JE, Anyanwu EC, Scarlett HP (2004) Mass use of
insecticide-treated bednets in malaria endemic poor coun-
tries: public health concerns and remedies. Journal of
1 Globally, women, children, and adolescents in Public Health Policy, 25(1), 9–22
sub-Saharan Africa are known to bear the great- Gamble C, Ekwaru JP, ter Kuile FO (2006) Insecticide-trea-
est burden of malaria morbidity and mortality. ted nets for preventing malaria in pregnancy. Cochrane
List any six factors most peculiar to the region Database of Systematic Reviews, Issue 2
Garner P, Gülmezoglu AM (2006) Drugs for preventing
that account for this high burden. malaria in pregnant women. Cochrane Database of Sys-
2 List five consequences of malaria infection in tematic Reviews, Issue 4
children and pregnant women. Greenwood BM, Bojang K, Whitty CJM et al. (2005)
3 An integrated approach is advocated as an effi- Malaria. Lancet, 365: 1487–1498
Hirsch B, Gallegos C, Knausenberger W et al. (2002) Pro-
cient and cost-effective strategy for the manage- grammatic environmental assessment for insecticide-trea-
ment of malaria co-infection with HIV/AIDS. ted materials in USAID activities in sub-Saharan Africa.
Briefly discuss what you understand by integrated Agency for International Development (USAID), Office
management and describe how such an integrated of Sustainable Development. http://www.afr-sd.org/
documents/iee/docs/32AFR2_ITM_PEA.doc, cited 16
approach might be operationalized in practice. May 2008
4 What are artemisinin-based combination treat- Jeffery GM (1984) The role of chemotherapy in malaria
ments (ACTs) and what are the advantages of control through primary healthcare: constraints and
their use in the treatment of malaria? future prospects. Bulletin of World Health Organization,
62(Suppl.), 49–53
5 What are the challenges of community delivery of John CC, Sumba PO, Ouma JH (2000) Cytokine responses to
malaria treatment through existing primary Plasmodium falciparum liver-stage antigen 1 vary in rainy
healthcare systems? Is home treatment of malaria and dry seasons in highland Kenya. Infection and Immu-
a better option? Discuss the reasons for your nity, 68(9), 5198–5204
Korenromp EL, Williams BG, Gouws E (2003) Measure-
position. ment of trends in childhood malaria mortality in Africa:
6 List six factors that contribute to the worsening an assessment of progress toward targets based on verbal
of the global problem of malaria? How can these autopsy. Lancet Infectious Disease, 3, 349–358
be addressed? What should be the role of Roll Korenromp EL, Williams BG, de Vlas SJ (2005) Malaria
attributable to the HIV-1 epidemic, sub-Saharan Africa.
Back Malaria initiative in global malaria Emerging Infectious Diseases, 11(9), 1410–1419
control? Ladner JL, Leroy VR, Simonon A (2002) HIV infection,
malaria, and pregnancy: a prospective cohort study in
Kigali, Rwanda. American Journal of Tropical Medicine
and Hygiene, 66(1), 56–60
Lalloo DG, Olukoya P, Olliaro P (2006) Malaria in adoles-
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Chapter 13
The Global Burden of Childhood Diarrhea
Cynthia Boschi-Pinto, Claudio F. Lanata, and Robert E. Black
Learning Objectives After reading this chapter and global burden of childhood diarrheal morbidity
answering the discussion questions that follow, you and mortality is then provided by world regions
should be able to and by age groups. The unequal distribution of
diarrhea between rich and resource-poor countries
Define the different types of childhood diarrhea
is highlighted. The relative contributions of differ-
and distinguish their clinical manifestations.
ent diarrheal disease pathogens (enterotoxigenic
Describe the magnitude and unequal distribu-
Escherichia coli, G. lamblia, Rotavirus, Campylo-
tion of childhood diarrhea by age group and by
bacter, Shigella, Cryptosporidium parvum, Enta-
different world regions.
moeba histolytica, and Vibrio cholerae) as well as
Analyze the relative contributions of different
risk factors (access to clean water and sanitation,
diarrhea pathogens, as well as environmental
maternal education, poverty and undernutrition)
and socio-behavioral risk factors to the causa-
are analyzed. The chapter appraises the evidence
tion of childhood diarrhea.
base of various treatment and prevention options,
Appraise and prioritize the evidence base of var-
including promotion of exclusive breastfeeding,
ious treatment and prevention options.
hand washing, vaccines, oral rehydration therapy
(ORT), zinc supplementation, and improved
access to basic care. It concludes with a call for
prioritization of interventions to control diarrhea
Introduction
deaths in order to optimize the use of scarce
resources. The need to monitor and evaluate pro-
Using data from the Child Health Epidemiology
gress toward reduction of global inequity in child-
Reference Group (CHERG) of the Department of
hood diarrheal morbidity and mortality is also
Child and Adolescent Health and Development,
stressed.
World Health Organization, this chapter provides
Major changes are taking place worldwide in
a comprehensive overview of the current status of
the area of child health as efforts are geared
the global burden of childhood diarrhea, highlight-
toward achievement of Millennium Development
ing evidence of the relationship between diarrheal
Goal (MDG) # 4 of reducing by two-thirds,
diseases and child health. To set the discussion in
between 2000 and 2015, under-5 mortality rates
context, the chapter begins with a summary of the
(Bryce et al. 2006; United Nations Development
definition and description of clinical manifesta-
Programme 2003). This goal is, however, contin-
tions of childhood diarrhea. An exposition on the
gent on progress of other Millennium Develop-
ment Goals (MDGs), particularly those related
to eradication of extreme poverty and hunger
and improvement of maternal health. Countries
C. Boschi-Pinto (*)
with the highest burden of neonatal and under-5
Department of Child and Adolescent Health and
Development, World Health Organization, Geneva, mortality are those with the highest burden of
Switzerland maternal mortality as well. The concept of
226 C. Boschi-Pinto et al.
continuum of care from mothers to neonates to remain in less developed countries where poverty is
infants and under-5s highlights the importance of the underlying factor.
jointly addressing maternal and child health. In
the specific context of diarrheal disease for exam-
ple, it is well known that children exclusively
breastfed are about six times less likely to die of Morbidity and Mortality Burden
diarrhea than children who are not exclusively
breastfed. Diarrhea is a very common disease among children
in developing countries, with an estimated fre-
quency of about 3 episodes per child per year. In
addition, it is one of the major under-5 killers world-
Definition and Clinical Manifestations wide. The first estimates of diarrheal morbidity and
mortality among children less than 5 years of age in
There is great variability in the definition of diar- developing countries were published in 1982, by
rhea in the literature. However, for most epidemio- Snyder and Merson. They followed two other meth-
logical studies, diarrhea is defined as a condition in odologically comparable reviews by Bern et al.
which three or more liquid stools are passed within a (1992) and Kosek et al. (2003). These studies have
24-h period (Morris et al. 1994). Most diarrheal made available, important and continued sources of
episodes terminate within a week (an episode is information and constitute together major evidence
considered terminated if there are at least 2 days of the declining mortality trend from diarrheal dis-
free of diarrhea); however, a few episodes may last eases. Two decades ago, diarrhea was responsible
longer and continue for 2 weeks or more. The World for almost 5 million deaths among children under-5
Health Organization (WHO 1988) defines persis- (Snyder and Merson 1982). Estimates have shown a
tent diarrhea as an episode that continues for at steady decline ever since: 3.3 million deaths in the
least 14 days. Dysentery is defined by the presence 1990s (Bern et al. 1992) and 2.5 million in the year
of blood in loose or liquid stools. 2000 (Kosek et al. 2003). However, in spite of this
Diarrheal diseases may cause severe loss of water decline, diarrhea is still the second leading cause of
and electrolytes such as sodium, chloride, potas- under-5 mortality globally.
sium, and bicarbonate. When there is inadequate As opposed to the decreasing mortality trend, the
replacement of liquid and electrolytes, children can overall incidence of diarrhea has remained relatively
become dehydrated. Although the early stages of stable over time. These three reviews have estimated
dehydration present no signs or symptoms, as it a worldwide incidence of 2.2 episodes per child
advances, symptoms become pronounced and may under-5 per year in the 1980s (Snyder and Merson
progress to shock. If the child is not promptly rehy- 1982), 2.6 episodes per child under-5 per year in the
drated, death follows very rapidly. Case fatality 1990s (Bern et al. 1992), and 3.2 episodes per child
rates in under-5s have been reported to be 0.2% in under-5 per year in the year 2000 (Kosek et al.
developing countries overall, ranging from 0.1 to 2003).
0.5%, and being highest in younger children (Insti- The Child Health Epidemiology Reference
tute of Medicine 1986). Dehydration can be Group (CHERG), coordinated by the Department
prevented by giving the child more fluids than of Child and Adolescent Health and Development
usual. Increased intake of fluids supplemented by of the World Health Organization (WHO), has
oral rehydration salts together with continued feed- recently commissioned a systematic literature
ing has proven to be a powerful intervention for review to identify articles published between 1990
the prevention of childhood deaths from diarrhea and 2002 that reported diarrhea morbidity rates in
(Victora et al. 2000). Since the early 1980s, substan- children less than 5 years of age. Studies included in
tial efforts have been aimed at the reduction of the review were community-based surveys carried
diarrhea mortality. However, considerable morbid- out in low- and middle-income countries that
ity and mortality attributable to diarrheal disease reported frequent home visits. Studies of outbreaks
13 The Global Burden of Childhood Diarrhea 227
and studies focused on HIV/AIDS patients were 3.2 episodes per child under-5 per year estimated
excluded from the review. Thirty-three papers were and reported by Kosek et al. (2003). Incidence rates
finally included in the analysis. Countries in which were slightly higher in Africa, the Americas, and
studies were carried out were grouped according to the Eastern Mediterranean region (5 episodes per
the six WHO regions of the world: Africa, Amer- child per year) than in Southeast Asia and the
icas, Eastern Mediterranean, Europe, Southeast Western Pacific region (3 episodes per child per
Asia, and Western Pacific regions. year). Rates were generally highest in children
The median incidence of diarrheal disease among aged 6–23 months.
under-5s in the studied countries was 3.5 episodes Information on the prevalence of diarrhea was
per child per year (Table 13.1), very similar to the obtained from the Demographic and Health Surveys
Table 13.1 Reported incidence (episodes per child per year) of diarrheal diseases among children less than 5 years of age and
corresponding age-adjusted rates
Age-
Reported adjusted
Incidence incidence
Country/author(s)/year 0–5 6–11 12–23 24–35 36–47 48–59 0–4 years 0–4 years
Guinea-Bissau 13.0 10.2 10.2
(Mølbak
et al. 1997)
Nigeria 3.3 4.1 2.9 2.2 2.6
(Oni et al. 1991)
Kenya 3.5 3.1
(Mirza et al. 1997)
Ghana 2.5 2.5
(Morris et al. 1996)
Kenya 7.3 5.8
(Thomas and
Neumann 1992)
Zimbabwe 2.0 2.0
(Root 2001)
Zimbabwe 6.2 6.2
(Root 2001)
Age-adjusted median 5.0
for (sub-Saharan)
Africa
Brazil (Lima 6.8 5.3 5.3
et al. 2000)
Brazil (Barreto 7.1 7.7
et al. 1994)
Brazil (Linhares 6.0 4.9
et al. 1996)
Chile (Ferreccio 2.3 2.1 1.5 1.3 0.9 1.5 1.5
et al. 1991)
Honduras 5.0 3.4 3.2 2.6 1.5 3.2 3.2
(Kaminsky 1991)
Mexico (Guerrero 2.9 2.4
et al. 1998)
Guatemala (Cruz 7.6 6.8
et al. 1992)
Peru (Yeager 7.3 10.3 9.1 6.3 7.4
et al. 1991)

Age-
Reported adjusted
Incidence incidence
Country/author(s)/year 0–5 6–11 12–23 24–35 36–47 48–59 0–4 years 0–4 years
Brazil (Schorling 9.4 14.1 15.1 12.2 8.7 7.2 10.4 10.4
et al. 1990)
Brazil (Moore 5.5 4.5 2.4 3.4
et al. 2000)
Mexico (Cravioto 4.4 4.5 3.6
et al. 1990)
Argentina (Viboud 0.8 0.8
et al. 1999)
Venezuela (Pérez-Schael 2.4 1.8 1.7 1.8
et al. 1990)
Peru (Lanata et al. 1996) 8.3 6.8
Age-adjusted median for 5.0
(Latin) America
Egypt (Naficy et al. 7.3 8.8 5.5 2.9 5.5
2000)
Pakistan (Chavasse 7.1 7.1
et al. 1999)
Egypt (Abu-Elyazeed 4.9 2.5 1.0 3.0
et al. 1999)
Pakistan (Van der Hoek 5.8 5.2 5.1 2.1 1.6 3.9 3.9
et al. 2002)
for the Eastern
Mediterranean region
Indonesia (Dibley 0.8 0.9
et al. 1996)
Thailand 2.0 2.4 1.2 0.4 0.9 0.9
(Punyaratabandhu
et al. 1991)
Bangladesh 5.1 6.2 5.4 4.3 3.6 2.4 4.5 4.5
(Baqui et al. 1993)
India (Gupta 2.0 3.1 2.0 1.3 1.1 1.9
et al. 1996)
India (Lal 1994) 6.0 5.5 4.2 4.8
India (Rahmathullah 5.6 5.6
et al. 1991)
for Southeast
Asia
China (Chen et al. 1991) 2.3 2.3
Malaysia (Yap 0.2 0.2
et al. 1992)
Papua New Guinea 2.7 5.4 5.1 2.8 1.5 1.2 3.0 3.0
(Wyrsch et al. 1998)
for Western
Pacific
Global median 3.3 5.5 4.5 3.0 2.1 1.6 3.6 3.5
(25% and 75% IQI) (2.5– (3.6– (2.6– (2.2– (1.4– (1.3– (1.9–5.5) (2.3–5.7)
6.8) 9.2) 5.5) 4.3) 3.1) 2.2)
(DHS), which are nationally representative surveys year 2004. The distribution of these deaths, how-
that report on the occurrence of diarrheal disease ever, is heavily unbalanced; the greatest mortality
episodes in the 2 weeks prior to the surveys. Data burden being in sub-Saharan Africa and in South-
from these surveys were abstracted and analyzed to east Asia, which account together for approxi-
explore trends over time. Figure 13.1a suggests recent mately 80% of all under-5 deaths due to diarrheal
decrease in the prevalence of diarrheal disease in diseases. In contrast, the burden of diarrheal mor-
Africa, the Americas, and the Eastern Mediterranean tality in more developed regions has been reduced to
region, while an increase is indicated in Southeast Asia very low levels: merely 1% in Europe and 3% in the
and in the Western Pacific region. Nevertheless, these region of the Americas (Boschi-Pinto et al. 2008).
data should be interpreted with caution as they reflect The estimated regional distribution of diarrheal
information based on a 2-week period recall and do deaths for the year 2004 is shown in Fig. 13.2.
not take seasonality into account. Moreover, coun- Similarly, the distribution of diarrheal deaths
tries examined and averaged in region prevalence between and within countries shows a wide variation.
might not be the same in different periods of time. Some of the main reasons for this discrepancy are
Other limitations are possible changes in questions directly or indirectly linked to poverty. Poor access to
and interviewers. Therefore, comparability over water, sanitation and hygiene, poor housing, crowding
time cannot be directly inferred from these and limited or no access to care constitutes some of the
data and the interpretation of results is not main risk factors for the development of diarrheal
straightforward. The distribution of diarrheal disease disease. Country- specific estimates have highlighted
prevalence by age group was consistent over the years, that low- and middle-income countries account for
showing a peak among children aged 6–11 months and 99% of the global under-5 deaths caused by diarrheal
declining thereafter (Fig. 13.1b). diseases. The country-specific distribution of deaths
Common sources of information for mortality level due to diarrheal disease is shown in Fig. 13.3.
and cause of death are vital registration systems and Strikingly, these estimates have also revealed that
nationally representative surveys. However, such data just 15 countries account for almost three-quarters
are scarce in less developed countries. Almost none of of all under-5 diarrhea deaths worldwide (Boschi-
thecountriesthataccountfor98%ofallunder-5 deaths Pinto et al. 2008). Eight out of these 15 countries are
havevitalregistrationsystemstosupportaccurateattri- in sub-Saharan Africa and four are in Southeast
bution of the causes of child deaths (Rudan et al. 2005). Asia. This large variation on the distribution of
Nationally representative surveys such as DHS and the diarrhea deaths is further witnessed within coun-
Multiple Indicators Cluster Surveys (MICS) do not tries. In the Americas, Huicho et al. (2006) have
usually collect or report causes of death. Therefore, shown that proportional mortality from diarrhea
the main currently available sources of data that allow varied from 7% in the Peruvian coastal area to 9%
the estimation of cause-specific mortality are special in the Andean region to 11% in the jungle, in the
population epidemiological studies. The most impor- period 1996–2000. A study carried out in southeast
tant limitations of this type of studies are the lack of Brazil (Guimaraes et al. 2001) has shown a threefold
representativeness, possible site bias, and misclassifica- difference (from 10.8 to 30.1%) in the proportions
tion of causes of death. However, these remain the of infant deaths due to diarrhea between six districts
major or only source of cause-of-death information. under study. Even more appalling is the variation
observed in Mexico (Mota 2000): an approximate
20-fold difference between the states of Chiapas
(highest) and Sinaloa (lowest).
Geographic Distribution of Deaths Due In India, a study carried out in six rural and three
to Diarrhea urban areas representing eight major national states
showed that 88% of the infant deaths due to diarrhea
Based on these latter data sources, it has been occurred in rural areas while only 12% happened in
estimated that about 1.9 million children less than urban sites (Tandon et al. 1987). Within districts in a
5 years of age died from diarrheal diseases in the rural area of Ethiopia, a sixfold difference in
a b
30 40
25
30
20
15 20
10
10
5
0
0
1986–1990 1991–1995 1996–2000 2001–2006
<6 months 6–11 12–23 24–35 36–47 48–59
months months months months months
Africa Americas
Eastern Mediterranean Europe
South-east Asia Western Pacific
Global 1986–1990 1991–1995 1996–2000 2001–2006
Fig. 13.1 (a) Global and regional trends in the prevalence of period. (b) Diarrhea prevalence among children under-5 in
diarrheal diseases among children under-5 in the 2 weeks the 2 weeks preceding DHS surveys by age group and time
preceding DHS surveys by the WHO regions and time period. Source: Macro International (2007)
41%
Africa
37%
South-east Asia
13%
Eastern Mediterranean
6%
Western Pacific
3%
Americas
1%
Europe
0% 10% 20% 30% 40% 50%
Fig. 13.2 Estimated distribution of under-5 deaths due to diarrhea by the WHO regions in the year 2004. Source: Boschi-
Pinto et al. (2008)
Fig. 13.3 Distribution of estimated number of deaths due to diarrheal disease among children under-5 in the year 2004 (1,000
deaths per dot). Source: Boschi-Pinto et al. (2008)
mortality rates was observed. Areas furthest away Age Distribution of Deaths Due
from the only health center in the district had the to Diarrhea
highest mortality burden (Shamebo et al. 1991).
Although DHS do not usually report causes of Diarrhea deaths are less frequent among neonates
death, the 2004 survey carried out in Bangladesh than among children 1–59 months of age, reaching
(BDHS 2004) included this information. A fourfold its maximum burden between the first and the ele-
variation in deaths due to diarrhea was revealed venth months of life, when breastfeeding tends to be
between the five divisions assessed (Fig. 13.4). Diar- terminated and infants are first exposed to adverse
rhea proportional mortality ranged from 2.1% in environmental factors such as contaminated water
Rajshahi division to 8.5% in Chittagong division. and food and lack of sanitation and of personal and
Chittagong
Sylhet
Division
Dhaka
Barisal/Khulna
Rajshahi
0% 2% 4% 6% 8% 10%
Diarrhea proportional mortality
Fig. 13.4 Diarrhea proportional mortality among under-5s by Bangladeshi divisions. Source: Bangladesh DHS (2004)
domestic hygiene (Ehiri and Prowse 1999). The children 4–5 years old. Hammer et al. (2006) have
recent WHO estimates show that almost 95% of shown that, in a malaria holoendemic area of north-
all under-5 deaths due to diarrhea occur after the western Burkina Faso, mortality attributed to acute
first month of life (WHO 2005). Studies from dif- gastrointestinal infection peaks among infants 6–11
ferent regions of the world, carried out at various months. Studies carried out in Asia (Baqui et al.
periods of time, provide further evidence that diar- 2001) have also shown that proportions are consis-
Table 13.2 Age distribution of diarrhea deaths among under-5s

1–11 <1 12–59 Total (0–59)
Period Neonatal % months % year % months diarrhea deaths
References Region of study (N) (N) (N) %(N ) (N)
Baqui et al. Southeast Asia 1988– 8 (10) 45 (55) 53 (65) 47 (57) 122
(1998) 1993
Baqui et al. Southeast Asia 1992– 6 (6) 57 (60) 63 (66) 37 (39) 105
(2001) 1996
Barros et al. America 1982– ... ... 86 (25) 14 (4) 29
(1987) 1986
Bendib et al. Africa 1985– 10 (27) 73(203) 83(230) 17 (46) 276
(1993) 1989
Campos et al. America 1986 ... ... 83 (35) 17 (7) 42
(1995)
De Francisco Africa 1988– 10 (10) 37 (38) 47 (48) 53 (54) 102
et al. (1993) 1989
Ekanem et al. Africa 1991 0 (0) 24 (9) 24 (9) 76 (28) 37
(1994)
Garrib et al. Africa 2000– 0 (0) 43 (12) 43 (12) 57 (16) 28
(2006) 2002
Jinadu et al. Africa 1987 ... ... 59 (23) 41 (16) 39
(1991)
Marsh et al. Eastern 1988– 0 (0) 72 (13) 72 (13) 28 (5) 18
(1993) Mediterranean 1991
Stanton and Eastern 1994– 12 (8) 38 (25) 50 (33) 50 (33) 66
Langsten Mediterranean 1996
(2000)
Yassin (2000) Eastern 1992– 10(8) 68 (53) 78 (61) 22 (17) 78
Mediterranean 1996
Median All 1990 8% 45% 61% 39% 942 deaths
(25% and (1987– (0–10%) (38– (47– (17–
75% IQI) 1994) 70%) 83%) 53%)
rhea deaths are indeed less frequent among neo- tently lower among neonates (median 9%; range 3–
nates (median = 8%; range: 0–12%) and highest 15%) and are equal to or greater than 85% among
among children 1–11 months (median = 45%; children 1–11 months (median 91%; range 85–
range: 24–73%). These studies are summarized in 97%). Anand et al. (2000) reported that, in a rural
Table 13.2. area of a northern state in India, 12% of the 88
Studies that focused on slightly different age diarrhea deaths among infants that occurred in the
group breakdowns have shown similar patterns. In period 1972–1974 were in the neonatal period, and
northern Nigeria (Bradley and Gilles 1984), deaths 88% in the post-neonatal period. In this same area,
due to diarrhea had the following age pattern: 16% in 1982–1984, 95% of diarrhea deaths happened
among neonates, 11% among children 1–5 and 6–11 after the 28th day of life and in 1992–1994 this
months of age, 9% in children 1–2 and 2–3 years proportion was equal to 97%. Similarly, studies
old, 6% among those 3–4 years old, and 8% among from Bangladesh (Baqui et al. 2001) have shown
that 85% of infant diarrhea deaths happened in the lack of comparability with respect to some design
post-neonatal period in 1988–1993, increasing to issues, these studies constitute an important body
91% in 1992–1996. of evidence of the burden of diarrheal diseases over
Likewise, global diarrhea mortality rates are time. Several other studies have also reported
highest in the youngest (infants) than among chil- major reductions in diarrhea mortality rates as
dren 1–4 years of age. Kosek et al. (2003) have well as in the proportional mortality due to diar-
reported a global median mortality rate more than rhea over time (Table 13.3). Impressive decreases
twofold higher in infants (8.5 per 1,000 children per of 76 and 81% in mortality rates among infants
year) than in children 1–4 years (3.8 per 1,000 chil- and children 1–4 years of age, respectively, have
dren per year) in the developing world. been described by Miller et al. (1994) in Egypt
during the 1980s. Guimaraes et al. (2001) also
reported a decrease in proportional diarrhea mor-
tality of more than 70% among Brazilian infants in
Assessing ‘‘Trends’’ in Diarrhea Mortality the 1990s.
Further indication that, at least for some
The decreasing trend in diarrhea mortality among countries, diarrhea mortality has been declining
children less than 5 years of age is largely docu- over the years can be found in studies by Villa
mented. The first sources of evidence are the three et al. (1999), Miller and Hirschhorn (1995),
reviews mentioned in the introduction of this chap- Victora et al. (2000), and Baltazar et al. (2002).
ter (Snyder and Merson 1982; Bern et al. 1992; These declining trends are reportedly owed to
Kosek et al. 2003). Regardless of the possible lim- the progress in case management of diarrheal
itations inherent to these types of review and of the diseases.
Table 13.3 Decrease of diarrhea mortality over time among under-5s

References Region Period Measure Decrease (%) Age group
Anand et al. (2000) Southeast Asia 1983–1993 Proportional diarrhea 31 1–11 months
mortality
Campos et al. (1995) Americas 1986–1989 Number of diarrhea deaths 69 0–11 months
El-Rafie et al. (1990) Eastern 1982–1987 Cause-specific mortality 58 0–11 months
Mediterranean rate
El-Rafie et al. (1990) Eastern 1982–1987 Cause-specific mortality 43 1–4 years
Mediterranean rate
Guimaraes et al. (2001) Americas 1980–1989 Proportional diarrhea 58 0–11 months
mortality
Guimaraes et al. (2001) Americas 1990–1998 Proportional diarrhea 72 0–11 months
mortality
Gutierrez et al. (1996) Americas 1984–1989 Proportional diarrhea 28 0–59 months
mortality
Gutierrez et al. (1996) Americas 1990–1993 Proportional diarrhea 33 0–59 months
mortality
Huicho et al. (2006) Americas 1996–2000 Proportional diarrhea 82 0–59 months
mortality
Jaffar et al. 1997 Africa 1989–1993 Cause-specific mortality 64 0–11 months
rate
Jaffar et al. (1997) Africa 1989–1993 Cause-specific mortality 53 1–4 years
rate
Miller et al. (1994) Eastern 1980–1990 Cause-specific mortality 76 0–11 months
Mediterranean rate
Miller et al. (1994) Eastern 1980–1990 Cause-specific mortality 81 1–4 years
Mediterranean rate
Mota-Hernández, (2000) Americas 1990–1994 Cause-specific mortality 62 1–4 years
rate
No authorship – report Americas 1985–1993 Cause-specific mortality 69 0–59 months
MoH, Mexico (1994) rate
Information on the proportion of deaths due to due to interventions, coverage, or to new emerging
diarrheal disease was obtained from studies carried diseases and competing causes of death.
out between 1981 and 1998 in 25 countries from Vital registration data on under-5 mortality rates
different regions of the world. These studies (per 1,000 under-5 population) for 20 countries in
allowed the abstraction and plot of 69 data points Latin America from 1970 to 1990 have been pub-
that are shown in Fig. 13.5(a). Time period of the lished by Bern et al. (1992). Although these data
studies is distributed around an average mid-sur- represent real trends, they also have some severe
veillance period 1985–1990. The plotting of the limitations such as lack of comparability due to
diarrhea proportional mortality obtained from huge variability in the vital registration systems
these studies suggests a decreasing trend over between countries (e.g., different coverage, under-
time, possibly reflecting the secular downward reporting rates, and miscoding of causes of death)
trend in child mortality that has been accompanied and over time. Furthermore, where coverage is
by a decrease in the proportion of deaths due to incomplete, the poorer population, with higher
diarrhea. As these studies were carried out in dif- mortality rates and different patterns of causes of
ferent sites and had different designs, the plot of death, is likely to be underrepresented. Even within
the data points does not represent real-time trends. countries, these trends may be difficult to compare
Yet, they provide some further indication of the without a correction factor, as the systems and cov-
decline in diarrhea proportional mortality over erage tend to improve over time. Finally, these data
time. It is worth noting that the data used in these also have the limitation of not capturing recent data
figures refer to studies that were mainly carried out and trends. Consequently, data presented in
in the late 1980s and early 1990s. This represents a Fig. 13.5(a and b) should be interpreted with cau-
more than 10-year lag time. Hence, this currently tion, especially if attempting to extrapolate them to
available data are unable to capture recent changes recent years.
a b
50 12
Mortality rates (1000 U5 population)
10
40
% diarrheal deaths
8
30
20
4
10
2
0 0
1980 1985 1990 1995 2000 1973 1978 1983 1988
Year Mid-year
Argentina Belize Brazil Chile Colombia
Costa Rica Cuba Dom Rep Ecuador El Salvador
Guatemala Jamaica Mexico Nicaragua Panama
Paraguay Peru Uruguay Venezuela
Fig. 13.5 (a) Proportion of deaths due to diarrhea among 1,000 under-5 population) in some Latin American countries,
children under-5 by mid-year of study, 1981–1998. Source: 1970–1990. Source: Bern et al. (1992)
Boschi-Pinto et al. (2008). (b) Diarrhea mortality rates (per
Etiology clean water and sanitation, and mother’s education are

all closely intertwined and denounce social inequalities
Major pathogens involved in diarrheal diseases have that are reflected in the health status of the child. In
been the focus of several community- and facility- some countries, disparities are also observed by sex of
based studies. Results from community-based studies the child, girls being less likely to survive or to be taken
are usually more representative of the overall occur- to a health facility than boys (Larson et al. 2006).
rence of disease than facility-based studies, as their Diarrhea could well be considered as a "sentinel" dis-
findings are independent of the severity of disease or ease in terms of inequities in general social welfare and
care-seeking behavior. In community-based studies, in access to health care as it can be easily prevented and
enteropathogens have been generally identified and averted through affordable means.
reported in about 50% of stool samples collected Data from DHS surveys carried out in 41 countries
during episodes of diarrhea. In facility-based studies, between 2002 and 2007 have been analyzed, revealing
this proportion was between 60 and 70%. a 34% increase in diarrhea prevalence in the 2 weeks
A recent review of studies published since 1990 before the survey among children of mothers with no
showed that the enteropathogen most frequently education as compared to those children of mothers
isolated from stools in community-based studies with secondary or higher level of education. Children
was enterotoxigenic E. coli. This pathogen was iden- living in rural settings had a 10% higher prevalence
tified in about 14% of samples collected during than children from urban areas.
episodes of diarrhea. Giardia lamblia, enteropatho- The association of these risk factors and diar-
genic E. coli, and Rotavirus were identified as the rheal mortality is exemplified in some studies.
next most commonly isolated pathogens, with Gurgel et al. (1997) have shown that, in an
reported prevalence between 8 and 10%. Other urban setting in northeastern Brazil, higher diar-
common enteropathogens included Campylobacter, rhea mortality rates were seen in districts with
Shigella, C. parvum, and E. histolytica. higher proportions of slums than in those with
In facility-based studies, rotavirus was the fewer slums (p < 0.001). Gutierrez et al. (1996)
enteropathogen most frequently isolated, with a have shown a strong inverse correlation between
prevalence that varied between 18 and 25%. Bac- under-5 mortality from diarrheal diseases and the
terial pathogens such as enterotoxigenic E. coli, proportion of literate women (Pearson correlation
enteropathogenic E. coli, Campylobacter, and Shi- = 0.7958). In a metropolitan area of northeastern
gella were also frequently identified. Vibrio cho- Brazil (Campos et al. 1995) and in rural districts
lerae is frequently isolated in some settings, and of Sierra Leone (Amin 1996), higher proportions
in more recent studies, Norovirus has been recog- of diarrhea deaths were reported among children
nized as an important cause of severe diarrhea in whose mothers had lower level of education than
both developed and developing countries. among those whose mothers had at least second-
ary school education. The DHS carried out in
Bangladesh in 2004 has also examined the distri-
bution of causes of death according to the level of
Risk Factors mother’s education. An increased 50% diarrhea
mortality was observed among children whose
Some of the well-established determinants of diar- mothers had lowest level of education.
rheal morbidity and mortality are socioeconomic The major route of transmission for diarrheal
status (Yeager et al. 1991), crowding, access to pathogens is the fecal–oral route. Consequently,
clean water and sanitation (Rahaman et al. 1985), both access to clean water and safe disposal of
and maternal education (Betrand and Walmus human feces are expected to reduce transmission of
1983). These main determinants of the development most pathogens. Poor sanitation, lack of access to
of diarrheal disease are intrinsically linked to clean water, and inadequate personal hygiene are
poverty. responsible for an important proportion of child-
Place of residence within countries (rural or urban, hood diarrhea. Therefore, hygiene and feces disposal
districts, provinces, etc.), wealth, crowding, access to practices at home are key determinant factors for
reduction of the incidence of diarrheal disease. Con- degree of malnutrition. A dose–response relation-
taminated water plays an important role in the trans- ship was reported in studies from India (Bhandari
mission of some pathogens that cause diarrhea. et al. 1992), the Philippines (Yoon et al. 1997), and
Huttly et al. (1997) have shown that promotion of Sudan (Fawzi et al. 1997) and a review of six pro-
hand washing can reduce diarrhea incidence by an spective studies (Pelletier et al. 1993) has demon-
average of 33%. In a recent meta-analysis, Ejemot strated a consistent increase in mortality with
et al. (2008) found that interventions promoting poorer nutritional status. Caulfield et al. (2004)
hand washing resulted in a 29% reduction in diar- performed a combined analysis of data from 10
rhea episodes in institutions in high-income countries longitudinal community-based studies. The authors
(IRR 0.71, 95% CI 0.60–0.84; 7 trials) and a 31% found that the relative risk of death from diarrhea
reduction in such episodes in communities in low- or was increased for children who were less than –1z
middle-income countries (IRR 0.69, 95% CI 0.55– weight for age, and that the risk increased progres-
0.87; 5 trials). However, effects on reduction of mor- sively with each z-score below the median. The
tality have not been shown. Yet, another six observa- authors further estimated that 61% of under-5
tional studies did demonstrate a median reduction of deaths attributable to diarrhea are associated with
55% in all-cause child mortality associated with children being underweight.
improved access to sanitation facilities (Esrey et al.
1985). Sanitation schemes such as latrines generally
require proper education and active involvement of Preventive and Treatment Interventions
the community in order to be effective. The use of
potties was identified as an important intervention to Promotion of Exclusive Breastfeeding
avoid fecal contamination of household’s soil by
toddlers (Yeager et al. 2002). Nevertheless, behavior
Exclusive breastfeeding means no food or drink
change is complex, and significant resources are
(not even water) other than breast milk is permitted,
needed to tackle such interventions.
except for supplements of vitamins and minerals or
necessary medicines. The WHO has established,
based on sound evidence, that the optimal duration
Synergy with Malnutrition of exclusive breastfeeding is 6 months (WHO 2001).
A meta-analysis of three studies carried out in devel-
oping countries shows that children under 6 months
Diarrhea and undernutrition act synergistically in an
of age that are breastfed are six times less likely to
implacable manner as frequent and prolonged epi-
die of diarrhea than infants who are not breastfed
sodes of diarrhea usually lead to malnutrition and
(WHO 2000). When exclusive breastfeeding is con-
malnutrition facilitates the progression of diarrhea
tinued during diarrhea, it also diminishes the
toward death (Fontaine and Boschi-Pinto 2006).
adverse impact of poor nutritional status. Estimates
Strong evidence of such fatal synergy is provided by
suggest that breastfeeding promotion could also
several studies worldwide. Community-based studies
decrease all-cause mortality in children under-5 by
report an increased risk of mortality from diarrhea
13% (Jones et al. 2003).
among children who had low weight for their age. In
a study carried out in an urban setting of northeast
Brazil, Gurgel et al. (1997) showed that diarrhea and
malnutrition were recorded together in 26% of the
Vaccines
318 under-5 deaths caused by diarrhea. In rural
India, Bhandari et al. (1992) have also demonstrated One of the major complications of measles infection
that severely malnourished children had a 24-fold is diarrheal disease secondary to immunodeficiency.
higher diarrheal case fatality rate as compared to It has been estimated that high coverage of measles
normally nourished children. vaccines would prevent up to 3.8% of diarrheal epi-
Moreover, the risk of dying from diarrheal dis- sodes and 6–26% of under-5 deaths due to diarrhea
ease has been shown to be proportional to the (Feachem and Koblinsky 1983). Currently available
vaccines against cholera are likely to be safe and offer importance has been given to increased fluids plus
reasonable protection for a limited period of time; continued feeding (Victora et al. 2000).
however, they are rarely used in developing countries A new ORS solution with lower salt and glucose
and only Vietnam has established routine cholera content was launched by the WHO and UNICEF in
vaccination (Keusch et al. 2006). It has been esti- May 2002. Some of the advantages of this new
mated that rotavirus accounts for at least a yearly solution are reduced stool output and duration,
475,000 deaths among under-5s (Parashar et al. less vomiting, and decreased need of intravenous
2003). In 1998, a live rotavirus vaccine was intro- fluids, thus improving acceptance by mothers and
duced in the United States (Glass et al. 1999), but it health workers.
was withdrawn from the market due to the detection
of an increased occurrence of intussusceptions
among vaccinated children (CDC 1999). Two new Zinc Supplementation
vaccines have been recently introduced into the mar-
kets, which were proven to be safe and effective: an
A review of relevant clinical trials has indicated that
attenuated human rotavirus strain (Ruiz-Palacios
zinc supplementation given during an episode of
et al. 2006) and a bovine-based tetravalent rotavirus
acute diarrhea reduces both duration and severity
vaccine (Vesikari et al. 2006). These vaccines are
of the disease and could prevent about 300,000 child
currently being used in several countries in the Amer-
deaths each year (Black 2003). The WHO and UNI-
ican region.
CEF currently recommend that all children with
acute diarrhea be given zinc for 10–14 days during
and after diarrhea (WHO/UNICEF 2004). Zinc
Oral Rehydration Therapy (ORT) supplementation and the newly formulated ORS
used in combination with promotion of exclusive
breastfeeding, general nutritional support, and
Case studies in countries such as Brazil (Victora et al.
selective and appropriate use of antibiotics can
1996), Egypt (Miller and Hirschhorn 1995), and
further reduce the number of diarrheal deaths
Mexico (Gutierrez et al. 1996) have demonstrated
among children. Moreover, zinc supplements admi-
an association between increased use of ORT and
nistered during 10–14 days have been shown to
marked declines in mortality due to diarrhea. Oral
reduce the incidence of diarrhea in the following
rehydration therapy (ORT) was introduced in 1979,
2–3 months.
consisting of the oral administration of sodium, a
carbohydrate, and water (Hirschhorn and Green-
ough 1991). It rapidly became the foundation for
the control of diarrheal diseases, but scientific pro-
Access to, and Quality of, Care
gress together with considerations on feasibility has
led to a series of changes in the recommendations on Reductions in diarrheal mortality are known to be
the use of ORT for home treatment of diarrheal linked to increased utilization of health services.
diseases. In the early 1980s, it was recommended Figure 13.6 illustrates the differences in care seeking
that all diarrhea episodes should be treated with a for diarrhea observed in 19 countries with available
solution of oral rehydration salts (ORS). With the DHS data for the years 2005 and 2006. According to
recognition that access to ORS was limited and that these data, the proportion of children with diarrhea
more than two-thirds of diarrhea cases were not in the 2 weeks preceding the survey that were report-
accompanied by dehydration, the focus thus shifted edly taken to a health facility or provider showed a
to the prevention of dehydration through recom- fivefold difference, varying from 14% in Rwanda to
mended home fluids (RHFs). In 1988, continued 70% in Uganda. In 17 of the 19 (89%) countries
feeding was added as one of the appropriate manage- observed, appropriate care was sought in less than
ments of diarrhea cases. Later, in 1990–1991, empha- 50% of diarrheal cases and in 10 (53%) countries,
sis shifted to the amount of fluids given rather than less than 30% of the ill children were taken to either
the type of fluid. Finally, since 1993, more a health facility or provider.
Uganda 2006
India 2005/2006
Honduras 2005
Egypt 2005
Moldova 2005
Colombia 2005
Country & year of survey
Cambodia 2005
Zimbabwe 2005/06
Haiti 2005/06
Armenia 2005
Nepal 2006
Guinea 2005
Congo (Brazzaville) 2005
Ethiopia 2005
Benin 2006
Senegal 2005
Mali 2006
Niger 2006
Rwanda 2005
0 10 20 30 40 50 60 70 80
% children with diarrhea taken to a health facility
Fig. 13.6 Children under-5 with diarrhea symptoms who were taken to a health provider in some selected countries of the
world 2005–2006. Source: DHS (2005–2006)
Some identified predictors of healthcare and higher education of the mother. In rural set-
utilization by children with diarrheal disease tings, where access to licensed providers is much
include length of illness and maternal education. more restricted, the most important predictors
Children whose diarrhea last for 2 or more days were younger age of the child, longer duration
are more likely to be taken to a health facility of illness, and mother’s education (Larson et al.
(Thind 2003) than those children whose diarrhea 2006).
last for less than 2 days. Also, mothers with a Overall, children who live in urban settings,
higher level of education are more likely to take children whose mothers have at least secondary
their children to a health facility during an epi- school education, and those who are from
sode of diarrhea than those with lower levels of households in the highest wealth quintile have a
education (Thind 2003). In an urban area of Gui- much higher likelihood of seeking treatment for
nea-Bissau, care-seeking behavior of mothers of diarrhea from a health professional or facility.
deceased children in the post-neonatal period was Figure 13.7 illustrates the differences in care
investigated. Median time from the onset of symp- seeking according to the place of residence and
toms to first consultation was 2 days for acute level of mother’s education in some selected
diarrhea and 14.5 days for chronic diarrhea countries. Considerable differences are also pre-
cases. The health center was the place of first sent in diarrhea case management according to
consultation for 56.5 and 66.7% of acute and the place of residence (urban–rural). Children
chronic cases, respectively (Sodemann et al. with diarrhea living in urban areas are not only
1997). In Bangladesh, the most common more likely to be taken to a health facility than
predictors for seeing a licensed provider, after children living in rural areas, but they are also
adjustment for host and illness characteristics, more likely to be adequately treated with ORT
were higher income, longer duration of illness, and increased fluid intake.
100% 100%
90% 90%
Proportional under-five diarrhea mortality
Proportional under-five diarrhea mortality

80% 80%
70% 70%
60% 60%
50% 50%
40% 40%
30% 30%
20% 20%
10% 10%
0% 0%
d
la li
sh
er o
N on
N a
Ph Be l
ilip nin
Ke s
om a
E ia
M ar ea
am ua
do e
d
la li
sh
er o
N on
N a
Ph B l
pi n
Ke s
om a
Er ia
M car ea
am ua
do e
a
a
a
ng Ma
ng Ma
ne
ne
ha
am s
C ny
In biqu
si
ha
am s
ilip eni
C ny
In biqu
si
er
ep
er
ep
b
de
C BFa
de
C BFa
o
N ritr
oz ag
N itr
oz ag
ne
ne
pi
C
ig
ig
ol
ol
i c
i
Ba
Ba
Rural Urban No education Secondary or higher
Fig. 13.7 Children under-5 with diarrhea symptoms taken to a health facility according to the place of residence (rural and
urban) and level of mother’s education. Source: DHS (2004)
Conclusions Nevertheless, children from less privileged

regions of the world suffer, on average, more
Despite the decline in numbers and rates of than 3 episodes of diarrheal disease each year
diarrhea deaths worldwide over the past decades, and almost 2 million under-5s continue to die
diarrheal diseases remain the second leading sin- every year as a consequence of diarrheal dis-
gle cause of death among children less than 5 eases. Careful planning and prioritization of
years of age in the world. This burden is espe- interventions to control diarrhea deaths as well
cially high in the African and Southeast Asia as monitoring and evaluating their progress in
regions. Determinants of the disease and preven- low-income areas are crucial to reduce under-5
tion measures are well established and case man- diarrhea mortality toward the levels attained by
agement is accessible, effective, and affordable. more developed regions of the world.
Key Terms
Campylobacter Entamoeba histolytica Oral rehydration therapy

Case fatality rate Escherichia coli Persistent diarrhea
Cholera Exclusive breastfeeding Prospective studies
Cryptosporidium parvum Giardia lamblia Rotavirus
Dehydration Maternal mortality Shigella
Demography and Health Median incidence Under-5 mortality
Surveys (DHS) Multiple Indicator Cluster Vibrio cholerae
Diarrhea episode Surveys (MICS) z-Score
Dysentery Neonatal mortality
Questions for Discussion verbal autopsy study. Bulletin of the World Health Orga-
nization, 76: 161–171.
Baqui AH, Sabir AA, Begum N et al. (2001) Causes of child-
1. Estimates show a steady decline in childhood hood deaths in Bangladesh: an update. Acta Paediatrica,
diarrheal mortality from 3.3 million deaths in 90: 682–690.
the 1990s to less than 2 million currently. How- Barreto ML, Santos LM, Assis AM et al. (1994) Effect of
ever, diarrhea remains the second leading cause vitamin A supplementation on diarrhea and acute lower
respiratory tract infections in young children in Brazil.
of under-5 mortality globally, and although mor- Lancet, 344: 228–231.
tality has been decreasing, childhood diarrheal Barros FC, Victora CG, Vaughan JP (1987) Causes of peri-
morbidity remains relatively stable. Why is this? natal mortality in Pelotas, RS (Brazil). Use of a simplified
2. What factors explain the wide variations classification. Revista de Saúde Pública, 21: 310–316.
Bangladesh Demography and Health Survey (DHS) (2004)
observed in the distribution of diarrheal deaths Bangladesh: improving maternal and child health in the
between and within countries? In a country such south-east Asia region http://unpan1.un.org/intradoc/
as India, for example, what factors would groups/public/documents/APCITY/UNPAN022523.pdf
account for urban–rural differentials in child- Cited 2 August 2008.
Bendib A, Dekkar N, Lamdjadani N (1993) Factors asso-
hood diarrhea mortality? ciated with neonatal, infant and child mortality: Results
3. Diarrheal deaths are less frequent among neonates of a national survey in Algeria. Archives of French Pedia-
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bidity and mortality from childhood diarrhea tudes and practice as predictors of diarrheal disease in
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Chapter 14
Tuberculosis in Childhood and Pregnancy
Krishna Reddy, David Moore, and Robert Gilman
Learning Objectives After reading this chapter and impact on TB incidence, accounting for an
answering the discussion questions that follow, you estimated excess of 34% of new TB cases
should be able to (Cantwell and Binkin 1997). Other factors contri-
buting to the global resurgence of TB include
Present a concise overview of the global burden of
poverty, overcrowding, increased travel and immi-
TB among women and children, highlighting dif-
gration, ineffective TB surveillance and control
ferences in trends in developed and less-developed
programs, emergence of multidrug-resistant TB,
countries.
and non-completion of treatment regimens. TB
Identify risk factors for childhood TB and dis-
control features among the health targets of the
cuss the challenges of diagnosing and tracking
Millennium Development Goals (MDGs) of the
TB in children.
United Nations because it is both primarily a dis-
Describe the pathogenesis of TB and discuss the
ease of the poor and a cause of poverty for indivi-
relationship between TB and HIV/AIDS.
duals, societies, and governments. Box 14.1 pre-
Appraise the global challenges posed by multi-
sents definitions of some of the most commonly
drug-resistant TB.
used terms in TB epidemiology.
Critically assess options for treatment and pre-
Of the estimated 8.3 million new TB cases
vention of TB among women and children, and
diagnosed in 2000, approximately 11% were chil-
discuss the associated challenges.
dren (Nelson and Wells 2004), often diagnosed on
the basis of exposure history and clinical signs
and symptoms without microbiological confirma-
tion. Most of these children are found in devel-
Childhood Tuberculosis: Introduction
oping countries, where TB occurs at all ages; in
industrialized countries, conversely, TB occurs
The global prevalence of tuberculosis (TB) is
primarily in older adults. Childhood TB is
greater now than ever before. The World Health
often overlooked in public health intervention
Organization has declared TB a global emergency
planning. Many TB control programs do not
that is expected to account for over 30 million
consider the treatment of children to be of para-
deaths in the next decade. It is estimated that
mount importance because children tend to have
between 2000 and 2020, almost 1 billion people
lower bacillary loads and usually do not transmit
will be newly infected with Mycobacterium tuber-
TB. Nevertheless, childhood TB has important
culosis and 200 million people will develop
public health implications. TB in a child repre-
active disease. HIV infection has had a profound
sents a sentinel event within a community, as
childhood infection most often represents recent
transmission from an infectious adult with pul-
monary TB. In addition, the strains of M. tuber-
K. Reddy (*)
Internal Medicine, Massachusetts General Hospital, Boston, culosis that affect children are representative of
MA, USA the infectious strains currently being transmitted
246 K. Reddy et al.
Active TB: An illness in which TB bacteria are multiplying and attacking a part of the body, usually
the lungs. The symptoms of active TB disease include weakness, weight loss (hence the name
consumption or wasting), fever, no appetite, chills, and sweating at night and for TB of the lungs
(pulmonary TB), severe cough, pain in the chest, and coughing up blood.
Anergy: The inability to react to a skin test because of a weakened immune system. This is often
observed in HIV infection or other severe illnesses.
Antigen-specific anergy: This describes a lack of reaction by the body’s defense mechanisms to foreign
substances and consists of a direct induction of peripheral lymphocyte tolerance. An individual in a
state of anergy often indicates that the immune system is unable to mount a normal immune response
against a specific antigen.
Apgar scores: Simple and repeatable method to quickly and summarily assess the health of newborn
children immediately after childbirth.
Bacille Calmette–Guérin (BCG): A vaccine for TB named after the French scientists who developed it,
Calmette and Guérin. BCG is rarely used in the United States, but it is often given to infants and small
children in other countries where TB is common.
BACTEC radiometric assay: Nonselective culture medium to be used as an adjunct to aerobic blood
culture media for the recovery of mycobacteria, yeast, and fungi and is useful for rapid detection of
microorganisms in clinical specimens.
Caseating granuloma: An organized collection of macrophages with central areas of necrosis that
appears cheese-like and is peculiar to tuberculosis infection.
CD4 lymphocyte: A type of white blood cell which carries the CD4 cell surface receptor and helps the
body fight infection through cell-mediated immunity.
Congenital TB: Congenital TB may occur as a result of maternal TB when it involves the genital tract
or placenta. The signs and symptoms are nonspecific. Three possible modes of infection of the fetus
have been proposed: Hematogenous infection via the umbilical vein, fetal aspiration of infected
amniotic fluid, and fetal ingestion of infected amniotic fluid.
Contact tracing: The identification and diagnosis of persons who may have come into contact with an
infected person. People who have been exposed to TB are screened for TB infection and disease.
Delayed hypersensitivity: Delayed hypersensitivity reactions are inflammatory reactions initiated by
mononuclear leukocytes. The term delayed is used because it involves a secondary cellular response,
which appears 48–72 h after antigen exposure.
Directly Observed Therapy Shortcourse (DOTS): A way of helping patients take their medicine for
TB. If you get DOT, you will meet with a health-care worker every day or several times a week. You
will meet at a place you both agree on. This can be the TB clinic, your home or work, or any other
convenient location. You will take your medicine while the health-care worker watches.
Droplet nuclei: Very small droplets (1–5 mm in diameter) that may be expelled when a person who has
infectious TB coughs or sneezes; they can remain suspended in the air for several hours, depending on
the environment.
Ethambutol: A drug used to treat TB disease; it may cause vision problems. Ethambutol should not be
given to children who are too young to be monitored for changes in their vision.
Extrapulmonary TB: Active TB disease in any part of the body other than the lungs (for example, the
kidney, spine, brain, or lymph nodes).
False-negative reaction: A negative reaction to the tuberculin skin test in a person who has TB
infection; it may be caused by anergy, recent infection (within the past 10 weeks), or very young
age (younger than 6 months old).
14 Tuberculosis in Childhood and Pregnancy 247
False-positive reaction: A positive reaction to the tuberculin skin test in a person who does not have
TB infection; it may be caused by infection with nontuberculous mycobacteria or by vaccination with
BCG.
Ghon focus: A primary lesion of granulomatous inflammation caused by mycobacterium bacilli
(tuberculosis) developed in the lung of a previously uninfected individual and only detectable by
chest X-ray if it calcifies or grows substantially.
Ghon complex: A calcified focus of infection and an associated lymph node. These lesions are
particularly common in children and can retain viable bacteria, so are sources of long-term infection
and may be involved in reactivation of the disease in later life.
Hematogenous dissemination: Ability to spread by entering the blood directly by intravasating into
venous capillaries.
Hepatotoxicity: Chemical-driven liver damage especially from drugs, especially antituberculosis
drugs, e.g., rifampin and isoniazid. The liver plays a central role in transforming and clearing
chemicals and is susceptible to the toxicity from these agents.
Induration: Swelling that can be felt around the site of injection after a Mantoux skin test is done; the
reaction size is the diameter of the indurated area (excluding any redness), measured across the
forearm.
Isoniazid: A medicine used to prevent active TB disease in people who have latent TB infection. INH
is also one of the four medicines often used to treat active TB disease.
Latent TB: Persons with latent TB infection carry the organism that causes TB, but do not have TB
disease, are asymptomatic, and are noninfectious. Such persons usually have a positive reaction to the
tuberculin skin test.
Lowenstein-Jensen medium: A growth medium specially used for culture of M. tuberculosis. The
media must be incubated for a significant length of time, usually 4 weeks, due to its slow doubling
time compared with other bacteria (15–20 h).
Microscopic observation drug susceptibility (MODS): Culture method shown to be more sensitive, a
faster and cheaper test than current culture-based tests for TB. It involves direct observation of M.
tuberculosis and simultaneously yields drug resistance.
Miliary TB/Disseminated TB: A form of tuberculosis that is characterized by a wide dissemination
into the human body and by the tiny size of the lesions (1–5 mm). Its name comes from a distinctive
pattern seen on a chest X-ray of many tiny spots distributed throughout the lung fields.
Multidrug-resistant TB (MDR-TB): Active TB disease caused by bacteria resistant to two or more of
the most important medicines: Isoniazid (INH) and Rifampin (RIF).
M. tuberculosis: Pathogenic bacterial species in the genus Mycobacterium and the causative agent of
most cases of tuberculosis.
Natural history: The uninterrupted progression of a medical condition in an individual.
Perinatal TB: Tuberculosis can be acquired in the perinatal period. Infants may acquire tuberculosis
(TB) by transplacental spread through the umbilical vein to the fetal liver, by aspiration or ingestion
of infected amniotic fluid, or via airborne inoculation from close contacts (family members or nursery
personnel).
Pleural effusions: Excess fluid between the two membranes that envelop the lungs called the pleural
space.
Primary TB: Occurs when a person first becomes infected. This is when the body forms tubercles on
the lungs to contain the bacteria. There are rarely any symptoms with primary TB.
Pulmonary TB: Active TB disease that occurs in the lungs, usually producing a cough that lasts 3
weeks or longer. Most active TB disease is pulmonary.
Pyrazinamide: A drug used to treat TB disease, usually during the initial phase of treatment; this
should not be given to pregnant women.
248 K. Reddy et al.
Reactivation TB: Postprimary TB resulting either from the reactivation of a latent primary infection
or, less commonly, from the repeat infection of a previously sensitized host.
Rifampin: A drug used to treat TB disease, also used for preventive therapy in people with a positive
skin test reaction who have been exposed to isoniazid-resistant TB. Rifampin has several possible side
effects (for example, hepatitis, turning body fluids orange, and drug interactions).
Sensitivity: Measures the proportion of actual positives which are correctly identified as such (i.e.,
the%age of sick people who are identified as having the condition).
Smear-negative: Sputum smear test which involves staining of three sputum samples for acid-fast
bacilli, and negative acid-fast bacilli smear results (three) from sputum is considered smear-negative.
Smear-positive: For a smear to be positive, there must be at least 5,000–10,000 acid-fast bacilli per
milliliter of sputum.
Specificity: Measures the proportion of negatives which are correctly identified (i.e., the%age of well
people who are identified as not having the condition).
Sputum induction: Indicated on patients with suspect tuberculosis who are unable to cough and
produce an adequate sputum sample. Involves making a patient breath 3% hypertonic solution via a
jet nebulizer for approximately 30 min, then the patient is instructed to induce a deep cough from their
chest and not to expectorate saliva or postnasal drip but a specimen from their chest.
Stegen–Toledo Criteria: This is based on signs and symptoms, such as persistent cough, abnormal
findings of chest radiography, and contact with a patient with active tuberculosis for diagnosis of
pediatric tuberculosis. Patients are classified into four categories: for unlikely tuberculosis, the score
was 0–2; for suspected tuberculosis, 3–4; for probable tuberculosis, 5–6; and for highly probable
tuberculosis, 7.
String test: Involves swallowing a string to obtain a sample from the upper part of the small intestine.
The sample is then tested to detect the presence of intestinal parasites or acid-fast bacilli. The string
test is rarely used in the United States.
TB meningitis: Infection of the meninges – the system of membranes which envelops the central
nervous system. Fever and headache are the cardinal features.
Teratogenic: Able to disturb the growth and development of an embryo or fetus.
Tubercle bacilli: Another name for M. tuberculosis organisms, which cause TB disease
Tuberculin: A protein extracted from M. tuberculosis that is used in a skin test to determine if a person
has been exposed to tuberculosis. The tuberculin preparation in most common use today is purified
protein derivative (PPD) tuberculin. PPD is injected (or multiple punctured) into the skin. The PPD
tuberculin test done by intradermal injection is also known as the Mantoux test.
Tuberculin skin test (TST)/Mantoux test: A test that is often used to detect latent TB infection. A
liquid called tuberculin is injected under the skin on the lower part of your arm. If a reaction is seen at
and around the site of injection, the test is positive (you probably have latent TB infection).
Source: U.S. Department of Health and Human Services (2007)
in the community as a whole. Thus, identifica- and control of the disease in this population – is
tion of childhood TB is important for assessing diagnosis. Unlike adults, in whom bacteriologic
overall TB control in a population. Furthermore, confirmation is the mainstay of diagnosis, children
infected children represent the pool from which are found to be positive on culture or smear in only
a significant proportion of future cases of adult 20–30% of treated TB cases. Adequate diagnostic
TB will arise. specimens are difficult to obtain in children because
The biggest obstacle to attaining accurate epide- children rarely produce sufficient sputum and, even
miologic data of TB in children – and to prevention when they do, their specimens usually contain very
low concentrations of mycobacteria. Compounding of contact history, clinical symptoms, chest radio-
the diagnostic dilemma are the limitations of most graphy, and tuberculin skin testing. Analyses of
existing diagnostic tests: the more sensitive tests these algorithms have demonstrated poor sensitiv-
(automated mycobacterial culture tools such as ity (Hesseling et al. 2002).
MBBacT and BACTEC) are very expensive, while Another limitation of surveillance data in some
traditional, less expensive tests (such as Lowenstein- places is the delay in reporting TB cases to local and
Jensen culture) are slow and have poor sensitivity. national control programs. A study of tuberculous
Thus, because of limited resources and personnel in meningitis in South African children revealed that
endemic areas, limited efforts are made to bacterio- only 56% of cases had been registered (Berman et al.
logically confirm a diagnosis of TB in a child. Con- 1992). This is particularly notable because meningitis
sequently, many children with TB are never diag- is the most lethal form of TB and therefore among
nosed or registered as cases of TB. On the other the most likely to be reported, in theory. In 1991, the
hand, a proportion of children treated for TB may International Union Against Tuberculosis and Lung
not actually have the disease; clinical scoring sys- Disease (IUATLD) declared that reliable statistics
tems used for diagnosis in the absence of bacterio- regarding the incidence of childhood TB can be
logic confirmation suffer from poor specificity. obtained only in developed countries (Hershfield
The increasing burden of TB and HIV in children 1991). Thus, there is a need for more accurate identi-
around the world perpetuates a cycle of malnutrition fication of the burden of TB in the pediatric popula-
and poverty. The paucity of accurate epidemiological tion in developing countries where the burden of
data combined with the substantial TB-associated disease is the greatest.
morbidity and mortality among children in high-
burden settings underscore the need for a more precise
and thorough picture of TB in this population.
Global Trends
In spite of the drawbacks of existing data, some

conclusions can be drawn with regard to global
Surveillance and Global Burden
trends in childhood TB. In developing countries,
TB in children constitutes 15–40% of the total num-
Limitations of Existing Data ber of TB cases (Mwinga 2005). In developed coun-
tries, the proportion tends to be less than 5%. Dur-
The global burden of tuberculosis in children is ing the 1990s, adult TB case numbers increased in
unclear. Accurate statistics are limited due to the every region of the world except Western Europe; it
difficulty of diagnosing TB in children, the lack is likely that childhood TB also increased in these
of commonly used standard case definitions, the regions. The trend in TB rates varies across coun-
inadequate surveillance systems in developing tries. Among industrialized countries, some have
countries, and the dearth of importance given to witnessed a sustained decline in the incidence of
childhood TB by TB control programs (Shingadia childhood TB, while others have experienced a
and Novelli 2003). There are very few epidemio- slowing in the rate of decline or even a reversal.
logic studies of TB in children, and many of the Many developing countries, meanwhile, have
available studies were conducted in areas with observed increases in incidence. For example,
relatively low incidences of TB, or in hospital- almost all African countries have reported an
based populations, who may not be representative increase in notification rates, and some have seen
of the general pediatric population. Furthermore, their rates more than quadruple compared to those
differences in methodology and case definitions in the 1970s (Mwaba et al. 2003). Though pediatric
complicate any potential comparisons between TB appears to be increasing in many parts of the
countries. In studies published to date, case defi- world, the increase may reflect a reporting bias, in
nitions of childhood TB are rarely based on bac- that areas with little change or a decrease may be
teriology, but instead on a variable combination less likely to publish these results.
250 K. Reddy et al.
The United States has had a well-established to 0.8/100,000 in 2000 (Nelson and Wells 2004).
system of TB surveillance since 1953. After years These changes paralleling a decline in adult TB
of declining overall TB case rates, the United case rates attributed to an effective DOTS program
States saw an increase in the TB case rate from in the country. A bacille–Calmette–Guérin (BCG)
1984 to 1992, coinciding with the HIV epidemic vaccine campaign may have contributed to the
(Nelson and Wells 2004). During this period, the decrease in TB meningitis.
number of childhood TB cases rose by 40%. The
trend was later reversed largely through public
health interventions. Incidence rates in children in
the United States have been declining since 1992. Risk Factors
In England and Wales, the TB rate decreased from
7/100,000 in 1978 to 3.2/100,000 in 2003 (Chintu Factors contributing to the risk of becoming
and Mwaba 2005). In developed countries, TB infected with M. tuberculosis and developing active
rates tend to be higher among foreign-born chil- TB disease can be divided into those that increase
dren. In the United States, childhood TB case rates transmission and those that increase susceptibility.
are substantially higher among ethnic and racial Marais et al. (2005) summarized many of these
minorities and the foreign-born than among Cau- factors (Box 14.2). The risk of developing TB and
casians (Starke 1999). the clinical manifestations of the disease in child-
Most developing countries have seen an hood vary by age. Studies of the natural history of
increase in published case rates of childhood TB. childhood TB (conducted before 1950, prior to the
In Botswana, reported case rates in children ages 9 advent of chemotherapy) revealed that age at the
and under increased from 199/100,000 in 1996 to time of infection is the most important determinant
229/100,000 in 2000 (Nelson and Wells 2004). In of risk of progression from M. tuberculosis infection
Tanzania, TB surveillance among children under to active disease in immunocompetent children
age 15 revealed that case rates increased from (Marais et al. 2004). Largely because their immune
38/100,000 in 1996 to 45/100,000 in 2000 (Nelson defenses are relatively immature, young children
and Wells 2004). Smear-positive cases accounted
for only 8% of all TB reported in children in Tan-
zania. A recent autopsy study of children dying of
respiratory disease in Zambia found evidence of Box 14.2 Risk Factors for Transmission of
TB in 20% of cases, in many of which TB was M. tuberculosis and Development
diagnosed only postmortem (Chintu et al. 2002). of Tuberculosis
The rates of adult and childhood TB in South
Africa are among the highest in the world: a pro- Community Level: Individual Level:
spective, clinic-based study in South Africa found Transmission Susceptibility
the incidence of TB among the adult population Number of infectious Immune compromise
cases
(13 years of age) to be 845/100,000/year,
Duration of Malnutrition
while the incidence in the child (<13 years of age) infectiousness
population was 441/100,000/year (Marais et al. Delayed diagnosis Substance abuse
2006b). Delayed treatment HIV
In Latvia, TB case rates in children increased Ineffective treatment Age
from 7.5/100,000 in 1991 to 38.9/100,000 in 2000 Exposure Genetic susceptibility
(Nelson and Wells 2004). In Russia, childhood TB Duration Immune stimulation
Proximity Immunization
case rates increased from 7.5/100,000 in 1989 to
Mycobacterial load Environmental
18.6/100,000 in 2001 (Nelson and Wells 2004). mycobacteria
Meanwhile, in Peru, case rates of childhood TB Crowding Local defenses
actually decreased from 61/100,000 in 1994 to Poverty
43/100,000 in 2000; cases of TB meningitis in chil- Source: Marais et al. (2005)
dren under age 5 decreased from 3.4/100,000 in 1992
carry the greatest burden of disease among the

pediatric population, being the most likely to Box 14.3 Latent Infection Versus Disease
develop active disease after infection with
M. tuberculosis and the most likely to have signifi- Latent Infection
cant signs or symptoms of TB (Vallejo et al. 1994) M. tuberculosis spreads to lung of new host
and extrapulmonary and severe disseminated from person with infectious tuberculosis
disease. The lowest age-specific rates of TB in Contained by host immunologic response
most populations are usually found in children Most commonly detected by tuberculin
between the ages of 5 and 14, sometimes called the skin test; interferon blood assay is newer
‘‘favored age.’’ technique
It is not clear why children of these ages are New host is not infectious
apparently protected, to a degree, from developing May or may not require treatment
TB, though it suggests an effect of the maturing Treatment is generally with isoniazid alone
immune system. The gender ratio for childhood Disease
TB is about 1:1, whereas in adults the disease is
found more commonly in men. Referred to as ‘‘tuberculosis’’
Mycobacteria are no longer contained by
immune cells
Some cases are infectious (depends on loca-
Pathogenesis tion and mycobacterial load; rare in children)
Diagnosed by detection of mycobacteria in
Infection Versus Disease patient specimens (gold standard) and/or
combination of radiographic findings, clin-
Traditionally, a distinction has been made between ical history and exam, and contact tracing
‘‘infection’’ and ‘‘disease’’ with respect to tuberculosis Lungs are most common site, but can affect
(Box 14.3). When a person with transmissible TB many other sites
disease coughs or sneezes, microorganisms are Treatment requires multiple drugs
expelled in droplets into the air and can be inhaled
by another person. After this initial exposure, some
children will become infected with M. tuberculosis. apparent, either by clinical signs and symptoms or
This is marked by conversion of the tuberculin skin by chest radiograph. The term ‘‘tuberculosis,’’ or
test (TST). A positive reaction to the TST represents TB, is generally used to refer to those who have
delayed-type hypersensitivity – the individual active disease and not to those with infection only.
mounts an immune response to the tuberculin antigen The distinction between infection and disease is
after (presumably) having been exposed previously to made partly because disease requires treatment
the antigen in M. tuberculosis. A person with a positive (with three or more drugs) while treatment for infec-
TST and no signs or symptoms of active disease is said tion (with a single drug) may or may not be indi-
to be latently ‘‘infected’’ with M. tuberculosis. The cated. The risk of a child becoming infected with
annual risk of infection (ARI) has been reported to M. tuberculosis depends on contact and environ-
be 1–2% in many endemic regions and up to 5% in mental factors. The risk of a child developing TB
some (Cauthen et al. 2002). disease following infection is affected by host immu-
Following M. tuberculosis infection in HIV- nologic and genetic characteristics.
negative adults, the lifetime risk of developing
active TB is about 5–10%; the lifetime risk is
considered to be higher when infected with
M. tuberculosis as a child. In HIV-infected adults, Early Pathogenesis
the risk of progression to active disease is approxi-
mately 10% per year. Active ‘‘disease’’ occurs when Initial infection in the lung results in a Ghon focus
clinical manifestations of tuberculosis become and regional lymphadenitis. This primary complex
252 K. Reddy et al.
may not be obvious on a chest radiograph. In most sputum specimens. Whether a patient has smear-
children, the complex resolves spontaneously. Some positive or smear-negative disease depends on the
children, especially infants, may develop progres- person’s load of mycobacterial bacilli as well as the
sive lymphadenopathy. Alternatively, in progres- availability of a diagnostic sample from the diseased
sive primary tuberculosis, the primary parenchymal lung segment. The source cases with the greatest
infiltrate can progress to a caseating lesion. This likelihood of transmitting M. tuberculosis to others
lesion may rupture into the pleural or pericardial are those with sputum smear-positive pulmonary
spaces leading to effusions. Erosion of caseating disease. However, those with sputum smear-
lesions into pulmonary vessels can result in hema- negative pulmonary TB have also been shown to
togenous dissemination to the lung or to distant contribute to transmission; one study showed that
anatomic sites. The most common manifestation 17% of M. tuberculosis transmission was attributed
of this is miliary tuberculosis, which usually affects to smear-negative, culture-positive adults (Behr
infants and young children. Older children and ado- et al. 1999). Those with only extrapulmonary TB
lescents tend to develop adult-type reactivation dis- are rarely infectious.
ease. Cavitating disease becomes a more common
manifestation of tuberculosis in children over 10
years of age, and these children pose a transmission
risk similar to that of adults. Nutrition and Tuberculosis
Malnutrition may play an important role in the

progression of tuberculosis in children by altering
Transmissibility immune function. Malnourished children have been
found to have diminished CD4 lymphocyte activa-
In order for tuberculosis to be transmissible, the tion capacity and cytokine production (Rodriguez
disease must spread into the bronchial tree, gener- et al. 2005). The type of malnutrition may also be
ally via progressive liquefaction and caseation fol- important. A study in Uganda found a significantly
lowed by cavity formation. In the majority of chil- lower CD4 lymphocyte count in children with none-
dren with tuberculosis, the disease remains in the dematous malnutrition as compared to those with
lymph nodes and does not extend to the bronchus. edematous malnutrition (Bachou et al. 2006). The
When disease does spread in children, it often TST also appears to be affected by malnutrition. A
occurs via the blood. Therefore, TB in children is negative TST correlated strongly with malnutrition
rarely transmissible and rarely positive on sputum in Peruvian children presenting with a presumptive
smear. Another reason for the low infectiousness of diagnosis of pulmonary TB (Salazar et al. 2001). In
children with TB is the paucibacillary nature of a study of randomly selected Peruvian adults, pro-
childhood TB. Cavitation, which is fairly common tein-deficient patients had antigen-specific anergy
in adults and rare in young children, represents a to tuberculin but not to candida or tetanus antigens
breeding ground for M. tuberculosis. Estimates of (Pelly et al. 2005).
the number of tubercle bacilli found in TB lesions
are 107–109 in cavities, and 102–105 in solid caseous
areas (Moulding 1999); nevertheless, acid-fast
bacilli are usually difficult to find in histological Clinical Presentation
sections. Since most children, especially those with
lymph node disease, have relatively small amounts The presentation and clinical features of TB in
of caseation and cavitation and low bacillary num- children differ from those in adults. Children
bers, tubercle bacilli are relatively difficult to detect infected with M. tuberculosis develop active dis-
in their specimens. ease very rapidly, even in a matter of weeks.
Pulmonary TB can be ‘‘smear-positive’’ or Studies of the natural history of TB indicate
‘‘smear-negative’’ cases, depending on whether the that over 95% of children who develop active
organism is detected on acid-fast bacillus smears of TB do so within 12 months after initial infection
(Marais et al. 2006b). In adults, there is a much systems are immature and compromised, respec-
greater incidence of TB caused by reactivation of tively – were prone to developing disease manifesta-
dormant organisms. There is usually a period of tions indicative of poor organism containment,
years to decades between infection and reactiva- such as miliary disease.
tion-type disease. Thus, the clinical distinction
between primary infection and disease is less
clear in children than it is in adults, and the
approach to diagnosis and prevention differs
between children and adults.
Diagnosis
Symptoms of childhood TB may differ between
developing and developed regions. A study of Per- The accurate diagnosis of pediatric tuberculosis is
uvian children revealed that the typical symptoms a major challenge. Misdiagnosis of childhood pul-
of pulmonary TB in this population was similar to monary TB has multiple origins, including the
those in adults (Salazar et al. 2001). In developed nonspecificity of signs and symptoms, low bacil-
countries, children usually have minimal or no lary load, inherent limitations of current diagnos-
symptoms at the time of presentation with TB. tic assays, and techniques used to obtain samples
Case ascertainment strategies may partly account (Eamranond and Jaramillo 2001) (Box 14.4 and
for the difference. Table 14.1). The mainstay of diagnosis in adults –
Of those who are symptomatic, the most com- bacteriologic confirmation – is of limited use in
mon manifestations are chronic cough, fever, and children because their disease spreads much less
weight loss, or failure to gain weight. Over half of frequently to the bronchus and, therefore, tuber-
children with TB initially have minimal symptoms cle bacilli will not appear in sputum samples.
and require chest radiograph to confirm the diag- Early diagnosis depends on early symptomatic
nosis. However, in many children with presumed presentation and sensitive diagnostic tools. Fac-
TB, chest radiograph shows no abnormalities. tors such as limited access to health care (which,
in turn, is affected by poverty and discrimination)
contribute to delays in diagnosis. Delays in diag-
nosis increase the morbidity and mortality of
childhood TB for the patient and increase the
Spectrum of Disease duration of infectivity of those patients who are
infectious, thereby adding to the public health
Childhood TB is often reported as a single disease problem.
entity despite the fact that it includes a wide spec-
trum of pathology with important prognostic impli-
cations. A prospective, clinic-based study in South
Africa (Marais et al. 2006c) reported the manifesta-
tions of childhood TB: of 439 children treated for Box 14.4 Challenges of TB Diagnosis in
TB during the study period, 85 (19.4%) were later Children
classified as not having TB (due to lack of bacter-
iologic or histologic confirmation of TB and lack of Sputum specimens difficult to acquire
radiographic and extrapulmonary signs of TB); 307 Low mycobacterial counts ! false-negative
(69.9%) were classified as having intrathoracic TB smear stains and cultures
only; 72 (16.4%) had extrathoracic TB only, includ- Inherent limitations of diagnostic assays
ing central nervous system, abdominal, osteoarticu- Nonspecific clinical signs and symptoms
lar, and skin disease; and 25 (5.7%) had both intra- Nonspecific radiographic findings
and extrathoracic TB. Twenty-six children (5.9%) Barriers to access to health care
were diagnosed with disseminated (miliary) TB or Relatively limited importance in national
tuberculous meningitis. Young children (<3 years TB control programs
of age) and HIV-infected children – whose immune
254 K. Reddy et al.
Table 14.1 Advantages and disadvantages of various methods for diagnosis of tuberculosis
Diagnostic
method Advantages Disadvantages
Smear Rapid, low tech Very low sensitivity
microscopy
Lowenstein- Definitive diagnosis Low sensitivity, very slow, requires biosafety area
Jensen culture
Automated Definitive diagnosis, reasonable Very costly and requires biosafety area
mycobacterial sensitivity
culture
MODS culture Definitive diagnosis, good sensitivity, Requires biosafety area
fast and simultaneous drug
sensitivity testing
PPD Good for screening, can aid in diagnosis Does not distinguish between infection and disease, false
positives and false negatives occur, less useful in endemic
regions
PCR Rapid Poor sensitivity, costly, requires qualified lab personnel,
false positives due to contamination
Chest radiograph Aids in detection of lung pathologies Not available in some areas; low sensitivity and specificity
Thorax CT Enhanced visualization of small lesions Costly, requires scanner
Source: Eamranond and Jaramillo (2001)
Differences in Diagnostic Approaches in diseases, such as pneumonia and asthma. Studies

Developing and Developed Regions attempting to identify signs and symptoms to be
applied to the diagnosis of pulmonary TB have
In developed countries, diagnosis of childhood TB shown poor sensitivity and specificity. A critical
is generally based on tuberculin skin testing, chest review found that various clinical scoring systems
radiograph, history of exposure to an adult with are limited by a lack of standard symptom defini-
infectious TB, and culture of gastric washings, naso- tions and adequate validation (Hesseling et al.
pharyngeal aspirate, or induced sputum. In devel- 2002). Another study examined WHO criteria –
oping countries (especially in rural areas), diagnosis assessing the combination of (1) recent weight loss
is more complicated due to lack of radiological or failure to gain weight adequately, (2) cough or
machines, microscopes, and tuberculin skin testing, wheezing for >2 weeks, and (3) recent household
as well as a greater risk of specimen contamination contact with an adult case of pulmonary TB – and
during transport (Eamranond and Jaramillo 2001). demonstrated a positive predictive value of only
Because many childhood TB cases in developed 63% as compared to culture-confirmed TB or prob-
countries are detected by population-based tuber- able TB (as demonstrated by chest radiograph or
culin skin testing or by contact tracing, many chil- tuberculin skin test reaction greater than 15 mm)
dren are asymptomatic at the time of diagnosis. In (Houwert et al. 1998). Among children in Lima,
developing regions, in contrast, most childhood TB Peru, the triad of cough lasting 2 weeks, fever,
is diagnosed by evaluation of children with sympto- and TST 10 mm had a positive predictive value
matic disease. of 73% and sensitivity of 44% for culture-positive
pulmonary disease (Salazar et al. 2001). Marais
et al. (2006b) reported that in a prospective, com-
munity-based study of symptom-based diagnosis of
Limitations of Clinical Diagnosis childhood tuberculosis in South Africa, the combi-
nation of cough of 2 weeks duration, failure to
Nonspecific clinical signs and symptoms complicate thrive during the previous 3 months, and fatigue
the diagnosis of childhood TB. The diagnosis is had a sensitivity of 62.6%, specificity of 89.8%,
sometimes confused with that of other pulmonary and positive predictive value of 83.6% for
false-negative results (Box 14.6). In endemic

Box 14.5 Stegen–Toledo Criteria for the areas, a positive TST is common in randomly
Clinical Diagnosis of Childhood TB selected healthy children, thereby limiting the
test’s ability to diagnose active disease. The risk
Finding Score
of exposure and infection increases with age as
Positive culture 7
TB granuloma 4
the child is exposed to more tubercle bacilli in the
Positive purified protein derivative 3 community. In a shantytown on the outskirts of
>10 mm Lima, Peru, rates of positive purified protein deri-
Known contact in the last 2 years 2 vative (PPD) skin test reactions were 12% in the
Suggestive radiograph 2 0–1-year-old age group, 18% in the 2–4-year-old
Suggestive clinical picture (cough >2 2 group, 24% in the 5–14-year-old group, 60% in
weeks)
Highly probable TB Score 7
the 15–24-year-old group, and 68% in the
Probable TB Score 5–6 25-year-old group (Getchell et al. 1992). In
Suspicious TB Score 3–4 industrialized countries, conversely, less than 5%
Unlikely TB Score 0–2 of children may be positive.
Source: Oberhelman et al. (2006) Once exposed and infected, tuberculin reactivity
becomes apparent in 3–6 weeks in most children,
but very young children may take up to 3 months
to develop a positive tuberculin skin test, due to
confirmed or probable TB in HIV-uninfected chil- their immature immune systems. The TST is nega-
dren 3 years of age. These criteria were less accu- tive in up to 10% of children with culture proven
rate in HIV-infected children and children under TB and up to 40% of those with TB meningitis
3 years of age. (Walls and Shingadia 2004); this low negative
Clinical scoring systems such as the Stegen– predictive value limits the usefulness of TST as a
Toledo criteria (Toledo and Stegen 1979) (Box diagnostic rule-out tool.
14.5) incorporate factors such as positive culture,
TB granuloma, positive TST, and clinical suspicion
for the diagnosis of TB. These scoring systems may
be useful when there is a positive culture or TB
granuloma, as these are given the most weight in
Box 14.6 Causes of Inaccuracy of Tuberculin
the scoring system. However, these are not the situa-
Skin Test
tions when diagnosis is in doubt. A more typical
scenario is a child with negative or pending culture False Positives
data and inconclusive radiograph – in this situation
the Stegen–Toledo scoring system is less useful in Infection with nontuberculousmy cobacteria
diagnosing TB. BCG vaccination
False Negatives
Delayed skin test conversion
Tuberculin Skin Test (TST)
Short time lapse after infection
Infancy
In endemic areas, a positive TST reaction is the
most commonly used sign of M. tuberculosis Immunosuppression/anergy
infection. In very young children, a positive TST Malnutrition
represents recent infection by definition, and, HIV
because of the high risk of progression to active Other immunosuppressive illnesses or
disease in young children, is often a trigger for treatments
initiation of preventive chemotherapy. However, Intestinal parasitic infection
TST usefulness is limited by false-positive and
256 K. Reddy et al.
Effect of BCG Vaccination on TST yields are also low – reportedly less than 30–40% in
children with suspected TB (Zar et al. 2005), though
In areas with a high BCG vaccine coverage, which it is difficult to define cases in the absence of a
includes most TB endemic regions, there is debate microbiological gold standard. A prospective
regarding the utility of TST. BCG vaccination can study in Peru (Oberhelman et al. 2006) found that
complicate the interpretation of a subsequent tuber- of 165 children with clinically suspected TB, only 15
culin skin test, namely by causing false-positive (9%) had a confirmed positive culture for TB in a
reactions. Our data from a peri-urban shantytown clinical specimen (stool, nasopharyngeal aspirate,
in Lima, Peru with high rates of TB and BCG or gastric aspirate). Of the 59 children with ‘‘highly
vaccination indicate that people with two or more probable’’ TB (Stegen–Toledo score of 7 or higher),
BCG scars have significantly larger TST reactions, 10 (16.9%) had a positive culture. A more recent
even after adjusting for potential risk factors (Saito study of bacteriologic yield in South African chil-
et al. 2004). A study in Brazil of children ages 7–14 dren for whom there was radiographic suspicion of
found that the proportion of PPD reactions intrathoracic TB and who received antituberculosis
10 mm was 14.2% in those with no BCG scar, treatment revealed that 122 (62.2%) of the 196 sub-
21.3% in those with 1 scar, and 45.0% in those with jects from whom specimens were collected had bac-
2 scars (Bierrenbach et al. 2003). On the other hand, teriologic confirmation by culture or sputum smear
in a prospective cohort study of BCG-vaccinated (Marais et al. 2006a). Children with uncomplicated
newborns in Lima, at 6 months of age only 3 of 68 lymph node disease comprised the largest propor-
vaccinated infants had a TST greater than 10 mm, tion (47.9%) of the group and had the lowest bac-
and all 3 had household contact with a known case teriologic yield (34.7%). It is important to empha-
of active TB (Santiago et al. 2003). A study of TST size that this study included only children with
in children ages 3–60 months in Botswana, also an radiographic evidence of TB, and that for many
area with a high rate of BCG vaccination, found children, multiple, nonroutine specimens (such as
that 79% had 0-mm induration, 7% had a reaction gastric aspirates, nasopharyngeal aspirates, induced
10 mm or greater, and 2% had a reaction 15 mm or sputum, and pleural fluid aspirates) were assessed.
greater (Lockman et al. 1999). Together, these Of the total cohort of 307 children, 68.7% were
results suggest that the age at time of TST and the tested for HIV and 8.1% were found to be HIV-
lapse between BCG and TST may influence the positive.
relative utility of TST in areas of high BCG Lowenstein-Jensen medium is the most com-
coverage. monly used medium for culturing M. tuberculosis
in resource-poor areas, but its clinical utility is
limited by lengthy incubation periods – up to
7–10 weeks in some cases. The BACTEC radio-
Microbiological Diagnosis metric assay improves the yield of positive cul-
tures from clinical specimens and has a shorter
The gold standard for diagnosing adult TB, bacter- incubation time for detection (9–14 days). How-
iologic confirmation, is of limited use in children for ever, it is not commonly used in resource-poor
reasons previously described. In many endemic and settings because of the very high costs of the
resource-poor areas, sputum smear microscopy is instruments.
the only diagnostic test available for TB. The There is an urgent need for a more sensitive
Directly Observed Therapy Shortcourse (DOTS) and rapid method of diagnosing TB in children.
strategy for global TB control targets sputum A new technique that has potential in this
smear-positive cases. This poses a problem for con- realm is the microscopic observation drug sus-
trol of TB in children. Even when specimens are ceptibility assay (MODS). This is an inexpensive
obtained, smear microscopy is positive in less than method for detection of M. tuberculosis (and
10–15% of children with suspected TB (Zar et al. thus definitive diagnosis of active disease)
2005). The yield is higher in older children and in based on culturing the organism in a liquid
children with adult-type, cavitating disease. Culture medium (Moore et al. 2004). The assay also
offers the benefit of simultaneous isoniazid and study (Chow et al. 2006) and as young as 1 year of
rifampicin susceptibility testing. Studies in adults age in a more recent study of detection of Helico-
(Moore et al. 2006) and children (Oberhelman bacter pylori (personal communication). In another
et al. 2006) in Peru have found MODS to be study, the string test was found to be more effective
more sensitive and more rapid than the traditional than induced sputum for diagnosing TB in HIV-
Lowenstein-Jensen culture method in isolating positive adults (Vargas et al. 2005), who, like chil-
M. tuberculosis from sputum (in adults) and from dren, tend to have difficulty in producing a sputum
nasopharyngeal aspirates, gastric aspirates, and specimen for TB diagnosis.
stool (in children). In the pediatric population,
mean time to isolation of M. tuberculosis was 11
days for MODS and 26 days for Lowenstein-Jen-
sen (p<0.001) (Oberhelman et al. 2006). Contact Tracing
The most efficient method of finding children

newly infected with M. tuberculosis is by contact
Specimen Acquisition tracing of adults with transmissible pulmonary
TB. Many children with radiographic signs of TB
Further complicating diagnosis is the difficulty in have no physical findings and are discovered only
obtaining bacteriologic specimens. Children under via contact tracing. WHO guidelines advise active
8 years of age rarely produce adequate sputum and screening of all children under 5 years of age in
tend to swallow it when they do. Other options for household contact with an adult with sputum
obtaining specimens include sputum induction or smear-positive TB disease. Contacts can be
retrieval of swallowed sputum from the stomach screened for TB by physical exam, TST, and
by gastric aspiration. The yield of M. tuberculosis chest radiography. Contact tracing and screening,
from three consecutive morning gastric aspirates while theoretically of great use, are not widely
from children with TB has been reported as employed in resource-poor settings as these
28–65% (Zar et al. 2005). This procedure is limited would place an excessive burden on the health-
by contamination with nontuberculous acid-fast care system for relatively small gains in public
organisms from the mouth, need for an overnight health and detection of active cases. The large
fast, collection of multiple specimens, discomfort number of adult cases and the limited availability
for the child and health-care personnel, and, in of screening tests like TST and chest radiography
many cases, hospital admission. Nasopharyngeal limit the use of contact tracing in children. In these
aspiration yields results comparable to gastric settings, it is recommended that scarce resources
aspiration, but the former offers the benefits of for contact screening and tracing be focused on
being minimally invasive and not requiring hospita- those children with the highest risk of progressing
lization or fasting (Franchi et al. 1998). However, from initial infection to active disease, namely
nasopharyngeal aspiration has yet to be widely used children <3 years of age and immunocompro-
because it provokes coughing and is not well toler- mised children.
ated by some children.
Sputum induction was demonstrated to be well
tolerated in children, and it provides good diagnos-
tic yield (Zar et al. 2005). A novel application of an Extrapulmonary TB
old technique for specimen acquisition from the
stomach is the string test, in which a capsule con- Tuberculosis most commonly affects the lungs (pul-
taining a coiled string is swallowed and maintained monary TB), but it can also affect sites outside of
in situ for 4 h prior to removal through the mouth the lungs. As a proportion of total tuberculosis
via the other end of the string. The string can then be cases, extrapulmonary tuberculosis is more com-
examined by culture. This procedure was well toler- mon in children than in adults. Of reported cases
ated by children as young as 4 years of age in a TB of TB in children under 15 years of age in the United
258 K. Reddy et al.
States between 1985 and 1994, 22% were extrapul-

monary only; the proportion was 25% in children Box 14.7 Impact of HIV on Childhood
under 4 years of age (Ussery et al. 1996). In compar- Tuberculosis
ison, the rate among the general US population
between 1991 and 1994 was 16%, as reported by HIV in adults ! TB in adults ! TB in
the Centers for Disease Control. children
Children under age 6 can develop central nervous Further limits utility of tuberculin skin test
system and disseminated TB in less than 3 months Diagnosis of TB can be confused with that
after infection. Thus, severe extrapulmonary forms of other HIV-related illnesses
of TB can manifest before the TST becomes reac- Increases mortality rate from TB
tive. The rapid progression and propensity for Increases TB relapse rate
extrapulmonary spread place children at risk for
the most severe clinical outcomes of TB. In a study
of Peruvian children presenting with presumptive 1985 increasing twice as fast in countries with high
pulmonary TB, concurrent extrapulmonary TB HIV seropositivity rates as compared to those with
was noted in 21 (16%) of 135 children; those with low or intermediate HIV rates (Cantwell and Binkin
positive culture who were found to have extrapul- 1997). HIV has brought the problems of a ‘‘telescop-
monary TB were significantly younger than those ing down’’ of the time to development of active
without signs or symptoms of extrapulmonary dis- disease (Daley et al. 1992), an increase in the TB
ease (Salazar et al. 2001). Because presumptive pul- reactivation risk of coinfected individuals, and a
monary TB was a criterion for entry, it is likely that rapid spread of drug-resistant disease (Shafer et al.
the proportion of extrapulmonary cases among 1995) (Box 14.7). Adults with HIV are at greatly
total TB cases (not just the proportion of pulmon- elevated risk for both primary and reactivation TB,
ary cases that have an extrapulmonary component) as well as for recurrent episodes due to exogenous
is actually higher. reinfection. Among patients with HIV, concomitant
Superficial lymphadenitis is the most common TB doubles the risk of death, independent of the
form of extrapulmonary TB; bones, joints, and CD4 count (Whalen et al. 1995).
skin can also be affected. The most serious In many developing countries, childhood TB
forms of extrapulmonary TB in children are has increased along with the emergence of the
tuberculous meningitis and disseminated (mili- HIV pandemic in adults and in children. In a
ary) disease; the latter occurs after hematogen- study of 45 HIV-infected children admitted to
ous spread to distant organs. Eighty of TB the infectious diseases ward of a hospital in
meningitis cases occur in children 4 years of Lima, Peru, it was found that 8 (17%) had evi-
age and younger. A study of TB in England dence of TB either by positive culture or by PCR
and Wales found that about 4% of children (Ramirez-Cardich et al. 2006). Some studies of
with TB had central nervous system (CNS) dis- childhood TB have shown a concordance between
ease (Kumar et al. 1997). The overall mortality increasing case rates of childhood TB and increas-
of CNS TB has been reported to be 13%, with ing rates of HIV-infected adults in the community
about half of survivors developing permanent (Starke 1999). In countries with high HIV infec-
neurological sequelae. tion rates, there is an increasing number of chil-
dren with dual HIV and TB infection (Mukadi
et al. 1997). One study from Zambia found that
the prevalence of HIV-1 in children with TB
HIV increased from 24% on 1989 to 68% in 1992
(Luo et al. 1994). A more recent pediatric autopsy
Trends in TB-HIV Co-infection study also found high rates of coinfection at autopsy
(Chintu et al. 2002). However, although there is
HIV has had a profound impact on the global bur- some evidence that TB rates are higher in HIV-
den of TB, with average annual TB case rates since infected children than in the general pediatric
population, the evidence is not as strong as that for the risks of mycobacteremia and extrapulmonary
adults. In fact, many studies worldwide have failed TB increase. Third, chest radiographic findings
to find an increased rate of TB in HIV-infected may also be very similar among TB and non-TB
children as compared to HIV-negative children, HIV-related disease. Our data indicate that,
though this may reflect difficulties in case ascertain- among hospitalized children with HIV in Peru,
ment. Moreover, the increased tendency for extra- radiographic changes were similar among TB-posi-
pulmonary TB in HIV-infected patients is more tive and TB-negative patients (Ramirez-Cardich
pronounced for adults than for children. Even et al. 2006). Furthermore, many other HIV-asso-
when examining the HIV pandemic only in adults, ciated pulmonary diseases, such as Pneumocystis
HIV’s effects on childhood tuberculosis can be carinii pneumonia and lymphocytic interstitial
appreciated. High rates of HIV infection in adults pneumonitis, mimic TB in terms of signs, symp-
are associated with high rates of adult TB. Infectious toms, and findings on chest radiography. Chronic
adults can transmit TB to children, thereby increas- HIV-related signs and symptoms and the rapid pro-
ing rates of latent infection and TB disease among gression of TB seen in this population limit the
children. utility of symptom-based diagnosis and chest
radiography.
Other obstacles to early diagnosis are the diffi-
culty in obtaining specimens suitable for diagnosis
Mortality from TB-HIV Coinfection and the limited utility of TST in this population.
Studies have found TST to be less useful in children
Children with HIV have a greater risk of death from with HIV (Palme et al. 2001), most likely because of
TB and have higher TB relapse rates than children anergy. The sensitivity of TST has been reported as
without HIV. The mortality rate from TB was found 50% or less in HIV-infected children with bacterio-
to be up to six times greater in Ethiopian children logically confirmed TB, even with an induration size
who were HIV-seropositive as compared to those cutoff of 5 mm.
who were HIV-seronegative (Palme et al. 2001). A
study from Cote d’Ivoire showed that during a 6-
month treatment period for TB, mortality rates
among HIV-positive children with CD4 under 10
Multidrug-Resistant Tuberculosis
and HIV-negative children were 50% and 4%, (MDR-TB)
respectively (Mukadi et al. 1997).
Drug resistance impairs response to standard treat-
ment, resulting in increased mortality (Park et al.
1996). Drug resistance initially arises in patients
Additional Diagnostic Challenges who do not adhere to anti-TB treatment; others
can later become infected with these resistant
In children infected with HIV, TB diagnosis poses strains. Therefore, a reduction in drug-resistant
challenges additional to those described earlier. and multidrug-resistant (MDR, defined as resis-
First, bacteriologic confirmation, as in children tance to isoniazid and rifampicin) tuberculosis
not infected with HIV, is difficult to obtain. Second, depends on the proper allocation of public health
the presentation of HIV disease itself may be quite resources to ensure that patients complete their
similar to that of TB in the absence of HIV coinfec- appropriate treatment regimen. Children rarely
tion. In both, common presentations include mal- contribute to the emergence of drug-resistant tuber-
nutrition, fever, night sweats, weight loss, failure to culosis because of the paucibacillary nature of their
thrive, and cough. The clinical presentation of TB in disease. They can, however, be infected by drug-
HIV-infected children with relatively preserved resistant strains originating from adult patients
immunocompetence can be very similar to that in with high bacillary loads.
children without HIV. However, with increasing Because of the previously mentioned difficulties
levels of immunosuppression in children with HIV, in securing a microbiologic diagnosis in children,
260 K. Reddy et al.
drug-resistant TB is difficult to confirm. Conse-

quently, there is limited data in the literature Box 14.8 BCG Vaccination
about MDR-TB in children. Usually, the diagnosis
will be made based on confirmation of drug resis- Effective in preventing tuberculous menin-
tance in the index (usually adult) case. Other times gitis and miliary tuberculosis
diagnosis is made only after the child fails first-line Globally, no clear efficacy in preventing
treatment. In general, the types of strains encoun- pulmonary (transmissible) TB
tered in children will reflect those found in the com- Utility depends on geographic region –
munity; resistance patterns in children have been appears to be less effective closer to the
found to be similar to those of adults from the equator
same areas. A study of TB culture-positive children Effect may wane over time
conducted in South Africa between 1994 and 1998
found that 5.6% were resistant to isoniazid and 1% No proven benefit of repeat vaccination
was multidrug resistant (Schaaf et al. 2000). These May complicate interpretation of tubercu-
results were similar to surveillance data from adults lin skin test
during the same period: 3.9% isoniazid resistance
and 1.1% multidrug resistance.
vaccination protects primarily against disseminated

forms of TB during early childhood (Box 14.8).
HIV and MDR-TB On% a worldwide basis, BCG does not clearly
provide protection against pulmonary TB; there is
The HIV pandemic appears to be contributing to great variation in the literature regarding the effi-
the spread of MDR-TB. In a recent hospital-based cacy of the vaccine. Reported protection from pul-
study of consecutive adults with laboratory-proven monary TB ranges from 0% in South India to 77%
tuberculosis in Lima, Peru (Kawai et al. 2006), 31 in the UK Medical Research Council trial (Hart
(43%) of 72 patients with HIV had MDR-TB, and Sutherland 1977). A meta-analysis across dif-
whereas 20 of 215 (9%) of non-HIV-infected ferent populations, study designs, and forms of TB
patients had MDR-TB. In Peru, MDR-TB is asso- found that BCG’s protection (in terms of relative
ciated with previous TB treatment, previous isonia- risk or odds ratio) against all forms of TB was
zid preventive therapy, hospitalizations, and care in approximately 0.52 when approximated from
centers for people with HIV, all of which link HIV case–control studies, while its protection against
to MDR-TB (Kawai et al. 2006). Though there is tuberculous meningitis and disseminated infection
limited information on MDR-TB in children in children was 0.64 and 0.78, respectively (Colditz
infected with HIV, it can be appreciated that chil- et al. 1994).
dren can contract drug-resistant M. tuberculosis A study in Malawi reported that BCG did not
from adults. protect against pulmonary TB but did protect
against leprosy (Ponnighaus et al. 1992); the
latter finding has been corroborated in other
studies. A large study in India found that BCG
Vaccination offered no overall protection against adult-type
TB and a low level of overall protection (27%;
The Bacille Calmette–Guérin (BCG) vaccine is the 95% CI=–8 to 20) in children (Datta et al.
world’s most widely used vaccine. However, in con- 1999). A meta-analysis revealed that study sites
trast to the decrease in caseloads seen with increased at a greater distance from the equator were asso-
vaccine coverage against other diseases like polio ciated with a higher efficacy of BCG vaccine
and measles, there has been an increase in TB rates (Wilson et al. 1995). Geographic differences in
despite high BCG coverage. BCG plays a narrow exposure to environmental mycobacteria may
role in the prevention of TB. Neonatal BCG explain, in part, the variation in BCG efficacy
across different populations (Black et al. 2002). Preventive Chemotherapy in Children

Other possible contributing factors include the with HIV
use of different BCG preparations, genetic sus-
ceptibility, nutrition levels, and other socioeco- Because HIV-infected children coinfected with
nomic variables. The long-term efficacy of BCG M. tuberculosis are thought to be at high risk of
is not clear. A study in American Indians and progression to active tuberculosis, preventive che-
Alaska natives found that BCG reduced TB inci- motherapy is recommended in this group, as well as
dence by 52% and that the efficacy persisted for in HIV-infected children recently exposed to an adult
50–60 years (Aronson et al. 2004). In contrast, a with infectious TB. However, in the literature, there
review of 10 randomized trials of BCG showed is very limited data on the efficacy of preventive
that efficacy waned over time – an annual decrease chemotherapy in HIV-infected children. In HIV-
of 5–14% in the rate ratio of TB in unvaccinated infected adults with positive TSTs, isoniazid prophy-
versus vaccinated individuals (Sterne et al. 1998). laxis for 6 months reduced TB risk by about 70%,
The WHO recommends BCG vaccination at birth according to one study (Halsey et al. 1998).
except to babies with symptomatic HIV infection,
though symptomatic HIV infection at birth is not
common. However, in many TB-endemic areas, Treatment
BCG is recommended for all infants as early as
possible. A review of BCG administration to
Treatment of children with tuberculosis follows the
infants with asymptomatic HIV infection found
same principles as treatment of adults. Treatment of
that the benefits outweigh the risks of complica-
drug-susceptible TB, reviewed elsewhere (Enarson
tions (O’Brien et al. 1995). There is no proven
et al. 2005), generally consists of a 2-month intensive
benefit of repeat vaccination.
phase of 3–4 drugs (often isoniazid, rifampicin, pyr-
azinamide, and streptomycin and/or ethambutol)
and a 4–6 month continuation phase (often isoniazid
and rifampicin). Tuberculosis is entirely curable if an
Preventive Chemotherapy appropriate medication regimen is followed. Treat-
ment failure and the emergence of drug-resistant
Preventive chemotherapy is recommended for some strains of M. tuberculosis can arise when treatment
children latently infected (as determined by TST) regimens are not completed, such as when a patient
with M. tuberculosis. Because the TST is stops taking the medicines as soon as his/her symp-
not adequately sensitive to exclude infection with toms improve. The Directly Observed Therapy
M. tuberculosis, preventive chemotherapy is also Shortcourse (DOTS) strategy is promoted by the
recommended for those in household contact with World Health Organization to increase the likeli-
known cases of infectious tuberculosis. A study in the hood that treatment will be completed. However,
United States demonstrated the benefit of 12 months DOTS is not always carried out, particularly in
of isoniazid therapy in reducing complications from resource-poor settings. MDR-TB, when detected, is
progression of M. tuberculosis infection (Comstock treated with second-line drugs, which are more costly
et al. 1974). Preventive chemotherapy with isoniazid and more toxic than first-line drugs.
for 6–9 months has been shown to reduce the risk of
TB in infected children by at least two-thirds. How-
ever, poor adherence limits the effectiveness of this Conclusions
regimen. Hepatotoxicity from isoniazid preventive
therapy is extremely rare among children; a prospec- Despite the availability of effective treatment, child-
tive cohort study in the United States found that hood tuberculosis continues to be a major problem in
none of 1,468 patients under age 15 who received many parts of the world, and in fact is increasing in
isoniazid prophylaxis developed hepatotoxicity incidence in some regions (Box 14.9). Accurate epide-
(Nolan et al. 1999). miologic data are limited because of the difficulties in
262 K. Reddy et al.
BCG vaccination, while effective in reducing the

Box 14.9 Childhood Tuberculosis – Conclusion risk of severe manifestations like miliary disease and
tuberculous meningitis, is not clearly effective in redu-
Childhood TB is increasing in many parts cing the risk of pulmonary TB. The global HIV pan-
of the world demic is contributing to the resurgence of TB among
Global pandemic of HIV is contributing to children. While there is no definitive evidence that
resurgence of childhood TB HIV increases the risk of developing TB among chil-
Accurate epidemiologic data is limited dren, this relationship is more clearly defined in adults,
Differences in presentation and methods of who can then spread TB to children. HIV has been
diagnosis in developed versus developing shown to increase mortality and relapse rates from TB
regions among children. The challenges to diagnosis of child-
Difficult to establish diagnosis hood TB include the nonspecific signs and symptoms,
Clinical signs and symptoms are the difficulties in obtaining specimens from children,
nonspecific and the low sensitivity of bacteriologic assays carried
Clinical scoring scales are usually not out in endemic regions. The emergence of drug-
useful resistant strains of TB underscores the need for more
Diagnostic specimens are difficult to effective methods of establishing microbiologic diag-
obtain from children nosis and assessing drug sensitivity.
Microbiologic assays used in endemic
regions have poor sensitivity for diagno-
sis of childhood TB as children have Maternal and Congenital Tuberculosis:
relatively low bacillus loads
Introduction
BCG vaccine reduces risk of the most
severe forms of TB but is not clearly effec- Women face a growing burden of tuberculosis.
tive in reducing risk of pulmonary (infec- Epidemiologic studies have demonstrated that
tious) TB women have a higher rate of progression from
High rate of latent infection and malnutri- infection to active disease than men and a higher
tion in endemic regions confounds inter- case-fatality rate (Holmes et al. 1998). Several fac-
pretation of tuberculin skin test tors may contribute to the apparent lower frequency
Emergence of drug-resistant strains com- of tuberculosis in women (Box 14.10). Some studies
plicates treatment have suggested differences in the immune responses
of women and men. An alternative explanation is
establishing standard case definitions, obtaining bac- that there is no biological difference, but care-seek-
teriologic confirmation, and ensuring proper surveil- ing behaviors are gender dependent. In particular,
lance at local, regional, and national levels. Key dif- women may be more affected than men by physical,
ferences exist between developed and developing geographic, and economic barriers to accessing
regions in terms of presentation and diagnosis of TB. health-care services. In many societies, women
It is important to note that particular schemes for take on multiple occupations – namely, taking care
prevention and diagnosis may be more appropriate of the family and home and doing agricultural and
for some regions as opposed to others. In developed other types of work outside the home. Thus, many
countries, detection of latent infection (and thus pre- women lack the time and resources necessary to
vention of active disease) is accomplished through seek care and to adhere to TB treatment regimens,
tuberculin skin testing. This is more difficult to carry including directly observed therapy (DOT), as sug-
out in endemic regions because of the high back- gested by a randomized control trial of DOT
ground level of positive tuberculin skin tests and the (Zwarenstein et al. 1998).
high prevalence of BCG vaccination, malnutrition, Stigma may also play a role in TB burden in
and HIV infection, which complicate the interpreta- women. Although both men and women may face
tion of skin test results. stigma associated with TB, women – particularly
TB. Some thought that the enlarging uterus, via

Box 14.10 Tuberculosis in Pregnancy – increases in abdominal and thoracic pressures,
Conclusion helped to close pulmonary cavities and that the
hormonal alterations of pregnancy improved the
The increase in HIV and TB among women course of the disease. In the mid-1800s, an opposing
of childbearing age has led to an increase in view emerged. A review of 24 patients reported that
TB in pregnant women pregnancy worsened the course of TB (Grisolle
Pregnancy does not appear to increase the 1850). Some suggested that woman with pulmonary
risk of developing TB TB should not marry, if married should not con-
Symptoms of TB may be confused with ceive, if pregnant should terminate, and if delivered
common manifestations of pregnancy should not breast-feed (Tripathy and Tripathy
Fetal and maternal outcomes depend on 2003). A study published by Hedvall in 1953 chal-
location of disease, point of disease pro- lenged this notion. Two hundred and fifty women
gression and pregnancy at which diagnosis (370 pregnancies) with TB were followed through-
is made, and adherence to treatment out pregnancy – before the arrival of antitubercu-
Isoniazid, rifampicin, and ethambutol are losis drugs – 9% of the subjects improved, 7%
considered safe to use during pregnancy worsened, and 84% remained unchanged during
Congenital TB is rare pregnancy. During the first postpartum year, 9%
Diagnosis is generally made in the context improved, 15% worsened, and 76% remained
of a recent maternal history of TB stable. None of the women died during pregnancy,
and none of the infants developed congenital TB.
those who are coinfected with HIV – may be more The findings of this study are often cited as the
susceptible in many societies. With respect to tubercu- natural history of TB in pregnancy. There is no
losis and pregnancy, much of the literature is outdated clear evidence of an altered risk of becoming
and difficult to interpret in the context of current infected with M. tuberculosis, progressing to active
management practices. Nevertheless, some conclu- disease, or reactivating latent infection during preg-
sions may be drawn using existing data. Because of nancy. Still, there were some concerns about the risk
the increase in the proportion of persons with TB who of progression of TB during the postpartum period,
are women of childbearing age, there has been an though over time this has been rejected by most
increase in the number of women with TB who studies. There is no evidence that pregnancy
become pregnant. The greatest burden of TB for increases the risk of TB among women with HIV.
women is during their childbearing years (ages 15– A case–control study of HIV-positive and HIV-
49). However, there is no clear increase in the risk of negative pregnant women in the Dominican Repub-
developing TB during pregnancy. Because pregnancy lic found that pregnancy did not increase the risk of
may be one of the few times when some women have developing active TB in either group (Espinal et al.
contact with the health-care system, it is an opportune 1996).
time to screen for TB for high-risk individuals and/or
persons living in endemic areas. This also implies that
enhanced case ascertainment may affect the reported
case rates of TB in the population of pregnant women Presentation and Diagnosis
as compared to other populations.
The presentation of TB in pregnant women is gener-
ally similar to that in nonpregnant women. However,
one study found that pregnant patients with TB were
Effect of Pregnancy on Tuberculosis significantly more likely to be asymptomatic than their
nonpregnant counterparts and were significantly more
Tuberculosis in pregnant women has been a con- likely to present with unilateral, non-cavitary, smear-
troversial topic since the days of Hippocrates, who negative disease (Carter and Mates 1994). Up to 20%
believed that pregnancy has a beneficial effect on of pregnant women with TB have been found to be
264 K. Reddy et al.
asymptomatic (Good et al. 1981). Again, because pregnancy. Little is known about pyrazinamide’s
pregnant women are more likely to seek health care effects on the fetus; thus it is generally avoided.
than their nonpregnant counterparts, more cases of Streptomycin is known to be teratogenic with
TB may be detected incidentally. about one in six fetuses developing palsies of the
Diagnosis may be delayed by the nonspecific nature vestibulocochlear nerve or deafness.
of early symptoms and the high background frequency The use of isoniazid, rifampicin, ethambutol, and
of malaise and fatigue in pregnancy (Doveren and pyrazinamide has been considered compatible with
Block 1998). Llewelyn et al. (2000) found a median breast-feeding (Brost and Newman 1997). There
lapse of 7 weeks between onset of symptoms and diag- have been no reports of adverse events among
nosis of TB in 13 pregnant women. Further complicat- infants of nursing mothers receiving these drugs.
ing diagnosis is the fact that pregnant women are more MDR-TB is difficult to treat in pregnant women
likely to postpone having chest radiography (Doveren because some of the medicines that would be used in
and Block 1998); this makes investigation of smear- the treatment have adverse or unknown effects on
negative TB, in particular, more difficult. Despite its the fetus (Tripathy and Tripathy 2003). Cases of
limitations, TST can still be used as an indicator of MDR-TB in pregnancy should be managed on an
latent infection as pregnant women are not at higher individualized basis.
risk of cutaneous anergy than their nonpregnant coun-
terparts (Jackson and Murtha 2001).
Perinatal and Maternal Outcomes

Treatment of Latent Infection in Disparate perinatal and maternal outcomes from
Pregnancy TB in pregnancy have been described. One study
noted increased abortion rates, high levels of pre-
Preventive chemotherapy with isoniazid is recom- eclampsia, and increased levels of difficult labor
mended for some pregnant women with latent infec- requiring intervention in women with TB (Bjerkedal
tion with M. tuberculosis, as determined by TST. et al. 1975). Other studies have noted overall good
Threshold induration size of TST is generally similar fetal outcomes (Schaefer et al. 1975). Recent studies
to that among the general population. Initial reports have demonstrated that fetal and maternal out-
suggested an increased risk of isoniazid-induced hepa- comes depend on the location of disease (pulmon-
titis in pregnant women, but more recent analyses have ary or extrapulmonary), the point (early or late) in
suggested that this was an artifact due to overreporting the pathophysiologic course at which diagnosis is
(Ormerod 2001). Nevertheless, preventive chemother- made, the point of pregnancy at which the diagnosis
apy for latent infection is usually postponed until after is made (with cases with late diagnosis having worse
delivery. fetal outcomes (Figueroa-Damian and Arredondo-
Garcia 1998)), and adherence to treatment. A study
in Mexico found that pregnant women with TB
who began antituberculosis treatment during the
Treatment of Active Disease in first trimester had perinatal morbidity outcomes
Pregnancy similar to those in women without TB, while those
who started treatment later in pregnancy had sig-
Before the arrival of antituberculosis drugs, nificantly higher obstetrical morbidity and neona-
advanced TB caused substantial mortality for both tal mortality (Figueroa-Damian and Arredondo-
mother and child. One study found a 30–40% mor- Garcia 1998). After a follow-up study of 215 preg-
tality rate in patients with advanced TB (Schaefer nant women with active pulmonary TB, de March
et al. 1975). With regard to treatment of active TB in (1975) came to the conclusion that neither preg-
pregnancy, the primary concern is the risk of tera- nancy, birth, nor lactation predisposed women for
togenicity. Some first-line drugs (isoniazid, rifampi- any risk of relapse of pulmonary TB when it is
cin, and ethambutol) are considered to be safe in adequately treated.
These studies indicate the need for early diagno- HIV

sis and treatment of TB in pregnant women. TB is
not a medical indication for abortion, as good A resurgence of TB among pregnant women in New
maternal and fetal outcomes can be obtained, par- York in the early 1990s was linked to HIV coinfec-
ticularly if diagnosed and treated early. tion (Margono et al. 1994). More recently, in ende-
mic communities, cases of active TB are increasing
among pregnant women; this increase appears to be
associated with the HIV epidemic as opposed to
Congenital and Perinatal Tuberculosis pregnancy itself. In endemic communities, HIV test-
ing is generally recommended only for high-risk
Congenital tuberculosis has been defined as TB women diagnosed with active TB, as HIV testing
lesions in an infant plus one of the following: of all TST-positive women would not be economic-
(1) lesions in the first week of life, (2) primary hepatic ally feasible.
complex or caseating granuloma, (3) documented TB
infection of placenta or endometrium, (4) exclusion
of postnatal transmission by separation of the infant
from the mother and other potential sources of infec- Extrapulmonary Tuberculosis
tion (Cantwell et al. 1994). These criteria have
become increasingly difficult to follow in current In endemic areas, extrapulmonary TB is becoming
practice. Congenital TB is rare, especially if the more prevalent among pregnant women; this is
mother has been treated appropriately during preg- partly associated with the HIV pandemic. There is
nancy. It occurs almost exclusively when the placenta some evidence that extrapulmonary TB represents a
is actively infected; thus, pulmonary TB in the relatively high proportion of total TB cases among
mother poses little risk of congenital TB. Congenital pregnant women (Kothari et al. 2006). TB at extra-
TB may be suspected if aggressive broad spectrum pulmonary sites can adversely affect the outcome of
antibiotics are ineffective and tests for other conge- pregnancy. A study in India of pregnancy outcomes
nital infections are negative. If the mother is known in women with TB found significantly higher fre-
to have TB, and if she has been diagnosed recently, quencies of hospitalization during pregnancy, fetal
the suspicion is further raised (Ormerod 2001). TST growth retardation, and low Apgar scores in women
is not useful for detection in infants since it is always with extrapulmonary TB (other than TB lymphade-
negative initially and can take several months to nitis) as compared to uninfected women (Jana et al.
become positive. Thus, diagnosis relies on clinical 1999). Tuberculous lymphadenitis had no effect on
suspicion and contact investigation – a maternal his- perinatal outcome.
tory of TB exposure is important in diagnosis – and
demonstration of acid-fast bacilli in tissue or fluids;
gastric aspirates are recommended. Mortality rates
from congenital TB approaching 50% have been Conclusion
described (Nemir and O’Hare 1985).
Perinatal TB, acquired after birth, can occur via Because of the increase in incidence of HIV and TB
airborne infection from the mother, adult caregiver, among women of childbearing age, there has been
or another infectious adult contact (nurses, health- an increase in the incidence of TB in pregnant
care workers) (Burk et al. 1978). Transmission of women (Box 14.9). However, the data on TB in
M. tuberculosis in breast milk has not been reported, pregnancy are limited. Pregnancy does not appear
although theoretically it could occur if the mother to increase the risk of developing TB. Diagnosis of
has a tuberculous breast abscess. If the mother has TB in pregnant women may be delayed by nonspe-
active TB, expressed breast milk can be used to feed cific symptoms, which can be confused with
the infant until the mother is deemed noninfectious, common manifestations of pregnancy. Fetal and
at which point direct breast-feeding can commence maternal outcomes depend on the location of
(Jones 2001). disease, the points of disease progression and
266 K. Reddy et al.
pregnancy at which diagnosis is made, and adher- Congenital TB is rare. Diagnosis relies on clinical
ence to treatment. Isoniazid, rifampicin, and etham- suspicion, especially with a recent history of mater-
butol are considered safe for use during pregnancy. nal TB.
Key Terms
Acid-fast bacilli (AFB) Extrapulmonary TB Superficial lymphadenitis

Active TB Extrathoracic TB TB granuloma
Anergy Fetal growth retardation TB meningitis
Annual risk of infection (ARI) Ghon focus Teratogenic
Antigen-specific anergy Hematogenous dissemination Tubercle bacilli
Apgar scores Hepatotoxicity Tuberculin skin test (TST)
Bacille Calmette-Guérin (BCG) Induration Perinatal tuberculosis
BACTEC radiometric assay Intrathoracic TB Presumptive diagnosis
Caseating granuloma Isoniazid Primary TB
Caseating lesion Latent TB Progressive lymphadenopathy
Cavitating disease Lowenstein-Jensen medium Progressive primary TB
CD4 lymphocyte Microscopic observation drug Pulmonary TB
Chest radiograph susceptibility (MODS) Purified protein derivative
Congenital TB Miliary TB (PPD)
Contact tracing Multidrug-resistant TB Pyrzinamide
Delayed hypersensitivity (MDR-TB) Reactivation TB
Directly Observed Therapy Mycobacterial load Regional lymphadenitis
Shortcourse (DOTS) Natural history Rifampicin
Droplets Specificity Sensitivity
Effusions Sputum induction Smear-negative
Ethambutol Stegen–Toledo criteria Smear-positive
Exogenous reinfection String test
Questions for Discussion embark on mass TST and BCG vaccination

campaign for infants and young children as a
means of controlling TB. As the regional MCH
1. List any five factors that contribute to the global
program director, what advice would you give
resurgence of TB.
him/her regarding evidence of the effectiveness of
2. Discuss any three reasons why diagnosis, moni-
this intervention?
toring, and treatment of TB in children have
implications for community control of TB.
3. List five challenges that are usually encountered
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Chapter 15
Impact of HIV on the Health of Women, Children, and Families
in Less Developed Countries
Hoosen M. Coovadia and Nigel C. Rollins
Learning Objectives After reading this chapter and (e.g., poverty), cultural factors (e.g., subordinate
answering the discussion questions that follow, you position of women, emphasis on male-directed and
should be able to controlled prevention methods), and access to care
(especially limited for women in rural areas). The
Present a brief description of the global preva-
chapter progresses to discuss strategies for preven-
lence of HIV/AIDS among women, children,
tion of HIV among women and emphasizes the need
and adolescents.
for improved antenatal care services with effective
Summarize the impact of HIV/AIDS on the
counseling on options for prevention of mother-
family and community, including the challenges
to-child transmission, cervical barrier methods of
posed by the increasing scale of AIDS orphans
prevention (e.g., diaphragms, female condoms,
globally.
microbicides, and HIV vaccine), and detection and
Discuss factors that increase women’s vulner-
treatment of sexually transmitted infections, espe-
ability to HIV/AIDS.
cially those due to herpes virus 2. With regard to
Evaluate strategies for the prevention and com-
HIV/AIDS among children, the chapter provides
prehensive management of women, adolescents,
an overview of the global burden of the disease
and children at risk of HIV/AIDS.
and its impact on this population group. A discus-
sion of strategies for comprehensive management of
children at risk for HIV/AIDS is provided. The
chapter concludes with an examination of the
Introduction
impact of HIV/AIDS on the family and community,
highlighting the challenge posed by the increasing
This chapter presents an overview of the global
scale of AIDS orphans globally. It is recommended
burden of HIV/AIDS with a focus on women and
that prevention programs targeted at women and
children. It begins with a discussion of the preva-
children should aim at creating social, political,
lence of the disease among women, highlighting the
economic, and cultural environments that empower
factors that increase women’s vulnerability to HIV/
women, challenge stigma and discrimination
AIDS, including biological factors (the greater ana-
against women, and aggressively combat poverty,
tomical, physiological, and pathological features
gender, and racial inequalities.
that increase the likelihood of women more than
HIV/AIDS is one of the worst pandemics to have
men being infected in sexual intercourse), social
ever afflicted humankind. More than 22 million
factors (e.g., stigma, discrimination, and sexual vio-
people have already died from the disease since it
lence), political factors (e.g., compromised political
was first recognized in the United States in 1981.
rights and repressive legislation), economic factors
It is one of the major killers of human beings,
together with tuberculosis and malaria. Human his-
tory has been punctuated by major pandemics,
H.M. Coovadia (*)
Nelson R. Mandela School of Medicine, University of Natal, times without number, that swept across countries
South Africa and through populations. Some of the better known
272 H.M. Coovadia and N.C. Rollins
diseases are plague (the ‘‘Black Death’’) which deva- A key characteristic of this epidemic is that it
stated Europe in the fourth and fifteenth centuries, often affects the most disadvantaged and poorest
smallpox, tuberculosis, syphilis, and influenza communities worldwide, groups who are at the
which threatens the world once again. By the end margins of society, or sections of the population
of 2005 there were about 38.6 million persons subordinated to those who hold political, eco-
(range = 33.4–46.0 million) who were estimated nomic, and social power. These include women
to be infected with HIV globally. The total number and men in developing countries, women in all
of people living with HIV/AIDS had gone up dur- societies, gay men, intravenous drug users, alcohol
ing the previous 2 years in all regions of the world, abusers, and children. This chapter is about two of
except the Caribbean. An estimated 4.1 million these groups, women and children in developing
people became newly infected with HIV and 2.8 countries. We discuss aspects of the disease in these
million lost their lives to AIDS. Globally, the num- groups with which we are most familiar through
ber of persons becoming newly infected every year our professional and personal lives.
peaked in the late 1990s and stabilized thereafter.
However, in some countries, the incidence of HIV
continues to increase. Sub-Saharan Africa, which Mothers
contains 10% of the global population, is the hard-
est hit with about 24.5 million, which is roughly HIV in Women: Prevalence
two-thirds of the global burden (UNAIDS 2007).
The epidemic is quite diverse throughout the con- Of the roughly 40 million persons who are HIV
tinent with most countries following the worldwide infected and who remain alive, 17.5 million (16.2–
trend, while in some countries, the epidemic con- 19.3) are women of child-bearing age (UNAIDS
tinues to increase. With an estimated 5.5 million 2005). There was an increase of a million more
(4.9 million–6.1 million) people living with HIV HIV-infected women in 2005 compared to 2003
(UNAIDS 2006), South Africa is the country (UNAIDS 2005). There were similar increases in
with the largest number of infections in the world. numbers of HIV-infected women (about 2 million)
The country’s Department of Health estimates in south and Southeast Asia (UNAIDS 2005).
that 18.3% of adults (15–49 years) were living About 70% of all women (i.e., 13.5 million) who
with HIV in 2006 (Department of Health, South are HIV infected are in sub-Saharan Africa. Glob-
Africa 2007). More than half (55%) of all South ally, about 46% of all those who are HIV infected
Africans infected with HIV reside in the KwaZulu- are women (15–49 years old), and in the Caribbean,
Natal and Gauteng provinces (Dorrington et al. North Africa, and the Middle East it is roughly
2006). Staggering increases in HIV during the 50%; in sub-Saharan Africa it is 57%. It is the
past decade have been quite dramatic in some young (15–24 years old) who are most vulnerable.
African countries: this is illustrated by the rapid In sub-Saharan Africa, adolescent women are three
escalation of HIV in South Africa where the to six times more likely to become HIV infected
antenatal clinic prevalence has gone up from than their male peers, and in southern Africa, this
<1% in 1990 to 20% in the year 2000. A corre- proportion is up to 75%. Therefore, there is a very
sponding rise in adult mortality has paralleled this large pool of women who could potentially give
increase (UNAIDS 2007). However, in recent birth to children who would be either HIV infected
years, there has been stabilization or a promising themselves or be exposed to the virus in the womb
decline in prevalence in Uganda, Kenya, Tanzania, and during childbirth every year. Some hundreds of
Rwanda, Zambia, Zimbabwe, Burkina Faso, and thousands of children could also become HIV
Ghana (UNAIDS 2007). In South Africa, the lat- infected due to breastfeeding. In southern Africa,
est HIV data collected at antenatal clinics suggest the overall HIV prevalence at antenatal clinics is
that HIV infection levels might be leveling off, with about 20%; in Botswana, Swaziland, and Kwa-
HIV prevalence in pregnant women at 30% in 2005 Zulu/Natal in South Africa, the figures range from
and 29% in 2006 (Department of Health, South 30 to 40% (Department of Health, South Africa
Africa 2007). 2007).
15 Impact of HIV in Less Developed Countries 273
Vulnerability of Women to HIV infections, is through heterosexual contact (African

Union 2006), while across Asia, infection occurs
HIV adversely affects every dimension of women’s mostly through intravenous drug use and commer-
sexual and reproductive health: pregnancy, child- cial sex workers (UNAIDS 2005).
birth, use of contraceptives, infant feeding choices, There are a number of social, political, and cul-
exposure to and treatment of sexually transmitted tural reasons for the increased vulnerability of
diseases, and vulnerability to sexual violence. HIV women to HIV. Younger women, in particular, are
worsens some reproductive health diseases, increases culturally and socially unable to negotiate safer sex,
the severity of others, decreases fertility, and affects including the use of condoms, with their male part-
sexual health. The reasons for the disproportionate ners; they are often subjected to coercion in sexual
burdens of HIV among women are multiple and not relations, and their rising expectation of modern life
always clearly understood (Collazos et al. 2007). The encourages them into sexual liaisons with older men
key reasons accounting for the vulnerability of (transactional or barter sex) who may have more
women to HIV are a combination of biological and resources but also higher HIV prevalence. Women,
social factors (Box 15.1). Biological factors relate to especially at younger ages and in rural areas, are less
the greater anatomical, physiological, and patholo- well informed about HIV transmission than young
gical features which increase the likelihood of males. Education can make a difference in gaining
women more than men to be infected in sexual inter- knowledge on HIV/AIDS and may reduce acquisi-
course. Social factors are determined by the expo- tion of HIV – but knowledge does not assure choice
sure of women to risky contextual factors, sexual and autonomy. Women are often subjected to phy-
customs, and practices. The primary route of HIV sical and sexual violence, and although this occurs in
transmission in Africa, accounting for 85% of all most regions of the world, it is especially damaging to
the health of women in regions where HIV is preva-
lent (Zablotska et al. 2007). There is considerable
overlap between HIV, sexually transmitted diseases,
and violence (Karamagi et al. 2006). It is known that
Box 15.1 Factors that Increase Women’s
women with HIV are more likely to have experienced
Vulnerability to HIV
sexual and physical violence than women without
Biological factors: HIV risk two to four times HIV. Women have learned that disclosure of their
HIV status may entail serious problems and cannot
higher for women than men
Social factors: coercive sex, especially young be lightly undertaken. In some settings, more in
Africa than in the developed world, in excess of
women
Political factors: compromised political rights; 20% of women disclosing their HIV status to part-
ners have met with negative responses, including
regressive legislation
Economic factors: poverty and food insecurity violence. Frequently, violence against women and
children occurs within families or within the circle
disproportionately affect more women than
of acquaintances and friends of the family. Coercive
men
Cultural factors: subordinate position of sex and rape are often antecedents of HIV infection
in some African countries. It has been estimated that
women; use of condoms
Access to health services: often restricted, 2 million girls (5–15 years of age) are coerced into the
sex trade every year, and that a third to half of
especially rural women
Reproductive health services: antenatal and married women in some regions are subjected to
physical abuse by their partners. Women who suf-
other services often unavailable, inaccessible,
fered food insecurity and hunger more frequently
and inadequate; family planning often limited
agreed to sex without condoms, intergenerational
to technical services without provision of com-
sex, and multiple partners (Weiser et al. 2007). Per-
prehensive sexual health services or options
sistent and residual cultural practices, such as female
for prevention of mother-to-child transmis-
genital mutilation (FGM) (see Chapter 10), may
sion and infant feeding
predispose women to sexually transmitted diseases,
including HIV; 130 million women in the world are integrity of the vaginal mucosa, rendering women
said to be living with the effects of this destructive more vulnerable to HIV transmission. Young
practice. Partner infidelity often places women at risk women in particular have immature cervices and
of being the passive victims of sexually transmitted less vaginal secretions; these make them prone to
diseases. Marriage and their own fidelity are insuffi- vaginal lacerations during sex. Sexually transmitted
cient to protect women against acquiring HIV. In infections in women’s HIV-infected partners may
southern Africa (Harare, Durban, Soweto) 66% of increase the viral load in these partners and raise
women had one lifetime partner and 79% had their propensity to transmit HIV sexually. There are
abstained from sex until marriage at 17 years. Yet more than 340 million cases of curable sexually
40% of young women were HIV infected (Chen et al. transmitted infections every year, with women hav-
2007). In India, most females have been HIV infected ing greater vulnerability than men (UNAIDS 2006).
by their husbands who had contracted the infection The high prevalence of vaginal infections among
from sex workers (UNAIDS 2005). In Colombia, women in Africa [bacterial vaginosis (30–60%); vul-
72% of women who were HIV positive at antenatal vovaginal candidosis (10–13%); trichomonas vagi-
clinics were in stable relationships (UNAIDS 2005). nalis (7–23%)] predisposes them to HIV transmis-
Shame, stigma, and discrimination hinder sion (Chen et al. 2007). Despite the high risk that
women with HIV or at risk for HIV from protecting these infections pose for the spread of HIV, health
themselves or seeking assistance and support (Ehiri services for prevention and treatment are poorly co-
et al. 2005). Social and cultural taboos on sexuality coordinated, and coverage is low (UNAIDS 2006).
aggravate the position. These factors prevent Women are said to progress to severe HIV disease at
women from making autonomous decisions for lower viral loads and higher CD4 counts than men
their personal and family health and benefit, includ- (Umeh and Currier 2005; Gilad et al. 2003; Naprav-
ing preventing them from accessing health and nik et al. 2002; Suligoi 1997). Although this requires
other services which may offer counseling, prophy- better evidence; ovulatory hormones may play a
laxis, treatment, and care. Poverty and lack of edu- role in this effect. The implications of these virolo-
cation and economic opportunities ensure that gical and immunological characteristics are that
women stay in a subordinate position in society. initiation of antiretroviral therapy for women
Political rights may be compromised: in some should be at lower viral loads.
developing countries legislation bars women from
entering into independent contracts, denies them
the right to inherit land and property, and binds
them to regressive laws on marriage, divorce, and HIV/AIDS Among Adolescents
child custody (Krishnan et al. 2008). Conflicts, fam-
ines, wars (see Chapter 7), internal and external Although the burden of HIV/AIDS among adoles-
migrations, and foreign occupation affect women cents has been discussed in Chapter 24 (Adolescent
more than they do men, exposing them to sexual Health), it is germane to mention here that youth
exploitation and risks, and multiple health, social, aged 15–25 years are at high risk for infection and
and financial difficulties (Parker et al. 2000). Traf- represent the population group with the largest
ficking of young women, often into commercial sex number of infected persons. Over 10 million HIV
work, and criminalization of sex workers add to the infections worldwide are among youth aged 15–24
structural conditions that increase the risk of HIV years, which represent almost 7,000 infections per
infection. day (United Nations 2001). Over half of all new
In addition, there are biological factors deter- infections occur among adolescents (UNAIDS
mining vulnerability to HIV which are more promi- 2003; Senderowitz 1997). In Africa and the Carib-
nent in women than men. The risk of becoming HIV bean, the epidemic disproportionately affects young
infected during unprotected sexual intercourse is women, with infection rates for young women two
two to four times higher for women than men. to three times higher than for young men.
Sexually transmitted infections are more common Targeting adolescents is regarded as a feasible
in women; these infections may compromise the means of halting the spread of infections, for they
have not yet established deep-rooted behavioral thirteen of these were conducted in Africa and three
patterns and may therefore, be more amenable to in Latin America. Twelve of the sixteen studies were
prevention interventions in comparison to older school based and four were community based. It was
people (Cowan 2002; Aggleton and Rivers 1998). found that the interventions reviewed were not
This promising aspect of working with adolescents, resoundingly successful in achieving their goals of
however, also requires that programs be carefully increasing knowledge of HIV/AIDS, altering atti-
designed and attuned to the particular characteris- tudes, improving negotiation and communication
tics of, and culture inherent among, adolescents skills, or in influencing positive behavior evidenced
(Population Council 2000). To be effective, inter- through consistent condom use, abstinence, or redu-
ventions must take account of the basic truths of cing the number of partners (Magnussen et al. 2004).
adolescent behavior: exploration, experimentation, ABC (abstinence, be faithful, use condoms) is
and rebellion, which can often lead to early initia- promoted as the foundation of prevention messages
tion of sex, multiple sex partners, and lack of con- but is often not applicable or practiced by groups at
dom use (Magnussen et al. 2004). Attitudes of invin- risk, and oversimplifies the determinants of infec-
cibility also seriously alter the adolescents’ tion and opportunities for prevention. For example,
perception of HIV/AIDS/STD risks (Magnussen women in Africa often do not live under fair and
et al. 2004). In addition, social forces combine just social conditions or have sufficient economic
with these behaviors to form in the adolescent, power to negotiate condom use or the right to refuse
ingrained negative messages that subsume positive, sex. Therefore, other interventions are required.
healthy behaviors and attitudes. For example, pov- The subordinate position of women in many
erty, the shift from rural to urbanized cultures, the affected societies mandates the development of
exploitative economic power of ‘‘sugar daddies’’ women-controlled prevention measures. These
(Silberschmidt and Rasch 2001), delayed marriage, include the use of female condoms and detection
and pervasive gender inequality block access to con- and treatment of sexually transmitted infections,
doms and information, and place adolescents in especially those due to herpes virus 2. Promising,
precarious, high-risk situations (Magnussen et al. but as yet unproven interventions, which may be
2004). Thus, interventions predicated on the idea especially useful to women include cervical barriers
that there are equal rights in a sexual relationship such as diaphragms, microbicides, and HIV vac-
may be counterproductive in many cultures cines. Male circumcision may prove to be effective;
(Stanton et al. 1998). it has been demonstrated to reduce HIV transmis-
Magnussen et al. (2004) conducted a review of the sion to males in a controlled trial in South Africa
effectiveness of interventions to prevent HIV/AIDS (Flynn et al. 2007; Muller et al. 2003), but what is
among adolescents using data from the literature. urgently needed is evidence that male circumcision
Only studies that included a control group, and will reduce HIV transmission to females. The use
which involved pre- and post-intervention assess- of antiretrovirals (ARVs) (for prevention, post-
ments were included. Outcomes assessed included exposure prophylaxis, and for treatment in the
changes in safe sex practices (abstinence, condom form of highly active antiretroviral therapy
use, limitation of sexual partners, avoidance of [HAART]) may not be sufficient on its own to
casual sex), knowledge about HIV/AIDS transmis- prevent HIV transmission; ARVs will have to be
sion and prevention methods, perception of HIV/ combined with reduction of risky sexual behavior.
AIDS/STD risks, self-efficacy with regard to con-
dom negotiation and refusal of sex, uptake of volun-
tary counseling and testing (VCT), and reduction in
incidence of HIV/AIDS/STDs. Studies were assessed HIV in Women: Health Services Provision
in terms of intervention format (e.g., education, role-
play, video), duration, and setting (school or com- Health service inadequacies and subjective factors
munity based). Reported improvements in outcome are the key reasons for avoidable deaths in women.
measures in intervention versus control groups were Lack of healthcare facilities, personnel and trans-
assessed. Sixteen studies met the inclusion criteria; port, and delays in providing treatment are the
major administrative avoidable factors; personal as tuberculosis, malaria, miscarriages, and stillbirths.
beliefs, such as fatalism and non-caring attitudes, They are more likely to die from cervical cancer
are also responsible. Of those who need HAART, secondary to undiagnosed human papilloma virus
less than 10% in Africa and less than 15% in Asia (HPV) infection, and especially so when living in
have access to it. However, due to new scale-up rural areas. Malnutrition may also supervene. Yet,
initiatives through United Nations agencies HIV-related symptoms are rarely documented in
(‘‘35’’ and Universal Access Programmes), up to antenatal notes presumably because health workers
350,000 deaths were averted in 2005 (WHO/ rarely ask the necessary questions. In countries with
UNAIDS 2003). Prevention interventions are avail- the highest infant deaths, there are also unacceptable
able to less than 20% of those at risk of acquiring maternal deaths. In South Africa, HIV-related
HIV in developing countries. Women-directed pre- maternal deaths increased steadily from 14.5% in
vention services are often more deficient than those 1998 to 20.1% in 2002–2004; HIV accounted for
for both sexes. For example, antiretroviral therapy more than 50% of non-obstetric maternal mortality.
increased from 7% of those who required it in The most common reasons for these maternal deaths
developing countries in 2003 to 20% in 2005, pre- are an absence of practical guidelines for midwives’
vention services to reduce mother-to-child transmis- antenatal assessments and for management of preg-
sion of HIV expanded from 7.6 to 9.0%, and nancies in HIV-positive women (McIntyre 2003).
antiretroviral prophylaxis for prevention of Voluntary counseling and HIV testing (VCT)
mother-to-child transmission (PMTCT) went up centers are often inadequately provided. VCT cen-
from 3.3 to 9.2% during the same period (WHO/ ters are a gateway to a very large number of other
UNAIDS 2005). While PMTCT coverage further public services such as welfare, health, support
increased to 34% in 2007 (UNAIDS 2007), this is organizations, advice on safe and satisfying sexual
still grossly inadequate and represents a failure of lives, and referral to abuse centers. Counseling may
commitment and prioritization by governments, also strengthen women’s resolve to deal with vio-
UN agencies, and civil society itself. There are, lence, adhere to treatment schedules, and make
however, some successes: prevention activities are appropriate decisions on infant feeding. In order
reducing HIV prevalence among young women to avoid dealing with HIV/AIDS as a special dis-
(and men) in Uganda (Green et al. 2006), among ease, and thereby exacerbating stigma and discrimi-
sex workers and their clients in Thailand, Cambo- nation, many African countries are beginning to
dia, Senegal, and India, and among intravenous treat HIV/AIDS as a routine problem, and provid-
drug users in Brazil (Piot et al. 2001). ing advice and tests as is done for other common
The coverage of antenatal clinic services is often disorders.
patchy in sub-Saharan Africa. About 40–50% of the Psychosocial support is essential for HIV-
poorest pregnant women lack access to antenatal infected women and is often neglected in developing
clinic services and to a professional healthcare pro- countries. Counseling and testing for HIV is in itself
vider. The coverage for effective neonatal care is even insufficient to provide the depth of psychological
worse. Counseling at such health facilities on options support required to deal with anxiety, distress, fear,
for prevention of transmission of HIV to the infant is denial, guilt, etc. Specially trained individuals who
critical. These are of considerable value for HIV- are very often either unavailable or unaffordable are
infected women as the risks of a premature birth needed to provide individual, couple, family, group,
and of low birth weight infants are not negligible. and community counseling on HIV/AIDS.
HIV-infected women fare worse than uninfected Family planning services can play a supportive
women: they are more likely to experience more role during the HIV epidemic, as both HIV and
adverse pregnancy outcomes, complications, and reproductive health disorders are rooted in poverty,
mortality. They are more often anemic, have preg- gender discrimination, and social marginalization. In
nancy-induced high blood pressure, lower weight, Africa, the coverage is often restricted and integra-
and more infections of the urinary tract. They also tion with reproductive health and other services is
experience greater frequency of syphilis, vaginal dis- uncommon. This diminishes potential synergies in
charge, and increased severity of complications such disease prevention and control. These services can
provide HIV prevention messages (condom use, years are living with HIV worldwide, of whom 2.0
abstinence, fidelity) and manage sexually transmitted million are in sub-Saharan Africa. Many of them
diseases. Family planning centers can improve pre- have no access to specific care and treatment, and
vention of mother-to-child transmission programs they survive or die depending on their chances of
by promoting interventions that decrease incidence joining the queue for general child health preven-
of HIV in women of child-bearing age (primary pre- tion and treatment services.
vention), and which prevent unintended pregnancies.
Fifty percent of unintended pregnancies globally
are terminated annually, 19 million unsafely (see
Chapter 11). Therefore, access to safe and legal abor- Impact of HIV on Children
tion is essential. The complicated interactions
between antiretrovirals and hormonal contraceptives HIV is a lethal disease in adults and children.
may also be addressed at these facilities. Whereas clinical features and deterioration in
many adults become prominent only 9–10 years
after infection, the decline in health is much more
rapid in children. The mortality from childhood
HIV in Women and Pregnant Women: HIV, in the absence of treatment and care, is very
Impact high, with a quarter to a third dying before 1 year
of age, and the majority before their fifth birthday.
In the most seriously affected countries in southern It is estimated that children constitute 14% of the
Africa, AIDS has become the main cause of maternal total HIV infections worldwide, but they account
death in all age groups. Measurements of the burden for 18% of all deaths due to AIDS. In 2005, about
of disease in South Africa confirm that AIDS is a 570,000 children died from HIV/AIDS. Sickness
major cause of death among all women (with the 25- and death are often due to the HIV disease process
to 29-year age group being at most risk) and that itself, as it erodes and destroys vital tissues and
these women have a higher mortality than men (47% organs. More often, morbidity and mortality in
versus 33%). Diarrhea, tuberculosis, and lower children are due to a relentless destruction of the
respiratory tract infection are the other important immune system which opens the floodgates to mul-
causes of years-of-life lost. tiple infections and cancers. It follows that the
types of infections that supervene are those that
are latent and common in the environment. In
Africa, the overwhelming causes of ill health and
Children of death are pneumonias (often due to pneumocys-
tis and bacteria), diarrhea, sepsis, malnutrition,
Epidemiology and tuberculosis. In endemic areas, malaria is
also important. These diseases are generally indis-
Nearly all HIV-positive children in developing tinguishable from those in the general population
countries became HIV infected through transmis- of children, except that they are more frequent and
sion of the disease from their mothers during preg- the clinical manifestations are more severe than in
nancy, through delivery, and postnatally from HIV-uninfected children. Even in countries where
breastfeeding. The highest transmissions occur dur- HIV prevalence is high, the proportion of children
ing delivery and from breastfeeding. HIV-infected with HIV/AIDS is fairly small – in South Africa it
children and HIV-uninfected children born to HIV- is less than 10% of all children. It follows that
infected women (who are also considered to be vul- thousands of children die of common diseases
nerable to many adverse medical and social pro- without any indication of their underlying HIV
blems) are the face of the AIDS epidemic which is status. In the most severely affected countries,
often ignored. They often remain invisible to policy under 5 deaths attributable to HIV/AIDS vary
makers, program implementers, and service provi- considerably from across the regions, reaching
ders. About 2.3 million children under the age of 15 roughly 45% in Botswana. In Africa as a whole,
AIDS was responsible for 2% of under 5-year

mortality in 1990; this had risen to 6.5% in 2003 Box 15.2 Comprehensive Management of Children
(Newell et al. 2004a; Zaba et al. 2004). Globally, at Risk of HIV
however, it has been estimated that a fraction of
under 5-year mortality is caused by HIV/AIDS, Prevention of HIV infection in women of
and that prevention activities relevant for HIV in child-bearing age
children could prevent 150,000 of the 11 million Family planning for HIV-infected women
child deaths from the common diseases that occur Options for termination of pregnancy in HIV-
annually (Coovadia and Schaller 2008). infected women
The latter part of the last century had witnessed Prevention of mother-to-child transmission of
the creation and global spread of a number of health HIV
programs aimed at preventing major diseases and Diagnosis of HIV infection in infants and
reducing mortality in children. The benefits were children
gratifying and resulted in improving survival and Care of HIV-uninfected children born to HIV-
falling mortality rates. In sub-Saharan Africa, many infected women
of these gains are being reversed by the impact of the Clinical staging of HIV infection
AIDS epidemic. Infant mortality rates in this region Clinical management of HIV-infected children
have increased by more than 19%; in South Africa, Antiretroviral therapy
where the under 5 mortality had fallen to 55 per Chronic care of HIV-infected children
1,000 births by 1994, it has now risen to about 87 Terminal care of HIV-infected children
per 1,000 births (Coovadia and Schaller 2008). The Counseling and psychosocial support
global community has formulated ideas on further Nutritional care
progress in global health by establishing the Millen- Family support
nium Development Goals: the figures given above Referral to welfare and social services
for maternal mortality and the rates for child mor-
tality reduce the prospects of success in meeting total of 700,000 newly infected by HIV had been
these goals by 2015. In industrialized countries, infected through breastfeeding (WHO 2004a).
HIV infection in infants and children is a rapidly A number of earlier trials in Africa and Thailand,
diminishing problem (McIntyre and Gray 2002); using drugs and combination antiretrovirals
mortality rates for HIV-infected children and ado- (ARVs) appropriate for developing regions, found
lescents have decreased from 5% in 1996 to cur- that in non-breastfeeding women, zidovudine
rently less than 1% (Volmink et al. 2006). (AZT) can reduce transmission by between 50 and
70%, while in women who breastfeed this reduction
varies between 63% at 6 weeks and 23% at 24
months (WHO 2004b). The reduced efficacy at 24
Prevention of Mother-to-Child months is due to continued transmission of HIV
Transmission (PMTCT) of HIV through breast milk. Even when the mother is not
able to get to a clinic to give birth and receive the
Box 15.2 presents a summary of strategies for com- appropriate ARVs, postpartum nevirapine (NVP)
prehensive management of children at risk of HIV. to the infant can reduce MTCT significantly, to
Striking reductions in perinatal transmission (dur- 20.9% at 6–8 weeks, while NVP+AZT reduces
ing late pregnancy and delivery) of HIV and longer transmission to 15.3% (WHO 2004b). When com-
child survival within research cohorts have been bined with elective caesarean section and avoidance
achieved by comprehensive prevention of mother- of all breastfeeding, these interventions have
to-child transmission (pMTCT) programs. The use reduced the risk of HIV transmission to infants to
of antiretrovirals in pMTCT programs has been approximately 1% (WHO 2008).
critical for their success. However postnatal trans- Total avoidance of breastfeeding by an HIV-
mission (through breastfeeding) remains unre- positive mother is patently very effective in preventing
solved; in 2003 an estimated 300,000 infants of a transmission of the virus to the child through this
route. However, this option is not feasible for the perinatal period, most pediatric infections can be
majority of women in developing regions, mainly averted by preventing maternal HIV infection in
due to stigma of HIV associated with avoidance of the first place or by preventing of unwanted preg-
breastfeeding, costs of formula, difficulties in hygienic nancies by HIV-positive women. Indeed, a recent
preparation of artificial milks, lack of refrigeration study undertaken in eight African countries showed
and electricity, and unsafe or erratic water and for- that reducing the HIV prevalence of women by as
mula supplies. Most importantly, the dangers of for- little as 1.5% or decreasing the number of unwanted
mula feeding – morbidity and deaths due to diarrhea pregnancies in HIV-positive women by only 16%
and pneumonia, which are the result of contamina- yielded a reduction in MTCT equivalent to that
tion by polluted water and addition of unhygienic achieved using single-dose nevirapine (sdNVP),
foods – often outweigh the risks of HIV transmission given to the mother during labor and to the infant
(Coutsoudis et al. 1999; Coovadia et al. 2007). Mixed directly after birth (Sweat et al. 2004).
breastfeeding (breast milk and other foods/liquids), The addition of short courses of ARVs to sdNVP
which is the most common type of breastfeeding uni- in both breastfed and formula fed infants greatly
versally, increases the risk of HIV transmission decreases the risk of HIV infection in the infant, and
(Magoni et al. 2005). Solids are recommended for the World Health Organization (2006) recommends
infants only in the weaning period. Six months of that AZT + sdNVP be given to otherwise healthy
exclusive breastfeeding (EBF), where the infant is HIV-infected women to prevent MTCT. Over 24
fed breast milk only, with no other foods or liquids, months, average MTCT of HIV without ARVs is
is optimal for child growth and development. Solids between 30 and 45%, with combination ARVs these
given too early in infancy have been consistently figures drop to between 2 and 3% in non-breast-
shown to have deleterious effects on child health and feeding babies and around 5% in breastfeeding
increase HIV transmission (Magoni et al. 2005). populations (WHO 2004a).
However, in better resourced areas these differences
have not been detected, which reinforce the UNAIDS
guidelines on replacement feeding in HIV-infected Access to Treatment
women, viz. ‘‘where replacement feeding is acceptable,
feasible, affordable, sustainable and safe, avoidance Box 15.3 summarizes the impact of AIDS on
of all breastfeeding is recommended, otherwise exclu- children. Less than 5% of HIV-positive children
sive breastfeeding is recommended for the first few
months’’ (WHO/UNICEF/UNAIDS 2004). In devel-
oping countries, EBF for the first 6 months is very
often more appropriate, as this is affordable, may lead Box 15.3 Impact of AIDS on Children
to lower HIV transmission than mixed feeding, and
improve infant survival (Coovadia et al. 2007;
Loss of family and identity;
Magoni et al. 2005; Coutsoudis et al. 1999).
Depression;
Community-based interventions to support
Reduced well-being;
EBF within HIV-infected and uninfected popula-
Increased malnutrition, starvation;
tions, have been successful in changing behavior
Failure to immunize or provide health care;
from mixed to exclusive breastfeeding (Bland et al.
Decline in health status;
2008; Orne-Gliemann et al. 2006; Bhandari et al.
Increased demands on labor;
2003; Haider et al. 2000; Rodriguez-Garcia et al.
Loss of schooling/educational
1990). Even in high prevalence HIV countries, opportunities;
breastfeeding could prevent 13% of under-5 deaths;
Loss of inheritance;
while in low HIV prevalence countries, about 15%
Forced migration;
of under-5 deaths could be averted (WHO 2004a).
Homelessness, vagrancy, crime;
As the majority of HIV-positive children acquire
Increased street living;
the virus from their mothers, it makes sense that, in
Exposure to HIV infection.
addition to the use of antiretrovirals during the
who require AIDS treatment have access to it. A

recent study from the United States suggests that Box 15.4 Potential Impact of AIDS on Family and
appropriate treatment for HIV/AIDS in children the Community
may reduce pneumocystis pneumonia 14-fold,
bacteremia 10-fold, and bacterial pneumonia 5- Relationships
fold (Klugman 2007; Fisher et al. 2001). More Intra-family conflict;
than 90% of HIV-infected children are in Africa Rejection of family member;
and they have the least access to the services Stigmatization, discrimination and isolation;
they require. Expensive drugs, lack of trained Death of member, grief;
personnel, inadequate health facilities such as Increased number of multi-generational
hospitals and clinics, and budgetary constraints households lacking middle generation;
were believed to be extreme barriers to imple- Change in family composition and in adult
mentation of combination antiretrovirals for and child roles.
children and adults in developing countries.
Resources
Experience has proven that these barriers are
surmountable. Impoverishment;
Loss of labor;
Loss of income for medical care and
education;
Families Forced migration;
Time and money spent for funerals.
Impact on the Family
Resilience
HIV/AIDS wreaks havoc on many aspects of Demoralization;
social and economic life, especially on the family Stress;
(Box 15.4). The consequences of parental death Inability to parent and care for children;
on children can be extensive. Globally, there are Dissolution;
about 15.0 million AIDS orphans, of whom 12.3 Long-term pathologies (increased depressive
million are in sub-Saharan Africa, and most of behavior in children).
the latter (8.5 million) are in east and southern
Africa. By 2010 it is estimated that sub-Saharan Community stresses*
Africa will have 18.4 million AIDS orphans Reduced labor;
(UNAIDS/UNICEF/USAID 2002). Welfare ser- Increased poverty;
vices and child care support from the state to Inability to maintain infrastructure;
households ravaged by the disease is paltry. In Loss of skilled labor, including health work-
Botswana 34.3% of households that require sup- ers, teachers and agricultural extension
port for orphans receive it, in Kenya the figure is workers;
10.3%, and in Ethiopia 3.6% (UNAIDS/ Loss of agricultural inputs and labor;
UNICEF/USAID 2002). It is tragic that the cat- Reduced access to healthcare;
astrophic effects of apartheid on infant and child Elevated morbidity and mortality;
development and on the fulfillment of their Psychological stress and breakdown;
potential are being repeated by the HIV/AIDS Inability to marshal resources for community-
epidemic in South Africa. wide funding schemes or insurance.
Family life, at the very center of nurturing and
caring activities for the tender young, remains *Source: Besley (2006)
under threat as it has been throughout modern
times in South Africa. There has been an unremit- for more than 150 years. Colonial depredations,
ting erosion of the integrity of African family life migrations, urbanization, and industrialization
shaped the evolution of early African family struc- children for sustained periods. Indeed, a World
ture; apartheid twisted the shape and form of the Bank study (Subbarao and Coury 2004) showed
extended family. AIDS now looms large to wreak that only about 4 out of 10 children in South Africa
further damage and leave behind a trail of thou- whose mothers had died lived with their fathers; this
sands of orphans and vulnerable children. This compares with 9 out of 10 in Malawi and Zambia.
disastrous epidemic will cast a dark shadow well Dr. Mamphela Ramphele, who was head of the
into the future of these countries, unless extraor- University of Cape Town and worked at the
dinary measures are taken to control the disease World Bank, observes that even when men are
and mitigate its effects on family life. there, they ‘‘die’’ as husbands and parents because
The impact of AIDS on families is well known. In of alcohol, drugs, and other social ills (Ramphele
a recent 40-country study in Africa (UNAIDS 2005). In a study by Professor Linda Richter of the
2006), 16.5% of households with children, mostly University of KwaZulu/Natal and her colleagues
female headed households, were caring for orphans (Richter et al. 2005) a majority of the men expressed
and more than 90% of orphans who had lost both deep guilt, both personally and socially, for the ills
parents were being cared for by extended families. experienced by women and children. The burden of
Both the insidious progression of the silent unde- care for children, orphaned or affected by HIV/
tected infection, and the relentless march of the AIDS, in South Africa is borne largely by women,
overt disease, eats away steadily at the fabric of especially young women who are themselves despe-
the nuclear or extended family. All that finally exists rately vulnerable to HIV.
is the frayed and torn remnants of a family struc-
ture, with children insecurely bound to desperate
and frail grandmothers, and lives punctured by fre-
quent and recurring illnesses. The financial and Conclusion
personal burdens become overwhelming as there is
loss of productive capacity of parents, decrease in It is sobering to remember that in the face of such
incomes, and an increase in health costs, poverty, an unprecedented global catastrophe, the breadth
starvation, and destitution. Orphaned children and diversity of the issues which have to be learned
(both HIV uninfected and HIV infected) and other from experience and experiment remain enormous.
children in the household suffer greatly from mal- The scientific challenges that still have to be con-
nutrition, infectious diseases, homelessness, depres- fronted and overcome, the national and interna-
sion, fear, guilt, shame, and death. Children of HIV- tional policies and programs that remain unat-
infected mothers with advanced AIDS are 3.5 times tended to and are yet to be implemented are huge.
more likely to die irrespective of their own HIV We have dealt with a small and specific area only.
status, when the mother dies the children are more A comprehensive response to the vulnerability of
than 4 times at risk of death (Newell et al. 2004b, women to HIV, and the afflictions and distress
Zaba et al. 2005). Children are often forced to caused to them by the infection, is a central pillar
assume headship of the family and home; there is in the strategy to confront and control this epi-
little for shelter, food, education, hygiene, and per- demic. A credible program for women would
sonal needs, less for comfort and enjoyment, and include the following: scaling-up VCT, prevention,
nothing but emptiness tinged with fear for the times treatment, and care (including psychosocial sup-
ahead. Poverty increases the exposure to child abuse port); establishing child- and women-friendly,
and sexual coercion. Already about 25,000 children equitable, effective, and efficient health services;
are sexually abused annually in South Africa preserving and protecting breastfeeding during
(Lauren 2004). HIV/AIDS accounts for some of the HIV epidemic and implementing appropriate
these 25,000 and likely many more are too far infant; feeding policies; and including men in HIV
removed from social concern to comprise even a policies. The following basic interventions could
statistic. The figures are stupefying: more than half avert substantial numbers of maternal deaths: poli-
of all South African men do not live with their cies and training on implementing appropriate
guidelines on management of HIV-positive preg-

nant women, and improved access to comprehen-
sive essential obstetric care and to safe abortion Box 15.6 Care for AIDS Orphans
services (Box 15.5). Programs directed at women
should aim at creating social, political, economic, Provide access to shelter, food, education,
and cultural environments which empower healthcare.
women; counteract stigma and discrimination Facilitate care and other grants from state
against women; and aggressively combat poverty, welfare services.
and racial and gender inequalities. Socio-economic improvements to house-
hold (e.g., household income).
Combat stigma and discrimination.
Prevent exploitation and abuse.
Protect inheritance.
Box 15.5 Prevention of HIV Infections
in Women
Interventions proven to work: condoms for

men and women; promotion of safe sexual have to be overcome include shortage of trained
behaviors (delayed sexual debut, reduction in health personnel, a dearth of adequately
number of casual sexual partners) equipped and functioning health facilities, and
Potential, but unproven interventions: equitable and efficient health systems. The
male circumcision; combination antiretro- family is the quintessential unit in a just and
virals; chemoprophylaxis of herpes sim- benevolent society; it can be the foundation for
plex virus-2 and treatment of HSV-2 infec- reconstructing communities ravaged by AIDS
tions; treatment of non-pathogenic vaginal and for preventing the spread of the infection
infections; pre-exposure prophylaxis; by HIV. Accordingly, the integrity and function-
microbicides, diaphragms; penile hygiene; ing of families in HIV-endemic regions should be
HIV vaccines. promoted, protected, and supported. Belsey
(2006) suggests the following child-related strate-
gies for affected families: strengthen capacity of
Key interventions for children include scaling families to protect and care for children;
up of prevention services to reduce MTCT as improve capacity of children and young people
described in this text, strengthening HIV-specific to meet their own needs; strengthen community
treatment programs, and improving general child responses and create an enabling social environ-
health treatment, prevention, and care services, ment; and ensure appropriate legislation and ser-
and improving the care of orphans and vulnerable vices in government. A comprehensive account
children (Box 15.6). It is imperative that imple- of policies, programs, and services to strengthen
menting authorities in Africa expand their families and communities within HIV-endemic
pMTCT services using ARV regimens best suited regions has been documented by Dairo and
for their social and economic conditions, integrate Aglobitse (2004).
HIV services into general child health services, Finally, it bears repeating that the fundamental
provide sound programs on infant feeding, and success of many health promotion measures and
monitor and evaluate all of these. It is now clear the effects of health interventions for children
that combination antiretroviral treatment depend on the environment in which they are
(HAART) is feasible, affordable, safe, and effec- born and in which they grow, develop, and mature.
tive among children in developing countries. Reversing poverty and improving the social, eco-
The current problem is one of scale – the nomic, and political position of African people are
small proportion treated of the large numbers essential to addressing these contextual factors
in need demands urgent expansion of treatment for children, as indeed they are for African socie-
programs in Africa. The key limitations that ties as a whole.
Key Terms
Abstinence, be faithful, use Highly active Prevention of mother-to-child

condoms (ABC) antiretroviral therapy transmission (PMTCT)
Antiretrovirals (ARVs) (HAART) Safe sex practices
CD4 count HIV/AIDS Single-dose nevirapine
Commercial sex work Human papilloma virus (HPV) (sdNVP)
Condom use Mother-to-child transmission Transactional sex
Endemic (MTCT) Viral load
Exclusive breastfeeding (EBF) Nevirapine (NVP) Voluntary counseling and
Female genital mutilation Pandemic testing (VCT)
(FGM) Pneumocystis carinii Zidovudine (AZT)
Gender inequality pneumonia
Heterosexual contact
Aggleton P, Rivers K (1998) Interventions for adolescents.

Questions for Discussion In: Gibney L, DiClemente RJ, Vermund SH (Eds.) Pre-
venting HIV in Developing Countries: Biomedical and
1. In an essay of about 1,000 words, discuss factors Behavioral Approaches. New York: Plenum Press,
pp. 231–255
that increase women’s vulnerability to HIV/ Belsey MA (2006) AIDS and the Family: Policy Options for a
AIDS. Crisis in Family Capital. Department of Economic and
2. What factors limit the potential of ABC (absti- Social Affairs. New York: United Nations, 126 pp
nence, be faithful, use condoms) programs to Bhandari N, Bahl R, Mazumdar S et al. (2003) Effect of
community-based promotion of exclusive breastfeeding
reduce the incidence of HIV/AIDS among on diarrheal illness and growth: a cluster randomised
women in less developed countries? controlled trial. Lancet, 361(9367), 1418–1423
3. Discuss the current state of knowledge and Bland RM, Little KE, Coovadia HM et al. (2008) Interven-
recommendations regarding the prevention of tion to promote exclusive breast-feeding for the first 6
months of life in a high HIV prevalence area. AIDS,
mother-to-child transmission of HIV using anti- 22(7), 883–891
retroviral drugs. Chen L, Jha P, Stirling B et al. (2007) Sexual risk factors for
4. Describe the current state of knowledge and HIV infection in early and advanced HIV epidemics in
international recommendations regarding sub-Saharan Africa: systematic overview of 68 epidemio-
logical studies. PLoS, 2(10), e1001, http://www.pub-
breastfeeding and prevention of mother-to-child medcentral.nih.gov/picrender.fcgi?artid=
transmission of HIV/AIDS. 1994584andblobtype=pdf, cited 11 August 2008
5. Summarize the impact of HIV/AIDS on Collazos JA, Asensi VB, Carton JAB et al. (2007) Sex differ-
ences in the clinical, immunological and virological para-
a. children’s health and well-being meters of HIV-infected patients treated with HAART.
b. the family AIDS, 21(7), 835–843
Coovadia HM, Rollins NC, Bland RM et al. (2007) Mother-
c. the community to-child transmission of HIV-1 infection during exclusive
breastfeeding in the first 6 months of life: an intervention
cohort study. Lancet, 369(9567), 1107–1116
Coovadia HM, Schaller JG (2008) HIV/AIDS in children: a
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Chapter 16
Malnutrition and Maternal and Child Health
Olaf Müller and Albrecht Jahn
Learning Objectives After reading this chapter and Box 16.1 presents a glossary of terms that were
answering the questions that follow, you should be frequently in this chapter. The nutritional status of
able to women and children is particularly important
because of its far-reaching effects on overall popu-
Identify the various manifestations of undernu-
lation health and economic development. As an
trition (hunger, undernourishment, stunting,
example (Blössner and de Onis 2005), a malnour-
wasting, underweight, protein-energy malnutri-
ished mother is likely to give birth to a low-birth-
tion, and micronutrient deficiency) and describe
weight (LBW) baby who is susceptible to disease
their management and control.
and premature death. This undermines the eco-
Identify the global magnitude of obesity among
nomic development of the family and society and
women and children.
continues the cycle of poverty and malnutrition
Identify and discuss the various biological, envir-
(Fig. 16.1).
onmental, sociocultural, and behavioral factors
Maternal and child undernutrition remains a
that underlie malnutrition (overnutrition and
globally dominant public health challenge, and is a
undernutrition) among women and children.
particular problem in the impoverished commu-
Appraise the evidence base of interventions to
nities of developing countries (Caulfield et al.
prevent malnutrition among women and chil-
2006). Southern Asia and sub-Saharan Africa
dren and assess the feasibility of achieving the
(SSA) are the geographic regions with the highest
Millennium Development Goal target of redu-
prevalence of malnutrition from undernutrition.
cing by half of 1990 figures, the proportion of
Diets in these populations are frequently deficient
people who suffer from hunger.
in macronutrients (protein, carbohydrate, and fat)
and/or micronutrients (electrolytes, minerals, and
vitamins) which can lead to protein-energy malnu-
trition (PEM) and specific micronutrient deficien-
Introduction
cies (MND), respectively. Industrialized countries
and urbanized areas of developing countries have
Malnutrition represents an imbalance between the
the highest prevalences of malnutrition in the form
nutrients the body needs and the nutrients it
of overweight or obesity, since energy-dense foods
receives. It, therefore, includes undernutrition
that lack micronutrients are common and
(inadequate intake of calories and/or nutrients)
inexpensive.
and overnutrition (consumption of too many cal-
PEM and MND significantly overlap, and the
ories or too much of any specific nutrient – protein,
lack of one micronutrient is typically associated
fat, vitamin, mineral, or other dietary supplement).
with other MNDs. PEM occurs in an estimated 1
billion people worldwide and MNDs affect at least 2
O. Müller (*)
billion people. The most important MNDs are defi-
Department of Tropical Hygiene and Public Health, Medical
Faculty, Ruprecht-Karls-University of Heidelberg, ciencies in iron, iodine, vitamin A, and zinc. The
Germany prevalence of vitamin C, D, and B deficiency has
288 O. Müller and A. Jahn
Hunger: the body’s way of signaling that it is running short of food and needs to eat something.
Malnutrition can lead to hunger and may be present in individuals who are normal or overweight
because of micronutrient deficiencies (‘‘hidden hunger’’).
Malnutrition: a state in which the physical function of an individual is impaired to the point where
he or she can no longer maintain natural bodily capacities such as growth, pregnancy, lactation,
learning, physical work, disease resistance, and/or recovery from disease. The term covers a range of
problems from being dangerously thin (see underweight) or too short for one’s age (see stunting) to
being deficient in vitamins and minerals (see micronutrient deficiency) or being too fat (see obesity).
Malnutrition is measured not by the quantity of food consumed but by age and physical measure-
ments of the body, such as weight and/or height.
Undernourishment: describes the status of people whose food intake does not include enough
calories (energy) and micronutrients (essential vitamins, minerals, and electrolytes) to meet minimum
physiological needs. The term is a measure of a country’s ability to gain access to food and is normally
derived from Food Balance Sheets prepared by the UN Food and Agriculture Organization (FAO).
Stunting: reflects shortness-for-age; an indicator of chronic malnutrition and calculated by com-
paring the height-for-age of a child with a reference population of well-nourished and healthy
children.
Wasting: reflects a recent and severe process that has led to substantial weight loss, usually
associated with starvation and/or disease; calculated by comparing weight-for-height of a child
with a reference population of well-nourished and healthy children; often used to assess the severity
of emergencies because it is strongly related to mortality.
Underweight: measured by comparing the weight-for-age of a child with a reference population of
well-nourished and healthy children.
Protein-energy malnutrition: occurs when food intake does not include enough calories from
macronutrients (protein, carbohydrate, and fat).
Micronutrient deficiency: occurs when food intake does not include the right type or amount of
micronutrients.
Overweight/Obesity: measured by comparing weight-for-height by age, or body mass index (BMI)
for age (WHO 2008a), reflects over-consumption of some macronutrients (protein, carbohydrate, or fat).
declined greatly in recent decades (Müller and Kra- and mortality (Fig. 16.2). Malnutrition remains
winkel 2005). The prevalence of overweight and the most important risk factor for the burden of
obesity is increasing across the world (Wang and diseases globally (Lopez et al. 2006). It is the direct
Lobstein 2006). In particular, countries undergoing cause of about 300,000 deaths per year and is
transition to developed economies are beginning to indirectly responsible for about half of the roughly
see a rise in the prevalence of overweight and obesity 11 million deaths per year in young children
(Wang and Lobstein 2006). These countries will (Lopez et al. 2006). Malnutrition also contributes
bear a double burden of disease from malnutrition significantly to the roughly half a million women
– both under- and overnutrition. who die during pregnancy or childbirth annually
The high prevalence of infectious diseases is a (Freedman et al. 2005). The risk for morbidity and
major determinant for the burden of malnutrition mortality is directly correlated with the degree of
from undernutrition in developing countries (Rice malnutrition. However, most of the morbidity and
et al. 2000). By interfering with the immunological mortality burden is associated with low to moder-
capacity to defend against infectious diseases, mal- ate malnutrition, which has important implica-
nutrition is a major underlying cause of morbidity tions for control strategies (Caulfield et al. 2006).
16 Malnutrition and Maternal and Child Health 289
Fig. 16.1 The cycle of Income Poverty

poverty and malnutrition.
Source: Bhagwati et al.
(2004) Low food Frequent Hard Frequent Large
intake infections Physical pregnancies families
Labor
Malnutrition
Direct loss in Indirect loss in Loss in resources

productivity from productivity from from increased
poor physical poor cognitive health care costs of
status development and ill health
schooling
not addressed concurrently. Both better health

and better nutrition are required for child survival
and development (Mason et al. 2006).
While infectious diseases are a main contributor
to the burden of undernutrition in developing coun-
tries, chronic diseases associated with overnutrition
are also on the rise. The United Nations has esti-
mated that by 2015, non-communicable diseases
associated with overnutrition will surpass undernu-
trition as the leading causes of death in low-income
countries (Tanumihardjo et al. 2007). Developing
countries will be faced with the challenge of mana-
ging and controlling both infectious and chronic dis-
eases simultaneously.
Poverty is the main underlying cause of under-
Fig. 16.2 Leading causes of death in children under 5 years nutrition (Fig. 16.3). Women of reproductive age
in developing countries and the contribution of undernutri-
tion. Source: World Health Report (WHO 2003); Caulfield
and children are the populations most affected by
et al. (2004) malnutrition due to biological and socioeconomic
factors. Malnutrition further exacerbates poverty
through increased costs of health services, reduced
The disability-adjusted life years (DALY) lost working capacities, impaired school performances,
attributed to diseases in under five children, in and probable long-term effects on the prevalence
addition to maternal and perinatal conditions, and severity of chronic diseases during adulthood
nutrition deficiencies, and endocrine disorders, (Caulfield et al. 2006). Poverty in low-income coun-
amount to 42% of the global disease burden tries is less likely to be associated with obesity, as it is
(Mason et al. 2006). Thus, programs covering mainly the wealthy individuals in these countries that
aspects of women and children’s health and nutri- have access to refined foods and live sedentary life-
tion address a substantial proportion of global styles. However, obesity in high-income countries is
health problems. The interaction of health and highest in impoverished populations because of
nutrition is evident in the experiences of a number economic factors that favor high energy intake and
of large-scale community-based programs in Asia. low micronutrient intake (Tanumihardjo et al. 2007).
From these projects, it was concluded that health The degree and distribution of PEM and MND in
interventions are less effective when nutrition is a given population depends on a number of direct
Fig. 16.3 Determinants of Malnutrition

malnutrition. Source: Müller Marasmus, kwashiorkor,
and Krawinkel (2005) Micronutrient
deficiencies
Insufficient supply Severe or frequent

of protein, energy or infections; diarrhea
micronutrients
Insufficient household Insufficient child and Ill health, unhealthy

food security maternal care environment
Poverty
Low status and
War, natural disaster,
little education of
civil disorder
women
and indirect factors. Direct factors include breast- of age (Müller and Krawinkel 2005). The absolute
feeding habits and types and amounts of foods number of cases has not changed much over the last
eaten by an individual. Indirect factors are extremely decade. However, while there were major reductions
broad and include the political and economic situa- in the number of PEM cases in China during this
tion, the level of education and sanitation, season period, this reduction was balanced by a correspond-
and climate conditions, food production capacity, ing increase in the rest of the developing world (Mül-
cultural and religious food customs, the prevalence ler and Krawinkel 2005).
of infectious diseases, existing nutrition programs, In children, PEM is defined by comparing age-
and the availability and quality of health services and sex-specific weights and heights with the corre-
(Müller and Krawinkel 2005). Similarly, the preva- sponding weights and heights of a healthy reference
lence of overweight and obesity in a population population (Fig. 16.4). The resulting z-scores are the
depends on various individual and environmental difference between the weight or height and the
factors, such as diet, exercise, and the role of the corresponding median value in the reference popu-
built environment in supporting healthy behaviors. lation, divided by the standard deviation of the
The following sections provide an overview of the
global burden of disease related to malnutrition
among women of reproductive age and children with
particular reference to protein-energy malnutrition,
micronutrient deficiency, and obesity. For each of
these, we examine the magnitude of the problem glob-
ally, determinants, management and control.
Protein-Energy Malnutrition
Burden of Disease
Fig. 16.4 Normal distribution of child growth for the
NCHS/WHO reference population.a Source: Blössner and
Worldwide, an estimated 852 million people were de Onis (2005)
undernourished in 2000–2002, with the great majority a
The distribution of child growth is shown as a function of
(815 million) living in developing countries; roughly standard deviation (SD) range. Child prevalences are shown
150 million of this burden is in children under 5 years as percentages between the SD ranges.
reference population (Caulfield et al. 2006). A otherwise stable communities (Gross and Webb
weight below two standard deviations of normal 2006). In areas of such silent emergencies, there
weight for age is defined as underweight, a height are major differences in the degree of malnutrition
below two standard deviations of normal height for and associated childhood mortality even between
age is defined as stunting, and a weight below two neighboring villages (Müller and Becher 2006).
standard deviations of normal weight for height is Besides an insufficient supply of macronutrients,
defined as wasting. While wasting indicates recent severe and chronic infectious diseases constitute the
weight loss, stunting is usually the product of major cause for PEM development. Figure 16.5
chronic weight loss and the term underweight illustrates the relationship between malnutrition
encompasses both stunting and wasting. Globally, and infection.
information on prevalence of underweight is much In particular, diarrhea, but also, other bacterial
more available than on stunting and wasting. How- (e.g., pneumonia, septicemia), viral (e.g., measles),
ever, there is good correlation between stunting and and parasitic (e.g., malaria, helminth infections),
underweight. diseases are responsible. Decreased food intake
Of all children under the age of 5 years in devel- resulting from anorexia, impaired nutrient absorp-
oping countries, about 31% are underweight, 38% tion, increased metabolic requirements, and asso-
are stunted, and 9% are wasted, with the highest ciated nutrient losses are the directly underlying
prevalences in Asia and sub-Saharan Africa (Müller mechanisms (Müller and Krawinkel 2005).
and Krawinkel 2005) (Table 16.1). However, mal- In children, PEM usually manifests between 6
nutrition is not mainly a problem of politically months and 2 years of age and is associated with
unstable areas and it is not mainly associated with early weaning, inappropriate introduction of com-
acute disaster. More often it is a silent emergency in plementary food, low-protein diet, and severe or
frequent infection. Complementary feeding is the
process of introducing other foods and liquids into
Table 16.1 Prevalence of PEM in under 5-year-old children
in 1995 for UN regions the diet when breast milk alone is no longer suffi-
Stunting Underweight Wasting cient (Caulfield et al. 2006). Major problems with
(%) (%) (%) complementary feeding are as follows: complemen-
Africa 39 28 8 tary food is introduced too early or too late (ideal
Asia 41 35 10 timing is around 6 months of age); foods are served
Latin America 18 10 3
too infrequently, in insufficient amounts, or their
and
Caribbean consistency or energy density is inappropriate; the
Oceania 31 23 5 micronutrient content of foods is inadequate or
Source: FAO (2004) other factors in the diet impair the absorption of
Decreased
dietary intake Impaired
Infection immune
Mal- function
absorption
Catabolism, Impaired
nutrient barrier
disposal protection
Malnutrition
Nutrient
sequestration
Fig. 16.5 Interdependence
of infection and nutrition.
Source: Adapted from
Brown (2003)
foods; and microbial contamination occurs (Caul- to infections, and mechanical delivery complica-
field et al. 2006). tions in cases of stunting.
Severe malnutrition consists of wasting and/or The best documented and studied adverse out-
edema and is prevalent almost exclusively in chil- come of maternal malnutrition is intrauterine
dren. Marasmus, one of the three principal types of growth retardation, resulting in low birthweight
protein-energy malnutrition, is severe wasting, mar- and ultimately in increased perinatal and neonatal
asmic kwashiorkor is severe wasting in the presence mortality rates. According to a recent WHO report,
of edema, and kwashiorkor is edema (Müller and women with a BMI below 20 have a 1.8 higher risk
Krawinkel 2005). The word ‘‘kwashiorkor’’ origi- of low birthweight. Using the example of Nepal, it
nates from the Ga language in Ghana and implies was estimated that 12.3% of all neonatal deaths are
the ‘‘disease that the young child developed when attributable to maternal malnutrition (Blössner and
displaced from his mother by another child or preg- de Onis 2005). Low-birthweight rates are conse-
nancy.’’ Early marasmus occurs in infancy and is quently regarded as the best proxy for maternal
frequently associated with contaminated bottle malnutrition in international health statistics. The
feeding (leading to illness) in urban areas (Müller overall pattern is similar to childhood malnutrition
and Krawinkel 2005). with the highest rates observed in Asia, followed by
In women of reproductive age, PEM is defined as Africa (Table 16.2).
a body mass index (BMI) below 18.5–20, according The negative health effects of maternal malnutri-
to different sources. In SSA a BMI below 18.5 can tion in children continue after birth as intrauterine
be found in 10–20% of women, with higher rates growth retardation contributes to stunting, which
during acute famine; an even higher prevalence is predisposes girls to delivery complications later in
observed in some South Asian countries, such as life, and finally affects the next generation
Bangladesh, with up to 40% of women being (Fig. 16.6).
affected (Begum and Sen 2005). Assessing the con- Furthermore, there is ample evidence that a
sequences of maternal malnutrition is complicated, number of chronic diseases in adulthood such as
as the resulting ill health affects the mothers as well diabetes and hypertension are triggered by ‘‘fetal
as their children. Mothers are directly affected by a malnutrition’’ through fetal programming (Caul-
higher risk of maternal death and morbidity due to field et al. 2006). Maternal and child malnutrition
maternal depletion, anemia, increased susceptibility often go hand in hand, as they share many of the
Table 16.2 Percentage and number of low-birthweight infants by UN regions

in 2000
Percentage
of
low- Number of
birthweight low-birthweight Number of live
infants infants (1,000s) births (1,000s)
World 15.5 20,629 132,882
Asia 18.3 14,195 77,490
- Eastern 5.9 1,203 20,537
- South-central 27.1 10,819 39,937
- Southeastern 11.6 1,360 11,743
- Western 15.4 813 5,273
Africa 14.3 4,320 30,305
Oceania 10.5 27 255
Latin America and 10.0 1,171 11,671
Caribbean
North America 7.7 343 4,479
Europe 6.4 460 7,185
Source: UNICEF and WHO (2004)
Fig. 16.6 Malnutrition Higher mortality Impaired

throughout the life cycle. Rate mental development
Source: ACC/SCN (2006) Reduced capacity to
Care for child Increased risk of adult
BABY Chronic disease
OLDER PEOPLE Low Birthweight
Malnourished Untimely/inadequate
feeding
inadequate Inadequate Inadequate Frequent infections
food, health, fetal Catch-up growth Inadequate food
and care nutrition CHILD
Stunted
Reduced mental
WOMAN PREGNANCY
capacity
Malnourished Low weight gain
ADOLESCENT Inadequate food,
Stunted health, and care
Higher maternal Inadequate food,
mortality Health, and care Reduced physical
Capacity and fat-free mass
same socioeconomic risk factors such as poverty and sodium intake in the first phase when emergency
and illiteracy (Müller and Krawinkel 2005). This is measures take care of the risk of hypoglycemia,
well illustrated in a study in Bangladesh (Begum hypothermia, and dehydration. Oral, enteral, and
and Sen 2005), where maternal as well as child mal- parenteral volume load needs to be checked carefully
nutrition was closely linked to the poverty level in order to avoid the imminent heart failure. Finally,
(Table 16.3). it is recommended to always treat the severely mal-
Table 16.3 Mother’s and child’s nutritional status by household poverty level in Bangladesh
Mother’s average BMI Percentage of malnourished children(< 2SD)
Poverty level BMI Below 18.5 Below 16 Underweight Wasted Stunted
Extreme poor 18.7 52.9 9.1 59.2 12.8 54.8
Moderate poor 19.1 45.9 5.9 49.8 10.6 46.7
Middle non-poor 20.0 35.3 4.5 40.9 10.0 39.5
Top non-poor 21.0 27.6 2.4 34.8 7.8 28.9
Source: Begum and Sen (2005)
Management and Control nourished child with an effective broad-acting anti-

biotic – even when that child does not manifest the
Compared to marasmus, kwashiorkor and marasmic symptoms of an infection (Müller and Krawinkel
kwashiorkor consistently have a much higher case 2005). Management strategies for severe PEM have
fatality rate. The high mortality indicates the need been changed in recent years to community-based
for a systematic approach to the severely malnour- therapeutic care which has substantially increased
ished patient. In addition to an appropriate diet, a coverage and reduced mortality (Collins et al. 2006).
complex management scheme is mandatory to While previous efforts to combat PEM were to a
reduce mortality (Müller and Krawinkel 2005). large degree focused on identifying and treating
Essential steps are the reduction of volume, protein, severely malnourished patients, recent efforts
emphasize prevention through combined nutritional supplemental food as an incentive to participate in

and disease interventions (Caulfield et al. 2006). Pre- other interventions. Such an approach has been
ventive interventions to improve dietary intake range used for example in the Integrated Child Develop-
from income generation to nutritional education, to ment Service Program of India. It has been esti-
food prize subsidies and food supplementation (Mül- mated that such programs have the potential to
ler and Krawinkel 2005). To address infectious dis- reduce PEM by 2.0–2.5% per year (Caulfield et al.
eases as a cause of PEM, promotion of breastfeeding, 2006). However, few programs have used a compre-
improved water supply and sanitation, and hygiene hensive approach toward optimizing feeding prac-
education as well as functioning health services are tices, and proper evaluation of such interventions is
all of major importance (Caulfield et al. 2006). lacking.
With regard to breastfeeding, a consensus has High immunization coverage and early and cor-
been reached that 6 months is the recommended rect management of infectious diseases play a major
duration of exclusive breastfeeding and that the role in the prevention and treatment of PEM (Caul-
decision about the total duration of breastfeeding field et al. 2006). In children of poor communities,
should be left to the mother (Caulfield et al. 2006). treatment of helminth infections three times per
Promotion of exclusive breastfeeding is particularly year had a positive effect on child growth and devel-
effective through lay support and it has been esti- opment (Nemer et al. 2001). PEM and diarrhea
mated that such programs would reduce under-five regularly interact in a vicious cycle, but control of
mortality by 13% (Caulfield et al. 2006). diarrhea depends not only on the medical sector.
Community-based programs targeted at improv- Hand-washing interventions can reduce the risk of
ing complementary feeding have mostly achieved diarrhea by about 45% and are considered cost-
good coverage and it has been estimated that they effective (Caulfield et al. 2006).
have the potential to reduce under-five mortality by Growth monitoring has been regarded as a
6% in developing countries (Mason et al. 2006). potentially important instrument in child health
Usually interventions require a combination of clinics. However, there is often a lack of appropriate
community-based and facility-based activities, follow-up action, which may explain why a review
with sufficient support from regional and/or central by Garner et al. (2000) found no evidence of its
levels. For comprehensive nutrition programs in effects on child health. It is recognized that mes-
poor countries it has been estimated that an amount sages for correct nutrition are largely universal and
of US $5–10 per child would be the minimum and that growth monitoring is not the only model for
US $10–20 would be advisable for reducing under- service delivery (Caulfield et al. 2006). In its multi-
weight prevalence by around 1–2% per year faceted horizontal approach, the WHO-supported
(Mason et al. 2006). As both coverage and intensity Integrated Management of Childhood Illness
are the main determinants for effectiveness, under- (IMCI) initiative also addresses malnutrition
funded programs often fail to achieve targets. With (Chapter 27). This intervention has recently been
regard to staff requirements, an effective staff-to- shown to be effective (Müller and Krawinkel 2005).
population ratio appears to be 1:500 for full-time Unlike in child health, most current Safe
employed community workers and 1:10 or 1:20 for Motherhood programs do not include components
part-time volunteer community workers. For its which specifically target maternal PEM. However,
successful program, Thailand trained 600,000 there is a range of relevant activities implemented as
volunteer village workers (1% of the population) part of antenatal care programs, the most impor-
who operated at about 1:20 for part-time work tant being the promotion of adequate and balanced
with similar supervision ratios (Mason et al. 2006). diet through health education in antenatal classes.
Motivation is key to success, with supportive super- These include information about the specific nutri-
vision, status considerations, and small financial or tional requirements during pregnancy and lactation
in-kind remunerations all having a role. and options to cover these using locally available
Except in very poor populations, supplementary and acceptable types of food. Harmful traditional
feeding is not considered cost-effective (Mason et al. restrictions to pregnant women’s diets – if existing
2006). However, child survival programs have used and relevant – may also be addressed in a culturally
acceptable way, where these may play a major role. Iron deficiency affects around 50% of all preg-
Weight monitoring during pregnancy will identify nancies worldwide, with a wide regional variation.
women with inadequate weight gain (< 1 kg/month In Africa, prevalence ranges from 2% in a local
in the second and third trimesters) who should be survey in Egypt to 73% in Wad Medani, Sudan;
counseled and followed up on an individual basis as national data for Mozambique indicate a preva-
part of antenatal care. The presumptive treatment lence of 48%. In Asia, estimates range from 5% in
of malaria and helminth infections, recommended Tehran, Iran, to 94% in low socioeconomic-level
as a routine intervention in antenatal care in ende- pregnant women in Coimbatore, India. South
mic countries by WHO, contributes to improving American data range from 4% in Santiago, Chile,
the nutritional status of pregnant women even if this to 65% in Lima, Peru (González-Cossı́o 2006).
is not the primary objective of these interventions. According to the World Health Report 2002,
Direct food supplementation is not considered an about one-fifth of perinatal mortality and one-
effective approach because its cost-effectiveness is tenth of maternal mortality in developing countries
questionable, it would not reach women preconcep- are attributable to iron deficiency. Correspond-
tionally or in early pregnancy, and it would pose ingly, there is a high prevalence of anemia in preg-
logistical problems (Huffman et al. 2001). However, nancy (hemoglobin below 11 g/dL) in these coun-
it may have to be considered in situations of acute tries, with a reported prevalence of 35–75%. At
natural or man-made disaster, e.g., in refugee com- least half of all anemia cases in pregnancy have
munities. Given the obvious link between PEMs, been attributed to iron deficiency (Walraven 2006).
poverty, and female education, long-term strategies Folic acid deficiency is also associated with ane-
to reduce maternal malnutrition will have to focus mia. Folic acid is critically important for fetal devel-
on broader issues (Table 16.3). opment as it is an essential cofactor in the nucleotide
biosynthesis. Its deficiency constitutes a well-estab-
lished risk factor for neural tube defects and poten-
tially other malformations; periconceptual folic
acid supplementation reduces the prevalence of
Micronutrient Deficiencies neural tube defects by 70% (Fikree and Fariyal
2006).
Burden of Disease The term iodine deficiency disorders (IDD) has
replaced the terms endemic goiter and cretinism.
Micronutrient deficiencies (MNDs) that are of par- IDD occurs mainly in inland areas far from the
ticular global concern are iron, folic acid, iodine, sea and is highly prevalent in many developing
vitamin A, and zinc. Iron is an essential part of countries. Pregnant women and young children
hemoglobin, myoglobin, and different enzymes. Its are the main risk groups. Lack of iodine leads to
deficiency mainly leads to anemia but may also have reduced production of thyroid hormone and stimu-
a number of other adverse effects (Caulfield et al. lation of thyroid-stimulating hormone (TSH) pro-
2006). About 1 billion people suffer globally from duction. It is estimated that globally about 740
iron deficiency anemia, mainly young children and million people are iodine deficient, up to 300 million
pregnant women in developing countries. Iron defi- have goiter, and 20 million are brain damaged due
ciency is usually caused by a low intake due to poor to the effects of maternal iodine deficiency on fetal
diet, chronic iron loss due to parasitic infections development (Müller and Krawinkel 2005). Iodine
(e.g., hookworm, schistosomiasis, whipworm), or deficiency is considered a public health problem if
elevated iron needs (e.g., during pregnancy and goiter is detected in more than 5% of the school-
early childhood) (Zimmermann and Hurrell 2007). aged population (Caulfield et al. 2006).
Diet is the most important determinant, with bioa- Vitamin A deficiency disorders (VADD) are
vailability (the extent to which the nutrients can be again mainly a problem in children and pregnant
used by the body) being considered as important as women. It is estimated that 250 million children are
iron content. Iron exists in plant foods, but it is affected by vitamin A deficiency worldwide, mainly
more plentiful and bioavailable in meat. in developing countries (Caulfield et al. 2006).
VADDs are associated with significantly increased peanut butter), which contain multiple micronutri-
morbidity and mortality in children and pregnant ents to be mixed with food. A principle limitation of
women. Vitamin A deficiency contributes to anemia all these interventions except dietary diversification
development and is essential for eye and immune is the orientation on single nutrients, leaving plant
system functioning. VADD are the most common ingredients (e.g., phytosterols and fiber) outside the
causes of blindness in children, leading to xer- scope despite their role for the prevention of cancer
ophthalmia in 3 million and consequent blindness and cardiovascular diseases.
in 300,000 preschool children each year. While diar- Micronutrient supplementation is usually pro-
rhea morbidity and mortality has clearly been vided through the existing health services and with
shown to be associated with vitamin A deficiency, priority to vulnerable populations such as pregnant
the evidence for associations with acute lower- women and children (Müller and Krawinkel 2005).
respiratory-tract infections (ARI) and malaria is While some micronutrients have to be taken daily or
much weaker (Müller and Krawinkel 2005). weekly (e.g., iron and zinc), others can be stored in
The global burden of zinc deficiency has only the body and have only to be given in intervals of
recently become fully recognized (Caulfield et al. months to years (e.g., vitamin A and iodine). How-
2006). Zinc deficiency is frequent in developing ever, delivery, compliance, and potential toxicity
countries, affecting up to 2 billion people. Zinc need to be considered. For iron deficiency in child-
deficiency interferes with a number of biological hood, iron-fortified weaning foods and low-dose
functions such as gene expression, protein synthesis, iron supplements are advocated by WHO and UNI-
skeletal growth, gonad development, appetite, and CEF (Caulfield et al. 2006; Zimmermann and Hur-
immunity. Zinc deficiency has consequently been rell 2007). Iron supplementation is associated with
demonstrated to be a major determinant for diar- significantly reduced anemia incidence rates and
rhea and pneumonia, but there is conflicting evi- reversal of developmental delays in preschool chil-
dence regarding its role in malaria and growth retar- dren of poor countries. However, despite the recom-
dation (Müller and Krawinkel 2005). It has mendations of iron supplementation for pregnant
furthermore been associated with complications in women and young children being in place for dec-
pregnancy and childbirth, lower birthweight, and ades, progress in anemia control has been slow. The
increased infectious disease morbidity and mortal- main reasons for this are lack of political commit-
ity. Meat is a good source of zinc, while fiber and ment and problems with prolonged adherence to
phytates inhibit the absorption. Thus, populations daily supplementation. Moreover, there remains a
living on plant-based diets are at a high risk for controversial discussion on the risk–benefit ratio of
deficiency. providing iron supplementation to young children
living in malaria endemic regions (Sazawal et al.
2006).
Increasing zinc intake is a complex task (Caul-
Management and Control field et al. 2006). Possible interventions are supple-
mentation, fortification, and dietary diversification.
The provision of micronutrients through food with Currently, the WHO recommends zinc only for the
a high content of absorbable micronutrients is con- treatment of diarrhea and severe malnutrition.
sidered the best way for preventing micronutrient However, there is strong evidence that zinc supple-
deficiencies. In communities where an adequate mentation is highly effective in the prevention of
intake of micronutrients is not possible, specific diarrhea and pneumonia. Practicable models for
preventive and curative micronutrient interventions zinc supplementation programs still have to be
are needed (Müller and Krawinkel 2005). There is a developed.
growing consensus on the importance of multiple Vitamin A supplementation can be curative or
micronutrient interventions in populations with a preventive. It has been shown to reduce blindness
high prevalence of malnutrition (Müller and Kra- and infectious disease morbidity and mortality,
winkel 2005). A special kind of intervention is the and this intervention is now widely implemented
provision of ‘‘sprinkles’’ and fat-based spreads (like (Caulfield et al. 2006). Supplementation has been
associated with a 20–30% reduction in all-cause However, the achieved concentrations of micronu-
mortality in young children. Vitamin A capsules trients in these crops are very low. For vitamin A, it
providing 200,000 international units have at least is unknown whether or not ß-carotin from the
90% prophylactic efficacy for 4–6 months against ‘‘golden rice’’ is bioavailable and how much rice
xerophthalmia. High-dose oral supplementation is needs to be consumed to cover the needs; for iron
recommended every 4–6 months for children under the concentrations in bioengineered rice are not
5 years in areas of vitamin A deficiency. Vitamin A higher than in natural varieties, e.g., basmati or
supplements are frequently delivered through jasmine rice.
immunization programs, but the safety and efficacy Micronutrient supplementation for pregnant and
of supplementation during pregnancy and early lactating women is part of almost all antenatal care
infancy continues to be discussed controversially. programs, including the supplementation of iron and
Vitamin A deficiency has also been addressed folic acid, which is recommended by WHO. Beyond
through food fortification programs in South that, various combinations of micronutrients have
America and Southeast Asia. been suggested for routine supplementation during
Micronutrient fortification is generally consid- pregnancy by agencies such as UNICEF and
ered superior to supplementation in the long term, national authorities. These combinations usually
as costs are lower and compliance is better. How- include iron, folate, iodine, zinc, calcium, magne-
ever, most experience with food fortification comes sium, other minerals and a range of vitamins (Huff-
from developed countries, with salt and sugar being man et al. 2001). While many of these components
the usual carriers (Caulfield et al. 2006). Until may be beneficial, evidence from randomized trials
today, only iodine fortification is globally success- currently only support the supplementation of iron,
ful. From 1990 through 1998, the number of coun- folate, and iodine, according to the evidence com-
tries with salt iodization programs has increased piled in WHO’s reproductive health library (version
from 46 to 93, and more than two-thirds of people 10). In HIV-infected mothers a multivitamin combi-
living in the 130 IDD-affected countries have access nation substantially improved perinatal outcomes
to iodized salt. In Latin America, there is some and maternal T-cell counts (Fawzi et al.
experience with iron fortification of wheat flour, 1998).Given the late attendance in antenatal care –
but fortification of sugar with vitamin A failed due most women present themselves in the second or
to high costs and potential toxicity (Caulfield et al. third trimester – and logistical problems in ensuring
2006; Zimmermann and Hurrell 2007). Fortifica- a constant supply in many developing countries, the
tion approaches are generally limited to popula- potential benefit of micronutrient supplementation is
tions with access to and availability of the fortified often lost. Thus, micronutrient supplementation
products. However, in regions of severe iodine defi- through antenatal care is not the magic bullet that
ciency, high-dose iodine supplementation is also it may seem. Finally, it is no substitute for popula-
successfully used. tion-based interventions to improve the nutritional
Diet-based strategies are probably the most pro- status at the population level and to improve
mising approach for a sustainable control of MND women’s health throughout the life cycle.
(Müller and Krawinkel 2005). Increasing dietary
diversification through consumption of a broad
variety of foods, preferably accessed through
Underlying Factors Contributing to
home gardens and small livestock production, has
been shown to be effective. Households should be
Protein-Energy Malnutrition and
informed and supported to increase production of Micronutrient Deficiencies
dark-green leafy vegetables, yellow and orange
fruits, poultry, eggs, fish, and milk. A possible Complicating the ability to procure appropriate
future strategy to prevent MND is the breeding of nutrition are interactions between underlying fac-
micronutrient-rich crops employing either a con- tors associated with micronutrient deficiencies and
ventional breeding technique or a genetic modifica- malnutrition. Contributing factors to micronutrient
tion of existing crops (Müller and Krawinkel 2005). deficiencies and malnutrition can be grouped into
three categories: individual factors, community/ based on food customs and parental education in
sociocultural factors, and physical environmental their community.
factors (Fig. 16.7). Individual factors are character- Social Cognitive Theory (SCT) holds that perso-
istics that are intrinsic to a person, including age, nal and environmental factors as well as attributes
gender, and health status. For example, having a of behavior affect a person’s behavior (Glanz et al.
diarrheal infection decreases the body’s ability to 2002). This theory has been determined to be an
absorb nutrients (Bhutta et al. 2008). Community appropriate model for food behaviors (Parraga
or sociocultural environmental factors include com- 1990). According to this theory, self-efficacy is cen-
munity practices, customs, and attitudes that affect tral to behavior change. This theory focuses on the
nutrition and feeding patterns. Physical environ- interaction of personal factors, environmental fac-
mental factors involve overarching influences that tors, and behavior. In regard to risk factors for
are beyond the community and individual levels and malnutrition, personal factors include individual
affect the availability of diverse food sources that factors and some sociocultural factors. The envir-
are safe and healthy. Both community environment onment includes community and surroundings, as
and physical environment comprise the overarching well as some sociocultural factors, influencing avail-
group of environmental factors. Individual factors ability of safe and healthy food. In this way, issues
often interact with environmental factors through such as the self-efficacy of individuals and a com-
behavior to impact nutrition. For example, a child’s munity that supports proper nutrition can play an
age and gender can determine what they eat. This is important role in countering malnutrition. Public
INDIVIDUAL FACTORS
Age
Gender
Infection & disease; diarrhea
Child Education & nutritional knowledge
DIETARY BEHAVIORS What

ENVIRONMENTAL FACTORS children eat
COMMUNITY ENVIRONMENT (SOCIO- When children eat
CULTURAL) How much children eat
Food customs Insufficient supply of
Household food security micronutrients
Child care & care-giver attitudes
Poverty
Parental Education & nutritional knowledge
Hygiene practices (handwashing, fecal
disposal, etc)
OUTCOME
PHYSICAL ENVIRONMENT
Malnutrition &
Climate
Season micronutrient
HAS EFFECT ON: deficiencies
War Availability of safe,
Disaster diverse and healthy
Political instability food sources
Sanitation
Fig. 16.7 Underlying factors contributing to malnutrition and micronutrient deficiencies. Source: Adapted from Mueller and
Krawinkel (2005); Based on SCT conceptual model (Glanz et al. 2002).
health programming aimed at improving maternal America and South America, Europe, Australia,
and child health through nutrition can use innova- and Japan. These areas have the highest levels of
tive behavioral approaches in addition to providing overweight and obesity in the world, and Southeast
nutrition and healthcare, such as appropriate edu- Asia and sub-Saharan Africa have the lowest over-
cation, identifying environmental barriers, and all prevalence, which is also reflected by respective
understanding nutritional practices on individual, levels in children (Fig. 16.8). Countries currently
family, and societal levels. experiencing economic growth (Brazil, Chile, Mex-
ico, and Egypt) have overweight prevalences near-
ing industrialized countries. It is estimated that by
2010, 46% of school-age children in the Americas
Obesity will be overweight, along with 41% in the eastern
Mediterranean region, 38% in Europe, 27% in the
Burden of Disease west Pacific, and 22% in Southeast Asia (Wang and
Lobstein 2006). Sufficient data for Africa were una-
The term malnourishment has traditionally meant vailable for prevalence projection. There is a short-
undernutrition. However, malnutrition should also age of data on the prevalence of overweight in
be used to refer to overnutrition (Tanumihardjo lower-income countries, particularly those with
et al. 2007). While overweight and obesity are often large underweight populations. The global preva-
thought of as problems of developed nations, recent lence of overweight in developing countries was
studies have found the prevalence of childhood over- thought to be 3.3% (although some countries were
weight and obesity to be increasing across the world much higher) in 1995 (de Onis and Blössner 2000).
(Wang and Lobstein 2006). These increases are parti- Out of 34 countries, trends suggest that prevalence
cularly pronounced for developed countries and urba- was decreasing in 8, stable in 14, and increasing in
nized populations, but the economic development and 16. The highest prevalences were in the Middle East,
urbanization of developing countries are correlated North Africa, and Latin America.
with overweight increases in these regions as well Transitioning developing countries are begin-
(Wang and Lobstein 2006). Both under- and over- ning to bear a double burden of disease from
nutrition can result from inadequate food supply malnutrition – both under- and overnutrition (Fig.
and other conditions of poverty. Therefore, countries 16.8). A study of Pakistani school children found
undergoing economic transition may experience pro- that over a decade there was only a slight non-sig-
blems with both under- and overnutrition concur- nificant decrease in underweight children, but an
rently (Tanumihardjo et al. 2007). Both conditions increase in overweight children from 3.0 to 5.7%
of malnutrition cannot be considered separately (Jafar et al. 2008). In a comparative study of wasting
from issues of food insecurity, disparities in socioeco- and obesity among preschool children in 94 coun-
nomic status within and between countries, unequal tries that used weight-for-height distribution, it was
global trade arrangements, and the global occurrence found that for developing countries levels of wast-
of cultural, social, and epidemiological transitions ing are generally higher than those of overweight
(Darnton-Hill and Coyne 1997; Anonymous 2008). (de Onis and Blössner 2000). In Africa and Asia
Comparing data across countries is often diffi- they may be 2.5–3.5 times higher. The overall pre-
cult because of differing measurements and defini- valence of overweight in developing countries was
tions of overweight and obesity. Also, criteria for found to be 3.3%, compared with the overall pre-
classification vary. The global prevalence of over- valence of wasting of 9.4%. Levels of wasting and
nutrition is increasing, with few exceptions. Wang overweight varied by country, with wasting ranging
and Lobstein (2006) found that this increase occurs from 0 to 23.3% and overweight from 1 to 14.4%.
at the fastest rate in developed countries and urba- Forty-five percent of developing countries had
nized areas, but also occurs in transitional and low- more overweight than wasting, 48% had more wast-
income countries. ing than overweight, and three countries (Uzbeki-
From the 1970s to the 1990s the prevalence of stan, Kiribati, and Algeria) had similarly high levels
obesity has doubled or tripled in countries in North of overweight and wasting. However, while 45
Fig. 16.8 Weight-for-height distribution among preschool children in 94 countries. Source: de Onis and Blössner (2000)
countries have wasting >5%, and 18 have wasting > high stunting levels. This prevalence is generally
10%, only 21 countries have overweight > 5%, and greatest in rural areas.
merely 2 have overweight > 10%. This suggests that The divide between urban and rural populations
wasting is still a much more significant health con- is also evident. One in 8 children in urban China was
cern than overweight for most developing countries, overweight in 1997, and this is projected to be 1/5 in
despite recent increases in the prevalence of 2010, compared with a projected rural rate of only
overweight. 1/14 (Wang and Lobstein 2006). However, Mendez
The double burden is evident in the occurrence of et al. (2005) examined the association of adult
under- and overnutrition within the same house- female overweight with urban/rural distribution
hold. Garrett and Ruel (2005) investigated the pre- and level of income in 36 developing countries
valence of a stunted child and overweight mother in (Fig. 16.9).
the same household. In low- and middle-income They found that while increasing country income
countries, this prevalence is generally below 10%. and urbanization was associated with a higher pre-
It occurs most frequently in Latin America, fol- valence of overweight in general, it also narrowed
lowed by Africa and then Asia (less than 5%). Over- the gap between urban and rural overweight.
weight mothers are common in many developing Among women of low socioeconomic status in
countries. In Latin America, country rates of over- higher-income developing countries, overweight
weight among mothers ranged from approximately remained high for both urban (51%) and rural
30–50%, except in Haiti (12%). In Africa, the range (38%) women. Lower and middle-income countries
was from 4% in Madagascar to 55% in Egypt. are undergoing transition from under- to overnutri-
Former Soviet Union countries had rates of tion, and having the burden of both. In countries
15%, significantly more than the 4% in Bangla- with high prevalence of low birthweight there is a
desh and 2% in Nepal. The prevalence of over- greater risk of stunting and, in turn, later availabil-
weight is greater in urban areas than rural areas ity of food may lead to an increase in body weight
(except in Kazakhstan). Child stunting is common but not height proportionately (Wang and Lobstein
even in countries with a high prevalence of over- 2006). Countries with stunting >50% may have
weight mothers, although the prevalence of stunting many children at risk for this and subsequent
is more common in rural rather than urban areas. chronic diseases (Wang and Lobstein 2006). This
The prevalence of households with a stunted child could also explain the occurrence of overweight
and overweight mother exceeds 10% in Bolivia, mothers with stunted children, as the mothers them-
Guatemala, Peru, and Egypt. High prevalence selves may have been stunted as children leading to
occurs when there are both high overweight and a greater risk for obesity (Garrett and Ruel 2005).
Fig. 16.9 Prevalence of overweight (BMI 25) in women aged 20–49 in 36 developing countries by gross national income
(GNI) and level of urbanization. Source: Mendez et al. (2005)
Risk for overweight also depends on the eco- origin, with nearly 50% of black women having a
nomic state of a country and on the socioeconomic BMI greater than 30. However, the prevalence of
status of an individual within that country. In gen- obesity correlates with the prevalence of poverty
eral, risk for overweight increases as a country’s among race/ethnicities, such that race/ethnicities
economy improves. Reversal in economic develop- with the greatest poverty levels also have the highest
ment can lead to a decline in overweight (Russia, levels of obesity.
Poland, Cuba), and recovery can lead to a rapid They also found that obesity is associated with a
increase in obesity (Croatia and East Germany) lack of family resources and food insufficiency. Food
(Wang and Lobstein 2006; Franco et al. 2008). insecurity is the lack of access to safe and healthy
Within countries, overweight is more prevalent in food at a level sufficient for well-being. Food inse-
socially disadvantaged individuals in high-income curity may lead to overweight when the limited foods
countries, while advantaged individuals are more at available have sufficient or excess energy density, but
risk in low-income countries (Friel et al. 2007). fail to meet the body’s micronutrient requirements
Wealthy individuals in poor countries are those (potentially leaving the consumer still hungry). These
who can afford energy-dense, nutritious foods. types of food are often cheaper than fruits, vegeta-
They are also able to lead more sedentary lives. bles, and whole grains. Households classified as hav-
These are two contributors to overweight. In rich ing food insecurity actually have the highest BMI
countries, risk to the poor may be explained by and prevalence of obesity.
healthier foods being more expensive than less A person’s physical environment affects his or
healthy foods, with all economic factors favoring her ability to maintain a healthy weight. Friel et al.
high energy intake and low micronutrient intake, (2007) found that inequities that lead to food inse-
characteristics that lead to weight gain and obesity curity are likely to correlate with lower access to
(Tanumihardjo et al. 2007). Low-income groups are material and psychosocial support for healthy
also affected by constraints on their ability to travel behaviors and constraints on work availability
to buy food, lack of healthy options in their immedi- and flexibility. Community design influences an
ate vicinity, and constraints on leading an active life individual’s ability to walk to get to places, have
(Friel et al. 2007). spaces for recreation, and have the convenience of
Tanumihardjo et al. (2007) found that across the reliance on cars. Sedentary work, disinclination to
world, living in poverty is a better predictor of over- active transport, and easy access to high-energy
weight and obesity than race or ethnicity. The rela- food all underlie risk for overweight. Friel et al.
tionship between obesity and poverty is shown in (2007) also found that globally, there is an increas-
Fig. 16.10. In the United States for example, adult ing prevalence of refined foods, high-saturated fat
obesity is most prevalent in citizens of African foods, and reductions in energy expenditure.
Increased trade between countries and changes in
the food industry has saturated the market with
foods that are cheap, high-energy, and low in nutri-
Poverty
ents. Bulk purchases, convenient food, and over-
Food sized proportions are becoming readily available,
Hunger and advertising often focuses on increasing the
Insecurity
desirability of unhealthy food. These findings are
complemented by Garrett and Ruel (2005) who
Undernutrition Overnutrition found that increases in economic development
and urbanization lead to the consumption of pro-
cessed foods with more sugar, salt, and fat, and
Nutrient Hidden increasingly sedentary jobs and use of labor-saving
Obesity
deficiencies hunger technologies.
Obesity increases risk for a number of chronic
Fig. 16.10 Obesity and poverty. Source: Tanumihardjo et al. diseases, including diabetes and heart disease (Garrett
(2007) and Ruel 2005). In the United States, obesity is the
second leading cause of death after smoking, with its the certainty of conclusions. Efforts to manage and
direct and indirect costs amounting to US $117 billion control the growing obesity epidemic need to
in 2000 (Wang and Lobstein 2006). While clinically address its multiple determinants (Fig. 16.11).
significant morbidity rates related to obesity are rare These include an individual’s environment and
in children, childhood obesity has been shown to health behaviors.
confer risks for long-term morbidity and mortality, Special attention has been given to children and
including high blood pressure, diabetes, respiratory adolescents, as overweight and obesity at younger
disease, orthopedic problems, and psychosocial disor- ages may persist throughout life and confer greater
ders (de Onis and Blössner 2000; Yoon et al. 2006). risks for morbidity and mortality. While physical risk
Persistence into adulthood is a concern. Increasing from obesity at young ages is rare, social isolation
prevalence rates of overweight and obesity worldwide and its effects on psychosocial development are of
suggest that the burden of chronic disease is going to concern (de Onis and Blössner 2000). Additionally,
increase, even in adolescence and early adulthood persistence of childhood overweight and/or obesity
(Wang and Lobstein 2006). into adulthood is common, with a half to a third of
overweight adolescents becoming overweight adults
(Wang and Lobstein 2006). Stunted children are
particularly at risk for weight gain disproportionate
Management and Control to height increases, and early catch-up growth inter-
ventions are necessary in order to prevent this (Wang
Available reviews of interventions for overweight and Lobstein 2006). In general, eating and activity
and obesity focus on individual behavioral factors habits formed in childhood may carry to adulthood,
such as diet and exercise. They are located primarily and parents should be encouraged to model good
in industrialized countries and target adult popula- eating habits for their children (de Onis and Blössner
tions. Therefore, they have limited generalizability 2000). There is also evidence that breastfed infants
to pediatric populations and for prevention pur- self-regulate their energy intake better than formula-
poses. These studies are additionally affected by fed infants. This suggests that breastfeeding may be a
high attrition rates (many around 40%) that limit protective factor against overweight (de Onis and
Sociopoliticial, sociocultural, socioeconomic, socioenvironmental context

(natural resources; norms and values; governance; policies, regulations and
supporting systems)
Food environment Natural and Social Social

(trade agreements; build environment stratification
production; environment (financial (eg. Income;
processing; (urban design; land capacity; living education;
distribution; use; transport mode; conditions; occupation; sex;
advertising; price) public facilities; transport access; ethnicity)
market access) remoteness; social
support; social
cohesion; working
practices; eating Differential
habits; social exposure and
norms)
vulnerability
Individual level factors (food consumption; nutrient intake; energy expenditure;

Fig. 16.11 Conceptual
framework of the social
psychological factors; biological factors)
determinants of inequities in
obesity. Source: Friel et al. Inequalities in Obesity Rates
(2007)
Blössner 2000). Reducing the promotion of energy- Internationally, trade is an important issue
dense food to children is a potential strategy (Wang related to the prevalence of overweight. There is a
and Lobstein 2006). need for trade agreements that allow most people to
Prevention efforts involving diet and exercise benefit, and regulation of global food marketing to
interventions targeting children were found in prevent exploitation of vulnerable societies and
meta-analysis to be ineffective at preventing weight populations. The World Health Organization
gain, despite improvements in diet, increased exer- (WHO 2008b) has created a global strategy for
cise, and increased knowledge of healthy behaviors diet, physical activity, and health that focuses on
(Summerbell et al. 2005). The authors suggest that national food and agricultural policies. Their aim is
the lack of effect may be due to failure of the studies the development of multisectoral policies that pro-
to take into account the complexity of the problem mote public health in general, physical activity, and
and the diversity of its determinants. educational information.
Friel et al. (2007) found environmental factors Targeting the population at all levels is essential.
that affect health behaviors to be present at the Direct approaches such as changing an individual’s
local, national, and global levels. Local influences behavior, through personal skills and enhancement of
are those that directly influence an individual’s the local environment have limited sustainability and
nutritional intake and energy expenditure. Strate- transferability. Additionally, uptake is generally higher
gies for increasing healthy food intake include for groups with greater social status. This serves to
urban planning for access to nutritious food and potentially increase the disparity between socioeco-
local community food initiatives. Strategies for nomic levels. Successful actions should address
increasing energy expenditure focus on physical national and international support for the equitable
education in schools and other methods of encoura- distribution of nutritious food and local environments
ging active transport. The opportunity for exercise that lend themselves to healthy behaviors.
and reduction of car transport are important fac- Given the increasing co-occurrence of under- and
tors. In Brazil, the Agita Sao Paulo physical activity overnutrition in the same countries and households,
program (Matsudo et al. 2003) increased physical new strategies will have to be developed to address
activity in the general population using a multi- both conditions simultaneously. Most programs
strategy approach. This approach included build- that address food insecurity do not address obesity
ing, widening, and removing obstacles from paths, (Tanumihardjo et al. 2007). Garrett and Ruel (2005)
building exercise tracks with shade and water avail- found that successful strategies from Brazil, China,
able, maintaining green areas, and creating bicycle and Finland included community involvement and
storage close to public transport stations, schools, ownership, capacity-building for community orga-
and workplaces, and encouraging mass active trans- nizations, evidence-based information and counsel-
port through implementing private and public ing, inclusion of the food industry in labeling and
incentive policies. regulation, and support for physical exercise. Qual-
At the national level, support and reinforcement of ity needs to be emphasized over quantity, as well as
local initiatives is essential. For example, Norway the importance of child care and feeding, not just
reversed its shift toward high-fat, energy-dense diets household access to food.
by using food subsidies, price manipulation, retail
regulations, clear nutrition labeling, and public educa-
tion (Norwegian Nutrition Society 2004). Mauritius
was also successful with a strategy including price Conclusion
policies, agricultural policies, and widespread educa-
tional activities (United Nations 1997). Coherence is A review of interventions that show evidence of
necessary for inter-sector action at the national and effectiveness in addressing maternal and child
international levels. For example, Healthy Food For undernutrition was recently published by the
All, in Ireland (EPHA 2008), is a multi-agency, equal- Maternal and Child Undernutrition Study Group
ity-oriented program that focuses on access, afford- (Bhutta et al. 2008). According to the group, poten-
ability, and availability of food. tially viable interventions include promotion of
breastfeeding, promotion of complementary feed- literacy, and political commitment will have a sus-
ing, micronutrient interventions, and general sup- tainable effect on health and nutrition leading to
portive strategies to improve family and community overall development and improvement of living
nutrition. They also suggest a reduction of disease standards (Ehiri and Prowse 1999).
burden through promotion of hand-washing prac- Sub-Saharan Africa (SSA) is considered to be
tices and strategies to reduce the burden of malaria trapped in poverty with decreasing food production
in pregnancy (Table 16.4). per capita and consequently increasing hunger and
Only multiple and synergistic interventions poverty (Sanchez and Swaminathan 2005). Com-
embedded in true multisectoral programs will have munity-based health and nutrition programs have
sustainable impact on the reduction of malnutri- been more successful in developing countries out-
tion. This is because malnutrition has many causes side SSA. Reasons may have to do with lack of
and synergistic relationships with diarrhea, reduced community participation, lack of infrastructure
immunity, and disease (Bhutta et al. 2008). These and staff, insufficient emancipation from former
need to include large-scale agricultural and micro- colonial or existing neo-colonial repressive condi-
nutrient interventions, provision of safe drinking tions, unrestricted donor influences, and lack of
water and sanitation, education and support on political commitment (Mason et al. 2006). The
better diets, special attention to vulnerable groups first Millennium Development Goal is to eradicate
such as pregnant women and young children, and extreme poverty and hunger by 2015. The two tar-
quality health services. Nutrition education focus- gets associated with this goal are (i) to reduce by half
ing on locally available protein- and micronutrient- of 1990 figures, the proportion of people living on
rich plants should be considered as a particularly less than a dollar a day, and (ii) to reduce by half of
effective and sustainable intervention. In the long 1990 figures, the proportion of people who suffer
run, however, only a sufficient consideration of from hunger (The United Nations Millennium Pro-
contextual factors such as women’s status and edu- ject 2005). Prospects for achieving these targets vary
cation, social inclusion, community organization, by region as they are influenced by the range of
Table 16.4 Interventions that affect maternal and child undernutrition

Evidence for implementation in specific, situational
Sufficient evidence for implementation in all 36 countries contexts
Maternal and birth outcomes
Iron folate supplementation Maternal supplements of balanced energy and protein
Maternal supplements of multiple micronutrients Maternal iodine supplements
Maternal iodine through iodization of salt Maternal de-worming in pregnancy
Maternal calcium supplementation Intermittent preventive treatment for malaria
Interventions to reduce tobacco consumption or indoor air Insecticide-treated bednets
pollution
Newborn babies
Promotion of breastfeeding (individual and group counseling) Neonatal vitamin A supplementation
Delayed cord clamping
Infants and children
Promotion of breastfeeding (individual and group counseling) Conditional cash transfer programs (with nutritional
education)
Behavior change communication for improved complementary De-worming
feeding
Zinc supplementation Iron fortification and supplementation programs
Zinc in management of diarrhea Insecticide-treated bednets
Universal salt iodization
Hand-washing or hygiene interventions
Treatment of severe acute malnutrition
Source: Bhutta et al. (2008)
social, economic, and political factors already refer- hunger – measured by the proportion of people lack-
enced in this chapter. Estimates by de Onis et al. ing the food needed to meet their daily needs – has
(2004) project that the prevalence of childhood declined in the developing world. But progress overall
underweight will increase by 9% in sub-Saharan is not fast enough to reduce the number of people
Africa. In eastern Africa, it is projected to increase who go hungry, which increased between 1995–1997
by 25%. Only northern Africa is likely to reach the and 2001–2003. An estimated 824 million people in
Millennium Development Goal target for hunger the developing world were affected by chronic hunger
reduction with a forecasted reduction in the preva- in 2003 (United Nations 2006). The worst affected
lence of childhood underweight from 9.5% in 1990 regions – sub-Saharan Africa and southern Asia –
to 4.2% in 2015 (de Onis et al. 2004). Figure 16.12 have made progress in recent years although
presents the 2015 projections of the prevalence of advances have not kept pace with those of the early
underweight children for the African sub-regions 1990s. Beyond that, increases in food prices and other
compared with the Millennium Development Goal adverse macroeconomic developments threaten to
for those sub-regions. The prevalence of under- reverse the downward trend and have already
weight is projected to be reduced from 35.1 to resulted in an estimated additional 50 million people
18.5% in Asia between 1990 and 2015. Eastern going hungry in 2007 (FAO 2008; Anonymous 2008).
Asia shows the largest improvement with a pro- It is germane to note that progress toward achieve-
jected decline of 84% during the same time period. ment of the other seven MDGs would directly or
Southeastern and South Central Asia were fore- indirectly contribute to major reductions of undernu-
casted to experience substantial improvements, with trition in developing countries (Sachs and McArthur
reductions in the prevalence of underweight of 49 2005). Discouraging as the above statistics are, a
and 42%, respectively (de Onis et al. 2004). Never- review by the UN Millennium Project (2005) con-
theless, both sub-regions will have high levels of cludes that hunger can be halved by 2015 and even
childhood underweight in 2015. Western Asia was eradicated with deliberate and timely implementation
estimated to be the Asian sub-region with the lowest of seven recommended interventions (Box 16.2).
reduction in the prevalence of childhood under- The main challenge of the MDGs is the financing
weight (29%). An 8.7% decrease is projected for and the implementation of effective interventions at
Latin America and all of its regions are projected scale. Although the GAVI Alliance and the Global
to experience decreasing trends with changes of – Fund for AIDS, Tuberculosis and Malaria
72% for the Caribbean, –54% for Central America, (GFATM) have added significant funds to health
and –65% for South America (de Onis et al. 2004). programs in poor countries, funding is still below
According to the United Nation’s MDG progress the required levels. Also, sustainability is an issue
report in 2006 (United Nations 2006), chronic and additional financing instruments are only able
Fig. 16.12 Projections of

Underweight Prevalence in
African sub-regions in 2015
compared with the
Millennium Development
Goal. Source: de Onis et al.
(2004)
Box 16.2 Recommendations for Halving Hunger by 2015
1. Move from political commitment to action

Advocate political action to meet intergovernmental agreements to end hunger
Strengthen the contributions of donor countries and national governments to activities that
combat hunger
Improve public awareness of hunger issues and strengthen advocacy organizations
Strengthen developing country organizations that deal with poverty reduction and hunger
Strengthen accurate data collection, monitoring, and evaluation
2. Reform policies and create an enabling environment
Promote an integrated policy approach to hunger reduction
Restore budgetary priority to the agricultural and rural sectors
Build developing country capacity to achieve the hunger goal
Link nutritional and agricultural interventions
Increase poor people’s access to land and other productive resources
Empower women and girls
Strengthen agricultural and nutrition research
Remove internal and regional barriers to agricultural trade
Increase the effectiveness of donor agencies’ hunger-related programming
Create vibrant partnerships to ensure effective policy implementation
3. Increase the agricultural productivity of food-insecure farmers
Improve soil health
Improve and expand small-scale water management
Improve access to better seeds and other planting materials
Diversify on-farm enterprises with high-value products
Establish effective agricultural extension services
4. Improve nutrition for the chronically hungry and vulnerable
Promote mother and infant nutrition
Reduce malnutrition among children under five years of age
Reduce malnutrition among school-age children and adolescents
Reduce vitamin and mineral deficiencies
Reduce the prevalence of infectious diseases that contribute to malnutrition
5. Reduce vulnerability of the acutely hungry through productive safety nets
Build and strengthen national and local early warning systems
Build and strengthen national and local capacity to respond to emergencies
Invest in productive safety nets to protect the poorest from short-term shocks and to reduce
long-term food insecurity
6. Increase incomes and make markets work for the poor
Invest in and maintain market-related infrastructure
Develop networks of small rural input traders
Improve access to financial services for the poor and food-insecure
Provide and enforce a sound legal and regulatory framework
Strengthen the bargaining power of the rural and urban poor in labor markets
Ensure access to market information for the poor

Promote and strengthen community and farmer associations
Promote alternative sources of employment and income
7. Restore and conserve the natural resources essential for food security
Help communities and households restore or enhance natural resources
Secure local ownership, access, and management rights to forests, fisheries, and rangelands
Develop natural resource-based ‘‘green enterprises’’
Pay poor rural communities for environmental services.
Source: The UN Millennium Project (2005)
to cover some aspects of maternal, neonatal, and education, disease burden, and lack of women’s
child health (Costello and Osrin 2005). empowerment have been widely discussed in the
According to recent estimates, the total donor literature (Ehiri and Prowse 1999).
cost of supporting the global MDG financing Practical action is urgently needed to optimize
gap is around US $100 billion per year which the benefits of these known interventions. To ensure
is equivalent to the annual costs of the United progress in the reduction of undernutrition and its
States for the war in Iraq or roughly one-tenth associated consequences in less developed coun-
of the global military budget. This amount tries, it is time the plethora of evidence on effective
equals 0.5% of total donor gross national pro- interventions were translated into large-scale popu-
duct (GNP), well within the long-standing 0.7% lation-based programs. With increased funding by
commitment for development aid (Sachs and international health and development agencies,
McArthur 2005). As shown in Table 16.4 these interventions should be backed with adequate
(Bhutta et al. 2008), effective interventions for community and political support and participation.
addressing undernutrition among women and Only then can there be visible and sustained
children are already known and the underlying improvement in global maternal and child
determinants of undernutrition, poverty, poor malnutrition.
Key Terms
Malnutrition Overweight Growth monitoring

Undernutrition Obesity Safe Motherhood
Hunger Sedentary lifestyle Xerophthalmia
Underweight Anorexia Protein-energy malnutrition
Stunting Marasmus Micronutrient deficiency
Wasting Disability-adjusted life years Complementary foods
Low birthweight Millennium Development Complementary feeding
Poverty Goals Exclusive breastfeeding
Fetal malnutrition Food supplementation Body mass index (BMI)
Micronutrient fortification Food insecurity
Undernourishment Kwashiorkor
Questions for Discussion Bhutta ZA, Ahmed T, Black RE et al. (2008) What works?
Interventions for maternal and child undernutrition and
survival. Lancet 371(9610), 417–440
1. What are the consequences of maternal Blössner M and de Onis M (2005) Malnutrition: quantifying
undernutrition? the health impact at national and local levels. WHO
2. Discuss the various approaches for the man- Environmental Burden of Disease Series, No. 12. Geneva:
agement and control of protein-energy malnu- World Health Organization
Brown KH (2003) Diarrhea and malnutrition. Journal of
trition and micronutrient deficiencies, identi- Nutrition 133(1), 328S–332S
fying evidence of effectiveness of each Caulfield LE, de Onis M, Blössner M et al. (2004) Under-
approach. nutrition as an underlying cause of child deaths associated
3. Community-based health and nutrition pro- with diarrhea, pneumonia, malaria, and measles. Amer-
ican Journal of Clinical Nutrition 80, 193–198
grams have not been as effective in sub-Saharan Caulfield LE, Richard SA, Rivera JA et al. (2006) Stunting,
Africa as they have been in other developing wasting and micronutrient deficiency disorders. In: Jami-
countries. Why? son et al. (eds.) Disease Control Priorities in Developing
4. In 2005, the United Nations Millennium Project Countries. Oxford University Press and the World Bank
Collins S, Dent N, Binns P et al. (2006) Management of
proposed seven recommendations for halving severe acute malnutrition in children. Lancet 368,
world hunger by 2015 (Box 16.2). How attain- 1992–2000
able are these recommendations? Using one Costello A, Osrin D (2005) Viewpoint: the case for a new
developing country as a specific example, what Global Fund for maternal, neonatal, and child survival.
Lancet 366, 603–605
are the potential barriers against implementation Darnton-Hill I, Coyne ET (1997) Feast and famine: socio-
of these recommendations? economic disparities in global nutrition and health. Public
5. In their review of the effectiveness of interven- Health Nutrition l(1), 23–31
tions for addressing maternal and child under- de Onis M, Blössner M (2000) Prevalence and trends of over-
weight among preschool children in developing countries.
nutrition, the Maternal and Child Undernutri- American Journal of Clinical Nutrition 72, 1032–1039
tion Study Group (Bhutta et al. 2008) concluded de Onis M, Blössner M, Borghi E et al. (2004) Estimates of
that only multiple and synergistic interventions global prevalence of childhood underweight in 1990 and
embedded in true multisectoral programs will 2015. JAMA 291(21), 2600–2606
Ehiri JE, Prowse JM (1999) Child health promotion in develop-
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specific examples, discuss what they mean by social interventions? Health Policy and Planning 14(1), 1–10
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Chapter 17
The Global Burden of Obstetric Fistulas
L. Lewis Wall
Learning Objectives After reading this chapter and An obstetric fistula is an abnormal opening
answering the discussion questions that follow, you between a woman’s bladder and her vagina (some-
should be able to times between her rectum and vagina, or involving
other structures) that develops as a result of obstetric
Discuss the global burden of obstetric fistula.
injury, most commonly from prolonged obstructed
Analyze the biomedical and sociocultural causes
labor (Fig. 17.1). Although this condition was com-
of obstetric fistula, using the Worldwide Fistula
mon in the United States and Europe 150 years ago,
Fund’s pathways to the development of obstetric
advances in obstetric care have eliminated obstetric
fistula.
fistula from the collective memory of industrialized
Appraise prevention strategies for obstetric fis-
societies. However, it remains a pressing and much-
tulas as they relate to the provision of timely
neglected issue for women in impoverished, non-
obstetric services, health systems development,
industrialized countries, perhaps afflicting as many
and cultural changes.
at 3.5 million women in Africa and Asia alone (Wall
et al. 2005). To set this chapter in proper context,
operational definitions of a number of technical
Introduction terms that are used frequently are presented in
Box 17.1.
This chapter presents an overview of the global bur- Because obstetric fistulas will not heal on their
den of obstetric fistula. Using the Worldwide Fistula own (they require surgical repair) women who
Fund’s pathways to the development of obstetric develop this condition face a future of severe stig-
fistula, the biomedical and sociocultural causes of matization due to the constant incontinence of urine
the condition are analyzed, including the role of (and perhaps feces) that dominates their lives. Yet
obstructed labor, women’s low status in society, mal- most women who develop a fistula are young when
nutrition, illiteracy, limitation in access to emergency this injury occurs, sometimes only 12 or 13 years old
obstetric services, early marriage, and traditional (Holme et al. 2007; Wall 2006a; Wall et al. 2004;
harmful practices. The consequences (medical and Onolemhemhen and Ekwempu 1999).
social) of obstetric fistula as well as treatment options
and challenges are discussed. The chapter concludes
with an appraisal of short- and long-term prevention Obstructed Labor and Its Consequences
strategies as they relate to the provision of appropri-
ate and timely obstetric services, health systems
development, and cultural changes that institutiona- Humans have the most complicated obstetrical
lize gender equity from birth through the life course. mechanics of any primate species. This is due to the
uniquely problematic combination of the upright,
bipedal human posture and the large size of the
L.L. Wall (*)
Department of Obstetrics and Gynecology, Washington human fetus. The upright human posture imposes
University School of Medicine, St. Louis, Missouri, USA certain mechanical constraints on human pelvic
312 L.L. Wall
A fistula is an abnormal communication or

passageway between two body cavities or
organs that are not normally connected
(Wall 2006a).
An obstetric fistula is a fistula that devel-
ops during childbirth, most commonly
from prolonged obstructed labor (Wall
2006a).
Obstructed labor occurs when the descent
of the fetus through the birth canal is
arrested and no further progress can be
Fig. 17.1 Vesicovaginal fistula with probe. In the above made in spite of strong uterine contrac-
figure, a metal probe has been inserted through the woman’s tions. This can be overcome only by opera-
urethra and the end of the probe can clearly be seen in her
bladder, due to a large fistula where the bladder base should tive intervention. Obstructed labor causes
be. Source: Wall (2006a) fistulas through pressure necrosis: the fetal
head pushed against the mother’s pelvic
bones crushes the soft tissues trapped
anatomy that are not present in other animal species between these two bony plates, shutting
that do not habitually walk upright on two legs. The off their blood supply and resulting in the
pelvis of our closest biological relative (the chimpan- death of these tissues (Arrowsmith et al.
zee, Pan troglodytes), for example, is configured as a 1996).
simple cylinder, with the pelvic inlet, the mid-pelvis, A vesicovaginal fistula is a fistula that
and the pelvic outlet all aligned with one another develops between a woman’s bladder and
along a single axis with an elongated anterior–poster- her vagina, resulting in continuous loss of
ior plane. As a result, birth for a chimpanzee fetus is a urine (Wall 2006a).
‘‘straight shot’’ through the pelvis, a simple downward A rectovaginal fistula is a fistula that devel-
drop from the pelvic brim through an unconstricted ops between a woman’s rectum and her
mid-pelvis and out through a capacious pelvic outlet vagina, resulting in continuous loss of
that opens posteriorly. This anatomical configuration bowel contents (Wall 2006a).
means that parturition for the chimpanzee is a rapid
process that proceeds relatively unhindered.
The human situation is much more complicated. abnormalities present, labor may become arrested.
Human birth requires the fetus to traverse a pelvis Obstructed labor occurs when the fetus cannot
in which not only the inlet, the mid-pelvis, and the descend any further through the maternal pelvis,
outlet have different dimensions but also the in spite of strong uterine contractions. When this
planes of those dimensions are not aligned along occurs, the resulting ‘‘obstetric dilemma’’ can be
a single axis. As a result, the human fetus must overcome only by surgical intervention. In indus-
constantly change its configuration as it proceeds trialized countries this usually means the perfor-
through the birth canal utilizing a complicated, mance of a prompt cesarean delivery. In impover-
seven-step mechanism involving engagement, des- ished, non-industrialized countries with a poor
cent, flexion, internal rotation, extension, external medical infrastructure, this usually means either a
rotation, and expulsion in the normal process of long delay before appropriate obstetrical care is
labor (Smellie 1752). If there is disproportion received or simply no care at all. Under these cir-
between the size of the head and the maternal cumstances, obstetric catastrophes are common.
pelvis, if there is a fetal malpresentation (such as When obstructed labor is allowed to continue
a transverse lie), or if there are bony or soft-tissue unrelieved, the fetal head (or other presenting part,
17 The Global Burden of Obstetric Fistulas 313
in cases of non-vertex presentations) is wedged ever as a tragic stillbirth. If the mother survives this ordeal
more tightly into the mother’s pelvis as the force of (which may last as long as 5 or more days) – and many
the uterine contractions continues unabated. As the women do not survive – she is often left with a con-
head has reached an immoveable bony obstacle, stellation of crippling injuries called the obstructed
further its descent becomes impossible (Fig. 17.2). labor injury complex (Table 17.1).
The soft tissues of the mother’s pelvis – her blad- The most common injury from obstructed labor
der, urethra, vagina, cervix, and rectum – become is a vesicovaginal fistula, a hole between a woman’s
compressed between these two bony plates and sus- bladder and her vagina (Fig. 17.1). In this situation
tain a serious crush injury. Eventually the pressure the tissues of the vesicovaginal septum which nor-
exerted by this process cuts off the blood supply to mally separate these two organs have been
these tissues and they die. In well over 90% of cases, destroyed by pressure necrosis and have sloughed
the fetus also dies from asphyxiation (Dolea and off. The woman with this unfortunate condition
AbouZahr 2003). In a day or two the dead fetus loses all urinary control: the urine simply runs out
slowly macerates, decaying enough so that its tis- of her bladder, into her vagina, across her perineum,
sues soften and it can change its conformation in its and down her legs, 24 hours a day. Not only is this
mother’s pelvis, eventually sliding out of her vagina physically uncomfortable (for the urine irritates the
skin and forms encrustations on her vulva) but also
the resultant odor and social embarrassment lead to
further stigmatization, ostracism, depression, and
social withdrawal. If the woman is unfortunate
enough to have sustained a rectovaginal fistula as
well, her situation is even worse due to the constant
commingling of urine and feces to which she is
subjected (Wall 2006a).
The location and nature of the fistula that
develops in obstructed labor is determined by
the point at which labor becomes obstructed,
the amount of pressure applied to the surround-
ing tissues, the duration of that compression, and
the nature of the tissues thus compressed. In
addition to the fistula itself, many women
develop profound vaginal scarring with wide-
spread destruction of neighboring tissues that
makes subsequent surgical reconstruction difficult
(Wall et al. 2005).
Epidemiology of Obstetric Fistulas
Obstetric fistulas no longer exist in the industrialized

world because pregnant women have universal
access to emergency obstetric services, but fistulas
Fig. 17.2 Obstructed labor. It is an 18th-century obstetrical remain tragically common in impoverished, non-
engraving showing obstructed labor. The distance between industrialized countries. Current estimates (which
the pubic symphysis and the sacrum is too narrow to allow are the result of educated guesswork rather than
passage of the fetal skull, the descent of which has been
arrested at this point. Note the pronounced overlapping of
detailed epidemiological studies) suggest that there
the fetal parietal bones as a result of this process. Source: are as many as 3.5 million women in underdeveloped
Smellie (1752) countries with an unrepaired vesicovaginal or
314 L.L. Wall
Table 17.1 Spectrum of injuries seen in the obstructed labor rectovaginal fistula, with tens (if not hundreds) of
injury complex thousands of new cases developing each year (Wall
Acute obstetric injury and Arrowsmith 2007). Since obstetric fistulas are
Hemorrhage, especially postpartum hemorrhage from not generally fatal by themselves, the number of
uterine atony women suffering from this condition continues to
Intrauterine infection and/or systemic sepsis
grow.
Deep venous thrombosis
Massive vulvar edema Because obstetric fistulas are a form of severe
Pathological uterine retraction ring (Bandl’s ring) obstetric morbidity, their prevalence tends to track
Uterine rupture maternal mortality statistics. The vast majority of
Urologic injury maternal deaths (99% each year) occur in the impo-
Vesicovaginal fistula verished parts of Africa, south Asia, and similar
Urethrovaginal fistula parts of the world (Mathers and Loncar 2006).
Ureterovaginal fistula
Complex combinations of fistulas (vesicocervical, Most maternal deaths (especially in the developing
vesicouterine, etc.) world) are due to a handful of consistent (and per-
Urethral damage, including complete loss of the urethra sistently deadly) causes: hemorrhage, infection,
Urinary stress incontinence hypertensive disorders of pregnancy, complications
Secondary hydroureteronephrosis and chronic
pyelonephritis of unsafe abortion, and obstructed labor. In most
Renal failure cases of maternal death, multiple factors contribute
Gynecologic injury
to the final outcome, but in those parts of the world
Amenorrhea where obstructed labor is common and maternal
Vagina scarring and stenosis, often with loss of coital mortality is high, obstetric fistulas will be a preva-
function lent problem. Case series from developing countries
Cervical damage, including complete loss of the cervix
Secondary pelvic inflammatory disease
suggest that around 2% of women who develop
Secondary infertility prolonged obstructed labor will develop a fistula
(Dumont et al. 2001). The World Health Organiza-
Gastrointestinal injury
Rectovaginal fistula tion’s Global Burden of Disease Study (Dolea and
Acquired rectal atresia AbouZahr 2003) suggests that there were 6.5 mil-
Anal sphincter injury with resulting anal incontinence lion cases of obstructed labor in the least developed
Musculoskeletal injury regions of the world each year. If 2% of these
Osteitis pubis and related injuries to the pelvic bones women develop an obstetric fistula, then there
Diffuse trauma to the pelvic floor would be 130,000 new fistula cases each year in
Neurological injury these countries.
Foot drop (injury to the lumbosacral nerve plexus and/or
common peroneal nerve)
Neuropathic bladder dysfunction
Dermatological injury Social Causes of Fistula Formation
Chronic excoriation of the skin from maceration by urine
and feces
Obstetric fistulas are caused by the interaction of
Fetal/neonatal injury
Approximately 95% perinatal case fatality rate
biological factors (obstructed labor) and the social
Neonatal sepsis environment in which those biological factors are
Neonatal birth asphyxia found (Fig. 17.3). The principal cause of obstructed
Neonatal birth injury, including scalp necrosis, nerve labor is cephalopelvic disproportion. The factors
palsies, and intracranial hemorrhage.
that lead to cephalopelvic disproportion are both
Psychosocial injury biological and social. Proper nutrition in childhood
Social isolation
is critical if young women are to reach reproductive
Divorce
Worsening poverty age in a state of overall good health (Konje and
Malnutrition Oladipo 2000) but equally important is the age at
Depression, sometimes leading to suicide which marriage takes place and when entry into
Source: Arrowsmith et al. (1996) reproductive life begins.
Fig. 17.3 Pathways to

Low socio-economic status of women
development of obstetric
fistula. Source: Wall (2005)
Malnutrition Limited social roles Illiteracy & lack of formal

education
Early marriage
Childbearing before pelvic

growth is complete
Relatively large fetus or Cephalopelvic

malpresentation disproportion
Lack of access to
emergency obstetric
Harmful traditional
Obstructed labor
practices
“Obstructed Labor Injury Complex"

Fecal incontinence Fetal death Urinary incontinence
Fistula formation
Complex urologic injury
Vaginal scarring and stenosis
Secondary infertility
Musculoskeletal injury
Foot-drop
Chronic skin irritation
Offensive odor
Stigmatization
Isolation and loss of social support
Divorce or separation
Worsening poverty
Worsening malnutrition
Suffering, illness, and premature
death
Because females reach the point of reproductive up in these societies have faced nutritional discrimi-
potential before they attain full growth in pelvic nation as children, further hindering their pelvic
capacity, obstructed labor is more common in growth. Lack of education has consistently emerged
populations where girls marry soon after menarche in studies as a marker for obstetric morbidity and
and begin to have children in their early teens, while mortality, probably because poorly educated
they are still children themselves (Moerman 1982). women are less likely to gain access to the health-
Societies in which this pattern is replicated tend to care system when obstetric complications arise.
be societies in which even adult women (much less Once labor becomes obstructed, prompt inter-
young teenage girls) have low social status, poor vention is necessary if the cascade of complications
economic prospects, limited social roles, and poor that can result from this process (Obstructed Labor
access to education. Often women who have grown Injury Complex) is to be avoided. Most often this
316 L.L. Wall
requires prompt delivery by cesarean section, but economic costs, both the costs of transportation
access to effective obstetric surgery is often limited and the ‘‘opportunity costs’’ (lost wages, lost time
and delayed, with tragic consequences. It must be working in the fields, etc.) that may be incurred.
emphasized that an obstetric fistula can occur in any Often, particularly in cases of prolonged labor, the
pregnancy – even among women who have success- easiest decision is just to ‘‘wait and see what hap-
fully given birth previously – if labor becomes pens’’ in the hope that the woman will eventually
obstructed and prompt access to emergency obste- deliver the baby by herself and that everything will
tric care is not available. Thaddeus and Maine come out all right in the end. Once labor has lasted
(1994) have investigated the causes of delay affect- over 24 hours, this is particularly dangerous. In
ing obstetric emergencies in which the pregnant many parts of Africa (particularly in northern
women subsequently die. Their discussion can Nigeria) women are normally expected to stay
equally be applied to obstetric fistula formation secluded within the family compound and are not
because the fundamental assumption underlying normally allowed to travel without male accompa-
their work applies in both cases: in order to avoid niment or permission. If the appropriate male
a catastrophic outcome when an obstetric emer- authority figure is not present during obstructed
gency arises (hemorrhage, sepsis, hypertensive cri- labor, delays may be encountered before permission
sis, obstructed labor) women must receive prompt can be secured to take the woman to a health-care
access to competent emergency care. When care is facility. Once the decision has been made that some
delayed, the outcome is often poor. What causes kind of intervention is appropriate, the intervention
delay in the treatment of obstructed labor? Thad- that is chosen may still not lead to appropriate
deus and Maine (1994) describe three principal treatment. In many parts of southern Nigeria, for
causes of delay in scenarios that result in maternal example, charismatic ‘‘spiritual churches’’ run
death: (1) delay in deciding to seek care; (2) delay in maternity homes where the primary services pro-
arriving at a suitable health-care facility; and (3) vided are prayer and religious rituals rather than
delay in receiving appropriate care at that facility. advanced obstetric care. Whatever the moral or
In many poor countries, childbirth is regarded as spiritual value that such services may have, they
a natural phenomenon that should take place out- are not effective in relieving the mechanical obstacle
side of the hospital/clinic setting. Most births in to delivery in obstructed labor. This only leads to
sub-Saharan Africa take place at home, generally further delay. In some cases the therapy chosen may
in the presence of family members or a traditional actually be directly harmful to the laboring woman.
birth attendant, whose specific duties and responsi- For example, some recipes used by traditional hea-
bilities will vary greatly among different cultures. lers in treating women in prolonged labor in parts of
When an obstetric complication such as prolonged Africa do appear to have oxytocic properties that
labor arises, the immediate questions that need to be enhance uterine contractility and result in more
asked are: Is this a problem? What is causing it? forceful contractions. While this might be useful in
What should be done about it? The assumptions labors in which progress is slow due to uterine iner-
from which one starts in trying to answer these tia, giving such medications to a woman who is in
questions have a direct impact on what happens obstructed labor will only accelerate the likelihood
subsequently. For example, in many parts of Africa of a catastrophic outcome by increasing the pres-
trouble in childbirth is often attributed to some kind sure of the fetal head on the entrapped tissues.
of moral failure on the part of the laboring woman. In other cases traditional therapy itself may lead
Difficult labor is frequently seen as retribution from directly to the formation of a fistula. Among the
God or the ancestors for adultery or some other Hausa people of northern Nigeria obstructed labor
moral lapse, rather than being the product of faulty is often attributed to a condition known locally as
obstetrical mechanics. In such cases the efforts of gishiri (‘‘salt’’) (Wall 2002). When gishiri is present,
the birth attendants may well be directed toward it is said that a film or web has grown over the
getting the woman to confess ‘‘what she has done’’ vaginal outlet, hindering birth. The traditional
rather than to seek medical attention. The decision treatment for this diagnosis is to consult with a
to seek care for an obstetric problem involves traditional barber surgeon, who takes a knife or
other sharp instrument and makes a series of ran- cesarean section may still have to go to the market
dom cuts in the vagina. In theory this removes the to find intravenous fluids, sterile gloves, antibiotics,
obstructing ‘‘web,’’ but in reality it is far more likely and other necessary surgical supplies, which they
to cause bleeding, infection, and direct injury to the themselves must bring to the hospital before an
urethra, bladder, vagina, and/or rectum than to operation can begin. In many cases, ‘‘payment in
open the vaginal outlet in any significant way to advance’’ may be demanded before an operation
speed delivery. can start, and sadly, there are many documented
After the decision has been made to seek care at a cases in which hospital personnel have demanded
clinical facility, the task of arranging transportation bribes before they would provide life-saving obste-
begins. Depending on where the laboring woman is trical services to vulnerable, suffering women in
located, it may be difficult even to get to a service- labor (Wall 2006a).
able road, particularly during the rainy season. She In most parts of sub-Saharan Africa, the mater-
may have to walk for miles while in labor just to get nal health-care system is broken and few people are
to a location where road transportation might be trying to fix it. This has led some authors to con-
available. If she is unable to walk due to her condi- clude that the much heralded ‘‘Safe Motherhood’’
tion, she may have to be carried on a litter by family initiative launched in the 1980s has become ‘‘an
members or balanced on the handlebars of a bicycle orphan initiative.’’ Correcting this problem is an
while the rider tries to navigate down a footpath urgent international public health issue (Weil and
through the bush. Even if transportation is avail- Fernandez 1999).
able, the owner or the driver of the vehicle may not
wish to carry a pregnant woman in difficult labor
for fear of soiling the vehicle, losing business from
other passengers, incurring the wrath of angry Treatment
ancestral or other spirits, or being held liable should
she have an obstetric mishap while en route to the A woman who presents to hospital immediately
hospital. The state of roads in many parts of Africa after surviving obstructed labor needs prompt sup-
is appalling, the vehicles not much better, and portive care with intravenous fluids, antibiotics,
mechanical failures, accidents, and unpredictable and placement of an indwelling urinary bladder to
delays are commonplace. It is also not unheard-of, decompress the bladder and allow it to rest. The
for vulnerable people to face extortion from the process of obstructed labor usually compresses the
purveyors of transportation in their time of need bladder neck and urethra so tightly that the woman
(Wall 2006a). may not have been able to urinate for several days.
Once the woman in obstructed labor has reached In these cases, her bladder generally will be dis-
the hospital, her dilemma is not yet over. Many tended, atonic, and often bleeding from the trauma
women with obstetric complications make heroic it has sustained. Prompt decompression and relief
efforts to get medical care only to find that it is not of the overdistension is necessary both to provide
available at the facility they have reached and they patient comfort and to prevent further damage to
must set out again on another journey to a different the bladder. If a fistula is already present, immedi-
place in order to get help. Many African hospitals – ately instituting prolonged catheter drainage will
particularly in rural areas – do not have anyone on prevent further injury and may even allow the fis-
staff that can perform a cesarean delivery (Elkins tula to heal spontaneously over the course of several
and Wall 1996). And even if such capabilities exist weeks. Sometimes prolonged bladder drainage is
(at, for example, a major university teaching hospi- successful even with relatively large fistulas if it is
tal in the capital city), the facility may be so over- instituted immediately after the injury is apparent.
whelmed with emergency cases that the suffering If the fistula is long standing, prolonged bladder
patient has to wait in line among the other obstetric drainage is unlikely to be curative, and surgical
emergencies that are stacked up waiting for the only intervention will probably be needed.
available operating theater to become free. Patients It is not the purpose of this chapter to describe
who arrive at a hospital needing an emergency the surgical repair of obstetric fistulas in detail, for
318 L.L. Wall
their manifestations vary widely, as do the specific (Wall 2005). After this is done, the vaginal incision
surgical techniques needed to deal with specific is closed separately. The bladder should be drained
types of injury. Some fistulas are simple and their with an indwelling urinary catheter for a prolonged
repair is straightforward. Other fistulas are extre- period of time (usually 10–14 days) so that it does
mely complicated, accompanied by multiple other not become distended with urine, create pressure on
pelvic injuries, and may require extensive pelvic the suture line, and result in breakdown of the repair
reconstructive surgery to repair the damage. Some and a recurrence of the fistula (Wall 2005).
fistulas are totally inoperable. The first consistently Fistula surgery can usually be done under spinal
successful surgical operations to repair vesicovagi- anesthesia, at low cost, using standard surgical
nal fistulas were performed in the late 1840s by instruments and sutures. It rarely requires access
American surgeon J. Marion Sims, who initially to ‘‘high technology’’ to be successful. Physicians
developed his technique by operating on a small with basic surgical skills can learn to repair straight-
group of African-American slave women with fistu- forward, uncomplicated fistulas in short order,
las who had been given to him by their owners for but skill in treating ‘‘high-risk’’ fistulas requires
the purpose of attempting to cure them (Wall patience, persistence, extensive experience, and
2006b). He housed them in a small hospital he con- access to facilities with more advanced capabilities.
structed behind his home in Montgomery, Ala- Ideally this should be at a specialist fistula center
bama, for this purpose. Desperate for cure, stigma- dedicated exclusively to the treatment of these inju-
tized by their injuries, and ostracized even within ries. A good case can be made for repairing obstetric
their own slave society, these women eventually fistulas in dedicated wards and specialist centers,
became Sims’ surgical assistants, helping him oper- rather than trying to integrate these patients into
ate on one another in turn until he was finally the general hospital population. First, because
successful in closing their fistulas. This process of obstetric fistulas are not surgical emergencies,
therapeutic surgical experimentation lasted nearly 4 unless they are repaired in facilities where such sur-
years during which time one slave woman, Anarcha, gery is the institution’s exclusive concern, these
underwent 30 operations before she was cured (Wall women are always in danger of being bumped
2006b). from the operating list for more urgent cases such
Although there have been many advances in sur- as road traffic accidents, strangulated hernias,
gical technology and many changes in surgical tech- infected wounds, and so on. Second, because these
nique, the basic principles involved in vesicovaginal women may be physically offensive to others from
fistula repair have not changed much in the last 75 the loss of urine and/or feces that plagues their lives,
years. Fistula repair involves surgical separation of they are often rejected by other patients and do not
the tissue planes of the overlying vagina from the fit in well on general hospital wards (Wall 1998;
underlying bladder, wide mobilization of those tis- Prevention of Maternal Mortality Network 1992).
sues so that the hole in the bladder can be closed Because the real reasons (obstructed labor) they
(originally with permanent sutures that had to be have sustained their injuries are often poorly under-
removed after several days, now with absorbable stood by the communities from which they come
suture material). The bladder repair must be water- (and often by themselves as well) women with fistu-
tight and this should be confirmed at the time of las may be further stigmatized by moral reproach
surgery. Ideally, the bladder should be closed in two from others who assume their affliction is the result
layers for greater strength, although this may not be of a hideous venereal disease or a punishment from
possible in all circumstances. In many cases, parti- God or the ancestral spirits. These women often do
cularly when the fistula is large or when it is sur- much better from a psychosocial perspective if they
rounded by dense scar tissue, it is often desirable to can live together, talk with each other, and recover
bring a fresh blood supply into the surgical site by from surgery as part of community bound together
mobilizing a vascular pedicle of uninjured tissue by their shared experience of suffering. Many
from another nearby location (such as the bulboca- women with fistulas do not realize that their situa-
vernosus fat pad underlying one of the vulvar labia) tion is not unique until they find the company of
and suturing this in place over the bladder repair other women with similar problems. Third, because
women with fistulas are typically young, illiterate, family life education, frank discussions about
impoverished, isolated from their families, and cast reproductive physiology and sexual health, access
adrift in the wider society, they generally lack the to contraception and family planning information,
social support and political influence that may be and information concerning the prevention and
needed to navigate their way through the hospital treatment of sexually transmitted diseases. Gaining
system in order to receive proper care (Wall 1998; cultural acceptance for such programs may not be
Prevention of Maternal Mortality Network 1992). easy in all cultures. Third, harmful traditional med-
These barriers can be eliminated by institutions ical practices (such as female genital cutting) should
whose sole mission is the care of such patients. be eliminated. Although in some cases these prac-
Finally, special fistula programs are more likely to tices are directly responsible for the creation of
be able to muster the resources needed to deal with fistulas (such as gishiri cutting in northern Nigeria),
complicated cases and to maintain the level of in most cases these traditions are not direct causal
expertise required to provide high-quality care. factors; rather they are associated with fistulas
because both the traditional cutting practices and
the high prevalence of fistulas are markers of the
low socioeconomic status of women and their rela-
Prevention of Obstetric Fistulas tive lack of personal autonomy and political power
in those societies where these practices and fistulas
Review of the obstetric fistula pathway (Fig. 17.3) coexist. Fourth, a major effort must be made to
reveals how deeply this problem is ingrained within make the male population of fistula-prevalent socie-
the social, political, and economic structures of the ties understand the direct stake that they themselves
societies where fistulas are prevalent. Because both have in women’s reproductive health. All males
the prevention (cesarean delivery) and the treatment have important relationships with women as their
(surgical repair) of fistulas are surgical interven- sons, husbands, brothers, and fathers. The interests
tions, the fistula problem can be solved only by the that men have in raising and being a part of strong,
development of a robust medical infrastructure flourishing families are put in jeopardy in cultures in
that can cope with acute problems as they arise which women’s health is neglected and their
and treat them appropriately after such damage mothers, wives, sisters, and daughters are put at
has been done. This clearly will require long-term risk. Emphasizing this point is crucial for sustain-
planning and the investment of substantial financial able, long-term change.
resources in all countries in which obstetric fistulas Obstetric fistulas will be eliminated only when
are found, but this is unlikely to happen until other the principal root cause of the problem – obstructed
cultural changes also take place. labor – is eliminated. Since it is very difficult to
First of all, eradication of the obstetric fistula predict with any precision which women are going
will require that female children come to be valued to develop obstructed labor, the best preventive
just as much as male children in these societies. Girls strategy is to insure that all women in labor are
must be given proper nutrition, health care (includ- attended by a trained birth attendant who can
ing vaccinations), and education during childhood detect abnormal labor and refer such cases to
so that they reach reproductive age fit enough to appropriate obstetrical facilities where they can be
become healthy wives and mothers. Second, child- dealt with quickly and competently. Attaining this
bearing should be postponed until pelvic growth is goal will require the gradual elevation of the general
complete. Early marriage should be discouraged. standards of obstetric care throughout the develop-
The number of early teenage pregnancies must be ing world, with a decreased emphasis on the use of
reduced, as these young women are at particularly traditional untrained birth attendants who do not
high risk for developing obstructed labor. Abun- possess adequate technical skills. Trained midwives
dant evidence suggests that the best way to do this who can evaluate the progress of labor, detect
is to provide equal educational opportunities for abnormalities, and provide appropriate triage dur-
females, who will turn out to be better wives and ing childbirth are required, with universal access to
mothers as a result. This will also require enhanced higher level referral when abnormalities in labor
320 L.L. Wall
arise. There is good evidence from large multicenter for women, early marriage and constricted life
trials that graphic recording of the progress of labor choices, female illiteracy, harmful traditional
on a partograph decreases the number of prolonged medical practices, and poor distribution of
labors, decreases unnecessary interference with nor- health-care services are intertwined. Together,
mal labor, and enhances the appropriate triage and all of these factors prevent timely access to emer-
treatment of women with abnormalities of labor if gency obstetric care when it is needed.
use of such graphic records of labor is combined The problem of obstetric fistulas has been largely
with an appropriate system of clinical analysis and neglected by the international public health com-
prompt referral (World Health Organization 1994). munity. Inadequate resources have been devoted
to developing the infrastructure for obstetric care
necessary to detect obstructed labor and to pre-
vent it from becoming prolonged. Prompt access
Conclusion to emergency obstetric services must remain a
high priority for maternal health worldwide.
Obstetric fistula is a devastating complication of When obstetric fistulas arise, most can be repaired
childbirth in which obstructed labor produces an using ‘‘low-technology’’ surgical services at mod-
extensive crush injury to the soft tissues of the est cost, but inadequate resources have been
maternal pelvis, opening an abnormal passage- mobilized to treat women currently suffering
way between the pregnant woman’s vagina and from a fistula. Dealing with the backlog of unre-
her bladder and/or rectum. The fistula renders the paired obstetric fistulas should be a high priority
afflicted woman totally incontinent of urine and/ in the development of surgical services for women
or feces. This problem is confined almost exclu- in non-industrialized countries. This can best be
sively to women in impoverished, non-industria- done by creating special surgical wards in general
lized countries. hospitals to treat ‘‘low-risk’’ fistulas and by creat-
The fistula problem is embedded in a complex ing specialist fistula referral centers in those parts
social matrix in which low socioeconomic status of the world where fistulas are common.
Key Terms
Cephalopelvic disproportion Obstetric fistula Traditional birth attendant

(CPD) Obstructed labor Vesicovaginal fistula
Cesarean section Obstructed labor injury Worldwide Fistula Fund
Fetal malpresentation complex
Fistula Rectovaginal fistula
Incontinence Specialist fistula center
Questions for Discussion 2. Using the World Fistula Fund’s pathways to the
development of obstetric fistula, describe the
1. Define the following terms: biological, socioeconomic, and cultural factors
that contribute to the development of the
a. Fistula. condition.
b. Obstetric fistula. 3. Outline and discuss measures (medical and non-
c. Vesicovaginal fistula. medical) for treatment, prevention, and eradica-
d. Rectovaginal fistula. tion of obstetric fistula.
References Prevention of Maternal Mortality Network (1992) Barriers to

treatment of obstetric emergencies in rural communities of
West Africa. Studies in Family Planning, 23(5), 279–291
Arrowsmith S, Hamlin E, Wall L (1996) Obstructed labor Smellie W (1752) A Set of Anatomical Tables, 2nd ed. Lon-
injury complex: Obstetric fistula formation and the multi- don, England: Wilson & Durham
faceted morbidity of maternal birth trauma in the devel- Thaddeus S, Maine D (1994) Too far to walk: maternal mor-
oping world. Obstetrical and Gynecological Survey, 51, tality in context. Social Science and Medicine, 38, 1091–1110
568–574 Wall L, Arrowsmith S (2007) The ‘‘continence gap’’: a critical
Dolea C, AbouZahr C (2003) Global Burden of Obstructed concept in obstetric fistula repair. International Urogy-
Labor in the Year 2000. Evidence and Information for necology Journal, 18(8), 843–844(2)
Policy (EIP) Unit, World Health Organization. Geneva: Wall LL (1998) Dead mothers and injured wives: the social
World Health Organization. www.who.int/healthinfo/ context of maternal morbidity and mortality among the
statistics/bod_obstructedlabour.pdf, cited 2 August Hausa of northern Nigeria. Studies in Family Planning,
2008 29(4), 341–359
Dumont A, de Bernis L, Bourvier-Colle MH et al. for the Wall LL (2002) Fitsari ’dan Duniya: an African (Hausa)
MOMA Study Group (2001) Cesarean section rate for praise-song about vesicovaginal fistulas. Obstetrics and
maternal indication in sub-Saharan Africa: a systematic Gynecology, 100, 1328–1332
review. Lancet, 358, 1328–1334 Wall LL, Karshima J, Kirschner C et al. (2004) The obstetric
Elkins TE, Wall LL (1996) Report of a pilot project on the vesicovaginal fistula: characteristics of 899 patients from
rapid training of pelvic surgeons in techniques of obstetric Jos, Nigeria. American Journal of Obstetrics and Gyne-
vesico-vaginal fistula repair in Ghana and Nigeria. Jour- cology, 190, 1011–1119
nal of Pelvic Surgery, 2, 182–186 Wall LL, Arrowsmith SD, Briggs ND et al. (2005) The obste-
Holme A, Breen M, MacArthur C (2007) Obstetric fistulae: a tric vesicovaginal fistula in the developing world. Obste-
study of women managed at the Monze Mission Hospital, trical and Gynecology Survey, 60(Suppl 1), S1–S55
Zambia. BJOG, 114(8), 1010–1017 Wall L (2005) Hard questions concerning fistula surgery in
Konje JC, Oladipo LA (2000) Nutrition and obstructed third world countries. Journal of Women’s Health, 14(9),
labor. American Journal of Clinical Nutrition, 72(Suppl), 863–866
291S–297S Wall L (2006a) Obstetric vesicovaginal fistula as an interna-
Mathers CD, Loncar D (2006) Projections of global mortal- tional public health problem. Lancet, 368, 1201–1209
ity and burden of disease from 2002 to 2030. PLoS Med- Wall LL (2006b) The medical ethics of Dr. J. Marion Sims: a
icine, 3(11), e442 fresh look at the historical record. Journal of Medical
Moerman ML (1982) Growth of the birth canal in adolescent Ethics, 32(6), 346–350
girls. American Journal of Obstetrics and Gynecology, Weil O, Fernandez H (1999) Is safe motherhood an orphan
143(5), 528–532 initiative? Lancet, 354, 940–943
Onolemhemhen OD, Ekwempu CC (1999) An investigation World Health Organization (WHO) (1994) Maternal health
of sociomedical risk factors associated with vaginal and safe motherhood programme. World Health Organi-
fistula in northern Nigeria. Women’s Health, 28(3), zation partograph in management of labour. Lancet, 344,
103–116 1399–1404
Chapter 18
Health Challenges for Women, Children, and Adolescents
with Disabilities
Amy T. Wilson
Learning Objectives After reading this chapter and nonenforcement of such policies and laws where
answering the discussion questions that follow, you they exist. International and national efforts and
should be able to strategies to improve inclusion and access to health
and social care for women and children with disabil-
Discuss the meaning and causes of disabilities.
ities are discussed.
Present an overview of the global prevalence of dis-
The United Nations Convention on the Rights
abilities among women, children, and adolescents.
of Persons with Disabilities (2007) defines disabil-
Discuss the relationship between poverty and
ity to include persons who have long-term physi-
disability.
cal, mental, intellectual, or sensory impairments
Appraise how local attitudes and beliefs frame
which in interaction with various barriers may
society’s perspective on disability and the effects
hinder their full and effective participation in
these have on the health of women, children, and
society on an equal basis with others. The World
adolescents with disabilities.
Health Organization (2005) estimates that 600
Evaluate international and national efforts and
million people, of which half are female and
strategies to improve access to health and social
one-third are children, live with a mental, physi-
care for women, children, and adolescents with
cal, or cognitive disability and that 70–80% of this
disabilities.
population reside in developing countries. This
amounts to nearly 200 million children who
never reach their full cognitive potential (Msall
and Hogan 2007). Of these, 80% live in impover-
Introduction
ished rural areas. According to data from UNI-
CEF (2007a), there is a wide variation among
This chapter discusses the definition and causes of
countries in the percentage of children with dis-
disability; global prevalence of disabilities; and the
ability, ranging from 2% in Uzbekistan to 35% in
relationship between poverty and disability. Since
Djibouti (Table 18.1).
one of the greatest barriers against access to appro-
Disparities in disability among countries can
priate health care for women and children with dis-
be explained by variations in largely preventable
abilities is negative societal attitude, this chapter
causes related to nutrition, exposure to environ-
examines how local concepts and beliefs frame a
mental risks, accidents and conflicts, chronic
society’s perspective of disability and how this per-
infections, congenital impairments, and access
spective affects the status of women and children
to health-care services (Table 18.2). In the devel-
with disabilities. Another important barrier that
oped world, the prevalence of disability has been
women and children with disabilities face is the lack
significantly reduced by health systems that
of national disability policies or laws or the
address the causes of motor disabilities (WHO
2007).
A.T. Wilson (*) Frequently, individuals with disabilities do not
Gallaudet University, Washington, DC, USA have the opportunity to attend school, work in the
324 A.T. Wilson
Table 18.1 Percentage of children aged 2–9 years with at health facilities, clinic buildings with steps but no
least one disability, 2005 ramps, lack of Braille or audio informational materi-
Country Percentage als for blind people, and medical staff that are unable
Djibouti 35 to communicate with their deaf clients. While pov-
Central African Republic 31
erty can lead to disability, disability is also a major
Cameroon 23
Sierra Leon 23
cause of poverty. Having a disability can trigger
Bangladesh 18 social and economic difficulties for individuals,
Mongolia 17 their families, their communities, and even countries.
São Tomé and Prı́ncipe 16 For children, lack of services appropriate to their
Ghana 16 needs can result in slower learning and difficulty
Iraq 15 progressing in school. These difficulties in childhood
Jamaica 15
may lead to inability to live as independent adults
Montenegro 13
later on. In addition, inaccessible environment often
Thailand 12
Albania 11 makes it difficult for adults with disabilities to secure
Serbia 11 employment, to perform a job as required, or to keep
FYR Macedonia 10 employment.
Bosnia Herzegovina 7 Without the right to appropriate education or
Uzbekistan 2 access to employment, people with disabilities are
Source: UNICEF (2007a) effectively denied the right to become independent
and contributing members of society. In order to
improve the quality of life for people with disabil-
Table 18.2 Preventable causes of disability ities, their families, and society as a whole, the
Disability Associated health condition global community needs to (a) standardize the
Blindness Vitamin A deficiency terms concerning disability, (b) collect accurate
Deafness Measles, mumps, rubella, bacterial and valid data about all aspects of people with
meningitis disabilities in order to assist and monitor them
Motor disability Polio, cerebral palsy, iodine (e.g., kind of disability, educational level, socio-
deficiency
Motor and cognitive Accidents and injury
economic status), (c) create national programs,
disability policies, and strategies for including people with
disabilities, (d) increase and improve the health
Source: Rasheed (1999)
and rehabilitation services available to people
with disabilities, and (e) promote the economic
formal marketplace, or live independent, fulfilling and social acceptance, inclusion, and empower-
lives. Due to lack of appropriate services, they are ment of people with disabilities in their homes
forced to depend on their families and commu- and national communities.
nities for physical and economic support. Women Disabled People’s Organizations from around the
with disabilities can be treated differently accord- world along with Member States of the United
ing to why they are disabled, where they live, what Nations met for over a period of 5 years to write
their disability is, and what myths or beliefs may the United Nations Convention for the Rights of
exist about their right to be wives and mothers. People with Disabilities. Adopted on December
Both disabled women and children may confront 2006, it aims to protect and monitor the human
social stigmatization and exclusion from family rights of all persons with disabilities. It encourages,
and community life as a result of just being ‘‘. . . governments to work towards developing appro-
different. priate education policies and practices for children
Although many poor people struggle to obtain and adults with disabilities, to include persons with
appropriate health care, poor people with disabil- disabilities in strategies and plans aimed at eradicat-
ities, and specifically women, are often the least ing poverty, promoting education and enhancing
able to access needed health care. Additional obsta- employment, and to take account of the right of
cles can include inaccessible public transport to persons with disabilities to housing, shelter,
18 Health Challenges for Women, Children, and Adolescents with Disabilities 325
Box 18.1 Articles 25 and 26 of the UN Convention for the Rights of People with Disabilities
Article 25 – Health: States Parties recognize that persons with disabilities have the right to the
enjoyment of the highest attainable standard of health without discrimination on the basis of
disability. States Parties shall take all appropriate measures to ensure access for persons with
disabilities to health services that are gender-sensitive, including health-related rehabilitation. In
particular, States Parties shall
(a) provide persons with disabilities with the same range, quality and standard of free or affordable
healthcare and programmes as provided to other persons, including in the area of sexual and
reproductive health and population-based public health programmes;
(b) provide those health services needed by persons with disabilities specifically because of their
disabilities, including early identification and intervention as appropriate, and services designed
to minimize and prevent further disabilities, including among children and older persons;
(c) provide these health services as close as possible to people’s own communities, including in rural
areas;
(d) require health professionals to provide care of the same quality to persons with disabilities as to
others, including on the basis of free and informed consent by, inter alia, raising awareness of the
human rights, dignity, autonomy and needs of persons with disabilities through training and the
promulgation of ethical standards for public and private healthcare;
(e) prohibit discrimination against persons with disabilities in the provision of health insurance, and
life insurance where such insurance is permitted by national law, which shall be provided in a fair
and reasonable manner;
(f) prevent discriminatory denial of healthcare or health services or food and fluids on the basis of
disability.
Article 26 – Habilitation and rehabilitation:
1. States Parties shall take effective and appropriate measures, including through peer support, to
enable persons with disabilities to attain and maintain maximum independence, full physical,
mental, social and vocational ability, and full inclusion and participation in all aspects of life. To
that end, States Parties shall organize, strengthen and extend comprehensive habilitation and
rehabilitation services and programmes, particularly in the areas of health, employment, educa-
tion and social services, in such a way that these services and programmes
(a) begin at the earliest possible stage, and are based on the multidisciplinary assessment of
individual needs and strengths;
(b) support participation and inclusion in the community and all aspects of society, are voluntary,
and are available to persons with disabilities as close as possible to their own communities,
including in rural areas.
2. States Parties shall promote the development of initial and continuing training for professionals
and staff working in habilitation and rehabilitation services.
3. States Parties shall promote the availability, knowledge and use of assistive devices and technol-
ogies, designed for persons with disabilities, as they relate to habilitation and rehabilitation (p. 1).
Source: United Nations Enable (2007)
326 A.T. Wilson
transport and supportive equipment’’ (United community, and society. As such, it underscores that
Nations Enable 2007). Two integral articles protect- society’s failure to recognize the needs of people with
ing the rights of people with disabilities in receiving disabilities marginalizes and excludes them from full
appropriate health care are Article 25 and 26 (United integration into society. Rather than entirely focus-
Nations Enable 2007), which must be considered by ing on cures or rehabilitation, the social model
Member States when writing health-care policies encourages the community to modify the environ-
(Box 18.1). United Nations Conventions are interna- ment so that all people can participate fully in all
tional law and the countries that sign and ratify the aspects of society. The political framework for a
convention have the legal responsibility to enforce social conceptualization of disability calls for an atti-
them. National civil rights laws must reflect the arti- tudinal change by society to see people not as dis-
cles agreed upon in the convention. Disabled Peo- abled, but different, to reduce the social, natural, and
ple’s Organizations and their advocates are working built environmental barriers, and to advocate for
diligently to ensure that the articles in the convention disabled persons’ human rights rather than only lob-
are becoming national policy. In the past, strategies bying for better health care.
to assist those with disabilities focused on treating To compare the two models, consider the case of
their medical problem. In current, transformative deaf children. Historically, the medical model pre-
strategies, the disabled people advocate for them- scribed many arduous years learning to speech-read
selves with health-care programs as allies alongside for these children. This ‘‘solution’’ placed the bur-
them, their families, and their communities. den of disability on the child. Alternatively, the
social model’s approach would adapt the environ-
ment to respect and to include the child’s difference
by, for example, providing closed captioning or
Definition of Disability teachers fluent in sign language.
Finding consensus on the definition of disability has

been difficult, mainly because of the different medi-
cal and social perspectives from which people view
Disability-Adjusted Life Year (World
disabilities. Historically, disability has been concep- Development Report)
tualized as a medical problem caused by a disease, a
trauma, or some other health condition. The dis- Attempts to quantify the impact of disabilities vary
abled person was seen first and foremost as ‘‘dis- widely depending on whether one believes that a
abled.’’ Medical professionals attempted to cure the disability is a health burden or a societal issue that
individual or change the person’s behavior so that he must be addressed. In 1993, The World Bank
or she would fit into the community as a ‘‘normal’’ addressed the definition of disability when it con-
person. Often children and adults with disabilities ducted a study concerning the global burden of
were institutionalized or put under custodial care disease in collaboration with the World Health
where they were left to survive or receive rehabilita- Organization and the Harvard School of Public
tion. In this medical model, the person is seen as Health. One outcome of the collaboration was the
defective, and the role of how the social and physical disability-adjusted life year (DALY), a quantitative
environment may disable the individual is ignored. indicator of the state of the health of a country.
The political framework for this medical conceptua- The purposes of the DALY were to ‘‘(a) assist in
lization of disability focused on reducing functional setting health service priorities; (b) identify disad-
limitations and providing preventative health care. vantaged groups and target health interventions,
The other conceptualization of disability is the and (c) provide a comparable measure of output
social model, which classifies functioning and dis- for intervention, program, and sector evaluation
ability from the perspective of a person’s life circum- and planning.’’
stances. This model considers how the environment The DALY was created to calculate the total
influences whether a person with a disability is amount of healthy life lost by a person from either
included in and able to gain access to, their family, premature mortality, poor health, or some degree of
disability, either physical or mental, during a spe- ICHS International Classification of

cific period of time. A panel of experts weighed Impairments, Disabilities, and Handicaps
how diseases and disabilities affected mortality
(WHO)
rates in order to create ‘‘disability weights.’’ To
calculate the burden of the disability/disease, one Another conceptual framework of disability is the
takes the predetermined disability weight and then International Classification of Impairments
multiplies it by the number of years lived in ‘‘that (ICIDH) and its newer version, the International
health state’’ and then adds the number of years Classification of Functioning, Disability and
lost due to that disease/disability. Theoretically, Health (ICF) (WHO 2003). The ICF differs
the DALY can help a country determine how to from the DALY in that it is not quantitative
use funds more cost effectively and prioritize and that it recognizes that a person’s disability
health interventions. For instance, if a country varies according to the degree to which the
found that HIV/AIDS imposed the heaviest health impairment affects his or her ability to function
burden on its populace, resources could be tar- in the environment. The 1980 version of ICIDH
geted to address HIV/AIDS. (WHO 1980) was first in distinguishing ‘‘disabil-
Critics of the DALY argue that methods to col- ity’’ from ‘‘impairment’’ and ‘‘handicap.’’ While
lect data required to calculate disability are ineffi- historically these three terms were used inter-
cient and require huge amounts of resources. More- changeably, the move from a medical model to
over, critics point out that the DALY itself and its a social model requires that the definition of these
disability weights include value judgments that have terms be more clearly distinguished.
economic, political, and ethical implications. Its ‘‘Impairments’’ are the result of a disease or a
false assumptions include that disabilities affect disorder (such as cerebral palsy) which causes ‘‘a
quality of life across the globe – with no regard to restriction or a lack of ability to perform an activity
individual health status or environmental factors – in a manner or within a range considered normal for
and that the medical diagnosis of the disability – not a human being.’’ A ‘‘disability’’ (such as lack of
family circumstance, location, or access to health muscle coordination, which limits one’s ability to
care – is the sole indicator of quality of life with a do fine motor work) is a result of impairment and
disability (Metts 2000). defined as a loss or an abnormality of anatomical,
In addition, the DALY equation and the dis- physiological, or psychological structure or func-
ability weights imply that nondisabled persons are tion. ‘‘Handicaps’’ are the result of impairments
more valuable to society. However, health inter- and disabilities and are defined as disadvantages
ventions and proper support can assist disabled that a person experiences because society prevents
people in participating in and contributing to or limits the role they would normally play in
society. For example, a wheelchair user may score society depending upon their age, gender, and
very low on the DALY. However, this wheel chair social/cultural factors. A woman with cerebral
user may be a brilliant woman, married with chil- palsy may experience the handicap of not finding
dren, living in her own home, and earning an employment if a computer keyboard is not adapted
income and contributing to society as a computer to accommodate her ataxia. Impairment, such as a
software designer. Critics worry that because the cleft lip, may not cause a disability but may be a
DALY does not accurately portray the potential of handicap since it could limit a person’s ability to
disabled persons to contribute to society, policy relate socially.
decisions based on its framework may favor the The ICIDH also helped highlight for researchers
application of scarce health resources to extend and policy makers the role, power, and responsi-
the lives of the able-bodied over those with a dis- bility of society to become more accommodating
ability. The amount of funds officials will be willing for people with disabilities. For example, society
to allocate to education, job training, social inclu- can alter its attitudes toward disabilities and con-
sion, health services, accessible architecture, trans- struct accessible classrooms, offices, hospitals, and
portation systems, and other support infrastructure other public spaces. Removing barriers to
for disability may be far less.
328 A.T. Wilson
participation in family, community, educational, and its effect on a preschooler’s life. The ICF recog-
and vocational activities can then vastly improve nizes that ‘‘since an individual’s functioning and
economic, social, and health opportunities for peo- disability occurs in a context, the ICF also includes
ple with disabilities. However, while the ICF serves a list of environmental factors.’’ As such, the World
to classify disabilities without regard to the ability Health Organization has shifted in looking at dis-
of an individual to function in society, it does not ability from a medical model to a social model.
allow for the quantification of the burden of dis-
ease and disabilities on a society. As a result,
DALYs are still used in analyzing disease burdens
on a society and in calculating the cost–benefit of Disability in Developing Countries
proposed interventions.
Currently, the World Health Organization refers Traditionally, in developed countries, people with
to the ICIDH as the International Classification of disabilities were hidden from society and considered
Functioning, Disability, and Health (ICF) and sug- diseased or sick and in need of protection, treatment,
gests using it in clinical settings, health services, or and/or a cure. It was their families or welfare, health,
surveys and with individuals or at population levels. religious, and charitable organizations that assumed
WHO (2007) writes that the ICF ‘‘ . . .is a classifica- responsibility for caring for these individuals by
tion of health and health related domains that locking them away in institutions or sending them
describe body functions and structures, activities to special schools or sheltered workshops. Health
and participation. The domains are classified from care centered on developing prosthetics or providing
body, individual and societal perspectives’’ (WHO rehabilitation in order to fix the disability without
2003). Table 18.3 provides an example of ICF regard to the person’s spiritual or psychological self.
model scenarios that describe both the disability People with disabilities were not afforded the same
Table 18.3 ICF model scenarios in preschool children with physical disability in developing countries
Dimension Definition Girl, 3 years Boy, 5 years Girl, 4 years
Pathophysiology Molecular/cellular Burns to face, chest, Left cerebrovascular Hearing loss after cerebral
mechanisms arms accident malaria
after severe
dehydration
Body structures Organ structure/ Unable to lift arm Hemiplegia; Speech delays, 50db hearing
and body function above head or adaptive delays loss
functions extend elbows
Activity Ability to perform Runs well; Walks; very strong Speech understood 50% of
(functional) essential activities: memorizes songs with left hand time
strengths feed, dress, toilet, and stories
walk, talk
Activity Difficulty in Unable to carry Cannot run; has lost Speech not understood by
(functional) performing essential water from well animals during peers
limitations activities chores
Participation Involvement in Goes to church/ Helps in meal Loves to make baskets; herds
community roles mosque preparation animals
typical of peers
Participation Difficulty in assuming Because of stigma, No soccer because he No hearing aids available
restrictions roles typical of peers unable to leave is considered
hut for school ‘‘lame’’ by peers
Contextual Attitudinal, legal, Has younger Grandmother is Audiologist is available in
factors policy, and brother; minister positive influence; capital city (500 miles
architectural at church she encourages away); home village is not
facilitators encourages craft work on bus route
singing
Source: Msall and Hogan (2007)
civil and human rights that others enjoyed such as programs, in developing countries, movement
education, employment, freedom to marry, vote, toward a socially empowering model of full integra-
drive, use their natural language (sign language), tion of people with disabilities into society is still not
make decisions about their health care (could be prevalent. Nevertheless, a disproportionate share of
sterilized against their will), or own property. disabilities is born by the poorest individuals in the
Although not yet fully equal, women with dis- developing world. The WHO estimates that 10% or
abilities in developed countries, and in a few devel- 600 million people live with disabilities worldwide.
oping countries, enjoy richer, fuller lives than in the Metts’ World Bank study (2000) estimates that
past. Unfortunately, the governments of many ‘‘half a billion disabled people are undisputedly
developing countries have not legally recognized amongst the poorest of the poor,’’ while Elwan
the rights of their disabled citizens – or, if they do, (1999) contends that 15–20% of the poorest in
these laws often are poorly enforced. In some developing countries have disabilities. James
instances, people with disabilities have been targets Wolfensohn, former president of the World Bank,
of genocide and infanticide (Supple 2007). In some has said that ‘‘Unless disabled people are brought
cases, discrimination against children comes from into the development mainstream, it will be impos-
within the family itself. Parents can decide not to sible to cut poverty in half by 2015 or to give every
feed or care for their disabled child as they would girl and boy the chance to achieve a primary educa-
their able-bodied children. Parents can also make tion by the same date – goals agreed to by more than
health decisions, such as sterilization and institutio- 180 world leaders at the United Nations Millen-
nalization, over the objections of their disabled nium Summit in September 2000" (2002). Yet, dis-
child (Sullivan and Knutson 2000). ability is not mentioned specifically in any of the
Today, in most developing countries, clinics, Millennium Development Goals and its role in con-
health centers, and hospitals are not accessible to tributing to other MDGs is largely ignored in the
people with disabilities. Common barriers include, development framework (Secretariat of the African
but are not limited to, no ramps for people with Decade for Persons with Disabilities 2007).
motor difficulties, no materials in Braille, large Since people with disabilities are marginalized by
print, or on tape for women with vision difficulties, their community and discriminated against, it is
no sign language interpreters for deaf people, no one difficult to gather data on the incidence, distribu-
who can explain information at an appropriate level tion, or trends of disability. Barriers to data collec-
to people with cognitive impairments, and no doc- tion include the different conceptualizations of
tors or nurses trained or educated about the special disability throughout the world and the limited
health needs of people with disabilities. If a person number of censuses, surveys, or health records
with a disability is able to visit a clinic, there is still which can reliably report the number of people
often the view that they are not normal and must be with disabilities within a country. Eide and Loeb’s
cured or rehabilitated. Women with disabilities (2006) literature review of existing studies concern-
report that medical personnel often ask questions ing disability statistics showed the need to standar-
about their disability even when they seek assistance dize measures since the data suffered from ‘‘poor
for an entirely unrelated problem. For example, a quality, lack of comparability, and limited applic-
woman’s concern about sexually transmitted disease, ability.’’ Historically, the United Nations Disability
the flu, or a lump in her breast may be ignored in Statistics Database, or DISTAT, has amassed the
favor of asking about her spinal cord injury. largest amount of disability statistics assembled
Due in part to the lack of strong policies protect- from individual countries’ own national surveys,
ing the rights of people with disabilities, domestic censuses, and administrative records from as early
and foreign charitable organizations have histori- as 1970 and until 1995. Critics claim that the col-
cally assumed the role of caretaker and continues to lected data are outdated, random, inadequate for a
do so in recent years. Since the majority of these systemized analysis, and plagued by conceptual and
organizations are administered without the involve- definitional problems. For example, DISTAT
ment or the participation of people with disabilities reports data for Bangladesh from a 1987 demo-
in the planning, running, or evaluation of their graphic sample survey where interviewees were
330 A.T. Wilson
asked if anyone in the home was disabled and if so, overcrowded urban areas in search of employment
were they blind, crippled, deaf and dumb, mentally and find themselves working in unregulated, unsafe
handicapped, or other. Did the interviewees under- work environments that put them at high risk of
stand the terms given? Would the interviewer be accident-related impairments (such as spinal cord
able to explain the terms? How did their culture injury, physical, and/or cognitive injuries due to
view disability? Would family members hide the neurotrauma, partial or complete amputation of
person with a disability or even understand if a limbs), diabetes, exposure to dangerous chemicals
family member had a disability? Many concerns which can cause chronic respiratory or cardiovascu-
with the survey questions and design undermine lar diseases, and cancer. Women may be injured as a
the validity of the survey’s findings. Because of the result of violence from their employer or as a con-
lack of reliable data, monitoring equality and sequence of advocating for better working condi-
opportunity for people with disabilities in receiving tions. Poor people may have no recourse but to live
health care over time is relatively unfeasible. in unsanitary conditions where they are exposed to
However, interest in collecting valid data concern- pollutants in the air and water, debilitating diseases
ing disabilities is increasing. In 2001, the United such as tuberculosis or leprosy and other infectious.
Nations International Seminar on Measurement of The United Nations (2007) estimates that up to 25%
Disability formed the Washington Group on Dis- of disabilities may be the result of injuries and vio-
ability Statistics with the goal to standardize the lence such as child abuse, domestic abuse, youth
collection of disability statistics in order to compare violence, traffic accidents, falls, burns, war, and
the data between countries. The United Nations abandoned land mines, cluster bombs, chemicals,
Statistics Division annually collects country data and bullets. Disabilities may also occur because
such as: ‘‘. . . population size and composition, ferti- uneducated poor people may be unaware of the
lity, mortality, infant and fetal mortality, marriage high risks of passing on congenital disabilities when
and divorce’’ (United Nations 2006) in its Demo- marrying within the family (for example, Down syn-
graphic Yearbook and in March 2006, added basic drome, deafness, muscular dystrophy), or that a
statistics on disability. The World Bank is currently woman has a higher risk of giving birth to a disabled
working toward gathering disability statistics in part- child when over the age of 40, or if she has previously
nership with other international organizations. given birth to one or more children with a disability.
The Cycle of Poverty and Disability Disability Leads to Poverty
Poverty Leads to Disability When disabled people are excluded from the oppor-
tunity to gain the skills they need to take care of
Despite the inconsistency between how disability is themselves or denied the chance to generate their
defined and measured, and the questionable validity own income, they may slide into poverty. The UN
of the data that have been collected, one fact remains states that only 2% of people with disabilities are
consistent – the strong link between poverty and able to access basic services within their commu-
disability. Poverty can lead to disability, and disabil- nities. Marginalization from social institutions,
ity can lead to poverty. Poverty is a major factor in which create and enforce policy concerning basic
the increase in the number of people with disabilities services, means that children and adults with dis-
throughout the world. Preventable communicable, abilities do not attend school or receive vocational
perinatal, and maternal diseases, which cause dis- training, have lower expectations for themselves,
abilities, are regularly found in children of the are more vulnerable to exploitation and abuse, and
poor. Malnutrition, lack of immunizations, contami- are not included in economic development projects
nated injections, inadequate and poor health or med- or programs offered by domestic or international
ical care all contribute to disabilities. Refugees and organizations. Often times, a child or an elderly
people living in poorer rural areas are drawn to person with disabilities may be hidden away in
their homes because of a family’s shame, overpro- and devalued attributes: Specific physical or intellec-
tectiveness, or a lack of knowledge on how to care tual attributes may be valued or devalued depending
for their disabled family member. The disabled per- upon the society in which a child with a disability is
son then becomes permanently dependent on the born. For example, a ‘‘different’’ child may be
family that may then suffer economically if a wage accepted as a special gift from God, which leads to
earner needs to stay home to care for them. Some overprotection of the child. (c) Anticipated role: The
disabled children, adolescents, and adults, rejected role that people are expected to fulfill as adults in
by their families, become beggars or street workers their community determines how they are accepted
who are even more excluded from society. into their society. For example, the eldest adult son
For women with disabilities, the results of mar- in a family may assume extra responsibilities or a
ginalization can lower an already low ability to gain young woman may be expected to bring wealth to
access to resources needed for a health life. In many her family through marrying someone of similar or
countries, able-bodied women and girls have less higher status. The families may be concerned that
access to resources or opportunities compared to because of the disability, the child would not be able
able-bodied men and boys. Women and girls with to fulfill his or her anticipated role upon adulthood.
disabilities often receive even less attention and care Finally, lack of understanding about the cause
from their families and their communities. They are of a disability may lead to social exclusion. Some
denied rehabilitation, good nutrition, access to families with a disabled child are ostracized by their
maternal health care, or health care meant to pre- neighbors because of fear that the disability can
vent and treat illness. Only 1% of girls with disabil- spread to others or that associating with the child
ities in developing countries are enrolled in school or her family will bring bad luck. All of these
and their literacy rate is under 5%. Girls who do factors lead to discrimination toward people with
attend school attend for a shorter amount of time disabilities and their families and prevent them
than boys. In adulthood, women with disabilities do from participating fully in the economic, social,
not have equal access to paid employment. More- educational, and political life of their communities.
over, they are twice as unlikely to find work as their For women and girls with disabilities, discrimi-
male counterparts and are often forced to work in nation raises even more barriers to participation in
the informal market. Globally, approximately 300 society. If a baby girl is born with a disability and is
million women and girls with disabilities are doubly allowed to live, she must contend with negative
discriminated against because they live not only as attitudes and beliefs about disability from her
females but also as females with disabilities. family and community. Often girls with disabilities
are hidden within their homes where they care for
children and relatives, cook, clean, and do daily
chores. They have less access to health-care ser-
Countering Negative Social Beliefs vices, will not attend school or work, will be subject
Toward People with Disabilities to physical abuse, sexual abuse and higher risk for
HIV infection, will not receive rehabilitation ser-
Groce (2000) writes that various cultures assign a vices or HIV/AIDS education, testing, or access to
person’s disability or ‘‘difference’’ to three major clinical programs, and will receive less care and
categories of social beliefs that are frequently nega- food in the home than her siblings (Werner 1999).
tive: (a) causality: a cultural explanation which may Disabled women are discriminated against and
stem from religious beliefs or folk medicine for why remain marginalized and poor as a result of attitu-
a difference occurs. For example, a mother who dinal, social, cultural, environmental, and eco-
believes her child has a disability because of the nomic barriers of society. They often have no rights
evil eye cast her way during pregnancy may treat to own or inherit land, to earn a fair wage, be
the disabled child differently than her other children. promoted, or work without job discrimination.
Another mother of a child with epilepsy may believe The responsibilities and roles traditionally
the disability to be caused by ‘‘spirits’’ and could assigned to women for care of children and other
think of her child in a negative manner. (b) Valued family members mean that the experience of disability
332 A.T. Wilson
Fig. 18.1 Disabled village children disability frequency educational material. Source: Werner (1999)
is different for women than men. Some societies disabled village children. While the actual figures
believe that women with disabilities are unable to fill would be different depending on time and place,
the roles of a ‘‘good’’ wife and mother, thus assuming illustrative guides such as this one can be powerful
they are sexually inactive. As a result, societies may tools in expanding local knowledge about disability.
deny these women reproductive and maternal health
care and HIV/AIDS/STD information. However, it
has been shown that people with disabilities are as A Changing Approach to Health Care
sexually active as their able-bodied peers, are able to for the Disabled Poor
and do become pregnant, are as frequently homosex-
ual and bisexual as society as a whole, use drugs and
Through time, a new perspective has emerged
alcohol, and are at higher risk of being victims of
through the work of human rights advocates and
domestic and sexual abuse. Disregarding the sexual
Disabled People’s Organizations where, as explained
activity of disabled women, society keeps health care
earlier in this chapter, people accept the social model
inaccessible to their special needs and denies the sex-
of disability. This change may particularly improve
ual and physical abuse they suffer. This cycle serves as
the lives of women and children with disabilities.
an example of how societal beliefs and incorrect
assumptions put women, their children, their part-
ners, and families at greater health and economic risk.
Interventions aimed at educating local health- Prevention, Increased Information,
care workers on the nature of disabilities may help and Advocacy
counteract the prevalence of negative societal beliefs
toward disabled women and children, especially as Many childhood disabilities are preventable. Health
they relate to health care. Below is a chart from care for low-income countries must incorporate stra-
Disabled Village Children: A Guide for Community tegies to address sources of disabilities, such as pro-
Health Workers, Rehabilitation Workers, and tein energy malnutrition, iodine deficiency, and
Families (Fig. 18.1). This chart uses records of 700 infectious disease. Table 18.4 suggests some success-
children seen at PROJIMO, Mexico, between 1982 ful public health strategies for reducing the overall
and 1985. It uses visuals, such as the little drawings prevalence of disabilities and achieving a healthier
of people, to show how many children might have society.
each disability in a group of 100 significantly
Table 18.4 Strategies for preventing disabilities and promoting disability awareness
Primary Level Secondary Level Tertiary Level
Increase immunization coverage Screen for genetic disorders Improve mother–child interaction to
encourage better bonding and lower
negative attitudes
Provide iodine, iron, zinc, and vitamin Screen for neonatal hypothyroidism Provide better education and training for
A supplementation through national children in need
programs
Develop school-meal programs Identify intellectual and other Use different tools to improve hearing
disabilities in school and the impairment
community
Improve parenting skills through Increase level of awareness within the
schemes such as the Portage guide to community; teachers to identify
home teaching impairments
Improve antenatal and postnatal care
through programs such as Safe
Motherhood
Share information on birth spacing
and harm of consanguineous
marriage
Source: Maulik and Darmstadt (2007)
334 A.T. Wilson
Although little research has been done in the area vocational services. Most services are offered in
of gender, development, and disability other than large urban areas which may be difficult for people
gathering statistics, international agencies are now with disabilities to access because of transportation
beginning to recognize the need for more informa- and communication barriers. About 30 years ago,
tion (Singleton 2004). In 1997, disabled women from the World Health Organization and UNESCO
around the world began to organize and network at recognized this dilemma and noted that rehabilita-
the International Leadership Forum, where women tion services were few and far between in rural areas.
from 80 countries met in Washington, DC, as a In response, the concept of Community-Based
follow up to the 1995 United Nations 4th World Rehabilitation (CBR) was created where services
Conference on Women in Beijing. The purpose of would be brought and taught to community and
the 1997 Forum was to monitor progress on the family members of those with disabilities. The goal
implementation of the Beijing Platform for Action. was to integrate people with disabilities in their
In addition, 10,000 women met at the United home communities, to begin educating the child as
Nations ‘‘Beijing+5: Women 2000 – Gender Equal- a toddler, to eliminate physical and social barriers in
ity, Development and Peace for the 21st Century.’’ the community, to improve the health of the person
Among the participants were 65 women with dis- with a disability, and to make them more indepen-
abilities from 31 countries who participated in the dent socially and economically. CBR is the official
overall activities and in a training program. The approach used by many countries although not all
nonprofit group Mobility International – USA CBR is the same. Some countries have set up centers
holds Women’s Institutes on Leadership and Dis- where visits are made, while others have trained
ability and has published materials which document nonprofessionals to make home visits to train
the many successes of women with disabilities from family and community members on how to do activ-
around the world (MIUSA 2007). ities with their disabled child such as physical ther-
apy, vocational training, games to stimulate their
child’s interest in the world around her, and using
Community-Based Rehabilitation sign language with deaf children and adults. The
ideal CBR program would be administered by peo-
Eighty percent of people with disabilities in devel- ple with disabilities and disabled trainers, but this is
oping countries live in rural areas where they have often not the case. The African Development Foun-
little or no access to schooling, health care, or dation lists both the pros and the cons of the CBR
Table 18.5 The achievements and limitations and risks of the CBR approach
Positive achievements Limitations and risks
Creates self-employment Becomes a top-down and technical project of community
Builds up self-confidence and reduction of dependence leaders, professionals, or the donors
and begging Does not rely on active participation and involvement of
Positively changes community attitude PWDs
Integrates person with disabilities (PWDs) into social and Competes for scarce community resources
economic development Emphasizes ‘‘fixing’’ children’s disabilities, neglecting the
Encourages funders to support more community-based vocational, educational, and employment components
activities Creates suspicion among PWDs that they are being used by
Empowers people with disabilities to display their talents nondisabled persons
within the society while participating in income- Undermines local initiatives
generating activities Becomes politically motivated (e.g., a wheel chair donated
Utilizes locally available resources to a deaf person by a politician who had no knowledge of
Creates sustainability by developing society’s capability the latter’s needs)
Achieves the hitherto unreached Becomes difficult to coordinate because of lack of
cooperation from the individual, family, or the community
Duplicates services from other programs
Source: African Development Foundation (2007)
approach to reaching people with disabilities in participate in the creation of public policy, will
rural areas (Table 18.5). their economic, educational, and legal rights be
A greatly modified and more holistic vision of achieved. The health needs of women with disabil-
CBR is being written through the collaboration of ities will increasingly include problems beyond
the International Labor Organization, the World maternal health care, and health interventions
Health Organization, UNESCO, Disabled must consider the unique characteristics of these
People’s Organizations, and 13 International Non- women’s lives that affect their ability to address
governmental Organizations. The new CBR guide- these problems.
lines, being field tested in 25 countries, contain five International health-care providers attempting
key domains which are necessary for all people to to work with women and children with disabilities
live with dignity and well-being and which reflect in developing countries must seriously consider
many of the core concepts found in the UN Con- effective strategies suggested by people with disabil-
vention on the Rights of People with Disabilities. ities (Wilson 2006). A preliminary suggestion is that
The key components of the new CBR guidelines are the organization’s staff includes people with disabil-
health from existing health facilities, education ities both domestically and in the host country. This
from regular school or college, livelihood through change would necessitate a working environment
traditional skills, income generation programs and that is accessible to all. MIUSA (2007) publishes a
micro-credit, social inclusion and participation manual, funded by the United States Agency for
through local cultural initiatives and community International Development, which clearly describes
life, and empowerment (Khasnabis and Heinicke how to make projects and programs inclusive both
2008). Rather than the older version of CBR at home and abroad. The manual includes sugges-
which was medically focused, these CBR guidelines tions such as how to adapt technology for people
support including people with disabilities in all with disabilities or how to make meetings, confer-
aspects of society, which can be seen in Fig. 18.2. ences, web sites, and information accessible to
everyone.
Another suggestion for health care providers
working with women and children overseas is that
they work directly with organizations run by dis-
abled women rather than organizations that may be
taking care of women with disabilities rather than
empowering them. While in some cases, women’s
disabilities may be so severe that this approach may
not be possible, in many cases; international orga-
Components of CBR The Universe of CBR nizations can involve disabled women in the plan-
ning, implementation, and evaluation of the project
Fig: 18.2 The components and universe of CBR. Source:
Khasnabis and Heinicke (2008) or program. Often, Disabled People’s Organiza-
tions (DPOs) are run by disabled men. Therefore,
if no women’s organization exists, the local DPOs
Strategies and Health-Care Programs
should be encouraged to work with female members
for Women with Disabilities of the DPO either separately or in collaboration
with the entire DPO. When possible, it is advisable
Development agencies are looking at poverty reduc- to work directly with women who are disabled –
tion programs, the human rights of women with they know themselves best.
disabilities, and long-term strategies to empower In the case of working with children with disabil-
women with disabilities. These agencies must be ities, it is best to work directly with those who are
aware that the resources and opportunities afforded affected by or live with the child. Parents are the
to men are not granted to women. Not until these best advocates for their children and have made
inequalities are balanced out, until women are the foremost impact on local and national policies
represented in government institutions and can throughout the world. Parents are often eager to
336 A.T. Wilson
fight for the rights of their children and to find them about sexuality, pregnancy, childbirth and parent-
appropriate health care. In addition, adults who ing, protection against sexual abuse, and against
have grown up with the disability are also able to HIV/AIDS or STDs.
provide valuable insight and advocacy. Disabled Women and girls with disabilities should be pro-
adults may also be able to help parents and health- vided health education as well as the opportunity to
care workers better understand how a disabled child learn more about their own disabilities and how to
perceives their world and the services they receive. care for themselves. Only if women and girls with
With age-appropriate support, disabled adolescents disabilities possess the knowledge about their own
can advocate for themselves. As they are young health care needs will they be able to take control
enough to remember what it is like to be a child, over, and make informed decisions about, their own
they may, accordingly, have further firsthand health and well-being. They can then educate their
insights to share on the needs of younger disabled families, neighbors, and health-care providers about
children. their needs.
The health care provider must also understand Women and girls with disabilities or parents of
(a) the many challenges and barriers that women children with disabilities could benefit from support
with disabilities confront in their daily lives; (b) groups. It is empowering for women to meet with
how different cultures respond to disability; and one another to share their stories and experiences
(c) how societies construct the meaning of disabil- and to know there are others who understand what
ity. For example, a health-care worker would need their lives are like. Women can share the knowledge
to ask and answer questions such as, ‘‘In the they have learned with one another, plan social
majority culture, is being deaf perceived as either outings for their own pleasure, and to model to the
a negative or a positive attribute? Is there a reli- community their ‘‘normalness,’’ and open the group
gious belief that blindness is a gift, or punishment, to others who may have no network outside of their
from God?’’ Providers should also be trained and home where they can make friends and learn social
knowledgeable about the special health-care needs skills. They can also work with one another to bring
of women with disabilities and how best to care attention to the unfair treatment of, or discrimina-
for them. (The best source for information on tion against, women and girls with disabilities in
health care for women with disabilities in devel- their community. Support groups sometimes
oping countries is ‘‘A Health Handbook for become more formal women’s organizations where
Women with Disabilities,’’ which was developed members organize, learn leadership skills, start up
with help of 40 different groups of women with small businesses, network with other disability orga-
disabilities in 27 countries around the world.) nizations, request funding for small projects, and
Health-care providers can be advocates and work advocate for their civil and human rights both
alongside parents and women with disabilities to regionally and nationally.
lobby local and national government agencies to Both support groups and more formalized
write appropriate and fair health-care policies or women’s organizations can work alongside health-
to uphold existing ones. care providers in being more ‘‘out’’ about their dis-
Women and girls with disabilities in developing ability and increasing community awareness.
countries should be made aware that even small Groups of women can make simple posters portray-
steps toward equal health care could make a big ing aspects of their discrimination or things that
difference in their lives. Most often women and should be changed in their environment. Empow-
girls with disabilities are not taught about groom- ered women can hold information sessions (‘‘aware-
ing and self health care since they are excluded ness events’’) for families, organize shows (hand-
from formal schooling and from the informal edu- made art, cooking, or a little play) for the
cation of family conversations where information immediate community, visit community services
and experiences are shared by mothers, sisters, together, and work toward improving their assistance
and aunts or by other women in the immediate to people with disabilities. Instead of remaining iso-
community. Therefore, they may lack basic lated at home, women can support one another in
knowledge about proper care of their own body, joining community or church activities, in town or
tribal meetings, and at family gatherings. They can (MDG #1) will be possible only through recog-
play an active role in promoting change and changing nizing that disabled people and their families
attitudes about people with disabilities. represent a very substantial proportion of the
Health-care providers can learn from these dis- poor. A reduction in child mortality (MDG #4)
ability groups as well as support them in creating must combat under-5 mortality of disabled chil-
appropriate materials (information, books, tools, dren, which can be as high as 80% in some
trainings). Talk to them about their needs; let them regions of Africa (UNICEF 2007b). Similarly,
educate you about their situation. Do not impose the improvement in maternal health (MDG #5) will
changes without their involvement and direct parti- be achieved only by addressing the disabling
cipation. They may not be aware of the existing impairments associated with pregnancy and
disability policies or health policies within their childbirth, affecting up to 20 million women a
country or the UN Convention on Rights of people year. To combat HIV/AIDS, malaria, and other
with disabilities. Health-care workers should teach diseases (MDG #6), we will need to account for
them how to be advocates for themselves in getting the fact that disabled people are particularly
appropriate health care and help them establish sup- vulnerable to these diseases (which are also a
port groups and assist them in some of the activities major cause of disabling impairments) (Secretar-
mentioned above. Health service organizations iat of the African Decade for Persons with Dis-
should cooperate with other agencies that represent abilities 2007).
women and girls with disabilities and encourage
them to lead the way in promoting the changes
related to health care (topics such as establishing
women health/body education, multileveled accessi- Conclusion
bility of the health-care system and information,
education of professionals in health-care system, Meeting the unique health needs of women,
public awareness employment of women with dis- children, and adolescents with disabilities in
abilities in health-care system). developing countries demands (a) a societal
change in its attitudes concerning disability; (b)
writing and enforcing health-care policies country
Incorporating Disability into MDG
by country; (c) empowering people with disabil-
Strategies ities to advocate for their own health care per-
sonally and politically; and (d) comprehensive
Achieving MDGs will require an explicit disability training for health-care practitioners in under-
dimension to be incorporated into these efforts. standing how to communicate effectively with
For example, the Secretariat of the African Decade their disabled clients as well as to offer appropri-
for Persons with Disabilities (2002) asserts that ate and accessible services to people with
the eradication of extreme poverty and hunger disabilities.
Key Terms
Able-bodied Autonomy Closed captioning

Abuse Built environment Cognitive disability
Access to health care Cerebral palsy Community-Based
Accidents Chronic infections Rehabilitation (CBR)
Amputation Civil rights Conflicts
338 A.T. Wilson
Congenital impairments Handicap Poverty

Deaf children Human rights Quality of life
Dignity Impairment Rehabilitation
Disability Inclusion Sign language
Disability-adjusted life year Injuries Social acceptance
(DALY) International Classification of Social stigmatization
Disability weights Functioning, Disability and United Nations Convention on
Discrimination Health (ICF) the Rights of Persons with
Disparities International Classification of Disabilities
Down syndrome Impairments (ICIDH) United Nations Disability
Empowerment Malnutrition Statistics Database
Environmental risks Marginalization (DISTAT)
Exclusion Mobility United Nations Enable
Exploitation Motor disabilities Violence
Gender Muscular dystrophy
Habilitation Neurotrauma
and Development Cooperation. University of Leeds,

Questions for Discussion Leeds England: The Disability Press
Elwan A (1999) Poverty and disability: a survey of the litera-
1. Briefly discuss one major barrier to having a ture. Social Protection Discussion Series No. 9932. Social
Protection Unit, Human Development Network, The
universally acceptable definition of disability. World Bank. http://siteresources.worldbank.org/DISABI
2. Distinguish between the medical and social fra- LITY/Resources/280658-1172608138489/Poverty DisabEl
meworks by which disability can be defined. wan.pdf, cited 8 August 2008
3. List any five causes of disability among women, Groce N (2000) Guest Editorial: Framing disability issues in
local concepts and beliefs. Asia Pacific Disability Reha-
children, and adolescents in less-developed bilitation Journal, 10
countries. Khasnabis C, Heinicke MK (2008) The participatory devel-
4. In an essay of not more 1,000 words, describe the opment of international guidelines for CBR. Leprosy
relationship between disability and poverty. Review 79: 17–29, http://www.lepra.org.uk/lr/Mar08/
Lep17-29.pdf, cited 22 August 2008
5. In what ways does disability affect access to Maulik P, Darmstadt G (2007) Childhood disability in low-
health and social services for women, children, and middle-income countries: Overview of screening, pre-
and adolescents in less-developed countries? vention, services, legislation, and epidemiology. Pedia-
6. List any five strategies for improving the quality trics, 120, S1–S55
Metts R (2000) Social Protection Discussion Paper No. 0007.
of life of women, children, and adolescents with World Bank. http://siteresources.worldbank.org/SOCI
disabilities. Discuss the potential barriers to ALPROTECTION/Resources/SP-Discussion-papers/Di
implementing any of them. sability-DP/0007.pdf, cited 8 August 2008
MIUSA: Mobility International USA (2007) Institute on
Leadership and Disability (WILD). http://miusa.org/
wild, cited 8 August 2008
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Chapter 19
Unintentional Injuries in Children
William Pickett, Marianne Nichol, and John E. Ehiri
Learning Objectives After reading this chapter and developing countries are also least equipped to
answering the discussion questions that follow, you prevent and manage injuries. Risk for uninten-
should be able to tional injury varies by developmental stage,
socioeconomic factors, environmental factors
Identify key approaches for quantifying and
that protect or endanger the child, and charac-
measuring the burden of childhood injury.
teristics of child behavior. Effective strategies for
Discuss the contribution of injuries to global
prevention must consider engineered changes to
childhood mortality.
the physical environment and legislative regula-
Discuss the importance of analyzing childhood
tion, in addition to educational interventions.
injury from a developmental perspective (i.e.,
Injury prevention is a growing field and, while
according to developmental stages of children).
disease surveillance is an established practice,
Identify and appraise developmental, environ-
effort is needed to create inexpensive and evi-
mental, socioeconomic, and behavioral corre-
dence-based prevention strategies for developing
lates of childhood injuries.
and developed nations.
Discuss factors related to inequity in childhood
With the advent of methods to control the devel-
injury with regard to developed and less-developed
opment and spread of infectious disease, the pre-
countries.
vention of childhood injuries has emerged as per-
Assess the evidence base of interventions to pre-
haps the leading public health challenge in some
vent childhood injuries.
countries. There are few children in our world who
do not feel the impact of injuries in their lives.
Injuries happen frequently. They leave a substantial
toll in terms of pain and suffering. The medical
Introduction
system and society in general incur great costs
from injuries. In North America, as in many devel-
Unintentional injuries are the leading cause of
oped countries, once a child survives through
death for children in many developed countries,
infancy, injury becomes the leading potential cause
contributing more to potential life years lost
of death until middle age. Injury also contributes
than most other major causes of childhood ill-
more in terms of children’s potential life years lost
ness combined. While infectious diseases and
than cancer, cardiovascular disease, and other
nutritional deficiencies still dominate the mor-
major causes of illness combined.
bidity and mortality of children in developing
Within the past few decades, the epidemic of
countries, 98% of unintentional injuries occur
injuries has emerged as a major focus for preven-
in these parts of the world. Unfortunately,
tion programs (WHO 2006). Once viewed and per-
haps dismissed as unfortunate ‘‘accidents,’’ health
W. Pickett (*)
professionals have come to realize that injuries can
Department of Community Health and Epidemiology,
Abramsky Hall, Queen’s University, Kingston, Ontario, be viewed conceptually as a disease with known
K7L 3N6, Canada causes, documented physical effects, and
342 W. Pickett et al.
predictable patterns of occurrence. Disease models Key Definitions

and preventive thinking, originally developed for
other causes of illness, have been adapted to child- A number of technical terms are used in this chapter,
hood injury and have been helpful in establishing and here, we provide operational definitions for the
prevention initiatives and standardized treatment terms used repeatedly.
protocols. Through this process, a new collection
of sciences emerged – those concerned with best
practices for injury control.
Injuries in children may be more severe and Injury Terms
have more lasting consequences than similar inju-
ries in adults. Vulnerabilities include the potential Injury is defined as physical harm to the body
for growth plate fractures that could result in dis- caused by an acute physical, thermal, or chemical
figurement as the bone continues to grow, general force. Studies of childhood injury typically use
organ immaturity that confers greater susceptibil- thresholds such as death, admission to hospital
ity to the harmful effects of environmental toxins, overnight, and presentation for medical treatment
thin epidermis that increases the severity of burns, to make inferences about severity. Trauma is a term
proportionately greater body surface area to that is often used interchangeably with injury and
volume that increases relative surface fluid loss refers to injuries that reach a certain threshold of
after burns, smaller airways conferring greater severity based upon standard clinical criteria. Unin-
risk for aspiration, and immunological immaturity tentional injuries are those injuries without known
that may complicate recovery from injury (Bartlett intentional causes. Injury surveillance is the routine
2002). monitoring, analysis, and interpretation of injury
Injury control scientists often categorize inju- data for the purpose of informing prevention, treat-
ries into intentional and unintentional. Inten- ment, and research efforts. This specialized form of
tional injuries are those involving intentional disease surveillance provides evidence from which
harm to the victim and include not only injuries the problem of injury can be understood and
caused by others but also those due to self-harm. addressed in an effective manner.
Unintentional injuries are those that have been
traditionally called ‘‘accidents’’ (a term that is
often discouraged these days because it implies
that injuries are fatalistic in nature with no Child Development Terms
underlying causes). Because intentional and
unintentional injuries have such different pat-
One focus of this chapter is to profile the occurrence
terns and etiologies, they are rarely considered
of injury over key developmental stages. The latter
together.
simply refers to age groups that share common
This chapter will focus on unintentional injuries
developmental characteristics and associated injury
to children. The main purpose is to profile the
risks. Here, we have concentrated on infants (<1
occurrence of unintentional injuries in populations
year), preschoolers (1–4 years), young children (5–9
of children and to comment on their underlying
years), and adolescents (variably defined, depend-
determinants as well as possible approaches to
ing upon the data source).
prevention. In doing so, we present known dispa-
rities in childhood injury risk according to estab-
lished social determinants, rates of fatal and trau-
matic injury across countries, leading external
Descriptive Epidemiology Terms
causes, and consequences of traumatic injury by
age and sex. Current evidence surrounding the
relative effects of different preventive approaches There are also a number of standard epidemiologi-
is summarized with suggested implications for pre- cal terms used in this chapter. The first of these is the
vention and future research. term risk for injury, which is a per capita rate of
19 Unintentional Injuries in Children 343
injury occurrence (e.g., per 1,000 persons) within a of fatal and nonfatal injury. Patterns of injury vary
population over a fixed period of time. A childhood strikingly between different data sources and injury
injury rate can be interpreted as the probability that control scientists need to look at all available
a child in a defined population will experience sources in order to obtain a complete composite
an injury during a relevant time period, typically picture.
1 year. Patterns of injury refer to analyses that
describe common characteristics associated with
injury events (e.g., demographic, external causes,
locations, timing, etc.) that are helpful for the plan- Fatal Childhood Injuries
ning of prevention efforts.
Rates of fatal childhood injury have been compared
cross-nationally in order to demonstrate the magni-
Measures of Disease Burden tude and universal nature of the problem. One of
the most notable recent reports of this kind is the
UNICEF Report from Rich Nations (UNICEF
Potential years of life lost (PYLL) refers to the
2001). This landmark report clearly shows that
cumulative number of potential years lost (average
child deaths due to injury are universally important,
life expectancy minus age at death) attributable to a despite striking variations in fatal injury risks across
disease within a defined population. PYLL is a
different societies. The authors were unable to
particularly important measure of disease burden
obtain analogous data from countries without cen-
for childhood injury because it captures the rela- trally, organized vital statistics registries; however,
tively long length of time between the disease event
it is expected that rates from those nations would
and the life expectancy in the absence of the event.
dwarf those depicted in Fig. 19.1. Among the coun-
A second measure of injury burden is the economic tries examined, 4–6-fold differences in rates of fatal
cost of injury. Economic costs are typically divided
injury were observed. This suggests that environ-
into two categories: direct and indirect costs. Direct
mental conditions leading to injury risks as well as
costs refer to medical costs including treatment and approaches to childhood injury control vary widely
rehabilitation. Indirect costs refer to productivity
between countries and cultures.
losses attributable to injuries and are calculated
Boys consistently experience higher rates of fatal
using measures such as goods and services that are injury than girls. This is a finding that is almost
not produced due to the injury, time lost from work,
always observed irrespective of data source or
lost wages, lost benefits, and lost ability to perform
population under study. There are many arguments
household responsibilities. about why this pattern of injury exists. Some scien-
tists would argue that the pattern is a natural phe-
nomenon as boys are more likely to behave in
manners that place them at increased risk. Others
Significance of Topic would attribute the pattern to the ways in which
boys and girls are nurtured. For example, boys in
In the past, injury surveillance projects have demon- developing countries are typically allowed more
strated the magnitude of the childhood injury pro- freedom than girls, which contributes to a higher
blem relative to other health conditions. These incidence of falls, drowning, and motor vehicle
studies have shown that it is important to use dif- crash injuries in boys (Bartlett 2002). However,
ferent data sources to examine the childhood injury girls in developing countries are more likely to
problem, as the risks and patterns observed vary by experience burns attributable to time spent indoors
severity of injury. For example, patterns of causes and cooking (Krug et al. 2000). Irrespective of the
and consequences may differ substantially between explanation, variations in exposure exist between
fatal and nonfatal injuries. As well, traumatic inju- the sexes and these lead to differential injury risks.
ries that require hospital-based medical care and The result is an overall higher burden of injury
rehabilitation are very different from other forms experienced by boys.
Fig. 19.1 Injury deaths by

gender and country. Source:
UNICEF (2001)
Nonfatal Childhood Injuries multiple injury events, which in some cases is likely
to reflect differences in access to medical care. Addi-
Rates of nonfatal injury have also been examined in tional analyses of these cross-national data (not
cross-national studies. The example provided in shown) indicate that nonfatal adolescent injuries
Fig. 19.2 highlights an international comparison of result in major productivity losses assessed by time
nonfatal injuries among adolescents in 35 (mainly lost from school, work, or other usual experiences.
European) countries (Pickett et al. 2005). These They also lead to major direct costs attributable to
comparisons focus on childhood injuries requiring emergency medical care, hospitalization, and post-
medical attention from a doctor or a nurse. In addi- injury rehabilitation.
tion to being a major health problem, one should
realize that experiences with injury are a normative
part of growth and development. Figure 19.2 clearly
depicts that most boys and a large percentage of Injury Pyramids
girls from the general school systems experience
one or more medically treated injuries each year. Injury control researchers often speak of fatalities
Differences between countries in the observed risks as representing the ‘‘tip of the iceberg’’ or the ‘‘top of
are mainly attributable to children reporting a pyramid’’ with respect to the magnitude of the
Fig. 19.2 Annual

prevalence of medically
treated injuries among
adolescents in 35 countries.
Source: Pickett et al. (2005)
underlying problem. This concept has been illu- These ratios vary by demographic group and for
strated using a diagram called an ‘‘injury pyramid.’’ different external causes of injury, and provide a
A good example of this concept is presented in rough illustration of the relative severities of differ-
Fig. 19.3 using national data compiled by the US ent injury patterns. For children aged 5–14 years in
Centers for Disease Control and Prevention the United States, the ratio is 1 death to 41 hospi-
(Fingerhut and Warner 1997). Among the general talizations to 1,100 emergency department visits (no
US population (all ages), for every death experi- data on total injury events were provided). Similar
enced due to injury, there are approximately 20 injury pyramid ratios of 1 to 160 to 2,000 have
people hospitalized, 250 people who present to an been published for children aged 0–14 years in the
emergency department, and 400 people who experi- Netherlands (UNICEF 2001) and 1 to 73 to 1,612 in
enced an acute injury episode (1 to 20 to 250 to 400). Alberta, Canada (Spady et al. 2004). These ratios
Fig. 19.3 Injury pyramid

for the United States, 1995.
Source: Fingerhut and
Warner (1997)
Deaths (1)
147,891
Hospital Discharges
(18)
2,591,000
Emergency Department Visits (250)
36,961,000
Episodes of Injuries Reported (400)
59,127,000
help to describe the extent and distribution of the combined cancers and heart disease on the other
problem. They are particularly informative for hand accounted for 16.2% and 12.2% of total
populations of children who experience enormous PYLL, respectively (CDC 2005).
risks for both fatal and nonfatal injury.
Economic Costs of Injury

Person Years of Life Lost
Another important measure of disease burden that
Person years of life lost (PYLL) provide another has been emphasized in recent years is the economic
helpful measure describing the relative burden of costs of injury and there is a growing literature in
injuries experienced in child populations. This sta- this field of study, particularly in North America.
tistic sums up the differences between the ages at Much of this literature aims to demonstrate the
which children die and their expected lifespan based enormous importance of injury as a health problem
upon life expectancy projections for their popula- and is used as a tool for injury control practitioners
tion. For example, if a child dies prematurely at the to lobby for increased societal resources. For exam-
age of 10 due to an injury event, and their expected ple, a recent US analysis estimated the lifetime costs
lifespan is 75 years, this injury has contributed 65 attributable to childhood injury at 50.5 billion US
PYLL to an overall summary figure. In some coun- dollars (Finkelstein et al. 2006). This estimate was
tries, because injury is so heavily concentrated in broken down to 11.9 billion dollars in lifetime med-
children and young people, it is thought to contri- ical costs and 38.6 billion in total lifetime produc-
bute more PYLL than all other major causes of tivity losses. Among children 0–14 years of age,
death including respiratory disease, cardiovascular fatal, hospitalized, and nonhospitalized injuries
diseases, and cancer. To illustrate, in 2004, uninten- accounted for 8.4, 8.4, and 33.8 billion dollars in
tional injury was the leading cause of death in the total lifetime costs, respectively. These costs have
United States in terms of years of potential life lost obvious impact on societies and the individuals
(PYLL), accounting for 19.1% of total PYLL due within those societies, and are a major burden that
to premature death in the United States; all goes beyond the direct effects of pain and suffering.
Common Causes of Unintentional with 5.7 deaths per 100,000 persons and 7.3
Childhood Injury deaths per 100,000 persons among those 5–9 and
10–14 years, respectively. The unintentional
Childhood Injury from a Developmental injury mortality rate among those 15–19 years of
Perspective age in 2004 was 32.9 deaths per 100,000 persons
(CDC 2005).
Analyses of the risks for injury experienced by
children of different ages provide important
information. Studying childhood injury from a
developmental perspective is helpful for the External Causes of Childhood Injury
design of focused prevention initiatives that are
tailored to the needs of specific groups of chil- Leading causes of injury-related death have been
dren. This information is also helpful in setting described for children of different ages. These are
priorities about the groups of children who are helpful in planning tailored injury control strate-
most at risk, assuming that larger childhood gies. Table 19.1 provides such an analysis for
injury risks would be preferentially addressed children in the United States. The patterns
over smaller ones. Many people have studied observed here are typical of many developed
variations in injury experiences among children nations (CDC 2003). Among the very young
of different ages and hence developmental stages. (infants <1 year), the leading causes of uninten-
One approach to such analyses is to examine the tional fatal injury include suffocation, followed by
proportions of all deaths that are attributable to traffic crashes, drowning, fire, and flames. As chil-
injury. According to the WHO (2006), the pro- dren enter their preschool years, traffic crashes,
portions of deaths attributable to injury increase drowning, fire and flames predominate. This pat-
as children age. Worldwide, injury accounted for tern becomes more apparent as children enter into
approximately 1.5% of deaths observed among adolescence. This figure is also helpful in showing
infants, 6% of deaths among preschoolers aged the relative importance of unintentional versus
1–4 years, 25% of deaths to children 5–9 years, intentional (homicide, suicide) injury events as a
and 31% of deaths to children 10–14 years of cause of fatal injury, with noted variations between
age. age groups.
A second approach to the profiling of injury risks Data from emergency department-based sur-
across childhood developmental stages is to exam- veillance systems can also be used to examine
ine age-specific rates of injury. In the United States, developmental changes in patterns of nonfatal
the rate of unintentional injury remains relatively injury. Flavin and colleagues used a regional,
stable throughout childhood. According to the population-based surveillance in Canada to iden-
CDC (2005), the rate of unintentional injury in tify leading external causes of acute injury in the
2004 among those 0–4 years of age was 11,375 very young (Flavin et al. 2006). Patterns observed
injuries per 100,000 persons. Similarly, the rate among these nonfatal injuries were strikingly dif-
among those 5–9 years of age was 9,203 injuries ferent than the above fatal injury patterns.
per 100,000 persons and the rate among those Across all developmental groups examined (<1,
10–14 was 11,075 injuries per 100,000 persons. 1–2, 3–4, 5–6 years), the leading external cause of
Among adolescents 15–19 years of age, the rate of nonfatal injury was falls. Falls have not been
unintentional injury in 2004 was 12,950 per 100,000 identified as a major contributor to fatal child-
persons. hood injuries. Ingestion of foreign bodies, which
Annual rates of unintentional injury mortality occurs as a result of children’s propensity to
are similar across age groups as well, except for a explore their environments using their mouths,
marked increase among those 15–19 years of age. was listed as the second leading cause of injury
The rate among those 0–4 years of age was 13.4 among the youngest age groups. Being struck by
deaths per 100,000 persons in 2004 compared an object or a person was another leading cause
Table 19.1 Leading causes of injury death by age group highlighting unintentional injury deaths, United States – 2003
Rank <1 year 1–4 years 5–9 years 10–14 years
1 Unintentional suffocation Unintentional MV traffic Unintentional MV traffic Unintentional MV
619 502 597 traffic
911
2 Unintentional MV traffic Unintentional drowning Unintentional fire/burn Suicide suffocation
144 456 137 152
3 Homicide unspecified Unintentional fire/burn Unintentional drowning Unintentional
135 229 126 drowning
142
4 Homicide other spec. Unintentional suffocation Unintentional land Homicide firearm
classifiable 159 transport 139
100 50
5 Unintentional drowning Homicide unspecified Homicide firearm Unintentional land
58 153 48 transport
81
6 Homicide suffocation Unintentional pedestrian/ Unintentional suffocation Unintentional fire/
39 other 37 burn
116 78
7 Undetermined suffocation Homicide, other spec. Unintentional other Suicide firearm
38 classifiable transport 73
84 21
8 Unintentional fire/burn Unintentional fall Homicide unspecified Unintentional
32 54 18 suffocation
44
9 Unintentional natural/ Unintentional poisoning Unintentional poisoning Unintentional
environment 49 18 poisoning
20 43
10 Unintentional poisoning Homicide firearm Unintentional natural/ Unintentional firearm
20 40 environment 36
17
Source: CDC (2003)
in most age groups examined. Being struck by an Social Disparities and Vulnerable
object or a person and collisions with objects or Populations
people emerge as leading causes of injury in the
older age groups and reflect the increasing mobi- While very good literature exists to describe risks
lity of children as they age. The rank order of for childhood injury and immediate circum-
patterns of childhood injury observed in US stances surrounding childhood injury occurrence,
emergency departments is shown in Table 19.2 there is much to learn about underlying causes
(CDC 2004). of injury to children. It has only been in the past
The locations where injuries occur also vary as two decades that research efforts have gone
children age. Most injuries among the youngest age beyond basic descriptive efforts to the examina-
groups happen at home where parents or guardians tion of determinants using modern study
are the responsible authority (Flavin et al. 2006). As approaches. One etiological topic of emerging
children become older, they spend more time out- interest is the idea that there are underlying
side the home and consequently experience injuries social determinants for health and illness and
in a more diverse array of locations such as daycare hence injury experiences are directly influenced
centers, schools, organized sports facilities, and by social disparities. This is supported by mod-
occupational environments. These variations will ern population health theory, which suggests
have an obvious influence on the targeting of inter- that many diseases have underlying biological,
ventions to those responsible for the care of physical, and social determinants. The result
children. has been the identification of strong gradients
Table 19.2 National estimates of the 10 leading external causes of nonfatal injuries treated in hospital emergency depart-
ments, United States 2004, by age group
Rank < 1 year 1–4 years 5–9 years 10–14 years
1 Unintentional fall Unintentional fall Unintentional fall Unintentional fall
126,281 888,335 676,704 668,589
2 Unintentional struck by/ Unintentional struck by/ Unintentional struck Unintentional struck
against against by/against by/against
30,760 368,104 404,124 593,752
3 Unintentional other bite/ Unintentional other bite/ Unintentional cut/ Unintentional
sting sting pierce overexertion
12,753 145,001 115,886 272,797
4 Unintentional fire/burn Unintentional foreign body Unintentional pedal Unintentional cut/
11,372 113,084 cyclist pierce
101,891 155,040
5 Unintentional foreign body Unintentional cut/pierce Unintentional other Unintentional pedal
9,767 86,787 bite/sting cyclist
93,317 140,063
6 Unintentional other Unintentional overexertion Unintentional MV – Other assault struck by/
specified 76,876 occupant against
7,979 74,399 116,670
7 Unintentional inhalation/ Unintentional fire/burn Unintentional Unintentional MV –
suffocation 57,728 overexertion occupant
7,801 73,980 99,353
8 Unintentional MV – Unintentional other/ Unintentional foreign Unintentional
occupant specified body unknown/unspecified
6,992 49,446 58,303 95,311
9 Unintentional cut/pierce Unintentional poisoning Unintentional Unintentional
6,152 47,402 dog bite other transport
52,568 70,429
10 Unintentional poisoning Unintentional unknown/ Unintentional Unintentional
5,814 unspecified other transport other bite/sting
47,076 49,071 70,286
MV = Motor vehicle
Spec. = Specified
Source: CDC (2004)
in risk for poor health and some of these gradi- In a recent analysis, Edwards and colleagues
ents have been demonstrated for different types examined risks of fatal injury among British
of injury. To illustrate, higher risks for child- children aged 0–15 years of age according to eight
hood injury are typically observed in association household socioeconomic classes (Edwards et al.
with poverty and mechanistically the hazardous 2006). The results presented in Table 19.3 show a
social and physical environments and adult/child classic example of a ‘‘risk gradient’’ associated with
behaviors that are associated with poverty. One social disparity, with children from lower social
of the classic relationships demonstrated in multi- classes experiencing 2–12-fold risks for fatal injury
ple research contexts is risk for childhood injury compared with the highest socioeconomic class.
and its association with socioeconomic status. These types of gradients are typically observed
Among young children, higher socioeconomic sta- among young children and for serious traumatic
tus is protective, whether measured in terms of events. Among adolescents, risk gradients may not
household income, parental occupation, or paren- be observed in all situations, depending on the type
tal education. Lower socioeconomic status is a risk of injury outcome under study. Explanations for
factor and most studies of this issue show charac- this typically focus upon population mixing and
teristic gradients in risk across socioeconomic the lessening importance of the home environment
strata. as a key determinant. In addition, because sports
Table 19.3 Deaths from injury and poisoning and rates per young age, children on farms experience dramatic
year per 100,000 children aged 0–15 years by eight class NS- increases in risks for fatal injury and serious trauma
SEC, 2001. Example of a socioeconomic gradient in risks for
fatal injury compared with the general population (Brison et al.
Deaths Rate (95% CI) per 2006). Among preschoolers, this occurs due to rou-
NS-SEC 2001– year per 100,000 tine exposure to industrial hazards as children
2003* children accompany adults during the course of farm work.
1. Higher managerial/ 85 1.9 (1.6–2.4) Farm families may not have immediate access to
professional childcare and there is a strong tradition of involving
occupations
children in work at an early age. As children grow
2. Lower managerial/ 111 1.6 (1.3–1.9)
professional and develop, they experience additional risks due to
occupations their participation in agricultural work, including
3. Intermediate 59 2.9 (2.2–3.7) the risks associated with tractor and machinery
occupations operation, care of large animals, and working at
4. Small employers/ 105 2.9 (2.4–3.5)
heights. Farm children provide a classic example
own account
workers of a vulnerable group at high risk for injury due to
5. Lower supervisory/ 91 2.7 (2.2–3.3) the setting in which they grow up.
technical
occupations
6. Semiroutine 148 4.0 (3.4–4.7)
occupations Childhood Injuries in Developing
7. Routine 180 5.0 (4.3–5.8)
occupations Countries
8. Never worked/long 383 25.4 (22.9–28.1)
term unemployment The vast majority of available data on the occur-
Total 1162 4.0 (3.8–4.2)
rence of childhood injuries are from developed
*Excludes one child for whom NS-SEC was missing countries. However, childhood injury poses an
NS-SEC = National Statistics Socio-Economic Classifica-
tion even greater burden to developing nations where
Source: Edwards et al. (2006) nearly 98% of all worldwide childhood injuries are
thought to occur (Taft et al. 2002). Children in such
countries are five times more likely to die from
injury prior to age 15 than children in developed
are a major cause of injury in adolescent popula- countries. To illustrate, in 2000 the annual mortality
tions and participation is in part driven by family rate due to injury among children in United States
wealth, relationships may be confounded by parti- was 9.8 deaths per 100,000 persons. In Vietnam and
cipation in sports. South Africa, annual mortality rates due to injury
There are other disparities in the occurrence of were 38.1 and 44.3 per 100,000 persons, respec-
childhood injury in addition to those observed by tively. Causes of injury mortality in developing
socioeconomic status. Gradients in risk for child countries are consistent with those observed in
injury have been observed between rural and industrialized nations, namely motor vehicle acci-
urban populations. Some of the most vulnerable dents, drowning, fire, poisonings, and falls (Taft
populations of children are those that reside in et al. 2002). However, the problem exists at a
remote geographic areas. Consequences of injuries much larger scale.
in rural and remote areas are complicated by a lack Despite the magnitude of the problem, injuries in
of immediate access to trauma care. Even within developing countries are often ignored in preven-
these rural and remote areas, some populations are tion efforts because of the continuing higher preva-
especially vulnerable. lence of morbidity and mortality from nutritional
Children on farms are one such group due to the deficiencies and infectious disease (Bartlett 2002).
unique nature of their residential environment. This means that while rates of injury are higher in
Farm-related injury accounts for up to 50% of developing compared with developed nations, they
occupational deaths among children. Starting at a constitute a smaller percentage of overall illness and
death. In addition, the view that injuries are ‘‘acci- expensive in low-income countries and are not
dents’’ and occur randomly is pervasive and may available for much of the population. In Vietnam,
impede the development of strategies to reduce for example, the cost of a child safety car seat is
them. In the last few decades, higher income coun- equivalent to approximately 101 hours of work,
tries have begun to devote more resources toward whereas in the United States it is equivalent to 2.5
injury prevention and research, resulting in a 50% hours of work (Taft et al. 2002). A bicycle helmet,
decrease in child injury deaths between 1970 and which in the United States requires 0.5 hours of
1995 in the Organization for Economic Co-operation work to purchase, requires 15.2 hours of work in
and Development (OECD) countries (UNICEF Vietnam (Taft et al. 2002). Social inequity and
2001). The opposite is more likely to be true in devel- poverty represent major barriers to the implemen-
oping countries, where injury rates are actually tation of childhood injury prevention programs,
increasing in response to growing motor vehicle traf- both on the individual level (within
fic, migration of populations to unsafe urban areas, countries) and cross-nationally.
and the widening availability of products and drugs Differences in risks for childhood injury
that are unregulated (Bartlett 2002). observed between countries further highlight
Children in developing countries are a vulner- social inequity as a major determinant of health
able population for unintentional injuries for a and the importance of initiatives such as the
number of reasons. As with the example of chil- Millennium Development Goals which are trying
dren growing up on farms in developed nations, to address such inequities between countries. In
children who work are exposed to hazards in a developed nations, injury rates have been declining
workplace that is designed for adults. They may due to prevention efforts; in low- and middle-
be expected to use tools or machineries that are income countries, lack of resources poses a signifi-
inappropriate in size, complexity, or strength cant barrier to such implementation (Taft et al.
required (Bartlett 2002). Tasks that are compli- 2002).
cated or require concentration may also put chil-
dren at greater risk for injury, as mistakes and
fatigue could increase the likelihood for injury
(Bartlett 2002). Additionally, unsafe living condi- Behavioral Risk Factors
tions, a lack of safe play spaces, and inadequate
childcare contribute to injuries in developing One general risk factor for injury in childhood is
nations (Bartlett 2002). risk-taking behavior. This has provided an addi-
Two important causes of injury-related mortal- tional focus for applied research. Among infants,
ity include deaths due to fire and flames and deaths the injury experiences are almost totally depen-
to passengers of motor vehicles. In developed dent upon the behavior of adults to minimize
countries, prevention efforts such as improved exposure to hazards in the home environment.
construction codes, public education, emergency As children grow and develop, experimentation
response and the wide use of smoke detectors are with various risk-taking behaviors becomes nor-
commonplace. In developing countries, substan- mative and these in turn place children at risk.
dard housing in combination with lack of electri- Most children are impulsive and curious. These
city, and thus open flame cooking and use of heat- are normative and often transient patterns of
ing fuels, is a main contributor to increased rates of behavior, yet some patterns become engrained.
injury due to fire (Taft et al. 2002). Older children When combined with unsafe physical environ-
are affected by increases in motor vehicle crashes ment, these behavioral patterns can have serious
that reflect rapid increases in vehicular traffic, par- consequences.
ticularly in urban areas of developing regions. As an extension of this concept, there has been
Road travel hazards are compounded by poorly considerable focus on the effects of adolescent risk
maintained roads and vehicles and additional taking in recent childhood injury control literature.
pedestrian and cyclist traffic (Bartlett 2002). Adolescents commonly experiment with a variety of
Child safety products remain prohibitively adult behaviors as they enter high school. The
influence of the peer group grows and many of these Injury control scientists often refer to the ‘‘3 E’s’’
behaviors are performed in groups and are hence for injury prevention, those being educational pre-
clustered in nature. Experimentation with smoking, vention strategies, engineered changes to physical
alcohol, and other drugs are common examples of environments, and the enforcement of regulations
clustered risk behaviors, as are unprotected sexual and legislation. The general sense is that all three
intercourse and truancy from school. In isolation, strategies are helpful in preventing injuries, but
such behaviors are modestly associated with a num- there are serious limitations with those strategies
ber of adverse health outcomes including childhood that rely exclusively on education to promote beha-
injury and psychosomatic health complaints. When vioral change. Education is a necessary and impor-
these behaviors become part of a clustered phenom- tant part of most injury prevention efforts. It may
enon, this ‘‘multiple risk’’ pattern leads to substan- be quite effective in influencing behavior, but by
tial health problems. itself, it is a generally unproven strategy in terms
Figure 19.4 provides an illustration of the con- of affecting risk for childhood injury. In contrast,
cept of multiple risk behaviors and its association there is better evidence demonstrating the beneficial
with injury. This comes from a cross-national effect of comprehensive strategies that include engi-
study conducted among children aged 11–15 neered environmental changes and enforcement.
years in 12 countries (Pickett et al. 2002). Higher The field has known this for years in the area of
risks for injury were observed in association with transportation injuries with major advances in pre-
the number of clustered risk behaviors that chil- vention associated with better automobile design,
dren reported. Injury risk gradients were observed drinking and driving legislation, and enforced traf-
in each of the 12 countries under study and within fic laws. However, many existing prevention efforts
all demographic subgroups examined in each in the field of childhood injury control continue to
country. They were also observed for different be based upon education alone with the hopes of
injury outcomes. A lifestyle that includes engage- appropriate behavior change leading to injury risk
ment in multiple risk behaviors appears to be an reductions.
important determinant of childhood injury. This In a recent systematic review, Towner and
pattern is generalizable to children from a wide colleagues (Towner and Dowswell 2002) updated
variety of backgrounds and cultures. More recent the existing evidence surrounding the prevention
analyses suggest that a strong and supportive of unintentional injuries to children. Following a
environment does not necessarily mitigate the search of the biomedical literature and contact
effects of these health risk behaviors on risk for with key informants, they compiled and reviewed
injury. evidence on evaluated intervention studies
related to childhood injury prevention since
1992. Results were summarized according to var-
ious child environments, including interventions
Strategies for Prevention for road environments (pedestrian, bicycle, car
passenger, and bus passenger injuries), home
The ‘‘gold standard’’ for evidence surrounding environments (burns and scalds, poisonings, fall
the effectiveness of injury prevention strategies prevention, and general home injuries), and lei-
is the randomized controlled trial. Yet, there are sure environments (aimed at drownings, play
only a modest number of randomized controlled and leisure injuries). The amount of available
trials in existence for several key approaches to evidence varied by topic and was often quite
childhood injury prevention. Systematic reviews modest. In addition, less than a third of the
that synthesize all of the available evidence do studies used research designs where the evidence
exist (Ehiri et al. 2006a, b; Towner and Dow- was rated as good/reasonable (Table 19.4).
swell 2002; Towner et al. 2001), but they stress Many of the existing trials focused solely on
how inconclusive much of the existing evidence behavior change as the primary outcome, while
is with regard to many available prevention even fewer assessed the effects of interventions
strategies. on injury outcomes.
Fig. 19.4 Associations

between numbers of health
risk behaviors and
adolescent injury. Source:
Pickett et al. (2002)
Table 19.4 Level of evidence in support of common interventions to prevent child injury
(Good evidence***,
reasonable evidence**, some evidence*)
Interventions in the road environment
General
– Area wide urban safety measure Injury reduction**
– 20 mph zones Injury reduction***
Behavior change***
Pedestrian injuries
– Education/enforcement aimed at driver Behavior change*
– Education aimed at child/parent Behavior change**
Injury reduction*
Bicycle injuries
– Bicycle training Behavior change**
– Bicycle helmet educational campaigns Behavior change***
– Bicycle helmet legislation Behavior change***
Injury reduction**
Car passengers
– Child-restraint educational campaigns Behavior change**
– Seat belt educational campaigns Behavior change**
– Child-restraint loan schemes Behavior change***
– Child-restraint legislation Behavior change***
Injury reduction**
Bus passengers
– Education aimed at child Behavior change*
Interventions in the home environment
General
– Product design Injury reduction*
– Safety devices Injury reduction*
Burns and scalds
– Smoke detector promotion programs Behavior change***
Injury reduction***
– Tap water temperature reduction Behavior change*
Injury reduction*
– Parent and child education Behavior change*
Poisoning
– Child-resistant packaging Injury reduction***
– Parent education Behavior change*
Falls prevention
– Window bars (education and environmental Behavior change**
modification and legislation) Injury reduction*
– Parent education Injury reduction*
General campaigns
– Parent education on hazard reduction Behavior change**
Interventions in the leisure environment
Drowning
– Parent and child education Behavior change*
– Adult supervision of public swimming pools, Injury reduction*
beaches, etc.
– Pool design and protection Injury reduction*
Play and leisure injuries

– Environment equipment – playground layout, equipment and surfacing Hazard reduction*
– Training schemes for adult supervision Little evidence
– Protective equipment Injury reduction*
Community-based studies
– Programs targeting a range of injury types in a range of different groups Behavior change**
Injury reduction**
Source: Towner et al. (2001)
The results presented in Table 19.4 demonstrate and test more sophisticated theoretical models of
how much there is to learn about the effects of disease (injury) etiology and qualitative studies that
existing injury prevention methods and the uncer- provide additional insight into the occurrence of
tainty surrounding many popular approaches such injury events. This appears to be naturally occurring
as parental education. There is excellent evidence as the science of injury control becomes multidisci-
that enforced speed zones and traffic calming laws plinary in nature, and each science influences the
work. There is good evidence regarding the effec- thinking of others. Major needs in the area of eva-
tiveness of training and public campaigns aimed at luative research remain. There is insufficient evidence
promoting the use of bicycle helmet, child passenger surrounding the relative effects of different child-
seat, and installation of smoke detectors in promot- hood injury control strategies on risks for injury
ing healthy behaviors. However, stronger evidence and a dire need for randomized controlled trials
suggests that legislation is more effective in prevent- and systematic reviews in this field. These types of
ing associated injuries. The use of passive measures efforts are emerging as the discipline of childhood
such as child-resistant packaging and window bars injury control matures and these remain obvious
on apartment windows has proven effective as well. priorities for research.
Yet these represent a relatively small number of This chapter suggests some simple but impor-
proven successes and this area of evaluative study tant lessons for policy and practice. First, it is clear
is ripe for further development. that the injury control field has put together some
solid arguments about the magnitude of the child-
hood injury problem and the impact it has on
society. These arguments need to be embraced by
Conclusion the public health system and government policy
makers and childhood injury needs to be recog-
Childhood injury research has evolved over the last nized for the major problem that it is.
few decades from a field that was dominated by Second, childhood injuries do not occur ran-
descriptive study to a discipline that is beginning to domly within society. The vast majority of injuries
embrace more sophisticated designs and the concepts worldwide occur in developing areas and injury
of evidence-based practice. The science of injury sur- rates within countries are higher among low-
veillance is quite strong, particularly in the field of resource populations. Some groups tend to be
pediatrics. There is an excellent understanding of the especially vulnerable to specific forms of injury
magnitude of the childhood injury problem, what it (i.e., young girls are more likely to be scalded
looks like, and the burden that it imposes on modern while cooking than are boys). These groups need
society. Etiological research that examines possible to be identified systematically and should poten-
determinants of childhood injury has been domi- tially become targets for focused prevention strate-
nated by ‘‘risk factor’’ studies that quantify associa- gies. There is a special need for inexpensive and
tions between physical and social exposures and the practical interventions that could be implemented
occurrence of injury. There is an ongoing need for in developing as well as developed countries.
more depth in this field, including studies that adapt Finally, it is clear that many traditional approaches
to childhood injury prevention, while acceptable to society, we need to not only gather better evidence
society, have little or no evidence to support their about the relative effects of the injury prevention
ongoing use. This is particularly true for educa- strategies in common use, but also base our prac-
tional strategies aimed at behavioral change. As a tices on what we know to be effective.
Key Terms
Accidents Helmets Premature death

Adolescence Home environment Preschoolers
Burden of injuries Homicide Scalds
Burns Injury control Smoke detectors
Child development Injury pyramid Social determinants
Child passenger seat Injury risk gradients Social disparities
Child-resistant packaging Injury surveillance Socioeconomic factors
Child safety Intentional injuries Speed zones
Childhood injuries Legislation Suffocation
Disfiguration Life expectancy Suicide
Drownings Parental education Traffic calming laws
Enforcement Physical environment Trauma
Engineered changes Play spaces Unintentional injures
Environmental factors Poisonings Vulnerable populations
Evidence-based prevention Potential years of life lost
Falls (PYLL)
Fire Poverty

Bartlett SN (2002) The problem of children’s injuries in low-
1. What are injury pyramids? Of what value are income countries: a review. Health Policy and Planning,
they in childhood injury epidemiology? 17(1), 1–13
2. Briefly explain the two approaches used in the Brison RJ, Pickett W, Berg R et al. (2006) Fatal agricultural
analyses of childhood from a developmental per- injuries in preschool children: Risks, injury patterns and
strategies for prevention. CMAJ, 174(12), 1723–1726
spective. What are the benefits of a developmen- Centers for Disease Control and Prevention (CDC) (2003) Ten
tal approach to childhood injury epidemiology? Leading Causes of Injury Death by Age Group Highlight-
3. What factors explain the disparities in childhood ing Unintentional Injury Deaths. Atlanta, Georgia: Cen-
injuries by socioeconomic strata? ters for Disease Control and Prevention, National Center
for Health Statistics. ftp.cdc.gov/pub/ncipc/10LC-2003/
4. It is said that 98% of all worldwide childhood PDF/10lc-unintentional.pdf, cited 8 August 2008
injuries occur in less-developed countries. What Centers for Disease Control and Prevention (CDC) (2004)
factors explain the increased vulnerability for National Estimates of the Ten Leading Causes of Non-
children in less-developed countries? Fatal Injuries. Atlanta, Georgia: Centers for Disease
Control and Prevention, National Center for Health
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scientists often refer to the ‘‘3 E’s.’’ What do 2004-nonfatal.pdf, cited 8 August 2008
they mean by this? What are the limitations of Centers for Disease Control and Prevention (CDC) (2005)
childhood injury prevention strategies that rely Web-Based Injury Statistics Query and Reporting System
(WISQARS). Atlanta, Georgia: Centers for Disease
solely on education?
Control and Prevention, National Center for Health Sta- people. Archives of Pediatric Adolescent Medicine,
tistics. www.cdc.gov/ncipc/wisqars, cited 8 August 2008 156(8), 786–793
Edwards P, Roberts I, Green J et al. (2006) Deaths from Pickett W, Molcho M, Simpson K et al. (2005) Cross national
injury in children and employment status in family: study of injury and social determinants in adolescents.
Analysis of trends in class specific death rates. British Injury Prevention, 11(4), 213–218
Medical Journal, 333(7559), 119 Spady DW, Saunders DL, Schopflocher DP et al. (2004)
Ehiri JE, Ejere HOD, Magnussen L et al. (2006a) Interven- Patterns of injury in children: a population-based
tions for promoting booster seat use in four to eight year approach. Pediatrics, 113(3 Pt 1), 522–529
olds traveling in motor vehicles. Cochrane Database of Taft C, Paul H, Consunji R, Miller T (2002) Childhood
Systematic Reviews, Issue 1 Unintentional Injury Worldwide: Meeting the Challenge.
Ehiri JE, Ejere HOD, Hazen AE et al. (2006b) Interventions Washington, DC: SAFE KIDS Worldwide
to increase children’s booster seat use: a review. American Towner E, Dowswell T, Jarvis S (2001) Updating the evidence, a
Journal of Preventive Medicine, 31(2), 185–192 systemic review of what works in preventing childhood unin-
Fingerhut LA, Warner M (1997) Injury Chartbook. Health, tentional injuries: Part 2. Injury Prevention, 7(3), 249–253
United States, 1996–1997. Hyattsville, Maryland: Towner E, Dowswell T (2002) Community-based childhood
National Center for Health Statistics injury prevention: what works? Health Promotion Inter-
Finkelstein EA, Corso PS, Miller TR (2006) Incidence and national, 17(3), 273–284
Economic Burden of Injuries in the United States. New United Nations Children’s Fund (UNICEF) (2001) A Lea-
York: Oxford University Press gue Table of Child Deaths by Injury in Rich Nations
Flavin MP, Dostaler SM, Simpson K et al. (2006) Stages of (Innocenti Report Card No. 2). Florence: UNICEF Inno-
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Pickett W, Schmid H, Boyce WF et al. (2002) Multiple risk www.capic.org.uk/documents/Childinjuryprevention_
behavior and injury: An international analysis of young WHO2006_2015.pdf, cited 24 August 2008
Part IV
Programs, Policies, and Emerging
Concerns
Chapter 20
Evidence-Based Maternal and Child Health
Alan Tita and John E. Ehiri
Learning Objectives After reading this chapter and that involves explicit and rigorous application of
answering the discussion questions that follow, you essential processes outlined in Box 20.1 (Neilson
should be able to 1998). Evidence-based care is dynamic; it evolves as
new research is produced and older interventions
Present a synopsis of the status of evidence-based
debunked. This chapter presents a synthesis of the
global maternal and child health practice and
status of evidence-based global maternal and child
policy, with particular emphasis on developing
health practice and policy, with particular emphasis
countries.
on developing countries. It defines evidence-based
Discuss the methods, advantages and criticisms
care and examines its advantages, criticisms and
of evidence-based practice.
methods. Relevant historical milestones in the emer-
Discuss relevant historical milestones in the
gence of the evidence-based maternal and child health
emergence of the evidence-based maternal and
movement are discussed. A selection of some specific
child health movement.
maternal and child health interventions that are
Identify and describe specific examples of mater-
currently considered evidence based is presented,
nal and child health interventions that are cur-
and research priorities relevant to achievement of
rently considered evidence based and evaluate
the maternal and child health-related Millennium
research priorities relevant to achievement of
Development Goals (MDGs) are discussed. To set
maternal and child health-related Millennium
the chapter in proper context, maternal and child
Development Goals (MDGs).
health is considered from the perspectives of two
main practice domains (maternal and perinatal
health, and infant and child health) that chrono-
logically relate to the continuum of pregnancy,
Introduction
delivery and birth, and child development, taking
into account, the overlap between maternal and
Evidence-based care has been defined as the conscien-
child health issues during pregnancy and the neo-
tious, explicit and judicious use of current best evi-
natal period. Perinatal health as used in this chap-
dence in making decisions about the care of indivi-
ter refers to both the intrauterine health of the
dual patients or populations (Sackett et al. 1996). It
viable foetus and the neonatal health.
shifts emphasis away from practice that is based
solely on pathophysiological reasoning, experience,
intuition, authoritarianism or conventional wisdom
(Evidence-Based Medicine Working Group 1992) to Advantages of Evidence-Based Practice
one that emphasizes the use of systematic research
Ever since the evidence-based care revolution was
explicitly introduced in the early 1990s (Evidence-
A. Tita (*)
Obstetrics and Gynecology, University of Alabama, Based Medicine Working Group 1992), its principles
Birmingham, USA have been adopted by a broad array of clinical
362 A. Tita and J.E. Ehiri
the best evidence. However, there is some evidence

Box 20.1 Key Processes in the Systematic that practitioners can devote scarce time to selec-
Review of Research Evidence tive, efficient problem-driven searching, appraisal
and incorporation of best evidence into their prac-
Clear objectives tice (Sackett et al. 1996). In fact, not everyone is
Explicit pre-stated criteria for including expected to have the training and expertise to con-
studies duct systematic reviews of research. There are
Identify all relevant published and unpub- resources such as the Cochrane Library, whose his-
lished studies tory is introduced later in this chapter, populated by
Establish explicit study exclusion criteria experts who provide this service. Third, it is argued
Careful data abstraction that evidence-based care is ‘‘cookbook’’ practice.
Pooling of data from similar studies (meta- This is refuted by the emphasis of evidence-based
analysis) only where appropriate care on both practitioners’ experience and consid-
Description of results eration of the individual problem scenario in apply-
Drawing appropriate conclusions and ing evidence. Fourth criticism is the contention that
Discussing implications for current prac- purchasers and managers can hijack evidence-based
tice and future research care to cut the cost of health care. While this is
Source: Adapted from Neilson (1998) certainly possible, such a scenario would indicate a
misuse of evidence-based care itself. In fact, correct
use of evidence-based practices involving the most
disciplines and by health-care planners, policy efficacious interventions may actually raise costs
makers and evaluators. Because evidence-based in some situations, while the avoidance of non-ben-
practices and interventions are underpinned by eficial or harmful interventions will lead to cost sav-
research proving their efficacy or effectiveness, they ings in others. Finally, evidence-based care is criti-
are expected to lead to improvements in relevant cized as being restricted to randomized controlled
health outcomes, the efficient delivery of health- trials and meta-analyses. In response, it
care services and patient satisfaction. Widespread is important to emphasize that the purpose of
application of proven interventions or practices evidence-based practice is to identify the best
leads to cost savings by precluding the allocation of external evidence with which to answer practical
scarce resources, especially in developing countries, questions – regardless of research methodology.
to unnecessary interventions (Neilson 1998). For example, the best evidence about a diagnostic
test may be available from properly conducted cross-
sectional studies, while the best information regard-
ing prognosis may be gleaned from cohort studies.
Criticisms of Evidence-Based Practice In developing countries, several barriers may
account for the low practice of evidence-based
The growth in evidence-based care has not occurred care. These include limited resources, lack of poli-
without criticism. Five major attacks have been tical foresight to invest in evidence-based practices,
identified and addressed by leaders of the evidence- unethical promotion of drugs by pharmaceutical
based care movement (Sackett et al. 1996). First, companies, corruption, traditional training of
there is the assertion that everyone already practices health professionals which does not offer requisite
evidence-based care. However, this is refuted by skills and over-dependence on scientific informa-
variations among practitioners in the provision of tion from developed countries which may not be
interventions for the same public health or clinical relevant or applicable to developing countries. One
problems in the same setting. Second, some argue study of barriers to the practice of evidence-based
that evidence-based practice can be conducted only reproductive health care in sub-Saharan revealed
from academic ivory towers and armchairs, and that plain lack of awareness of evidence-based
busy practitioners cannot find the time to conduct interventions and lack of materials and supplies
systematic reviews of available literature to obtain necessary to implement these evidence-based
20 Evidence-Based Maternal and Child Health 363
interventions were by far the two most prevalent

barriers (Tita et al. 2005). On the whole, few Box 20.2 USPSTF Grading of Evidence by
studies have actually assessed determinants and Research Design
barriers associated with evidence-based practice
of clinical medicine in general or maternal and Grade I
child health care in particular in developing Evidence obtained from at least one prop-
countries. erly designed, randomized controlled trial
Grade II-1
Evidence from well-designed controlled
trials without randomization
Research Methods and Hierarchy for Grade II-2
Evidence-Based Care Evidence from well-designed cohort or
case–control analytic studies, preferably
Organizations such as the Cochrane Collaboration, from more than one centre or research group
the United States Preventive Services Task Force Grade II-3
(USPSTF) and the Canadian Task Force on Peri- Evidence from multiple time series with or
odic Examination use comparable systems to grade without the intervention. Dramatic results in
the quality of evidence, the internal validity of stu- uncontrolled experiments (such as the results
dies and the strength of recommendations arising of the introduction of penicillin in the 1940s)
from the research. The USPSTF, for example, has could also be regarded as this type of evidence
traditionally graded the quality of evidence accord- Grade III
ing to a hierarchy based on research designs as out- Opinions of respected authorities, based on
lined in Box 20.2 (US Preventive Services Task clinical experience, descriptive studies and
Force 2008). case reports, or reports of expert committees
It is evident from the USPSTF grading that Source: US Preventive Services Task Force
experimental designs (randomized controlled (USPSTF) (2008)
trials), particularly with respect to the evaluation
of therapeutic (or public health) interventions, are
accorded the strongest weight. Although not expli- Evidence-Based Maternal and Perinatal
citly included in this framework, systematic reviews Health
and meta-analyses of randomized controlled trials,
therefore, provide better evidence than do indivi- Evidence-based medicine and obstetrics. The histor-
dual trials and have been given a Grade 0 category ical development of evidence-based maternal and
by some. Basic science studies, involving animals, perinatal health care can be traced back to the his-
for example, are not included in grading systems but tory of evidence-based obstetric care (King 2005).
have been accorded a Grade IV category by others. Although the term evidence-based medicine
Thus, despite their importance in illuminating appears to have been first coined by Gordon Guyatt
pathophysiological mechanisms, the value of basic of McMaster University in Canada in 1990 (King
science studies as an evidence basis for human or 2005), the movement towards evidence-based care
population-based intervention is low. Recognizing pre-dated this use. As early as 1972, Archie
that evidence from a well-conducted observational Cochrane in the United Kingdom emphasized the
study could be of better quality than evidence from need for careful evaluation of health care interven-
a poorly conducted clinical trial, additional grading tions, especially through randomized controlled
for the internal validity of each study is incorpo- trials in his monograph, Effectiveness and Effi-
rated. The strength of recommendations is also ciency, Random Reflections on Health Services
graded, for example, from A to D, indicating a (Cochrane 1972). The principles he set out in this
range from strong evidence for benefit (Level A) to text were straightforward. He suggested that
strong evidence for ineffectiveness or harm (Level because resources would always be limited, they
D) (U.S. Preventive Services Task Force 2008). should be used to provide equitably, those forms
of health care that had been shown in properly steps have led to major advances in the development
designed evaluations to be effective. In particular, of evidence-based obstetric care in the developed
he stressed the importance of using evidence from world. A chronological account of the history of the
randomized controlled trials (RCTs) because these Cochrane Library can be found here: http://www.
were likely to provide much more reliable informa- cochrane.org/consumers/docs/01Cochrane5min.
tion than other sources of evidence. Cochrane’s ppt#263,2,Slide 2.
simple propositions were soon widely recognized The proliferation of clinical trials in Obstetrics as
as seminally important by lay people as well as by a result of the work of Cochrane, Chalmers and their
health professionals. In 1979, he wrote, ‘‘It is surely colleagues included hallmark and influential perina-
a great criticism of our profession that we have not tal trials such as the Collaborative Eclampsia and
organized a critical summary, by specialty or sub- Magpie trials coordinated from Oxford (Box 20.3),
specialty, adapted periodically, of all relevant ran- the Term PROM, Post Term and Term Breech trials
domized controlled trial’’ (Cochrane 1979). from Canada, and multiple trials from the Maternal
Taking up the challenge already in 1974 and Fetal Medicine Units Network in the United States.
recognizing the lack, and non-use of good evidence At the same time, there was the introduction and
in obstetric care, Ian Chalmers, based at the time in proliferation of the methodology of rigorous assess-
Cardiff, UK, initiated a project to accomplish the ment of evidence through systematic reviews. This
systematic identification and collection of con- ultimately led to the Cochrane Pregnancy and Child-
trolled trials in obstetric and perinatal medicine. birth Database of Systematic Reviews, a vital com-
These efforts by Chalmers and colleagues were ponent of the pregnancy and childbirth section of the
given added impetus when in 1979, Archie Cochrane Library, with systematic reviews continu-
Cochrane awarded a wooden spoon to Obstetrics ously updated as new trials are published.
as the specialty with the worst use of randomized Unfortunately, the growth of evidence-based care
trials (best available evidence) to inform its prac- in developed countries was not accompanied by a
tices (the wooden spoon is a figurative trophy due to similar growth in the developing countries. Maternal
who ever comes last in any contest). Chalmers sub- and perinatal mortality remain disproportionately
sequently established the National Perinatal high in developing countries, particularly those in
Epidemiology Unit in Oxford and continued the sub-Saharan Africa (WHO 2004). Attempts to
development of the perinatal trials registry. By resolve these serious public health problems have
1985, over 3,500 reports of trials were included. Chal- been punctuated by at least two important initia-
mers, Enkin and Keirse collaborated in the produc- tives: the Safe Motherhood Initiative and the Avert-
tion of the groundbreaking publication Effective ing Maternal Death and Disability initiative.
Care in Pregnancy and Childbirth [http://www. The Safe Motherhood Initiative (see Chapter 22)
childbirthconnection.org/article.asp?ClickedLink¼ arose from a Safe Motherhood conference convened
194&ck¼10218&area¼2], which appeared in 1989, in Nairobi, Kenya, in 1987 by the World Bank, the
with an introduction from none else than Archie World Health Organization and the United Nations
Cochrane (Chalmers et al. 1989). The text was a Fund for Population Activities (Mahler 1987). The
compilation of reviews of existing clinical trials purpose of the conference was to address the
addressing various perinatal topics. This enterprise neglected problem of over 500,000 maternal deaths
effectively put obstetrics at the forefront of the evi- that occurred annually (99% in developing coun-
dence-based medicine movement. In his introduc- tries). The ensuing Safe Motherhood Initiative
tion, Cochrane referred to this publication as a real aimed to reduce maternal mortality in developing
milestone in the history of randomized trials and in countries by 50% in one decade. The four-part strat-
the evaluation of care and suggested that other egy identified to achieve this lofty goal involved:
specialties should copy the methods used. His
encouragement and the endorsement of his views 1. adequate primary care, including food for
by others led to the opening of the first Cochrane females and universal family planning;
Centre (in Oxford, England) in 1992 and the found- 2. good prenatal care, including nutrition and early
ing of The Cochrane Collaboration in 1993. These identification and referral of high-risk patients;
worse than originally thought. However, aware-

Box 20.3 Collaborative Eclampsia and Magpie ness of the problem was enhanced and an under-
Trials standing of major causes of mortality increased.
The Averting Maternal Death and Disability
The Collaborative Eclampsia Trial and the (AMDD) program originated out of the Mailman
Magpie Trial are two of the most important School of Public Health at Columbia University in
(and largest) obstetric trials ever conducted. 1999 under the leadership of the late Alan Rosen-
Both were led by Lelia Duley at the Resource feld, and Deborah Maine (Maine and Rosenfield
Centre for Randomized Trials at the Oxford 2001). Through their seminal article in the Lancet
Institute of Health Sciences. titled Maternal Mortality – A neglected tragedy.
– The Magpie Trial was a randomized pla- Where is the M in MCH? they were influential in
cebo-controlled trial in 33 countries that generating the awareness that led to the Safe
evaluated whether or not pregnant women Motherhood Initiative. The AMDD advocates
with pre-eclampsia, and their babies, bene- that focus on emergency obstetric care is the strat-
fit from magnesium sulphate. The study egy most likely to lead to the greatest reduction in
involving over 10,000 women found that maternal mortality.
women who were allocated magnesium sul- The Institute of Medicine, through the Board on
phate had a 58% lower risk of eclampsia Global Health of its Committee on Improving
than those allocated placebo. Also, it is Birth Outcomes, has also weighed in with sug-
likely that magnesium sulphate reduces gested strategies on solving the problem of safe
the risk of maternal death. There were no motherhood in 2003. In the publication, Improving
short-term substantive harmful effects to Birth Outcomes: Meeting the challenge in the devel-
mother or baby (The Magpie Trial Colla- oping world, [http://www.nap.edu/catalog.php?
borative Group 2002). record_id¼10841] they proposed the following
– The Collaborative Eclampsia Trial was set prioritized recommendations for immediate
up to determine which, if any, of the follow- improvement of birth outcomes:
ing anticonvulsants should be used to treat Every delivery, including those at home should
women with eclampsia: diazepam, pheny- be attended by a skilled birth attendant such as a
toin or magnesium sulphate. This clinical midwife, a nurse or a physician.
trial, conducted in 12 different countries Essential obstetric and neonatal care should be
across three continents, concluded that accessible to address all complications of child-
magnesium sulphate was superior to the birth that cannot be managed by a skilled
other two treatments (Duley 1995). attendant.
As a result of this pioneering research, Postpartum care should be available during the
countless numbers of young mothers were critical first hours following childbirth and over
and will be saved from death or disability, the first month.
especially in developing countries where the Reinforcement of pre-conceptional and antena-
risk of eclampsia can be 20 times that of indus- tal care through family planning services to
trialized countries (Duley 1995). women and men of reproductive age and several
other interventions (Bale et al. 2003).
More recently in late 2006, through a series of
3. assistance of a trained person at all births; papers published in the Lancet as part of the
4. access to essential elements of obstetric care for build-up to the 20th anniversary of the Safe
women at higher risk. Motherhood Initiative, the Lancet Maternal
Health Steering Group also advocated the strat-
An appraisal after one decade indicated no major egy involving professionalization of maternity
progress in reducing maternal mortality and sug- care as the absolute priority (Campbell and Gra-
gested that the magnitude of the problem was ham 2006).
All of these initiatives and strategic positions by Based on the results of the systematic reviews,
influential groups have certainly been useful in interventions are categorized in the WHO RHL
increasing awareness and renewing commitment to according to their effectiveness or lack thereof,
the problem of maternal health. In addition, some into six categories: beneficial, likely beneficial,
of the individual interventions proposed have a with a trade-off, of unknown effectiveness, likely
proven evidence base. However, the strategies to be ineffective and likely to be harmful.
have generally been premised on problem analyses Selected maternal and perinatal interventions
that indicate a high plausibility for their effective- listed in the 2006 version of the WHO Repro-
ness. Unfortunately, from an evidence-based prac- ductive Health Library as beneficial or likely
tice standpoint, these proposals are often imple- beneficial, and their effects, are listed in
mented without a careful evaluation of their Box 20.5.
actual effectiveness, especially through cluster-
randomized trials, which usually represent the
best source of evidence in such circumstances
(Tita et al. 2007). Arguments have been proffered
Knowledge Gaps, Research Priorities and
that some of the individual interventions are
already proven in clinical trials and that it may Implications for the MDGs
therefore be unethical to conduct further trials to
test strategies offering them. However, it is uncer- The Millennium Development Goal #5 to
tain that a package of several competing interven- improve maternal health has the reduction of
tions, especially when implemented within a maternal mortality ratio in developing countries
resource-constrained system, necessarily leads to by 75% by 2015 as its main objective. Clearly,
improved outcomes. In fact, the persistent high there are evidence-based interventions aimed at
rates of maternal mortality and morbidity give alleviating individual factors that contribute to
credence to the uncertainty surrounding the effec- the high rates of maternal mortality. As already
tiveness of proposed strategies so far. It is there- outlined, these high rates have remained
fore, crucial and ethical that proposed strategies to unchanged in spite of multiple remedial initia-
improve maternal health and mortality be under- tives and strategies premised on analyses of the
pinned by strong evidence, ideally from cluster- underlying barriers and causes (Tita et al. 2007).
randomized trials evaluating such strategies. This analysis approach is analogous to patho-
physiological reasoning in clinical medicine,
which does not always lead to effective therapy.
Therefore, before strategies proposed as part of
Current Evidence-Based Maternal and initiatives to reduce maternal mortality are
Perinatal Interventions widely adopted, their effectiveness should be
established through cluster-randomized trials or
Evidence-based practice is dynamic; new interven- other methods deemed suitable for the situation.
tions are adopted and others discarded as new evi- Consequently, research to evaluate and validate
dence accumulates from research. It is therefore interventions that are individually effective
impossible to cite an exhaustive list of evidence- against major causes of maternal mortality
based interventions. Nevertheless, the most perti- should be prioritized. Given the variations in
nent resource for evidence-based maternal health settings in the developing world, the local reality
care relevant to developing as well as developed should be considered in designing and evaluating
countries is the World Health Organization Repro- such strategies. Finally, research should continue
ductive Health Library [http://apps.who.int/rhl/en/]. to develop additional interventions against
It is an electronic database of systematic reviews causes of maternal mortality. Examples of such
from the Cochrane Database accompanied by com- interventions include those to primarily prevent
mentaries and information on implications for prac- pre-eclampsia/eclampsia, haemorrhage and
tice (Box 20.4). obstructed labour.
Box 20.4 Evidence-Based MCH Resources
1. The World Health Organization Reproductive Health Library: The WHO Reproductive Health
Library (RHL) is a resource that puts the best research evidence available from systematic reviews
into practical context for use to improve health outcomes. Started in 1997, the RHL is available
both on CD-ROM and Online, and is published in several languages including French, Spanish
and English. It is Cochrane-based and regularly updated with new evidence and additional
resources on an ongoing basis online, and with CDs published annually. It is available free to
developing country workers on CD-ROM or on the Internet and to workers in developed
countries for an annual fee. Internet link: http://www.who.int/rhl/en/
2. The Cochrane Library and the Cochrane Pregnancy and Child Birth Database: The Cochrane
Library contains high-quality, independent evidence to inform health care decision making
from systematic reviews, particularly of clinical trials. These are considered the gold standard in
evidence-based health care. Found within this Library is the Pregnancy and Childbirth Database
which focuses on maternal and child health clinical and public health issues. The Cochrane
Library (http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME) is available
to readers in low-income countries at no cost and can be accessed either directly or through the
Health InterNetwork Access to Research Initiative (HINARI). The HINARI program, http://
www.who.int/hinari/en/, set up by the WHO and several major publishers, provide health workers
and researchers with access to published research information. Individuals in about 113 countries
have access to nearly 4,000 journals through this initiative.
3. Better Births Initiative: The Better Births Initiative aims to ensure that clinical policies and
procedures used in essential obstetric services are grounded in reliable research evidence. It is
targeted at health-care providers and assists them in understanding research evidence, making
decisions about best practice, and establishing implementation procedures to assure change. It is
aimed at middle- and low-income countries, where resources for health care are limited and better
services will reduce maternal mortality. Internet link: http://www.liv.ac.uk/evidence/BBI/
home.htm
4. The Lancet Neonatal Survival, Child Survival, and Maternal Survival Series: Although falling
within the sphere of Level III (expert review) evidence, the series of papers on each of these
three areas provide an instructive overview of each target area. Currently available evidence-based
interventions are also discussed in some of the papers. The series are important because they likely
represent the mainstream orientation of actions to address each of these problem areas. The
papers in these series can be traced through a PubMed or MedLine search.
Evidence-Based Infant and Child Health international commitment was again reaffirmed at
the World Summit for Children in New York, USA.
Information on the precise historical development As already discussed, progress made in infant and
of evidence-based childcare is sparse. However, child health led to a seminal paper that called for
there is evidence that efforts at improving child attention to the ‘‘M’’ in MCH (Rosenfield and
health, and the progress made, have historically Maine 1985). In contradistinction to maternal and
exceeded those of maternal health. Jim Grant, the perinatal health, over the last two decades following
late director of the United Nations International Jim Grant’s initiative, there has been a reduction in
Children’s Fund (UNICEF), launched the revolu- average global child mortality, albeit with a recent
tion in child survival with widespread international stagnation in a few countries severely affected by
support in 1982 (UNICEF 1996). In 1990, this the HIV/AIDS pandemic. Better understanding of
Box 20.5 Beneficial and Likely Beneficial Maternal and Perinatal Health Promotion Intervention
Beneficial Interventions
Active management of the third stage of labor (involving administration of medications to promote
uterine contraction after delivery of the baby) to decrease blood loss.
Use of antibiotics for preterm, pre-labour rupture of membranes to prolong pregnancy and reduce
maternal and infant infections.**
Administration of prophylactic antibiotics to women undergoing caesarean section to reduce post-
operative infections.
Use of antibiotic treatment of asymptomatic bacteriuria to prevent pyelonephritis in pregnancy and
to reduce preterm delivery.**
Administration of corticosteroids to women with impending preterm delivery to reduce neonatal
mortality and morbidity related to prematurity.*
Use of external cephalic version at term to reduce rates of breech delivery and cesarean section.**
Injection of saline solution with oxytocin into the umbilical vein to reduce the need for manual
removal of placenta.
Administration of magnesium sulphate over other anticonvulsants to women with eclampsia to
prevent recurrent seizures.
Administration of magnesium sulphate to women with pre-eclampsia to reduce eclampsia and
maternal death.
Induction of labor after 41 completed weeks of gestation to reduce perinatal death and cesarean
section.*
Routine supplementation with iron and folate during pregnancy to prevent maternal anemia.
Routine periconceptional supplementation with folate to reduce neural tube defects.*
Provision of social support to women in labor, to reduce the need for pain relief and operative vaginal
delivery and enhance their labor experience.
Use of combination injectable contraceptives to prevent unwanted pregnancies.
Use of emergency contraception after unprotected intercourse to prevent unwanted pregnancy.
Use of medical methods involving RU-486, misoprostol and methotrexate for safe first trimester
abortion.
Use of tubal sterilization by minilaparotomy, where laparoscopy is not available to definitively
prevent unwanted pregnancy.
Administration of intrapartum Nevirapine followed by a single dose within 72 hours to the newborn
to reduce mother-to-child transmission of HIV infection.*
Regular use of condom to reduce HIV transmission particularly in sero-discordant couples.
Routine screening during pregnancy and treatment of syphilis to decrease congenital syphilis.*
Administration of long- or short-course Zidovudine to reduce the risk of mother-to-child transmis-
sion of HIV infection.*
Likely beneficial interventions
Use of prophylactic antimalarials or presumptive treatment during pregnancy in women of low parity
in endemic areas to decrease low-birth-weight babies and maternal anaemia.**
Use of prophylactic antimalarials or presumptive treatment during pregnancy in endemic areas to
decrease recurrent malaria.
Use of breast and nipple stimulation at term to reduce post-term pregnancy.*
Early use of antibiotics in women with intra-amniotic infection to prevent postpartum complications.
Use of exclusive breastfeeding up to 6 months to reduce morbidity and possibly mortality due to
diarrheal infections.*
Use of orally and rectally administered misoprostol after other uterotonics to reduce further blood
loss.
Use of manual or electric vacuum aspiration over rigid curettage to treat incomplete abortion.
Education about contraceptive use to increase contraceptive use up to 6 months postpartum.
Use of levonorgestrel or mifepristone over Yuzpe regimen (birth control pills) for more effective
emergency contraception.
Use of erythromycin or amoxicillin to treat genital chlamydia during pregnancy.**
Use of broad-spectrum antibiotics to treat gonorrhoea treatment during pregnancy.**
*Perinatal interventions
**Maternal and perinatal interventions
these gains has been attributed to the pioneering and between countries. In Brazil, for example,
work of Moseley and Chen, who proposed a fra- data indicate a sixfold disparity in child mortal-
mework for studying child survival in developing ity rates between the richest 10% and the poor-
countries (Mosley and Chen 1984). They postu- est third (Victora et al. 2000). Other reports
lated that underlying socioeconomic factors affect from several developing countries also demon-
child survival through five key proximate determi- strate significant deficits in the proportion of
nants: maternal factors, nutritional deficiency, children reached by individual evidence-based
environmental exposures, injury and self-efficacy interventions.
(personal illness control). This framework served Overall, a review of the historical background
as a backbone for the development of child survi- of child survival programs reveals that proven
val programs. While the reduction in child mortal- individual interventions are used without specific
ity coincided with the implementation of child sur- evaluation of the effectiveness of different stra-
vival programs involving use of evidence-based tegies utilized to deliver these interventions to
interventions such as immunization, oral rehydra- large populations. This situation is similar to
tion therapy for diarrhoea, and the improvement that of maternal and perinatal health, with the
in health and nutrition of women and their chil- major difference that the child health efforts
dren, few efforts were made to document the nevertheless coincide with improvements in
actual effectiveness of the program strategies and child mortality. In the next section, we present
to identify components that actually work. One some of the individual interventions with an evi-
strategy that has received considerable program- dence basis.
matic evaluation from its onset is the Integrated
Management of Childhood Illnesses (IMCI)
(Chapter 27). Overall, the strategy has not yielded
consistent improvements in childcare as expected.
Current Evidence-Based Infant and Child
This is due to multiple barriers, which have led to Interventions
sub-optimal implementation. Nevertheless, over
100 countries have already adopted IMCI as the Notwithstanding improvements in child mortal-
primary approach to improving child health, and ity, over 10 million children under 5 years of age
its implementation is ongoing (Ingle and Chetna continue to die annually. The vast majority
2007). occur in developing countries including over
Furthermore, the trend indicating decreased 40% in sub-Saharan Africa and about 35% in
child mortality conceals serious disparities within south Asia. It has been estimated that 90% of
Knowledge Gaps, Research Priorities and

Implications for the MDGs
The Millennium Development Goal #4 to improve
child health has the reduction of child mortality by
two-thirds of 1990 levels by the year 2015 as prime
objective. However, as is still the case with maternal
health targets, there is still much to be accom-
plished. Improvements noted over the years in
child mortality have occurred without close evalua-
tion and monitoring for effective strategies. There-
fore, the main priority in this area is the need for
research to evaluate and identify strategies that are
effective in producing measurable benefits. In addi-
tion, strategic programming should take into con-
sideration, the local reality. Such programming
requires a solid base of epidemiological information
on local causes of child mortality and their distribu-
Fig. 20.1 Leading clinical causes of under-5 child mortality tion within the population. Therefore, observa-
tional research in this area is needed. Further
research, including basic and clinical trial research,
is needed to develop other relevant evidence-based
child mortality is attributable to just a few clin- interventions such as vaccines for malaria and
ical conditions (Fig. 20.1) (Black et al. 2003). for microbes causing pneumonia and diarrhoea,
Besides neonatal complications, diarrhoea, pneu- and to plan interventions to prevent and treat
monia, malaria and AIDS account for over 50% malnutrition.
of deaths, while malnutrition interacts with these
clinical conditions to produce the majority of
deaths (Black et al. 2003).
It is therefore evident that key interventions Conclusion
for each of these conditions are needed. The
Cochrane database of systematic reviews remains As in clinical medicine, the need for maternal and
the leading single source of reliable reviews of child health interventions to be evidence based is
evidence on a wide range of interventions that intuitive. Unfortunately, this has not been the his-
address child health problems. Evidence Based torical reality. Policies should be based on the best
Child Health, a quarterly publication of the available evidence and warrant systematic reviews
Cochrane Child Health Field based in Australia, of applicable clinical trials and/or observational
publishes prioritized summaries of some of these studies, as appropriate. When strategies are
systematic reviews with commentaries. Also, a designed based on situational analyses, it is vital
number of common child health problems are that their implementation include demonstration
addressed in Clinical Evidence, an electronic projects or action research using preferably clus-
compendium of evidence-based clinical interven- ter-randomized trials to verify their effectiveness.
tions issued and regularly updated by the British Many available evidence-based interventions are
Medical Journal (BMJ) Publishing Group. Some not reaching those in need. While development of
of the currently available effective interventions additional evidence-based interventions is impor-
are shown in Table 20.1. Interventions affecting tant, findings ways to reach individuals and
neonatal health have been previously listed families with already validated, evidence-based
under maternal and perinatal interventions interventions remains an abiding global health
(Box 20.5). challenge.
Table 20.1 Selected evidence-based interventions to promote child health
Intervention Source Summary of evidence

Lazzerini and In areas where diarrhoea is an important cause of
Oral zinc for treating acute persistent diarrhoea in Ronfani child mortality, research evidence shows zinc is
children (2008) clearly of benefit in children aged 6 months or
older
Antiretrovirals for reducing the risk of mother-to- Volmink et al. Short courses of antiretroviral drugs are effective
child transmission (MTCT) of HIV infection (2007) for reducing mother-to-child transmission of
HIV and are not associated with any safety
concerns in the short-term
Efficacy and safety of cesarean delivery for Read and Elective Cesarean Section is an efficacious
prevention of mother-to-child transmission Newell intervention for the prevention of MTCT among
(MTCT) of HIV-1 (2005) HIV-1-infected women not taking antiretroviral
drugs or taking only Zidovudine
Vaccines for preventing influenza in healthy children Jefferson et al. Influenza vaccines are efficacious in children older
(2008) than 2, but little evidence is available for children
under 2 years of age
Vitamin A for preventing acute lower respiratory Chen et al. Vitamin A supplements prevent acute lower
tract infections in children up to 7 years of age (2008) respiratory tract infections in children with low
serum retinol or those with poor nutritional
status
Antibiotics for preventing complications in children Kabra et al. Antibiotics may be beneficial in preventing
with measles (2008) complications such as pneumonia, purulent otitis
media and tonsillitis in children with measles
Neuraminidase inhibitors for preventing and Matheson Neuraminidase inhibitors are effective in
treating influenza in children et al. (2007) shortening illness duration in healthy children
with influenza, but efficacy in ‘‘at-risk’’ children
remains to be proven. Oseltamivir is also
effective in reducing the incidence of secondary
complications and may be effective for influenza
prophylaxis
Vitamin A for treating measles in children Huiming et al. Two doses of vitamin A were associated with a
(2005) reduced risk of mortality and pneumonia-
specific mortality in children under the age of 2
years
Chemoprophylaxis and intermittent treatment for Meremikwu Prophylaxis and intermittent treatment with
preventing malaria in children et al. (2008) antimalarial drugs reduce clinical malaria and
severe anemia in preschool children
Interventions to improve water quality for Clasen et al. Interventions to improve water quality are
preventing diarrhoea (2006) generally effective in preventing diarrhoea, and
interventions to improve water quality at the
household level are more effective than those at
the source
Hand washing for preventing diarrhoea Ejemot et al. Hand washing can reduce diarrhoea episodes by
(2008) about 30%. This significant reduction is
comparable to the effect of providing clean water
in low-income areas
Rotavirus vaccine for preventing diarrhoea Soares-Weiser Rhesus rotavirus vaccines (particularly RRV-TV)
et al. (2004) and the human rotavirus vaccine 89-12 are
efficacious in preventing diarrhoea caused by
rotavirus and all-cause diarrhoea
Insecticide-treated bed nets (ITNs) and curtains for Lengeler ITNs are highly effective in reducing childhood
preventing malaria (2004) mortality and morbidity from malaria
Key Terms
Abortion Effectiveness Nevirapine

Allocation of resources Efficacy Oxytocin
Amoxicillin Emergency contraception Patient satisfaction
Analytic studies Emergency obstetric care Perinatal mortality
Antenatal care Erythromycin Placebo
Archie Cochrane Evidence-based care Postpartum care
Averting maternal death and Family planning Postpartum complications
disability initiative Folate Pre-conception
Better Births Initiative Gonorrhoea Pre-eclampsia
Birth outcomes Harmful interventions Prophylactic antibiotic
Breech delivery Intra-amniotic infection Randomized controlled trials
Caesarean section Iron RU-486
Case-control studies Laparoscopy Safe motherhood initiative
Chlamydia Levonorgestrel Skilled attendant
Clinical trials Low birth weight Syphilis
Cluster-randomized trial Magnesium sulphate Systematic reviews
Cochrane Pregnancy and Child Magpie trials The Cochrane Library
Birth Database meta-analysis Trimester
Cohort studies Methotrexate Tubal sterilization
Collaborative eclampsia trial Mifepristone Uncontrolled experiments
Condom Minilaparotomy Unnecessary interventions
Cookbook practice Misoprostol Vaginal delivery
Corticosteroids Mother-to-child transmission Zidovudine
Cost savings Neural tube defects
Board on Global Health (BGH), Institute of Medicine

Questions for Discussion (IOM). Washington, DC: National Academy Press.
Black RE, Morris SS, Bryce J. (2003) Where and why are 10
1. What is evidence-based practice and what are its million children dying every year? Lancet, 361: 2226–2234
Campbell OM, Graham WJ (2006) Strategies for reducing
limitations? maternal mortality: getting on with what works. Lancet,
2. In an essay of about 1,000 words, present an 368: 1284–1299
argument to counter the five criticisms of evi- Chalmers I, Enkin MW, Keirse MJNC (eds.) (1989) Effective
dence-based practice. care in pregnancy and childbirth. Oxford University Press.
Chen H, Zhuo Q, Yuan W et al. (2008) Vitamin A for pre-
3. What are the major barriers against the imple- venting acute lower respiratory tract infections in children
mentation of evidence-based maternal and child up to seven years of age. Cochrane Database of Systema-
health services in developing countries? tic Reviews, Issue 1
Clasen T, Roberts I, Rabie T et al. (2006) Interventions to
improve water quality for preventing diarrhea. Cochrane
Database of Systematic Reviews, Issue 3
Cochrane AL (1972) Effectiveness and Efficiency: Random
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Chapter 21
A Global Perspective on Teen Pregnancy
Andrew L. Cherry, Lisa Byers, and Mary Dillon
Learning Objectives After reading this chapter and Children born to adolescent mothers are more
answering the discussion questions that follow, you likely to have low birth weight and to be victims
should be able to of physical neglect and abuse. Because teenagers
have higher risks of adverse pregnancy outcomes
Discuss the problem of teen pregnancy from a
compared to their adult counterparts (Chen
global perspective, and identify regional and
et al. 2007), health care for them and their
cross-national themes, trends, progress, and
babies is more costly (Miller 2000). Death rates
challenges.
for teenage mothers and their babies are higher
Describe social, economic, and cultural
in less developed countries, the rates are at epi-
determinants of teenage pregnancy and
demic proportions. Thus, the birth of a child to
review the gaps in knowledge and research
a mother who has only just left childhood herself
priorities.
is a cause for concern across countries and cul-
Evaluate programs and policies designed to
tures. This chapter discusses the problem of teen
reduce the health, economic, and social risks
pregnancy from a global perspective and
associated with teen pregnancy.
explores regional and cross-national themes,
trends, progress, and challenges. Social, eco-
nomic, and cultural determinants are discussed.
Programs and policies designed to reduce health,
Introduction economic, and social risks among pregnant teens
are reviewed and gaps in knowledge and
Adolescence (ages 10–19 years) is a period of research priorities are identified. To set the dis-
transition, growth, exploration, and opportu- cussion in specific regional contexts, the chapter
nities. It is a period when young people have examines the situation in North America (repre-
increased interest in sex, with attendant risks of sented by the United States), Europe and
unintended pregnancies, health risks associated Central Asia (represented by United Kingdom
with early childbearing, abortion outcomes, and and Russia), East Asia and the Pacific (repre-
sexually transmitted infections, including HIV/ sented by Vietnam and Japan), South Asia
AIDS. Adolescents who have unintended preg- (represented by India), Central and South
nancy face a number of challenges, including America (represented by Mexico), Africa (repre-
abandonment by their partners, inability to com- sented by Nigeria), and Middle East and North
plete school education (which ultimately limits Africa (represented by Egypt). These countries
their future social and economic opportunities), were purposively highlighted because they are
and increased adverse pregnancy outcomes. known to drive trends in teen pregnancy rates
in their respective regions and globally.
Cross-national studies provide different views
A.L. Cherry (*)
School of Social Work, University of Oklahoma, Tulsa, OK, on teenage pregnancy and the social, intellectual,
USA and moral forces that sustain and restrain teen
376 A.L. Cherry et al.
pregnancies. Teenagers who engage in premarital Girls aged 15–19 from the lowest socioeco-
sex do so in the broader context of their socie- nomic groups are three times more likely
ties’ cultural and socioeconomic environment. than their economically better-off peers to
Essentially, all negative consequences that result give birth in adolescence and have twice as
from a teen birth have as their sequel public many children.
attitude, political policy, and poverty. To pro- Of the 260 million girls and young women
vide a common understanding, definitions of aged 15–19, about 11% (29 million) lack
some terminologies used in teenage pregnancy access to effective contraceptive protection.
research, and which are frequently referenced in Of the 29 million girls who lack contraceptive
this chapter, are presented in Box 21.1. protection, 16.2 million are married and say
Although many countries have experienced they want to delay childbirth; 9.8 million are
significant declines in the rates of teenage preg- unmarried and sexually active; 3.2 million are
nancy since the mid-1990s, current rates remain adolescents, both married and unmarried,
unacceptably high in many countries and regions who use traditional methods. As shown in
of the world. According to available data Table 21.1, Canada’s teenage birth rate is six
(UNFPA 2005) times that of Japan or Switzerland and more
than twice that of Sweden and Finland.
Adolescent girls account for 11% of all births (15
However, Canada’s rate is significantly lower
million a year).
than that of the United States and
Teen birth rates vary between a low of 29 per
slightly lower than the rate in the United
1,000 in Europe and 58 per 1,000 in Asia to a high
Kingdom.
of 130 per 1,000 in Africa.
Box 21.1 Key Definitions

Teenage pregnancy: Generally speaking, teenage pregnancy is a term used to refer to a situation where
girls become pregnant when they have not reached legal adulthood. Thus, the definition of teen
pregnancy varies from country to country and from culture to culture. Whereas industrialized
countries use age to define teen pregnancy, many less developed countries tend to define teen
pregnancy as a problem mostly when the teenage girl is unmarried. In the United States, teen
pregnancy is defined as a minor becoming pregnant. The term ‘‘minor’’ is used to refer to a person
who is under the age in which one legally assumes adulthood and is legally granted rights afforded to
adults in society. Depending on the jurisdiction and application, this age may vary, but is usually
marked at either 18 or 21. In the United Kingdom, a woman is said to be a pregnant teenager if she
falls pregnant before the age of 18.
Reproductive health: Refers to the biological, psychological, and social aspects of female and male
sexual and reproductive behavior. Reproductive health services include the provision of information,
contraceptives, and abortion and postabortion services.
Socioeconomic risk: An economic and/or social factor that increases the vulnerability of the teen
mother and her child to poor outcomes in the biological, psychological, and/or social areas of life.
These factors operate on the level of the individual, family, community, and nation. Examples of
individual and familial socioeconomic risks include ignorance, low educational attainment, and low
expectations for the future, unemployment, and poverty. Community and national factors include
inadequate housing, neighborhood deprivation, permissive social norms, limited job opportunities,
and lack of access to health care.
21 A Global Perspective on Teen Pregnancy 377
Table 21.1 Adolescent fertility rates for selected countries, 2005 (per 1,000 females aged 15–19 years)
Country Pregnancy rate Abortionrate Birth rate Death rate per live birth Maternal mortality rate
United States 68 22 46 6.5 7 in 100,000
Canada 37 17 20 4.8 1 in 100,000
United Kingdom 42 20 22 5.2 13 in 100,000
France 12 7 5 4.3 10 in 100,000
Germany 14 3 11 4.2 8 in 100,000
Sweden 24 17 7 2.8 1 in 100,000
Israel 24 9 15 6 5 in 100,000
Russian Federation 100 55 45 18 55 in 100,000
India 70 25 45 65 450 in 100,000
Japan 9.6 6 3.6 3.3 45 in 100,000
Vietnam 103 83 20 20 170 in 100,000
Brazil 110 40 70 33 74 in 100,000
Mexico 86 24 62 24 100 in 100,000
Egypt 65 20 45 33 170 in 100,000
Nigeria 125 25 100 88 530 in 100,000
Sources: AGI (1998); UNFPA (2005)
Regional and Country-Specific

Perspectives
North America
United States of America
Early pregnancy and childbearing are pressing

concerns for adolescent health in the United
States. About 31% of American women become
pregnant before the age of 20. Nearly 13% of the
sexually active American men between the ages of
15 and 19 report that they have fathered a preg-
nancy (Suellentrop and Flanigan 2006). Teen
pregnancy rates vary widely by race and ethnicity. Fig. 21.1 Trend in teenage pregnancies in the United States,
In 2002, the pregnancy rate for non-Hispanic 1950–2000. Source: CDC, National Center for Health Statis-
white teens was 49 per 1,000 of girls 15–19 years tics (2001)
of age. The pregnancy rate for Hispanic teens was
135.2. For African-American teens it was 138.9 Birth rates also fell steadily throughout the 1960s
(Ventura et al. 2006). Approximately 80% of teen- and 1970s and were fairly steady in the early 1980s.
age pregnancies are unintended. In 2002, they They rose sharply between 1988 and 1991, before
accounted for one-fifth of all accidental pregnan- declining throughout the 1990s. In recent years, this
cies in the United States (Finer and Henshaw downward trend has occurred among teens of all
2006; National Campaign to Prevent Teen Preg- ages and races. In spite of these declines, the United
nancy 2006). There were over 760,000 pregnancies States still has one of the highest teen pregnancy and
to women under the age of 20 in 2002 and about birth rates in the industrialized world (Fig. 21.2).
420,000 births to teens in 2004. The rate of teen Rates of teen pregnancy in the United States are
childbearing in the United States has fallen steeply two to six times higher than those in most of
from 96 births per 1,000 girls aged 15–19 in 1950 Western Europe including France, Holland,
to 49 in 2000 (Fig. 21.1). Denmark, and Sweden (Hoffman 2006). Negative
Flanigan 2006). Teenage girls with older partners

are more likely to become pregnant than those with
partners closer in age. A study by Darroch et al.
(1999) showed that 6.7% of girls aged 15–17 have
partners 6 or more years older. The pregnancy rate
for this group was shown to be 3.7 times as high as
the rate for those whose partners are no more than
2 years older (Darroch et al. 1999). Similarly, the
greater the number of sex partners, the more likely
teens are to be involved in a pregnancy; as a study
by Suellentrop and Flanigan (2006) showed, 37%
Fig. 21.2 Teenage pregnancy rates in selected high-income of teen girls and 18% of teen boys with three or
countries, 1998. Source: Tripp and Viner (2005) more partners have either experienced or have been
involved in a pregnancy. With less than two part-
consequences for both the mother and the child go ners, only 25% of teen girls and 9% of teen boys
beyond pregnancy and child birth. It is estimated have either experienced or have been involved in a
that teenage pregnancy costs the United States pregnancy.
between $7 and $9 billion annually (Hoffman Teen mothers and their children are more likely
2006; National Campaign to Prevent Teen Preg- to live in poverty (Crosby and Holtgrave 2006).
nancy 1997). In the United States as in many other Compared to teenagers from higher income
industrialized countries, teens can be classified families, teenagers from low-income families are
into two broad categories in terms of their atti- more sexually active and less likely to use contra-
tudes toward pregnancy, namely those with no ception correctly (AGI 1998). Teens from low-
intention of getting pregnant and who never income families make up 38% of all females who
planned on teen parenting and those that actually are between the ages of 15 and 19; yet, these teens
want to become pregnant. Evidence shows that account for 73% of all pregnancies in that age group
teens who desire to become pregnant are often (AGI 1998). About 60% of these teens live in pov-
those with low expectations for their future, low erty at the time of the birth (AGI 1994). They are
self-esteem, alienation from their own family, and less likely to complete their school education; more
a history of sexual abuse or poor parenting (Ste- likely to face limited career and economic opportu-
vens-Simon et al. 2005). For these teens, preg- nities, and less likely than older women to obtain
nancy is often seen as a way to bring meaning to timely prenatal and postnatal care (Ganesh 2005).
their lives. These and other factors contribute to the result that
Research evidence has shown that age of first babies born to teenagers are more likely to be pre-
sexual intercourse is an important determinant of term and have low birth weight. Babies of teenage
pregnancy risk; 46% of teenage girls and 22% of mothers are also at greater risk of serious and long-
teenage boys who engage in their first sexual term illness, developmental delays, and death in the
experience before the age of 15 have been involved first year of life compared to infants of older
in a pregnancy. For teens who engage in their first mothers (WHO 2004).
sex experience at age 15 or older, the risk declines Public perception about teen pregnancy and
to 25% and 9% for girls and boys, respectively childbearing in the United States is that problems
(Suellentrop and Flanigan 2006). Teens that use associated with a teenage pregnancy should fall on
contraception during their first sexual experience the shoulders of the teen moms and their parents
are less likely to experience a pregnancy; 27% (Mauldon and Delbanco 1997). It is perceived that
of teen girls and 12% of teen boys who used the teenage mother made the choice of becoming
contraception at first sex have been involved in a pregnant, and therefore, it is her responsibility to
pregnancy. For teens that did not use contracep- provide for herself and her child. A large number of
tion at first sex, 43% of girls and 18% of boys have people believe that only minimum resources should
been involved in a pregnancy (Suellentrop and be provided to teenage mothers and their children.
Increasing resources to teenage mothers, they and deal with a limited number of providers that
argue, would only encourage young women to perform only a certain number of abortions
become pregnant and give birth. A substantial pro- annually. Travel, especially across states, entails
portion of the public does not want to pay for cost and safety issues for teenage girls. The cost of
services needed to level the playing field for teenage the abortion itself is out of pocket since federal
mothers and their children compared to all other funds do not pay for abortion unless incest, rape,
older mothers and their children. Public attitude in or an endangerment to the mother’s life is involved.
the United States toward childhood and teenage The final barrier is the anti-abortion sentiment in
pregnancy is based in part on the religious and the United States. A young woman needing an
moral principles brought over by settlers from Wes- abortion must consider the possibility of confront-
tern Europe in the 1600s. At the time, the most ing pro-life protesters outside doctors’ offices and
important sanction was not children or teenagers clinics when seeking an abortion. A great deal of
giving birth, but whether the young girl was married stigma is still associated with being a teen mother in
or not. Early colonial church records indicate that if the United States.
a young woman became pregnant out of wedlock, Programs to prevent unintended pregnancy
she would confess her transgression and marry the among teenagers have taken many forms in the Uni-
father if possible (Ravoira and Cherry 1992). ted States, ranging from sex education in schools,
In the 20th century, however, this view and provision of free condoms, family planning services,
response to pregnancy and childbirth out of wed- and faith-based initiatives to increase abstinence.
lock changed rather rapidly beginning with the sex- Currently, prevention policy and funding is focused
ual revolution of the late 1960s and early 1970s on promotion of abstinence. Although abstinence-
(Lynch 2005). Many longheld ideas and attitudes only programs have been show to be ineffective in
were altered. There was also a shift in the view of reducing teen pregnancies and preventing sexually
pregnant teens. Instead of teen pregnancy being transmitted infections (STIs) among teenagers (San-
viewed as a moral issue, policy makers, service pro- telli et al. 2006), they emerged as the cornerstone of
viders, and the public began to view it as a systems current policy in the United States under the Bush
issue (Arney and Bergen 1984). Historically, one administration. According to recent data from Alan
major influence on teen pregnancy rates in the Uni- Guttmacher Institute (2006):
ted States was the legalization of abortion in 1973
(Roe vs. Wade 1973) (Supreme Court of the United Eighty-six percent of public school districts that
States 1973). Twenty-nine% of the 757,000 preg- have a policy to teach sex education require that
nancies to teens (15–19 years) in 2002 resulted in abstinence be promoted.
abortion (Ventura et al. 2006). The 1973 legaliza- About 35% require abstinence to be taught as
tion of abortion gave pregnant teenagers access to the only option for unmarried people and either
legal abortions for unwanted pregnancies without prohibit the discussion of contraception alto-
parental consent. By the end of the 20th century this gether or limit discussion to its ineffectiveness;
right of teenage girls to an abortion without paren- the other 51% have a policy to teach abstinence
tal consent was scaled back by both federal and as the preferred option for teens and permit dis-
state legislation (AGI 2008). In 2008, the majority cussion of contraception as an effective means of
of states require parental notification or consent of preventing pregnancy and sexually transmitted
one or sometimes both parents. Currently, only 15 illnesses (STIs).
states and the District of Columbia allow a minor to More than half of the districts in the southern
seek an abortion without parental consent (AGI United States with a policy to teach sex educa-
2008). In addition to parental consent, many other tion have an abstinence-only policy, compared
factors affect a woman’s access to abortion services with one in five of such districts in the Northeast.
in the United States. Limited services are one of the There are three federal programs dedicated to
major barriers. Providers are only available in 16% funding restrictive abstinence-only education:
of all the counties in the country (Henshaw and Section 510 of the Social Security Act, the
Finer 2003). This means an adolescent must travel Adolescent Family Life Act’s teen pregnancy
prevention component, and Community-Based and STI among adolescents in Western Europe. The
Abstinence Education (CBAE). The total fund- rate of teenage pregnancy in England is triple the rate
ing for these programs in 2006 was $176 million. for Germany and France (Fig. 21.3) and six times
Federal law establishes a stringent eight-point higher than the rate in the Netherlands (Tripp and
definition of ‘‘abstinence-only education’’ which Viner 2005). In 2005 it was estimated that 42 of every
requires programs to teach that sexual activity out- 1,000 pregnant women were teenagers. This figure was
side of marriage is wrong and harmful – for people more than three times the rate for France and Ger-
of any age. The law also prohibits programs from many in the same year. Rates of teenage pregnancy fell
advocating contraceptive use or discussing contra- during the 1970s and 1980s in many European coun-
ceptive methods except to emphasize their failure tries including the UK. The rate of decline was much
rates (Dailard 2002). Federal guidelines now define slower in relative to her neighbors (Fig. 21.4).
sexual activity to include any behavior between two In England, less than 33% of teens are sexually
people that may be sexually stimulating, which active before they are 16. However, half of those
could be interpreted as including kissing or hand- who are sexually active use no contraception the
holding (Dailard 2006). first time they engage in intercourse (AGI 2002). As
There is currently no federal program dedicated a result, 39,286 teen pregnancies were recorded in
to supporting comprehensive sex education that 2002 (AGI 2002). In 1999, over 15,000 pregnant
teaches young people about both abstinence and girls under 18 years of age opted for an abortion
contraception (Dailard 2006). (AGI 2002). In England, at the beginning of the
21st century, 90% of all teenage mothers have their
babies outside marriage. There is pronounced
concern among the public about the high rate of
Europe and Central Asia teen pregnancy, unwed births, and the number of
teens who contract sexually transmitted diseases.
England, United Kingdom Before World War II, little thought was given
to teen pregnancy, and for the most part, unin-
The teenage pregnancy rates vary greatly across Eur- tended pregnancy was handled using ‘‘homes
ope. England has the highest rate of teenage pregnancy for unwed mothers’’ and adoption (Justin 2005).
Fig. 21.3 Live births per 1,000 women aged 15–19, selected European countries, 1996. Source: Wellings (2007)
these groups, the tradition of early childbirth within

marriage has a common history. A 1994 survey of
Pakistani and Bangladeshi women in their twenties
who had given birth in their teens found that over
90% were or had been married, compared with 55%
for native English women (Health Education
Authority 1994). Surveys have also reported that
Pakistani and Bangladeshi women are least likely
of all ethnic groups to have had sex before the age of
16 (Wellings et al. 1994). In addition, the relation-
ship between low socioeconomic status and early
Fig. 21.4 Age-specific fertility rates in women aged 20 years pregnancy appears to be strong for these ethnic
and younger from selected European countries. Source:
minority groups. For example, 41% of Afro-Carib-
Wellings (2007)
beans, 82% of Pakistanis, and 84% of Bangladeshis
have incomes less than half the national average
Today, however, almost everyone in England may compared with 28% of English nationals (Policy
know of a teenage girl who has given birth to a Studies Institute 1997). Some individuals in ethnic
child out of wedlock. Out of wedlock births to minority groups are at risk, especially if they are
teenagers are socially unacceptable in England but excluded from school or are in a foster care situa-
because 90% of teenage girls are not married when tion. Other advocates point out that sexual health
giving birth, public health and social services have services were typically not designed in a way that
accepted the reality of the phenomenon. would reach specific ethnic minority groups
The trend in England is to view teen pregnancy as (Department of Health 1999).
a ‘‘personal responsibility’’ issue (AGI 2002). Based A sexually active teenager who does not use
on this paradigm and the logical programming that contraception has a 90% chance of conceiving over
follows, it will be difficult for English health and the first year of sexual activity and of contracting a
social service providers to use the more pragmatic sexually transmitted infection. In a single act of
models that have worked in other Western Eur- unprotected sex with an infected partner, teenage
opean nations. It is likely that officials will continue girls in England have a 1% chance of acquiring
to use poorly developed sexual education curricula HIV, 30% risk of getting genital herpes, and 50%
and blame the teenage girls and boys for the high chance of contracting gonorrhea (Nicoll et al. 1999).
rate of teen pregnancy. Efforts to address the ser- Chlamydia affects English teenage girls more than
ious problems faced by teenagers at risk of unin- any other age group (Nicoll et al. 1999). It is the
tended pregnancy are hampered by lack of recogni- leading cause of ectopic pregnancy and can lead to
tion of the diversity of modern England by infertility. It can cause discharge and pain, but is
politicians and public officials. For example, in usually asymptomatic, so the sufferer may never
England, there are no comprehensive statistics on know they are infected. Diagnoses of Chlamydia in
either live births or abortions by ethnic group (AGI Genito-Urinary Medicine clinics for 16–19-year-olds
2002). The mother’s ethnic group is not recorded if rose by around 53% between 1995 and 1997. This
the pregnancy is aborted or during the birth regis- age group also had the highest diagnostic rates
tration. Information is collected on the mother’s (1,035 per 100,000) in 2001 (Nicoll et al. 1999).
country of birth, but this does not identify the England is unique in that it continues to value the
specific ethnicity. Although official surveys recog- involvement of the parent, but tolerates the adoles-
nize three ethnic minorities whose teenage girls cent’s decision to terminate her pregnancy. The
are at increased risk of becoming a teen parent, ultimate authority does not lie with the teenager, how-
Bangladeshis, Afro-Caribbean, and Pakistanis ever, but with the practitioner. Before performing an
(AGI 2002), there is no way of identifying the extent abortion, practitioners are required to attempt to per-
of teen pregnancy by ethnic group. This can hinder suade the teenager to contact her parents about her
the understanding of teen pregnancy because for desire to abort her pregnancy. If she refuses, the
practitioner can perform the abortion if the teenager is any group of teens has ever experienced. The downfall
deemed capable of understanding the implications of the Soviet Union was followed by a decade of
and potential complications of the procedure. It can deteriorating infrastructure, a major increase in pov-
be assumed that there is much variability in terms of erty, and an overall decrease in quality of life (Singh
individual practitioners’ attempts to dissuade teen- and Darroch 2000). Over the last 25 years, in most
agers from seeking an abortion (Wellings 2001). industrial countries around the world, there has been a
According to a report by Wellings (2001), slightly decline in teen birth rates, with the exception of Russia.
over half of teenagers who are 16 years old and Adolescent birth rates, which fell between 1970 and
younger terminate their pregnancy. According to the 1995 in most Western countries (Singh and Darroch
report, this statistic has changed little since the 1970s. 2000), rose by 54% in Russia. A comparative study of
For young people in their twenties, over a third of teen pregnancy rates in developed countries (Singh
conceptions end in abortions, and this figure is rising. and Darroch 2000) showed that Russia has one of
Furthermore, it was noted that one in ten 16–19-year- the highest teen pregnancy rates (more than 100 per
old girls who have had an abortion have had one 1,000) of all industrialized countries.
earlier, and 2% have had both an abortion and a Unintended adolescent pregnancies are common
birth. Pregnant teenagers are also 1.5 times more likely in the Russian Federation in part because of the
than women who are in their twenties to have an limited availability of accurate and confidential
abortion at 13 weeks or later. Nevertheless, abortion information on contraception and a reluctance to
ratio (the proportion of pregnancies that are termi- discuss sexual issues openly at home or to provide
nated) is low in the UK compared with other Eur- sex education at school. In Russia, teens receive the
opean countries (Wellings 2007). However, it has been same reproductive services as adults. As data on teen
on the rise and is beginning to approximate more to fertility are not collected separately, few official sta-
the European picture (Wellings 2007). This is in con- tistics are available on teen pregnancy and birth
trast to the situation in the United States, where the rates. Even so, the statistics kept by the Ministry of
abortion ratio is very low and falling. Public Health and other agencies about services pro-
There has been research into factors that influence vided to people by age and sex can reveal a great deal.
a teenager’s decision to have an abortion. Moore et al. In 1997, according to official marriage records in
(1996) report that ‘‘. . . a greater influence seems to be Moscow, 305 girls, who were 16 years of age, were
young women’s perceptions of their future prospects. married. Among 16-year-old boys, only 26 were mar-
Those who have higher education aspirations are ried. There were 867 Moscow girls who were married
more likely to have abortions, and students tend to at 17 years of age and only 120 married boys of the
have more abortions than non-students.’’ same age. These numbers suggest that teenage girls
While affluent areas in England have high rates tend to marry males who are older than they are.
of teenage pregnancy, it is the poorer areas that In Moscow, according to official reports (UNICEF
have the highest rates. The Department of Health’s 1999), 75 girls under the age of 15 became mothers in
(2001) report on strategies to reduce teen pregnancy 1996. Girls who were 16 years of age gave birth to 315
makes several good points about teen pregnancy. It babies. For three of the 16-year-old mothers, it was
identifies economic barriers, lack of social support their second child. Seventeen-year-old Moscow girls
systems, lack of education about sex and preventive gave birth to 864 babies. For 16 of them, it was their
measures, and lack of skills needed for decision second child. Among Moscow girls under the age of
making regarding relationships and unwanted preg- 15, there were 71 legal abortions in 1996. Girls between
nancy (Department of Health 2001). the ages of 15 and 19 had 10,536 abortions the same
year. This was a drop from a 1994 high of more than
12,000 abortions performed on Moscow adolescents
Russian Federation (UNICEF 1999). Available data show that at least
56.1% of adolescent pregnancies end in abortion
Teenagers that live in the Russian Federation coun- (Singh and Darroch 2000). In 1996, there were
tries of the former Soviet Union have been living 2,700,000 legal abortions recorded in Russia as a
through some of the most extreme and rapid changes whole. Teenage girls accounted for about 270,000 or
a tenth of these abortions. The number of abortions Table 21.2 Age-specific fertility (15–19 years) in
officially reported does not account for illegal abor- selected countries of the EASP region
tions. Some experts suggest that abortions in the coun- Births/100 women aged
Country 15–19 years
try are probably more than 25% under-reported and
Cambodia 23
does not account for illegal abortions.
China 5
It is believed that poverty plays a significant role in Democratic People’s 5
teen pregnancies in Russia. A lack of educational and Republic of Korea
job opportunities result in girls and boys seeking other Indonesia 45
paths to self-fulfillment. Inadequate health services for Japan 1.39
the poor also contribute to the problem. Russian teens Lao People’s Democratic 51
Republic
face inadequate family planning services and little
Malaysia 29
school-based sexuality education (UNICEF 1999). Mongolia 38
There is a lack of choice between effective birth control Myanmar 36
methods. Abortion has traditionally been the way Philippines 41
Russian teenage girls and women controlled their Republic of Korea 4
reproductive lives (RAND 2001). This method was Singapore 8
supported by the central government in part because Thailand 60
Vietnam 35
of cost and the reliability of abortion. To increase the
use of other methods, a mass education campaign is Source: Mehta et al. (1998)
needed to correct years of misinformation by the cen-
tral government health service (Cohen 1997).
newly married couples are often under pressure
from their family and community to have children
shortly after marriage. As contraceptives are
East Asia and the Pacific becoming more widely used among older women
of reproductive age, fertility has become concen-
In East Asia as in other regions of the world, teen trated among young married women (Singh and
child birth is highly correlated with the level of each Samara 1996). Rapid economic, social, and demo-
country’s socioeconomic development and varies graphic changes have led to changes in adolescent
from a low fertility rate of 1.39 per 100 among 15- sexuality in the region. A trend toward increasing
to 19-year-old girls in Japan to a high of 60 per 100 age of marriage has led to a perceived increase in the
in Thailand (Table 21.2). acceptance of premarital sex among young people.
In much of East Asia and the Pacific region, Limited information is available on the sexual pat-
premarital sexual activity is considered uncommon. terns of unmarried adolescents. However, recent
A survey conducted by East-West Center (1997) in studies (Cherry et al. 2001) have found that atti-
the Philippines showed that most sexual activity tudes and behaviors toward sex are becoming
takes place within the context of a committed rather more open to sexual activity before marriage and
than a casual relationship. Reported levels of pre- at an earlier age. While pregnancy outside of mar-
marital sex are higher than many have assumed, but riage is still rare in much of the region, it is more
most premarital sexual activity, particularly for common in the Pacific area and is considered an
women, appears to be initiated at some point during emerging problem needing special attention. In
a process that leads to formal marriage. Indeed, the some South Pacific countries, adolescent mothers
very definition of what is premarital is not always constitute over 10% of the total births (House and
entirely clear. Nasiru 1999).
However, early initiation of marriage is high and Social and cultural restrictions on adolescent
adolescent pregnancy rates are high. In countries premarital sexuality lead many teenagers to
where early marriage is common, fertility rates terminate their pregnancies to avoid detection by
tend to be high (Singh and Samara 1996). In many their elders. Abortions are common, and due to
Asian cultures, childbearing is highly valued, and socio-cultural factors and financial restraints,
these abortions are often performed secretly in are very important. Buddhism has contributed a
unsafe conditions by unqualified providers (Mehta great deal to the religious and social life of Japan.
et al. 1998). It has had a tremendous influence on the arts, social
institutions, and philosophy (Buckley 1998). These
traditions define Japanese society, and most Japa-
Japan nese people affirm some religious affiliation (Picken
1994). Today, young women in Japan often talk of
Japanese adolescent girls have the lowest pregnancy being disillusioned with married life. They spend
and birth rates in the world; only 4 girls per 1,000 long hours at home alone while their husbands are
(15–19 years) give birth in Japan. It is even lower for away at work. They are also burdened with the care
girls between the ages of 15 and 17. They give birth and demands of older relatives. They are finding it
to 1.1 children per 1,000 girls. The low birth rate can increasingly difficult to accept the long-established
be attributed to a number of factors. However, it is role of mother and wife based on the competing
no coincidence that Japan’s young people lead the demands of tradition and a modern world. In
world in the use of condoms for protection against response, Japanese women are determined to
unwanted pregnancy and STIs (Bankole et al. develop a role for themselves that combines mother-
1998). The teen abortion rate in Japan is among hood, self-fulfillment, and social usefulness. In spite
the 10th lowest in the world (Cherry et al. 2001). of their efforts, Japanese culture continues to cele-
The adolescent abortion rate in 2005 was approxi- brate male dominance and female submissiveness
mately 6 per 1,000 (see Table 21.1). Even so, there is (Miyazaki 1999).
concern about Japanese teenagers using abortion as One interesting variation on the small family
a way to control births. In 1995, around 1.2 million theme that is seen in most developed and developing
Japanese women had an abortion (Shirk 1997). countries is the choice of gender of the only child. In
A woman may seek an abortion to save her own countries such as China and India, where there is
life, eliminate risks to her physical health, if rape or pressure to reduce family size, the desire is to have a
incest was involved, and for economic or social male child. In Japan, however, this phenomenon is
reasons. Japan has a unique situation due to its not true; a large proportion of couples in Japan
1948 Eugenic Protection Law (Ota 1967) which want a female child. Parents in Japan believe girls
allowed abortion in the case of hereditary or mental will have more options than boys in the future
disease not only in the mother or father but also in (Women Envision 1999).
fourth-degree relatives. The national goal was the
prevention of a genetically inferior population.
Abortions rose to a high of 1,170,000 compared to Vietnam
1,731,000 births. These stipulations were taken out
in 1996 mainly due to the influence of disability Much like other developing countries in this region
rights organizations (United Nations 2002). of the world, early in its history, the Vietnamese
An important long-term social problem that will society adopted the patriarchal family as the basic
continue to affect Japanese girls and young women social institution. With the introduction of Confu-
is the general status of women in Japan. In Tokyo, cian culture, societal norms were defined in terms of
prostitution is legal as long as a pimp is not involved the duties and obligations of a family to a father, a
(Yayori 1999). A man can legally have sex with a child to a parent, a wife to a husband, and a younger
child as long as he or she is over the age of 12 and brother to an older brother. They believed the wel-
consents (Reitman 1996). Furthermore, incest is not fare and continuity of the family group were more
a crime unless it is a rape (Reitman 1996). Interna- important than the personal interests of any one
tionally, Japan is known as the largest market for individual. In the first decade after World War II,
enslaved women in the world (Yayori 1999). the vast majority of North and South Vietnamese
Nonetheless, Japan is essentially a secular society clung tenaciously to traditional Confucian customs
where religion is not a central factor in daily life; and practices. This attitude changed, however, with
even so, certain religious traditions and practices the introduction of Communism. The Communists
criticized the traditional concept of family as rem- SAVY (Ministry of Health, Vietnam 2003) found
nants left over from the failed feudal system that that 7.2% of the females reported having an
resulted in their third world status. abortion.
The concept of teen pregnancy in Vietnam is
rarely mentioned as a separate issue from the overall
high birthrate. In the larger society, it is considered
normal for girls in Vietnam to marry at 13 or 14 South Asia
years of age and begin to have children before they
are 16. Moreover, teen pregnancy is not considered India
a major concern in Vietnam; rather it is the high
poverty rate and the extensive use of child labor that In the late 1990s it was estimated that 42,000 babies
are considered problematic. Poverty, along with the were born every day in India and that 4 women died
possibility of added family income from working out of every 1,000 live births. This is an average of
children, tends to pressure mothers to bear more about 40 women per day (Cherry et al. 2001). Cur-
children. rently, 70 (per 1,000) adolescent females aged 15–19
Modern contraception was introduced in Viet- are estimated to become pregnant with 45 (per 1,000)
nam on a limited scale in the 1960s, but it took 20 giving birth (Cherry et al. 2001). Problems for Indian
years before family planning was actively promoted women begin at birth. Boys are considered more
to reduce the rapid population growth. The highest desirable. Traditionally, sons remain in their par-
intrauterine device (IUD) prevalence rate in the ents’ home even after marriage. Girls are often seen
world is found in Vietnam, where it became the as a burden, as they not only leave the family when
method of choice when the country launched its married but also need an adequate dowry. Conse-
two-child policy in the early 1980s (Johansson quently, girls may be fed less if there is insufficient
et al. 1998). Contraceptive services and legal abor- food, and their education is neglected. Clinics in
tion are provided free of charge through an exten- India advertise pregnancy testing to determine the
sive public health network. In some provinces in sex of the fetus. In many instances, abortions are
Vietnam, particularly in the north of the country, performed if it is a female (Cherry et al. 2001).
various incentives and fines are applied to ensure Although such practices are now illegal, they still
compliance with the two-child norm. As in other occur (Cherry et al. 2001). In 2006, for the first
countries, laws to reduce the fertility rates in Viet- time in India since the law against sex selection
nam resulted in an increase in abortion rates. The abortions (the Female Foeticide Law) was passed
annual rate of adolescent abortions is over 100 per in 1994 a doctor was sentenced to jail and fined for
1,000 (Table 21.1). This puts the total number of using ultrasound technology to determine the sex
abortions at 2.5 per woman, one of the highest of an unborn child for purposes of abortion (White
reported rates of induced abortion worldwide 2006).
(Johansson et al. 1998). For the urban, middle-class adolescent girl in
Abortion has been available on request in Viet- cities such as Delhi and Bombay, life is materially
nam since 1975. There are no criminal codes asso- more comfortable. She is more likely to be given an
ciated with performing an abortion on a minor education. Once married, however, she is still
female. In 1989, a national law established free expected to be a mother and homemaker. Like her
abortion services through the public health services village counterpart, if she fails to provide a son the
and created support for sick leave related to abor- consequences can be severe. Reports continue to
tion. The Survey Assessment of Vietnam Youth describe girls burning to death in kitchen fires,
(Ministry of Health, Vietnam, 2003), a nationally most of which have been identified as either suicide
representative study of youth in Vietnam conducted or murder (Shaha and Mohanthy 2006; Jutla and
in 2003, indicates that the abortion rate is very low Heimbach 2004). The best data available are from
for married adolescents aged 15–19. It has been the 1992 to 1993 National Family Health Survey
estimated that the inclusion of unmarried adoles- of India (International Institute for Population
cents would greatly increase the abortion%age. Sciences 1995) which indicates that girls are
breastfed for shorter periods than boys and are less on these behaviors (Kapilashrami n.d.). The find-
likely to be vaccinated or to receive treatment for ings suggest that there is a lower level of decision
diseases such as diarrhea, fever, and acute respira- making related to abortion for adolescents (below
tory infections. Hence, child mortality in the 0–4 the age of 20) in comparison to women that were
years age group is 43% higher for females (at 42 between the ages of 21 and 24, and older. Spacing of
per 1,000) than for males (29 per 1,000) (Sen 1994). children was the main reason for seeking an abor-
India’s National Family Planning initiative has con- tion. Sex selection is the reason given for one out of
tributed to increased awareness about family plan- every eight abortions. Age and being married
ning, contraceptives, and available medical services. played a major role in differentiating trends in
According to the Department of Family Planning girls and young women. The younger the woman,
statistics, the percentage of females either sterilized the more likely the doctor was to insist on spousal
or fitted with an IUD increased from 10.4% in 1971 consent even though the law does not require spou-
to 44.1% in 1991 (Department of Family Welfare sal involvement. Unmarried adolescents faced a
1990–1991). Most of this increase has been achieved higher cost for a private sector abortion than for
through sterilization of women with a mean age of married teenagers (Ganatra and Hirve 2002). A
31. These women have on average 3.3 living children finding that puts into question the effectiveness or
(Department of Family Welfare 1990–1991). This lack of public education about abortion is that 60%
profile has changed little over the years. This means of the adolescents that received an abortion did not
that India’s Family Planning has not been very know that abortion was legal even for unmarried
successful in recruiting teenage girls or younger women (Ganatra and Hirve 2002).
couples, and it has not been able to popularize the Legalizing abortion does not by itself guarantee
use of safer forms of birth control, like the condom safe abortion. Abortion has been legal on broad
(Zodgekar 1996). grounds in India for almost 30 years; yet, many
An abortion in India can be performed if any women, especially in rural areas, cannot access a
one of six criteria are met: (1) to save the life of legal abortion. Authorized facilities that provide
the woman, (2) to preserve the physical health of safe abortions services are inadequate in number,
the woman, (3) to preserve the mental health of the and some women have found their treatment by
woman, (4) in cases of rape or incest, (5) fetal government health professionals to be degrading
impairment, or (6) for social or economic reasons. (Kapilashrami n.d.). As a result, women frequently
Abortions performed to ensure a male child is a go outside the authorized system and obtain an
serious problem in India. The decade 1991–2001 illegal abortion, many of which are unsafe.
saw a decline in the birth of girls per 1,000 as
compared to boys from 945 to 927. Some states
have more pronounced declines such as Punjab
(875 to 793) and Haryana (879 to 820). The statis- Central and South America
tics were accompanied by some poignant
statements which reflected that it may become The Pan American Health Organization (PAHO)
impossible to make up for the missing female states clearly and in numerous ways that poverty
babies (UNFPA 2003). greatly increases the risks of pregnancy among
It is difficult to report findings related to abor- Latin American adolescents between the ages of 15
tion that go beyond the mere reporting of its legal- and 19 years (PAHO 2000). PAHO bases it conclu-
ity. Estimates of the adolescent abortion rate are 45 sion on studies that show that about 70% of preg-
per 1,000 (Table 21.1). The stigma of having an nant teens come from the most disadvantaged
abortion creates barriers to studying why Indian groups in Latin American, such as those girls living
women seek abortion and the actual services they in rural areas of their country. Poverty and teen
receive. Nevertheless, a recent study of decision motherhood in Central and South America has ser-
making, reasons for seeking an abortion, variation ious consequences for the children of these teen
in provider services, and the young women’s aware- moms. The children are likely to be undernourished;
ness of the legality of abortion provides some data they are less likely to attend school, and show
poorer motor skills than children of adult women women have economic value that far exceeds the
(UNICEF 2008). In Chile and Mexico, approxi- value of their fertility. The meaning of these events
mately 75% of women who gave birth before the is even more understandable when it is remembered
age of 20 are the children of teen mothers themselves that women in Mexico did not have basic civil rights
(Cherry et al. 2001). The number of teen pregnan- or the right to vote until the mid-1950s. This left
cies is similar in the countries that are found in the Mexican women powerless in family relationships,
Central and South American regions of the world. their community, and in legal matters. They had
The teen pregnancy rates in South America vary difficulty in making their husbands share the
from a low of 56 per 1,000 teens (15–19 year) in responsibility for contraception and childcare and
Chile to a high of 101 per 1,000 teen girls in Vene- were often left destitute if their husband for what-
zuela. In Central America, the rates vary from a low ever reason was no longer in the home.
of 91 per 1,000 in Panama to a high of 149 per 1,000 From a national perspective, these traditional
in Nicaragua (Gatti 1999). ideals of the past, early marriage, childbirth, and
large families do not fit with the demands of a
growing industrial complex. They do not fit with
Mexico the increasing awareness of ecological and popula-
tion stressors. High birth rates, while prized in tra-
Like most developing countries, Mexico is com- ditional agrarian cultures in Central and South
mitted to reducing its population growth and America, are seen as deleterious to the environment
improving its public health (Po 1997). Mexico is a and the economy of these developing industrial
developing nation sharply divided by income and states. The industrial sites that are rapidly being
education. While a middle class is developing in the developed in Central and South America are largely
cities, there remains widespread poverty and sharp owned by multinational corporations. These indus-
divisions between the wealthy educated elite and the trial sites are similar to the maquiladora plants and
poor. Among urban residents, 40% have incomes factories that have been built along the border
below the poverty level. More revealing, a large%- between Mexico and the United States. These fac-
age of government employees can be classified as tories typically owned by firms in the United States
having incomes below the poverty level. Many areas profit greatly from the labor of Mexican girls and
of Mexico are experiencing a significant industrial young women they hire. Today there are more than
boom. Industrialization with the promise of high 4,000 such plants employing almost 1 million work-
pay and steady work is drawing the young from ers in Mexico. Almost 80% of these plants are
the depressed and rural countryside to the urban located along the border. Since the 1970s, the
areas. The wages and benefits from industry (most majority of workers at these assembly plants have
often multinational corporations) have fueled a been girls and young women.
consumer movement in Mexico like none it has While it is legal to hire adolescents when they
ever witnessed. This prosperity has also created a turn 16, and some children work legally with their
major cultural conflict. Although a traditional parent’s permission, or with permission obtained
agrarian culture has characterized family life in from local authorities at the age of 14, it is common
Mexico for almost 500 years, these agrarian tradi- for girls as young as 12 (with false documents) to be
tional roles for men and women do not fit with the working for some of the largest multinational com-
pragmatism of commerce. Women are working out- panies in Mexico. To obtain and keep their jobs at
side the home more often; they are becoming better many plants, the adolescent girls and young women
educated, and especially in affluent urban areas the are required to submit to medical examinations and
young women are cosmopolitan. Most importantly, pregnancy tests to prove that they are not pregnant.
women bring home a paycheck. Among Mexican adolescents under the age of 20,
In modern Mexico traditional family values have over 500,000 become pregnant each year. Of these,
given way to family economics. This is especially 380,000 adolescents gave birth; the other 120,000
true when the traditional way of life results in the lose their babies through abortion or medical com-
subjugation of girls and women. Today in Mexico, plications (Cherry et al. 2001). Between 300,000 and
600,000 women of all ages have clandestine abor- District and most of the 31 states in Mexico permit
tions each year. The government-run National legal abortions if it endangers a woman’s life or if
Health System reported that four women die every the pregnancy was the result of rape. The abortion
day in Mexico from maternity-related causes, and must be performed within 12 weeks of gestation.
40% of these women die from the consequences of The Federal District specifies additional conditions
induced abortion. Contraceptive use has been low related to termination of a pregnancy. A person can
among sexually exposed adolescents in Mexico. One receive 6–8 years in prison if they inflict physical or
study of adolescents living in Leon, Mexico, found moral violence that results in the end of a preg-
that male students scored higher on knowledge of nancy. The most restrictive states only allow abor-
sexuality but that female students had a greater tion in the case of rape. Other states consider fetal
knowledge of contraception. Both males and defects and the woman’s health as a legitimate rea-
females among the lower socioeconomic class son to seek an abortion. Chiapas in 1991 passed a
scored lower on knowledge of sexuality, contracep- law that would have expanded legal abortion to
tion, and sexually transmitted diseases than those of include a woman who was single or in certain
the middle and upper classes (Huerta-Franco et al. cases where seeking an abortion was a couple’s
1996). decision. Later in that same year, the state legisla-
‘‘Contraceptive use among women without edu- ture suspended the law (AGI 2000).
cation who live in rural areas is under 30% among
women from urban areas with six or more years of
schooling, the contraceptive use exceeds 75%’’
(Cherry et al. 2001). Among adolescents, the IPPF Sub-Saharan Africa
report noted that although 68% of adolescents ask
for contraceptives, only 29% use them. At the turn The African continent is generally divided into two
of the 21st century, adolescents were giving birth to parts: the north, which is located above the Sahara
more than 500,000 children a year in Mexico. Ado- Desert, and the sub-Saharan countries that are
lescent childbirths tend to be unplanned, and the located below the Sahara Desert (the world’s largest
younger the mother is, the less likely she is to be desert). The majority of Africans live in sub-Saharan
married. Unmarried adolescent mothers face social Africa. Sub-Saharan Africa includes the countries of
ostracism at all social levels. They have insufficient Ethiopia, Somalia, Uganda, Angola, Cameroon,
family support and no financial support from the Ghana, Nigeria, the Democratic Republic of the
government. If a girl becomes pregnant, there is Congo, South Africa (including the homelands:
intense pressure for her to marry, even if she thinks Botswana, Lesotho, Namibia, Transkei, and others),
that a forced marriage would end up in severe mar- and a number of islands, the largest of which is
ital conflict and divorce (AGI 1994). The conse- Madagascar. In the mid-1980s, there was widespread
quences of not marrying would limit her prospects concern that the population explosion taking place in
of marrying again in the future. sub-Saharan Africa would destabilize the entire con-
Teenagers in Mexico who become pregnant often tinent of Africa. The number of adolescents giving
find themselves alone and facing a major crisis. The birth was far too high for both wed and unwed
pregnancy rate for adolescents in 2005 was 86 per adolescent girls in much of sub-Saharan Africa. At
1,000 (see Table 21.1). In Mexico, contraceptives that time, great emphasis was placed on programs
are often difficult to acquire, especially for the that provided effective contraception methods to
rural or urban poor. In addition, abortion is illegal slow down the population growth (Metz 1991). In
throughout Mexico. Still, 24 per 1,000 adolescents 2000, there was continued concern over the high
sought an abortion in 2005 (Ross-Fowler 1998). number of adolescents becoming pregnant; however,
These circumstances often lead to sad choices for of greater concern was the spread of HIV infection,
all involved (Ross-Fowler 1998). especially among adolescents and teenagers. Bots-
Because abortion is illegal in Mexico, the woman wana, the country in the sub-Sahara with the world’s
and the person performing the abortion are both highest HIV infection rate reports that 36% of
faced with imprisonment (AGI 2000). The Federal adults were infected in the year 2000. Deaths from
AIDS dropped the life expectancy of people born in with women in the urban areas. These relationships
Botswana from 71 to 39 years of age. It was also the often involve unprotected sex (UNICEF 2008). This
first time that the United States Census Bureau pre- leads to the men contracting STIs and HIV/AIDS
dicted that a country’s population would drop which are then taken back home to their wives.
because of AIDS (Haney 2000). In Nigeria, 15- to 29-year-olds accounted for 63%
Even in the face of this most devastating pan- of all AIDS cases among females between 1986
demic, in Africa as elsewhere, more teenage girls are and 1995.
enrolled in school and delaying the birth of their In the year 2000, slightly over 40% of Nigerians
first child. In some rural areas, however, large live in an urban area, twice the number that lived in
families with 4–10 children is still the norm, large cities in 1970. Nigeria has a long history of urban
families for the most part are viewed as more of a development, particularly in northern and south-
burden than a help. Traditional values based on an western regions. A vast number of these urban
agrarian culture have been replaced with urban atti- areas were important cities many centuries before
tudes and ideas. In the past, adolescent childbearing the Europeans arrived. Lagos was colonial Niger-
was confined to marriage; today, early childbearing ia’s capital and is today the leading port city. It is
increasingly occurs outside of marriage. Rapid one of the largest cities in the world (Metz 1991). In
social changes as a result of Western influence, 2003, about 66% of Nigerian girls aged 15–19 had
commerce, and knowledge of the world outside of weekly access to at least one of the three main types
sub-Saharan Africa have convinced large numbers of media – newspapers, radio, or television, and
of teenage girls that adolescent pregnancy could be about 10% had access to all three types. However,
hurtful to their health and future and to the future 34% did not have any media exposure in the aver-
of the child they may deliver. Consequently, age week (AGI 2004).
although sexual activity has increased slightly, Between 1980 and 2003, the birthrate among
births among adolescent girls are not increasing in Nigerian girls aged 15–19 decreased by 27%
most sub-Saharan African countries. The rate of (from 173 to 126 births per 1,000 girls this age)
unintended births has either leveled off or is declin- and remained relatively stable in 2005 at 125 per
ing. Nevertheless, as a region, most sub-Saharan 1,000. Nonetheless, 46% of women nationally
Africa still has the highest rates of adolescent preg- and about 70% of those in some regions still
nancies in the world (Amazigo et al. 1997). give birth before their 20th birthday (National
Population Commission (NPC), Federal Repub-
lic of Nigeria and ORC Macro 2003). Prenatal
Nigeria care by a doctor or nurse-midwife during preg-
nancy, at delivery, and during postpartum
Nigeria has the largest population of any country in (within 2 months of delivery) vastly improves
Africa, an estimated 131 million people (UNICEF birth outcomes. In Nigeria, only half of young
2008). Despite having the largest population in women aged 15–24 who have given birth receive
Africa, Nigeria has one of the lowest HIV/AIDS prenatal care. Young women in rural areas are
infection rates in sub-Saharan Africa. Nevertheless, much less likely than those in urban areas to
rapid increase in HIV infection is imminent, if sex- have professional care during their pregnancy
ual behaviors do not change. Young married men in (40% vs. 78%). Less educated women (under 7
Nigeria like in other sub-Saharan African nations years of education) are also much less likely to
are drawn to industrial areas where work is avail- have had professional care than more educated
able and where they can provide for their wife and young women (39% vs. 81%). The likelihood of
children back home. At first they tend to return a young woman receiving obstetric care during
home every 2 or 3 weeks with their earnings and delivery is even poorer. Only 30% of young
renew their relationship with their wives and chil- women aged 15–24 giving birth are attended by
dren. Overtime, however, the men tend to return a trained health professional (Singh et al. 2004).
home less often. While away from their families, The inadequacy of Nigeria’s maternal and child
many men become involved in sexual relationships health services has tragic consequences. The rate of
infant mortality is high (88 deaths per 1,000 births), as areas, social conditions are poor and there are limited
is the rate of maternal mortality (533 maternal deaths educational and job opportunities for adolescents,
per 100,000 live births) (WHO 2004). One study found especially girls. Marrying at a young age and having
that 72% of all deaths among young women under the children while still in her teens is a social expectation
age of 19 were due to the consequences of unsafe and may seem to be a more certain route to social
abortions (Shane 1997). Many other young women standing than education. However, having children
who survive unsafe abortion suffer complications early can have negative consequences because young
leading to infertility (Shane 1997). Nigerian abortion mothers are often physiologically immature and lack
laws in the northern states are different from abortion access to adequate health care. Due to the lack of
laws in the southern states. In the northern states, government-sponsored programs that disseminate
where the population is predominantly Muslim, abor- educational materials on various types of birth con-
tion is only allowed when it is needed to save the life of trol, 58% of Nigerian females use the form of birth
the woman. In the southern states where the popula- control that is most familiar to them, injectable
tion is predominantly Christian, three exceptions per- implants (Amazigo et al. 1997).
mit legal abortion: to save the life of the woman, to
preserve her mental health, or to preserve her physical
health. Two physicians must certify that the preg-
nancy constitutes a danger to the woman’s life in Middle East and North Africa
both the northern and southern states. Fines for indi-
viduals performing an illegal abortion are 14 years of Middle East and North Africa is considered a region
imprisonment. The woman receiving the abortion with strong family values and conservative, patriarchal
also faces this length of time in prison. There is a culture. A woman’s virginity at marriage is highly
harsher sentence for those performing an illegal abor- valued, and women are often sheltered from sexual
tion if the woman dies. Induced abortion is a major situations. This conservatism can benefit a young
cause of maternal morbidity. Girls between 15 and 19 woman’s well-being, but can also serve as a barrier
years of age make up the highest risk group (Shane for young women accessing reproductive health infor-
1997). mation and services. This region is not what it was a
The widespread use of injectable contraceptives generation ago; young people are spending more years
and the pill, which is common among sub-Saharan in school and are marrying later. Many girls are reach-
African women, is in great part due to the limited ing puberty sooner due to improved nutrition, and the
range of methods provided by government pro- period of unmarried adolescence is growing longer,
grams. Government services promoted methods leading to longer period of risk for unintended adoles-
that required minimal education, little client involve- cent pregnancy. As Fig. 21.5 shows, births to teenagers
ment, and few follow-up services. These forms of aged 15–19 years range from a low of 7 per 1,000 in
contraception, however, do not protect the woman Tunisia to a high of 93 per 1,000 in Yemen (DeJong
or man from STIs, including HIV/AIDS. In rural et al. 2007).
Rate per 1,000 15–19 year olds
50
40
30
20
10
0
n an t co ria it n ria ia
me yp oc wa Ira ge nis
Ye Om Eg or Sy
M Ku Al Tu
Fig. 21.5 Births per 1,000 women aged 15–19, selected countries, 2004. Source: World Bank (2006)
Early marriage is still common in some of the puberty and marriage, negative and risky behaviors,
areas of the region. Average age at first marriage prevention and treatment of health problems, and
usually occurs between 17.9 and 24.3 years of age social and psychological development. Education is
(Ozcebe and Akin 1995). However, in Syria, 25% of free and compulsory in Egypt, but only 58% of
girls are married by age 19, in Algeria 10% are adults can read (U.S. Department of State 2007).
married between 15 and 19 years of age, and in Gender roles continue to change in Egypt for both
Egypt 14% of young women are married before boys and girls. At times, these role changes occur
age 20. Early marriage often leads to early preg- faster than attitudes. The gap between what is per-
nancy and associated biological risks. As young ceived as socially "right" and what is "reality" fuels
men are usually valued greater than young the conflict over the change in the role of Egyptian
women, young women often do not receive the women and girls. Although girls are valued for their
health care and attention they need during preg- fertility, during childhood, male siblings receive pre-
nancy (Ozcebe and Akin 1995). Additionally, ferential treatment. In one study (Ragheb and Guir-
young women are often married to older men who gis 1998), the average number of doctor visits was
have had prior sexual relations and may be carriers 1.6 for boys vs. 0.9 for girls. Additionally, the better
of sexually transmitted infections (Ozcebe and Akin educated the mother is, the more likely that her
1995). daughter will be attending school (Ragheb and
Throughout the region, there is a lack of access to Guirgis 1998). Both boys and girls clearly prefer
information and services that deal with sexual and segregated gender roles, but they have come to
reproductive health (DeJong et al. 2007). Discus- believe that decision making should be shared.
sion of sex is taboo and there is a belief that talking Many more adolescent girls than boys, however,
openly about sexual health may encourage young think decisions concerning contraceptives, health
women to have premarital sex. This creates an care, and the wife working outside the home should
obstacle to informed discussion. However, as the be as much their decision as their husbands (Ragheb
risk of STIs, adolescent pregnancy, and unsafe and Guirgis 1998).
abortion increases, steps have been made in some In a national survey of Egyptian adolescents in
nations toward sexual health education. Algeria, 1998 (Digges 1999) both boys and girls agreed that a
Iran, Morocco, Tunisia, and Bahrain have recently wife should get her husband’s permission for every-
included human reproduction and health education thing she does (girls 89% and boys 91%). They
in their national school curriculum (Dejong et al. agreed that the husband should know about preg-
2007). Iran has developed a reproductive health nancies, childbirth, and any birth complications
curriculum for high schools and requires all univer- (girls 89% and boys 93%). And, most adolescents
sity students to take a course that includes repro- agree that the wife should keep trying to have a male
ductive health. High schools and universities are baby, even if she was satisfied with the number of
also beginning to develop extra-curricular repro- children she had (girls 81% and boys 80%) (Digges
ductive health awareness activities across the region 1999).
(Dejong et al. 2007). The number of adolescent girls who marry began
to fall in the 1990s. Yet, despite the decline, it is
still high in rural Upper Egypt. The median age of
Egypt first pregnancy is 17.6 years of age, which indicates
that 50% of adolescent girls become pregnant
The nations in the region above the sub-Sahara are before they turn 18. One of the reasons for the
represented in this section by Egypt. National young age at first pregnancy is that less than 16%
Policy for Youth in Egypt encourages ‘‘healthy of married adolescent girls use a contraceptive
development,’’ which means that overall health is and which typically only after the first birth, which
integrated with education, psychological develop- most often happens in the first year of marriage
ment, skills training, work, and legal protection (Digges 1999). There are about 45 stillbirths per
for youth. The five health areas emphasized in the 1,000 live births and 74 infant deaths per 1,000 live
youth policy are basic nutrition, preparation for births in Egypt (Sahar 1999). Eighty percent of
adolescents believe that the best place to have a In this study, it was shown that 86% of the
child was in a government hospital, although actual pregnancies were terminated at 12 weeks. At
delivery of Egyptian children is split about 50% in least 14% of the women admitted were suffering
a government hospital and 50% at home (Qayed from excessive blood loss, and 5% had one or
and Waszak 1999). Almost all older adolescent more infections. Based on these numbers, the
girls in Egypt are familiar with ‘‘family planning’’ abortion rate in Egypt is estimated to be some-
and most have a positive attitude about contracep- where around 15 per 100 pregnancies. Treatment
tion. However, knowledge of specific methods var- for complications from unsafe abortion requires
ies. For instance, 53% of adolescent girls and a substantial amount of Egyptian health-care
younger women are familiar with injectables as resources (Huntington et al. 1998). Others have
compared to 21% of older women. Also, 92% of argued that stillbirths and miscarriages are
all adolescent females and women know about more common among adolescent and teenage
‘‘intrauterine devices’’ (IUD), compared to 79% of mothers and can be mistaken for and tend
males (Qayed and Waszak 1999). to increase the abortion estimates. In 2005,
Among adolescent wives in Egypt, the use of 20 per 1,000 adolescent females sought abortion
contraception increases as the number of children (Table 21.1).
increases. A study by Qayed and Waszak (1999) In Egypt, other North African countries, and in
showed that 15% of those with one child were Arab countries, teenage pregnancy is common (65
using contraception, compared with 79% of those per 1,000) (Table 21.1). The difference between
with four or more children (Qayed and Waszak teenagers who are pregnant or parenting is that in
1999). The majority of Egyptian women, over almost all cases the teen mom is married. In Egypt
90%, have used contraception at some point in as in many other countries in the region, most girls
their lives. At any given time, 80% will be using a marry in their teens. Then, because of societal pres-
contraception method. The intrauterine device sures to prove their womanhood and to increase
(IUD) continues to be the most popular method. their status, many girls become pregnant soon
Abortion is legal if it is determined that a con- after marriage. Yet, few of these married adoles-
tinued pregnancy will pose a risk to the mother’s cents know about or understand the concept of
life. This allowance is not officially in the penal reproductive health (Sallam et al. 1998). Even so,
code, but it is an accepted practice. A woman, how- contraceptive use has increased among adolescent
ever, must obtain certification from three doctors wives and young married women from 24% in 1980,
that her life is in danger. A woman’s right to seek an to 30% in 1984, and 48% in 1991 (USAID 2000).
abortion alone is denied with the legal codes Traditionally, Egyptian men have preferred
that demand a husband’s consent. The only allow- that their wife (almost always an adolescent)
able exception to a husband’s consent is if a doctor have a child as soon after marriage as possible.
deems that the abortion is necessary. More than Hence, at least 50% of adolescent girls who
one-third of women who experience an unintended marry are pregnant the first time within 4
pregnancy said they tried to terminate their preg- months of being married. Consequently, very
nancy through abortion. Due to its illegality, high rates of stillbirth and infant death are
many women sought clandestine or unsafe abor- found among married adolescent girls. In the
tions. Women need information on the risks of early 1970s, there was little hope that family
unsafe abortion, and physicians need training in planning would work in Egypt. The average
treating abortion complications (Kader and Mak- family had eight children. Any suggestion that
louf 1998). population growth was a problem attracted pro-
Although there are no government statistics tests from religious and political leaders. In
on the number of abortions performed annually 1970, only about 8% of women used any kind
in Egypt, in studies of females being admitted to of contraceptive.
Egyptian hospitals, 19% or one in five females In Egypt and other societies in which female
were admitted for treatment of an induced or chastity at marriage is of paramount importance,
spontaneous abortion (Huntington et al. 1998). unmarried pregnant adolescent girls will often
commit suicide or may be murdered by family mem- openness, the underlying value of holism can
bers. In some cases, she might be relegated to a life apply. Sexuality as just one aspect of wellness pre-
of prostitution (Gordon 1991). Most near Eastern sents a holistic orientation to the self that can poten-
societies place great value on female chastity at tially translate into nations based on a collectivist
marriage (Gordon 1991). Adolescent and teen preg- orientation to the self, family, and community. This
nancy in Egypt is a concern because of the young presentation may create an openness and freedom
age at which wedded adolescent girls give birth to in tailoring approaches within countries. Key to the
their first child and the number of times they will success of this development is the inclusion of
become pregnant during their lifetime. Few girls in researchers and service providers within the country
Egypt become pregnant before marriage. If an and policy officials. Another subject of study would
unmarried girl does become pregnant and does not be the change processes for countries that have the
marry quickly, the consequences can be, and often most restrictive policies related to female reproduc-
are, disastrous for the girl (Shawky and Milaat tive decision making. For example, Colombia has
2000). recently liberalized its abortion law (AGI 2006).
The process of change within this highly restrictive
country would inform other changes related to poli-
cies regarding teen sexual health.
Conclusion – Research Priorities As mentioned in the previous section, effort to
include previously under-researched groups is criti-
This section has two inter-related purposes: (1) to cal to address the health of each nation’s adolescent
describe the aspects of research that will lead to the populations. A priority area should be in-depth
most relevant global knowledge of teen pregnancy research of indigenous peoples, rural residents,
and (2) to identify topics for research focus. Addres- and populations that are disenfranchised and who
sing these two areas will guide the development and often carry a greater burden of risk factors and
sustainability of evidence-based policies and prac- negative outcomes. A contemporary area of
tices for teen mothers and their children. The first research within at-risk populations is the identifica-
aspect of relevant research is context. Collaborative tion and study of individuals that have avoided
research internationally and within the countries is negative outcomes. Research of the decisions and
the only viable route for future research. For exam- social networks of these ‘‘resilient’’ individuals
ple, we know that Western European countries would create knowledge of a neglected group that
experience a low rate of teen pregnancy. One pro- could lead to interventions for the larger at-risk
posed reason for these low rates is the holistic orien- populations. The inclusion of males as a population
tation of these nations to adolescent sexuality. This of study is another critical piece to the future
means that adolescent sexuality is viewed as an research agenda. While childbearing is a female
integral part of a young person’s well-being. reality and parenting is considered a female respon-
A topic for international consideration is to test sibility, the influence of males needs further study in
this approach to adolescent sexuality in other coun- order to inform prevention of teen pregnancy and/
tries. The most obvious argument against the devel- or interventions of existing families involving teen
opment of this type of research relates to cultural parents.
congruence with the obvious question of how Wes- The course of research across all areas of interest
tern European approaches can be replicated and tends to be cross-sectional. This research should
tested within countries that do not promote adoles- continue in an international multi-site context to
cent sexuality. In order to address this barrier, enhance comparisons within and across nations.
the focus must be not on the approach but on the An important topic for research would relate to
underlying value. While specifics of the Western the economic outcomes associated with basic repro-
European approach such as national advertising ductive health provision in the immediate and long
campaigns related to sexual health and the provi- term. The reliability and validity of measures across
sion of contraceptive products to minors do not nations and even within nations is also an issue for
currently correspond to every nation’s level of research.
Finally, some saw the worldwide decline in teen research can test the themes, where knowledge can
pregnancy as a result of effective pregnancy preven- be developed around the themes, and where under-
tion programming. Others attributed the decline to standing of this phenomenon can go beyond the
religious campaigns promoting abstinence. Still individual teenage girl’s reasons for becoming preg-
others interpreted it as confirmation that globaliza- nant. Today’s adolescents are the next generation
tion has taken roots. Researchers saw the phenom- of parents, workers, and leaders. To fill these
enon as an opportunity that could provide informa- roles to the best of their ability, they need the
tion on events and characteristics that coalesced to guidance and support of their family and their
cause this cross-national change in a teenage girl’s community. They also need governments that
sexual behavior. The cross-national themes identi- are committed to their health, development, edu-
fied in this chapter provide a platform on which cation, and well-being.
Key Terms
Abstinence Gonorrhea Prostitution

Abstinence-only policy Incest Rape
Abuse Infertility Reproductive health
Adolescence Intrauterine device Roe vs. Wade 1973
Adverse pregnancy outcomes Low birth weight Sex education
Age of sexual intercourse Low-income families Sexual revolution
Anti-abortion Miscarriage Socioeconomic risk
Birth rates Neglect Sterilization
Chastity Obstetric care Stillbirths
Chlamydia Population growth Teen birth rates
Condoms Postnatal care Teen pregnancy
Contraception Poverty Unprotected sex
Faith-base Premarital sex Unsafe abortion
Family planning Prenatal care Virginity
Gender Pro-life
Questions for Discussion 5. It is known that England has higher rate of teen
pregnancy compared to other countries in Wes-
tern Europe, e.g., triple the rate in Germany and
1. What are the risk factors for unintended preg-
France. Outline and discuss the factors that
nancy among adolescents?
account for these disparities.
2. Outline and discuss the health, economic, and
social consequences of unintended teenage
pregnancy.
3. Which programs are known to be most effective References
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why?
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Chapter 22
Progress and Challenges in Making Pregnancy
Safer: A Global Perspective
Monir Islam
Learning Objectives After reading this chapter and shown in Chapters 12, 14, and 15, malaria, tubercu-
answering the discussion questions that follow, you losis, and HIV/AIDS have significant negative
should be able to impact on maternal mortality, which can reverse
the progress made over the decades. The challenge
Discuss global trends and distribution of
ahead is to refocus program content and to shift
maternal and infant mortality.
from development of new technologies to the
Identify the impact of HIV/AIDS, malaria, and
establishment of viable organizational strategies
tuberculosis on maternal and neonatal morbidity
that build health system infrastructure and ensure
and mortality.
effective and efficient continuum of care. Strate-
Appraise the challenges of ensuring equitable
gies for improvement include revising the structure
and sustainable reduction in adverse pregnancy
and content of current maternal and newborn
and birth outcomes.
health programs, developing funded national
Analyze strategies and techniques for improv-
implementation plans to achieve universal cover-
ing of current maternal and child survival
age for maternal and newborn health-care services,
programs.
and initiating action to muster the political com-
mitment needed to achieve and sustain these sys-
tems and programs. Much of the challenge, in fact,
is to accommodate both programmatic and sys-
Introduction
temic concerns which are organizational rather
than technical problems.
Each year, there are at least 3.2 million stillborn
During the early years of the 20th century,
babies, more than 4 million neonatal deaths, and
standard maternity care among well-to-do women
more than half a million maternal deaths world-
in Europe, North America, and Japan consisted of
wide. The vast majority of these deaths are preven-
home deliveries with regular, frequent visits by an
table, and countries with the highest burdens of
obstetric specialist (Loudon 1992). The arrival of
maternal and neonatal morbidity and mortality
modern obstetric care during the late 1930 s did
are those which currently appear to be making the
not alter this practice, but gradually moved the
least progress in reducing these rates. Inequities in
whole process to institutional settings. Women
morbidity and mortality rates are increasing both
were kept in the hospital for 10 or more days follow-
between and within countries. Thus, for all the very
ing delivery, depending on whether the birth was
real progress that has been made, the world is far
normal or complicated. Today, many women with
from eliminating avoidable suffering and premature
uncomplicated childbirth are discharged within a
mortality among women of reproductive age. As
day or two, and sometimes, even as little as a few
hours after childbirth. This is possible, given the
availability of postpartum follow-up and care by
M. Islam (*)
Department of Making Pregnancy Safer, World Health skilled health-care providers. Antenatal care is a
Organization, Geneva, Switzerland relatively new concept, as services became generally
400 M. Islam
available only following World War II. Today, discontinued, for example – then the maternal
pregnant women in most developed countries death toll would be four times its current rate.
receive an integrated package of antenatal, child- This means that three-quarters of all possible
birth, and postpartum care. maternal deaths worldwide are currently avoided.
Maternal health-care services in developing However, great inequalities persist between regions
countries, by contrast, have followed a very differ- and populations, as maternal deaths are even more
ent path. Overall, antenatal care tends to be the inequitably spread than newborn or early child-
primary service to receive resources and is widely hood deaths. In developed countries, nearly all
implemented within maternal health programs. the ‘‘natural’’ maternal mortality is averted, while
Today in developing countries, most pregnant only two-thirds is averted in Southeast Asia and
women visit antenatal care services at least once the Eastern Mediterranean region. This proportion
during pregnancy (WHO 2003). By contrast, child- drops to only one-third in African countries (WHO
birth care (in health facilities or at home) and access 2005). Only 1% of maternal deaths occur in the
to emergency obstetrics and newborn care services developed world. Maternal mortality ratios range
are far less available or accessible (WHO 2003). In from 830 per 100,000 live births in many African
many settings, systematic and regular postpartum countries to 24 per 100,000 live births in many
follow-up and care are not available at all (WHO European countries. Of the 20 countries with the
2003). Even when women have access to skilled care highest maternal mortality ratios, 19 are in sub-
at the time of childbirth or are able to deliver in a Saharan Africa. Regional rates may also mask
health facility, they are often discharged within a large disparities between countries in the same
matter of hours and not seen again by a health region (Fig. 22.1).
professional until a considerable time afterward. Maternal mortality varies between and within
Therefore, an integrated package of care is not regions, countries, and populations. Regions with
available to most pregnant women in developing low overall mortality rates, such as the European
countries. region, also contain countries with high mortality
rates. Within a single country there can be striking
inequities and differences between population groups,
with national figures masking substantial internal var-
The Magnitude of the Problem iations based on geography, economics, and social
status. Rural populations suffer higher mortality
Box 22.1 provides a glossary of definitions of terminol- rates than urban populations, and within urban popu-
ogies that are frequently used in this chapter. The lations mortality is higher in urban slums. Mortality
prevalence of maternal mortality is currently esti- rates vary widely by ethnicity and/or socioeconomic
mated at 529,000 deaths per year (WHO 2004), status, and remote areas can have disproportionate
which equals a global ratio of 400 maternal deaths death tolls. The main differences in maternal mortality
per 100,000 live births. In the last decade alone, between the world’s regions are not simply explained
about 7 million women died during pregnancy, child- by variations in economic growth. For example, Viet-
birth, or the postpartum period. However, progress in nam, Sri Lanka, and Cape Verde have achieved much
averting maternal deaths and improving women’s lower levels of maternal mortality than Yemen and
health has been significant. Côte d’Ivoire, despite being matched on gross national
In areas where there is no access to health care to income per head.
avert maternal deaths, ‘‘natural’’ mortality is Risk factors for maternal mortality have been stu-
approximately 1,000–1,500 maternal deaths per died extensively. For example, McCarthy and Maine
100,000 live births. This estimate is based on his- (1992) proposed a framework of determinants: distant
torical studies and data from contemporary reli- factors such as individual, family, and community
gious groups who do not intervene in childbirth status interacting with intermediate factors such as
(Van Lerberghe and De Brouwere 2001). If women the mother’s health status, reproductive status, access
were still experiencing ‘‘natural’’ maternal mortal- to health services, and health behaviors. The distant
ity rates today – if health services were determinants act on the intermediate factors, which
22 Progress and Challenges in Making Pregnancy Safer 401
Maternal death: The death of a woman while pregnant or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the
pregnancy or its management, but not from accidental or incidental causes.*
Maternal conditions: A maternal death is one for which the certifying physician has designated a
maternal condition as the underlying cause of death. Maternal conditions are those assigned to
pregnancy, childbirth, and the puerperium, ICD-10 codes A34, O00–O95, O98–O99.*
Maternal mortality ratio: The number of maternal deaths per 100,000 live births. The maternal
mortality rate is a measure of the likelihood that a pregnant woman will die from maternal causes.
The number of live births used in the denominator is a proxy for the population of pregnant women
who are at risk of a maternal death.*
Natural maternal mortality: Death of women caused by a naturally occurring disease process that is
not mediated by obstetric factors.*
Obstetric complications: Disruptions and disorders of pregnancy, labor and delivery, and the early
neonatal period. Examples of such complications include prenatal drug exposure, poor maternal
nutrition, minor physical anomalies (or MPAs: indicators of fetal neural maldevelopment, occurring
near the end of the first trimester), and birth complications.
Birth rate: Calculated by dividing the number of live births in a population in a year by the midyear
resident population.*
Infant mortality rate: Calculated by dividing the number of infant deaths during a calendar year by
the number of live births reported in the same year. It is expressed as the number of infant deaths per
1,000 live births.*
Neonatal mortality rate: The number of deaths of children under 28 days of age, per 1,000 live births.*
Post-neonatal mortality rate: The number of deaths of children that occur between 28 days and 365
days after birth, per 1,000 live births.*
Perinatal mortality rate: The sum of late fetal deaths plus infant deaths within 7 days of birth divided
by the sum of live births plus late fetal deaths, per 1,000 live births plus late fetal deaths.*
Stillbirth: When fetal death occurs after 22 weeks of pregnancy (March of Dimes 2008).
Skilled health professional: An accredited health professional – such as a midwife, doctor, or nurse –
who has been educated and trained to proficiency in the skills needed to manage normal (uncompli-
cated) pregnancies, childbirth, and the immediate postnatal period and in the identification, manage-
ment, and referral of complications in women and newborns (WHO 2005).
Antenatal care: Appointments at clinics or hospitals for pregnant women, relating to their pregnancy.
Postpartum care: Encompasses management of the mother, newborn, and infant during the post-
partum period which includes the 6-week period after childbirth.
Emergency obstetrics: Emergency care given directly before, during, or after childbirth including
blood transfusions, improved surgical procedures and anesthesia, rapid transport to medical facil-
ities, and rapid response within those facilities (Fortney 2001).
Fertility rate: The total number of live births, regardless of age of mother, per 1,000 women of
reproductive age, 15–44 years.*
Total fertility rate (TFR): Shows the potential impact of current fertility patterns on reproduction,
that is, completed family size. The TFR indicates the average number of births to a hypothetical
cohort of 1,000 women, if they experienced throughout their childbearing years the age-specific birth
rates observed in a given year.*
*Source: CDC, National Center for Health Statistics (2007)
402 M. Islam
Fig. 22.1 Global situation of maternal mortality. Source: WHO (2005)
interact with unknown or unpredicted factors to lead and interviewed relatives to determine the factors lead-
to outcomes that include pregnancy, obstetric compli- ing to the death. They decided to classify the risk
cations, and death or disability. This framework factors under the three-delay framework, in which
brings up a number of important implications. One is delay in deciding to seek help (under-estimation of
that distant determinants like socioeconomic status warning signs and their severity, opposition to care
(SES) and education must act through other determi- by partner, poor impression of health services, lack of
nants in order to affect pregnancy outcomes. In other money), delay in getting to a health facility (physical
words, although many studies suggest correlations isolation of community, insufficient transportation,
between high SES and/or education with lower mater- having to travel to multiple facilities), and delay in
nal mortality (van Egmond et al. 2004), these factors receiving care from that health facility (poor quality
do not directly effect maternal survival. McCarthy and of care from providers, insufficient resources) are the
Maine (1992) illustrate this point by looking at high main contributors to maternal death.
mortality among people with religious opposition to A number of other indirect causes for maternal
medical care and the period of ‘‘interventionist obste- mortality are often mentioned. These include the
trics.’’ Both cases involve people with high education ‘‘four too’s’’ – too young, too old, too few births (refer-
and SES having higher mortality rates than people ring to primipara), and too many births (parity greater
with lower education and lower SES. Another impor- than four) (Aliyu et al. 2005a,b; Ronsmans and
tant point made by McCarthy and Maine (1992) is Campbell 1998; McCarthy and Maine, 1992) – and
that even in developed countries, obstetric complica- comorbid conditions such as malaria (Granja et al.
tions are very difficult to predict, with the majority 1998), micronutrient deficiencies including Vitamin A
occurring in women without any known risk factors. (Christian et al. 2000), iron and calcium (Villar et al.
Castro et al. (2000) studied risk factors for maternal 2003), severe anemia (Brabin et al. 2001), lack of
mortality in Mexico using a qualitative approach. antenatal care (Sibley at al. 2004), and unsafe abortion
They identified maternal deaths from hospital records (Goyaux et al. 2001; Jewkes et al. 1997; Johnson et al.
2002; Rahman et al. 2001). A knowledge, attitude, and and more than two-thirds occur during the first
practices (KAP) survey in Afghanistan (van Egmond week after birth. The global toll of postpartum mater-
et al. 2004) found a positive correlation between nal deaths is accompanied by the large and often
education and antenatal care, institutional delivery, overlooked number of stillbirths and early newborn
skilled attendance at birth, and use of family planning. deaths.
Ronsmans and Campbell (1998) provide evidence Maternal deaths result from a wide range of indir-
against the assumption that closely spaced births are ect and direct causes. The largest share of deaths is
a risk factor for maternal mortality. However, they attributable to direct causes (Table 22.1). These occur
only compared the current birth outcome with the following complications of pregnancy and childbirth,
previous birth outcome, so the interaction of close or are caused by interventions, omissions, incorrect
birth spacing for more than two pregnancies is a treatment, or events that result from these birth com-
possibility. plications. The five major direct causes of maternal
Risk factors for maternal mortality also include deaths are hemorrhage, infection, eclampsia (unsafe),
factors that interfere with the provision of care for abortion, and obstructed labor. The rates of maternal
life-threatening complications experienced during mortality depend on whether these complications are
pregnancy. Early complications are typically asso- treated adequately and in a timely manner. Serious
ciated with abortions (much more so than miscar- complications early in pregnancy are generally the
riage, possibly due to the illegality, stigma, and result of abortions, often illegal and performed under
method of inducing abortion), with the remainder of unsafe conditions. These account for approximately
complications clustering around birth and the period 12% of all maternal deaths (Khan et al. 2006). Preven-
immediately following. tion of unsafe abortions is possible through the use of
Between 11 and 17% of maternal deaths happen contraceptives to prevent unwanted pregnancies that
during the act of childbirth itself and between 50 and would lead to abortion and the legalization of abor-
71% occur during the postpartum period. Risk tends tion, which would permit women to have an abortion
to be concentrated on the childbirth, and many post- from a skilled provider.
partum deaths are a direct result of what happens Maternal deaths due to indirect causes represent
during birth. Therefore, particular attention is war- 16.7% of the global total (Khan et al. 2006). They
ranted during the hours and sometimes days that are may be caused by diseases (pre-existing or
spent in labor and giving birth. These are the critical concurrent) that are not complications of preg-
hours when a joyful event can suddenly turn into an nancy, but rather complicate pregnancy or are
unforeseen crisis. The postpartum period, despite its aggravated by it. These include malaria, anemia,
heavy death toll, is often neglected (Dhakal et al. HIV/AIDS, and cardiovascular disease. The dis-
2007). Mothers and their newborns are most prone ease role in maternal mortality varies from country
to complications during the first week of the postpar- to country, according to the epidemiological con-
tum period. About 45% of postpartum maternal text and the effectiveness of the health systems’
deaths occur during the first 24 hours after birth, response. Of the 136 million women who give
Table 22.1 Incidence of major complications of childbirth worldwide

Incidence (% of Number of Case-fatality Maternal Main sequelae DALYs
Complication live births) cases per year rate (%) deaths in 2000 for survivors lost (000)
Postpartum 10.5 13,795,000 1 132,000 Severe anemia 4,418
hemorrhage
Sepsis 4.4 5,768,000 1.3 79,000 Infertility 6,901
Pre-eclampsia 3.2 4,152,000 1.7 63,000 Not well 2,231
and evaluated
eclampsia
Obstructed 4.6 6,038,000 0.7 42,000 Fistula, 2,951
Labor incontinence
Source: AbouZahr (2003)
404 M. Islam
birth each year, some 20 million (approximately 2005). This region has 1.4 million newborn deaths and
15%) experience pregnancy-related illness after a further 1.3 million stillbirths each year (WHO 2005).
birth. The list of morbidities is diverse, ranging While the actual number of deaths is highest in Asia,
from fever to psychosis, and the range of care the rates for both neonatal deaths and stillbirths are
responses needed is equally varied. For women who greatest in sub-Saharan Africa (Pathmanathan et al.
almost die in childbirth, recovery from organ failure, 2003). Of the 20 countries with the highest neonatal
uterine rupture, fistulas, and/or other severe compli- mortality rates, 16 are in sub-Saharan Africa (Pathma-
cations can be long, painful, and leave lasting com- nathan et al. 2003) (Fig. 22.2).
plications. Other, non-life-threatening illnesses can The gap between rich and poor countries is widen-
be frequent as well. Some of these postpartum pro- ing: neonatal mortality is now 6.5 times lower in high-
blems are temporary, but others can become chronic income countries than in low-income countries (Tinker
illnesses. These include urinary incontinence, uterine and Ransom 2002). The lifetime risk for a newborn
prolapse, pain following poor repair of episiotomy baby to die is now approximately 1 in 5 for countries in
and perineal tears, nutritional deficiencies, depres- Africa, compared with 1 in 125 in developed countries
sion and puerperal psychosis, and mastitis. Even (Tinker and Ransom 2002). Obstetric complications,
less is known about these morbidities than about particularly in labor, account for as many as 58% of
maternal deaths. They are difficult to quantify, stillbirths and early neonatal deaths (Kusiako et al.
owing to problems with definitions and inadequate 2000). Intrapartum risk factors increase the likelihood
records (WHO 2005). More reliable information on of perinatal or neonatal death more than pre-preg-
the range of maternal morbidities is an important nancy or antenatal factors. Likewise, the repercussions
step toward better planning of services and improved for children who survive the death of their mothers can
care around childbirth. be staggering. In Nepal, for example, infants of
mothers who died during childbirth were 6 times
more likely to die in the first week of life, 12 times
more likely to die between 8 and 28 days, and 52
Mother and Newborn Outcomes times more likely to die between 4 and 24 weeks
Are Closely Linked (Katz et al. 2003). While early infant deaths were
attributable to obstetric complications, later deaths
Neonatal mortality is the death of an infant within were explained by an absence of appropriate childcare
28 days of birth. Reliable conclusions on global and nutrition (WHO 2005).
trends are not available given the short period of The health and survival of newborns is closely
time that neonatal mortality has been measured. linked to that of their mothers. First, because healthier
However, WHO estimates from 1995 to 2000 sug- mothers have healthier babies; second, because where
gest that most countries in the Americas, Southeast a mother gets no or inadequate care during pregnancy,
Asia, Europe, and the Western Pacific have made childbirth, and the postpartum period, her baby also
some progress in reducing the infant mortality rate. receives little or no care. Both mothers and newborns
Improvements have been less marked in the Eastern have a better chance of survival if they have skilled care
Mediterranean region (although regional averages during childbirth and access to emergency care
mask variations between countries), and the Afri- services (Tinker and Ransom 2002).
can region has experienced an increase in its neona-
tal mortality rate (WHO 2008).
Of the 136 million babies born every year, 3.3
million are stillborn and 4 million die during the first
The Progress and Reversal in Reduction
month of life (WHO 2005). Ninety-eight% of these of Maternal and Newborn Mortality
deaths occur in low-income and middle-income coun-
tries. Neonatal deaths contribute to about 40% of all Maternal: Industrialized countrieshalved theirmaternal
deaths in children under-5 globally and more than half mortality in the early 20th century by providing profes-
of all infant mortality. Globally, the largest numbers of sional midwifery care during childbirth and further
newborns die in the Southeast Asian region (WHO reduced it to current historical lows by improving
Fig. 22.2 Global patterns for newborn mortality. Source: WHO (2005)
access to emergency obstetric care after World War II health program. A district health-care system was
(Loudon 1992). Quite a few developing countries introduced and midwifery care was increased
have done the same over the last few decades. One through a network of ‘‘low-risk delivery centers’’
of the earliest and best-documented examples is that were supplemented by high-quality referral
Sri Lanka, where maternal mortality levels were com- care, all with close and intensive quality assurance.
pounded by malaria. Maternal deaths had remained This brought maternal mortality rates below 100 per
well above 1,500 per 100,000 live births in the first half 100,000 live births by around 1975 and then to below
of the 20th century despite 20 years of antenatal care 50 per 100,000 by the 1980 s (Katz et al. 2003).
(WHO 2005). In this period, midwifery was professio- Until the 1960 s, Thailand had maternal mortality
nalized, but access remained limited. Beginning in 1947, rates well above 400 per 100,000 live births, which is
mortality rates dropped in correlation to improved the equivalent of those in the United Kingdom in 1900
access and the development of health-care facilities in or the United States in 1939 (WHO 2005). During the
the country. This brought mortality ratios down to 1960 s, traditional birth attendants were gradually
between 80 and 100 deaths per 100,000 live births by substituted by certified village midwives, 7,191 of
1975 (WHO 2005). Improved management and quality whom were newly registered within a 10-year period.
of care further lowered mortality rates to less than 30 in This aided in a reduction in the mortality rate to 200
the 1990 s, according to a Ministry of Health time series per 100,000 live births (WHO 2005). During the
(Kusiako et al. 2000). 1970 s, the registration of midwives was stepped up
Malaysia also has a long-standing tradition of with 18,314 new registrations. Midwives became key
professional midwifery (since 1923). Maternal mor- figures in many villages, proud of their professional
tality was reduced from more than 500 per 100,000 and social status. Mortality dropped steadily and
live births in the early 1950 s to around 250 per caught up with the mortality in Sri Lanka by 1980.
100,000 live births in 1960 (Katz et al. 2003). The The main effort then went into strengthening and
country then gradually improved survival of mothers equipping district hospitals. Within 10 years, from
and newborns by introducing a maternal and child 1977 to 1987, the number of beds in small community
406 M. Islam
450
400
350
Maternal Mortality
300
250
200
150
100
50
0
1960 1964 1968 1972 1976 1980 1984 1988 1992
Thailand Sri Lanka Malaysia
Fig. 22.3 Maternal mortality since the 1960 s in Malaysia, Sri Lanka, and Thailand. Source: WHO (2005)
hospitals quadrupled, from 2,540 to 10,800, and the opposite is true as well. Systematic breakdown in
number of doctors in these districts rose from a few access to skilled care can rapidly result in an increase
hundred to 1,339. By 1990 the maternal mortality rate in unfavorable outcomes. In Malawi, a catastrophic
dropped below 50 per 100,000 live births (WHO 2005) shortage of staff in maternity units resulted in dete-
(Fig. 22.3). rioration of the quality of care within health facilities.
More recent improvements have occurred in Egypt, Between 1989 and 2001 the proportion of deaths
Honduras, and China. Egypt reduced its maternal associated with deficient health care increased from
mortality rate by more than 50% in 8 years, from 174 31% to 43%. The chances of Malawi women giving
in 1993 to 84 per 100,000 live births in 2000. This was birth in a safe environment diminished accordingly,
accomplished through major efforts to promote safer and the maternal mortality rate increased from 752
motherhood which doubled the proportion of births maternal deaths per 100,000 live births to 1,120 per
attended by a doctor or nurse and improved access to 100,000 in 2000, according to the Demographic and
emergencyobstetriccare (VanLerbergheand De Brou- Health Survey (WHO 2005). In Tajikistan, economic
were 2001). Honduras brought maternal deaths down upheaval following the break up of the Soviet Union
from 182 to 108 per 100,000 between 1990 and 1997 by and independence in 1991, compounded by civil war,
opening and staffing 7 referral hospitals and 226 rural led to a startling erosion of the capacity of the health-
health centers (Danel 1998). They also increased the care system to provide accessible care. This resulted in
number of health personnel and skilled birth atten- a tenfold increase in the proportion of women giving
dants. China reported a large decline in the maternal birth at home with no skilled assistance and a subse-
mortality rate over three decades from approximately quent increase in maternal mortality (Falkingham
1,500 per 100,000 live births in 1950 to 100–200 in rural 2003). Similarly in Iraq, sanctions during the 1990 s
areas in 1980, with the majority of childbirths occurring severely disrupted previously well-functioning health-
in facilities with easy access to emergency care (Path- care services, and maternal mortality ratios increased
manathan et al. 2003). Botswana, Cape Verde, Cuba, from 50 per 100,000 in 1989 to 117 per 100,000 in 1997
Costa Rica, Jamaica, Mauritius, and South Africa (UNICEF 1998). The maternal mortality rate was as
followed a similar path to increase skilled care during high as 294 per 100,000 in central and southern parts
childbirth and timely access to lifesaving emergency of the country. Iraq also experienced a massive
care. increase in neonatal mortality during this period,
The above examples illustrate that long-term initia- from 25 to 59 per 1,000 between 1995 and 2000
tives to provide skilled care during childbirth and (WHO 2005).
timely access to emergency care produce substantial In addition to breakdown in access to skilled
decreases in maternal mortality. Unfortunately, the care, HIV/AIDS, malaria, and TB during
pregnancy have an impact on maternal mortality. The reversal of progress in neonatal health in sub-
These indirect causes can reverse progress made over Saharan Africa is both concerning and unusual. His-
decades. Zimbabwe’s story of maternal mortality has torically, declines in child mortality have often
taken a detour on its road to success. In 1989–1990, a reversed when the social context deteriorated. Within
community-based study in urban Harare and rural Europe, these reversals often affected older children
Masvingo reported a maternal mortality ratio of 85 and remained modest for neonatal mortality (Lawn
per 100,000 and 168 per 100,000, respectively. The et al. 2005). The causes of the poor progress in redu-
Zimbabwe Demographic and Health Surveys showed cing both neonatal and later childhood deaths in sub-
a rise in this rate from 283 in 1994 to 695 per 100,000 Saharan Africa are likely to be many and complex.
in 1999 (Pathmanathan et al. 2003). According to the As demonstrated in Chapter 7 (conflicts and mater-
same surveys, skilled care during childbirth increased nal and child health), economic decline and conflicts
from 69% in 1994 to 73% in 1999. The cesarean are likely to have played significant roles through
section rate increased from 6% to 6.7% during that their disruptive effect on access to health services.
same period (Pathmanathan et al. 2003). The most The impact of the HIV/AIDS epidemic on mortality
likely explanation for this increase in the maternal is less established for newborns than for children
mortality rate is a change in the causes of maternal in the post-neonatal period. Infants born to HIV-
mortality. In the University Teaching Hospital in positive mothers are more likely to be stillborn, pre-
Lusaka, Zambia, a year prospective study in 1996– mature, and/or have very low birth weights (Ticconi
1997 found that indirect causes contributed to 58% of et al. 2003). Countries that make a deliberate and
the maternal deaths. Malaria, tuberculosis, AIDS, sustained effort to provide professional childbirth
and unspecified chronic respiratory infections were care, supported by timely emergency care facilities
the leading causes of maternal mortality (Ahmed with quality services, can improve maternal and new-
et al. 1999). born survival dramatically.
Newborns: Early newborn survival is directly
linked to maternal health and survival. Consecutive
household surveys from 34 developing countries
show that most countries have experienced a decrease
Significant Progress Has Been Made in
in neonatal mortality rates over recent decades (Lawn Coverage of Antenatal Care Services
et al. 2005). Much of the progress in child survival
has been made in the late neonatal period, with little In spite of the controversies regarding the impact of
improvement in the first week of life. This mirrors the prenatal visits on birth outcomes, there is sufficient
historical experience of many developed countries, evidence which supports the fact that prenatal visits
where neonatal mortality (and particularly early neo- have a positive effect on birth outcomes in less
natal mortality) did not decrease until years after a developed countries (Brown et al. 2008; Raatikainen
decline in post-neonatal and childhood mortality had et al. 2007). Early entry to antenatal care is impor-
been achieved (Koblinsky 2003). In many countries, tant for early detection and treatment of adverse
neonatal mortality has decreased at a slower rate pregnancy-related outcomes. Periodic health check-
than either post-neonatal or early childhood mortal- ups during the antenatal period are necessary
ity. Inadequate investment in maternal health services to establish confidence between the woman and
is the likely reason for this deficit. Household surveys her health-care provider in order to individualize
also suggest that there has been reversal and stagna- health promotional messages and to identify and
tion in newborn mortality across sub-Saharan Africa manage any maternal complications or risk factors.
since the beginning of the 1990 s. Indeed, the actual Antenatal visits are used to provide essential services
number of deaths has increased substantially in the that are recommended for all pregnant women, such
African region (WHO 2005). In only 5 years, the as tetanus toxoid immunization and the prevention
dramatic drop in deaths in Southeast Asia means of anemia through nutrition education and provi-
that Africa has the highest neonatal mortality rate sion of iron/folic acid tablets (WHO 1994). A WHO
in the world, with almost 30% of newborn deaths Technical Working Group recommended a mini-
worldwide (WHO 2005). mum of four antenatal visits for a woman with a
408 M. Islam
normal pregnancy (WHO 1994). This was not marginalized groups such as migrants, ethnic mino-
intended to imply that countries where pregnant rities, unmarried adolescents, the very poor, and
women receive more than the minimum number of those living in isolated rural communities (Sloan
visits should reduce that number. Rather, the objec- et al. 2002). Even in low-income countries, coverage
tive was to focus on the content of care and to set a rates for antenatal care (at least for one visit) are often
basic, essential standard for quality for all countries. quite high and often much higher than use of a skilled
Problems may arise at different times during preg- health-care professional during childbirth. There
nancy, so the assessment of risk factors and compli- were noticeable increases in the use of antenatal care
cations must be an ongoing process throughout in developing countries during the 1990 s (WHO
pregnancy, labor, delivery, and the postpartum per- 2005). The greatest progress was seen in Asia, mainly
iod. Some women will require more visits than as a result of rapid changes in a few large countries
others. The WHO recommended that pregnant such as Indonesia. Significant increases also took
women in developing countries should seek antena- place in the Caribbean and Latin America, although
tal care within the first 4 months of pregnancy countries in these regions already had relatively high
(WHO 1994). In developed countries such as the rates of antenatal care. In sub-Saharan Africa, by
United Kingdom and the United States, antenatal contrast, antenatal care use increased only marginally
care is recommended within the first 12 weeks of over the decade (although levels in Africa are rela-
pregnancy (American Academy of Pediatrics 2007; tively high compared with those in Asia) (Fig. 22.4).
National Institute for Health and Clinical Excellence While antenatal care coverage has improved sig-
2003). The WHO recently recommended a reduction nificantly in recent years in terms of increased access
in the number of antenatal visits in developed coun- and use of antenatal visits, it is generally recognized
tries because of evidence suggesting that having that the antenatal care services currently provided
fewer antenatal visits does not affect the outcomes in many parts of the world fail to meet the recom-
of care, other than women’s satisfaction levels (Villar mended standards. The proportion of women who
et al. 2001). However, women are still advised to are obtaining the WHO-recommended minimum of
attend antenatal care early and even earlier than pre- four visits is too low. A huge potential thus remains
viously recommended. In high-income and middle- insufficiently exploited, for example, by using antena-
income countries today, use of antenatal care by tal care as a platform for programs that tackle nutri-
pregnant women is almost universal, except among tion, HIV/AIDS, sexually transmitted infections,
100
1990
2000
75
50
25
0
Eastern South-East Europe Africa Americas Western World
Mediterranean Asia Pacific
Fig. 22.4 Antenatal care is a success story: uptake and demand are on the increase. Source: WHO (2005)
malaria and tuberculosis, among others. Diseases and in health-care facilities, both in rural and urban
other health problems can often complicate or areas.
become more severe during pregnancy. Many This tendency toward increased use of professional
women have their first consultation late in pregnancy, maternal and newborn care services should not give
whereas maximum health benefits require early initia- rise to excessive optimism. There are many countries
tion of antenatal care. Antenatal care is given by where hospitals with trained professional staff exist,
doctors, midwives and nurses, and many other cadres and yet mortality remains staggeringly high. In 1996,
of health workers (Koblinsky 2003). Little is known for example, Brazzaville, Congo, had a maternal mor-
about the capacities of non-professional workers such tality ratio of 645 per 100,000 live births (Belgrade,
as traditional birth attendants to deliver the known Serbia and Montenegro Statistical Office 2004),
effective interventions during pregnancy. despite having a university hospital and additional
health-care facilities. Adequate care is not merely
having a hospital with trained clinicians, but requires
a conducive environment with appropriate and timely
Skilled Care During Childbirth and supplies, along with quality management, supervi-
Lifesaving Emergency Care Is Increasing sion, and referral facilities (Ehiri et al. 2005).
Rates of caesarean section are one method for
Globally the availability of nationally representa- gauging access to care when complications arise
tive data on skilled attendants at birth is high with during childbirth. The overall caesarean birth rate
data for 93.5% of all live births. From this we know for developing countries stands at 12% (8.5% if
that 61.1% of births worldwide are attended by a China is excluded), with large variability between
professional who, at least in principle, has the skills and within countries (WHO 2005). Rural caesar-
to assist. Data from 58 countries that account for ean rates are often less than a third of urban rates,
76% of births in the developing world show that the and many countries, particularly in sub-Saharan
use of a skilled attendant at delivery (the key feature Africa, still have rural rates much lower than the
of first-level care) increased significantly, from 41% recommended 5% minimum (WHO 2005). These
in 1990 to 57% in 2003. This is a 38% increase in the data imply a continuing shortfall of lifesaving
number of women with a skilled birth attendant emergency obstetric care services in many coun-
between 1990 and 2003 (WHO 2007). The greatest tries. However, since 1990, overall caesarean rates
improvements occurred in Southeast Asia (from have been increasing (WHO 2005). Outside Africa
34% in 1990 to 64% in 2003) and North Africa increases of 2–5% per year are common and have
(from 41% in 1990 to 76% in 2003). These trends taken place in both urban and rural areas where
represent an increase in the number of women rates are now well above 10%. Private-sector cae-
with a skilled birth attendant of more than 85% in sarean section rates are higher and in some cases
both regions. Hardly any change was observed, are increasing at an alarming rate (WHO 2005).
however, in sub-Saharan Africa, where rates With cesarean section rates climbing, it is possible
remained among the lowest in the world at around that excessive surgical intervention during child-
40% (WHO 2007). Within these regional averages, birth will actually lead to an increase in maternal
there are significant differences between countries mortality in these regions, given complications
and between urban and rural areas, which often from surgery.
represent rich and poor sections of the population
(WHO 2005). Almost all of the increases in births
with a skilled attendant are driven by increases in
the presence of medical doctors at birth. In fact
Postpartum and Postnatal/Newborn
most regions, with the exception of sub-Saharan Care Need More Attention
Africa, show decreasing use of other types of
professional assistance. There is a marked increase While the need for immediate postpartum care is
in the proportion of deliveries that take place widely acknowledged, later postpartum care is often
completely forgotten and/or neglected. The poor
410 M. Islam
coverage of care in the postpartum period is reflected postpartum/natal period. This is done by creating
in the limited data available on a global level. Less synergies between maternal and child health services
than one in three developing countries report national and increasing the emphasis on provision of postpar-
data on postpartum care and even in countries with tum/neonatal care.
existing data the levels of coverage are often as low as
5% (Islam 2007). Despite the burden of morbidity
during this period, uptake of postpartum care in
developing countries is usually extremely low. Typi-
Inequities in Progress: The Rich–Poor
cally, it is less than half the uptake of antenatal or Divide
delivery care. Estimates based on the limited available
data indicate an overall use of postpartum care below There is ample evidence of inequities in the risk of
30% for developing countries (Lawn et al. 2005). In maternal death between and within developed and
many low-income countries, even where the propor- developing countries, irrespective of the stage of
tion of institutional deliveries is already high or is development or the condition of the health system.
increasing, women are often discharged less than Differences in maternal mortality between urban
24 hours after giving birth (Lawn et al. 2005). How- and rural areas within poor countries are substantial.
ever, more than half of maternal deaths and many In Egypt, the maternal mortality rate was over twice
newborn deaths occur after this period. In areas where as high in the nomadic frontier region than in the
the majority of births take place at home, postpartum metropolitan region, 120 vs. 48 deaths per 100,000
care may be unavailable or women may not know that (Ronsmans and Graham 2006). In Afghanistan the
services exist. differences were even more striking, with a mortality
Many service providers and families focus on the of 418 per 100,000 in the capital city of Kabul,
well-being of the new baby and may not be aware or compared with 6,507 per 100,000 in the remote dis-
able to assess the importance of women’s complica- trict of Ragh (Bartlett et al. 2005). Data from
tions, such as postpartum bleeding. Where childbirth selected population-based studies in sub-Saharan
is under professional supervision, be it at home or in a Africa are in accord with these urban–rural patterns.
health facility, women are usually expected to attend a A link between poverty and maternal health has
postpartum/postnatal checkup at a health facility been clear for more than a century. Figure 22.5
6 weeks after delivery. This may not be enough care
to be effective. Women may not attend because they
do not know that the service is available to them. They
may not perceive any benefit in attending or the
opportunity costs of attending may be too high
(Masuy-Stroobant 1997). Health staff themselves
may not feel empowered or skilled in providing post-
partum/postnatal interventions. Apart from some
countries, such as Sri Lanka, rates of postnatal visits
among women are low and inequitably spread. The
structures that exist are often not fully suited to the
needs of poor women who require increased first-level
care as well as easy-to-reach backup facilities for com-
plications. In most areas, there are severe shortages of
trained health workers with the capability to diagnose,
refer, and treat these problems. Recent evidence has
also shown that early postnatal care (within the first
day and first week after birth) is highly effective in
reducing newborn mortality. Countries are now begin- Fig. 22.5 Rich poor divide: birth attended by medically
ning to make concerted efforts to work toward a con- trained people by wealth quintile and regions. Source: Lancet
tinuum of care from early pregnancy through the Maternal Survival Series (2006)
shows data for the poverty gradient in comparison care, but not the full range of what they need to
to access to maternal health-care services. Sri Lanka avoid the majority of risk of maternal death (WHO
is a country that shows equitable use of health 2005). Adding up the optimistic (but also realistic)
professionals for births across all population groups. scenarios for each of the 75 countries would give
However, in Peru, for example, the estimate for the access to the full package of first-level and backup
poorest group is in excess of 800 maternal deaths per care to 101 million mothers (some 73% of the
100,000 live births compared with less than 130 per expected births) in 2015 and to their babies. If
100,000 for the richest quintile – a greater than six- these scenarios were implemented, the MDG for
fold difference (Ronsmans and Graham 2006). Some maternal health would be reached in every country
societal factors contributing to inequities are group and the reduction of maternal and perinatal mor-
characteristics such as ethnicity, caste, race, or emi- tality globally would be well on the way. Unfortu-
grant populations, whereas others are individual and nately achievement of MDGs does not reflect equity
include marital status or social standing (Ronsmans or universal coverage of care. Therefore, in almost
and Graham 2006). all countries, the rich population would achieve
MDGs but not the poor population. It is also clear
that achievement of MDG-4 (Reduction of Child
Mortality) will not be possible without substantial
Achieving Millennium Development advances for the newborn. This is related to
Goals improvement of maternal health. Without much
improvement in the control and treatment of
The Millennium Declaration set out eight specific malaria and HIV/AIDS in pregnancy, MDG-6
Millennium Development Goals (MDGs), each (related to HIV/AIDS, malaria, and TB) will not
with its own numerical targets and indicators for be achievable. Therefore, maternal health programs
monitoring progress. These goals give special prior- provide a unique strategic opportunity to achieve all
ity to the health and well-being of women, mothers, three health-related MDGs (WHO 2005).
and children. The target set for MDG-5 is a 75%
reduction in the global maternal mortality ratio
between 1990 and 2015. The evidence suggests that
a reduction of 75% is achievable with a 25-year time Challenges
frame, similarly to the way some industrialized
countries halved their maternal mortality rate in Reduction in maternal and neonatal mortality does
the late 19th century (mostly through the provision not require new technologies or new knowledge of
of skilled health-care professionals at birth). Evi- effective interventions. We know what needs to be
dence from several transitional countries also sug- done to save the lives of mothers and newborns. The
gests that a 75% decline can be achieved. As dis- challenges are how to deliver services and scale up
cussed earlier, during the last 40 years Thailand, interventions particularly to those who are vulner-
Malaysia, and Sri Lanka have substantially reduced able, hard to reach, marginalized, and/or excluded.
their maternal mortality, which is now comparable Effective health interventions exist for mothers and
to many industrialized countries. However, reliable babies, and several proven means of distribution are
trends are not available for many countries with available. However, none of them will work if poli-
high levels of maternal mortality, and some investi- tical will is absent where it matters most: at national
gators believe there is little to suggest any progress, and district levels (Van Lerberghe and De Brouwere
especially in sub-Saharan Africa. 2001). In many of the countries experiencing stag-
Seventy-five countries contribute to 96% of all nation and reversal (particularly in sub-Saharan
maternal and 92% of all neonatal deaths globally. Africa), barriers to the uptake of health benefits
Therefore, it is possible to envision various scenar- are a critical source of exclusion for many pregnant
ios for scaling-up services, taking into account the women. Often services simply do not exist or cannot
specific circumstances in each country. At present, be reached. For example, lack of access to facilities
some 43% of mothers and newborns receive some where major obstetric interventions can be
412 M. Islam
performed is the prime reason why large numbers of environment, financing remained a real barrier to
mothers in rural areas are excluded from lifesaving progress. With a decrease in gross domestic product
care during childbirth. But there are many other per capita in real terms between 1990 and 2002, total
barriers to the uptake of health benefits. These health expenditure in many African countries stag-
include service use that is often constrained because nated or decreased. Public health expenditure
of women’s lack of decision-making power, the low remained below US $10 per person. Up to 1999,
value placed on women’s health, and the negative or per capita was stagnant and external assistance did
judgmental attitudes of family members. not make up for this.
Policy challenges differ between countries that Civil service regulations and structural adjust-
are close to universal health-care access (where ment policies often leave little flexibility to improve
exclusion is limited) and those where exclusion is working conditions in the public sector, especially in
pervasive. The countries where exclusion is limited terms of salaries and incentives. As a result, many
to a small and marginalized proportion of the popu- health workers have moved to the private sector or
lation are usually on track or at least are slowly to other countries. Data from Ghana, Zambia, and
progressing toward the reduction of maternal and Zimbabwe show that losses of health workers from
newborn mortality. These are countries with well- the public health sector continued or accelerated
developed health systems, although they may not during the 1990 s. The stringent budgetary measures
always be health systems with an optimal range of under structural adjustment programs also imposed
technical interventions. Examples of countries in ceilings on personnel recruitment. Even in countries
this group include Brazil, Colombia, and the with unemployed health professionals, such as
Dominican Republic. For these countries, the chal- Zambia, governments often were not able to hire
lenge is targeting mothers and newborns that are additional staff (U.S. Agency for International
currently excluded from the possibility of claiming Development 2003).
entitlements. This tackles the roots of social exclu- Absenteeism was another major issue that
sion, removes the barriers to uptake of health ser- affected the already scarce human resources within
vices, responds appropriately to their needs, and health-care services. In Burkina Faso, for example,
offers them financial protection from the conse- absenteeism of health district doctors in seven rural
quences of illness and obtaining care. Most of the districts in 1997 varied between 30% to more than
countries that showed limited progress in mortality 80%. Vacancy rates for doctors in Ghana increased
reduction, stagnated, or went into reversal in regard from 43% in 1998 to 47% in 2002. Over the same
to maternal mortality show patterns of massive time period vacancy rates for registered nurses rose
exclusion or queuing. Such countries include Ban- from 26 to 57% (Dovlo 2003). Much of the absen-
gladesh, Chad, and Ethiopia. These countries typi- teeism was related to inadequate working condi-
cally have weak, low-density, and fragile health tions, insufficient salaries, and declining staff mor-
systems. Complex emergencies, in addition to high ale. In a number of countries, however, the HIV/
poverty rates and HIV/AIDS, lead to additional AIDS epidemic aggravated this acute human
constraints on health systems development. The resource crisis. Data are scarce but suggest that
main challenge is to build and implement primary besides contributing to absenteeism, HIV/AIDS
health care as the vehicle for maternal, newborn, may cost Africa’s health systems one-fifth of their
and child health care, with timely access to emer- employees over the next few years (Tawfik and
gency lifesaving services. Kinoti 2001). The absence of adequate measures
By the mid-1990 s, many countries were creating to protect health workers against HIV/AIDS and
district health systems within the context of a pri- the stress of caring for HIV/AIDS patients are addi-
mary health-care approach. They defined a mini- tional factors motivating migration of health-care
mum package of services and established a system employees.
for timely supply of drugs and equipment. How- The shortage of health personnel is the most
ever, as in the years after the Alma-Ata declaration, visible aspect of the human resources crisis in sub-
funding often did not follow. This was particularly Saharan Africa. The figures are stark: in Zimbabwe,
true in sub-Saharan Africa. In the bleak economic of the 1200 physicians trained during the 1990 s,
only 360 remained practicing in the country in 2001. years. Currently, only half the world’s women
Ghana’s loss of 328 nurses in 1999 was the equiva- receive care from a skilled professional while giving
lent of its annual output (U.S. Agency for Interna- birth, and they often do not receive the quality of
tional Development 2003). More than half of the care they need. Even fewer women receive the full
health professionals in Zimbabwe, Ghana, and package of care from pregnancy to the end of the
South Africa are thinking of migrating to other postpartum period. For those who are able to access
countries. At the same time, 35,000 South African care, the message is clear: women need protection,
nurses are not employed in the health sector and standards need to be improved, care must be
two-thirds of the health workforce in Swaziland is respectful, and the health personnel who attend
working in the private sector. them need to be remunerated and managed prop-
Other challenges are how to address the issues of erly if they are to remain in service.
deteriorating infrastructure, stock-out of drugs, Most countries facing major maternal and new-
dwindling supplies and equipments, lack of trans- born health and survival challenges have yet to
port, ineffective referral to and availability of develop national strategies for increasing access
24 hour quality services, particularly emergency to adequate health care or to translate these stra-
obstetric care services and weak management sys- tegies into investment plans that are endorsed by
tems. Part of the task ahead is political. Maternal, political authorities. There are three distinct, but
newborn, and child health cannot be reduced to a related, work strategies that must be taken up to
set of programs delivered to a target population. develop such comprehensive strategies: first,
Rather, mothers and children must be in a position national health authorities need to revisit the struc-
to claim entitlements as their right. This implies an ture and content of maternal and newborn health
adjustment of macro-level health policies and programs; second, they need to plan the scaling up
resource mobilization, at the country level and of services within a health system that is able to
internationally. Three issues need urgent attention: respond to current needs; and third, they need to
the funding of the health sector, the human resource enter the political arena to muster the political
crisis, and the accountability of health systems and commitment to universal coverage of maternal
providers to their clients. Politically, the problem of and newborn health services. The task ahead is
scaling up looks very different. Political solutions also one of refocusing program content. For too
emphasize the speed and visibility of results, afford- long attention has been directed toward the devel-
ability, buy-in of professional groups, and the opment of technologies, rather than toward
importance of existing hierarchies and structures, embedding these in viable organizational strate-
however fragile. Political solutions also take into gies. Strategies need to ensure a continuum of
account the views and demands of the electorate. care through pregnancy, childbirth, and the post-
A new era of strategic thinking for maternal and partum/postnatal period and include the home,
neonatal health should start with a realistic needs community, and health facilities. Much of the chal-
assessment of present care coverage and move for- lenge, in fact, is to accommodate both program-
ward by understanding supply constraints that have matic and systemic concerns: an organizational
blocked progress in developing countries for over 20 rather than a technical problem.
Key Terms
Antenatal care Distant factors Fertility rate

Birth outcomes Eclampsia Hemorrhage
Birth rate Emergency obstetric services Home delivery
Caesarean section Episiotomy Indirect causes
Direct causes Family planning Infant mortality rate
414 M. Islam
Intermediate factors Obstetric care Stillbirth

Interventionist obstetrics Obstetric complications Total fertility rate (TFR)
Maternal death Obstructed labor Traditional birth attendants
Maternal health programs Perinatal mortality rate (TBAs)
Maternal mortality ratio Post-neonatal mortality rate Uncomplicated care
Maternity care Postpartum care Unsafe abortion
Midwifery care Postpartum death Urinary incontinence
Miscarriage Pregnancy outcomes Uterine prolapsed
Neonatal mortality rate Prenatal mortality rate Uterine rupture
Newborn care services Severe anemia
Newborn outcomes Skilled health professionals
Questions for Discussion Ahmed Y, Mwaba P, Chintu C et al. (1999) A study of

maternal mortality at the University Teaching Hospital,
Lusaka, Zambia: the emergence of tuberculosis as a major
1. It is said that sustainable reduction in maternal non-obstetric cause of maternal death. The International
Journal of Tuberculosis and Lung Disease, 3(8), 675–680
and infant mortality will require emphasis on
Aliyu MH, Salihu HM, Keith LG et al. (2005a) Extreme
establishment of viable organizational strategies parity and the risk of stillbirth. Obstetrics and Gynecol-
that build health systems infrastructure and ogy, 106(1), 446–453
ensure effective and efficient continuum of care. Aliyu MH, Salihu HM, Keith LG et al. (2005b) Hyper-ferti-
lity and fetal morbidity outcomes trends in birth to fertile
Do you agree with this statement? Justify your
mothers by race/ethnicity and maternal age in the United
position in about 1,000 words, citing specific States. Journal of the National Medical Association,
country examples as appropriate. 97(6), 799–804
2. Draw a flow chart to illustrate McCarthy and American Academy of Pediatrics (2007) Guidelines for Perina-
tal Care (6th Edition). Washington, DC: American Acad-
Maine’s (1992) framework for determinants of
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et al.’s (2000) ‘‘three delays’’ framework for clas-
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Brabin BJ, Hakimi M, Pelletier D (2001) An Analysis of
attendant at birth, and access to emergency ser-
Anemia and Pregnancy-Related Maternal Mortality.
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tality in less developed countries? and perinatal outcomes in Kwale district, Kenya. BMC
Pregnancy Childbirth, 10(8), 2
5. In an essay of about 1,000 words, describe the
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Chapter 23
Global Immunization Challenge: Progress and Opportunities
Rebecca Affolder, Michel Zaffran, and Julian Lob-Levyt
Learning Objectives After reading this chapter and adolescents in even the poorest countries, could be
answering the discussion questions that follow, you protected against life-threatening and debilitating
should be able to disease within a generation. This chapter presents
a historical perspective on the emergence of vac-
Outline important milestones in the emergence of
cines as a means of disease control and prevention
vaccines as a means of disease control and
over the past two centuries. Beginning with discov-
prevention.
ery of smallpox vaccine by Edward Jenner in 1796,
Discuss factors that underpin the disparity in
the chapter identifies important milestones in wide-
access to vaccines between rich and poor countries.
spread use of vaccines in global health, including
Identify and appraise innovative options for
financing vaccine development, and for ensuring The smallpox eradication initiative of the World
wider access to new and underused vaccines in Health Organization in 1970s, the Child Survival
developing countries. Revolution, and the Expanded Program on
Evaluate strategies for ensuring sustainability in Immunization (EPI) of the 1980s
vaccine development, management, and access. The United Nations Millennium Summit of 2000
Outline priorities for future research, policy, and and the resulting global commitment to the Mil-
practice with regard to vaccine development, lennium Development Goals (MDGs)
procurement, and access. The International Conference on Financing for
Development held in Mexico in 2002 and the
corresponding financial commitments from
high-income nations to support achievement of
Introduction MDGs
Establishment of the Global Alliance for Vac-
Vaccines, having been developed over the last 200 cines and Immunization in 2000 to accelerate
years to become one of the most cost-effective and access to new and underused vaccines in poor
successful public health interventions, are one of the countries
most exciting technologies in the world today. Yet
Inequity in access to vaccines between rich and poor
every year, around 2.5 million children die from
countries and the underpinning factors are dis-
diseases that can be prevented by currently available
cussed, including lack of safety and quality assur-
or new vaccines. Vaccines have the potential to
ance systems in poor countries, focus of research
erase some of the most glaring global health inequi-
and development on rich nations’ priorities, and the
ties which currently shape the lives of millions.
diversion of scarce resources to other emerging glo-
Often the most vulnerable – women, children, and
bal health priorities. Various innovative options for
financing wider access to new and underused vac-
cines in poor countries are explored, including
R. Affolder (*)
GAVI Alliance Secretariat, 2 Chemin des Mines, 1202 Geneva, the role of the International Finance Facility for
Switzerland Immunization (IFFIm), the Advanced Market
418 R. Affolder et al.
Commitment (AMCs), the Heavily Indebted Poor Table 23.1 (continued)

Countries (HIPCI) and Multilateral Debt Relief Date Vaccine target Research strategy
(MDRI) initiatives, and the Debt Buy-Down pro- (EPI) DEFINED
gram of the World Bank. Issues of sustainability in AND LAUNCHED
vaccine development, procurement, and manage- 1976 Pneumococcus
ment are discussed as are priorities for future 1979 SMALL POX
ERADICATION
research, policy, and practice. CERTIFIED
The first immunization – and the origin of a 1981 Acellular Pertussis (aP)
smallpox vaccine – is believed to have been in 1981 Hepatitis B (HB)
1796 (Table 23.1) when British physician Edward 1984 Universal childhood
Jenner administered fluid from a cowpox lesion Immunization
Goal (UCI)
obtained from a milkmaid named Sarah Nelmes LAUNCHED
1984 Varicella (V)
Table 23.1 Timeline of vaccine discoveries and global events 1986 rDNA HB
Date Vaccine target Research strategy 1988 H. influenzae b (Hib) Protein-
conjugated
1796 Smallpox (Jenner) Use of related
capsular
animal virus
1988 GLOBAL POLIO
1881 Anthrax Chemical
ERADICATION
attenuation
INITIATIVE
1885 Rabies (Pasteur) Chemical LAUNCHED
attenuation
1991 Hepatitis A (HA)
1896 Cholera Inactivated whole
1993 DTPwIPVHib
organisms
1994 DTPa
1896 Typhoid Inactivated whole
1996 DTPwHB
organisms
1996 HBHA
1896 Plague Inactivated whole
organisms 1997 DTaP-Hib
1923 Diphtheria (D) 1997 DTaP-IPV-Hib
1926 Pertussis (wP) Inactivated whole 1998 Lyme
organisms 1998 Rotavirus
1927 Tetanus (T) Use of toxoids 1999 DTaP
1927 Tuberculosis (BCG) Passage in vitro 1999 HATy
1935 Yellow fever 2000 DTaP-HB-IPV
1936 Influenza Inactivated whole 2000 DTaP-HB-IPV-Hib
organisms 2000 Meningococcus C conjugate
1955 Polio (IPV) Inactivated whole vaccine.
organisms 2000 Pneumococcus conjugate
1957 DTPw vaccine
1958 Polio (OPV) 2000 GLOBAL ALLIANCE FOR
1961 DTIPV VACCINES AND
IMMUNIZATION
1963 Measles (M) Passage in vitro
(GAVI) LAUNCHED
1965 SMALLPOX
2003 Influenza (LAIV) Cell
ERADICATION
culture passage w/ cold
UNIT AT WHO
adaptation
CREATED
2006* HPV vaccine that protects
1966 DTPIPV
against infection with
1967 Mumps (M)
four HPV genotypes
1969 Rubella (R) Cell culture was licensed; a second
passage w/cold vaccine that protects
adaptation against two HPV
1971 MMR genotypes is likely
1972 Meningococcus Use of toxoids to be licensed soon.
1974 Expanded Programme
*WHO (2007a)
on Immunization
Sources: Andre (2003); Plotkin (2005)
23 Global Immunization Challenge: Progress and Opportunities 419
to a 13-year-old boy named James Phipps. Jenner public good. In response to a 1977 World Health
later found that the boy was ‘‘secure’’ to smallpox Assembly challenge (World Health Assembly 2003),
virus (Andre 2003). Louis Pasteur later coined the immunization coverage rose over the next decade,
term vaccine in reference to the Latin word for with the United Nations Children’s Fund (UNI-
cow: vacca. CEF) declaring 80% of the world’s children under
Records of a similar medical approach can be the age of 13 immunized against tuberculosis, polio,
found in Chinese literature dating back to the ele- and measles by 1990 (Hardon and Blume 2005).
venth century and linked with the fight against the A number of global initiatives contributed to
smallpox virus (Plotkin 2005). According to the the progression of immunization coverage rates in
National Library of Medicine (U.S. National the 1980s. UNICEF, with the support of other
Library of Medicine 2002), the practice of variola- international organizations, launched the ‘‘Child
tion, where small scabs of tissue containing small- Survival Revolution’’ in 1982 (UNICEF 1996).
pox were inhaled causing the individual to This initiative comprised four interventions for
contract the disease in a mild form, reduced the reducing mortality: growth monitoring, oral rehy-
mortality rate among those exposed to the disease dration, breastfeeding, and immunization
to 1–2% as opposed to 30% when individuals (GOBI). At the same time, WHO led major verti-
contracted the disease naturally. By 1700, the cal programs to combat vaccine-preventable
practice of variolation as a response to smallpox disease, diarrhea, and acute respiratory infections
had expanded to India, Africa, and throughout the (Hardon and Blume 2005). The Universal Child-
Ottoman Empire. Variolation was first practiced in hood Immunization (UCI) Goal was launched in
Europe by 1717 and, by 1721, in the American 1984 to catalyze efforts toward universal immuni-
colonies (U.S. National Library of Medicine 2002). zation coverage. UCI aimed at accelerating EPI,
The immunization field grew in the 19th and capitalizing on the success in mobilizing support.
20th centuries, with major breakthroughs in the As a result of these dedicated efforts, child
mid- to late 20th century through discovery of mortality declined in many countries (Hardon
vaccines that protect against such diseases as and Blume 2005).
influenza, polio, and yellow fever (Table 23.1). Yet, despite the overall success of accelerating
Prior to the development of such vaccines, the immunization coverage in the period described
loss of life from disease is illustrated in some above, significant disparities are apparent
staggering figures. For example, the influenza (Fig. 23.1). The expansion in coverage was largely
(or ‘‘Spanish flu’’) outbreak of 1918–1919 resulted in developed countries with large populations.
in more deaths than enemy fire in World War I One hundred and seven countries did not reach
(Plotkin 2005). The period of 1974–2000 can be the immunization coverage of 80%, and the
considered a second phase in the history of declaration of success did not reflect the uneven
immunization. The World Health Organization coverage within many countries – where some of
(WHO) launched the Expanded Program on the most vulnerable children in hard-to-reach
Immunization (EPI) in 1974, expanding the small- areas were missed. A great success for some
pox eradication effort which was focused on one masked the growing divide in access between
single vaccine into an infant program of six vac- North and South.
cines (against diphtheria, pertussis, tetanus, polio- The characteristics of the North/South divide,
myelitis, measles, and tuberculosis). At the time, which remains the current global situation, devel-
less than 5% of the world’s children were immu- oped during the 1990s. A gap in the routine immu-
nized against these six diseases. Meanwhile, an nization schedules for children in developed and
increased degree of population mobility, for developing countries emerged as new vaccines,
example, through commercial air travel, helped including those for hepatitis B, Haemophilus influ-
bring about the recognition that infectious disease enzae b (Hib), varicella, pneumococcal, meningo-
prevention required a coordinated, global effort. coccal, and combination formulations became a
The EPI launch marked an important turning routine part of the immunization schedule for chil-
point: immunization became an international dren and adolescents in high-income countries
Fig. 23.1 Global number of

unimmunized children under
5 years of age. Source:
WHO/UNICEF coverage
estimates 1980–2007, August
2008
(Hardon and Blume 2005). Research and develop- and measurable goals and targets for combating
ment priorities favored those products targeting poverty, hunger, disease, illiteracy, environmental
developed countries. Vaccine quality and safety, degradation, and discrimination against women.
taken for granted in many countries with robust Corresponding financial commitments from the
regulatory agencies, fell behind in many countries developed world in the form of aid, trade, debt
lacking an effective quality assurance program for relief, and investment were made at the Interna-
medical products. Quality and safety issues also tional Conference on Financing for Development
point to the weakness of health delivery systems in in Monterrey, Mexico (IFAD 2007).
many poor countries which limited the effective As part of a renewed commitment to poverty
rollout of routine immunization. The gap in finan- reduction and human development, the interna-
cial commitment to maternal and child health – tional community moved to address the growing
which underpins and drives the North/South divide inequalities in immunization and the unacceptable
in access to immunization – widened over the 1990s toll of infectious disease in developing countries.
as scarce resources were diverted to other emerging Marking the start of a ‘‘third phase’’ in the history
global health priorities. Many developing countries of immunization, the Global Alliance for Vaccines
struggled to improve or even maintain their immu- and Immunization (now the GAVI Alliance) was
nization rates. The end of the decade saw an overall launched in January 2000 to accelerate access to
decline in global immunization and vaccine produc- new and underused vaccines in the poorest coun-
tion, and particularly among the poorest popula- tries. GAVI, an innovative public/private partner-
tions in the poorest parts of the world. ship, brought together the major stakeholders in
The new millennium set the stage for a major immunization in order to achieve global immuniza-
shift in the global response to the growing inequities tion targets. These stakeholders included national
between North and South. Under the leadership of governments, UNICEF, WHO, The World Bank,
the then UN Secretary General Kofi Annan, the the Bill and Melinda Gates Foundation, the vaccine
UN Millennium Summit, the largest-ever gathering industry, public health institutions, and nongovern-
of world leaders, was convened at the United mental organizations (GAVI Alliance 2008a). Soon
Nations Headquarters in New York, USA, in after GAVI’s launch its mandate came to include
September 2000 (United Nations Development Pro- action on the child mortality target of the Millennium
gram 2003). At the close of the summit, world lea- Development Goals – namely, a 2/3 reduction of the
ders unanimously adopted the ‘‘United Nations under-5 mortality rate by 2015 (GAVI Alliance 2008b).
Millennium Declaration’’ taking on a clear obliga- In the years since GAVI’s launch, overall
tion to act through commitment to the Millennium DTP3 coverage increased from 64% in 1999 to
Development Goals (MDGs) (United Nations 73% in 2005 in GAVI-eligible countries, i.e.,
2006). These goal comprised a set of time-bound those with a gross national income (GNI) of less
than $1,000 per capita. The figures are more pro- These approaches may be in the form of highly suc-
nounced in the WHO African region where DTP3 cessful vertical campaign strategies for the global
coverage increased from 48% (1999) to 73% eradication of polio and control of measles, delivery
(2007) and has overtaken Southeast Asia (66% of basic vaccines in conflict environments, or in the
in 2007), which is now the region with most longer-term efforts to create sustainable markets for
unimmunized children (WHO 2007b). Much of new and underused vaccines in the poorest countries.
this increase in DTP3 coverage has been attribu- GIVS was approved by the member states of WHO
ted, through independent evaluation, to the and the Executive Board of UNICEF in 2005. It sets
Immunization Services Support provided by out a plan to address the global immunization chal-
GAVI to strengthen immunization delivery sys- lenges over the decade 2006–2015 and strives to act
tems and infrastructure (Lu et al. 2006). with equity and gender equality, in addition to per-
In terms of new and underused vaccine introduc- sonal ownership, partnership, and responsibility.
tion, the cumulative achievement of the poorest coun- Placing immunization firmly within the health sys-
tries to improve coverage is impressive (GAVI Alliance tem strengthening agenda, GIVS ‘‘aims to sustain
2008b). Over 5 years, 88.5 million additional children existing levels of vaccine coverage, extend immuniza-
were immunized against HepB3 (2000–2005). Four tion services to those who are currently unreached
and a half million additional children were immunized and to age groups beyond infancy, introduce new
against yellow fever in 2005, equaling a cumulative vaccines and technologies, and link immunization
13.1 million additional children immunized over with the delivery of other health interventions and
5 years against yellow fever. An additional 4.5 million the overall development of the health sector’’ (WHO/
additional children were immunized with Hib vaccine UNICEF 2005). The vision and goals of GIVS are a
in 2005, equaling a cumulative 13.2 million additional world in 2015 that highly values immunization and
children immunized with Hib vaccine over 5 years. that has equal access to immunizations for all.
Critical to these improvements has been the abil- This world would also support sustainable interven-
ity of the GAVI Alliance to raise new and additional tions in diverse social situations, changing demo-
resources – providing funds to introduce new and graphics and economies, as well as being a world
underused vaccines, improve injection safety, that will put vaccines to the best global health and
improve immunization delivery services, and security use.
strengthen health systems. GAVI-supported coun-
tries are continuing to produce impressive results
(GAVI Alliance 2008a). Despite the exciting results,
we must not lose sight that the key challenges
Addressing the Key Challenges: Funding,
remain gaining better data on disease burden to Sustainability, Equity
stimulate demand and ensuring the affordability
and long-term sustainability of new vaccine intro- Funding
duction. Until prices become more affordable, slow
uptake of new vaccines in the poorest countries Following the launch of GIVS in 2005, a WHO/
remains inevitable. How this challenge can be better UNICEF study examined the cost, financing, and
addressed through innovative approaches is cov- impact of immunization programs in the 72 poorest
ered in the discussion on funding challenges below. countries (WHO/UNICEF 2005). Implementation
The GAVI Alliance is but one element of a grow- of GIVS would protect more than 70 million chil-
ing complexity of agencies working on maternal and dren in the world’s poorest countries against the 14
child health issues; while it maintains a niche focus, major childhood diseases by 2015. The estimated
this requires close collaboration with partners in the total price tag for immunization activities for
broader global health community. The launch of the 2006–2015 in these countries is US $35 billion,
Global Immunization Vision and Strategy (GIVS) in one-third of which would be spent on vaccines and
2005 (WHO/UNICEF 2005) provided a critical two-thirds of which would be spent on immuniza-
overarching framework that exhibits the need for tion delivery systems. The study concluded that
coordinated mix of instruments and approaches. spending on immunization will need to rise from
US $2.5 billion per year (2006) to US $3.5 billion by middle-income markets. This is thanks to the sig-
2010 and US $4 billion by 2015 (WHO/UNICEF nificant size and growth of GAVI, as well as the
2005). price levels it has provided’’ (Boston Consulting
National budgets will ultimately fund vaccines Group 2005).
and health services. The challenge will be to grow As a catalyst for further innovation in finance,
and sustain financing from domestic resources. GAVI has had a critical role in developing two
How will the poorest countries reach this point? further mechanisms for financing vaccine introduc-
Donor funding in the interim and the growth of tion and development: the International Finance
poor economies will determine the ability of coun- Facility for Immunization (IFFIm) and Advance
tries to finance their health sectors. To illustrate Market Commitments (AMCs). The IFFIm,
the additional sums required, it is worth noting launched in 2006, is a pilot of the larger Interna-
that the Report of the Commission for Africa tional Finance Facility (IFF) that was originally
(2005) recommended that donors spend around proposed by the Government of the United King-
40% of the Commission’s proposed US $75 billion dom in 2005 to double global aid for development
package for Africa to strengthen health systems and to accelerate the availability of funds through
and ensure a satisfactory response to HIV and the GAVI Alliance in 70 of the poorest countries
AIDS by 2010. This call for additional spending around the world. The mechanism takes long term
is supported by analysis which shows that many (20 years), legally binding commitments from
countries will be able to work within a substan- donors (IFFIm 2008) and borrows against them
tially increased spending envelope for health (Fos- for 10 years in the capital markets, producing up-
ter 2005). Yet donor aid remains volatile. In health, front finance and thus stabilizing a portion of aid
the shortcomings of traditional aid – from poor flow to developing countries. Because of the inno-
allocation to an absence of a results-focused, coor- vative ‘‘frontloading’’ funding program, an antici-
dinated effort among donors – have clearly, if not pated IFFIm investment of US $4 billion is expected
tragically, been illustrated over the last decades to prevent 5 million child deaths between 2006 and
(Radelet and Levine 2007). 2015 and more than 5 million future adult deaths
Innovative financing mechanisms provide a way from hepatitis B-related liver disease. Advance
to overcome some of the current limitations of aid Market Commitments (AMCs) provide legally
while mitigating the political risks that many donors binding promises, usually offered by governments
associate with significantly scaling up finance to or other financial entities, to guarantee a viable
developing countries, for example, through trans- market if a vaccine is successfully developed. This
fers such as budget support. Global Funds and ensures revenues will be generated from the newly
Partnerships such as GAVI have shown that inno- developed vaccine that will match those of other
vative solutions to development challenges, includ- comparable medicines. AMCs speed the develop-
ing raising additional finance for development, can ment of new vaccines by enabling biotech and phar-
be generated by bringing together public and pri- maceutical companies to successfully invest in vac-
vate stakeholders, including the civil society. GAVI cine development (IAVI 2005).
provides the leverage so that both donor and devel- Beyond the clear benefit of providing long-term,
oping country governments can employ new and predictable finance to countries, allowing them to
innovative funding strategies – such as perfor- make longer-term budgeting and planning deci-
mance-based grants and co-financing (long-term sions, the predictable funding for immunization
subsidy agreements) for new vaccines – which char- through IFFIm has the potential to leverage signif-
acterize GAVI as an instrument for innovative icant market benefits by allowing bulk purchasing
financing. While it is too early to make any conclu- of vaccines. The predictability and legally binding
sive statement on the long-term market-shaping nature of the financial commitment provides
impact of GAVI, an independent study states that strengthened negotiating power and the ability to
‘‘emerging suppliers view the GAVI market as negotiate longer-term arrangements with suppliers,
attractive and credibility-building, with the added generating lower prices and therefore more vaccines
economic advantage of alignment with domestic or for the same envelope of funds.
A second market-shaping innovative mechanism The success to date of raising funds through
– an ‘‘advance market commitment’’ (AMC) pilot for innovative financing instruments will continue to
a pneumococcal vaccine – was launched in February catalyze more thinking on both innovative means
2006. An AMC is a financial commitment to subsi- for raising and delivering development aid and how
dize the future purchase, up to a pre-agreed price, of to better align these new instruments with more
a currently unavailable vaccine – if an appropriate traditional aid streams. Debt relief is an emerging
vaccine is developed and providing the demand exists area in innovative financing for health which could
when the vaccine is finally produced. By guarantee- usefully be applied to accelerate sustainable vaccine
ing that the funds will be available to purchase vac- introduction. The two major broad initiatives for
cines once they are developed and produced, the debt relief are the Heavily Indebted Poor Countries
AMC mimics a secure vaccine market and takes Initiative (HIPC) and Multilateral Debt Relief
away the risk that countries will not be able to afford Initiative (MDRI) programs.
a high-priority vaccine, addressing current market The HIPC Initiative was launched by the Inter-
failure: vaccines that would prevent millions of national Monetary Fund (IMF) and the World
deaths facing long delays before they are developed, Bank in 1996 and aims to reduce debt for heavily
tested, and produced for use in the poorest develop- indebted poor countries that face unsustainable
ing countries. debt burdens, that are pursuing reform programs,
By establishing a valuable market, AMCs provide and that have developed a poverty reduction strat-
incentives for private investment in the development egy paper. The HIPC estimates providing debt
of vaccines against neglected diseases. Such a ‘‘pull assistance in the amount of US $68 billion dollars
mechanism’’ is not an alternative, but is highly com- in debt relief, funded by bilateral creditors and
plementary to other public and philanthropic inter- multilateral lenders, to a total of 32 countries
ventions in the health sector and, more generally, in (Table 23.2). An additional nine countries are eligi-
development aid. AMCs will be most effective when ble for the HIPC initiative and may wish to use the
combined with push interventions because of the net- debt relief services in the future (International
work effects of the increased number of scientific Monetary Fund 2007a). HIPC debt relief represents
researchers working on the target diseases as well as only a relatively small share of government spend-
the enhanced probability that scientific research ing (about 5% for Burkina Faso between 2001 and
swiftly translates into the production of effective and 2004). However, where social expenditures also
safe vaccines. Push interventions include public and represent but a small part of the government bud-
philanthropic funding of research through academia, get, HIPC debt relief can have a considerable
public–private partnerships, and other bodies. The impact on social sectors. Several HIPCs are using
private resources mobilized by successful AMCs HIPC funds to scale up immunization financing.
would act in synergy with initiatives to expand immu- For example, in Benin, in 2004, 22% of the EPI
nization (e.g., GAVI and IFFIm) and strengthen program was funded by HIPC resources (Interna-
health systems. tional Monetary Fund 2008).
Table 23.2 Four generic categories of vaccines in relation to disease burden and reliability of markets
Developing countries Industrialized countries
Disease Current Disease Current
Category of vaccine burden markets burden markets Examples
Global market vaccines Large Small Large Large Hib conjugate; HepB;
Rotavirus
Industrialized market Small Small Large or Moderate Lyme disease
vaccines moderate
Impeded vaccines Large Small Large Large RSV
Developing market Large Small Small Small Malaria; tuberculosis; typhoid;
vaccines Shigella
Source: WHO (2000)
Taking the HIPC a step further, the Multilateral International, and the United Nations Foundation
Debt Relief Initiative (MDRI) was launched by the agreed to pay off the IDA credits upon successful
group of eight industrialized countries (G8) in 2005 achievement of the performance indicators, in this
and will provide 100% cancellation of debt owed by case receipt and distribution of vaccine and speci-
HIPCs to the International Development Associa- fied polio immunization coverage levels.
tion (IDA), to the African Development Fund Innovative financing, while not a magic bullet,
(AfDF), and to the IMF (International Monetary will nonetheless offer a range of new possibilities for
Fund, 2007b). This program enacts up-front, irre- countries to help reach the significant increases in
vocable debt cancellation for eligible countries finance required to meet the MDGs. Ultimately, the
(Table 23.2). The main objective of the MDRI is real test will be whether the donor community is
to enable HIPCs to mobilize funding for poverty successful in working together to ensure traditional
reduction programs in order to reach the Millen- aid is aligned to a mixed instrument approach. This
nium Development Goals. The intent is that addi- has been done before. Bangladesh, one of the poor-
tional resources made available through debt relief est countries in the world, has achieved the most
should be allocated to poverty alleviation pro- radical improvements in reproductive health the
grams. But as there is no formal obligation to allo- world has ever seen. This has impacted significantly
cate resources relieved by the MDRI to any specific on women’s and child mortality and morbidity,
sector, competition between departments for the use their social status and economic growth – despite
of these extra resources is likely. Potential impact of poverty, poor governance, political upheaval, and
the MDRI on health system strengthening and on an apparent lack of any potential for economic
financing immunization programs could be signifi- growth in the early years. The key was that for
cant. As annual amounts of debt service relief will 20 years from the mid-1970s, through a mixture of
be significant in many HIPCs, especially around aid instruments, donors and multilateral agencies
2020–2030, a small percentage of these resources provided substantial, predictable but coordinated
could have a reasonable impact on the health sector financial and technical support for salaries, a radi-
and in particular on immunization financing. cal expansion in the workforce (notably parame-
The GAVI Alliance partners are currently dics), associated infrastructure, and ‘‘expensive’’
exploring options for using debt relief – in the reproductive commodities which the government
form of an International Development Association delivered through state and civil society structures.
(IDA) buy-down – to specifically support countries’
vaccine programs. In addition, a number of bilat-
eral debt relief programs may also offer an oppor-
tunity for targeted debt relief. IDA buy-downs are Sustainability
currently being explored as new innovative finan-
cing mechanisms for vaccines. IDA is member of It has become clear that new technologies such as
the World Bank Group. It provides long-term loans vaccines or antiretrovirals (ARVs) for HIV have the
(also called concessional loans or credits) and grants potential to deliver a generational leap in achieving
to the poorest of the developing countries, particu- the MDGs. The health gains made in Europe over
larly those that are severely constrained by conflict, 150 years could be achieved in Africa over a 10–20-
epidemics, and debt. A buy-down refers to a third year period (WHO/UNICEF 2005). Of the more
party paying off all or part of a specific IDA credit than 10 million annual child deaths, an estimated
on behalf of the government upon successful 25% could be avoided through immunization with
achievement of pre-determined performance indica- existing and newly developed vaccines such as pneu-
tors. The World Bank began an IDA buy-down mococcal and rotavirus vaccines. Procurement of
pilot in 2003, when it provided the governments of essential health commodities is an area where this
Nigeria and Pakistan with roughly $48 million in can be carried forward without risk to macroeco-
IDA credits for the purchase of vaccine to help nomic stability. Yet without basic health systems –
achieve the global polio eradication objective. The essential for the sustainable availability of medical
Bill and Melinda Gates Foundation, Rotary products – the poor will never access these benefits.
Despite evidence of the cost-effectiveness of vac- market is shaped to promote competition and to
cines in particular and the economic and social bring prices within reach of the poorest countries.
benefits of health in general, the track record of Beginning in 2007, GAVI support shifted toward
national and donor budget allocations to date is national co-financing (as opposed to GAVI provid-
not good. GAVI-eligible countries have very mod- ing vaccines free). This is based on the intent by the
est health budgets, with government health spend- GAVI alliance partners to ensure that GAVI finan-
ing across Africa, for instance, averaging $13–$21 cial support is seen by all stakeholders as time lim-
per capita and with many countries below $10. ited and to ensure that countries move to a fuller
Responding to the needs of poor countries by ownership of their immunization program, includ-
investing in the critical foundation for the delivery ing the introduction of new vaccines. Co-financing
of basic health services requires a long-term view. therefore aims at supporting and stimulating evi-
While vertical approaches have been effective at dence-based priority-setting within the immuniza-
raising the profile and funding levels for vaccines, tion program and within the health sector more
countries must now be supported to move system- generally. Financial commitments, however small,
atically to introducing the full range of vaccines in also generally require a higher level of government
immunization programs as part of integrated engagement. Through this approach, which will be
maternal and child health services. With expensive evaluated in 2010, GAVI Alliance partners are
new vaccines coming to market (for example, three working to help countries to be on a trajectory of
doses each of pentavalent (DTP-HepB-Hib), rota- eventual independence from GAVI support,
virus, and pneumococcal conjugate vaccines could acknowledging, however, that, for most of the
amount to more than US $35 per child) it is clearly GAVI-eligible countries this is likely to require a
no longer appropriate to focus on financial sustain- very long time
ability of a single product in isolation from broader Over the next decade, the ability of developing
system sustainability. countries to achieve sustainable introduction of new
Moving toward a truly sustainable planning fra- technologies will be largely dependent on how
mework will not be a simple endeavor, yet it repre- donor funds are provided, particularly whether
sents an exciting opportunity for the GAVI Alliance there is a shift toward long-term, predictable aid
partners. One challenge will be to gather the infor- and if innovative financing instruments are appro-
mation on demand and future prices required by priately aligned and taken to scale. The other key
countries to inform longer-term planning and deci- determinant will be sustained political support
sion making. UNICEF’s commitment and global for health and for vaccines by developing country
procurement ability over the years has brought governments. Guyana is an example of a country
great benefits in terms of quality, security, and bet- that has been highly successful in achieving high
ter prices for such long established vaccines as BCG, immunization coverage and is the first GAVI-sup-
DPT, measles, and polio. But it has become clear ported country to fully finance the purchase of
that this procurement model is most effective in pentavalent vaccine from its national budget (Uni-
mature markets with overcapacity and competition, ted Nations 2007). Guyana’s continuing success is
and notably capacity in countries located in emer- in part due to a very strong political commitment at
ging markets (e.g., India, Brazil, Indonesia, and the highest levels to finance the national immuniza-
Cuba). tion program, including efforts to protect it from
New or combination vaccines such as DTP- economic shocks and shifts in donor priorities.
HepB-Hib challenge the established means of pro- More broadly, there has been a remarkable growth
curement, where cost limits the ability of donors to in the health budget from US $6.5 per capita in 1991
deliver affordable products to the poorest parts of to US $61 in 2006 (excluding overseas development
the world. It is only through competition that the assistance). This accounts for 10% of national
prices of new vaccines will become affordable to the expenditure, while the government’s goal is to
poorest countries. Clearly the key to success will be reach 15% (Ministry of Health, Guyana 2002; Edi-
the ability to mobilize additional donor funds, but torial, PharmacoEconomics and Outcomes News,
to use those funds in such a way that the vaccine 2007).
The Ministry of Health China/GAVI Hepatitis 2004). As an ethical or social justice issue,
B Vaccination Project is another example of where equity in health is therefore a critical element
political commitment and clear financial partner- for consideration and measurement, particularly
ship have brought remarkable results through a when looking at the trade-offs and choices
5-year US $76 million project, co-funded equally made around financial sustainability issues dis-
by the Government of China and the GAVI cussed in the previous section.
Alliance. Hepatitis B virus (HBV) is endemic in Many of the disparities in health result from
China where over one-third of the world’s HBV social determinants such as poverty, access to ser-
carriers reside. In 1999–2000, it was estimated that vices, education, gender, and ethnicity. Harnessing
HBV was responsible for 280,000 deaths annually, the potential of new medical technologies, such as
over one-third of the global death toll estimated to vaccines, to reach underserved groups will take con-
be between 600,000 and 700,000. Since 2002, certed effort and in some cases, explicitly defined
China has immunized 19.1 million children in the political choices. New vaccines against human
country’s poorest and most remote western and papilloma virus (HPV) provide the opportunity
central provinces against hepatitis B, reducing for such a political choice: to ensure that all
their risk of developing a deadly and common women, rather than just those in wealthy countries,
liver cancer. In the western provinces, the cam- are provided with a vaccine that will prevent most
paign, with technical guidance from WHO and cervical cancer cases. HPV vaccines, as the first
UNICEF, has reached almost 80% of newborns vaccines to focus primarily on women’s health, pro-
with a birth dose of vaccine in 2005, up from 47% vide the global health community an unprecedented
in 2002 (World Health Organization 2006, China – opportunity to tackle a key neglected women’s
GAVI Project Annual Reports). health issue – one which especially impacts on the
From an equity point of view, GAVI’s condition poorest women.
of support to the Ministry of Health, China, was Cervical cancer is not difficult to prevent; yet,
that vaccines be made available at no cost (remov- it affects an estimated 490,000 women each year
ing the previous charge). This policy was subse- and leads to more than 270,000 deaths (Ferlay
quently adopted across China for all vaccines. et al. 2006). It is largely a disease of poor women
who have limited access to health services; about
85% of women dying from cervical cancer live
in developing countries (Fig. 23.2) (Ferlay et al.
Equity 2006). The lack of effective cervical cancer preven-
tion interventions – part of a regular medical
While the spread of HIV and AIDS has led to checkup for women in wealthy countries – is a
recent discourse on health as a global security major factor in the high rates of cervical cancer
issue, most arguments – and certainly those among poor women. If current trends in women’s
related to maternal and child health – have at health continue, there are projected to be over
their root the principle of equity and the belief 1,000,000 new cases of HPV annually by the year
that health is a basic human right. Equity in 2050 (Boyle 2004).
health has been defined (for measurement and Many challenges must be addressed before HPV
operationalization) as ‘‘the absence of systematic vaccine can reach the millions of girls and young
disparities in health (or in the major social deter- women who would benefit from it, especially those
minants of health) between groups with different living in the developing world where the need is
levels of underlying social advantage/disadvan- greatest. With the right combination of scientific,
tage – that is wealth, power or prestige’’ (Brave- educational, and financing efforts, HPV vaccine
man and Gruskin 2003). The 2004 World Devel- could become available globally within a few
opment Report, Making Services Work for Poor years. Accelerating access to HPV vaccine could
People, noted that ‘‘the concern for equity is make cervical cancer – the second most common
either a social choice or based on the notion cancer among women worldwide – a rarity in just a
that health is a human right’’ (World Bank few decades.
Fig. 23.2 Global burden of N . A M E R IC A

morality from cervical 1 4 ,6 7 0
cancer, 2002. Source: Ferlay
et al. (2006)
A F R IC A EURO PE
7 8 ,8 9 7 5 9 ,9 3 1
A S IA
2 6 5 ,8 8 4
C - S . A M E R IC A
7 1 ,8 6 2
Gl obocan < 87.3 < 32.6 < 26.2 < 16.2 < 9.3 /100,000
2002
Another social determinant of health is where long-term finance (domestic and global) will be cri-
one lives. Within large developing countries, such tical to support that political commitment. New
as India, Nigeria, or China, there are significant technology, including new and better vaccines, will
inequities in the population’s health. Disparities in be vital.
access to, and utilization of, services within these
countries are often a result of factors such as geo-
graphy, social barriers, conflict, and weak govern-
ance. Of the 28 million children that missed out of Vaccine Research Priorities
immunization in 2005 more than 75% live in 10
countries (Fig. 23.1). India and Nigeria stand out Which Vaccines for the Future?
as countries with the largest number of unimmu-
nized children in the world. Research and development for vaccines and other
Reaching MDG 4 will thus require a significant essential health commodities point to another dis-
increase in investment in immunization – both parity between North and South and constitute a
domestic and external – in countries with large market failure. Priorities in the global allocation of
numbers of unimmunized children who account resources for vaccine research and development do
for more than half of all vaccine-preventable deaths not match the global burden of death and disease.
among children less than 5 years of age. With some Few resources are allocated to tackling diseases that
states or regions in some of these countries being disproportionately affect people in developing
equal or larger in population to many countries, a countries; new vaccines are therefore expensive
fresh state- or region-based approach will likely be and out of the reach of the poor. This discrepancy
required, with a focus on the poorest. For example, between need and reality is illustrated in Table 23.2,
child and maternal mortality rates in the poorest illustrating that normal market mechanisms do not
eastern provinces of China equal or exceed those work for the poor.
found in much of Africa (World Bank 2005). Among the vaccines currently under develop-
Despite economic growth, equity is worsening. ment, the three most needed today in terms of
National political commitment in such countries their potential public health impact are for AIDS,
will be key. A program approach, tailored to coun- TB, and malaria. Jointly, these diseases account
try-specific challenges, will be required. Additional for over 5 million deaths per year or around 50%
of all infectious disease deaths. The total investment vaccine delivery strategies where non-profes-
in vaccines against these diseases is far lower than sionals can administer vaccines. New administra-
their importance as dictated by disease burden and tion routes such as oral, nasal, and transcutaneous
it will probably take at least 5–10 years before a are currently being explored. One option currently
vaccine against any of these diseases is available. being explored through collaboration by WHO,
In the past two decades, advances in biotechnology PATH, and the Serum Institute of India is focusing
have resulted in the licensure of new vaccines such on the development of a measles aerosol vaccine
as Hib, acellular pertussis, HepB, and attenuated that could make a big difference in eliminating this
varicella. Most of the basic scientific breakthroughs disease by facilitating administration, during mass
have been generated in research institutions in the campaigns (Burger et al. 2008). The measles aero-
public sector whereas the cost for clinical develop- sol vaccine is useful in situations where the avail-
ment is borne by the pharmaceutical industry. This ability of trained medical personnel, who can
requires heavy investments that need to be recouped safely administer injections, is limited. Immuno-
from profits. The markets needed to recoup these genically in studies, the aerosol vaccine was proven
investments are in industrialized countries that can effective >80% of the time among infants <9
afford to buy. months of age and 86–100% among infants >9
The evolving disease burden in developing coun- months and school-aged children (Henao 2000).
tries will bring new diseases into prominence while This vaccine continues to be tested in clinical trials
sometimes allowing old ones to resurface. This will in order to find the most appropriate and effective
influence priorities for vaccine research (Table 23.3). aerosol delivery method.
The Severe Acute Respiratory Syndrome (SARS) Another interesting option is the concept of
epidemic, the outbreak of avian influenza, and the using plant-derived or edible vaccines that involve
emergence of bioterrorism threats such as Anthrax encoding protective antigens from pathogens into
have led to new research avenues for vaccines transgenic plants (Mor et al. 1998). The plants are
against these infections. The threat of a reassorted processed so that they can deliver a uniform dose of
influenza pandemic virus strain has highlighted vaccines. Human clinical trials have been conducted
the need for more resources and attention to the with bananas and raw potatoes, which showed
development and distribution of effective flu encouraging antibody responses (Sala et al. 2003).
vaccines. Plant-derived vaccines are formed when a gene
Table 23. 3 New vaccines required

Close to or already licensed
Non- vaccines (but not totally suited to
questionable the developing country burden
vaccines of disease) Neglected vaccines Others New threats
HIV, TB, Meningococcus, Streptococcus Shigella, Dengue, Respiratory Syncytial SARS,
Malaria pneumonia, Rotavirus Japanese encephalitis, virus, Herpes Anthrax,
Human papilloma virus Leishmaniasis, simplex, Smallpox,
Schistosomiasis, Enterotoxigenic pandemic
Cholera Escherichia coli influenza
Source: WHO/UNICEF (2005)
New Vaccine Administration Routes is integrated with a plant nucleus or chloroplast

genome. This transforms higher plants (e.g.,
tobacco, potato, tomato, and banana) into biore-
Alternative administration routes for vaccines
actors for the production of subunit vaccines for
would greatly contribute to improving immuniza-
oral or parental administration (Sala et al. 2003).
tion program safety and potentially reduce the
The potential advantage of this technology could
quantity of contaminated waste which needs to be
include thermostability, low investment needs, mul-
safely disposed. This could help avoid needle trans-
tivalency, and oral administration.
mission of blood-borne pathogens and ease
New Immunization Technologies increasing number of immunizations with

monodose preparations that would not require
New technologies that strengthen vaccine deliv- increased cold chain capacity.
ery are under development. Priority is given to (iii) Needle-free injections: Needle-free injectors
such technologies that will (a) expand access, (b) deliver vaccine at high velocity into the skin
improve safety, and (c) cut the cost of immuni- without penetration of a needle, thereby redu-
zation programs. They include the following five cing the risk of transmission of blood-borne
technologies: pathogens (WHO 2007c). Technologies are
being developed for both mono- and multidose
(i) ‘‘Sharps’’ processing: The increased use of auto- presentations. Multidose injectors available
disable (AD) syringes (syringes which lock them- have not been found safe and new models are
selves after a single injection) has greatly improved under development. There are several mono-
the safety of immunization programs by avoiding dose models available; however, they are not
the reuse of contaminated syringes and reducing feasible for large-scale programs because of
risks of transmission of blood-borne pathogens regulatory obstacles and high cost (WHO
such as hepatitis B, hepatitis C, and HIV (Lloyd 2000).
2000). This success is, however, highlighting (iv) Thermostable vaccine: Vaccine distribution and
another problem which the health sector is facing, storage without a cold chain would consider-
that of the handling of contaminated medical ably simplify the delivery system, reduce cost,
waste. In the case of immunization, this is mainly and allow for integrated supply mechanisms.
related to the disposal of used syringes and needles Removal of vaccines from the cold chain
(these syringes represent between 5 and 10% of all should be the highest priority for technology
injections given in the health sector but neverthe- research. Sugar glass drying is one such tech-
less the push to introduce AD syringes is increasing nology that has shown great promise (Lloyd
the pressure on immunization programs to tackle 2000). It can be used to produce multivalent
this challenge). Sharps are rarely disposed of at the vaccines that are completely heat stable, except
point of use. Since sharps are transported to the under extreme climatic conditions. The high
point of destruction, the risk of infection from cost of regulation/licensing and the uncertainty
accidental exposure to sharps must be minimized. about market prospects in industrialized coun-
Four different technologies are being explored for tries have so far impeded the development and
this purpose: corrosive disinfectants, thermopro- use of this technology.
cessing, needle destruction, and plastic melting
(Lloyd 2000). However, none of these options is
currently sufficiently developed to be put into use
in the field. Vaccine Management
(ii) Monodose pre-filled devices: Vaccine wastage
constitutes a considerable cost to immunization Vaccines are delicate products that are easily
programs. Monodose presentations eliminate destroyed if handled incorrectly. Vaccine manage-
wastage and the risk of contamination. When ment spans a spectrum of aspects involving the use
the monodose is pre-filled into an injection and disposal of vaccines, from the manufacturers to
device, it increases quality and safety at the the end-users, for which plans must be in place and
point of use. UniJect1 is one such device that regularly updated to ensure an effective and effi-
has been tested with HepB and tetanus toxoid cient service delivery including (i) inventory and
(TT) (Lloyd 2000). Village health workers can forecasting; (ii) stock control; (iii) in-country distri-
administer it. Currently, major obstacles reside bution; (iv) storing and handling; (v) equipment
in the cost of the device and the need for addi- replacement; (vi) procedures for the use of vaccine;
tional cold storage space when multidose pre- (vii) monitoring of vaccine storage; (viii) transport
sentation is exchanged for monodose, but ulti- management; and (ix) operational management. All
mately, the objective would be to provide an of these areas would benefit significantly from
research efforts to find alternative and innovative for which preventative technologies are needed
approaches. For instance, the heavy reliance on the most. Financing this effort, however, poses a con-
cold chain remains a major economic and logistical siderable challenge. A serious commitment to clos-
burden on programs. The possibility of taking ing the North/South divide and meeting MDGs will
greater advantage of the real thermostability of require a joint approach that involves increased
vaccines and the increasing use of the Vaccine Vial investment by developing country governments
Monitor by taking vaccines ‘‘out of the cold chain’’ and better, more stable aid flows from donors.
is a field which has only begun but could potentially Increased investment, particularly in the social sec-
revolutionize immunization delivery (Table 23.4). tor, will be critical to finance costs such as system
Vaccine Vial Monitors are heat-sensitive circular building that require large amounts of sustained
labels, no wider than a centimeter, that change finance. In-kind investments in commodities can
color as vaccines are exposed to heat. They are be scaled up rapidly without major concerns around
time–temperature indicators used to (i) ensure that absorptive capacity or macroeconomic stability.
the vaccines have not been damaged by excessive Long-term, predictable aid flows are also needed
exposure to heat, (ii) identify weaknesses in the cold to reduce volatility and provide increased certainty
chain, and (iii) take vaccines beyond the cold chain over future budget flows to enable better planning
to reach out to children who have no access to fixed in countries.
health facilities. Health workers can use the Vaccine As a global community, we must start approach-
Vial Monitor color to tell if the vaccine has been ing our work from a perspective that evaluates who
overexposed to heat and whether or not it is safe for is taking on the burden of risk – it clearly should not
immunization. This indicator cuts down on the be the poorest countries. Risk analysis is a common
uncertainty of vaccine safety due to potential tem- tool in the private sector – companies only take
perature changes during transport along the cold decisions based on the probable level of risk it
chain. Therefore, the vaccine vial monitor reduces implies for them. Yet the donor community consis-
waste. tently places the poorest countries in a position
where it is very difficult for them to make choices
of how or whether to radically scale up access to
basic services. The donor community, including the
Conclusion GAVI Alliance and the international financial insti-
tutions, needs to develop strategies to reduce finan-
Immunization remains one of the most cost-effec- cial and political risks. This means adjusting pro-
tive of all public health interventions. Maternal and cesses and requirements to support the long-term
child health-related MDGs will be difficult to meet integrated plans of developing countries. The finan-
without significantly scaling up the coverage of cial risks of development strategies must be more
existing vaccines and successfully introducing new equitably shared between donors and national gov-
pipeline products – ensuring that research and ernments. Development will be led by developing
development priorities are aligned with the diseases countries when they are enabled to plan ahead;
Table 23. 4 New vaccines required

Commodity Trends/developments Implication for logistics systems
Vaccines & GAVI is expanding access to new vaccines & Newer vaccines often require more storage space and
and financing vaccine development additional training for staff
& New vaccine delivery technology may & Reduced dependence on cold chain may make it more
reduce reliance on cold chain feasible to integrate vaccine logistics with other
& Increased focus on safe injection, new commodities
injection equipment, and better disposal of & New technology may also reduce vaccine waste
sharps & More staff, training, and systems are needed to manage
& Shift from donations to purchases procurement
when donors act on their recognition of the are ensured equitable access to basic services.
importance of predictable and long-term aid Accelerating the sustainable introduction of
flows to meet the MDGs. Development will new and underused vaccines is part of realizing
only happen when poor and vulnerable people this ambition.
Key Terms
Acellular pertussis Haemophilus influenza vaccine Rotavirus vaccine

Advance market commitment (Hib) Severe Acute Respiratory
(AMC) Hepatitis B vaccine (HBV) Syndrome (SARS)
Attenuated varicella Human papilloma virus (HPV) Smallpox
Auto-disable (AD) syringes vaccine Tetanus toxoid (TT)
Bacille Calmette-Guerin (BCG) Immunization coverage Vaccine distribution
Breastfeeding Immunization delivery systems Vaccine management
Cervical cancer Immunization programs Vaccine market
Child Survival Revolution Immunization rates Vaccine production
Cold chain Influenza Vaccine quality
Cold chain capacity International Finance Facility Vaccine safety
Diphtheria, pertussis, tetanus for Immunization (IFFIm) Vaccine vial monitor
vaccine (DPT) Measles aerosol vaccine Vaccines
Expanded Program on Oral rehydration therapy Variolation
Immunization (EPI) (ORT) Vertical programs
Global Alliance for Vaccines Pneumococcal conjugate Yellow fever
and Immunization (GAVI) vaccines
Global immunization targets Polio
Growth monitoring Population mobility
Questions for Discussion b. Advance Market Commitments (AMCs).
5. How successful are IFFMs and AMCs in accom-

1. What factors account for the disparity in immu- plishing their mission?
nization coverage between developed and less 6. Outline and discuss potentially viable strategies
developed countries? for ensuring sustainability in procurement,
2. What is the GAVI Alliance? How does its mis- access, and uptake of vaccines in less developed
sion compare with those of Global Immuniza- countries. What are the major barriers?
tion Vision Strategy (GIVS)? 7. What should be the priorities for future vaccine
3. What major barriers confront the GAVI Alli- research and development globally? Provide jus-
ance and GIVS in their efforts to ensure equity tification for your position.
in access to new and underused vaccines in devel-
oped and less developed countries?
4. In a narrative of about 1,000 words, describe the
meaning and mission of the following initiatives:
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Chapter 24
Adolescent Health
Elizabeth Lule and James Rosen
Learning Objectives After reading this chapter and The current world population of adolescents
answering the discussion questions that follow, you aged 10–19 is 1.2 billion, the largest ever
should be able to (UNFPA 2003; United Nations 2006a). This
total is projected to peak in the year 2030 at
Define adolescence and discuss the rationale
about 1.3 billion (UNFPA 2003; United Nations
for interest in health issues of concern to adoles-
2006a), with about 90% living in developing
cents by governments and international health
countries. However, as Fig. 24.1 shows, trends
agencies.
in the growth of this age group vary markedly
Analyze major health problems of adolescents
by region. The population of adolescents has
and identify global and regional disparities in
already peaked in the developed world and in
specific conditions that contribute to the burden
East and Southeast Asia, while the adolescent
of disease among adolescents.
population will not peak until 2015 in Latin
Appraise the effectiveness of programs to
American and the Caribbean and until 2030 and
address adolescent health problems.
2035 in South Central Asia and South Central
Discuss gaps in adolescent health policy and pro-
Asia, respectively. In sub-Saharan Africa, the
grams and identify future priorities.
population of adolescents will still be growing in
2050 (UNFPA 2003; United Nations 2006a).
Improving adolescent health is a challenge
everywhere. However, this chapter will focus on
Introduction
the developing world since that is where the vast
majority of adolescents live and where access to
Adolescence is as much a stage of development as it
health care is limited. Because of the relative
is a specific age range. The transitions that mark this
paucity of rigorous intervention research from
period of life do not conform to a standard time-
the developing world, this chapter will also draw
table. Nonetheless, this chapter will use the stan-
on evidence from more rigorously evaluated and
dard World Health Organization (1998) definition
researched programs on adolescent health in the
of adolescents as those people between the ages of
developed world.
10 and 19. Individual countries and different orga-
nizations may use somewhat different age cate-
gories to define adolescence. This chapter will, as
often as possible, use data for the 10–19 age group, The Importance of Adolescent Health
although not all data conform to this specific age
range.
Recent reviews (World Bank 2006a; National
Research Council and Institute of Medicine 2005;
Lule et al. 2006; Birdsall et al. 2001) have highlighted
E. Lule (*)
AIDS Campaign Team for Africa (ACTafrica) The World several reasons why countries have an interest in
Bank, 1818 H Street NW, Washington DC 20433, USA healthy adolescents, including the following:
436 E. Lule and J. Rosen
Trend in Population of 10–19 Year Olds by Selected Region,

1950–2050
400
350
300
More Developed
250 East Asia
LAC
Millions
200 Sub-Saharan Africa

South Central Asia
South East Asia
150
West Asia
100
50
50
50
60
70
80
90
00
10
20
30
40
20
19
19
19
19
19
20
20
20
20
20
Year
Fig. 24.1 Trend in Population of 10–19-year-olds by selected region, 1950–2050. Source: United Nations (2006b)
The size of the adolescent cohort: As noted, the Adolescent health affects economic prosperity:By
current generation of adolescents is the largest reducing HIV infection in young people, coun-
ever. They constitute one of every five per- tries can lessen the devastating social and eco-
sons. Adolescents are entitled to the universal nomic impact of HIV/AIDS. Encouraging
human rights that other age groups enjoy and young people to postpone marriage and child-
under which those groups are protected bearing can foster a reduction in family size
through various international agreements. and a slowing of population growth, which,
Making the most of the demographic dividend: when combined with investments in health
The demographic transition completed or under- and education, can contribute to higher eco-
way in most countries increases the proportion of nomic growth and incomes.
productive individuals relative to dependents, Adolescent health investments can reduce poverty:
which creates a window of opportunity condu- Death and illness exacerbates poverty by dis-
cive to economic growth. Countries that astutely rupting and cutting short school opportu-
exploit this demographic dividend through nities, by weakening or killing young people
investments in education, skills, and health of in the prime of their working lives, or by pla-
the working-age population while simulta- cing heavy financial and social burdens on
neously creating a favorable macroeconomic families and society. Keeping adolescents
policy climate can experience economic growth. healthy can help individuals and families out
Prevention is cheaper than cure: The disease bur- of poverty.
den in adolescence is largely preventable and act- Improving adolescent health will help accelerate
ing now to encourage healthy adolescent beha- achievement of the MDGs: Better adolescent
viors will avoid future loss from death and illness. health will directly or indirectly contribute to
Countries can save money by investing in pre- achieving most of the eight Millennium Devel-
ventive behaviors. opment Goals (MDGs) (Table 24.1).
24 Adolescent Health 437
Table 24.1 The path to achieving the MDGs runs through adolescence
Adolescent-focused activities to achieve
Millennium Development Goals Indicator the goal
Goal 1: Eradicate extreme Proportion living on less than $1 a day Preventing teen pregnancy
poverty and hunger Proportion of people who suffer from Reducing HIV infection in youth
hunger
Goal 2: Achieve universal primary Net enrolment ratio in primary education Gender equity in school enrollment.
education Proportion of pupils starting grade 1 who Prevention of teen pregnancy
reach last grade of primary Infrastructure development and
Literacy rate of 15–24 year-olds, women maintenance to ensure quality
and men education.
Goal 3: Promote gender equality Ratio of girls to boys in primary, secondary, Educating girls
and empower women and tertiary education
Among 15–24-year-olds, ratio of literate Changing social norms to promote
females to literate males gender equity
Goal 4: Reduce child mortality Infant death rate Preventing high-risk pregnancies to
young mothers and reducing
adolescent malnutrition
Goal 5: Improve maternal health Maternal mortality ratio (to the extent that Improving maternal care for pregnant
young mothers are at higher risk of adolescents
pregnancy-related death and disability)
Proportion of births attended by skilled Expanding post-abortion care for youth
health personnel
Contraceptive prevalence rate Expanding youth access to information
and services for pregnancy prevention
Goal 6: Combat HIV/AIDS, HIV prevalence among 15–24-year-old Expanding youth-specific HIV
malaria, and other diseases pregnant women prevention and care efforts
Prevalence and death rates associated with Educating youth how to identify the
tuberculosis and malaria symptoms of TB and get care for
themselves, friends, and family
members
Preventive malaria treatment for
pregnant adolescents
Goal 7: Ensure environmental Proportion of population with sustainable Investing in the human capital of young
sustainability access to an improved water source people, leading to lower fertility and
less pressure on natural resources
Goal 8, target 16: Develop and Unemployment rate of 15–24-year-olds Carrying out policies and programs to
implement strategies for decent expand youth employment
and productive work for youth
Source: Rosen (2004)
several common factors that can protect youth from

Common Influences on Adolescent risky sex. These include connectedness to parents and
Health parental expectations about school, marriage, and
sexuality; factors in the school environment such as
Researchers have identified many factors that either connectedness, family life education, and academic
increase (risk factor) or decrease (protective factor) the performance; expectations and attitudes of sexual
chances that an adolescent will have unhealthy beha- partners and peers; and feelings of self-efficacy and
viors. These factors operate at the individual, family, self-control.
institutional, and community level and include feelings One study in Zambia (Magnani et al. 2002) which
of self-efficacy, attitudes and behaviors of friends, sought to identify risk and protective factors influen-
connectedness with parents and other influential cing exposure of Zambian youth to HIV revealed that
adults, and involvement in the community. A recent level of education and current school attendance were
exhaustive review of quantitative studies conducted in protective with regard to initiation of sexual inter-
developing countries (Blum and Mmari 2005) found course. Living with both birth parents and having
knowledge about AIDS was protective against ever consequences of those behaviors (pregnancy, child-
having had sex. However, knowledge about using bearing, or a sexually transmitted infection). Those
condoms was a risk. Knowing peers that had had factors most amenable to change by programs that
sex was associated with a higher probability of ever directly address sexual and reproductive health issues
having had sex among youth (males and females). involve sexual beliefs, values and attitudes, skills and
Youth who engaged in higher risk activities (drinking behaviors of teens regarding having sex, using con-
alcohol and using drugs) were also more likely to have doms and other methods of contraception, and avoid-
had sex. Communication with the first close friend ing pregnancy and HIV and other STIs (Table 24.2).
about reproductive health issues was associated with Evidence from qualitative studies on the factors influ-
higher levels of sexual activity, likely reflecting the encing young people’s sexual behavior further under-
influences of peers. lines the importance of social expectations and the
Studies in developed countries also reveal the influence of sexual partners (Marston and King 2006).
importance of multiple influences on sexual behavior. Studies focusing on such other domains of adoles-
For example, Kirby et al. (2005) analyzed research on cent health as mental health have equally demon-
adolescent sexual and reproductive health in the Uni- strated the role of multiple factors (Patel et al. 2007),
ted States and identified over 400 factors that affect including psychological factors (e.g., sexual physical,
one or more sexual behaviors (the initiation of sex, emotional abuse, and neglect), family factors (e.g.,
frequency of sex, number of sexual partners, use of family conflict and poor family discipline), school fac-
condoms, and use of other contraceptives) or tors (failure of schools to prove appropriate
Table 24.2 Risk and protective factors most amenable to change directly by pregnancy and STD prevention agencies, United
States
Risk factor Protective factor
Family Greater parent/child communication about sex and condoms or
contraception especially before youth initiate sex
Peer Peers’ pro-childbearing attitudes or Positive peer norms or support for condom or contraceptive use
behavior
Permissive values about sex Peer use of condoms
Sexually active peers
Individual More permissive attitudes toward Greater feelings of guilt about possibly having sex
premarital sex
Perceiving more personal and social Taking a virginity pledge
benefits (than costs) of having sex
Greater frequency of sex Greater perceived male responsibility for pregnancy prevention
Having a new sexual relationship Stronger beliefs that condoms do not reduce sexual pleasure
Greater number of sexual partners Greater value of partner appreciation of condom use
Previous pregnancy or impregnation More positive attitudes toward condoms and other forms of
contraception
History of recent STD More perceived benefits and/or fewer costs and barriers to using
condoms
Greater self-efficacy to demand condom use
Greater self-efficacy to use condoms or other forms of
contraception
Greater motivation to use condoms or other forms of
contraception
Greater intention to use condoms
Greater perceived negative consequences of pregnancy
Greater motivation to avoid pregnancy, HIV, and other STDs
Older age of first voluntary sex
Discussing sexual risks with partner
Discussing pregnancy and STD prevention with partner
Previous effective use of condoms or contraception
Source: Kirby et al. (2005)
environment to support attendance), and community Major Adolescent Health Problems

factors (community disorganization) (Table 24.3).
These findings demonstrate the role of multiple indi- Overall Burden of Death and Disability
vidual, community, and sociocultural factors in ado-
lescent health. Tables 24.4 and 24.5 summarize the main causes of
In addition to sharing many root causes, studies death and disease burden in adolescents aged 10–19.
have shown that many of the health problems of From the immediate death and disability stand-
adolescents are inter-related. Mental illness is asso- point, adolescence is easily the healthiest time of
ciated with substance abuse, violence, and sexual and life (Fig. 24.2).
reproductive health problems (Patel et al. 2007). Pro- Death and disability rates for the 10–19 age
blem drinking is a factor in many fatal traffic crashes group are lower than for any other cohort. More-
and in suicide (WHO 2007d). Gender-based violence is over, many signs point to the fact that young people
associated with poor reproductive health outcomes as a group (at least in developing countries) have
and suicide (WHO, 2005a). Poor nutrition leads to gotten healthier over time (National Research
problems in pregnancy and childbirth (Behrman Council and Institute of Medicine 2005). Yet,
et al. 2004). many behaviors or conditions that begin or occur
Table 24.3 Selected risk and protective factors for mental health of children and adolescents
Risk factors Protective factors
Biological
Exposure to toxins (e.g., tobacco, alcohol) in pregnancy Age-appropriate physical
Genetic tendency to psychiatric disorder development
Head trauma Good physical health
Hypoxia at birth and other birth complications Good intellectual functioning
HIV infection
Malnutrition
Substance abuse
Other illnesses
Psychological
Learning disorders Ability to learn from experiences
Maladaptive personality traits Good self-esteem
Sexual, physical, emotional abuse and neglect High level of problem-solving
Difficult temperament ability
Social skills
Social
Family Inconsistent care-giving Family attachment
Family conflict Opportunities for positive
Poor family discipline involvement in family
Poor family management Rewards for involvement in
Death of a family member family
School Academic failure Opportunities for involvement in
Failure of schools to provide appropriate environment to support school life
attendance and learning inadequate or inappropriate provision of Positive reinforcement from
education academic achievement
Bullying Identity with school or need for
educational attainment
Community Transitions (e.g., urbanization) Connectedness to community
Community disorganization Opportunities for leisure
Discrimination and marginalization Exposure to violence Positive cultural experiences
Positive role models
Rewards for community
involvement
Connection with community
organizations
Source: Patel et al. (2007)
Table 24.4 Conditions causing greater than 1% of adoles- during adolescence – for example, tobacco and alco-
cent deaths hol use, poor eating habits, sexual abuse, and risky
Condition Percent of total sexual behaviors – have long-term health conse-
Lower respiratory infections 11.2 quences whose toll in death and illness is not
Road traffic accidents 10.0
counted during the adolescent years.
Self-inflicted injuries 6.0
Maternal conditions 4.8
In fact, as Figs. 24.3 and 24.4 show, 28% of the
Violence 4.8 disease burden and over 50% of premature deaths
Tuberculosis 4.0 among persons 15 and over are linked to behaviors
HIV/AIDS 3.9 or conditions that begin or occurred during
Falls 1.4 adolescence.
Protein–energy malnutrition 1.3 Adolescence-rooted risk factors are currently
Nephritis and nephrosis 1.1 a greater problem in wealthier countries, largely
Ischemic heart disease 1.0
because of the relatively greater impact of smok-
Cerebrovascular disease 1.0
Cirrhosis of the liver 1.0 ing and diet-related risks in those countries.
Nonetheless, the impact of these risks is pro-
Source: Mathers (2009)
jected to expand rapidly in many poorer coun-
tries as their epidemiologic profiles converge
Table 24.5 Conditions causing greater than 1% of adoles- with those of the developed countries (Mathers
cent DALYS and Loncar 2006). Through this lens, adolescent
Condition Percent of total health problems comprise problems and risk
Mental Illness* 18.59 behaviors that affect their immediate health and
Maternal conditions 6.69 well-being and those that have longer-term
Road traffic accidents 6.07 health impacts. The following sections analyze
Lower respiratory infections 5.43
some of the main contributors to adolescent
Asthma 3.53
health problems.
Violence 3.42
Self-inflicted injuries 3.18
Alcohol use disorders 2.94
Falls 2.90
Tuberculosis 2.10 Mental Disorders
HIV/AIDS 1.87
* Includes unipolar depressive disorders, schizophrenia, and Mental disorders, including unipolar depressive
bipolar disorder. disorders, schizophrenia, bipolar disorder, self-
Source: Mathers (2009)
Death and Disability Rates by Age

25.0 450
400
20.0 DALY Rates
Death Rates per 1000
DALY Rates per 1000
350
300
15.0
250
200
10.0
150
Death Rates
5.0 100
50
0.0 0
0–9 10–19 15–29 30–44 45–59 60–69
Age
Fig. 24.2 Rates of death and disease burden by age. Source: WHO (2007a)
Premature Death Attributable to Risk Factors with Roots in Adolescence

Risk Factor
Blood pressure
World Smoking and oral tobacco

Cholesterol
Body mass index
Developed Countries
Unsafe sex
Physical inactivity
Developing Countries Alcohol

with Low Mortality Iron deficiency
Illicit drugs
Lack of contraception
Developing Countries
with High Mortality Childhood sexual abuse
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%
% of Premature Deaths
Fig. 24.3 Premature deaths attributable to risk factors with roots in adolescents. Source: WHO (2007a)
DALYs Attributable to Risk Factors with Roots in Adolescence

Risk Factor
Unsafe sex
World Blood pressure
Smoking and oral tobacco
Alcohol
Developed Countries Cholesterol

Body mass index
Developing Countries Physical inactivity
with Low Mortality Iron deficiency
Illicit drugs
Developing Countries Lack of contraception
with High Mortality Childhood sexual abuse
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
% of DALYs
Fig. 24.4 DALYS attributable to risk factors with roots in adolescence. Source: WHO (2007a)
inflicted injuries, and alcohol use disorder, adolescence, lack of attention to mental health
account for about one-fourth of the disease bur- during the adolescent years can result in lifelong
den among 10–19-year-olds (Table 24.5) and disability and consequences that continue far into
affect between 20 and 25% of young people in adulthood. For this reason, prevention and treat-
any given year (Patel et al. 2007). Suicide is the ment are especially critical during the adolescent
third leading cause of death among young people years.
worldwide, accounting for 6% of deaths (Table
24.4). No clear trend has emerged in the preva-
lence of mental disorders in adolescence (Patel Intentional and Unintentional Injuries
et al. 2007). Many of the mental health problems
of the young are both preventable and treatable. Both intentional and unintentional injuries are
Like other health problems that begin during major causes of death and disease burden in
adolescents. Detailed discussion about injuries work in often-hazardous public transport jobs
among MCH populations is presented in Chap- (WHO 2007d).
ter 18. Intentional violence accounts for 4.8% of
all deaths and 3.4% of DALYs in adolescents
worldwide. A major contributor to violence is Diet, Nutrition, and Exercise
homicide. Homicide as a proportion of all
deaths varies widely by region, among males, Nutritional deficiencies in adolescent girls contri-
ranging between 2.4% in Southeast Asia and bute to problems in pregnancy and childbirth and
33.2% in the Americas. The same proportion increase the disease burden related to the maternal
among females aged 15–29 is significantly lower conditions. They account for 5% of all deaths in
(Fig. 24.5). Homicide rates in both males and adolescents (Delisle et al. 2001). Malnutrition may
females have trended upward in recent years also increase risk of HIV transmission, including
(WHO 2002). Non-fatal youth violence results from mothers to their infants, compromise antire-
in between 20 and 40 victims in need of hospital troviral therapy, and hasten the onset of full-blown
care for every youth who dies from homicide AIDS (World Bank 2006a). Many adolescents in
(WHO 2002). developing countries suffer from chronic undernu-
Unintentional injuries caused by road crashes trition which delays growth and physical matura-
are the second leading cause of death among tion and increases pregnancy-related health
adolescents, accounting for 10% of all deaths, problems (Behrman et al. 2004). Iron deficiency
and the third leading cause of disability-adjusted leading to anemia is the most common micronutri-
life year (DALYs), accounting for 6% of DALYs ent deficiency in adolescence (World Bank 2003).
(Tables 24.4 and 24.5). Adolescent males are Surveys show that almost 40% of adolescent girls
more than twice as likely as females aged 10–19 are anemic (Table 24.6). Poor dietary and exercise
to die from road traffic injuries (WHO 2007d). habits that begun in childhood and adolescence are
Relative to adults, adolescents are particularly at the root of many chronic diseases such as cardi-
vulnerable to road traffic injuries because of ovascular disease and diabetes that are major killers
their emotional and social immaturity, their among adults in the developed world, and now,
small size (for younger adolescents), their lack of increasing importance in developing countries
of driving experience, their greater propensity to (Adeyi et al. 2007). High cholesterol, low fruit
mix driving with alcohol and drug use, their ten- and vegetable intake, overweight, and physical inac-
dency toward greater risk-taking, their relatively tivity account for one in five deaths worldwide
infrequent use of safety devices such as crash (Fig. 24.3). Young people are increasingly over-
helmets and seat belts, and their tendency to weight and obese (National Research Council
Homicide as a Proportion of All Deaths, Ages 15–29
Western Pacific
Eastern
Mediterranean
WHO Region
Europe
Females
South-East Asia
Males
Americas
Africa
All
0 5 10 15 20 25 30 35
Percent
Fig. 24.5 Homicide as a proportion of all deaths in the 15–29 age group. Source: WHO (2002)
Table 24.6 Anemia status of adolescent girls 15–19, mid-1990s–2005

Country (year of survey) Mild anemia(%) Moderate anemia(%) Severe anemia(%) Any anemia(%)
Sub-Saharan Africa
Benin (2001) 42.1 21.6 1.5 65.2
Burkina Faso (2003) 37.6 13 1.3 51.9
Cameroon (2004) 34.7 10.2 0.7 45.6
Congo (Brazzaville) (2005) 42.3 13.6 0.5 56.5
Ethiopia (2005) 16.6 7.4 0.9 24.8
Ghana (2003) 37.3 7.9 0.7 45.9
Guinea (2005) 29.4 17.8 3.7 50.9
Lesotho (2004) 20.7 8.4 0.4 29.5
Madagascar (2003/2004) 35.6 8.3 4 47.9
Malawi (2004) 28.9 10.5 2.7 42.2
Mali (2001) 39.5 20.4 2.3 62.2
Rwanda (2005) 18 6.8 4.1 29
Senegal (2005) 41.5 15.9 3.1 60.5
Tanzania (2004) 33.6 14.6 0.8 49
Uganda (2000/01) 17.6 6.3 0.6 24.5
North Africa/West Asia/Europe
Armenia (2000) 8 0.9 0 8.9
Armenia (2005) 17.3 3.3 0.7 21.4
Egypt (2000) 24.5 5.2 0 29.7
Egypt (2005) 36.3 8.6 0 44.9
Jordan (2002) 15.8 4 0.3 20
Moldova, Republic of (2005) 21.7 2.1 0.1 23.9
Central Asia
Kazakhstan (1995) 38.8 6.4 0.4 45.6
Kazakhstan (1999) 25.8 6 0 31.9
Kyrgyz Republic (1997) 25.2 5.9 0.7 31.9
Turkmenistan (2000) 33 4.1 0.5 37.6
Uzbekistan (1996) 45.3 10.4 0.6 56.3
South and Southeast Asia
Cambodia (2000) 49.7 8.4 0.4 58.5
India (1998/1999) 36.3 17.8 1.9 55.9
Bolivia (1998) 17.7 4.5 0.7 22.9
Bolivia (2003) 27 3.8 0.1 30.9
Haiti (2000) 36.7 16.5 4.7 57.9
Honduras (2005) 14.8 1.7 0.3 16.8
Peru (1996) 27.2 3.8 0.1 31
Peru (2000) 24.5 4.5 0.2 29.2
Unweighted Average 29 9 1 39
Source: Demographic and Health Surveys (2008)
and Institute of Medicine (2005), and physical activ- huge. Half of the roughly 300 million young people
ity is on the decline (MacKay and Mensah 2004). smoking today will eventually die from tobacco use
(WHO 2001b). By 2030, tobacco is projected to be
responsible for about 8.3 million deaths per year
worldwide, or about 10% of total deaths, more
Tobacco, Alcohol, and Drug Use than any other cause (Mathers and Loncar 2006).
Most adult smokers worldwide begin smoking
Although tobacco use accounts for little disease bur- in adolescence or earlier (Jha et al. 2006). An esti-
den in the adolescent years, its impact in adulthood is mated 10.5% of young men and 6.7% of young
women aged 13–15 are currently smoking cigarettes, HIV/AIDS account for almost 10% of both deaths
according to 132 surveys conducted between 1999 and disease burden in adolescents (Tables 24.4 and
and 2005 (American Legacy Foundation 2002). 24.5). Moreover, unsafe sex, an adolescent-rooted
About double these%ages are using some type of reproductive health risk factor, accounts for 4.3%
tobacco product (Fig. 24.6). Rates of tobacco use of premature deaths worldwide and is the single
are lowest in Southeast Asia and the Western Pacific leading risk factor worldwide for DALYs later in
and highest in the Americas and Europe. life (Figs. 24.3 and 24.4). In high-mortality devel-
Alcohol use disorders in adolescents aged 10–19 oping countries, unsafe sex is the leading risk factor
currently account for about 3% of all DALYS for premature death (Kirby et al. 2006). Several
(Table 24.4). The earlier young people start drink- important trends are influencing sexual and repro-
ing, the more likely they are to suffer alcohol-related ductive health in adolescents. Worldwide, both
problems later in life (WHO 2001a). Most of this boys and girls are experiencing puberty at an earlier
disease burden stems from periodic heavy drinking age (National Research Council and Institute of
rather than chronic drinking (Ahlström et al. 2004). Medicine 2005). Meanwhile, age at first marriage
Surveys of in-school adolescents aged 13–15 years has gradually increased in most regions, with the
in 18 countries showed that 25% of boys and 15% exception of Latin America (Mensch et al. 2003).
of girls have had at least one heavy drinking episode The majority of young people initiate sexual activ-
(WHO 2004). Rates of heavy drinking range from ity during adolescence (Table 24.8). Contrary to
1% of girls in Tajikistan to 47% of girls in Zambia popular belief, today’s adolescents are not having
(Table 24.7). Alcohol-attributable DALYs for all sex at earlier ages than before in most countries
ages worldwide account for 3.6% of the total (National Research Council and Institute of
DALYs (Rehm et al. 2006). Internationally, the Medicine 2005). There is even recent evidence that
trend is that youth start drinking alcohol earlier very early sexual initiation is on the decline in
(WHO 2001a). Drinking, particularly heavy drink- sub-Saharan Africa (UNAIDS 2006). However,
ing, among youth is also on the increase (WHO premarital sex is increasing in most countries
2004). where data are available, largely because of
increases in the age at first marriage (Natio-
nal Research Council and Institute of Medicine
Sexual and Reproductive Health 2005).
Teen pregnancy, associated risk factors, and
Health problems associated with sexual and repro- intervention programs are discussed in detail in
ductive health such as maternal conditions and Chapter 21. Rates of contraceptive use among
Tobacco Use among 13–15 Year-olds

25.0%
Percent Using Tobacco
20.0%
15.0% Girls
Boys
10.0% Total
5.0%
0.0%
ca
as
an
pe
l
ta
ifi
si
ri
ic
To
ne
ro
c
tA
Af
Pa
er
Eu
rra
as
Am
rn
ite
-E
te
ed
es
ut
M
So
W
n
er
st
Ea
WHO Region
Fig. 24.6 Tobacco use worldwide. Source: Mochizuki-Kobayashi et al. (2006)

Table 24.7 Percent of students aged 13–15 reporting episodes of heavy drinking*
Country (year of survey) Total Boys Girls
Sub-Saharan Africa
Botswana (2005) 21 25 17
Kenya (2003) 20 24 15
Namibia (2004) 32 35 29
Senegal (2005) 5 7 2
Swaziland (2003) 19 24 16
Tanzania (2006) 6 8 3
Zambia (2004) 43 39 47
Zimbabwe (2003) 19 24 15
Latin America and the
Caribbean
Cayman Islands (2007) 28 28 28
Chile-Metropolitan 26 26 26
(2004)
Guyana (2004) 28 40 18
Uruguay (2006) 31 33 29
Venezuela-Barinas 20 26 15
(2003)
Middle East and North
Africa
Lebanon (2005) 14 21 7
Morocco (2006) 4 5 2
Tajikistan (2006) 2 2 1
Asia
China–Beijing (2003) 8 12 5
Philippines (2003) 19 26 14
Median 19 25 15
*Heavy drinking = drank so much alcohol that they were really drunk one or more times
during their life.
Source: Global School-Based Student Health Surveys (2007)
both married and unmarried adolescents are still of births worldwide. Yet adolescent girls face health
quite low (Table 24.8). Moreover, substantial pro- risks during pregnancy and childbirth, accounting
portions of young women are not using contracep- for 15% of the Global Burden of Disease for mater-
tion even though they are sexually active and do nal conditions and 13% of all maternal deaths
not want to have a child. A study of women in 53 (WHO and UNFPA 2006). Compared to women
developing countries found that this unmet need in their twenties and thirties, women under 20 years
for contraception was highest in younger women have a higher risk of dying from maternal causes
aged 15–24 years (Fig. 24.7) (Sedgh et al. 2007). (National Research Council and Institute of Medi-
Adolescent pregnancy and childbearing remains cine 2005). In countries where abortion is legally
a problem in many countries (see Chapter 21). Rates restricted, unsafe abortion is an important source
of adolescent childbearing have dropped in most of mortality and morbidity for young women.
regions in the past three decades (Bearinger et al. An estimated 14% of all unsafe abortions (about
2007), but remain high, especially in Africa. More- 2.5 million abortions per year) are to adolescents
over, childbearing before age 16, which greatly aged 15–19 years (Shah and Ahman 2004).
increases the risk of negative health consequences, As Fig. 24.8 shows, unsafe abortion is far more
remains a problem in some regions (Table 24.8). concentrated among adolescents in Africa than
Pregnant women under 20 bear a disproportionate in other regions; adolescents aged 15–19 in Africa
burden of pregnancy-related death and illness. account for about 25% of unsafe abortion in
The roughly 15 million adolescent girls aged 15–19 the region versus less than 10% in Asia and about
that give birth each year account for about 11% 15% in Latin America and the Caribbean.
Table 24.8 Indicators of sexual and reproductive behaviors among adolescents and youth by gender and
age group, late 1990s to early 2000s
A. Sexual Females, 20–24 Males, 20–24
activity Percent who initiated before age Percent who initiated before age
Region 15 18 20 15 18 20
East/Southern 17 57 77 14 45 65
Africa
West and Middle 21 59 77 12 40 61
Africa
Caribbean/Central 13 44 62 31 70 84
America
South America 9 41 61 31 73 87
Former Soviet 1 20 53 na na na
Asia
Middle East na na Na na na na
South and Southeast na na Na na na na
Asia
B. Marriage Females, 20–24 Males, 20–24
Percent who married before age Percent who married before age
Region 18 20 18 20
East/Southern 37 55 14
Africa
West and Middle 45 60 12
Africa
Caribbean/Central 35 53 22
America
South America 23 38 14
Former Soviet 16 50 na
Asia
Middle East 23 40 na
South and Southeast 42 60 na
Asia
C. Childbearing Percent of females aged 20–24 who had a Percent of males who ever fathered a
child before age child at age
Region 16 18 15–19 20–24
East/Southern 9 27 2 24
Africa
West and Middle 13 31 2 13
Africa
Caribbean/Central 7 22 2 27
America
South America 4 16 3 23
Former Soviet 0 4 na na
Asia
Middle East 3 11 na na
South and Southeast 9 24 na na
Asia
D. Contraceptive Use Percentage of sexually active females aged
15–19 using contraception
Region All Unmarried
East/Southern 21 28
Africa
West and Middle 20 26
Africa

A. Sexual Females, 20–24 Males, 20–24
activity Percent who initiated before age Percent who initiated before age
Caribbean/Central 24 na
America
South America 28 38
Former Soviet 25 na
Asia
Middle East na na
South and Southeast na na
Asia
Source: National Research Council & Institute of Medicine (2005)
na = not available
Fig. 24.7 Unmet need for Unmet Need for Contraception, by Age Group
contraception by age group
and region. Source: Sedgh Sub-Saharan Africa
et al. (2007)
15–24
North Africa and West Asia
Latin America and the 25–34
Caribbean 35+
Central Asia
All Countries
0.0 5.0 10.0 15.0 20.0 25.0 30.0

% of married women with unmet need
Fig. 24.8 Distribution of

unsafe abortion by age.
Source: Shah and Ahman
(2004)
The complications associated with abortion are Low levels of knowledge about HIV/AIDS,
the reason why maternal conditions are among the together with continued higher-risk sexual prac-
highest contributors to DALYs in adolescents. tices, increase the vulnerability of adolescents to
HIV infection. Most young people still lack com-
prehensive knowledge of HIV/AIDS. According
to surveys conducted in 31 countries since 2000,
HIV/AIDS and Other Sexually Transmitted the%age of youth who correctly identify ways of
preventing HIV transmission and who reject
Infections
major misconceptions about HIV transmission
ranges between 15 and 54% for males and 9
HIV/AIDS remains a serious threat to the and 53% for females (Table 24.10). This is far
immediate health of adolescents. Worldwide, below the target of 90% set by the international
HIV/AIDS accounts for 4% of deaths and community (UNAIDS 2006). Rates of higher-risk
about 2% of DALYs in adolescents (Figs. 24.3 sex, as measured by the%age of sexually active
and 24.4). Young people continue to be at the young people having sex with non-marital, non-
center of the HIV/AIDS epidemic. People under cohabitating partners, are also high. As Table
25 (including children through mother-to-child 24.10 shows, in 35 countries with surveys since
transmission) account for roughly half of all 2000, the median proportion having high-risk sex
new HIV infections (UNAIDS 2006). In Africa is 81% of males and 29% of females. No clear
and the Caribbean, the epidemic disproportio- trend has emerged in this indicator (UNAIDS
nately affects young women, with infection 2006). Moreover, the proportion of young people
rates for young women two to three times higher using a condom during higher-risk sex is still low,
than for young men (Table 24.9). Prevalence although apparently rising in some countries
trends in HIV infection among young people (UNAIDS 2006). Among young males, the pro-
are mixed. According to UNAIDS (2006), 6 of portion ranges from 12% in Madagascar to 86%
11 countries reporting HIV/AIDS data showed a in Armenia. Among females, the proportion
drop of 25% or more in prevalence in the 15–24 ranges from 5% in Madagascar to 62% in
age group between 2000/2001 and 2004/2005 Guyana (Table 24.10). The HIV/AIDS epidemic
(UNAIDS 2006). has also contributed to the growth in the num-
ber of adolescent orphans. Of the 130 million
orphans worldwide under age 18, about 15 mil-
Table 24.9 HIV prevalence among 15–24-year-olds by lion (11%) have lost one or both parents to
region and sex, 2005 HIV/AIDS (UNAIDS 2006). UNAIDS projects
Young women Young men this number to grow to 25 million by 2010
(15–24) rate (15–24) rate
Region (%) 2005 (%) 2005
(UNAIDS 2007). About half of orphans under
Sub-Saharan 4.3 1.5
18 are adolescents aged 12–17 (Ruland et al.
Africa 2005).
East Asia <0.1 0.1 Of the roughly 340 million new cases each
South and 0.4 0.6 year of curable sexually transmitted infections
Southeast Asia (STIs), between a fifth and half are young people
Eastern Europe 0.5 0.9
in the age group 10–24 (Bearinger et al. 2007).
and Central
Asia The disproportionately high burden of STIs
North Africa 0.2 0.1 among youth reflects the special biological,
and Middle social, and economic risks they face (WHO
East 2007b). Many millions more adolescents are
Caribbean 1.6 0.7
infected with incurable viral STIs such as
Latin American 0.3 0.5
human papilloma virus (HPV), which causes an
Source: UNAIDS (2006) estimated 500,000 new cases of cervical cancer
and 70,000 cases of other types of cancer
Table 24.10 Indicators of HIV/AIDS-related sexual behavior and knowledge, young people aged 15–24, 2000–2006
Percent engaging in Percent using a condom at Percent with comprehensive
higher risk sex last higher risk sex HIV/AIDS knowledge
Country (year of latest survey) Males Females Males Females Males Females
Armenia (2005) 78 0 86 – 15 23
Moldova (2005) 84 36 63 44 54 42
Turkmenistan (2000) – 2 – – – –
Uzbekistan (2002) 45 1 50 – – –
Latin American and the Caribbean
Bolivia (2003) 70 32 37 20 18 15
Colombia (2005) – 53 – – – –
Dominican Republic (2002) 83 29 52 29 – –
Guyana (2005) 81 40 68 62 47 53
Haiti (2005) 95 55 43 29 40 32
Honduras (2005) – 16 – 24 – 30
Nicaragua (2001) – 14 – – – –
Peru (2000) 29 – – – –
Cambodia (2005) 36 1 84 – 45 50
Nepal (2006) 20 – 78 – 44 28
Philippines (2003) 49 6 25 11 18 12
Vietnam (2005) 21 1 68 – 50 42
Sub-Saharan Africa
Benin (2001) 90 36 34 19 – –
Burkina Faso (2003) 78 23 67 54 23 15
Cameroon (2004) 91 44 57 46 34 27
Chad (2004) 76 7 25 17 25 17
Congo Brazzaville (2005) 94 60 38 20 22 10
Cote d’Ivoire (2005) 89 54 53 39 28 18
Ethiopia (2005) 37 6 50 28 33 21
Ghana (2003) 83 50 52 33 – –
Guinea (2005) 95 36 37 26 23 17
Kenya (2003) 84 30 47 25 – –
Lesotho (2004) 89 42 48 50 18 26
Madagascar (2003/04) 72 31 12 5 16 19
Malawi (2004) 62 14 47 35 36 24
Mali (2001) 85 18 30 14 15 9
Mozambique (2003) 84 37 33 29 33 20
Namibia (2000) 85 80 69 48 41 31
Niger (2006) 38 1 37 18 16 13
Nigeria (2003) 78 29 46 24 21 18
Rwanda (2005) 48 15 40 26 54 51
Senegal (2005) 91 11 52 36 26 20
Tanzania (2004) 83 29 46 39 40 45
Uganda (2006) 65 27 55 38 38 32
Zambia (2001/02) 86 30 42 33 33 31
Zimbabwe (2005/06) 78 16 68 42 46 44
Source: Demographic and Health Surveys (2008)
– = not available
annually (WHO 2007b). Cervical cancer is now peak years for incidence of HPV infection are
the most common type of cancer in women in between 16 and 20 (WHO and UNFPA 2006b),
developing countries (Parkin et al. 2005). The when most adolescents become sexually active.
Gender-Based Violence enormous number of risks and protective factors

potentially influencing adolescent health present
Gender-based violence (GBV) encompasses a range daunting challenges for public health programs.
of physical, sexual, and psychological violence direc- To address these complexities, an international
ted mainly at women and girls (IGWG 2006). consensus has formed around a basic set of prin-
Among the most serious and common forms of ciples or framework for approaching adolescent
these behaviors occur when an intimate male partner health interventions (WHO 1999). This model
abuses his female partner and when a man coerces a promotes a holistic, multi-intervention approach
woman or girl to have sex. Gender-based violence to adolescent health problems centered on provid-
also encompasses harmful traditional practices such ing adolescents with
as female genital mutilation (Chapter 10) and human
Information and skills to make the right deci-
rights violations such as trafficking in girls and
sions about behaviors that affect their health,
women. Gender-based violence is prevalent among
such as whether and when to have sex and
young people. A recent WHO study carried out in
whether to use tobacco
both developed and less developed countries found
Access to a broad range of health services that
that in 11 of the 15 settings worldwide, rates of
give them the means to act on their knowledge
reported sexual abuse among girls before age 18
A social, legal, and regulatory environment that
were between 7 and 12% (WHO 2005a). Other stu-
supports healthy behaviors and protects them
dies have shown similar results in a wide range of
from harm
settings (IGWG 2006). Many young women’s first
sex is coerced. In 10 of the 15 settings studied in the Most adolescent health programs incorporate
WHO study, over 5% of women reported that their these goals. Experience to date suggests that effec-
first sexual experience was forced, with more than tive, youth-focused efforts share a set of common
14% reporting forced first sex in Bangladesh, Ethio- programming principles (Box 24.1).
pia, Peru, and the United Republic of Tanzania However, few if any countries have taken an
(WHO 2005a). integrated, holistic approach. In practice, to the
Rates of physical violence by intimate male part- extent that countries have addressed adolescent
ners against younger women are also high. In 10 of health problems at all, it has been piecemeal, by
the 15 study sites participating in the recent WHO disease or condition. It is worth noting that, in
study, between 20 and 36% of young women aged general, the evidence base for effective interven-
15–19 report being subject to at least one act of tions to improve adolescent health, although
physical violence in the past year (WHO 2005a). expanding, remains weak. However, many youth
Moreover, in two-thirds of the study sites, rates of health interventions are relatively new and not yet
current physical violence are highest in the 15–19 well evaluated. Health interventions for youth
age group compared to older women (WHO 2005a). share this shortcoming with interventions in other
Gender-based violence often has lasting physical, areas of youth development (2006b). The following
social, emotional, psychological, and economic discussion summarizes knowledge of intervention
consequences (Patel et al. 2007) and is linked to effectiveness and important policy and program
many subsequent reproductive health problems gaps, organized by major adolescent health
(IGWG 2006). problems.
Evidence on Effective Programs to Interventions to Address Mental Disorders

Improve Adolescent Health
Patel et al. (2007) note a gradual improvement in
The wide range of adolescent health problems treatment of mental health problems in adolescents
and risk behaviors complicates the task of in recent decades, although evidence for interven-
improving adolescent health. Moreover, the tion effectiveness and cost remains limited. Mental
Box 24.1 General Principles of Health Programming for Adolescents
Recognize the diversity of the youth age group: A sexually inexperienced 11-year-old has vastly
different needs than a married 20-year-old. Programs should apply different strategies to reach
youth, who vary by age, sex, employment, schooling, and marital status.
Involve young people: Policies and programs are more effective when young people are involved in
all aspects of their design, implementation, and evaluation. Involvement must go beyond tokenism
and be genuine, meaningful, and sustained.
Make health services appealing to youth: A key to rapidly expanding young people’s access to
health services is to make them more youth friendly by using specially trained health workers and
by bolstering the privacy, confidentiality, and accessibility of care.
Address gender inequality: Gender inequalities expose young girls to coerced sex, HIV infection,
unwanted pregnancy, and poor nutrition. Efforts should focus on changing the factors that
perpetuate gender inequalities.
Address the needs of boys: Adolescence presents a unique opportunity to help boys form positive
notions of gender relations and to raise their awareness of health issues. At the same time, boys
seem to be disproportionately exposed to a number of adolescent health risks, including accidents
and injuries, suicide, tobacco use, substance abuse, and violence. Program design should take into
account the specific needs of boys and young men as well as of girls and young women.
Design comprehensive programs: Comprehensive programs that provide information and services
while addressing the social and political context are more effective than narrowly focused
interventions.
Consider all important benefits: Many adolescent health interventions focus on only one benefit.
For example, a school-based sex education program may focus exclusively on HIV prevention and
may neglect other possible benefits from the intervention, such as increased education, averted
teen pregnancy and abortions, and other averted STIs.
Address the many non-health factors that influence adolescent health: Linking school and livelihood
opportunities to adolescent health programs, at either the policy or the program level, is key to
helping young people avoid risky behaviors.
Address underlying risk and protective factors. Factors such as feelings of self-efficacy, attitudes and
behaviors of friends, connectedness with parents and other influential adults, and involvement in
the community can either increase (risk factor) or decrease (protective factor) the chances that a
young person will engage in unhealthy behaviors.
Source: Lule et al. (2006)
and behavioral disorders have been responsive to conclusively effective, particularly over the long
psychotherapy with a behavioral or cognitive- term (WHO 2002). Despite mental disorders
behavioral orientation. Early intervention for psy- being the single largest cause of burden of disease
chotic disorders in adolescents has also shown pro- in adolescents, countries have done relatively little
mise. However, there is insufficient evidence for the to address this problem. Few countries have
effectiveness of treatment for depression in adoles- adolescent-specific mental health policies, and
cents. Large-scale suicide prevention efforts show services for adolescents in developing countries
some promise, and drops in suicide rates among are almost non-existent. Wealthier countries offer
young people have occurred in countries with better mental health services, but care tailored to
national programs (Patel et al. 2007). However, adolescents is not always available (Patel et al.
very few suicide prevention efforts have proven 2007).
Interventions to Prevent Intentional Injury underway, but still lack evidence of effectiveness
(WHO 2002).
Table 24.11 shows strategies that proved effective in Most programs to address youth violence, in
reducing youth violence or risk factors for youth both developed and developing nations, are tar-
violence. At the individual level, social development geted toward managing the consequences of vio-
programs to reduce antisocial and aggressive beha- lence and supporting the victims. Countries have
vior have been found to be effective, beginning in neglected prevention efforts, in part because the
early childhood through adolescence. Such pro- public and policy makers have not seen violence as
grams that emphasize social and competency skills something preventable (Dahlberg and Krug 2006).
have been shown to be the most effective and are Moreover, much of the effort in youth violence
more effective the earlier they begin (that is, the prevention has gone toward untested programs
younger the age group) (WHO 2002). lacking a sound theoretical basis (WHO 2002).
Another set of interventions try to work on
improving relationships young people have with
parents, siblings, and peers. Home visitation by a
health-care professional and parenting training has
Interventions to Prevent Road Traffic
been shown to be effective in preventing later youth Injuries
violence if done when children are still small. Pro-
grams that pair adolescents with adult mentors Several interventions have proven effective in
who provide positive role models have been reducing adolescent deaths and injuries from
shown to be effective. Family therapy programs road crashes (WHO 2007d). Interventions that
that aim to improve parent–child communication have reduced speeding (which is a greater factor
and address problems of violence are also effective in crashes involving young drivers) include setting
(WHO 2002). Several types of interventions to and enforcing speed limits, traffic calming mea-
reduce youth violence have been tried and proven sures such as speed humps, and restrictions on
ineffective, including individual counseling, proba- alcohol consumption by youth behind the wheel
tion, or parole programs that include meetings with and on nighttime driving. Mandatory helmet
prison inmates describing the brutality of prison laws, free distribution of helmets, setting quality
life, programs modeled on basic military training, standards for helmets, and public awareness cam-
peer mediation or peer counseling, and gang pre- paigns to encourage helmet use have increased
vention programs. Many other approaches are helmet use for young motorcycle and bicycle
Table 24.11 Effective* youth violence prevention strategies by developmental stage and ecological context
Developmental stage
Ecological Infancy (ages Early childhood Middle childhood
context 0–3) (ages 3–5) (ages 6–11) Adolescence (ages 12–19)
Individual Social development Social development Social development programs
programs programs
Preschool Providing incentives for youths at high
enrichment risk for violence to complete
programs secondary schooling
Relationship Home visitation Mentoring programs
(e.g., family,
peers)
Training in Training in Family therapy
parenting parenting
*Demonstrated to be effective in reducing youth violence or risk factors for youth violence.
Source: WHO (2002)
riders, who are least likely to wear a helmet. cultural norms and fitting the program within those
Wearing a motorcycle helmet correctly can cut constructs; adhering to a social–ecological model of
the risk of death by almost 40% and the risk of behavior change; and taking a multifaceted
severe injury by 72%. Alcohol is a factor in a approach to include multiple stakeholders, includ-
high proportion of road accidents involving ado- ing health professionals, educators, and policy
lescents. Effective measures to reduce drinking makers (World Bank 2006a). Studies show that
and driving among adolescents include restriction efforts to prevent obesity are more likely to succeed
of alcohol use by adolescents and enforcement of among adolescents than among adults (Delisle et al.
stricter drinking and driving regulations. Gradu- 2001). Programs to encourage physical activity
ated driver licensing systems phase in young among schoolchildren are widespread and an
beginners to full driving privileges have been important source of physical activity for adoles-
shown to improve safety. Young drivers and pas- cents. There is some evidence that such programs
sengers are less likely to wear seat belts. Effective have helped keep obesity rates low in countries
strategies to encourage seat belt use include seat where such programs are widespread, such as
belt enforcement, ensuring that vehicles are fitted China (Willet et al. 2006).
with appropriate seat belts, public awareness Nutritional interventions in both developed
campaigns, and community projects involving and developing countries have traditionally
parents and peers. Several high-income countries neglected adolescents relative to other age groups.
have invested in successful, comprehensive, and The rising importance of diet-related chronic dis-
systematic programs to lower the burden from ease has begun to raise the profile of adolescent
road traffic injuries (Peden 2004). In developing malnutrition problems, but they still do not
countries, however, such systematic efforts are receive high priority. In developing countries,
almost universally absent, and investments in lack of financial and institutional capacity
reducing road traffic injuries among the general coupled with lack of appreciation of the impor-
population, including those that target adoles- tance of nutrition have hampered the ability to
cents, are extremely low (Norton et al. 2006). address adolescent nutrition problems (WHO
2005b; World Bank 2006a).
Interventions to Improve Nutrition, Diet,

and Physical Activity Interventions to Address Tobacco,
Alcohol, and Drug Use
To address anemia, a major problem among ado-
lescent girls in developing countries, daily iron sup- Price increases through taxation are a well-estab-
plementation for adolescent girls has been found to lished, effective tool for reducing or deterring
effectively reduce anemia and iron deficiency (Elder tobacco use by adolescents. Studies in the United
2002). Many high-income countries have success- States have shown that price increases have a
fully reduced diet and lifestyle-related chronic dis- greater effect on tobacco use by young people
eases rooted in adolescent behaviors and habits. than on use by older age groups (Jha et al.
Programs in developing countries are relatively 2006). Other interventions such as comprehensive
new and have yet to show changes in levels of bans on all advertising, including bans on the
chronic disease (Willett et al. 2006). Obesity preven- promotion of tobacco products and trademarks,
tion programs, many of them school-based and have also reduced tobacco use among young peo-
targeting the adolescent population, have shown ple (Jha et al. 2006). Another intervention that is
mixed results (World Bank 2006a). The key ele- effective in reducing youth smoking is compre-
ments of the successful interventions include having hensive restrictions on smoking in public spaces
an environmental and multidisciplinary approach; and private workplaces (Jha et al. 2006). Pro-
generating local adaptations of programs; exploring grams that give young people the skills to resist
peer pressure and other social pressures to smoke report, based on a review of 85 relatively rigor-
have demonstrated consistent and significant ous evaluation studies, divides 23 identified types
reductions or delays in adolescent smoking. of interventions into the following four groups
School-based programs are also more effective according to the strength of evidence of effec-
when combined with community-wide supportive tiveness, as summarized in Table 24.12:
efforts. Information campaigns that help young Interventions recommended for widespread
people see how the tobacco industry tries to implementation on a large scale (Go)
manipulate their behavior through advertising Interventions to be implemented more cautiously
have been highly effective in changing behavior along with careful evaluation of their impact on
and attitudes toward smoking among young peo- key health outcomes (Ready)
ple in the United States (American Legacy Foun- Interventions requiring further development and
dation 2002). With regard to use of alcohol and demonstration of effectiveness before they can be
other drugs, legal and regulatory restrictions on recommended for widespread implementation
minimum age, quantity, price, place, and time of (Steady)
sale have been shown to be effective in reducing And interventions that should not be implemen-
alcohol use. Some prevention programs that aim ted because there is sufficient evidence of their
to reduce the risk factors leading to substance lack of effectiveness (Do not go)
abuse have been shown to be effective, not, how-
ever, as short-term, stand-alone interventions. Programs with particularly strong evidence
There is also some evidence that early screening for effectiveness include curriculum-based sexu-
for drug problems followed by brief interventions ality and reproductive health education pro-
is effective. Harm reduction efforts, such as nee- grams in schools; clinic-based programs linked
dle exchange programs for intravenous drug with community interventions; and mass media
users, have been found to be effective in reducing efforts with messages delivered through radio,
some of the negative outcomes associated with television, and print media. Several other types
substance abuse, without affecting use one way of programs delivered promising results but still
or the other (Toumbourou and Stockwell 2007). lack convincing evidence on their effectiveness.
Despite the evidence supporting taxation to Although the focus of the UNAIDS review was
reduce tobacco use, relatively few countries have on HIV prevention, many of the behavioral out-
deployed such price increases. Only a few devel- comes studied are equally applicable to preven-
oped countries have implemented comprehensive tion of unwanted pregnancy and other key
programs that combine taxation with information reproductive health outcomes. These include
dissemination and comprehensive bans on adver- initiation of sex, number of sexual partners, use
tising. Political constraints and lack of awareness of condoms and other contraceptives, and use of
of intervention effectiveness have limited imple- other reproductive health services. The findings
mentation of programs in developing countries of the UNAIDS (2006) review are similar to
(Jha et al. 2006). those of the earlier FOCUS on Young Adults
(2001) review. Evidence from 70 rigorously eval-
uated programs in Canada and the United States
found evidence that a range of programs are
Interventions to Address Sexual and
effective in reducing sexual risk-taking, preg-
Reproductive Health, Including HIV/AIDS nancy, and childbearing among teens (Kirby
2001). Synthesis of developed and developing
The most recent major review of program effec- country studies (Kirby et al. 2006) found that
tiveness in this area is the 2006 report by the programs are particularly effective for adoles-
UNAIDS Inter-agency Task Team on Young cents who are at especially high risk of negative
People, Preventing HIV/AIDS in Young People: sexual and reproductive behaviors. Of all the
A Systematic Review of the Evidence from programs that have been rigorously evaluated,
Developing Countries (UNAIDS 2006). The none has reported a decrease in the age of sexual
Table 24.12 Recommendations on effectiveness of HIV prevention programs for young people
Setting Type of program
Go – Evidence threshold met
Schools Curriculum-based interventions with characteristics that have been found to be effective in
developed countries and are led by adults
Health services Interventions with service providers that include making changes to either the structure or
the functioning of the facilities themselves and are linked to interventions in the community
to promote the health services for young people
Mass media Interventions with messages delivered through the radio and other media (for example, print
media), except television
Interventions with messages delivered through the radio and television and other media (for
example, print media)
Ready – Evidence threshold
partially met
Health services Interventions with service providers and in health facilities and in the community that
involve other sectors
Geographically defined Interventions targeting youths using existing youth service organizations
communities
Young people most at risk Facility-based programs that also have outreach and provide information and services
Steady – Evidence threshold
not met
Schools Schools curriculum based with characteristics found to be effective in developed countries
and that are led by peers
Curriculum based without the characteristics found to be effective in developed countries
and that are led by adults
Curriculum based without the characteristics found to be effective in developed countries
and led by peers
Non-curriculum based without characteristics found to be effective in developed countries
and led by adults
Non-curriculum based without characteristics found to be effective in developed countries
and led by peers
Health services Interventions with service providers and in the community
Interventions with service providers and involving other sectors
Interventions with service providers and in facilities and involving other sectors
Interventions with service providers and in the community and involving other sectors
Mass media Radio only
Geographically defined Interventions targeting youths through new structures
communities
Interventions targeting the entire community through traditional networks
Interventions targeting the entire community through community events
Young people most at risk Outreach only interventions providing information and services
Source: UNAIDS IATT (2006)
debut or an increase in sexual activity among cancer. Public health officials are currently recom-
young people. This finding counters the criticism mending that all girls get the vaccine before they
that opponents of adolescent sexual and become sexually active, between 11 and 12 years
reproductive health programs often make, old, but as early as age 9. As yet, no country has
namely that programs hasten or increase sexual carried out widespread vaccination programs.
activity. Introduction of HPV vaccine in developing coun-
New research has shown the safety and effec- tries faces a range of policy challenges, including
tiveness of a vaccine to prevent human papillo- how to reach the target population of adolescents
mavirus (HPV), the major cause of cervical (WHO 2007c).
Another promising intervention is male cir- depending on the country, type of intervention,
cumcision for HIV prevention, which has been target group, and so on. For example, such pro-
shown to cut risk of HIV transmission by more grams cost between US $0.03 per adolescent
than half in males (Newell and Bärnighausen reached in a family life education radio program
2007). Based on these and other studies, experts in Kenya and US $71.00 per year per adolescent
convened by WHO and UNAIDS in March 2007 reached in a school-based HIV prevention pro-
recommended including male circumcision as an gram in Zimbabwe. Only a few programs have
additional HIV prevention intervention, one for documented their cost-effectiveness in terms
which adolescents and young men are likely to of DALYs. Cost–benefit analysis, which allows
be prime candidates (WHO and UNAIDS 2007). comparison across a range of interventions
Sexual and reproductive health interventions for inside and outside the health sector, has
adolescents are among the most widespread of been done for a few interventions (Table
adolescent health programs. However, few of 24.13). These studies show that health interven-
these interventions have been large scale, most tions aimed at adolescents have the potential to
being small, short-term programs carried out by be good public investments (Lule et al. 2006;
nongovernmental organizations (Lule et al. Knowles and Behrman 2003).
2006). Despite the disparities in health outcomes
for the youngest pregnant mothers, maternal and
newborn health programs have done relatively
little to focus their efforts on pregnant women
in the 10–19 age group (WHO and UNFPA
Table 24.13 Estimated benefit–cost ratios, selected invest-
2006a). HIV prevention programs for adoles- ments in youth
cents increased greatly in scope over the past Estimated benefit– Plausible
decade, but they still reach only a small group cost ratio range of
of adolescents (UNAIDS 2006). Levels of HIV/ (assuming 3% estimated
AIDS education in schools have increased, but annual discount benefit–cost
Investment rate) ratio
still less than half of school children receive such
Scholarship 4.4 2.8–25.6
education, and quality is low in many schools program
(UNAIDS 2006). Even though about half of (Colombia)
orphans under 18 are adolescents aged 12–17, Adult basic 27.6 8.1–1,764.0
programs (including reproductive health-care education and
literacy program
programs) typically do not focus on the needs (Colombia)
of this older age group (Ruland et al. 2005). School-based 0.5 0.1–4.6
Countries are increasingly enacting specific reproductive
national adolescent health policies or health program
addressing adolescent health concerns within to prevent HIV/
AIDS
national policies on key health issues but many (Honduras)
countries have yet to sufficiently carry out such Iron 45.2 25.8–45.2
policies. supplementation
administered to
secondary
schoolchildren
(hypothetical
low-income
Cost, Cost-Effectiveness, and Cost–Benefit country)
of Interventions Tobacco tax 20.2 7.0–38.6
(hypothetical
middle-income
Good cost studies of adolescent health programs country)
are rare, even in developed countries. The Source: Lule et al. (2006)
reported cost of such programs varies greatly
Conclusions potential synergies between HIV/AIDS and repro-

ductive health programming and in the need to
Adolescence has its own unique health problems, with improve effectiveness. For example, in low-HIV pre-
a disease profile that is different from small children valence countries, reproductive health programs
and older adults. Although, relatively speaking, 10–19 could be the entry point to increase HIV prevention
years is the healthiest time of life, the adolescent years and in high-prevalence countries, HIV programs
are still a time of significant disease burden. Moreover, could be the entry point to address reproductive
a large portion of the disease burden in adulthood has health concerns. There is simply not enough human
its roots in adolescent behaviors or conditions. The resource capacity (particularly in developing coun-
health problems of adolescence are inter-related, shar- tries) to address each adolescent health problem with
ing many of the risk and protective factors that influ- separate, vertical programs. In addition, adolescent
ence adolescent behavior and health conditions. These health programs need to be better integrated with
linkages provide opportunities for programs to have approaches outside the health sector, such as educa-
multiple positive impacts but also complicate the tion, which also affect health outcomes.
design of interventions to improve adolescent health. As is the case with other age groups, poor and
Countries have tried a variety of approaches to disadvantaged adolescents suffer disproportio-
improve adolescent health, some of which have proved nately from health problems (Lule et al. 2006).
effective, although generally only modestly (National Reaching these poor and hard to reach adolescents
Research Council and Institute of Medicine 2005). is another key programmatic need, one in which
The evidence base for what works is growing but still coordinated action is needed to keep adolescents
insufficient. Partly from lack of information about in school, give them the skills they need to compete
effective interventions and partly because of the per- in the workforce, and encourage them to become
ception that many of the health problems of adoles- active citizens (World Bank 2006b). Programs also
cents are ‘‘normal’’ and thus not preventable, countries need to do a better job of involving influential gate-
have been slow to recognize the importance of the keepers such as parents, teachers, employers,
burden of disease in adolescence. As a result, almost administrators, and community leaders, who have
everywhere, the health system response to adolescent significant sway over adolescent behavior and over
health problems has been inadequate. This is particu- the programs to be implemented.
larly so in developing countries. To achieve improvements in sexual and repro-
ductive health and HIV prevention, more attention
is needed to support marriage delays, address gen-
der inequalities, serve married adolescents, and
Policy and Programmatic Needs scale up efforts to serve adolescent males. Finally,
it is important for policy makers to recognize that
A key message that emerges from the evidence on each adolescent experiences the transition to adult-
risk and protective factors and on program effective- hood differently. Policies and programs should
ness is the need to move toward a more integrated focus less on age and more on recognizing the spe-
approach to addressing adolescent health problems. cific health and developmental needs of people as
Within each disease area, no single strategy is effec- they navigate the passage from childhood to
tive by itself. Comprehensive approaches to road adulthood.
safety, sexual and reproductive health, and violence
prevention that use multiple, concurrent strategies
are likely to be most effective in addressing adoles-
cent health problems. Moreover, adolescent health Monitoring and Research Needs
programming needs to reach across disease areas to
take advantage of the natural synergies and shared Better monitoring and research on adolescent
risks and protective factors, while also taking advan- health problems and interventions is urgently
tage of the existing infrastructure and health sys- needed to inform policy makers, including the
tems. Nowhere is this more apparent than in the following:
Collecting basic data on adolescent health: Our workers, refugees, AIDS orphans, and street
knowledge is still sparse on many basic facts children. More research is also needed on a
about adolescent health, including about the broad range of other adolescent health inter-
cause of death and burden of disease in the ventions, especially for those health problems
adolescent age group. Although information that are among the biggest killers and dis-
sources are improving, especially in the area of ablers of young people: HIV/AIDS and men-
sexual and reproductive health including tal illnesses for both males and females, mater-
HIV/AIDS, many gaps remain, particularly nal conditions for females, and road traffic
around some of the most important health injuries for males. In addition, research is
problems of adolescence such as mental ill- needed on programs that attempt to influence
ness, road injuries, and violence. Many coun- gender roles and social norms and investments
tries have incomplete or non-existent data on designed to avert drug and alcohol abuse and
adolescent health problems. Improved meth- to improve mental health. Program imple-
ods for collecting and analyzing data are mentation studies are urgently needed to
needed. examine the best way to roll out promising
Documenting the effectiveness of approaches: new prevention strategies including male cir-
There are still more questions than answers cumcision for HIV prevention and the HPV
about the effectiveness of the various adoles- vaccine. More study is also needed to examine
cent health interventions. Along with better how to integrate prevention and treatment of
process evaluation to understand the func- gender-based violence into adolescent health
tioning of successful programs, program eva- programming.
luation necessitates more rigorous research Enhancing understanding of the risk and protec-
designs including random assignment of treat- tive factors influencing adolescent behavior:
ment so that the effectiveness of programs can Even though our understanding of the
be better documented, both in terms of health major influences on youth behaviors has
outcomes and in terms of disease burden. come far, more refinement of such under-
Research could also help better document standing is needed, along with a better
the non-health effects of adolescent health understanding of how to incorporate such
interventions. knowledge into the design of programs and
Testing new interventions: A high priority is more policies.
research on multi-component programs and Improving cost, cost-effectiveness, and cost–bene-
on new types of interventions. One promising fit analysis: Particularly as programs move
area of research is the impact of targeted sub- from small pilot projects to large-scale inter-
sidies to keep adolescents in school and in ventions, more needs to be done to more fully
using such subsidies to improve adolescent estimate their cost-effectiveness and cost–
health behaviors (World Bank 2006b). In rela- benefit.
tion to sexual and reproductive health, new
interventions include approaches such as pro-
viding antiretroviral therapy to HIV-infected
youth and voluntary counseling and testing The Way Forward
for HIV, encouraging adolescents to have
fewer sexual partners, reducing the trafficking Global commitment to meeting adolescent health
of young people, preventing and addressing needs has never been higher. The 1994 International
the health consequences of early marriage, Conference on Population and Development (Uni-
and reaching young married women with ted Nations 1994) and the 2001 UN Special Session
information and services. Research must bet- on AIDS (United Nations 2001) affirmed the rights
ter inform interventions so that they reach of young people to high-quality sexual and repro-
groups at particularly high risk of poor health ductive health information and services. Similarly,
outcomes, such as child prostitutes, child the Framework Convention on Tobacco Control
(WHO 2003) prioritizes the youth dimension of the interventions. The more countries know about what
smoking epidemic. Now, countries need to translate works, the better the choices adolescents will make –
this commitment into national policies and pro- or that will be made for them. These are the choices
grams. Doing so requires building on and expand- that will ultimately shape their lives, the welfare of
ing the evidence base on effective and cost-effective their families, and the future of their communities.
Key Terms
Adolescence Homicide School factors

Adolescent behaviors Human papilloma virus (HPV) Self-control
Adolescent childbearing Intentional injuries Self-efficacy
Adolescent health Iron deficiency anemia Self-inflicted injuries
Adolescent orphans Male circumcision Sexual abuse
Alcohol use disorder Malnutrition Social development programs
Bipolar disorder Mandatory helmet laws Substance abuse
Community factors Overweight Suicide
Condom Parental expectations Teen pregnancy
Demographic transition Parenting training Tobacco use
Depression Peer pressure Unintentional injuries
Family factors Psychological factors Unsafe abortion
Family life education Reproductive health Unsafe sex
Gender-based violence (GBV) Road traffic injuries
HIV prevention programs Schizophrenia
Questions for Discussion a. Malnutrition

b. Mental disorders
c. Road traffic accidents
1. Define the term adolescence. Why should national
d. Substance abuse
governments and international health agencies be
e. Sexual and reproductive health problems
concerned about adolescent health issues?
(including HIV/AIDS/STIs)
2. In a narrative of about 1,000 words, describe
factors that increase (risk factors) or decrease 6. What measures would you recommend as prio-
(protective factors) an adolescent’s chance of rities for improving the health of adolescents in
involvement in unhealthy behaviors. Present developing countries?
your description from the perspectives of the
individual, family, institutional, and community.
3. List the major causes of morbidity and mortality
among adolescents. How does the prevalence of References
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Chapter 25
The Global Burden of Child Maltreatment
Andrea Gottsegen Asnes and John M. Leventhal
Learning Objectives After reading this chapter and presents an overview of the global problem of child
answering the discussion questions that follow, you maltreatment. The chapter begins with an examina-
should be able to tion of the challenges in building a consensus on a
universal operational definition of child maltreat-
Identify types of child maltreatment and discuss
ment. Types of childhood maltreatment and the
the scope of the problem from a global
scope of the problem are analyzed from a global
perspective.
perspective. The health and economic consequences
Discuss the challenges of establishing a univer-
of the problem are reviewed as are the concomitant
sally acceptable operational definition of child
risk factors, including child factors, parental fac-
maltreatment.
tors, family factors, and societal factors. The chap-
Analyze risk factors for child maltreatment,
ter concludes with an appraisal of strategies for
including those that relate to the child, parents,
prevention, highlighting action at (i) the societal
family, and society.
and community level (e.g., promotion of social,
Evaluate measures for prevention of child mal-
economic, and cultural rights; reducing income
treatment at the individual child level, parent–
and gender inequalities; and eradicating cultural
child relationship level, community and societal
acceptance of violent or exploitative behavior
levels.
toward children); (ii) the relationship level (e.g.,
early and frequent home visiting by trained provi-
ders who are able to establish a relationship with the
parent(s) and teach effective parenting, and (iii) the
Introduction
individual level (e.g., education of children about
how to avoid unsafe situations and protect them-
Physical and emotional maltreatment, sexual abuse,
selves when confronted with threatening situations.
neglect and negligent treatment of children, as well
This strategy may be most useful in the prevention
as their commercial and other exploitation consti-
of child sexual abuse).
tute a health challenge that is prevalent in all parts
Child maltreatment, including physical, sexual,
of the world. While deaths associated with child
and emotional abuse, neglect, and exploitation,
maltreatment represent only the tip of iceberg, mil-
occurs every day and in every corner of the world.
lions of children are victims of non-fatal abuse and
Although repeatedly documented in various forms
neglect. Ill-health associated with child abuse con-
throughout history, child abuse was not recog-
tributes significantly to the global burden of dis-
nized as a distinct public health problem until the
eases among children and increases their predispo-
early 1960s. In 1962, a landmark article entitled
sition to serious illnesses in adulthood. This chapter
‘‘The Battered Child Syndrome’’ was published in
the United States (Kempe et al. 1962). Although
previously published scholarly works had
A.G. Asnes (*)
Yale University School of Medicine, New Haven, addressed inflicted injuries in children, this article
Connecticut, USA (Kempe et al. 1962) was the first to estimate the
464 A.G. Asnes and J.M. Leventhal
incidence of child abuse and to identify the key In 1999, the World Health Organization con-
characteristics of children who were physically vened a group of experts on child maltreatment
abused. Notably, this publication led to public pol- that arrived at the following definition: ‘‘Child
icy in the form of the adoption of a set of laws that abuse or maltreatment constitutes all forms of phy-
mandate the report of child abuse in the United sical and/or emotional ill-treatment, sexual abuse,
States. In addition, this milestone ignited interna- neglect or negligent treatment or commercial or
tional interest in child maltreatment that recently other exploitation, resulting in actual or potential
culminated in the publication of both the United harm to the child’s health, survival, development, or
Nations Secretary-General’s Study on Violence dignity in the context of a relationship of responsi-
Against Children (United Nations 2005) and a guide bility, trust or power’’ (WHO 1999). Awareness of
to the prevention of child maltreatment jointly pub- differences between developed and developing
lished by the World Health Organization (WHO nations, as well as circumstances present in con-
2006b) and the International Society for Prevention flict-ridden nations, is reflected in the fact that the
of Child Abuse and Neglect (ISPCAN). WHO preceded this definition with the following
Defining child maltreatment in an international ‘‘preamble’’: ‘‘Background or baseline conditions
framework presents challenges not least because of beyond the control of families or caretakers, such
the difficulties in distinguishing between what con- as poverty, inaccessible healthcare, inadequate
stitutes discipline or punishment (Box 25.1) across nutrition, unavailability of education can be contri-
cultures, and even among individual families in the buting factors to child abuse. Social upheaval and
same culture. instability, conflict and war may also contribute to
increases in child abuse and neglect’’ (WHO 1999)
It is notable that prominent recent efforts to
address child maltreatment on an international
Box 25.1 Discipline or Punishment? level have focused on defining child maltreatment
itself as a primary goal. A unified definition of child
Discipline involves training and developing a maltreatment is widely believed to be crucial to
child’s judgment, boundaries, self-control, international attempts to address and eradicate
social conduct, and self-sufficiency. This can child abuse. It is thought that until such a definition
be confused with punishment. Corporal pun- can be identified, participation in eradication efforts
ishment is often inappropriately used in an by countries in which some abusive behaviors
attempt to correct and change a child’s beha- toward children are thought to be appropriate will
vior. The differences between discipline and be sorely limited. Cultural and regional variations
punishment are numerous. A child’s indivi- in the definition of child abuse and neglect are
dual worth should be recognized in positive reflected in the responses to a questionnaire devel-
strategies of discipline. These strategies aim to oped by ISPCAN. The questionnaire addressed
‘‘strengthen children’s belief in themselves and major behaviors included in a country’s perception
their ability to behave appropriately and to of child maltreatment, the extent of professional
build positive relationships’’ and should be response to maltreatment, the scope and availability
thought out and intended to encourage a of interventions to address maltreatment, the pub-
child to understand the expectations of their lic’s awareness of the child abuse problem, major
behavior. However, in punishment a care- barriers to improving the response to maltreatment,
giver’s anger and desperation is often reflected and strengths and strategies in preventing maltreat-
in the physical and/or emotional punishment ment. Active ISPCAN members with access to
of a child. This punishment uses external con- national perspectives and data were invited to
trols, involves power and dominance, and is respond to the survey. Although every country
frequently not tailored to the child’s age and/ that responded to the questionnaire in 2006
or developmental level. (N=72) agreed that physical and sexual abuse by
Source: World Health Organization (1999) a parent or caretaker should be considered child
abuse, significant variation was noted with respect
25 The Global Burden of Child Maltreatment 465
to specific behaviors, such as the failure to secure value presents enormous difficulty. Of the 72 coun-
medical treatment based on religious beliefs, cor- tries that responded to the questionnaire developed
poral punishment, or female circumcision (Daroh by ISPCAN, only 48.6% of all respondents
2006). reported that corporal punishment is considered
Practices and beliefs regarding corporal punish- abusive in their country (WHO 1999). That over
ment provide a good example of the importance of one-half of those countries who participated in the
defining what constitutes abusive behavior as survey consider corporal punishment in the home to
opposed to acceptable parenting practice and why be an acceptable child-rearing practice highlights
a clear definition of child maltreatment is impor- the degree to which such a behavior can be
tant. Corporal punishment is common and socially ingrained in the culture of a society. The World
acceptable in many societies throughout the world. Health Organization’s definition of child maltreat-
The United Nations Secretary-General’s Study on ment includes five basic categories of child abuse:
Violence Against Children estimates that between physical abuse, sexual abuse, emotional abuse,
80 and 98% of children worldwide suffer corporal neglect, and exploitation. Each category requires
punishment in their homes and that a third or more further definition and will be considered separately.
of these children are severely punished using imple- Fig. 25.1 depicts the typology of violence. Although
ments (United Nations 2005). In the past, an unwill- this typology reflects all kinds of interpersonal vio-
Fig. 25.1 A typology of violence. Source: WHO (2006)
ingness to overstep cultural boundaries in defining lence, this chapter focuses on one aspect of this
such practice as abusive has limited the evolution of typology – that related to child abuse.
a global definition of physical abuse. The United
Nations Secretary-General’s Study addresses and
attempts to dismiss the possibility of an accepted
tradition of violence toward children by stating, Physical Abuse
‘‘the study should mark a turning point – an end to
adult justification of violence against children, Box 25.2 presents an overview of some of the com-
whether accepted as ‘tradition’ or disguised as ‘dis- mon manifestations of child abuse and neglect. A
cipline’ ’’ (United Nations 2005). While the physically abused child can broadly be defined as
advancement of a universal definition of child ‘‘any child who receives a non-accidental physical
abuse is valuable, changing behavior in commu- injury as a result of acts . . . on the part of his parents
nities where this practice is a deeply felt cultural or guardians’’ (Kempe and Helfer 1972). Some
Box 25.2 Common Manifestations of Child Abuse and Neglect
Manifestations of child abuse and neglect: Injuries inflicted by a caregiver on a child can take many
forms. Serious damage or death in abused children is most often the consequence of a head injury or
injury to the internal organs. Head trauma as a result of abuse is the most common cause of death in
young children, with children in the first 2 years of life being the most vulnerable. Because force
applied to the body passes through the skin, patterns of injury to the skin can provide clear signs of
abuse. The skeletal manifestations of abuse include multiple fractures at different stages of healing,
fractures of bones that are very rarely broken under normal circumstances, and characteristic
fractures of the ribs and long bones.
The shaken infant: Shaking is a prevalent form of abuse seen in very young children. The majority
of shaken children are less than 9 months old. Most perpetrators of such abuse are male, though this
may be more a reflection of the fact that men, being on average stronger than women, tend to apply
greater force, rather than that they are more prone than women to shake children. Intracranial
hemorrhages, retinal hemorrhages, and small ‘‘chip’’ fractures at the major joints of the child’s
extremities can result from very rapid shaking of an infant. They can also follow from a combination
of shaking and the head hitting a surface. There is evidence that about one-third of severely shaken
infants die and that the majority of the survivors suffer long-term consequences such as mental
retardation, cerebral palsy, or blindness.
The battered child: One of the syndromes of child abuse is the ‘‘battered child.’’ This term is
generally applied to children showing repeated and devastating injury to the skin, skeletal system, or
nervous system. It includes children with multiple fractures of different ages, head trauma, and
severe visceral trauma, with evidence of repeated infliction. Fortunately, though the cases are tragic,
this pattern is rare.
Sexual abuse
Children may be brought to professional attention because of physical or behavioral concerns
that, on further investigation, turn out to result from sexual abuse. It is not uncommon for children
who have been sexually abused to exhibit symptoms of infection, genital injury, abdominal pain,
constipation, chronic or recurrent urinary tract infections, or behavioral problems. To be able to
detect child sexual abuse requires a high index of suspicion and familiarity with the verbal, beha-
vioral, and physical indicators of abuse. Many children will disclose abuse to caregivers or others
spontaneously, though there may also be indirect physical or behavioral signs.
Neglect: There exist many manifestations of child neglect, including non-compliance with health-
care recommendations, failure to seek appropriate health care, deprivation of food resulting in
hunger, and the failure of a child physically to thrive. Other causes for concern include the exposure
of children to drugs and inadequate protection from environmental dangers. In addition, abandon-
ment, inadequate supervision, poor hygiene, and being deprived of an education have all been
considered as evidence of neglect.
Source: Krug et al. (2002)
define physical abuse as ‘‘physical injury (ranging regardless of whether the caretaker intended to hurt
from minor bruises to severe fractures or death) as a the child’’ (Child Welfare Information Gateway
result of punching, beating, kicking, biting, shaking, 2006).
throwing, stabbing, choking, hitting (with a hand, Another definition suggests that a child need not
stick, strap, or other object), burning, or otherwise sustain an actual injury to be seen as physically
harming a child. Such injury is considered abuse abused. The World Health Organization contends
that physical abuse is defined as ‘‘the intentional use sexual abuse toward a child may be more severe
of physical force against a child that results in – or than the physical aspect and, certainly, more long
has a high likelihood of resulting in – harm for the lasting. By itself, emotional abuse leaves no physical
child’s health, survival, development or dignity’’ evidence and can be difficult for a child to disclose
(WHO 2006). to others. When emotionally abusive behavior is
normalized within a family, an understanding that
the behavior is not appropriate may elude a child.
Unlike children who are physically abused and may
Sexual Abuse have physical evidence of abuse, emotionally
abused children may offer few clues that they are
At its broadest level, sexual abuse can be defined as ill-treated at home. For this reason it is thought that
‘‘the involvement of dependent, developmentally emotional abuse may be the most underreported
immature children and adolescents in sexual activ- form of child maltreatment.
ities that they do not fully comprehend, to which they
are unable to give informed consent, or that violate
the social taboos of family roles’’ (Kempe 1978).
More simply, sexual abuse can be understood as Neglect
any sexual contact between an adult and a minor or
between two minors when one uses power over the Child neglect is best defined in terms of the basic
other. Sexual abuse can take many forms. These can needs of children. Some needs are material and
include rape, fondling, exhibition, voyeurism, expo- include adequate food, shelter, and clothing. Also
sure to pornography, and communicating in a sexual vital are children’s needs for education and medical
manner either directly or by mail, phone, or Internet. care. Less tangible are children’s needs for love,
nurturance, guidance, supervision, and protection.
If one imagines the provision of each of these needs
along a spectrum, it is easy to imagine the absolute
Emotional Abuse absence and absolute presence of each. Difficulties
arise toward the middle, where deciding what con-
Emotional abuse can be defined as ‘‘a pattern of stitutes actual neglect becomes debatable. The term
behavior that impairs a child’s emotional develop- neglect implies a failure on the part of caretakers to
ment or sense of self-worth. This may include con- provide adequately for their children. Clearly, pov-
stant criticism, threats, or rejection’’ (Child Welfare erty and/or lack of education can result in neglectful
Information Gateway 2006). Emotional abuse, or conditions for a child. Well-meaning and loving
psychological maltreatment, can be seen as distinct parents who are significantly impoverished may be
from emotional neglect, as in the withholding of unable to provide for even the most basic of their
love, support, or guidance from a child. Emotional children’s needs. Societal and environmental factors
abuse has been defined as a repeated pattern of must be taken into account when assessing indivi-
damaging interaction between parent(s) and child dual cases of neglect.
that becomes typical of a relationship. This form of
interaction conveys to a child that he or she is
‘‘worthless, flawed, unloved, unwanted, endan-
gered, or only of value in meeting another’s needs’’ Exploitation
(Kairys and Johnson 2002). Behaviors that transmit
these messages include spurning, terrorizing, ignor- The exploitation of a child refers to the use of the
ing, rejecting, and isolating children, as well as pro- child in work or other activities for the benefit of
viding inconsistent parenting or exposing children others. Examples of the exploitation of children are
to intimate partner violence. Emotional abuse is a child labor and commercial sexual exploitation of
critical component of all other forms of child abuse, children, as well as child trafficking. Child labor is
and the emotional impact of physical violence or more challenging to define because children may be
employed in safe and age-appropriate positions that approach is to review child fatality records, but
do not by definition infringe on their other basic the reported numbers of fatally abused children
needs. Exploitative child labor has been defined by in a given time period is likely to be small, and
UNICEF as ‘‘children. . .doing things that are numbers are likely to underestimate the phenom-
harmful to their healthy development [such as] enon of child homicides.
laboring long hours, sacrificing time and energy Another strategy used to collect data on child
that they might have spent at school or at home, maltreatment is the use of interviews of parents
enjoying the free and formative experience of child- about how they care for their own children. For
hood’’ (UNICEF 2006). Commercial sexual exploi- example, in a cross-national collaborative study,
tation of children can be defined as ‘‘children enga- investigators in Chile, Egypt, India, and the
ging in sexual activities for money, profit, or any Philippines queried mothers between 1997 and
other consideration due to coercion or influence by 2003 about discipline practices. During the 6
any adult, syndicate or group’’ (UNICEF 2006). months prior to being asked, mothers reported
Children may be directly forced to labor or engage that they hit a child with an object not on the
in sexual activities by adults in order to earn money. buttocks at incidence rates between 4 and 36%. In
They may also be indirectly driven to such activities Egypt, beating a child within the last 6 months
to survive if they have left otherwise abusive or reportedly occurred at a rate of 25%, while in
neglectful conditions at home and are living on the rural India, 10% of mothers reported kicking a
streets. child (Krug et al. 2002). Adults also may be inter-
viewed about how they were cared for when they
were children. This approach can provide an esti-
mate of the prevalence of the problem. In a random
The Worldwide Scope of Child Abuse survey of 2,869 young adults conducted in the Uni-
and Neglect ted Kingdom in 1998 and 1999, 16% of the respon-
dents reported that they had experienced some form
Reliable, international statistics for child abuse of child maltreatment. Serious maltreatment was
and neglect are not available. Definitional varia- experienced by 7% of respondents for physical
tions in child maltreatment contribute to the dif- abuse, 6% for emotional abuse, 6% for absence of
ficulty of accumulating reliable data, as does the care, 5% for absence of supervision, and 11% of
variation in the record keeping policies and prac- respondents reported sexual abuse involving con-
tices between different nations. Recent attempts tact (May-Chahal and Cawson 2005). Studies of
to focus worldwide attention on the problem of this kind may both underestimate and overestimate
child maltreatment share a primary goal of more the true prevalence levels of child abuse and neglect.
systematic collection of data on child abuse Maltreatment occurring during childhood has been
throughout the world. Data on child maltreat- found to be underreported in some studies, and
ment can be collected in several ways, each with adults may not clearly remember events that took
advantages and disadvantages. One strategy to place when they were 5 years old or younger
collect information is to examine official reports (Fergusson et al. 2000). Given that most serious
from child protective services, if they exist, or physical abuse occurs in children 3 years old and
from law enforcement agencies who investigate younger, adults recalling their own childhoods may
crimes against children. These data, while impor- be likely to underestimate their abuse histories. On
tant, are likely to underestimate actual numbers the other hand, reporting adults may exaggerate
of maltreated children because they represent what happened to them as children, and no objec-
only cases that have been reported or otherwise tive data are available to verify an individual’s
come to attention of local officials. Furthermore, report.
in countries where physical punishment is not The United Nations Secretary-General’s Study
considered to be child abuse, cases of children on Violence against Children highlights some
physically harmed by parents in the name of dis- early efforts to quantify the problem of child
cipline are not likely to be tabulated. Another abuse and neglect throughout the world. The
study notes that the World Health Organization as maltreatment is likely to consistently under-
has used only those data collected by countries count the extent of the phenomenon. Physical
themselves to estimate that approximately 53,000 abuse, for example, in most countries in the
children died worldwide as a result of homicide world, exists at one end of a spectrum with phy-
in 2002 (United Nations 2005). Younger children sical punishment at the other end. As noted by
are killed at significantly higher rates throughout the UN secretary general, when societies condone
the world than are older children. WHO esti- any form of violence against children, drawing a
mates that children younger than 5 years old line between acceptable violence and abusive vio-
are killed at twice the rate of children 5–14 lence presents a sometimes insurmountable chal-
years old. Rates of child fatalities from abuse lenge. The subject may fall irretrievably under the
also vary according to the economic status of category of ‘‘private’’ behavior and, therefore, be
the country or region analyzed. The lowest unavailable for public scrutiny. If, for example,
rates are found in high-income countries, and corporal punishment is seen as acceptable within
the highest rates are found in the poorest a culture, setting a standard for what constitutes
regions. In the WHO Africa Region, 17.9/ excessive physical punishment may not be possi-
100,000 boys under the age of 5 years and ble. A behavior similar to corporal punishment,
12.7/100,000 girls under the age of 5 years were in that it is seen as an acceptable practice in some
killed (Krug et al. 2002). In contrast, in the countries and cultures, is that of female ‘‘circum-
United States, child homicides occurred at a cision.’’ UNICEF estimates that in sub-Saharan
rate of 2.04/100,000 children in 2006. Based on Africa, Egypt, and the Sudan, 3 million girls and
data from 39 states, more than three-quarters women are subjected to genital cutting/mutilation
(78.0%) of children who were killed every year (Ezzati et al. 2004).
were younger than 4 years of age. Infant boys The WHO estimates that 150 million girls and 73
(younger than 1 year) had a fatality rate of 18.5 million boys under the age of 18 years experienced
deaths per 100,000 boys of the same age, and forced sexual intercourse or other forms of sexual
infant girls had a fatality rate of 14.7 per violence during 2002 (UNICEF 2005). Given that
100,000 girls of the same age (U.S. Department sexual abuse of children is often intra-familial and
of Health and Human Services 2007). carries social stigma worldwide, it is likely that any
However, the number of fatally abused chil- approximation of its incidence is a significant
dren in a given time period is likely to be under- underestimate. A different approach to understand-
estimated. Variation in the degree to which child ing the extent of the problem is to study its preva-
deaths are investigated or even reported contri- lence by asking adults about their childhood experi-
butes significantly to this problem. Undercount- ences of sexual abuse. Such studies have been
ing is a significant problem in developed countries conducted in a variety of countries and cultures,
as well. For example, a study done in the United and similar prevalence rates have been determined
States retrospectively analyzed medical examiner (Vogeltanz et al. 1999). A review of 19 studies of
data from one state over a 10-year period and adults completed in the United States or Canada
found that the state’s vital records system under- found that the rates of sexual abuse reported by men
recorded the coding of child deaths due to batter- were 3–16% and by women 3–62%. The review
ing or abuse by 58.7% (Herman-Giddens et al. determined that a summary statistic for women of
1999). Documenting the numbers of nonfatally 20% would be reasonable (Finkelhor 1994). A pro-
abused children throughout the world is ject in Turkey (Alikasifoglu et al. 2006) used a cross-
significantly more difficult than that of fatally sectional design in a random sample of high school
abused children. In the United States in 2006, girls to determine that 13.4% of the girls in the
an estimated 905,000 children were found to be sample reported some form of sexual abuse in child-
victims of maltreatment in the 52 states (Admin- hood, and a study of adult women interviewed in El
istration for Children and Families 2008). Not Salvador found that 17% reported a childhood
only are these data not routinely collected experience of sexual abuse (Barthauer and
throughout the world, but what is documented Leventhal 1999).
The International Labor Organization estimated Consequences of Child Abuse

in 2002 that 218 million children worldwide could and Neglect
be classified as ‘‘child laborers’’ (International
Labor Organization 2002b). Child laborers are a Health Consequences and Mortality
subgroup of those children engaged in ‘‘economic
activity.’’ Child laborers exclude those children at The immediate health consequences of child
least 12 years old who work for a few hours a week abuse are multiple. Table 25.1 presents an over-
in light work activities and those children at least 15 view of the consequences of child abuse and
years old whose work is not classified as ‘‘hazar- neglect. Infants who survive abusive head trauma
dous.’’ ‘‘Hazardous work’’ is defined as any activity have extremely high rates of brain damage and
or occupation that ‘‘has or leads to adverse effects subsequent neurological disability, including
on the child’s safety, health (physical or mental) and blindness, seizure disorders, mental retardation,
moral development.’’ In 2004, the International and paralysis. Even infants who have survived
Labor Organization estimated that 126 million chil- abusive head trauma without major neurological
dren were engaged in hazardous work (Child Labor
Coalition). A sub-classification of hazardous work Table 25.1 Consequences of child abuse and neglect
has been designated by the International Labor Physical
Organization as ‘‘unconditional worst forms of Abdominal/thoracic injuries
Brain injuries
child labor.’’ These include
Bruises and welts
a) ‘‘all forms of slavery or practices similar to slav- Burns and scalds
Central nervous system injuries
ery, such as the sale or trafficking of children, Disability
debt bondage and serfdom and forced or com- Fractures
pulsory labor, including forced or compulsory Lacerations and abrasions
recruitment of children for use in armed combat; Ocular damage
Sexual and reproductive
b) the use, procuring or offering a child for prosti- Reproductive health problems
tution, for the production of pornography, or Sexual dysfunction
for pornographic performances; Sexually transmitted diseases, including HIV/AIDS
c) the use, procuring or offering a child for illicit Unwanted pregnancy
Psychological and behavioral
activities, in particular for the production or Alcohol and drug abuse
trafficking of drugs as defined in the relative Cognitive impairment
international treaties . . .’’ (International Labor Delinquent, violent, and other risk-taking behaviors
Organization 2006a). Depression and anxiety
Developmental delays
The International Labor Organization esti- Eating and sleep disorders
Feelings of shame and guilt
mated that in 2000, 5.7 million children were in
Hyperactivity
forced or bonded labor, 1.8 million children were Poor relationships
engaged in prostitution or pornography, and Poor school performance
1.2 million children were victims of trafficking Poor self-esteem
Post-traumatic stress disorder
(International Labor Organization 2002). As
Psychosomatic disorders
striking as these statistics are, they are likely to Suicidal behavior and self-harm
under-represent the full extent of the global bur- Other longer-term health consequences
den of child maltreatment. Infrastructures for Cancer
Chronic lung disease
tracking child abuse vary enormously; even in
Fibromyalgia
developed countries with sophisticated data col- Irritable bowel syndrome
lection systems, many cases of child maltreatment Ischemic heart disease
go unreported, and in countries where no such Liver disease
Reproductive health problems such as infertility
infrastructure exists, the quantification of child
abuse becomes extremely difficult. Source: Krug et al. (2002)
deficit may go on to manifest high rates of cog- adult had as a child, the more likely that adult is to
nitive and behavioral dysfunction as they age. have heart disease, cancer, stroke, diabetes, skeletal
Inflicted burns can result in disfiguring scars fractures, liver disease, and generally poor health
and restriction of mobility if the skin over moving (Felitti et al. 1998). The evidence concerning the
joints is involved. Long bone fractures that are links between child maltreatment, high-risk beha-
not properly cared for may result in permanent viors, poor mental health, and poor physical health
physical disability. Children who are sexually suggests a complex interplay between each of these
abused can contract sexually transmitted infec- factors.
tions that may impair future fertility or be in
and of themselves life threatening, as in the case
of HIV/AIDS. Sexually abused girls may become
pregnant and incur the health risks associated Financial Costs
with pregnancy, a significant burden particularly
in developing countries. The costs associated with child maltreatment are
Striking long-term consequences of childhood difficult to assess. There are direct costs associated
maltreatment that have been repeatedly documen- with the immediate medical needs of children who
ted in the literature are adult ill-health (including have been physically harmed. There is the tremen-
both physical and mental health problems) and dous cost of ongoing health care for children with
adult engagement in high-risk health behaviors. major disability, both physical and mental, that is
Adult survivors of childhood abuse suffer at signifi- the direct result of child maltreatment. There are
cantly higher rates than others from depression, costs associated with the lost yield of children who
anxiety disorders, eating disorders, posttraumatic die prematurely or become physically or mentally
stress disorder, chronic pain syndromes, fibromyal- disabled as a consequence of child maltreatment.
gia, chronic fatigue syndrome, and irritable bowel The World Health Organization has summarized
syndrome. Adults who were abused as children the sources of costs incurred by systems responsible
report lower health status and higher use of health for interacting with maltreated children and their
services than non-abused adults. The actual world- families including
wide burden of child maltreatment is difficult to
– ‘‘expenditures related to apprehending and
estimate. Recently, the World Health Organization
prosecuting offenders,
analyzed the global and regional burden of diseases
– the costs to social welfare organizations of
attributable to selected risk factors. Among these
investigating reports of maltreatment and
risk factors was child sexual abuse. Across the
protecting children from abuse,
world, child sexual abuse is estimated to have con-
– costs associated with foster care,
tributed to between 4 and 5% of the burden of
– costs to the education system, and
disease in males and 7 and 8% of the burden of
– costs to the employment sector arising from
disease in females for depression, alcohol abuse,
absenteeism and low production’’ (Krug et al.
and drug abuse (Ezzati et al. 2004). These estima-
2002).
tions are derived from analyses of available litera-
ture describing the relationship between child sexual A recent effort to tally the annual direct and
abuse and adult manifestations of depression and indirect costs of child abuse in the United States
substance abuse. found that the yearly financial burden in the Uni-
Furthermore, adults maltreated as children are ted States due to child maltreatment was US $103.8
more likely to be obese or physically inactive, to billion. This included $6.6 billion for hospitaliza-
engage in smoking, substance use, and unsafe sex, tions, $1.1 billion for mental health costs, $25.4
to attempt suicide, and to have an unintended billion for child welfare costs, and $33 million in
pregnancy than non-abused adults (Springer et al. law enforcement costs. The cost of adult criminal-
2003). Possibly because of the link between child- ity related to child abuse was estimated to be $30
hood trauma and high-risk health behaviors, it has billion (Wang and Holton 2007). Add to these costs
been shown that the more adverse experiences an those of caring for adults with heart disease,
cancer, and diabetes stemming for child abuse, Parent Factors

whether directly or as a result of high-risk health
behaviors known to be associated with childhood It is widely believed that parents who were abused
abuse, and these costs become staggering. as children themselves are more likely than others to
abuse their own children. A recent systematic
review of the literature has raised concerns about
the limited research data to support this claim
Risk Factors for Child Abuse and Neglect (Ertem et al. 2000). It is likely that a personal history
of maltreatment in childhood is but one of many
Child maltreatment is a multi-factorial problem, factors that leads a parent to maltreat his or her own
and thus, no single factor can be identified as certain child. Abusive and neglecting parents are more
to lead to child maltreatment. Rather, multiple fac- likely to be young, poor, undereducated, and unem-
tors at both the individual and the societal level ployed. They are also more likely to suffer from
interact to produce this outcome. A helpful ecolo- serious mental illness or retardation. Addiction
gical model for the etiology of child maltreatment and substance use by parents are known risk factors
comes from Belsky (1993) who wrote that ‘‘there is for child maltreatment. Substance use has been
no one pathway to disturbances in parenting; linked to higher rates of physical and sexual abuse,
rather, maltreatment seems to arise when stressors perhaps by lowering inhibitions and impairing judg-
outweigh supports and risks are greater than pro- ment, as well as to higher rates of neglect. Parents
tective factors’’ (Belsky 1993). The stressors that can who have unrealistic developmental expectations of
lead to child maltreatment can be broken down into their children and a poor capacity for empathy with
child, parental, family, and societal factors. children are more likely to abuse them.
Child Factors Family Factors
The primary characteristic about an individual Overcrowded households and especially households
child most closely correlated with likelihood of containing many small children can contribute to
maltreatment is the age of the child. Younger child maltreatment. Violent relationships between
children, especially those under 3 years old, are adults in a home are associated with violence
significantly more likely to die from physical toward children in the home. Families who are
abuse throughout the world. Rates of nonfatal socially isolated and lack external supports are at
physical abuse vary from country to county, per- risk, as are those households whose composition
haps reflecting variation in cultural practices of changes frequently. Parents who are prevented
corporal punishment. Younger children are most from establishing a good relationship with children
dependent on caretakers for meeting basic human for any reason, whether by virtue of a personal
needs and are thus most vulnerable to neglect. inability or an inability imposed by outside circum-
Peak rates of sexual abuse are thought to rise stances, are at increased risk of maltreating their
after the onset of puberty, but younger children children.
are certainly victims of sexual abuse as well (Krug
et al. 2002). Children born of unwanted pregnan-
cies, multiple births (twins), and premature
infants are at increased risk of child maltreat- Societal Factors
ment. Children who are physically and/or men-
tally disabled, children who are chronically ill, as Poverty is strongly correlated with child maltreat-
well as children who by means of temperament ment, especially neglect. Parents living in poverty
are seen as ‘‘needy’’ are also at increased risk live with considerable stress that can have an impact
(WHO 2006). on their ability to parent effectively in multiple
ways. Poverty and unemployment are related to cultural rights, reducing income and gender
higher rates of substance use and abuse, as well as inequalities, and eradicating cultural acceptance of
mental and physical illness in adults. Poor commu- violent or exploitative behavior toward children
nities that lack resources and adequate infrastruc- (WHO 2006). A sound argument can be made that
ture offer little or no support to parents with while it would not rid the world of all child
impaired ability to care for children. Desperately maltreatment, the establishment of worldwide
poor parents may send children to work in unsafe social and economic equality would significantly
conditions or even indenture children as workers for decrease the amount of child maltreatment
others in order to survive. Cultural acceptance of throughout the world. While it is beyond the scope
violence contributes to higher rates of child mal- of this chapter to offer strategies to combat poverty
treatment, as in the case of corporal punishment. and social injustice, the degree to which these global
The degree to which a culture values, or devalues, problems contribute to child maltreatment must be
children also is an important societal level risk fac- highlighted. Another societal and community level
tor for maltreatment. strategy to prevent child maltreatment is the provi-
sion of both early childhood care and education as
well as the provision of universal education through
the secondary level. Finally, prevention of child
Prevention of Child Abuse and Neglect maltreatment can be pursued by attempting to
change cultural and social norms that support vio-
Child maltreatment is not a new problem. Yet, only lence against children and adults. Cultural accep-
very recently has the prevention of child abuse and tance of certain forms of child maltreatment, such
neglect come to international attention. On October as severe physical punishment and female genital
16, 2006, the World Health Organization issued a mutilation, can perhaps be addressed by public
news release titled ‘‘World Health Organization media and educational campaigns. The degree to
says violence against children can and must be pre- which such campaigns are or can be successful is
vented’’ (WHO 2006). Efforts to address the issue by unknown. An example of a governmental effort to
entities such as the World Health Organization, the change parents’ behavior comes from Sweden. In
United Nations, and UNICEF can certainly help to 1979, Sweden passed legislation that effectively
illuminate the scope of the problem and are an abolished corporal punishment as a legitimate
important first step. They can set an agenda for child-rearing practice. Recent research has shown
addressing the problem, as does the recently avail- that the 1979 legal reform in Sweden did not reduce
able guide to prevention of child abuse published the level of public support for parental use of
jointly by the World Health Organization and the corporal punishment as a means of disciplining
International Society for Prevention of Child Abuse children (Durrant 1999).
and Neglect. The guide recommends that countries On a relationship level, failures in attachment
identify a lead agency whose primary purpose is the between parents and children as well as inappropri-
prevention of child maltreatment. The lead agency ate developmental expectations contribute signifi-
would then work to involve other agencies who cantly to child maltreatment. Single parents and
work with families and children, such as child care parents who lack social support are more likely to
services, neighborhood community centers, and abuse or neglect their children. It is perhaps not
religious institution, as well as the media. The lead surprising, then, that among prevention programs
agency would also take responsibility for preparing that have been evaluated, home visiting programs
a national report on child maltreatment and efforts are most successful. In order to be successful, how-
to prevent it (WHO 2006). ever, home visiting must be initiated early, occur
Specific prevention strategies proposed by the frequently, and be carried out by a person able
guide are stratified into three levels: societal and both to establish a relationship with the parent(s)
community, relationship, and individual prevention and to teach effective parenting. Such programs are
strategies. On a societal and community level, stra- expensive (Leventhal 1996), and in communities
tegies include promoting social, economic, and where basic social needs are unmet, such as in
refugee communities or nations at war, a lofty goal can be used to assess the soundness of prevention
indeed. Another relationship level strategy is the use programs as they are implemented. Given the huge
of training programs in parenting for parents-to-be global burden of child maltreatment, it is apparent
and new parents. that many teachers, heath professionals, social
Children born of unwanted pregnancies, pre- workers, and other professionals interact regularly
mature, and otherwise disabled children are at with victims of child maltreatment, unaware of their
higher risk of maltreatment than others. Thus, plight, and therefore unable to help them. There is
individual level prevention strategies include an urgent need for all sectors involved in child
the prevention of unwanted pregnancy and health promotion to build consensus on common
improved access to pre- and post-natal care. An conceptual and operational definitions of child mal-
additional individual level strategy for preven- treatment in order to facilitate better case detection
tion is the direct education of children about and reporting. As with other public health pro-
how to avoid unsafe situations and protect blems, early detection and prompt intervention is
themselves when confronted with a threatening necessary to prevent long-term health and social
situation (WHO 2006). This strategy may be consequences of child maltreatment. As the WHO
most useful in the prevention of child sexual (2006) guide to action and evidence on child mal-
abuse. The prevention of child maltreatment is treatment asserts, professionals who interact on a
a relatively new and developing field. Child mal- regular basis with children need training that pro-
treatment was itself once an unrecognized provides knowledge of
blem. Strategies and programs to prevent child
Myths about child maltreatment
maltreatment are not fully tested in terms of
Physical and behavioral signs of possible and
measurable outcomes of success or failure. The
definitive maltreatment – as well as signs that
identification of appropriate outcome measures
are indicative of maltreatment
is in itself a challenge. It has been proposed that
How to respond when possible maltreatment is
in addition to obvious outcomes for child mal-
indicated – including the use of protocols for
treatment prevention programs such as decreas-
involving supervisors, reporting cases, and mak-
ing child deaths or rates of inflicted injury, pro-
ing referrals
tective factors be tracked, such as educational
Options for medical and psychosocial treatment
achievement or improved parental expectations
of victims
of the developmental abilities of children
(WHO 2006). The ability to identify and mea- It is germane to note that a number of indi-
sure meaningful outcomes for child maltreatment cators, algorithms, flowcharts, and checklists
prevention programs is crucial to the successful (e.g., Fig. 25.2) are currently available to facil-
adoption and implementation of such programs. itate early detection of child maltreatment. These
It is likely that only through documented indicators provide valuable resource for training
changes in valued outcomes will governments of primary health-care workers, pediatricians,
dedicate the financial resources necessary to Emergency Department doctors and nurses. It
institutionalize worthwhile prevention efforts is important that these tools are evaluated and
(Leventhal 2005). assessed for their adaptation in various cultures
and health-care settings, globally. Health policy
makers in all countries must recognize and
accord child maltreatment the importance that
Conclusions it deserves given its consequences over the life
span. Frontline health and other professionals
Improved recognition and tracking of all forms of who are in regular contact with children also
child maltreatment throughout the world have been need to be assisted not only in identifying and
identified as important steps in prevention. Epide- reporting the problem but also in providing
miologically sound data on the prevalence of child appropriate and timely treatment, prevention,
maltreatment and its consequences, once in hand, and support services to victims.
Fig. 25.2 Simple

START
intervention to improve
detection of child abuse in
emergency departments.
Source: Benger and Pearce Has there been a delay between injury and seeking medical advice for which
(2002) there is no satisfactory explanation?
No Yes
Is this history consistent each time?
Yes No
On examination, does the child

have any unexplained injuries?
No Yes
Is the child’s behavior and

interaction appropriate?
Yes No
LOW suspicion HIGH suspicion injury: Discuss with a senior doctor

injury. Diagnose in A&E or Pediatrics
and treat as
normal
FINISH: tick and sign
FINISH: Tick and sign
Key Terms
Battered child Depression Interpersonal violence

Behavioral dysfunction Discipline Long bone fractures
Blindness Effective parenting Mental retardation
Brain damage Emotional abuse Neglect
Child abuse Emotional ill-treatment Negligent treatment
Child factors Emotional maltreatment Non-fatally abused children
Child fatality records Exploitation Paralysis
Child labor Exploitative behavior Parental factors
Child laborers Family factors Permanent physical disability
Child maltreatment Fatally abused children Physical abuse
Child protective services Female circumcision Physical maltreatment
Childhood trauma Female genital mutilation Pornography
Cognitive dysfunction Fondling Prostitution
Commercial exploitation Gender inequalities Punishment
Corporal punishment Hazardous work Rape
Seizure Spurning Unintended pregnancy

Sexual abuse Substance abuse Unsafe sex
Shaken infant Suicide Voyeurism
Societal factors Trafficking
Child Welfare Information Gateway (2006) Child abuse and

Questions for Discussion neglect. http://www.childwelfare.gov/can Cited 8 August
2008
1. What is child maltreatment? Distinguish between Daroh D (ed.) (2006) World perspectives on child abuse.
West Chicago, IL: The International Society for Preven-
child discipline and corporal punishment. tion of Child Abuse and Neglect
2. Why is it important to establish a universally Durrant JE (1999) Evaluating the success of Sweden’s cor-
acceptable operational definition of child mal- poral punishment ban. Child Abuse Negl, 23: 435–448
treatment? What are the barriers in achieving this? Ertem IO, Leventhal JM, Dobbs S (2000) Intergenerational
continuity of child physical abuse: how good is the evi-
3. Define the following and provide specific exam- dence? Lancet, 356: 814–819
ples of each Ezzati M, Lopez AD, Rodgers A et al. (eds.) (2004) Com-
parative quantification of health risks; global and regio-
a. Physical abuse nal burden of disease attributable to selected major risk
b. Sexual abuse factors. Geneva: World Health Organization
c. Emotional abuse Felitti,VJ, Anda, RF, Nordenberg D et al. (1998) Relationship
of childhood abuse and household dysfunction to many of
d. Neglect the leading causes of death in adults: the Adverse Childhood
e. Exploitation Experience (ACE) Study. Am J Prev Med, 14: 245–258
Fergusson DM, Horwood LJ, Woodward LJ (2000) The
4. Outline the health consequences of child abuse stability of child abuse reports: a longitudinal study of
and neglect. the reporting behaviour of young adults. Psychological
5. List individual, family, community, and societal Medicine, 30: 529–544
level strategies for preventing child abuse and Finkelhor D (1994) Current information on the scope and
nature of child sexual abuse. Future Child, 4: 31
neglect. Herman-Giddens ME, Brown G, Verbiest S et al. (1999)
Under-ascertainment of child abuse mortality in the Uni-
ted States. Journal of the American Medical Association,
282: 463–467
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Chapter 26
Children in Difficult Circumstances
Nancy Mock and Elke de Buhr
Learning Objectives After reading this chapter and health of children in difficult circumstances. Since
answering the discussion questions that follow, you the 1980 s, the public health community has increas-
should be able to ingly recognized the needs of children and youth
who face particularly difficult circumstances.
Discuss the challenges in identifying and enu-
These children are sometimes referred to as ‘‘Chil-
merating children in difficult circumstances.
dren in Especially Difficult Circumstances’’
Analyze trends in the evolution of the problem of
(CEDC). These children work in exploitive situa-
children in difficult circumstances and discuss its
tions, do not live with their biological or adopted
public health impact.
families, and/or are involved in or affected by armed
Appraise the status of policies and programs to
conflict. Categories of children include ‘‘street chil-
protect and promote the health of children in
dren,’’ Orphans and Vulnerable Children (OVC),
difficult circumstances.
and children who are sexually exploited, trafficked,
or forced to work at the cost of their education and
health (UNICEF/UNAIDS/USAID 2004). While
enumeration of children suffering the effects of dif-
Introduction
ficult circumstances is fraught with definitional and
methodological problems (Skinner et al. 2006), the
Children in difficult circumstances represent a large
global magnitude of children in difficult circum-
and diverse group. Some form of social disruption is
stances is large and is growing because of HIV/
common to all their lives. All of these children have
AIDS, armed conflict, urbanization, and other
special needs, especially the need for psychosocial
developments. For example, the estimated number
support. Their other individual needs vary greatly
of orphaned children in 2004 was 85.5 million in
as the children’s specific circumstances are different
Asia and 43.4 million children in Latin America. As
and ever changing. The public health and medical
a result of HIV/AIDS, this number is expected to
management of children in difficult circumstances
grow at least through the next decade (UNICEF
requires intersectoral coordination and a holistic
2006).
approach to prevention and treatment. This chapter
Although the incidence of violent conflict has
presents a review of definitional and methodologi-
been slowing recently, conflict continues to displace
cal difficulties associated with identifying and enu-
children from their families. Conflict may involve
merating children in difficult circumstances. It
the use of child soldiers, increase a child’s likelihood
examines trends in the evolution of the problem
of orphanhood and migration as an unaccompanied
and its public health impact and analyzes the status
minor, and/or increase the chance that he/she will
of policies and strategies to protect and promote the
be injured and disabled by land mines and other
war-associated trauma (see Chapter 7 for discussion
of conflict and maternal and child health). No sta-
N. Mock (*)
International Health and International Development, tistical data documenting these affects are suffi-
Tulane University, New Orleans, LA, USA ciently reliable to report. However, millions of
480 N. Mock and E. de Buhr
children are affected by conflict in the Middle East, ‘‘orphan’’ tend to distinguish between paternal,
Africa, Asia, and Latin America. It has been esti- maternal, and double orphans. The understanding
mated that 300,000 children under 18 years of age of ‘‘vulnerable children’’ tends to be broad and
are currently being exploited as child soldiers in poorly defined and may include a variety of differ-
armed conflicts worldwide (UNICEF 2006). The ent groups of children. The term ‘‘street children’’
numbers of children living on the streets in cities also has various meanings and uses and is consid-
are also not known (Volpe 2002). However, with ered by many social scientists not to be helpful in
urbanization, this number of street children is grow- describing a category of children (Ennew 2003).
ing in most regions of the world. An increase in Children may literally live in the streets, work on
numbers of street children has been observed in the streets, or both. The terms ‘‘child work,’’ ‘‘child
many African cities (UNICEF 2003). labor,’’ and ‘‘worst forms of child labor’’ are defined
Child trafficking, sexual exploitation, and unac- in detail by the International Labor Organization
ceptable circumstances of child labor affect millions (ILO) but often confused in use. An additional
of children worldwide. More than 317 million of the problem is in defining the age range of childhood.
world’s children between 5 and 17 years of age were Again, agencies and countries define eligibility dif-
estimated to be working in 2004. Of these, an esti- ferently, leading to non-comparable research and
mated 217 million were involved in child labor, and statistical data.
126 million were estimated to be engaged in hazar- The concept of ‘‘vulnerable children’’ is used fre-
dous work (Hagemann et al. 2006). In 2002, an quently in the context of children affected by AIDS,
estimated 5.7 million children were working as though the term vulnerability is widely used in the
forced or bonded laborers, an estimated 1.2 million public health literature to identify children who are
children per year are trafficked, and another 1.8 affected by poverty and other social risks/threats.
million per year are forced into commercial sexual AIDS orphans are often more vulnerable than other
exploitation (UNICEF 2006). children as they are impacted by AIDS in a much
broader sense. This impact often begins long before
the death of one or both of their parents. However,
Definitions and Methodological Issues vulnerability clearly is not limited to HIV/AIDS. A
study by Skinner et al. (2006) suggests a range of
factors that may play an important role in causing
The study of children in difficult circumstances is
vulnerability, such as ‘‘severe chronic illness of a
confounded by the breadth of the concept and
parent or caregiver, poverty, hunger, lack of access
inconsistent use of the terminology. Box 26.1 pre-
to services, inadequate clothing or shelter, over-
sents some common definitions and their sources.
crowding, deficient caretakers, and factors specific
Difficult circumstances cover a broad range of pro-
to the child, including disability, direct experience of
blems that are often, but not always, caused by
physical or sexual violence, or severe chronic ill-
poverty. Frequently, but not always, they are asso-
ness’’ (Skinner et al. 2006). More recently, the ‘‘vul-
ciated with social dislocation from family and com-
nerable’’ group within the OVC rubric is being oper-
munity. Many of the categories used to describe
ationalized. For example, some of the more recent
certain subpopulations of children in difficult cir-
Demographic and Health Surveys (DHS) attempt
cumstances are used differently by different organi-
to measure the category of ‘‘vulnerable children’’ in
zations within the public health community. For
addition to the general orphan statistics. The
example, the term ‘‘Orphans and Vulnerable Chil-
Rwanda 2005 DHS (Institut National de la Statis-
dren’’ is frequently associated with HIV/AIDS
tique du Rwanda and ORC Macro 2006), for exam-
among organizations working in the HIV/AIDS
ple, operationalized ‘‘vulnerable children’’ as (a)
community. However, the term is more broadly
children ‘‘with a very ill parent’’ either living in the
applied to orphans and vulnerable children from
same household with the parent or not, (b) children
all causes by other agencies. There is no widely
‘‘living in a household with a very ill adult,’’ and (c)
accepted standard definition of the term ‘‘orphans
children living in a household with ‘‘an adult who
and vulnerable children’’ (OVC). Definitions of
died in the last 12 months’’ (Institut National de la
26 Children in Difficult Circumstances 481
Orphan – Orphan is typically defined as ‘‘a child under the age of 18 who has had at least one parent
die. A child whose mother has died is known as a maternal orphan; a child whose father has died is a
paternal orphan. A child who has lost both parents is a double orphan’’ (UNAIDS 2004).
Orphans Due to AIDS – AIDS orphans are a subgroup within the general orphan population.
According to UNAIDS, ‘‘a consensus was reached on the definition of an AIDS orphan as ‘a child
who has at least one parent dead from AIDS’, and a dual (or double) AIDS orphan as ‘a child whose
mother and father have both died, at least one due to AIDS’ ’’ (UNAIDS Reference Group 2002).
Other Vulnerable Children – According to UNICEF, the term ‘‘other vulnerable children’’ includes
‘‘those who are living with HIV/AIDS, those whose parents are sick with HIV/AIDS, and, more
generally, children who are especially vulnerable because of poverty, discrimination or exclusion,
whether as a consequence of HIV/AIDS or not’’ (UNICEF 2003).
Children Living on the Streets – Street children have been defined by the United Nations as ‘‘boys and
girls for whom ‘the street’ (including unoccupied dwellings, wasteland, etc.) has become their home
and/or source of livelihood, and who are inadequately protected and supervised by responsible
adults’’ (Wittig et al. 1997).
Working Children – According to ILO (ILO 1999), child work is ‘‘defined in terms of economic
activity. Economic activity covers all market production (paid work) and certain types of non-market
production (unpaid work), including production of goods for own use’’ (Hagemann et al. 2006).
Child Labor – ILO (ILO 2006) distinguishes child labor from child work. Child labor ‘‘comprises all
children under 15 years of age who are economically active, excluding (i) those under 5 years of age
and (ii) those aged 12–14 years who spend fewer than 14 hours a week on their jobs, unless their
activities or occupations are hazardous by nature or circumstance. Added to this are children aged
15–17 years, who are involved in hazardous work’’ (Hagemann et al. 2006).
Worst Forms of Child Labor (WFCL) – WFCL includes ‘‘all forms of slavery or practices similar to
slavery’’ and ‘‘work which, by its nature or the circumstances in which it is carried out, is likely to
harm the health, safety or morals of children’’ (International Labor Organization 1999).
Trafficked Children – ‘‘The recruitment, transportation, transfer, harboring or receipt of a child for
the purpose of exploitation is considered ‘trafficking in persons’ ’’ (United Nations 2000b).
Forced and Bonded Labor – ‘‘Any institution or practice whereby a child or young person under the
age of 18 years, is delivered by either or both of his natural parents or by his guardian to another
person, whether for reward or not, with a view to the exploitation of the child or young person or of
his labor’’ (UN Supplemental Convention on the Abolition of Slavery (United Nations 1956)).
Statistique du Rwanda and ORC Macro 2006). Trends in the Magnitude of the Problem
For Rwanda, this resulted in a population of
‘‘orphans and vulnerable children’’ (OVC) of Of all groups of children living in difficult circum-
25.6% among children younger than 15 years stances, OVCs and working children, child labor, traf-
(17.5% orphans þ 8.1% vulnerable children) and ficked children, and sexually exploited children have
28.6% among all children younger than 18 years been the most closely monitored over time. This
(20.5% orphans þ 8.1% vulnerable children) resulted because of the major international programs
(Institut National de la Statistique du Rwanda aimed at supporting these children. Trends in OVC
and ORC Macro 2006). numbers and characteristics are directly influenced by
key demographic indicators such as population

growth. The general trend has been a decline in the
absolute numbers of orphans in Asia and the Latin
American and Caribbean regions. However, the num-
ber of orphans in Africa has been increasing and is
projected to continue to grow (Fig. 26.1).
Fig. 26.2 Percent of children orphaned by AIDS versus all

other causes in countries with more than 15% orphans.
Source: UNICEF/UNAIDS/USAID (2004)
number of orphans is expected to grow by 20

million between 1990 and 2010, while a drop of
almost 20 million is expected in Asia during the
Fig. 26.1 Global trends in orphan numbers. Source: UNICEF/ same period of time. The total number of
UNAIDS/USAID (2004)
orphans in Latin America and the Caribbean is
expected to remain relatively stable (UNICEF/
Overall, 28% of these orphaned children are UNAIDS/USAID 2004).
believed to be AIDS orphans. Regional differ-
ences within sub-Saharan Africa are considerable,
with just 1% of AIDS orphans among all Methods for Estimating Categories of
orphaned children in Mauritania and 78%
AIDS orphans in Zimbabwe (Fig. 26.2). It has
been estimated that 16% of all households in sub-
Saharan Africa were caring for orphans between It is often a challenge to enumerate children in
1997 and 2002 (UNICEF 2003). Again, regional difficult circumstances while using traditional
differences are significant. In southern Africa methods that are used in demographic and health
where HIV infection rates are the highest, 20% assessments such as the Demographic and Health
of all households were estimated to be involved in Surveys (DHS) and the UNICEF Multiple Indi-
the care of orphaned children. Other parts of the cator Cluster Surveys (MICS). These children
continent reported this rate to be closer to 15% may not live in households, which are the unit
(UNICEF 2003). In all parts of Africa, the num- for many enumeration techniques. Instead, the
ber of orphans per household is expected to con- children may live in institutions, on the streets,
tinue to grow because of the impact of HIV/ or they are otherwise on the move. They may be
AIDS. With orphan numbers growing in HIV/ living in communities, but they may still not be
AIDS-affected populations, the HIV/AIDS epi- included in sampling frames such as child-headed
demic is responsible for reversing the global households. They also may be invisible, such as
trend of stagnant or decreasing numbers of trafficked children or those who are sexually
orphan populations. In sub-Saharan Africa the exploited. Therefore, in addition to traditional
techniques of census and probability sampling, susceptible to the introduction of a wide range of
household surveys that seek to enumerate chil- potential biases.
dren in difficult circumstances often require sta- There are currently two large-scale household
tistical modeling and the application of more survey programs of children that have been imple-
recent sampling strategies such as space–time mented in several countries: the USAID Demo-
sampling and respondent-driven sampling. graphic and Health Surveys (DHS) and the UNI-
The following section provides an overview of CEF Multiple Indicators Cluster Surveys (MICS).
the various methods available for estimating the The DHS and the MICS collect data from stratified
number of children in difficult circumstances. and nationally representative population samples
on a variety of demographic and health indicators
and include some orphan characteristics. Both the
DHS and the MICS define an orphan as a child
Population Census under 15 years of age that has lost one or both of
his or her parents; older children are not considered.
Data derived from a well-executed population census, The sampling frames for these surveys may exclude
designed to include all individuals in a population, a significant component of orphaned children. For
will present the most accurate picture of the total example, children living in child-headed house-
number of orphans and their population characteris- holds, children not living in households, such as
tics. A complete census is the preferred method for children in orphanages and other institutions, and
generating an estimate of the total number of orphans children living on the streets are often excluded.
in the population. However, population censuses are Other children that may not be included in these
high cost, logistically challenging, and usually con- survey frames include ‘‘those in residential transi-
ducted infrequently. Furthermore, census data tend tion and those employed as live-in domestic ser-
to undercount some population sub-groups. These vants’’ as well as children that are misclassified as
are often the smaller but most vulnerable groups non-orphan, having been claimed by adults in the
like the homeless, migrants, and other mobile or min- household as their own (the adoption effect) (Bicego
ority populations. For example, while household- et al. 2003).
based orphans are likely to be covered by a popula-
tion census, children in orphanages and in particular
orphans living on the streets tend to be un- or under-
counted. Adjustments for this undercounting can be Model-Based Estimates
made, but may be statistically challenging and are
often controversial (Rossi et al. 1999). As the impact of HIV/AIDS on children became
evident, accurate estimates of the number of AIDS
orphans were needed to guide public policy and
interventions. While orphan estimates can be
Population-Based Household Surveys derived from census or population-based surveys,
difficulties in assessing mortality from AIDS makes
Sample surveys are another important method for these methods less feasible for the generation of
generating estimates of orphan numbers. House- reliable estimates of this particular subgroup of
hold surveys are frequently used to generate esti- orphaned children. Model-based orphan estimates
mates of the percentage of orphans in a population. that are derived from adult mortality and fertility
Like a population census, a household survey and child survival statistics promise to overcome
requires considerable amounts of skill and some of these obstacles. Efforts to standardize
resources. While the survey sample size is much orphan estimation based on models have been led
smaller than a complete population enumeration, by the UNAIDS Reference Group on Estimates,
thousands of subjects still need to be interviewed to Modeling, and Projections, with UNICEF,
create valid estimates of sub-groups. In addition, USAID, and the US Census Bureau as participating
sampling on a national level is complex and partners. Building on earlier work by Grassly
Table 26.1 Health risks for different groups of vulnerable children
484
Children exposed to conflict or

Orphans and vulnerable children Street children Working children disaster
Nutrition – Several studies have found higher – There are no significant – There is no association – Nutrition measures are worse
incidence of malnutrition among OVCs differences in anthropometric between malnutrition and for children exposed to disaster
than non-OVCs of similar socio- parameters, incidence of work (study of boys only) (drought/tsunami)
economic backgrounds stunting, or underweight – Duyar and Ozener (2005) – Singh et al. (2006)
– Watts et al. (2007) between street and non-street – Jayatissa et al. (2006)
– Miller et al. (2007) slum children – There is a high prevalence of
– Jayasekera (2006) – Greksa et al. (2007) acute malnutrition among
– A study of Kampala youth found no – There is a high incidence of internally displaced and
statistical difference in anthropometric stunting (52%); street children refugee children
parameters of OVCs and non-OVCs weighed more and were taller – Toole and Waldman (1993)
– Sarker et al. (2005) than their socio-economic
– Maternal orphans had 11% lower height peers
compared to non-orphans – Gross et al. (1996)
– Beegle et al. (2005) – Street children’s nutrition is no
– Weight/age Z-scores were not different worse than that of children
between orphans and non-orphans; living at home with similar
weight/height Z-scores for orphans were economic backgrounds
0.3 standard deviations lower than those – Scanlon et al. (1998)
for non-orphans
– Lindblade et al. (2003)
– Under-nutrition and stunting are more
prevalent among young orphanage
children than young non-orphans or
village orphans; there is no statistical
difference between nutritional status of
village orphans and non-orphans
– Panpanich et al. (1999)
Diseases – OVCs <5 years are more likely than non- – Prevalence of disease is slightly – There is a higher incidence of
OVCs to suffer from diarrheal illness higher among street children, disease among drought-
even after adjusting for extreme poverty but most differences are not affected children
– Watts et al. (2007) statistically significant – Singh et al. (2006)
– There is no difference between orphans – Greksa et al. (2007) – 85% of children <5 years had
and non-orphans in prevalence of fever – There is a high prevalence of diarrhea in tsunami-affected
and malaria parasitemia or history of disease found among the Aceh community
illness studied street children – Brennan and Rimba (2005)
– Lindblade et al. (2003) population
– Incidence of diarrhea w/in last month – Ayaya and Esamai (2001)
among non-orphans is higher than village – Diseases are common among
orphans or orphanage children (30% for street children
– Anarfi (1997)
N. Mock and E. de Buhr
26

non-orphans, 10.8% for village orphans, – Many street children suffer
and 6.6% for orphanage children) from chronic diseases
– Panpanich et al. (1999) (typhoid, tuberculosis,
jaundice, liver, and kidney
disorders)
– West (2003)
– Trauma and certain infections
are more common among
street-based children than
children living with families

– Scanlon et al. (1998)
Sexually – There is greater sexual risk behavior – Sexually transmitted infections – Gonorrhea, herpes simplex,
transmitted (engaging in sexual intercourse, younger are not prevalent and syphilis are common
diseases age of sexual intercourse) among OVCs – Ayaya and Esamai (2001) among child prostitutes
than non-OVCs – There are higher rates of – United Nations 2000
– Thurman et al. (2006) hepatitis B markers found in
– There is a higher prevalence among street-based youth than
female OVCs than non-OVCs, but no children living with families
difference for male OVCs – Porto et al. (1994)
– Gregson et al. (2005) – There are higher rates of STDs
– HIV-1 seroprevalence rates are higher found in street-based youth
among orphans than non-orphans; much than children living with
higher among 0–4 years families
– Kamali et al. (1996) – Pinto et al. (1994)
– Sexually transmitted diseases
are prevalent among older
street children
– West (2003)
– An increasing number of street
children are living with HIV/
AIDS
– West (2003)
– Study of 143 street children
(age 7–18) found 112 had
genital herpes, 71 had
gonorrhea, 39 had HPV, 19
had vaginal trichomoniasis, 24
had chancroids, and 6 had
vaginal candidiasis, early
latent syphilis, and pubic
485
pediculosis
486

– Solorzano et al. (1992)
Injuries – Traffic-related injuries are one – There is a higher incidence of – There is a high rate of injury
of the main causes of street musculoskeletal disorders during armed conflict
child morbidity – Fassa et al. (2005) – Pearn (2003)
– Senanayake et al. (1998) – Injuries and illness result – Majority of those wounded
from work and permanently disabled are
– Mull and Kirkhorn (2005) women and children
– Various health problems/ – Sapir (1993)
injuries found in sample of
working children
– Esin et al. (2005)
– Gharaibeh and Hoeman
(2003)
– Manual labor exposes
children to injury
– Woolf (2002)
Mental health – Several studies found higher incidence of – Emotional/behavioral – There was a very high PTSD
mental health problems among OVCs disorders are more common prevalence after tsunami
than non-OVCs among working children – John et al. (2007)
– Ahmad et al. (2007) – Fekadu et al. (2006) – There was a high PTSD
– Cluver and Gardner (2006) prevalence (even higher among
– Atwine et al. (2005) children in more severely
– A high incidence of PTSD in Rwandan affected areas) following
orphans has been reported, but this has super-cyclone
not been compared to PTSD incidence – Kar et al. (2007)
among non-orphan population – Armed conflict causes
– Schaal and Elbert (2006) psychological trauma in
children
– Padmanabhan (1992)
Drug abuse – Alcohol abuse is more prevalent among – Drug abuse is common among
orphans than non-orphans street children
– Mabiala-Babela et al. (2005) – Anarfi (1997)
– There is a high prevalence
– Ayaya and Esamai (2001)
– Alcohol and tobacco use are
much higher among children
living on the street
– Forster et al. (1996)
N. Mock and E. de Buhr
26

– 66% of sampled street children
reported using drugs
– Abt Enterprises (2001)
– 67.1% of street children
sampled reported using drugs
the previous month
Sherman et al. (2005)
Violence – Orphans, especially girls, reported sexual – There are high rates of physical – Physical, verbal, and sexual – They bear disproportionate
abuse in new households and sexual abuse abuse are common among consequences of armed
– Salaam (2005) – Lalor (1999) child workers conflict
– There are higher rates of sexual – Gharaibeh and Hoeman – Pearn (2003)
abuse reported by street-based (2003) – Subject to abuse and
youth – 8 out of 10 young domestic kidnapping from soldiers
– Pinto et al. (1994) workers (Fiji) reported being – El-nagar (1992)
– 16% are sexually abused sexually abused by employer
– Senanayake et al. (1998) – Salaam (2005)
– 80% of street children sampled – Girl soldiers are frequently
were exposed to a ‘‘real or subjected to rape and other
constant threat of violence’’ forms of sexual violence
– Abt Enterprises (2001) – Coalition to Stop the Use
of Child Soldiers (2004)
– In DRC, almost all girls and
some boys reported being
raped or sexually abused by
commanders or other
soldiers
– Coalition to Stop the Use
of Child Soldiers (2004)
– 38.5% of child prostitutes
sampled (Cambodia)
reported being beaten or
tortured by brothel owner
– United Nations (2000)
Source: UNAIDS/UNICEF/USAID (2004)
487
and Timæus (UNAIDS/UNICEF/USAID 2004) surveys, analysis of program records, key infor-
(Table 26.1), the UNAIDS Reference Group pro- mant interviews, focus group discussions, and
posed a number of models to estimate the number related methods.
of maternal, paternal, and double orphans; the
number of AIDS orphans alone; and the total num-
ber of orphans in a population.
The mortality, fertility, and survival data that
Health Consequences of Living
feed into model-based population estimates are in Difficult Circumstances
not collected by the UNAIDS Reference Group.
They have to be derived from census data, house- The health consequences of being in difficult cir-
hold surveys, demographic projections, and/or cumstances are not well documented in the litera-
other sources. If statistics are not available or if ture. However, violence and psychosocial trauma
they are of poor quality, model-based orphan and social/behavioral problems are most consis-
estimates either cannot be calculated or they tently documented across almost all categories of
may be inaccurate. Model-based estimates thus children in difficult circumstances. Other types of
rely on the quality of the available data. This health effects are less consistent across the cate-
quality is likely to differ for each indicator and gories of children living in difficult circumstances
between countries. In addition, the models (Table 26.1).
depend heavily on the accuracy of their under-
lying assumptions.
Street Children
Minorities and High-Risk Populations Street children, for example, are not consistently
found to have poorer health outcomes than other
Some of the most vulnerable groups of OVC – children in their settings. However, it is consistently
such as children in orphanages and children living reported that drug abuse rates among street chil-
on the streets – are not adequately covered by dren are high, sometimes higher than those of their
any of the methods of generating orphan esti- non-street socio-economic peers (Ayaya and Esa-
mates that have been previously described. Not mai 2001). The literature also generally agrees that
living in a household and often without contact street children suffer from high rates of physical and
with family, both groups of children are unlikely sexual abuse (Lalor 1999). Some studies have found
to be included in population-based surveys that higher rates of sexually transmitted diseases (STDs)
are often focused on surveying heads of house- among street-based youth than their non-street-
holds. A population census may include orpha- based peers (Pinto et al. 1994).
nages, but orphans living on the streets will still
be overlooked. The model-based estimates are
calculated from population data derived from
census and household surveys and are thus as
likely as the previous methods to exclude orphans
Working Children
in a non-household setting. While this is not a
major problem for the population estimates since Child workers are not always found to be at greater
the numbers of orphaned children in orphanages health risk, except for occupational risk, which may
and on the streets are very small compared to the be particularly marked in some industries (Mull and
total number of orphans, it means that separate Kirkhorn 2005). Sexually transmitted diseases are
studies are needed to describe these special popu- common among child prostitutes and injuries fre-
lations and serve the information needs of pro- quently result from various types of labor (United
grams serving orphaned, abandoned, and run- Nations 2000a). Working children are often the
away children. These studies may involve sample victims of physical and sexual abuse at the hands
of their employers (Salaam 2005). Child soldiers are in centers specifically created for their care’’ (Dowell
especially vulnerable to violence and abuse (Coali- et al. 1995).
tion to Stop the Use of Child Soldiers 2004). A study by Oleke et al. (2006) observed major
changes in fosterage patterns under the impact of
conflict and HIV/AIDS among the Langi in Uganda,
resulting in an unclear and evolving situation.
Orphans and Vulnerable Children According to the authors ‘‘we are witnessing a cultural
transition of considerable dimensions: the earlier
Several studies report higher incidence of malnutri- situation dominated by the voluntary exchange of
tion among OVCs than non-OVCs of similar socio- children for the prime benefit of building closer ties
economic backgrounds (Watts et al. 2007; Miller between relatives is today substituted by an atin kic
et al. 2007; Jayasekera 2006). Higher HIV-1 sero- scenario, i.e., an orphan scenario in which the cus-
prevalence rates have also been found among tomary fostering pattern has almost ceased to exist.
orphan populations with rates being particularly The number of orphans is so overwhelming and the
high for orphans 0–4 years of age (Kamali et al. burden of taking care of them so immense that there is
1996). A greater incidence of mental health pro- often little or no room left for considerations of either
blems among OVCs has been indicated by many lending out or taking in children when there is not an
studies (Ahmad et al. 2007; Cluver and Gardner acute need to do so’’ (Oleke et al. 2006). This devel-
2006; Atwine et al. 2005). opment is explained by the authors as the likely ‘‘tran-
sition from ‘purposeful’ to ‘crisis’ fostering. Such a
transition is characterized by a situation where rela-
tives increasingly have to take on the duty of caring
Children Exposed to Conflict or Disaster for children due to conditions of death and dying as
opposed to a situation where child fostering occurred
The literature consistently finds that children purposefully for the strengthening of kin relations, for
exposed to conflict, or disaster, are at high risk for the exchange of labor resources, or for the learning of
various health consequences (Singh et al. 2006). skills, etc’’ (Oleke et al. 2006).
High incidences of post-traumatic stress disorder
(PTSD) have been found among children exposed
to natural disasters, and armed conflict is associated
with psychological trauma in children (John et al. Policies and Strategies for Addressing
2007; Kar et al. 2007; Padmanabhan 1992). Armed
the Problem of Children in Difficult
conflict disproportionately affects children, with
abuse, kidnapping, and injury being common con-
Circumstances
sequences. Higher rates of malnutrition and disease
have also been reported among populations of chil- Policies and strategies to address the problem of
dren exposed to conflict or disaster (Singh et al. children in difficult circumstances deal with both
2006; Toole and Waldman 1993). Studies indicate causes and consequences of difficult circumstances.
that children exposed to complex emergencies and A number of policy initiatives attempt to target the
disasters are especially vulnerable, even compared factors that can disrupt childhood in the first place.
to children in orphanages and other centers for Among these are the Convention on the Rights of
unaccompanied children that have not been the Child and the ILO Convention 182 on Worst
impacted by conflict. For example, a study by Dow- Forms of Child Labor, and other global initiatives
ell et al. (1995) found that ‘‘the extremely high mor- that aim to combat certain forms of child labor,
tality rates among unaccompanied refugee children trafficking, and/or sexual exploitation. These are
during the first 6 weeks after the arrival of Rwandan primary preventive measures that attempt to
refugees in Goma, Zaire, illustrates that unaccom- address the root causes of difficult circumstances.
panied children in refugee settings are at particular Other types of interventions focus on mitigating the
risk for disease and death even after they are placed harmful effects of the particular circumstance on
children who for any number of reasons are in Working Children

difficult circumstances. These interventions are dis-
cussed below according to the type of circumstance, In their recent report ‘‘The end of child labor:
as programs are usually more specific to the causes Within reach,’’ the ILO concluded that ‘‘child
of vulnerability. Any interventions in support of labor elimination and poverty reduction through
children in difficult circumstances must account economic development go hand in hand. The
for the differences in the needs of the various groups relationship is not automatic, however. Policy
of vulnerable children. While the spectrum of inter- choices matter and they must be coherent. The
ventions that are carried out is wide, best practices pace of child labor elimination accelerates when
are only beginning to emerge. strategies open up ‘gateways of opportunity’ for
poor people’’ (ILO 2006). According to the ILO,
Asia’s example particularly shows that poverty
reduction and access to education are prerequi-
Street Children sites for progress in the elimination of child
labor. Box 26.3 summarizes the case study of
The World Bank has developed a useful categoriza- child labor in China.
tion of at-risk youth (Box 26.2) that categorizes street
children according to their level of social isolation.
By category, intervention strategies for each of these
three levels are recommended (Volpe 2002). The
strategies include primary prevention (poverty alle- Orphans and Vulnerable Children
viation/poverty elimination), secondary prevention
(family-targeted support), and tertiary prevention The UK Consortium on AIDS and International
(‘‘treatment’’ of dislocated children). This framework Development (2004) suggests a number of core stra-
acknowledges the need for systemic approaches to tegies should be used to achieve best practices in
the problem of street children. OVC programming:
Box 26. 2 Categories of Risk and Intervention Strategies
Youth in primary risk are still attached to the family and society. However, because of poverty or
other factors of their situation, they could be compromised in the future. Programs at this level are of
a preventive nature and typically include universal family and child benefit services, along with
programs targeted to poor communities such as school support, health promotion, recreation, and
social integration, vocational training, and support to family livelihood.
Youth in secondary risk have weaker social ties and are already exposed to some form of specific risk
(such as school dropout, abuse, child labor). Programs at this level have a preventive nature but are
focused on a specific target group and include specialized family support, protection and organization of
working children, abuse prevention, dropout prevention, and other such services. One of the differences
between primary and secondary prevention programs is that secondary prevention requires creative and
costly assessment and detection of needs to determine which families and youth are at specific risk.
Youth in tertiary risk are those for who one or more of the previously mentioned risks are concrete
realities. Their ties with society and family are seriously weakened or severed. This group includes
children in the street and of the street. This is the place for rehabilitative programs such as group
homes, drop-in centers, targeted health and education services, psychological and legal support, job
training, children organization, and family and school integration. Interventions can be center based
or take place in the street.
Source: Volpe (2002)
Box 26. 3 Addressing Child Labor in China
China ratified ILO Convention No. 138 in 1999 and ILO Convention No. 182 in 2002. Convention No.
138 determined regulations for workers’ minimum age requirements by region. New regulations and
convention ratifications took effect on December 1, 2002, to ban the employment of any children under
the age of 16 years. The new regulations impose fines for violations and require employers to check
workers’ identification cards.
There are other indications that China is increasingly willing to address the issue of child labor.
During the consideration by the United Nations Committee on the Rights of the Child of China’s second
report in September 2005, there was official recognition that there were children in need of special
protection measures, including street children, children of migrants, and those vulnerable to trafficking.
China still faces multiple challenges in child protection owing to visible disparities between urban
and rural areas and a traditional culture favoring boys over girls.
Since the proportion of children working is low, the challenge is to reach out and identify the isolated
pockets of child labor. One group that is receiving greater attention is the children of migrant workers who
are left behind with family members or those who are living with their parents in cities, but without access
to education. Moreover, the problem of child labor may spread with the rapid growth of labor-intensive
industries.
IPEC has been working in Yunnan Province since 2000 as part of the Mekong sub regional project to
combat trafficking in children and women. In 2004, IPEC launched a new project to prevent trafficking in
girls and young women for labor exploitation within China. China was also represented at the first regional
capacity-building training course on child labor data collection organized by the ILO, together with the
inter-agency research project Understanding Children’s Work (UCW), held in Bangkok in November
2004. This reflects a growing willingness by China to learn from the experiences of other countries.
Source: IL0 (2006)
Strategy 1: Strengthen capacity of families to with Strategy 2, ‘‘Mobilize and support community-
protect and care for orphans and vulnerable chil- based responses,’’ as its central tenet.
dren by prolonging the lives of parents and pro-
viding economic, psychosocial, and other
support.
Strategy 2: Mobilize and support community- Children Exposed to Conflict or Disaster
based responses.
Strategy 3: Ensure access for OVC to essential
Much of the research of OVC in disasters and
services, including education, health care, birth
complex emergencies focuses on care for children
registration, and others.
that have been orphaned or separated from their
Strategy 4: Ensure that governments protect the
parents. This involves questions of physical and
most vulnerable children through improved pol-
emotional well-being as well as long-term
icy and legislation and by channeling resources
options and opportunities. Overall, institutional
to communities.
care is widely discouraged and foster care is
Strategy 5: Raise awareness at all levels through
often regarded as the preferred option. A study
advocacy and social mobilization to create a
by Duerr et al. (2003) found strong ‘‘empirical
supportive environment for children and families
support for the United Nations recommendation
affected by HIV/AIDS.
that during acute emergency situations, children
The World Vision research reviewed in Box 26.4 should be fostered with other families whenever
further confirms the success of these best practices, possible, not isolated from their communities
Box 26. 4 Promising Practices in OVC Responses
World Vision conducted qualitative research exploring and documenting communities’ experiences
and reflections of OVC programming in six countries – Kenya, Malawi, Rwanda, Swaziland,
Uganda, and Zambia, particularly looking at the role of Community Care Coalitions.
Community Care Coalitions with a broad spectrum of stakeholders were viewed very positively in
OVC programming. The central role of coalitions is to mobilize and coordinate OVC care activities.
Typical members of the coalitions include churches and faith-based organizations (FBOs), teachers,
community leaders such as chiefs, people living with HIV/AIDS (PLWHA), traditional birth
attendants, home-based care providers, health-care providers, OVC care providers, women’s groups,
and development committee members. In one case the coalition had a subcommittee consisting of
orphans and vulnerable children, and their inclusion was seen as a positive innovation.
Coalitions are a powerful conduit for advocacy, particularly regarding OVC access to education,
and child abuse including child labor. Coalitions provide a means for greater accountability in the use
of resources. Faith-based organizations in particular are central to the OVC response and provide a
range of services individually, as well as core members of community care coalitions. Strengths of
FBOs are their wide reach, volunteerism, and mobilization of existing resources.
In terms of mobilizing resources for community responses, the primary source of resources was
from within the community itself. Although resources within the community are inadequate, care
needs to be taken that the provision of external resources is done in a manner that does not under-
mine, but rather supplements and enhances, traditional coping mechanisms. Community care coali-
tions can provide a structure and means of channeling external resources into communities. The
coalition members can develop community plans with specific resource requirements and evaluation,
ensuring transparency to the wider community. Where there is a need for further training, NGOs are
natural allies and can provide both capacity building and resources to coalitions.
There are many unmet training needs, and when training such as proposal writing, home-based
care, and counseling was offered, it enhanced coalitions. Educating the community on the roles and
objectives of the coalition was essential to avoid unrealistic expectations from the community.
Child participation enhanced the planning, implementation, and monitoring of OVC activities
and should become the norm for all coalitions. Child/youth clubs and church activities lend them-
selves to greater child participation and this opportunity should be utilized. Such clubs are enhanced
by endorsement and appropriate support from adult patrons. Child-to-child approaches to care need
to be identified and enhanced with appropriate support.
Finally, community-to-community learning demonstrates potential to contribute to the scaling up
of OVC response. The methodology should be documented in a user-friendly toolkit and trainings,
including documentation of best practice, and monitoring and evaluation.
Source: UK Consortium on AIDS and International Development (2004)
in institutions (Duerr et al. 2003). A study of but as many signs and symptoms of emotional
different groups of orphans impacted by conflict distress as orphanage children. Group-home
in Eritrea (Wolff and Fesseha 2005) indicates orphans had fewer signs and symptoms of emo-
variation in adaptive skills and emotional dis- tional distress and greater adaptive skills than
tress between institutional orphans, group-home either reunified or institutional orphans, and
orphans, and orphans reunited with their family: they had fewer symptoms of emotional distress
‘‘Orphans reunified with extended families had than home-reared children. However, placing
greater adaptive skills than institutional orphans orphans in small group homes was far more
expensive than reunifying them with extended often result in orphanhood, dislocation from
families’’ (Wolff and Fesseha 2005). families, and social systems of support. Ultimately,
these circumstances may lead to adverse emotional
and physical health. Unfortunately, the evidence-
base available for guiding programs and policies to
Conclusions address this issue is highly limited due to the highly
contextual nature of difficult circumstances, the
Children are increasingly exposed to an array of problems of definition and enumeration, and the
difficult circumstances that may jeopardize their paucity of epidemiologic research on most cate-
growth and development. These circumstances gories of children in difficult circumstances.
Key Terms
Child soldiers Migration Psychosocial trauma

Child trafficking Occupational risk Secondary risk
Community care coalitions Orphan Social dislocation
Community responses Orphanages Street children
Drug abuse Orphans and vulnerable Tertiary risk
Family-targeted support children (OVC) Trafficked children
Forced and bonded labor Population census Urbanization
Foster care Post-traumatic stress disorder Violence
Group-home orphans (PTSD) Working children
Household surveys Poverty alleviation Worst Forms of Child Labor
Malnutrition Primary risk (WFCL)
Questions for Discussion c. Orphans and vulnerable children

d. Children exposed to conflict and disaster
1. Define and provide examples of the following: 5. In an essay of about 1,000 words, present a cri-
tique of existing strategies and policies for
a. Orphans
addressing the problem of children in difficult
b. Vulnerable children
circumstances.
c. Street children
d. Child labor
2. List the factors that contribute to the increasing
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Chapter 27
Integrated Management of Childhood Illness
Martin Meremikwu and John E. Ehiri
Learning Objectives After reading this chapter and are to (i) improve the case management skills of
answering the discussion questions that follow, you health professionals through the provision of locally
should be able to adapted guidelines and the development of activities
to promote the use of such guidelines; (ii) improve
Discuss milestones in the emergence of IMCI as a
health systems needed to allow effective manage-
strategy for child health promotion in developing
ment of childhood illnesses; and (iii) improve family
countries.
and community practices relevant to child health
Discuss the key objectives of the IMCI program.
promotion. This chapter presents a historical per-
Describe the core technical components of IMCI
spective on the emergence of IMCI as a strategy
with emphasis on the evidence base of the asso-
for child health promotion in middle- and low-
ciated interventions.
income countries and describes the core technical
Analyze limitations and challenges of the IMCI
components of IMCI with emphasis on their evi-
initiative.
dence base. Case studies of field implementation
Appraise the current status of IMCI and the pro-
are described. The chapter concludes with an apprai-
spects for scaling it up to improve child health
sal of the current status of IMCI and of the prospects
globally.
for scaling it up to improve child health globally.
Worldwide, children from low- and middle-
income countries are 10 times more likely to die
Introduction
before their fifth birthday than their counterparts
in industrialized, high-income countries (Global
The causes of morbidity and mortality among
Action for Children 2008). As shown in Fig. 27.1,
children in less developed countries are often multi-
about 70% of an estimated 10 million deaths among
ple and inter-related. For this reason, effective and
children under 5 years of age in these countries are
efficient treatment of these conditions requires a
due to preventable and curable diseases such as
comprehensive case management approach that
malaria, diarrhea, measles, HIV/AIDS, and acute
recognizes the complexity of childhood problems in
respiratory infections (ARI) (Global Action for
resource-limited settings. The integrated manage-
Children 2008). Malnutrition, an underlying cause
ment of childhood illnesses (IMCI) initiative was
of mortality, contributes to 53% of these deaths
introduced by the World Health Organization
(WHO 2003). Several internationally supported pub-
(WHO) and the United Nations Children’s Fund
lic health initiatives often referred to as child survival
(UNICEF) in the 1990s in response to the limitations
interventions have, to varying degrees of success,
of the child survival revolution of the 1980s that was
attempted to reduce the high rates of childhood
based on disparate vertical programs. Its objectives
death. Most of these initiatives were coordinated
and implemented by UNICEF and the World
Health Organization. Notable among these were
M. Meremikwu (*)
University of Calabar Teaching Hospital (UCTH), Calabar, the control of diarrheal diseases program, including
Cross River State, Nigeria the use of oral rehydration therapy, control of acute
498 M. Meremikwu and J.E. Ehiri
Table 27.1 Complexity of childhood illnesses

Possible cause or associated
Presenting complaint condition
Cough and/or fast Pneumonia
breathing Severe anemia
Plasmodium falciparum malaria
Lethargy or Cerebral malaria
unconsciousness Meningitis
Severe dehydration
Very severe pneumonia
Measles rash Pneumonia
Diarrhea
Ear Infection
‘‘Very sick’’ young Pneumonia
infant Meningitis
Sepsis
Fig. 27.1 Distribution of 11.6 million deaths among children Source: WHO (1999)
less than 5 years old in all developing countries, 1995. Source:
World Health Report (2003); Caulfield et al. (2004)
respiratory infections program, infant nutrition pro- This means that a single diagnosis may not be
grams including the promotion of breastfeeding, and possible or appropriate, and treatment may be com-
the Expanded Program on Immunization (Ehiri and plicated by the need to combine therapy for several
Prowse 1999; Pelletier et al. 1995). conditions (WHO 1999). Responding to this chal-
The verticality and multiplicity of these pro- lenge in the late 1980s and early 1990s, various
grams pose significant service delivery and admin- health programs, professionals, and international
istrative problems, especially at health facility levels development agencies began to experiment with
owing to their limited integrated approach and lack integrated case management strategies (Ehiri and
of emphasis on health systems development. In spite Prowse 1999). Programs that previously targeted
of the limitations of these vertical programs, global individual diseases began to tackle disease com-
health policy makers and funding agencies continue plexes. For example, the Technology for Primary
to support them. For example, current global initia- Healthcare (PRITECH) program of the United
tives for control and prevention of HIV/AIDS, States Agency for International Development
tuberculosis, and malaria have been mostly vertical (USAID) which initially concentrated on case man-
or semi-integrated at best. There is comparatively agement of diarrhea began to incorporate malnutri-
little emphasis on strengthening health systems that tion, aspects of ARI control activities, and hygiene
lack the capacity to support the large investments in promotion (Ehiri and Prowse 1999). Integrated
these initiatives. Vertical programs are more likely Management of Childhood Illnesses (IMCI) was
to achieve rapid short-term results than comprehen- subsequently launched by WHO and UNICEF in
sive, community-driven approaches advocated in 1992 and received endorsement by the World Bank
Alma-Ata Declaration of Primary Healthcare in their 1993 report (World Bank 1993). IMCI com-
(WHO/UNICEF 1978), but they have a tendency bines improved management of childhood illness
to divert resources from programs that offer longer with aspects of nutrition, immunization, and other
term, sustainable outcomes and opportunities for important factors that influence child health,
health system development. including maternal health (Fig. 27.2). Its overall
Lessons learned from experimentation with var- goals were to reduce death, the frequency and sever-
ious disease-specific child health initiatives of the ity of illness and disability, and to contribute to
1980s and 1990s in less developed countries improved growth and development (WHO 1999).
(Campbell and Gove 1996) showed that children It was perceived that these goals would be achieved
with severe illnesses often present with overlap- by (i) improving the case management skills of
ping signs and symptoms (Table 27.1). health professionals through the provision of
locally adapted guidelines and the development
27 Integrated Management of Childhood Illness 499
Fig. 27.2 Scope of

Integrated management of childhood illness (IMCI) as a key strategy
integrated management of
childhood illness. Source:
for improving child health
WHO (1999) Management of Nutrition Immunization Other disease
Illness prevention
Promotion of growth
and development
Integrated management of
childhood illness (IMCI)
Interventions currently included in the IMCI strategy
Promotion of growth Response to sickness (“curative

Prevention of disease care”)
Home -Community/home-based -Early case management
interventions to improve nutrition -Appropriate care-seeking
-Insecticide-impregnated bednets -Compliance with treatment
Health -Vaccination -Case management of: ARI, diarrhea,
Services -Complementary feeding and measles, malaria, malnutrition, other
breastfeeding counseling serious infection
-Micronutrient supplementation -Complementary feeding and
breastfeeding
-Iron treatment
-Antihelminthic treatment
Interventions included in the IMCI guidelines for first-level health

workers
Conditions covered by case Preventive interventions
management
Generic version Acute Respiratory infections Immunization
Diarrhea Nutrition counseling
Dehydration Breastfeeding support
Persistent diarrhea Vitamin A supplementation
Dysentery
Meningitis, sepsis
Malaria
Measles
Anemia
Ear infection
Using the IMCI HIV/AIDS Periodic de-worming
Adaptation Dengue hemorrhagic fever
Guide Wheeze
Sore throat
of activities to promote the use of such guidelines; It also incorporates a range of other preventive and
(ii) improving health systems needed to allow effec- curative interventions that aim to improve practices
tive management of childhood illnesses; and both in health facilities and at home.
(iii) improving family and community practices rele- There is an understanding that the combination of
vant to child health promotion. The core interven- interventions that make up IMCI may be modified to
tion is integrated case management of the five most include conditions that are important in individual
important causes of childhood deaths – ARI, diar- countries and for which there are effective preventive
rhea, measles, malaria, and malnutrition (Fig. 27.2). measures and/or treatment. The following section
provides further description of the three technical

components of IMCI, i.e., (i) improving the case Box 27.1 Principles of Integrated Care
management skills of health professionals through
the provision of locally adapted guidelines and the All sick children must be examined for ‘‘gen-
development of activities to promote the use of such eral danger signs’’ which indicate the need for
guidelines; (ii) improving health systems needed to immediate referral or admission to a hospital.
allow effective management of childhood illnesses; All sick children must be routinely assessed
and (iii) improving family and community practices for major symptoms (for children age 2
relevant to child health promotion. months up to 5 years: cough or difficult
breathing, diarrhea, fever, ear problems; for
young infants age 1 week up to 2 months:
bacterial infection and diarrhea). They must
also be routinely assessed for nutritional
Improving the Skills of Health Workers and immunization status, feeding pro-
blems, and other potential problems.
At the inception of IMCI in the early 1990s, empha- Only a limited number of carefully selected
sis was placed on training health-care workers to clinical signs are used, based on evidence of
improve the quality of health care at first-level their sensitivity and specificity to detect disease.
health facilities. Training in approaches for opti- These signs were selected considering the con-
mum integration of case management is the princi- ditions and realities of first-level health facilities.
pal activity of this component. The principles of A combination of individual signs leads to a
integration of care are outlined in Box 27.1. They child’s classification(s) rather than a diagnosis.
provide the core values for IMCI implementation. Classification(s) indicate the severity of condi-
Training provided under this component equips tion(s). They call for specific actions based on
health workers with the requisite skills to assess, whether the child (a) should be urgently referred
classify, treat, or make appropriate referral for to another level of care, (b) requires specific
sick children attending first-level health facilities treatments (such as antibiotics or anti-malarial
using a syndromic approach. treatment), or (c) may be safely managed at
As noted in Fig. 27.3, the IMCI approach has home. The classifications are color coded:
identified non-specific signs of serious illness that ‘‘pink’’ suggests hospital referral or admission,
should be routinely assessed for every sick child. ‘‘yellow’’ indicates initiation of treatment, and
These signs (referred to as ‘‘general danger signs’’) ‘‘green’’ calls for home treatment.
include convulsions, lethargy or unconsciousness, The IMCI guidelines address most, but not
vomiting, and inability to drink or breastfeed. A all, of the major reasons a sick child is brought
child with one or more of these general danger to a clinic. A child returning with chronic
signs is classified as having severe disease which problems or less common illnesses may
requires immediate referral to a higher level of care require special care. The guidelines do not
following a pre-referral treatment, where appropri- describe the management of trauma or other
ate. The IMCI case management training course acute emergencies due to accidents or injuries.
involves practical demonstrations and exercises in IMCI management procedures use a lim-
clinical settings that are aimed at exposing the trai- ited number of essential drugs and encou-
nee to the wide spectrum of case scenarios related to rage active participation of caretakers in
integrated case management of the sick child. The the treatment of children.
WHO first developed a standard and elaborate cur- An essential component of the IMCI guide-
riculum, in addition to learning and evaluation lines is the counseling of caretakers about
tools. The training was originally designed as an home care, including counseling about feeding
11-day in-service course, but has been modified to fluids and when to return to a health facility.
a shorter option and a pre-service version for health Source: WHO (2001a)
workers (nurses and community health workers) in
Fig. 27.3 Integrated case

Outpatient Health Facility
management process.
Check for DANGER SIGNS
Organization (2001a)
- Convulsions
- Lethargy/unconsciousness
- Inability to drink/breastfeed
- Vomiting
Assess MAIN SYMPTOMS
- Cough/difficulty breathing
- Diarrhea
- Fever
- Ear Problems
Assess NUTRITION and IMMUNIZATION STATUS and
POTENTIAL FEEDING PROBLEMS
Check for OTHER PROBLEMS
CLASSIFY CONDITIONS and IDENTIFY TREATMENT
ACTIONS
According to color-coded treatment
PINK YELLOW GREEN

Urgent Referral Treatment at Outpatient Home Management
Health Facility
OUTPATIENT HOME
HEALTH FACILITY OUTPATIENT HEALTH Caretaker is counseled on:
- Pre-referral treatments FACILITY - Home treatments
- Advise parents - Treat local infection - Feeding and fluids
- Refer child - Give oral drugs - When to return
- Advise and teach caretaker immediately
- Follow-up - Follow-up
REFERRAL
FACILITY
- Emergency Triage and
Treatment (ETAT)
- Diagnosis
- Treatment
- Monitoring and
Follow-up
training (WHO 2001a). The course also teaches and trainers, and, most prominently, the high
participants useful skills in communication and cost of project implementation (WHO 2004). Eva-
client counseling. luation reports have shown that IMCI is cost-
Several evaluations of the IMCI approach have effective in the long term (Bryce et al. 2004). How-
highlighted the positive impact of the enhanced ever, the provision of adequate funding for cost-
counseling and communication skills of the intensive training and early implementation activ-
IMCI-trained health workers (WHO 2004). The ities remains a challenge. While a few countries
primary criticism of the first component of IMCI have made visible progress in IMCI training of
is the slow pace of its implementation (WHO their health workers with donor support, a major-
2004). Several reasons have been given for this ity of others have yet to achieve a quarter of their
slow progress, including the length of training, coverage targets for IMCI training (WHO/UNI-
the challenge of locating suitable training sites CEF 1999).
Improving the Health-Care System communities and supporting families in order to

adopt health-promoting attitudes and to take
Improvement of health systems in the context of the action necessary to improve child survival, growth,
IMCI approach includes the following (WHO/ and development. Based on evidence from research
UNICEF 1999): and successful health-care intervention initiatives,
community IMCI recommends that families and
Improvement in the availability of drugs and
communities be encouraged and supported to take
supplies at first-level health facilities
beneficial actions in order to improve child survival,
Improvement of service quality and organization
growth, and development (UNICEF 2001). These
of health facilities
practices are grouped into four broad areas that
Improvement of referral pathways and care
promote (i) the child’s physical and mental growth;
Identification of methods for sustainable finance
(ii) disease prevention; (iii) appropriate home care;
Ensuring equity of access
and (iv) care seeking and compliance. The recom-
Linkage of IMCI and health information systems
mendations for these four areas are outlined here-
Contribution to health sector reform
under (UNICEF 2001):
Efforts to improve health systems through the
IMCI approach have received limited implementa-
tion support and are the least evaluated of the three
Physical and Mental Growth
components. In reality, initiatives to strengthen the
health system cut across all levels, sectors, and pro-
1. Breastfeed infants exclusively for at least 6
grams within the health-care delivery system. It is
months. Mothers found to be HIV positive
not feasible to domicile the task of improving the
require counseling about possible alternatives
health system within any single health-care initia-
to breastfeeding.
tive. It would also not be appropriate to attribute
2. Starting at approximately 6 months of age, chil-
any improvement in the system to a single program
dren should be fed freshly prepared energy- and
or intervention.
nutrient-rich complementary foods, while conti-
Health system strengthening needs to be rein-
nuing to breastfeed them for up to 2+ years.
forced and aggressively supported as a component
3. Ensure that children receive adequate amounts
of the IMCI strategy, since IMCI can only succeed
of micronutrients (vitamin A and iron in
within a strong health system. It is important that
particular), either in their diet or through
the opportunity provided by IMCI implementation
supplementation.
is used to leverage resources for health system sup-
4. Promote mental and social development by
port. Several cross-cutting issues that address
responding to a child’s needs for care, and
improvement of health-care systems are discussed
through talking, playing, and providing a stimu-
in Chapter 5 on Health Systems and Maternal and
lating environment.
Child Health. Readers are advised to refer to this
chapter for more information on health system
strengthening.
Disease Prevention
5. Take children as scheduled to complete a full

Community IMCI: Improving Family course of immunizations (BCG, DPT, OPV,
and Community Practices and measles) before their first birthday.
6. Dispose of feces, including children’s feces,
This component of IMCI adopts a multi-sectoral safely; and wash hands after defecation, before
approach in order to improve selected behaviors preparing meals, and before feeding children.
and practices at household and community levels. 7. Protect children in malaria-endemic areas, by
This component is referred to as Community IMCI ensuring that they sleep under insecticide-treated
or C-IMCI. It focuses on strengthening bed nets.
8. Adopt and sustain appropriate behavior regard-

ing prevention and care for HIV/AIDS-affected
people, including orphans. Box 27.2 General Principles of C-IMCI
Appropriate Home Care 1. C-IMCI is implemented at district and

community levels, but should be linked to
9. Continue to feed and offer increased fluids to a national strategic plan that provides pol-
sick children. icy direction and an enabling environment.
10. Give sick children appropriate home treatment Links should be established between com-
for infections such as diarrhea and malaria. munity and district-level planning and
11. Take appropriate actions to prevent and man- implementation as well as between district,
age child injuries and accidents. regional, and national levels
12. Prevent child abuse and neglect and take appro- 2. C-IMCI should identify and build on exist-
priate action when it has occurred. ing programs and community structures,
13. Ensure that men actively participate in provi- rather than create new ones
sion of childcare and are involved in reproduc- 3. Participatory approaches to planning and
tive health initiatives. implementing activities should be utilized
to ensure ownership and sustainability
Care Seeking and Compliance 4. Successful implementation of C-IMCI
requires effective partnerships at all levels.
14. Recognize when sick children need treatment Clear definitions of roles and responsibil-
outside the home and seek care from appropri- ities of all stakeholders are essential
ate providers. 5. C-IMCI recognizes the importance of cura-
15. Ensure that every pregnant woman has ade- tive and preventive interventions in the
quate antenatal care. This includes having at community for reducing child mortality
least four antenatal visits with an appropriate and morbidity and for promoting child
health-care provider and receiving the recom- growth and development
mended doses of the tetanus toxoid vaccination. 6. Implementation of C-IMCI requires the
The mother also needs support from her family other two IMCI technical components to
and community in seeking care at the time of be in place to provide support for families
delivery and during the postpartum and lacta- and communities. In some situations, how-
tion period. ever, where the other two components are
16. Follow the health worker’s advice about treat- not in place, it may be appropriate to
ment, follow-up, and referral. implement C-IMCI interventions. In such
cases, efforts should be made to ensure that
the other two components are introduced
General Principles, Programmatic 7. Phased introduction of promotion of key
Elements, and Frameworks for C-IMCI family practices is acceptable. Families and
communities must not be overwhelmed by
The Child Survival Collaborations and Resources the introduction of too much at once, but a
(CORE) Group, a member of the inter-agency work- good C-IMCI plan should include the even-
ing group on community IMCI, has played a key tual phasing in of all the appropriate practices
role in developing the guiding principles for this Source: WHO (2004)
component of IMCI (CORE Group 2007). The
Inter-agency working group for community IMCI
includes WHO, UNICEF, and others (notably the
CORE Group) and has identified seven general prin- These principles emphasize core values and ele-
ciples to guide the development, implementation, ments of the Alma-Ata concept of comprehensive pri-
and evaluation of C-IMCI at all levels (Box 27.2). mary health care, such as community participation,
integration with existing health programs, and inter- Table 27.2 Three programmatic elements of the C-IMCI
sectoral collaboration. This affirms the belief that Examples of corresponding
Alma-Ata remains the ideal and a reference point for Elements objectives
initiatives that seek to achieve holistic health care at the Element 1
Improving partnership Increase utilization of health
community level. It is important to note that these
between health facilities facilities and services.
guidelines notwithstanding, the key determinants of and services and the Establish mechanisms for
outcome are context, culture, and commitment to communities they serve community feedback on
values and objectives. Results of the multi-country and/or management of
health facilities and
evaluation of IMCI (Bryce et al. 2004) and country-
services
specific experiences (Schellenberg et al. 2004) lend sup- Element 2
port to proof of effects of the basic principles of the Increasing appropriate, Increase quality of care from
integrated approach. However, coverage or impact accessible care and community-based
remains sparse due to the impact of adverse socio- information from providers. Increase
ommunity-based promotion of preventive
economic contexts, cultural preferences or limitations,
providers practices by community-
and poor political commitment. The sixth principle based providers. Decrease
(Box 27.2) highlights the critical importance of concur- harmful practices of
rent implementation of the three components of IMCI community-based
providers
but admits that compromise and tendency toward dis-
Element 3
cordant implementation is common. This tends to Integrated promotion of key Increased adoption of key
dilute expected impacts of the strategy. family practices critical family practices for
To give further impetus to the implementation for child health and health, nutrition, and
of C-IMCI, two implementation frameworks have nutrition development. Engage
communities in selecting
been proposed: one by the Child Survival Colla- behaviors to be promoted
borations and Resources (CORE) Group and and identifying actions to
USAID’s Basic Support for Institutionalizing be taken
Child Survival (BASICS II) and the other by Source: Winch et al. (2001)
WHO Western Pacific Region. The CORE
Group/BASICS II proposed three programmatic
elements (Table 27.2) that constitute the opera- 1) Partnership and linkages – The implementation
tional framework for C-IMCI (Winch et al. of C-IMCI offers a distinct opportunity for
2001). This framework shows how the points of health and development programs in private
intervention could interplay with various inputs to and public sectors to work together in simple
achieve the implementation goals of C-IMCI. The collaboration, such as information sharing, or
framework highlights the centrality of partnership, coordination of shared resources. Partnerships
community involvement, and integration in the in C-IMCI link health facilities, the community,
design and implementation of C-IMCI, using the government (health and other sectors), pub-
experiences and examples of community-based lic and private health providers, different health
programming. organizations, and community-based organiza-
The C-IMCI framework developed by the WHO tions (CBOs) implementing C-IMCI. Effective
Western Pacific Region (WPR) shows the processes collaboration leads to coordinated efforts and
by which the three components of IMCI (i.e., subsequent improvement of mobilization and
improved health provider skills, strengthened utilization of resources. This increases the utili-
health system, and improved family practices) zation of health facilities and services at the com-
work to improve child health and development. munity level due to increased coordination of
Critical issues in planning C-IMCI services are communication through direct partnership
shown in Fig. 27.4. C-IMCI framework works to linkages.
improve child health and development through the 2) Community mobilization and motivation – Pro-
coordinated effect of four complementary processes motion of community mobilization and motiva-
(WHO 2004) (Fig. 27.5): tion increases the quality of care from
Fig. 27.4 Critical issues in Stakeholders Involvement

planning C-IMCI services.
Organization (2004) Collaboration and Partnership
Policies and Guidelines
Services
Key
Practices
Information
Drugs and Supplies Capacity Development
Communication
Component 1 Component 2
Improved health Strengthened
provider skills health system
Healthy Child
Component 3
Improved key
family practices
Partnerships Community Health Means for

and mobilization information improving
Linkages and and key
motivation promotion practices
Fig. 27.5 Operational framework for community IMCI (C-IMCI). Source: World Health Organization (2004)
community-based providers by establishing strategy for planning and implementing inter-

mechanisms for community feedback on and/ ventions in order to improve key practices. It
or management of health facilities and services. is a process in which families, community
It increases appropriate, accessible care and members, and decision makers are engaged
information in addition to promoting preven- in discussions. These discussions enable colla-
tive practices from community-based providers. boration and informed decision making for
Increasing mobilization leads to increased positive behavior change. Promotion activities
access for families to health providers or facil- should enhance the communities’ vision for
ities that treat sick children and communicate their future and should be complemented by
effectively. This increases the prevalence of ade- other interventions that focus on community
quate home care and promotes a home environ- mobilization, training, service-delivery
ment that decreases harmful practices of com- improvement, new or improved technologies,
munity-based providers and supports children’s and/or policy change.
healthy growth and development. 4) Means for improving key practices – An
3) Health information and promotion – Effec- increase in the adoption of key family prac-
tive, efficient communication is a central tices for health, nutrition, and development
needs to be targeted in C-IMCI interventions. Table 27.3 Indicators of health worker skills, health systems
Improvement of key practices is vital to the support, assessment, and referral of very sick children
enhancement of child health. Communities Category Indicators
should engage in selecting key practices that Health workers skills
enhance and identify the integrated promo- Assessment of sick Checked for presence of cough,
children diarrhea, and fever
tion of key family practices that are critical
Weight checked against growth
for the improvement of child health and chart
nutrition. Vaccination status checked
Assessed for feeding practices if
under 2 years
Checked for other problems
Correct Correctly classified
classification Correctly classified omitting coughs,
Evidence Base for IMCI Approach and colds, no dehydration
Correct treatment Pneumonia correctly treated
Implementation Experiences Malaria correctly treated
Anemia correctly treated
Most of the disease-based interventions which Child needing oral antibiotic and/or
oral anti-malarial prescribed drug
have been ‘‘integrated’’ within IMCI (viz., treat- correctly
ment of malaria, pneumonia, control of diarrheal Child not needing antibiotic leaves
and major vaccine preventable diseases) have their the facility without antibiotic
basis in sound research evidence. However, the Child needing vaccinations leaves
the facility with all needed
integration approach does not appear to have vaccinations
been supported by direct evidence from well- First dose of treatment given at
designed research prior to its implementation. A facility
Cochrane systematic review on health-care inte- Counseling and Caretaker advised to give extra
communication fluids and continue feeding
gration programs (including the IMCI) found Caretaker of child prescribed ORS,
insufficient studies to show whether or not strate- oral antibiotic, and/or oral anti-
gies that integrate health-care interventions at the malarial knows how to give the
point of delivery are effective (Briggs and Garner treatment
Caretaker of child prescribed oral
2007). In essence, the IMCI approach could be
medication advised on how to
described as a large implementation research pro- administer treatment
gram. The series of multi-country evaluation stu- Caretaker advised when to return
dies set up by the WHO and its technical partners immediately
Caretaker given or shown a
(Bryce et al. 2004; Tanzania IMCI Multi-Country
mother’s nutrition and counseling
Evaluation Health Facility Survey Study Group card
2004) has been a good attempt at evaluating IMCI Health systems support
as a global health-care initiative and as an imple- Availability of Index of availability of essential
mentation research program. There remains a drugs oral treatments (mean)
Availability of Health facility has equipment and
need for more controlled studies that are ade- vaccines supplies to support vaccination
quately designed and powered to answer pertinent services
questions. These questions pertain to the effective- Index of availability of four
ness of the integration approaches and whether or vaccines (mean)
not it would increase efficiency, improve quality Availability of Health facility has essential
supplies equipment and materials (includes
of care, and positively impact childhood morbid- accessible, working weighing scales
ity and mortality. Table 27.3 shows the indicators for adults and children, timing
that were used in the WHO multi-country evalua- device, child health cards, source
tion studies. Box 27.3 presents a summary of inter- of clean water, spoons, and cups
and jugs to mix and administer
pretation of the findings of the WHO multi-coun- ORS)
try evaluation of IMCI.

Coverage should be the driving force
Category Indicators
behind district, national, regional, and
Health facility has IMCI chart
booklet and mother’s nutrition and global child survival programs. Only by
counseling card paying close attention to whether
Supervision visits Health facility received at least one mothers and children receive interven-
supervisory visit that included tions can we decipher whether the deliv-
observation of case management
during the previous 6 months ery methods are effective and equitable
Very sick children and whether mortality reductions are
Assessment Child checked for three danger likely to occur. Public accountability at
signs: all levels can bring delivery bottlenecks to
– Able to drink or breastfeed the attention of all and encourage rapid
– Vomits everything
– History of convulsions
action to address them.
Child not visibly awake checked for Countries and districts should be encour-
lethargy aged to prioritize, and to implement first,
Referral Child needing referral is referred those interventions known to be cost-
Index of availability of injectable
drugs for pre-referral treatment
effective in reducing under-5 mortality.
(mean) Better tools to support policy and decision
Source: Tanzania IMCI Multi-Country Evaluation Health makers in estimating the costs and impact
Facility Survey Study Group (2004) of their choices are needed urgently.
Ensuring that resources are available, not
only for time-limited projects but also in
the longer term, is essential to allow suffi-
Box 27.3 Summary of Interpretation of cient time for planning and implementa-
Findings of the WHO Multi-country Studies on tion to mature and yield impact.
Evaluation of the Effectiveness of IMCI Much more policy-relevant research is
needed and should be conducted at the
Child survival efforts must begin with local country level, especially studies that focus
epidemiology, targeting the major causes on the effectiveness of policies and strate-
of death within each region, country, and gies implemented by Ministries of Health
even district. and their partners.
IMCI guidelines for the case management Source: Tanzania IMCI Multi-Country
of ill children in health facilities, supported Evaluation Health Facility Survey Study
by high-quality training and supportive Group (2004)
supervision, are the gold standard and
should continue to be implemented widely.
New multi-country study findings that Implementation Experiences – Successes
IMCI is efficient and costs less than routine
and Challenges
care in some settings are encouraging.
To be successful in reducing child mortal- The implementation of IMCI involves three
ity, programs must move beyond health phases: introduction, early implementation, and
facilities and develop new and more effec- expansion. The goal of preliminary visits and
tive ways of reaching children with proven activities in the introductory phase is to create a
interventions to prevent mortality. In most good understanding of IMCI strategy among
high-mortality settings, this means provid- health professionals and decision makers in the
ing case management services at commu- health sector. This will enable them to make
nity level, as well as focusing on prevention informed decisions on whether to adopt the strat-
and on reducing rates of under-nutrition. egy, to encourage their full participation in the
planning process, to agree on the management
structure for early implementation, and to win introductory and early implementation phases
the commitment of the national government were largely donor-supported which gave policy
through the Ministry of Health. While most of makers the erroneous impression that the
these visits succeed in convincing national govern- approach would always be donor-supported.
ments of the majority of countries in developing The result has been that most countries barely
countries to adopt the IMCI approach, the extent go beyond the early implementation phase, since
to which these efforts have won adequate political the expansion phase involves relatively high bud-
commitment remains unclear. gets which local authorities do not envisage in
Given the generally low priority accorded to the short or medium term and therefore are not
IMCI in most of the participating countries, it prepared to invest in. The continuing effort to
appears that these processes were either not summarize the available research reports on the
effective to win sufficient political support or implementation process and effectiveness of
failed to offer adequate information to policy IMCI beyond the scope of the WHO multi-coun-
makers in regard to cost-implications and bene- try studies is presented in Table 27.4. These
fits. The other potential reason is that the studies have addressed diverse outcome variables
Table 27.4 Summary of studies that evaluated different aspects of IMCI implementation
Source/year/
location Study design Objective Findings
Victoria et al. Observational study To describe geographical –Study found that areas of
(2006) patterns of implementation of greatest need (district and
(Brazil, the Integrated Management of communities with poor
Peru, Childhood Illness (IMCI) development and health
Tanzania) strategy in three countries, indices) were not prioritized.
Brazil, Peru, and Tanzania, IMCI implementation strategy
and to assess whether the lacks guidelines to promote
strategy was implemented in equity
areas with the most pressing –Authors propose ‘‘equity
child health needs analyses’’ to ensure that
geographical deployment of
new programs and strategies
reach those who need them
most
El Arifeen et al. Cluster-randomized: 20 first- To determine the effectiveness –Health systems supports were
(2004) level outpatient facilities in the and efficiency of IMCI generally available, but
(Bangladesh Matlab sub-district and their implementation in Bangladesh implementation of the
(Matlab sub- catchment areas were which includes health worker community activities was slow
district) randomized to either IMCI or training, health systems – Mean index of correct
standard care support, and community level treatment for sick children was
activities guided by formative 54 in IMCI facilities compared
research with 9 in comparison facilities
(range 0–100)
–Use of the IMCI facilities
increased from 0.6 visits per
child per year at baseline to 1.9
visits per child per year about
21 months after IMCI
introduction
–19% of sick children in the
IMCI area were taken to a
health worker compared with
9% in the non-IMCI area

Source/year/
location Study design Objective Findings
Ali et al. (2005) Quasi-experimental study To assess the effect on survival of –Mortality rate was comparable
(Ethiopia) community-based health at baseline but significantly
promotion activities lower in the intervention area
(community IMCI) in compared to the control area
Ethiopia post-intervention (adjusted
hazard ratio = 0.66; 95%
confidence interval: 0.46–0.95)
–Significant survival advantages
for females, children of
younger fathers, married
parents, living in larger
households, and those living
near a health center
Bryce et al. Non-randomized controlled trial To assess the effect of IMCI IMCI training is associated with
(2005) in two intervention districts relative to routine care on the significantly better child health
(Tanzania) (>90% of health-care workers quality and efficiency of care in facilities at no
trained in IMCI) and two providing care for sick additional cost to districts
control districts children in first-level health The cost per child visit managed
facilities in rural Tanzania and correctly was lower in IMCI
to disseminate the results for than in routine care settings:
use in health sector decision $4.02 versus $25.70,
making respectively
Kelly et al. Randomized controlled trial To assess caretakers’ The mean percentage of
(2007) comprehension and recall of messages recalled following
(Ethiopia) IMCI counseling messages IMCI counseling was 89.7%
when given under ideal immediately after the
messages consultation and 81.9% 1 day
later (N = 55 caretakers)
Mohan et al. Pair matched, community To assess whether training Mothers’ appreciation of the
(2004) randomized trial in 12 primary doctors in counseling need to seek prompt and
(India) health centers improves care-seeking appropriate care for severe
behavior in families with sick episodes of childhood illness
children using the IMCI increased, but their care-
approach seeking behavior did not
improve significantly
Gilroy et al. Randomized study in 10 health To evaluate the impact of IMCI IMCI training showed a non-
(2004) centers that were either training on quality of significant trend overall in
(Mali) randomized to training or counseling provided to improving drug counseling
comparison arms caregivers about provided to caregivers, with
administration of anti- significant improvements in
malarials to their children bilingual consultations
using various research methods. Generalizing the The Future of IMCI and Prospects
results may be misleading. The results are pre- for Scale-Up
sented here as general information on the scope
of research on the subject. As shown, the results Policy environment for scale-up of IMCI: The
highlight varying degrees of effectiveness in dif- African Regional Office of the WHO has defined
ferent country contexts and underscore the need scaling up of IMCI as ‘‘the acceleration and expan-
for further research to fully ascertain the impact sion of implementation of all components of IMCI
of IMCI globally. in all districts of the country to obtain maximum
impact on the reduction of morbidity and mortality leads to low prioritization of IMCI in the funding
due to malaria, pneumonia, diarrhea, measles, mal- program and agenda of national governments and
nutrition and HIV/AIDS in children under five major international donors. The poor policy con-
years of age’’ (WHO 2001a). Recent evidence from text of IMCI internationally and within implement-
the multi-country evaluation of IMCI suggests that ing countries has been the key determinant of pro-
gains of IMCI in a given country or area of a gress. Table 27.5 provides the results of a qualitative
country would only be significantly attained in the assessment of the IMCI environment using infor-
context of at least 80% coverage of the communities mation derived from WHO sources (WHO 2001a).
and health facilities (Tanzania IMCI Multi-Coun- As shown, the results highlight among other notable
try Evaluation Health Facility Survey Study Group factors limitations related to political support and
2004). The global consensus is that the implementa- commitment and the existence of IMCI implemen-
tion and scale-up of IMCI has moved at such a tation framework that is in discord with national
snail-speed in most countries that it would take strategic objectives and divergent preferences in
several decades to attain the level of scale-up that implementation mechanisms.
would significantly reduce morbidity and mortality Options for private sector participation in IMCI:
in under-5 children. Several reasons have been sug- Involvement of the private sector in IMCI holds
gested for this situation, ranging from lack of donor enormous opportunities for scale-up and sustain-
and indigenous resources to insufficient technical ability. Two pathways of private sectors participa-
and operational experience to serve as lessons to tion options are apparent: (i) IMCI has been pro-
countries that face various forms of bottlenecks. moted as a pro-poor, not-for-profit option. This
The most critical reason appears to be the lack of scenario favors a private–public option in which
political will at local and international levels. This the government courts private sector participation
Table 27.5 Qualitative appraisal of IMCI policy environment

Desirable determinants of policy environment Observations on prevailing IMCI policy contexts
Political support and commitment at all levels, Political support for IMCI has been far from adequate at
including supportive national policies, laws, and plans international and national levels. This is probably the key
reason for the slow pace of implementation, limited global
experience, and impact of the strategy
Policies that meet country’s expressed needs The low political commitment and low level of investment in IMCI
suggest that the policy framework for IMCI may be discordant
with national strategic objectives and preferences in delivery
mechanisms. Countries should be encouraged to adopt the
IMCI strategy only after careful appraisal shows that IMCI
aligns with the strategic direction of health-care programming
within that country
Operational policies that promote access, demand, All three components of IMCI seek to promote access, demand,
and quality and quality of care
Adequate financial and human resources International and national funding for IMCI is currently so low
that it would be impossible to demonstrate any impact of its
contribution to attainment of the health MDGs. Evaluation
studies have demonstrated effectiveness of the strategy and
potential for impact but adequate financial investment is
required to take the implementation to scale and to demonstrate
impact
Active private sector participation Available reports on implementation experiences lack information
on the participation of the private sector in IMCI. Efforts to
scale up implementation of IMCI should give careful
consideration to mechanisms to involve the private sector
Implementation of programs according to policies There is a need to provide adequate resources and structure for
(with efficient processes of evaluation and research) efficient monitoring and evaluation of IMCI at international,
national, and sub-national levels
through endowments, discounts, and various forms training that is country specific, IMCI contributes to
of solicitation for financial support. The private improving global quality of care. The IMCI model,
sector comes to this pro-poor option as an altruistic when implemented correctly, will improve service
corporate citizen, but would find opportunities to delivery. This model could then be applied to other
‘‘sell’’ its image and ultimately its goods. This option aspects of health care. Table 27.6 shows the areas in
raises issues about conflict of interest and ethics on which the strengths of IMCI could potentially contri-
the side of government and the private sector con- bute to the achievement of health system goals, espe-
tributors. (ii) The second option which is tagged cially as it affects child health, and therefore it should
‘‘pro-quality’’ marketing option woos the private be taken into account early in the reform process.
sector to invest in the IMCI approach as a business
venture under well-controlled regulatory condi-
tions. Quality improvement is a central theme of Table 27.6 Potential IMCI contribution to health system
reforms
IMCI and is capable of engaging the interest of the
Common reform aims Potential IMCI contribution
private sector. Private sector involvement boosts (World Bank) to health reforms
global resources available for IMCI implementation Increase technical Integration of vertical
and leads to a sustainable scale-up. In most develop- efficiency programs (acute
ing countries, the non-formal health sector domi- Improve allocative respiratory infection,
nates as a leading provider of private health-care efficiency control of diarrheal disease,
Improve effectiveness and expanded program on
services. The bulk of their clientele is the urban and quality immunization, malaria
rural poor and middle class (where it still exists). Prioritize inputs and control, nutrition)
Encouraging the private sector to participate in ser- deliver essential package Increasing technical
vice provision at the level of primary health care and of cost-effective services efficiency
Integrate vertical Improving effectiveness
to adopt IMCI as a key care approach expands the programs (and quality) of diagnosis
proportion of quality-assured care at that level. It Decentralize authorities, and treatment
will competitively lead to the contraction of the mar- responsibilities, and Improving provider
ket share of unorthodox practices. accountabilities motivation
Collaborate with private mproving client/patient
sector compliance and motivation
Coordinate donor Rationalization of drug use
Implication for Global Health System resources
Reform Improve client
responsiveness
IMCI, as a broad-based intervention strategy, is

potentially capable of effectively contributing to cur-
rent global aspirations to reform the health systems
of the poorest economies of the world and scale up
health-care intervention efforts in order to achieve Conclusions
impact in the short and medium term. Many health
systems in developing countries are currently under- The technical strengths of IMCI are integration and
going some type of reform. This is often spurred by a the expected improvement in technical efficiency and
de-centralization of management (WHO 1999). quality of care. The multi-country evaluation has lent
Improvements in equity, efficiency, quality of care, reasonable support to the claim that IMCI is a cost-
effectiveness, and sustainability are often the stated effective approach to improving the quality of health
objectives of global health system reform. care for children in low-resource settings. While there
In order for IMCI to be effective within a coun- is need for more evidence from controlled trials to
try, different levels of action are required for health further support or disprove this claim, implementa-
services in the home and community. Coordination tion experiences are relatively sparse. However, they
and quality of services should be improved to have provided evidence on the relative effectiveness of
increase the health-care effectiveness and to reduce IMCI compared to routine practice. While these
costs. By providing inclusive standards and valid implementation experiences lack statistical power of
proof, they show robustness in their contextual link malaria and HIV/AIDS. Effective control of these
with real national and district health policies and is crucial to achieving the health-related MDGs.
programs. Why then do donor communities ignore The general principles of IMCI, in addition to the
an initiative that promises to save cost and deliver on programmatic elements of the C-IMCI framework,
quality? Why are politicians not interested in support- are based on the assumption that integration of
ing IMCI? These are pertinent questions for the next these major disease interventions would occur at
round of the IMCI research project. all levels and lead to joint planning, budgeting,
There are issues about equity in the IMCI. One of implementation, monitoring, and evaluation. The
the key findings of the multi-country evaluation is that prevailing situation is that these heavily supported
IMCI in its present form has not adopted measures programs tend to be implemented disparately, with
that assure equity in implementation. The result is that little or no commitment in human and financial
those who need health care the most, due to deplorable resources. This does not conform to the basic prin-
health and development indices, are the least covered ciples of IMCI and detracts from the original goal
by IMCI in some countries. This presents issues about of primary health care as a holistic approach to the
the next phase of the IMCI scale-up. There should be a delivery of child health services in low-income coun-
strategic decision to target those with the poorest health tries. Those that fund malaria and HIV/AIDS treat-
outcomes and development indices also endeavoring to ment programs can encourage this integration pro-
avoid creation of new levels of inequity by completely cess by requiring integrated case management as
ignoring those that currently have relatively better one of the key criteria to fund and appraise program
development and health indices within countries. grants. Examples of these programs are the Global
IMCI has been one of the least supported inter- Fund to fight against AIDS, TB, and malaria, the
national public health initiatives. This is despite the US Presidential initiatives for HIV/AIDS and
fact that it has the potential to provide an efficient Malaria, respectively, and other equivalent grants
pathway for delivery of interventions to control made by the Bill and Melinda Gates Foundation.
Key Terms
Acute respiratory infections Expansion phase Malaria

(ARI) Health systems Malnutrition
Case management Health systems development Measles
Child survival revolution Hygiene promotion Nutrition
Community IMCI Immunization Oral rehydration therapy
Community mobilization In-service course Primary health care
Community-based Integrated care Quality improvement
organizations (CBOs) Integrated management of Quality of care
Convulsions childhood illnesses (IMCI) Service delivery
Diarrhea Lethargy Vertical programs
Early implementation phase
2. Outline and discuss the three technical compo-

Questions for Discussion nents of IMCI.
3. What are the principles of integrated care as
1. What is the rationale for adoption of IMCI as a defined and used in IMCI?
strategy for promoting child health in developing 4. What are the seven principles of community-
countries? integrated management of childhood illnesses
(C-IMCI)?
5. In an essay of about 300 words, describe the evi- counseling messages in Benin. Tropical Doctor, 37(2):
dence base of the disease-focused interventions 75–79
Mohan P, Iyengar SD, Martines J et al. (2004) Impact of
that are ‘‘integrated’’ within IMCI (i.e., treatment counseling on care seeking behavior in families with sick
for malaria, pneumonia, control of diarrhea, and children: cluster randomized trial in rural India. BMJ, 31,
major vaccine preventable diseases). 329: 266
6. In what ways can IMCI be scaled up to enhance Pelletier DL, Frongillo EA Jr, Schroeder DG et al. (1995)
The effects of malnutrition on child mortality in develop-
child health improvement in developing coun- ing countries. Bulletin of the World Health Organization,
tries? What are the barriers? 73(4): 443–448
Schellenberg A, Adam JR, Mshinda T et al. (2004) Effective-
ness and cost of facility-based integrated management of
childhood illness (IMCI) in Tanzania. Lancet, 364(9445):
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Chapter 28
Planning, Development, and Maintenance
of the MCH Workforce
Jeffrey M. Smith and Anne Hyre
Learning Objectives After reading this chapter and ultimately on the knowledge, skills, and motiva-
answering the discussion questions that follow, you tion of the people responsible for delivering ser-
should be able to vices. The provision of maternal and child health
(MCH) services at service delivery sites requires
Discuss the relationship between health worker
three basic elements: skilled personnel who pro-
density and maternal and child health
vide the services; an enabling environment for
indicators.
services (including infrastructure, supplies, and
Critically analyze the challenges in health sector
drugs), and organizational processes and policy
human resource planning, development, and
framework that define the package of services
maintenance in developing countries.
and how they are to be provided. Thus, the
Identify and discuss elements of successful train-
process of preparing, enabling, and supporting
ing programs with respect to deployment, integra-
health workers is central to the mission of pro-
tion, supervision, support, and retention of MCH
viding high-quality MCH services. Given that
workers.
two-thirds of the health budget in any given
Evaluate factors that influence the perfor-
country is typically devoted to the salary support
mance MCH workers and discuss gender
for health workers (Vujicic 2005), maximizing
issues related to MCH workforce in develop-
the efficiency and effectiveness of that workforce
ing countries.
should be a priority in the health sector. Also, in
developing countries, MCH services represent a
large proportion of the health services consumed
by the public. In some populations, the combi-
nation of children under 5 years of age and
Introduction
women of reproductive age can reach 40% of
the total. Yet, the ability to provide these ser-
As the World health Organization observed in
vices is continually challenged by lack of human
the 2000 World Health Report entitled, ‘‘Health
resources, maldistribution of the limited avail-
Systems – Improving Performance’’ (WHO
able health workers, verticalization of health ser-
2000), human resources, the different kinds of
clinical and non-clinical staff who provide services, issues of competency, and retention of
health staff. This chapter explores the nature of
vices to individuals and families, are the most
the MCH workforce, those factors necessary to
important of the health system’s inputs. The
performance of health-care systems depends develop and support these workers and help
them to perform, and the unique elements that
influence their ability to effectively provide
MCH services. To provide a common under-
J.M. Smith (*)
standing, some of the terminologies used in this
JHPIEGO Corporation/Johns Hopkins University
Bloomberg School of Public Health, Baltimore, chapter are defined in Box 28.1.
Maryland, USA
516 J.M. Smith and A. Hyre
Box 28.1 Key Definitions
Pre-service Education: The process by which students enrolled in a recognized educational institution
are given the knowledge, skills, and professional foundation to enter the health workforce upon
completion of their course of study. Graduates are awarded a diploma or degree upon successfully
completing all of the requirements of the curriculum and then must obtain a license to practice from
an appropriate regulatory agency or professional body (Schaefer 2002).
In-service Training: Continuing study by a health-care provider in order to gain new knowledge and/
or skills or refresh and strengthen the knowledge and skills used in his/her current practice. The
provider retains his/her original qualification and professional designation at the end of the course
(Sullivan 1995).
Competency-Based Training: The training process for developing the specific knowledge, attitudes,
and skills needed to provide a particular service or activity. It is skill focused and requires that the
participant demonstrate that he or she can perform the skill or activity by the end of the training
(Sullivan 1995).
Skilled Birth Attendant: The term ‘‘skilled attendant’’ refers exclusively to people with midwifery
skills (for example, midwives, doctors, and nurses) who have been trained to proficiency in the skills
necessary to manage normal deliveries and diagnose, manage, or refer obstetric complications. At
minimum, the person must be competent to manage normal childbirth and be able to provide
emergency (first-line) obstetric care. Not all skilled attendants can provide comprehensive emer-
gency obstetric care although they should have the skills to diagnose when such interventions are
needed and should have the capacity to refer women to a higher level of care (WHO 2004).
Midwife: A midwife is a person who, having been regularly admitted to a midwifery educational
program, duly recognized in the country in which it is located, has successfully completed the
prescribed course of studies in midwifery and has acquired the requisite qualifications to be regis-
tered and/or legally licensed to practice midwifery (International Confederation of Midwives 2005).
The Crisis in Human Resources for Health Development Goals (MDGs) – measles immuniza-
in Resource-Poor Settings tion and skilled attendance at birth (Fig. 28.1). Ana-
lysis of the health worker density necessary to achieve
In many countries in all regions of the world, the these outputs suggests that a density of about 1.5
absolute number of health workers is not adequate health workers per 1,000 population is associated
to provide the necessary services. This results in with 80% coverage of measles immunization and
rationing of services, concentration of services in that 2.5 skilled birth attendants per 1,000 population
the urban areas, and reduction in the quality of is necessary to provide 80% of women with a skilled
services due to the overburdening of health-care attendant at birth (Joint Learning Initiative 2004).
workers. Table 28.1 presents data on health worker Studies have also examined the effect of reductions
density, life expectancy, and infant and adult mor- in health sector human resources on maternal and
tality rates for selected countries. child health outcomes within countries. Beginning in
While there is no absolute recommendation for the 1992 in Indonesia health centers began reducing their
number of health workers per population, some data staffing levels in response to budget cuts imposed by
suggest that a certain density of health workers is the government in its bid to reduce its fiscal deficit.
necessary to achieve certain health goals, including The large reduction in staffing (1.8 to 1.2 physicians
two indicators related to the Millennium per health centre) led to a 39% increase in the child
28 Planning, Development, and Maintenance of the MCH Workforce 517
Table 28.1 Ratios of health workers to populations and selected health indicators, selected countries, 2000–2005
Country
Afghanistan Zambia Ethiopia Bolivia Sweden
28,574 11,479 75,600 9,009 9,008
Population 2004 (000)
Health Worker Density
(per 1,000 population)
Physicians 0.19 0.12 0.03 1.22 3.28
Midwives 0.01 0.27 0.01 0.01 0.70
Nurses 0.22 1.74 0.23 3.19 10.24
Life expectancy at birth (years) – males 42 40 49 63 78
Life expectancy at birth (years) – females 42 40 51 66 83
Adult mortality rate – males aged 15–60 509 683 451 248 82
Adult mortality rate – females aged 15–60 448 656 389 184 51
Infant mortality rate 257 182 166 69 4
Sources: Management Sciences for Health and Health and Development Service (2003); WHO (2006a)
Fig. 28.1 Immunization coverage and density of health workers. Source: Joint Learning Initiative (2004)
stunting rate (Barber and Gertler 2005). In the United maternal mortality is even higher, given that the
States and Canada there is evidence to suggest that presence of a health worker will more directly affect
reductions in nurse staffing levels in hospitals led to a the types of morbidities that lead to maternal death
decrease in quality of care and to an increase in than those that lead to infant or under-5 deaths
mortality and complications for certain procedures (Joint Learning Initiative 2004).
(Aiken et al. 2002). Currently, there is a substantial shortage globally
Similarly, the availability of health workers has a in the number of health workers able to provide
direct and positive effect on the morbidity and mor- MCH services. This shortage is especially acute in
tality of mothers, infants, and children. When Africa (Fig. 28.3). It is estimated that in the next 10
income, education, and poverty levels are controlled years, an additional 334,000 midwives (above cur-
for, a 10% increase in the number of health workers rent development plans) will be needed globally.
per 1,000 population leads to a 2–5% decrease in Furthermore, knowledge and skill updates will be
child mortality rates (Fig. 28.2). The benefit to required for another 27,000 doctors and technicians
and Dubois 2003). Simply put, in some countries,

there are not enough health workers to do the job,
regardless of the available funding to fight disease.
There are numerous factors contributing to the
health workforce crisis. The economic migration and
brain drain of health workers deepen the health crisis
in the countries they leave. In a recent article, Stilwell
et al. (2004) analyzed the extent of the problem of
health worker migration, examining the determinants,
effects on health systems, and strategic approaches to
its management. As they noted, the trend in health
Fig. 28.2 Health worker density and child mortality. Source: personnel migration is neither different from the over-
WHO (2006a)
all trend in international migration nor a new phenom-
to enable them to provide appropriate consultation enon. However, globalization and global acute short-
to these midwives. In the next 10 years, the expan- age of skilled health personnel in both rich and poor
sion, updating, and upgrading of the health work- countries mean that these personnel are highly sought
force for MCH will require an additional invest- after globally. With aging populations in many high-
ment of US $25 billion (WHO 2005). income countries and the growing shortage of health
This crisis in health workforce capacity and workers (especially nurses), countries such as the Uni-
capability puts at risk other investments and initiatives ted Kingdom and the United States have programs
to address health challenges. Limitations in human that specifically recruit health workers from develop-
resources may impede current investments in health ing countries to fill their vacancies (Stilwell et al. 2004).
care, including those that address MCH. For example, Factors that encourage migration of health personnel
although more resources are available from such from poor to rich countries (Fig. 28.4) have been
groups as the GAVI Alliance and the Global Fund to shown to include low wages, household poverty (the
Fight AIDS, Tuberculosis and Malaria, limitations in money sent back to their home countries by migrants
the health workforce reduce the capacity of countries is the most stable source of external finance in some
to benefit optimally from these resources (Dussault countries; the figures for the 1990s exceeded the
Fig. 28.3 Density of health-care providers (doctors, nurses, and midwives). Source: WHO (2006a)
Fig. 28.4 Factors affecting health professionals’ decision to migrate from five African countries. Source: Awases et al. (2003)
amount of official development aid flowing into MCH services are provided by a team of profes-
source countries (Connell 2002)), poor working con- sionals (Table 28.2) that depend on the scope of
ditions, lack of opportunities for promotion, desire to services provided. Often, the midwife is the central
gain experience, changes in labor and visa regulations, worker since her skill set most closely matches the
and active recruitment drives from poor countries by needs of the MCH population and because women
rich nations (Awases et al. 2003). often state a preference for a female health worker
Within countries, there is a concentration of health for these services due to cultural norms and
workers in urban areas, as a result of challenging customs.
working conditions, poor work environments, A strategy for training and deploying a midwife
quality-of-life issues, and low salaries. Health workers to a health center, and supporting her to deliver
are either leaving the public sector in favor of the basic emergency obstetric care, is considered a cen-
private sector or engaging in dual practice scenarios, tral strategy for reducing maternal and newborn
due to salary pressure, unclear career advancement, mortality (Campbell and Graham 2006). This
or restrictions on practice patterns. The economic ‘‘health center intrapartum care strategy’’ advocates
migration and maldistribution are compounded in that women deliver in a health center under the care
some areas by loss of health workers due to HIV/ of a midwife who is supported by a team of other
AIDS. This constellation of factors leads to lack of health-care providers. As opposed to a strategy that
motivation, decreased performance, and a downward promotes home-based care by a skilled attendant,
spiral of greater migration from the health workforce. this strategy enables women to receive care from a
provider who can address the majority of complica-
tions, in a location that allows timely intervention
and easy transport to other facilities if referral is
Who Provides Health Care to Mothers,
deemed necessary. This strategy also facilitates sup-
Newborns, and Children? port and supervision of midwives and provides mid-
wives with sufficient caseload to maintain their
As the components of MCH vary from country to clinical skills. The success of this strategy, however,
country, so does the constellation of workers who is contingent upon improving the quality of care
provide the services. Within a health-care system, offered at health centers and modifying health
Table 28.2 Typology of health workers
Category Worker type Education Skills/tasks
Informal Volunteers Variable, none specific Practical care

workers Family and to caring role Supervising medication
home carers Transporting individuals
Traditional Curanderas Variable Healing
healers Shamans Counseling
Use of traditional and natural medicines
Community Village health Primary-secondary school Ambulatory home and community-based care
workers workers with brief pre-service (immunization, oral rehydration, nutrition, etc.)
Community and on-the-job training Prevention, promotion, and management of
health workers basic health problems
Public health outreach
Referral function
Vocational Medical Secondary school, Assisting health professionals
workers assistants college Technical support
Nursing and Home-based care
dental aides
Laboratory
technicians
Health Doctors Tertiary – professional Diagnosing and treating acute and chronic
professionals Nurses college, university illnesses
Dentists Hospital and community care
Pharmacists Health promotion and education
Midwives Palliative care
Psychologists Record-keeping of past medical histories
Physician’s Referral function
assistants
Public health
officers
Teachers and Faculty Post-basic university Developing new knowledge
researchers lecturers (e.g., Master’s, PhD) Preparing health professionals for entry to the
Laboratory workforce
researchers Working with policy makers to implement new
Epidemiologists knowledge into policy and practice
Pharmaceutical
developers
Non-medical Managers All kinds Various support functions to health systems and
workers Accountants health workers
Drivers
Policy makers
Source: Joint Learning Initiative (2004)
center birthing environments to address cultural typically include preventative health activities,
and personal concerns of women and their families. counseling and information sharing, and services
Given the nature of MCH, facility-based services such as family planning (WHO 1995), treatment of
and personnel should be complemented by commu- newborn infections (Bang et al. 2005), and preven-
nity-based services and a variety of community tion of postpartum hemorrhage (JHPIEGO/MNH
health workers. Community health workers or Program 2004). Specifically, community-based
health volunteers provide a spectrum of MCH ser- health workers include village health volunteers,
vices that vary widely from country to country, but community health extension workers, traditional
birth attendants (TBAs), health promoters, and preferences of the population (effective
other workers. In some countries, skilled care has demand-based methodology)
been taken to the community level where commu-
The planning methodology chosen by a particu-
nity midwives reside in the villages they serve and
lar country depends on the specific characteristics of
provide services from their own homes or in the
the country’s health system and, frequently, on the
homes of their clients.
availability and quality of data necessary for plan-
ning and decision making. A single planning meth-
odology may not fit the requirements of every situa-
tion. Many countries have expressed a commitment
Planning for the MCH Workforce
to reduce maternal mortality by increasing the num-
ber of births attended by a skilled birth attendant
Health workforce planning requires the articulation (SBA) (Sachs and McArthur 2005). These efforts
of clear government policies that define the package provide an excellent illustration of the application
of health-care services to be provided, the types of of health workforce planning concepts. To increase
personnel who are needed to provide these services, the number of births attended by a skilled birth
and the job descriptions of those personnel. Thus, attendant, there must be a policy in place that
health workforce planning is a process of estimating describes what a skilled birth attendant is, what
the number and types of health personnel needed to the skill set is for that attendant and, specifically,
achieve predetermined health targets. The process which cadres of health workers are or will be con-
of planning has to answer the question ‘‘How many sidered as skilled birth attendants.
of each type of health worker does the health system Once the cadres for skilled attendants are clari-
need?’’ for example, how many midwives are needed fied in a country, the job description must be
to provide essential obstetric care to the current and updated to reflect the new or amended responsibil-
future population of women of reproductive age? It ities of these personnel. In-service training courses
must also address ‘‘Where and when these human (or pre-service education curricula) must be
resources are needed to accomplish the goals of the designed or redesigned, based on national clinical
health sector’’ and thus requires a level of micro- service delivery guidelines, so that providers are
planning that uses good data about the resources trained in a manner consistent with the country’s
for, and distribution of, health services (Joint service delivery processes. The training materials
Learning Initiative 2004). and the training process must be competency
Human resource planning requires highly specia- based, so that health workers acquire the skills in
lized technical skills because multiple and complex processes that most efficiently and effectively use
variables intervene in determining human resources the limited time, resources, and effort available.
needs. There are different methodologies, based on
different underlying assumptions, for developing
plans for the health-care workforce. Planning can
Determine the health-care personnel needed in Developing the MCH Workforce
ratio to the population distribution (population-
based methodology) Health workforce development is the process by
Assume that the populations will be served in the which the supply of skilled health workers is made
future in the way they are currently being served available. Development of the MCH workforce in
(utilization-based methodology) most countries includes the process of pre-service
Estimate the requirements to meet all or part of education – the production of new health workers,
the expected health-care needs in response to the as well as in-service training to maintain the skills of
types of diseases in the populations (needs-based those workers. While certain elements are recognized
methodology) as critical to the success of both pre-service educa-
Establish the requirements to satisfy the expected tion and in-service training, health worker develop-
development of health-care services and the ment must consider elements of human capacity
development in order to increase the impact of train- then apply the skill in a clinical setting under super-
ing on health services. These are discussed below. vision. Through this process, they are more likely to
achieve clinical competence and thus improve clin-
ical care. Whether the training program is a pre-
service education program (e.g., in a medical or
Elements of Successful Training midwifery school) or an in-service training program,
Programs there are several elements that increase the quality of
training and thus the likelihood that it will result in
Training programs must be designed to effectively competent providers.
transfer and assess the knowledge, skills, and atti-
tudes of MCH workers. Often, training programs
focus on acquisition of knowledge (technical
updates or classroom-based courses) and the obser-
Policy, Curricula, Service Delivery
vation or discussion of clinical procedures, rather Guidelines, and Learning Materials
than on the acquisition of competency in these
skills. If managed in a systematic and results- Evidence-based training materials that are supported
oriented manner, training has a positive impact on by clear reference documents should be developed
knowledge and skills (Fogarty et al. 2004). Compe- for both trainers and learners. Learners’ materials
tency-based training courses, which enable provi- should include the information to be learned, and
ders to individually develop clinical skills or modify the tools necessary for learning this information (e.g.,
attitudes, are typically more time-consuming, case studies for learning clinical decision making,
resource-intensive, and challenging to implement. role plays for building communication and counsel-
While challenging, this approach is a far more effec- ing skills), and detailed and explicit skill learning
tive mechanism for transferring critical clinical guides for developing clinical skills. These should be
skills (Limpaphayom et al. 1997). complemented by materials for teachers and trainers,
Decisions to conduct training interventions should such as knowledge assessment questionnaires,
be made following an assessment of the performance answer keys for case studies, and skill checklists for
of health workers and the ability of the health system assessing the development of clinical skills. All of
to meet predetermined targets or objectives. If that these materials should be based on national service
assessment suggests that limitations in MCH services delivery guidelines and policies that facilitate student
are due to a gap in the knowledge and skills of provi- learning and appropriate practice following the com-
ders, a training intervention should be considered. pletion of learning. If students are taught to provide
Further assessments, often called training needs care that is not supported by national clinical norms
assessments, must be done to identify whether an in- and guidelines, or vice versa, they will be unprepared
service training program or a pre-service program is for the clinical workplace, leading to the need for
necessary. Training needs assessments also look at the retraining and waste of resources.
current training and education system, the policy
environment in which health workers learn and
work, the learning materials and methodologies
used, and the capacity and capability of the training High-Quality Clinical Practice Sites
institutions and trainers/teachers.
To improve clinical care, training institutions and The development of clinical competency requires
programs must ensure structured opportunities for that learners be given an opportunity to practice
participants to develop necessary clinical skills. To the desired clinical skills in actual clinical facilities.
achieve these improvements, participants require During clinical practice they will use the knowledge,
adequate time to review the clinical procedure with skills, and attitudes being learned in the classrooms.
experienced trainers, practice the skill in a simulated The standard of clinical care in these facilities should
setting (such as a skill learning lab) in which they can be consistent with service delivery guidelines and the
master the steps of target psychomotor skills, and theory described in the curriculum. There is an
Box 28.2 Indonesia Case Study: Promoting High-Quality Training – The Indonesian
National Clinical Training Network
Since 1991, reducing maternal mortality has been a priority for Indonesia’s Ministry of Health. Early
efforts to tackle the problem focused on rapidly educating large numbers of midwives who would be
distributed widely across the country, and within a few years a remarkable 57,000 bidan de desa
(village midwives) were produced. Over time, however, concern was raised about the midwives’ skills,
and it seemed that the desire for quantity had overtaken a focus on quality. Many midwives lacked the
essential skills to deliver effective services, and the impact of the program was questioned. In 1997, a
major initiative was launched to upgrade the skills of these midwives using standardized, competency-
based training as the centerpiece of the strategy.
The Indonesian Association of Obstetricians and Gynecologists and the Indonesian Midwives
Association, together with partners and stakeholders, formed the National Clinical Training Net-
work (NCTN). The NCTN established standards for high-quality training, including standards for
training centers, training materials, and trainers. They realized the importance of high-quality clinical
experience and paid particular attention to the environments in which participants learned and
practiced their clinical skills. The quality of care at the clinical training sites was upgraded, the
clinical preceptors were given coaching skills, and training and assessment materials were revised.
Additional clinical practice sites were developed and students were taught in smaller batches. All of
these efforts were made to ensure that trainees were achieving competency.
The systematic process of training had an impact. The trainers and the government saw the
difference made by a high-quality training process that focused on skill development. The midwives
were providing more services and increasing their coverage in the communities. In 1999, the Ministry
of Health endorsed a policy that identified the NCTN as the sole provider of clinical training in
reproductive health in Indonesia. The principles of sound training demonstrated by the NCTN
became the standard throughout the country.
As a result of these efforts, the NCTN currently has the capacity to offer high-quality training in
maternal and newborn health. Since 2001, approximately 14,000 midwives have undergone training
through the NCTN. Quality has won out over quantity, and the country is on the path to achieving its
goal of reduced maternal mortality.
expected and desired process of professional sociali- National Clinical Training Network in Indonesia
zation that begins in training and extends to the (Box 28.2) provides a good example of in-service
workplace. Students or workers who have learned training that incorporates the elements of a success-
new skills will adopt the clinical behaviors that are ful training system, from the use of standardized
prevalent in the facilities where they learn and prac- curricula to the development of high-quality class-
tice. Therefore, the clinical practices of clinical staff room and clinical training environments.
and clinical preceptors may need to be standardized
so that they are modeling the specific clinical beha-
viors that are being taught. Often, initial work is Qualified Teachers and Trainers
necessary to upgrade and standardize the practices
in these clinical learning sites, in an effort to reduce Effective teaching requires that trainers and faculty
the gap between classroom theory and clinical prac- have the appropriate skills to enable them to correctly
tice. Although this is a challenging component of and efficiently transfer the course content. Teachers
any initiative to improve clinical training, if it is not need up-to-date clinical skills so that they are profi-
done, the other efforts are not likely to succeed. The cient in the knowledge and skills they are teaching. In
addition, they need strong training skills to allow them responses should be used by trainers to improve
to correctly use modern pedagogic approaches such as their training skills.
competency-based training. These skills include mas- Level 2 – Participant learning: Whether participants
tery of adult learning theories and principles (Brook- learned the required knowledge and skills. These
field 1986), the use of effective presentation techni- are assessments of knowledge and skills gained in
ques, management of small-group activities, clinical the course. This information is used as a basis for
coaching to support learners as they develop clinical determining whether participants can receive a cer-
skills, and the ability to coordinate and manage the tificate of competency and thus guides post-train-
development of clinical skills in both simulated and ing follow-up. It is also used for assessing the design
real health facility environments. of the training and its ability to achieve the stated
objectives of the training.
Level 3 – On-the-job performance: How and
whether participants applied the newly acquired
Well-Equipped Teaching Environments
knowledge, skills, and attitudes on the job. It is
measured through changes in on-the-job perfor-
Competency-based education and training require mance, and the results are used to reassess the
that learning environments be appropriately equipped quality of training courses and the extent to
to facilitate knowledge and skill transfer and assess- which trainees were able to transfer new skills
ment. Classrooms must have necessary audiovisual to the workplace.
equipment such as overhead projectors or video Level 4 – Effect of training: The extent to which
players. Clinical skill development laboratories must the quality or availability of services changed as a
be adequately equipped with anatomic models and result of the training intervention. It uses service
instruments to allow all students to have adequate delivery statistics and quality indicators and
opportunity for supervised practice before providing helps determine the appropriateness of using
services and performing procedures on real patients. training as the intervention to address service
In addition, clinical practice sites must be relevant to provision gaps.
the reality of where learners will practice after their Level 4 – Impact of training: This is a measure of
training is completed. Use of clinical practice sites the long-term contribution of training to
should be managed to ensure that students are super- improvements in population health outcomes –
vised and allowed to practice the skills in the curricu- reduction in diarrheal diseases among infants
lum. If a midwifery curriculum includes the care of and children, reductions in infant and maternal
patients in both inpatient and outpatient environ- mortality, etc. Training impact is more difficult
ments, suitable practice sites for both of these areas to measure since improvements in population
must be employed. The number of students going to health outcomes cannot result from training
an individual site must be limited to allow for both the alone, but from a range of medical and non-
development of student competencies and the main- medical programs and policies.
tenance of clients’ rights and privacy.
Deployment of Health-Care Workers

Evaluation of Training Interventions
After health-care providers are prepared, they must
The systematic evaluation of training is essential for
be deployed to health-care facilities where they can
ensuring that training interventions achieve the
apply their knowledge and skills to address the
objectives of improved performance and greater
needs of the community they are meant to serve.
availability of services. Evaluation approaches are
Deployment may be through voluntary choices of
typically conducted at five levels as follows:
the graduates/trainees; through enticements such
Level 1 – Participant reaction: How participants as salary differentials, priority for professional
liked the course and perceived its value. The advancement, etc.; or mandatory, based on
compulsory service programs or service require- Integration, Supervision, and Support

ments. Planning for successful deployment requires of MCH Workers
substantial coordination and collaboration between
the producers of human resources (typically the Successful deployment of new graduates must go
Ministry of Education and private schools) and beyond the identification of appropriate posts for
the consumers of human resources (typically the these health workers to fill. Especially, in the case
Ministry of Health). The goal of deployment is to of nurses and midwives who are trained in an
successfully link a newly trained and skilled health expanded set of skills or who learn new skills
worker with a facility or community prepared to through in-service training programs, efforts to
employ and utilize the worker. A key factor in effec- support the integration of those health workers
tive deployment is successful recruitment and selec- into, or back into, their health facilities must be
tion of students prior to enrollment. If students are undertaken. In a study of quality of child health
selected from the major urban centers in a country, services in primary health-care facilities in south-
it is challenging and often unlikely that these stu- eastern Nigeria, Ehiri et al. (2005) reported that
dents will be successfully deployed to rural health much of the supervisory activities of primary
centers upon graduation. To achieve a higher level health-care coordinators and national immuniza-
of deployment, especially of midwives and female tion program managers were in the form of ‘‘sur-
nurses, a strategy of targeted recruitment from loca- prise visits,’’ usually for punitive reasons (e.g., to
tions near the sites of deployment may have a better identify those who had not reported to work on
result. Factors such as origin, ethnicity, marital sta- time). Supervision of health workers must reflect
tus, and gender may need to be considered when not simply administrative supervision, whereby
deployment of graduates is planned (Fritzen 2007). workers’ attendance and adherence to stated poli-
Depending on the nature of the health system cies are monitored. Supportive clinical supervision
and its relation to the education system in the coun- should focus on the care provided, the quality of
try, graduates either enter the marketplace upon that care, and the ability of the provider to perform
graduation, where they are expected to find their the job according to standards. Supervisory pro-
own employment, or enter government service and cesses and checklists should reflect the clinical ele-
are employed, either partly or entirely, by the gov- ments of the job, and the supervisor must make
ernment. To ensure public welfare, health systems every effort to assess the provider in the actual
must be highly regulated if graduates are expected performance of clinical duties. To conduct this
to identify their own work opportunities. More type of supervision, clear performance standards
commonly in developing countries, graduates from must be available and must be known and under-
medical, nursing, and midwifery colleges enter gov- stood by both the supervision team and the health
ernment service and are meant to be deployed to worker.
government facilities. Deployment of graduates In the case of MCH, this supervision can be
into government service is facilitated by careful difficult, since provision of services, such as care
recruitment of students from priority areas where during labor and birth, cannot be scheduled, and
health workers are needed. Selection of students therefore frequently cannot be assessed in real time.
who are from areas that have a demonstrated need It also requires that the supervisor understand and
increases the likelihood that these students will possess the same clinical skills as the person being
return to their home districts upon graduation. supervised. When actual clinical care is to be
The alternative is that students enter the program observed but actual clients are not available, exter-
without discrimination on the basis of geographic nal supervisors should have the capacity to devise
origin and then are asked to accept posts. A robust simulated scenarios in which the health-care
strategy for deployment (including to underserved worker can demonstrate how he or she would typi-
areas) is needed to ensure that the financial, mate- cally perform. This approach gives a much more
rial, and technical resources invested in the produc- realistic assessment of quality of care and offers the
tion of human resources for health are not wasted supervisor the chance to make specific recommen-
by large losses due to attrition (WHO 2007). dations and give constructive feedback (Garrison
et al. 2004). In their study of quality of child health Incentives: Incentives for performance need not
services in primary health-care centers in southeast- be only financial incentives. Motivation can be
ern Nigeria, Ehiri et al. (2005) concluded that related to social and moral imperatives; pride
inadequacy in the quality of child health services and recognition by peers, supervisors, and cli-
in the facilities was a product of failures in a range ents; and social and professional advancement.
of quality measures – structural (lack of equipment Certainly, there is a financial threshold below
and essential drugs), process failings (non-use of which health workers are demotivated; however,
the national case management algorithm and lack increases in salary do not necessarily lead to
of a protocol of systematic supervision of health improved job performance.
workers). Thus, supervision of health workers is Skills/Knowledge: Workers need the appropriate
one element that ultimately supports performance. knowledge and skills to do their jobs well. Train-
Other elements include the physical and material ing can be an important intervention to improve
resources available to ensure the provision of care, performance. However, training in a vacuum
as well as the attitude and approach of co-workers. without accounting for other factors that influ-
Workers who struggle to provide care according to ence performance will rarely result in improved
standards should be asked what they need in order performance.
to solve the problem. When health workers parti- Organizational Support: The managerial, strate-
cipate in devising the solutions to their own pro- gic, and operational mechanisms of the organi-
blems, they are more likely to follow through with zation must be aligned with those of the workers.
the interventions and be motivated to solve other If the organization asks the workers to achieve
problems in the future. one objective, yet it is focused on the achieve-
ment of another competing objective, the work-
ers will ultimately become frustrated and face
limitations in their ability to perform.
Factors That Influence the Performance
These factors can be grouped into three cate-
of Health Workers gories: the capability to perform one’s job, the
opportunity to do one’s job, and the motivation to
Six general factors are thought to have a central do one’s job (Necochea and Bossemeyer 2005)
impact on performance (Stolovitch and Keeps (Fig. 28.5). Performance is at the center of these
1999): three areas, and interventions to improve perfor-
Job Expectations: Health workers need clear job mance must address all of these areas.
descriptions that outline what is expected of
them, what is allowed, and what skills they
require to do their jobs. These may be national
documents that can be adapted in the workplace.
Performance Feedback: Regular systems of feed- Motivation: Capability:
back should be established to allow health work- incentives knowledge,
skills
ers to know how they are performing. This feed-
back should come from managers, peers, and PERFORMANCE
clients to capture the opinion of all those who
are affected by the workers’ performance.
Tools/Environment: The health workers’ physi-
Opportunity:
cal, professional, and psychological environment resources
has a profound impact on performance. The
availability of equipment, supplies, and drugs,
as well as the physical infrastructure, including
power, water, and security, will either impede or Fig. 28.5 Influences on performance: a holistic and systemic
enhance performance of health workers. approach
Retention of MCH Workers deployment of health workers to rural and under-

served areas.
Retaining health workers in their jobs is an ongoing While approaches are being implemented to
and challenging problem that threatens the address the loss of workers from the health system,
advances made in health services and health system efforts to increase the skill mix of health-care teams
development. The migration of health workers to should also be considered. The training or retrain-
more urban areas within a country and to interna- ing of selected workers to take on new and
tional posts outside their home country is at the expanded scopes of practice may represent a tem-
center of the issue. One study estimated that in a porary solution. The evidence comes from both the
10-year period from 1986 to 1995, 61% of doctors developed world and several African countries.
who qualified from one medical school in Ghana While nomenclature varies, the principles of
left the country (Dovlo and Nyonator 1999). The enhancement (increasing the scope of practice of a
extent of loss of capacity is greatest in Africa, but health worker), delegation (shifting tasks from one
examples can be cited from every region of the worker to another, typically a more junior cadre),
world. and innovation (creating a new cadre that assumes
Loss of health workers represents a substantial some of the responsibilities of the other cadre) are
loss of time, financial resources, and energy con- prevalent in all efforts (Dovlo and Nyonator 1999).
sumed to educate and develop them. Furthermore,
faculty and educational institutions begin to see as
futile their efforts to educate new workers if the
wastage from the health system is substantial. The
Gender in Relation to MCH Workforce
health workers and educators who remain are bur- Development
dened with additional workload and greater respon-
sibility. In addition, the lack of expertise in work- Health workers involved in the care of women, new-
force management in many countries results in borns, and children are more likely to be female than
further inefficient use of health workers, inap- male. This is especially true in cultures in which
propriate skill mix to address health priorities, and women express a preference for a female provider
reduced performance, quality, and morale, in an for both their own and their children’s health care.
already underperforming and demoralized system. This gender differential has an impact on the health
Efforts to resolve the problem must look beyond workforce, especially as it relates to MCH services
simply enhancing remuneration. Solutions must and providers. Although careers and employment
look comprehensively at the multiple factors that patterns of female health workers in developing
lead to health workers’ decisions to migrate away countries have not been studied extensively, it is likely
from their posts. Numerous solutions have been that the greater challenges and outside responsibil-
proposed, including policies for the active recruit- ities that women face would affect their availability to
ment of students from rural backgrounds, develop- provide services. Female health professionals typi-
ment of more positive rural rotations during pre- cally shoulder a greater proportion of the family
service education, and efforts to address quality-of- responsibilities in the home and work a greater num-
life concerns (Kotzee and Couper 2006). In addition ber of hours caring for children and maintaining the
to efforts to address the movement of current work- home. A study of Canadian physicians with children
ers, attention must be given to identifying ways to found that male physicians spent an average of 11.4
prepare the next generation of health-care workers, hours per week on child care, whereas female physi-
with an eye toward presenting rural or simply cians spent an average of 39.7 hours per week on child
domestic health service in a more positive light. care (Woodward et al. 1996). The figures for less
There have been efforts to revise medical education developed countries would undoubtedly reflect simi-
to make the curriculum more geared to the prepara- lar, if not much wider, disparity.
tion of community-focused physicians (Bor 2002). In addition, there is a tendency to promote a
There must be further research on mechanisms to ‘‘fast-track’’ approach to the education and develop-
foster rural service and on creative approaches for ment of cadres of workers exclusively dedicated to
the care of women. Some countries have advocated TBA training in Ghana showed that while TBA train-
the shortening of midwifery education, thus risking ing resulted in a significant decrease in intrapartum
the quality of professional development in favor of fever and retained placenta, this finding was counter-
quantity and speed of production. Often the extent balanced by an increase in the rate of women with
to which the courses are shortened, or requested to prolonged labor >18 hours. The authors conclude
be shortened, for example, from a 2- or 3-year course that ‘‘the evidence for beneficial impact of TBA train-
of study to a 6- to 12-month program of preparation, ing on the health of mothers and newborns is not
is below the threshold necessary for student mid- compelling’’ (Smith et al. 2000). A study comparing
wives to achieve competency in the various skills the practices of trained and untrained TBAs in Ban-
necessary for them to be called skilled attendants. gladesh showed that although trained TBAs were
This could be due to an unspoken, and probably more likely to practice clean delivery, the infection
unintended, sense that the competencies necessary rates among patients of trained and untrained TBAs
for the care of pregnancy and childbirth are some- were no different (Goodburn et al. 2000).
how less complex or more easily learned. Calls for The WHO, in collaboration with United Nations
shortening midwifery education in countries are not Fund for Population Activities (UNFPA), the
typically accompanied by similar calls for shortening United Nations Children’s Fund (UNICEF), and
the education of nurses or physicians, potentially the World Bank, makes the following statement
suggesting that the education of those cadres regarding the skilled attendant (WHO 2004):
involved in the care of men is somehow of greater
The term ‘‘skilled attendant’’ refers exclusively to peo-
value. Fortunately, recent clarifications of the defini- ple with midwifery skills (for example midwives, doc-
tion and scope of practice of a skilled attendant are tors and nurses) who have been trained to proficiency
beginning to result in a more uniform approach to in the skills necessary to manage normal deliveries and
the preparation of midwives and other cadres with diagnose, manage or refer obstetric complications. At
minimum the person must be competent to manage
responsibility for maternal and childbirth care. normal childbirth and be able to provide emergency
(first-line) obstetric care. Not all skilled attendants can
provide comprehensive emergency obstetric care
although they should have the skills to diagnose
MCH at the Community Level when such interventions are needed and the capacity
to refer women to a higher level of care. Traditional
birth attendants, either trained or not, are excluded
The provision of some MCH services at the commu- from the category of skilled attendant at delivery.
nity level is thought to be effective and feasible, and
TBAs and other types of community health workers
community-based services play an important role in
can and do serve a vital role in the lives and experiences
MCH services. Programs have demonstrated that
of pregnant women. The efforts of community health
trained community-level health workers can effec-
workers can be focused along the lines of provision of
tively provide certain forms of family planning
selected, evidence-based interventions, including
(Douthwaite and Ward 2002), treat newborn infec-
tions, provide immunizations, prevent postpartum Acting as community educators for accurate mater-
hemorrhage (Derman et al. 2006), and educate and nal and neonatal health messages (e.g., nutrition,
mobilize the community toward better health ser- tetanus toxoid vaccination, etc.)
vices. The prevailing global opinion at present is Identifying pregnant women in the community
that efforts should be made to ensure that all and linking them with appropriate maternal
women have access to a skilled provider to assist health services
them during birth. A meta-analysis of 63 traditional Partnering with skilled providers (especially mid-
birth attendant (TBA) training programs showed wives and community midwives)
that while training has a positive effect on TBAs’ Promoting birth preparedness and complication
knowledge, attitude, behavior, and advice, this train- readiness
ing actually had a negative effect on maternal mor- Providing directed, limited antenatal care,
tality and a limited effect on perinatal/neonatal mor- including the distribution of iron and folate,
tality (Sibley and Sipe 2002). Furthermore, a study of tetanus immunization, etc.
Identifying, treating, and referring sick newborns potential for lasting results. Departments of min-
Understanding and accessing referral systems istries responsible for human resources for MCH
more readily and ensuring the continuum of must be strengthened and must achieve greater
care during the referral process coordination and specialists in health workforce
Providing selected family planning methods planning and management must be developed and
utilized. Inter-ministerial collaboration mechan-
The participation of TBAs in assisting births isms must bring together those responsible for
will continue for many years; it is neither practi- the production and the consumption of human
cal nor realistic to expect their activities to cease. resources for health.
Countries should seek an evolution of the role of The issue of migration of health workers must
the TBA into one in which she advocates for be addressed in line with the strategic approaches
women and skilled birthing care, and countries suggested by Stilwell et al. (2004). This calls for
should engage TBAs in a partnership to achieve development of mechanism to regulate the flow
this goal. The substantial reductions in maternal of health workers between countries. It is sug-
mortality in countries such as Malaysia, Sri gested that each country has to develop its own
Lanka, China, Egypt, and Honduras have all strategy to influence the retention, recruitment,
included a policy of enhancing skilled attendance deployment, and development of health workers.
and partnering with TBAs, while reducing their Mechanisms for collection of data on migration
utilization as isolated caregivers at birth. At pre- of health workers must be developed and
sent, the evidence does not suggest that scarce strengthened as a tool for good workforce plan-
resources should be devoted to training, super- ning. Establishing and maintaining appropriate
vising, or equipping TBAs as birth attendants. information systems on human resources, includ-
In summary, partnerships should be advocated, ing a database on migration, is a vital first step.
but material or strategic support will likely have Triangulation of data from different sources (e.g.,
limited impact. destination countries and countries of origin) to
provide the most comprehensive overall picture
has also been recommended (Diallo 2004).
There is evidence (Korte et al. 2003) that non-
Conclusion financial incentives (e.g., training, study leave, the
opportunity to work in a team, support and feed-
Improving MCH will be accomplished only by back from supervisors, and for those working in
strengthening the delivery of health services by rural areas provision of housing and transport,
health workers. As stated by Chen et al. (2004) agreement on the number of years that will be
in their work on human resources for health, spent in a rural location (rather than expecting a
‘‘The only route to reaching the health MDGs is worker to remain there indefinitely), offering
through the health worker; there are no short- further training, and offering financial incentives)
cuts.’’ Specific strategies have been suggested for may be important in motivating heath-care work-
analyzing the root causes of gaps in education, ers and improving retention.
deployment, and retention and for addressing the Finally, the knowledge base regarding planning
problems that have resulted from the chronic and development of the MCH workforce must be
underinvestment and lack of attention to human expanded. Additional effort must be given to
resources. The increased profile of the problem developing systems for counting health workers,
and the launch of several global initiatives to analyzing their work as well as their needs, and
address the problem are promising. The capacity supporting their performance. The education of
of countries to plan, develop, and maintain health workers should be revitalized to decrease
human resources for MCH must be strengthened. inefficiencies and outdated practices, increase
Governments, donors, and implementing partners connectedness to workplace expectations, and
must come together under a common framework develop a sense of critical and evidence-based
to implement creative interventions that have the self-appraisal.
Key Terms
Brain drain Health worker density Skilled attendance at birth

Community health extension Health worker development Skilled birth attendant
workers Health worker life expectancy Staffing levels
Community health workers Health workforce planning Traditional birth attendants
Competency-based training Human resource planning (TBAs)
Delegation Incentives Training needs assessments
Economic migration Innovation Village health volunteers
Emergency obstetric care In-service training Measles immunization
Enhancement Job Expectations Midwife
Globalization MCH human resource Organizational support
Health-care worker development Performance feedback
deployment MCH worker retention Pre-service education
Health promoters MCH workforce
Health volunteers

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August 2008
Chapter 29
An Agenda for Child Health Policy in Developing Countries
John E. Ehiri
Learning Objectives After reading this chapter and because the resources and efforts are often
answering the discussion questions that follow, you expended on specific disease conditions, with little
should be able to attention to the environmental, socioeconomic, and
health system factors that underlie the diseases.
Identify and discuss the environmental, social,
Disease-focused child health interventions may
and political factors that influence child health
reduce mortality, but because they are usually not
in less-developed countries.
designed to modify the ‘‘environmental’’ conditions
Discuss the limitations of global child health
that make children sick, their effectiveness in redu-
policies and programs that are based mostly on
cing the burden of childhood disease is usually very
vertical, disease-focused programs.
limited. As a typical example, childhood diarrheal
Analyze the background to, and rationale for, the
disease control efforts of the 1980s targeted the
Alma Ata Declaration of Primary Health Care.
reduction of mortality from dehydration by pro-
Present a coherent case for the adoption of a global
moting the use of oral rehydration solution (ORS)
child health policy that is based on the tenets of the
during diarrheal episodes. Increased intake of fluids
Alma Declaration of Primary Health Care.
supplemented by ORS together with continued
feeding has proven to be a powerful intervention
for the prevention of childhood deaths from diar-
Introduction
rhea (Victora et al. 2000). Estimates have shown a
steady decline ever since: 3.3 million deaths in the
There is considerable information on the effective-
1990s (Bern et al. 1992) and 2.5 million in the year
ness of several simple interventions to promote
2000 (Kosek et al. 2003). In spite of this decline,
child health in less-developed countries. The knowl-
diarrhea is still the second leading cause of under-5
edge and technology to implement these interven-
mortality globally. This chapter presents a critical
tions also exist. Nevertheless, each year, millions of
review of current strategies for child health promo-
infants and children suffer and die from conditions
tion in less-developed countries and discusses the
that can be easily prevented at minimal cost. Much
limitations of disease-focused approaches that do
progress has been made with regard to improve-
not address environmental and socioeconomic fac-
ment of child health over the past six decades. Yet,
tors that underlie morbidity and mortality among
there seems to be comparatively very little to show
children in poor countries. It is noted that after
for the huge resources and efforts that governments,
several years of investment in disparate vertical
bilateral agencies, foundations, and other global
interventions, preventable diseases still remain a
health agencies invest annually in child health pro-
major challenge for child health in less-developed
motion in less-developed countries. This is mostly
countries. The chapter concludes with a call for a
return to the tenets of the Alma Ata Declaration of
J.E. Ehiri (*)
Primary Health Care which emphasize action on
Division of Health Promotion Sciences, Mel & Enid
Zuckerman College of Public Health, University of Arizona, social determinants of health, a focus on health
Tucson, AZ 85724, USA systems development and access to basic services.
534 J.E. Ehiri
The Role of Medicine in Child Health integration into the recipient nations’ health systems.
These disparate programs have been credited with
There is a perception that much of the improve- some successes, including the eradication of smallpox
ment in population health recorded in many coun- and a decrease in tuberculosis prior to the HIV/AIDS
tries over the past century has resulted from pandemic. However, their impact on overall burden
advances in medical technology, pharmaceutical of disease among populations in less-developed coun-
discoveries, and therapeutic innovations. Today, tries has been minimal, and sustainability has been an
health-care systems of many high-income countries abiding problem. It has been argued (Ehiri and
have a range of innovative technologies and proce- Prowse 1999; Magnussen et al. 2004) that this limita-
dures for diagnosing and treating disease condition in overall impact is inevitable, given that these
tions for which medicine had no cure six decades disparate disease-focused interventions do not
ago, including cancers and cardiovascular diseases. address the social determinants of disease in these
Within the global health sphere, the successful era- settings. Although one disease might be controlled
dication of smallpox and typhus, significant or eliminated by an intervention, recipients of that
declines in maternal and child mortality, and intervention might die of other diseases or their com-
increases in life expectancy have helped to shape plications if the factors that underlie the proliferation
the view that medicine and therapeutic interven- of disease in the environment are not addressed. For
tions were the major contributors to the overall example, when smallpox vaccination became avail-
improvement in global health over the years. able in the early 19th century, smallpox deaths,
Informed by this view, global health agencies and which occurred mostly among children, fell precipi-
national governments of less-developed countries tously, but the overall mortality remained relatively
continue to lay emphasis on therapeutic interven- unaffected as deaths from diarrhea and related con-
tions to the neglect of investment in health systems ditions subsequently increased (Ehiri and Prowse
development, infrastructure strengthening, and 1999; McKeown 1979). As Sagan (1989) observed,
environmental and economic empowerment pro- ‘‘one cause of mortality simply replaced another.’’
grams. Moreover, health-care systems in many of This problem is a major weakness in current strategies
these countries have emerged from colonial medical adopted to reduce childhood diseases by donor agen-
services that focused to a huge extent on large cies and governments in less-developed countries.
hospitals in urban centers, even in situations
where a majority of the population live in remote
rural areas with limited physical and financial
access to the most basic health services. Thus, dur-
Child Health Problems Have
ing the 1950s and 1960s, when many less-developed Multifactorial Causes and Consequences
countries gained their independence, they essen-
tially inherited health-care systems that were Evidence shows that in many less-developed coun-
based on high-technology, urban-based curative tries, a significant proportion of the problems of ill-
care. Because many of these countries have not health and disease among infants and children are
invested efforts in purposefully creating and main- closely linked to both environmental conditions and
taining health systems that reflected their popula- poverty. The problem confronting Tanzania, for
tion’s dynamics and level of socioeconomic devel- example, is similar to that in many other less-
opment, they have perpetually continued to suffer developed countries – high incidence of infectious
from the effects of inadequate or non-existent and parasitic diseases, low nutritional levels, and
health systems and infrastructures with grave problems relating to pregnancy and childbirth
impacts on the health of women and children. (Sunguya et al. 2006; Mhalu 2005). There is general
Over the years, each childhood disease eradication acceptance (WHO 1995) that the primary cause of
program of major players in global health (bilateral these problems is poverty, which operates through
agencies and non-governmental organizations) has inadequate food intake, low educational levels, lack
operated autonomously, each disease program with of safe drinking water, poor environmental condi-
its own administration and budget and with very little tions, and lack of access to basic care. The brunt of
29 An Agenda for Child Health Policy in Developing Countries 535
the problem is borne by infants and children under Factors That Contributed to Population
the age of 5, who although constitute about 18% Health Improvements in High-Income
of the population account for 63% of all deaths
Countries
(Armstrong Schellenberg et al. 2008). It was not
surprising that the 10th Edition of the International In considering the best options for child health pro-
Classification of Diseases (ICD-10) (WHO 1992) motion in less-developed countries, it is important
includes a code for extreme poverty, Z59.5. As the to analyze and draw parallels with factors that con-
World Health Organization noted in its 1995 World tributed to population health improvements in
Health Report (WHO 1995), ‘‘poverty is the main high-income countries over the past century. This
reason why babies are not vaccinated, clean water parallel is not unreasonable given that many less-
and sanitation are not provided, and curative drugs developed countries are more or less currently at the
and other treatments are unavailable, and why level of health and social economic development
mothers die in childbirth. Poverty is the main that many high-income countries were several dec-
cause of reduced life expectancy, of handicap and ades ago. In his analysis of factors that contributed
disability, and of starvation’’ (WHO 1995). Tack- to improvements in health and growth of the popu-
ling child health problems too narrowly in less- lation of England and Wales, McKeown (1979)
developed countries and paying minimal attention showed that the high death rates of the past were
to primary prevention through action on household largely attributable to a combination of infectious
and community social and environmental health diseases, nutritional, and environmental factors. He
factors are expensive and unsustainable. estimated that from the beginning of the 18th cen-
Research conducted on the impact of disease- tury to the mid-1970s, 80–90% of the total reduc-
specific interventions in less-developed countries tion in death rate in England and Wales was as a
shows that children with severe illness often present result of the decline in deaths caused by infections
with multiple problems that call for a comprehen- and water- and food-borne diarrheal diseases. He
sive approach that recognizes the complexity of the noted that with the exception of vaccination against
problem (Campbell and Gove 1996). Responding to smallpox (associated with less than 2% of the
the challenge posed by this predicament, interna- decline in death rate from 1848 to 1871), it was
tional health agencies led by the World Health unlikely that immunization or therapy had any sig-
Organization (WHO) and the United Nations Chil- nificant effect on infectious diseases before the 20th
dren’s Fund (UNICEF) introduced the Integrated century given that much of the reduction in mortal-
Management of Childhood Illnesses (IMCI) in the ity from tuberculosis, respiratory, water- and food-
1990s (WHO 1999). Details of this strategy, includ- borne diseases had already occurred before effective
ing its objectives and country implementation immunization or treatment was available. In con-
experiences, are discussed in Chapter 27. The objec- clusion, he asserted that these improvements in
tives of IMCI include improvement in health sys- health had resulted more from ‘‘environmental pub-
tems and family and community practices. How- lic health,’’ political, economic, and social measures
ever, its actual implementation remains largely than from specific medical or therapeutic
focused on case management. As Rowe et al. interventions.
(1999) noted, the focus of IMCI on case manage- Several other analyses (Lucas 2003; United
ment does not significantly distinguish it from other Nations 1973) have yielded similar conclusions.
disease-focused policy initiatives of the past that Box 29.1 presents a summary of the factors that
have been criticized for their lack of attention to contributed to early reductions in mortality in Eur-
social determinants of health and disease in less- ope and North America. While it is important to
developed countries. The primary aim of the IMCI question the validity of these retrospective reviews,
strategy is to prevent deaths and disabilities by it is interesting to note the consensus among many
improving the case management of sick children in authors regarding the importance of social and
outpatient health facilities. Its guidelines have environmental factors. Beaver (1973) noted that in
therefore been focused on the treatment of indivi- the second half of the 18th century, infant mortality
dual children (Rowe et al. 1999).
536 J.E. Ehiri
fell in England and Wales when supplies of cheap

Box 29.1 Causes of Mortality Decline in the 18th cow’s milk became generally available throughout
and 19th Centuries in Europe, North America, the year. With regard to smallpox, for example,
Australia, and New Zealand Razzell (1974) noted the role of immunization, but
stressed the huge influence of improved hygiene,
Improved agriculture: Increased food production including the use of soap and washable cotton
and better nutrition (e.g., the Agricultural Revo- clothes in the first 40 years of the 19th century. In
lution in England included better fertilizers, crop France, Preston and van de Walle (1978) found that
rotation, and winter crops). mortality was relatively high in three urban areas,
Industrialization: The development of the factory but after 1850, mortality in these settings declined
system led to wider availability of manufactured dramatically as a result of improvements in water
goods. Factory production of machinery (e.g., supply and sewerage. As they noted, medical
iron plough, team engine) also contributed to improvements did not become important until
improved agriculture. diphtheria immunizations in the 1890s.
In considering the foregoing evidence, it is rea-
Improved transport: Facilitated the distribution
sonable to argue that the key to sustainable
of food and other goods (e.g., in Europe, rail-
improvement in child health in less-developed coun-
ways enabled food supplies to be sent rapidly
tries may lie in the development of infrastructures to
from rural to urban areas).
improve environmental public health, efforts to
Social reforms: Various health and social welfare alleviate poverty, and enhancement of people’s
schemes and regulations, including the regula- overall living standards.
tion of child labor in factories.
Greater control of temperature and humidity: Reg-
ulation of temperature and humidity in homes
and at work may have contributed to the decline Recommendations for a New Strategy
of some diseases.
Public sanitation: Including improved sewage Given the limitations of the current disease-specific
disposal, water supplies, and water purification approach to child health promotion in less-devel-
(e.g., filters that eliminated cholera and typhoid oped countries, a rethink of global child health
from the water). policy is needed. A historical analysis of specific
Improved personal hygiene: The availability of country experiences shows that comprehensive
cheap and easy-to-wash cotton clothing, potable approaches to child health promotion are effective
water supplies, and soap facilitated improved and sustainable. These include, for example, the
personal hygiene. creation of the Bhore Commission in India (Gov-
ernment of India 1946) which demonstrated signifi-
Asepsis and antisepsis: The exclusion and killing
cant improvements in child and population health
of disease-causing organisms was developed
through the establishment of rural health centers,
by Joseph Lister in the late 19th century
staffed by community health workers; the imple-
(e.g., the sterilization of surgical instruments).
mentation of ‘‘community-based health programs’’
Immunology: For example, Edward Jenner’s in Nicaragua, Costa Rica, Guatemala, Honduras,
inoculation against smallpox and discoveries Mexico, Bangladesh, and the Philippines; and the
by Koch and Pasteur that inoculation with a barefoot doctor program in China which deployed
mild form of the disease will prevent a serious trained community health workers to rural areas as
case. the gatekeepers of the nation’s health who provided
Biological factors: Increased resistance to some basic preventive and curative services to people in
diseases and some diseases becoming more their environments (Magnussen et al. 2004). As
benign (e.g., scarlet fever). part of the overall efforts to improve population
Source: Thomlinson (1976) health, these countries brought a new theme to
global health discourse: a commitment to social
justice and equity in health services. Contrary to determinants of health is a major limitation
the top-down, high-technology approach that con- (WHO 2008; Magnussen et al. 2004; Ehiri and
tinues to drive international cooperation in child Prowse 1999). Thus, the intent of this chapter is
health, the foundation of these country experiences not to revisit the protracted debate regarding the
is essentially a bottom-up approach that empha- merits of selective versus comprehensive
sized prevention and managed health problems in approaches to primary health care but rather to
their social contexts. These countries’ experiences propose that the comprehensive approach envi-
also embodied the tenets of the Alma Ata’s sioned in the Alma Ata Declaration (WHO/UNI-
Declaration of Primary Health Care by the WHO CEF 1978) be given a chance as a key element of
and the UNICEF in 1978, which made it the an evolving policy for child health promotion in
responsibility of governments and agencies to pro- less-developed countries. Three decades after the
mote equity and ensure that segments of the popu- Alma Ata Declaration, and on account of the
lation were not unduly suffering for the benefits apparent limitations of the selective approach to
received by others. The Declaration defined pri- primary health care, the 2008 report of the World
mary health care as ‘‘essential care based on prac- Health Organization (WHO 2008) has chosen as
tical, scientifically sound and socially acceptable its title ‘‘Primary Health Care: Now More Than
methods, made technologically and universally Ever,’’ thus revisiting the ambitious vision of pri-
available to individuals and families in the commu- mary health care as a set of values and principles
nities through their full participation, and at a cost for guiding the development of health systems. As
the community and country can afford to maintain the director general of the World Health Organi-
at every stage of their development, in the spirit zation, Dr. Margaret Chan observes the report
of self-determination and self-reliance’’ (WHO/ represents an important opportunity to draw on
UNICEF 1978). WHO/UNICEF asserts that pri- the lessons of the past, consider the challenges
mary health care forms an integral part of a coun- that lie ahead, and identify major avenues for
try’s development and health system. It is the first health systems to narrow the intolerable gaps
level of contact for the individual, family, and com- between aspiration and implementation (WHO
munity with the health system, bringing health care 2008). In embarking on this important policy
as close as possible to where people live and work, shift, the focus should not be on generalities but
and constitutes the first element of a continuing on a number-specific action steps, some of which
health-care process (WHO/UNICEF 1978). Pri- are discussed below.
mary health care was intended to cover the follow-
ing key areas: Development and Maintenance of
Health education Infrastructures to Support Integrated
Food supply and nutrition Systems of Care
Water and sanitation
Maternal and child health
Many less-developed countries continue to rely on
Immunization
vertical programs, with less emphasis on people’s
Prevention and control of locally endemic
involvement and development of systems and infra-
diseases
structures to sustain those programs. Whilst not
Treatment of common diseases and injuries
undermining the contributions of medicine to pub-
Provision of essential drugs
lic health, medical care should underpin the health
The selective approach to primary health care of a population or a group only when prevention
which used results of cost-effective studies (Walsh fails (Ashton and Seymour 1993). Reliance on case
and Warren 1979) to determine a package of management of specific diseases as a framework for
disease-focused interventions to be funded and health improvement in less-developed countries is
implemented in less-developed countries has expensive, unsustainable, and will result in few real
been tested and the results show that its inability health benefits if the underlying environmental and
to tackle broader environmental and social social causes are not addressed. For example,
538 J.E. Ehiri
although the current initiative on vaccines and members. Global health problems cannot be solved
immunization (GAVI Alliance), designed to help by distant policy makers and planners (Bichmann
countries to incorporate new vaccines into their 1988) as involvement of individuals and commu-
national health systems, has benefits for addres- nities fosters the mobilization of needed local
sing specific communicable diseases as discussed resources (Askew 1991). Implied in the concept of
in Chapter 23, their full potential will be difficult participation is decentralized physical location of
to achieve in the absence of effective health sys- hospitals and health centers, which emphasizes that
tems and supporting infrastructures. Limited programs need to be founded and researched in the
assessment of this initiative undertaken in locality in which they will be applied. The Alma Ata
Mozambique, Ghana, Lesotho, and Tanzania Declaration also recognizes that the issue of accessi-
(Brugha et al. 2002) revealed that the infrastruc- bility to health services and resources has historically
tural foundation needed for successful imple- been a barrier to effective care and that placing
mentation and sustainability was inadequate. emphasis on curative, tertiary care hospitals located
Moreover, maintaining the cost of expensive in urban centers often precludes access for a mostly
new vaccines after donor support ceases is finan- rural population.
cially unsustainable for many less-developed
countries. As with most vertical programs, ana-
lysts have expressed concern that raising poor
countries’ awareness of new vaccines and immu- Greater Collaboration and Reduction of
nization programs without support in imple-
menting such programs could end up creating
Overlap and Waste Among the Various
markets for these vaccines while doing little to Key Players in Global Child Health Practice
tackle major health problems (Fleck 2002).
Given that disease-focused models continue to Countries need to strengthen their primary
be funded and promoted in less-developed coun- health care through the development of intersec-
tries, it is apparent that adequate lessons have toral forums at every level. Human health
not been learned from experimentation with should be a cross-cutting issue throughout the
selective, vertical approaches; that the notion of decision-making process in different sectors and
self-reliance, community participation, and at different levels. Health policy development
health systems development proposed at Alma should involve those sectors, agencies, and social
Ata have diminished in importance; and that groups that are critical to achieving better
inadequate consideration is given to the link health. This can be achieved through advocacy
between health and socioeconomic development. for health objectives as integral to socioeconomic
Global health policy for the 21st century should development and through engagement of differ-
recognize that expensive high-technology models ent sectoral partners and community structures
to address diseases of poverty will not be sus- in the consensual process. Because health does
tainable where the infrastructures needed for not occur in isolation, the various sectors,
operationalization and institutionalization of including those within a national government
those technologies do not exist. and among aid agencies, need to work together
at every level of practice. The ministry of health
is not the sole agency charged with production
of health; the departments of agriculture, hous-
Community-Focused Approach to
ing, sanitation, and education, along with food
Intervention Development and distribution, are all involved in achieving opti-
Implementation mal health. Integrated planning, management,
and execution of public health policies and prac-
The Alma Ata Declaration requires that interven- tices by these different governmental depart-
tions come from the needs of the community, ments is essential to the promotion of public
expressed and subsequently led by community health in less-developed countries.
Development of Pro-poor Policies Political Commitment

Health policy makers should be aware that macro- Although the challenges of addressing the socioeco-
economic, labor, and social policies have the poten- nomic root causes of disease in less-developed coun-
tial to limit or enhance health opportunities for tries may seem insurmountable, analyses of factors
different groups in the population. International that contributed to health improvements in devel-
aid agencies and governments in less-developed oped countries provide cause for optimism. For
countries should be aware that the pursuit of liberal example, the appalling health conditions described
macroeconomic pro-growth policies has the ten- in the Report of the Sanitary Commission of
dency to provide better opportunities to those with Massachusetts to the Massachusetts State Legisla-
resources and high levels of education, while large ture in 1850 were similar to those that prevail in
segments of the population without these assets are many less-developed countries today (Evans et al.
unlikely to benefit and may in fact become casual- 1981). The report embodied the essential elements
ties of economic transition. Thus, it is the duty of of comprehensive primary health care – communic-
health policy makers to signal when other policies able disease control, promotion of child health,
may undermine efforts to promote health equity housing improvement, sanitation, training of com-
(McIntyre and Gilson 2000). munity health workers, public health education,
promotion of individual responsibility for one’s
own health, mobilization of community participa-
tion through sanitary associations, and creation of
Emphasis on Effective Training,
multidisciplinary boards of health to assess needs
Development, and Deployment of Child and plan programs. Recognizing the importance of
Health Professionals political commitment, the report called for estab-
lishment of a strong public health constituency and
As shown in Chapter 28, ensuring the quality of addressed inequity by highlighting major differ-
primary health care and reform of the health sector ences in life expectancies between US rural and
under primary health care should include coherent urban areas. Thus, many of the improvements in
human resource development plans at the village, Americans’ health have been attributed to the ensu-
district, state/regional, and national levels. Strategies ing political commitment and emphasis on public
for retention of trained personnel in remote and rural health and socioeconomic interventions implemen-
areas are also important. Primary health-care sys- ted by the various arms of the US government over
tems in developing countries provide interventions time. Governments in less-developed countries
that are already known to be effective. This means must commit to funding for sustaining community
that achievement of quality in primary health-care involvement in health. This can be achieved
facilities requires the proper performance of these through, for example, private-sector involvement
interventions according to prescribed standards. and through hosting village, district, or regional
However, the most common challenge is that often, people’s health assemblies so that the voices and
these interventions are not properly executed (Ehiri opinions of the people can be represented in the
et al. 2005; Gilson et al. 1995). In a recent study in design and implementation of health policies.
southeast Nigeria, Ehiri et al. (2005) revealed that
inadequacy in the quality of services provided by
community-based primary health-care workers is a
product of failures in a range of quality measures: Conclusion
structural, process failings, and lack of a protocol for
systematic supervision of health workers. Thus, qual- This chapter posits that global child health policies
ity improvement in this context is not simply a matter and programs based on vertical therapeutic inter-
of providing infrastructural resources but one of pay- ventions will not greatly alleviate the overall burden
ing attention to improvement in process, especially of childhood disease in less-developed countries
through training and supervision. unless the socioeconomic, political, and health
540 J.E. Ehiri
system factors that underlie child health and disease health. To engender real change, a rethink of the
in these countries are challenged. The chapter current disease-focused policy is urgently needed.
further argues that progress lies in a fundamental As evidence has shown, treating children of envir-
shift in emphasis from vertical, short-term measures onmentally induced ailments, whilst at the same
to a revitalization of Alma Ata’s primary health time, tackling the causative environmental and
care, with emphasis on poverty alleviation, commu- social factors, is a most comprehensive and sustain-
nity participation, and the development of health able alternative.
systems and infrastructures to create and sustain
Key Terms
Alma Ata Declaration Health system Poverty

Bilateral agencies Health care system Smallpox
Bottom-up approach Integrated Management of Selective primary health care
Comprehensive primary Childhood Illnesses (IMCI) Social determinants
health care International Classification of Sustainability
Equity Diseases (ICD) Top-down approach
Essential drugs Macroeconomics
Disease-focused interventions Non-governmental
GAVI Alliance Organizations (NGOs)

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About the Editor
John Ehiri, MSc (Econ.), MPH, PhD, is Professor and Director, Division of
Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health
(MEZCOPH), the University of Arizona, Tucson, Arizona, USA. His research
and teaching focus on social and behavioral aspects of disease prevention, and on
global maternal, child and adolescent health – all linked by program intervention
design, evaluation methodology and evidence-based policy/practice. He has over
20 years of research, teaching and service experience in global health.
Prior to joining the University of Arizona College of Public Health, Dr. Ehiri
was Associate Professor in the Department of Maternal and Child Health at the
University of Alabama at Birmingham (UAB) School of Public Health. He was
Principal Investigator and Chair, Executive Committee, UAB Framework Pro-
gram for Global Health, an initiative funded by the Fogarty International Center
of the US National Institutes of Health that builds global health education and
research capacity in the United States abroad, by supporting the development of
innovative, multidisciplinary global health programs. At UAB, Dr. Ehiri taught
core courses in the University’s Global Health Studies Program and was the
recipient of the President’s Award for Excellence in Teaching (School of Public
Health) in 2006. Prior to joining UAB, he was a Lecturer in International Health,
and Director of the Master of Community Health (MCommH) Program at the
Liverpool School of Tropical Medicine, England, United Kingdom. Dr. Ehiri
has provided technical assistance on various aspects of maternal, child, and
adolescent health to United Nations and bilateral agencies, and has supervised
students’ field projects in over 20 countries.
Dr. Ehiri obtained his PhD and MPH degrees from the University of Glas-
gow, Scotland, United Kingdom. He also holds an MSc (Econ) in health policy
and planning from the University of Wales, Swansea, United Kingdom. He has
authored/co-authored over 70 peer-reviewed articles on critical issues in global
maternal, child, and adolescent health.
J.E. Ehiri (ed.), Maternal and Child Health, DOI 10.1007/b106524, 543
About the Contributors
Rebecca Affolder, M.Phil., is head of the Executive Office of the GAVI Alliance.
Prior to joining the GAVI Alliance, she was part of the Secretariat to the
Commission for Africa, chaired by the UK Prime Minister. She was
responsible for the health section of the Commission’s Report, as well as for
consultation and presentation of the overall human development
recommendations following its publication in March 2005. From 2003 to 2004,
Rebecca worked with the UK Department for the Environment, Food and Rural
Affairs on the Modernizing Rural Delivery Programme. Prior to this, she held
posts with the Canadian International Development Agency (CIDA), both in the
Policy Branch and the Programme Against Hunger, Malnutrition and Disease.
She holds a BA (Hons) in History from the University of Alberta and an M.Phil.
from the University of Cambridge, where she studied the political and social
history of famine in Africa.
Ebere Anyanwu, B.Sc., MS, Ph.D., FRSH, M.Biol., C.Biol., was a lead researcher
at the Medical Center for Immune and Toxic Disorders and adjunct professor of
Anatomy and Physiology at the North Harris and Montgomery Colleges in
Houston, Texas. He has taught at various institutions of higher education in
the United Kingdom and the United States and has published over 84 papers in
international peer-reviewed health science journals. In 2004, Ebere Anyanwu
was awarded the International Health Professional of the 2004 by the
International Biographical Society, Cambridge, United Kingdom. He is a
fellow of the Royal Society (1979), a chartered biologist, clinically certified
forensic counselor, and diplomate of the American College of Forensic
Counselors. He is currently an independent international health research
scientist and consultant.
Robert E. Black, MD, MPH, is the Edgar Berman professor, chair of the
Department of International Health, and director of the Institute for
International Programs at the Johns Hopkins Bloomberg School of Public
Health, Baltimore, Maryland. Dr. Black is trained in medicine, infectious
diseases, and epidemiology. He has served as a medical epidemiologist at the
US Centers for Disease Control and worked at institutions in Bangladesh and
Peru on research related to childhood infectious diseases and nutritional
problems. His current research includes field trials of vaccines, micronutrients
and other nutritional interventions, effectiveness studies of health programs such
545
546 About the Contributors
as the Integrated Management of Childhood Illness approach, and evaluation of

preventive and curative health programs in low- and middle-income countries.
His other interests are related to the use of evidence in policy and programs,
including estimates of burden of disease, the development of research capacity,
and the strengthening of public health training in less-developed countries. As a
member of the US Institute of Medicine and advisory bodies of the World Health
Organization, the International Vaccine Institute, and other international
organizations, he assists with the development of policies intended to improve
global child health. He currently chairs the Child Health Epidemiology
Reference Group (CHERG) established by the WHO in 2001 to provide
external technical guidance and global leadership in the development and
improvement of epidemiological estimates for children under 5 years of age. He
also chairs the Child Health and Nutrition Research Initiative (CHNRI), an
international network of interested partners registered as a Swiss Foundation
and supported by the Global Forum for Health Research (GFHR) in Geneva,
Switzerland. He currently has projects in Bangladesh, Benin, Ghana, India, Mali,
Pakistan, Peru, Senegal, Zanzibar, and Zimbabwe. He has more than 450
scientific journal publications and is coeditor of the textbook International
Public Health (Jones & Bartlett Publishers, Inc., 2006, 3rd Edition).
Cynthia Boschi-Pinto, MD, MPH, Ph.D., is a medical officer in the Department
of Child and Adolescent Health and Development at the World Health
Organization, Geneva, Switzerland. She is responsible for activities related to
child health epidemiology and is the coordinator of WHO’s Child Health
Epidemiology Reference Group (CHERG). Her previous researches were on
spatial distribution of mortality, heterosexual transmission of HIV, and cancer
epidemiology. Her current interests are child mortality, burden of childhood
disease, and the use of evidence for priority setting and planning. Prior to
joining the WHO office in Geneva, Dr. Boschi-Pinto held several research and
teaching positions in epidemiology, child, and adolescent health. She was
professor at Universidade Federal Fluminense, head of the Department of
Epidemiology at the Institute of Public Health, and researcher at Oswaldo
Cruz Foundation (FIOCRUZ) in Rio de Janeiro, Brazil. She received her
medical degree from Universidade Federal Fluminense, an MPH with
specialization in epidemiology from FIOCRUZ, and a Ph.D. from the Harvard
School of Public Health.
Elke de Buhr, MS, Ph.D., is assistant professor at the Payson Center for
International Development, Tulane University, New Orleans. Her research
focuses on the rights and protection of children, and the health and well-being
of people of all ages. She currently is the monitoring/data collection specialist on
the Tulane University team that oversees the implementation of the Harkin-
Engel Protocol and the efforts undertaken by the international cocoa/chocolate
industry to eliminate the worst forms of child labor in the cocoa sector in West
Africa. This project, which involves repeated representative survey research as
well as other research and monitoring tasks, reports yearly to the US Congress on
progress made toward the implementation of the Protocol. Her earlier research
and projects include the study of orphans and vulnerable children in the
Democratic Republic of Congo, research on street children in Eastern Europe
and the Middle East, HIV/AIDS monitoring and evaluation in Rwanda, data
About the Contributors 547
management and capacity building in the health sector in Ethiopia, and

participation in the evaluation of the international response to the 2004 Indian
Ocean tsunami in South-East Asia. Elke de Buhr has worked as a consultant on
projects financed by CDC, UN-OCHA, UNAIDS, World Vision, among others.
She has a Ph.D. from Tulane University, an MS in International Development
from Tulane University, and a diploma in Political Science from Free University
of Berlin, Germany.
Lisa Byers, MSW, Ph.D., is a member of the Cherokee Nation in Oklahoma and
an assistant professor at the University of Oklahoma’s School of Social Work,
Tulsa Campus. She has dedicated her education and activities to the promotion
of tribal well-being. This endeavor has included an acknowledgment of both the
disparities that Native people face and the appreciation for the resilience of tribal
people, particularly elders. Dr. Byers was a National Institute of Mental Health
pre-doctoral fellow and a Council for Social Work Education minority research
fellow, which led to her focus on depression, discrimination, trauma, and
American Indian ethnic identity. She is codeveloper of a social work course
module for Oklahoma Native elders funded by the Council of Social Work
Education. In addition, she is working in the area of early childhood
intervention research within urban American Indian contexts through the
Indigenous Early Intervention Alliance in Phoenix, Arizona.
Andrew L. Cherry, Jr., DSW, ACSW, is endowed professor in Mental Health at
the School of Social Work, University of Oklahoma. He has worked in the
helping professions since receiving his BS degree from Troy State University,
Troy, Alabama, in 1969. While working as a child welfare worker in Alabama, he
became interested in the growing phenomena of teenage pregnancy. He received
his Master of Social Work from the University of Alabama in 1974 and worked
as a psychiatric social worker at Bryce Hospital, Tuscaloosa, Alabama. He
received his doctorate from Columbia University School of Social Work in
1986. Over the next few years as the incidence of teenage pregnancy rapidly
increased, he conducted several extensive studies of teenage pregnancy that
resulted in two books: Social Bonds and Teen Pregnancy (1992) and The
Socialization Instinct: Individual, Family and Social Bonds (1994). More
recently he was the series advisor for a set of 18 books entitled A World View of
Social Issues. He coedited and wrote several chapters in one of the books,
Adolescent and Teen Pregnancy: A Global View (Greenwood Press, 2001).
Dr. Cherry conducts research and evaluations in the areas of co-occurring
disorders, homelessness, services to children and families, teenage pregnancy,
and the influence of social bonds on human behavior. Professor Cherry has
authored four other books and two research textbooks.
Ian G. Child, MSHA, Ph.D. (ABD), is chairman and CEO of IRISS-
International, Inc. and an adjunct professor of Global Health at University of
Alabama at Birmingham. Early in his career he was a laboratory research
biochemist and then director of European product development for a major
British pharmaceutical company. Over a period of 30 years, he was president
of the UK, Canada, Australia, and New Zealand subsidiaries of the world’s
largest medical data research company; then joint founder of the leading United
States pharmacy computer services company; information systems advisor in six
Far East countries; president of a medical artificial intelligence software

company; and advisor to a joint clinical research organization in four US
universities. For many years he has had a deep interest in health-care systems
and social determinants of health in OECD countries and the complexities of
care delivery in developing countries.
Hoosen M. (Jerry) Coovadia, MBBS, M.Sc., MD, D.Sc., is Victor Daitz chair in
HIV/AIDS Research and is the director of Biomedical Science at the Centre for
HIV/AIDS Networking, Nelson R. Mandela School of Medicine, University of
Natal, South Africa. Prior to this, he was professor and head of Pediatrics and
Child Health at the same university. His research interest is in pediatric HIV/
AIDS, with particular emphasis on mother-to-child transmission. He has
published a number of groundbreaking research articles on this subject. He
and his team were the first to suggest, contrary to popular opinion, that
transmission of HIV from mother-to-child via breastfeeding could be
significantly reduced by exclusive breastfeeding. He has authored or
coauthored more than 200 articles in peer-reviewed journals and is coeditor of
Paediatrics and Child Health (Oxford University Press, 2000), a manual that
covers all aspects of child care in developed and less-developed countries and is
widely used by medical students and junior doctors around the world.
Dr. Coovadia has received numerous national and international honors and
awards. He was elected a fellow of the University of Natal in 1995 and was
awarded an honorary D.Sc. by the University of Durban, Westville, South Africa
in 1996. In 1999, President Nelson Mandela honored him with the Star of South
Africa for his contribution to democracy and health and he received a silver
medal from the Medical Research Council for excellence in research. In 2000, he
received the International Association of Physicians in AIDS and Care Award,
the Heroes in Medicine Award in Toronto, Canada, the Nelson Mandela Award
for Health and Human Rights, and was elected a Foreign Member of the
Institute of Medicine of the National Academy of Sciences, USA – an honor
that is seldom awarded. He was awarded a second honorary D.Sc. by the
University of Witwatersrand, South Africa, in 2007 and received the Science
for Society Gold Medal from the Academy of Science of South Africa. He was
appointed by the National Department of Health as chairperson of the National
Advisory Group on the HIV/AIDS and STD Programme from 1995 to 1997,
while his international stature in the area of HIV/AIDS led to his election as
chairperson of the XIIIth International Conference on AIDS held in Durban in
July 2000. Dr. Coovadia received his medical degree from the University of
Bombay, India, an M.Sc. in Immunology from the University of Birmingham,
England, and an MD from the University of Natal, South Africa.
Emmanuel d’Harcourt, MD, MPH, is senior technical advisor for Child Survival
at the International Rescue Committee. His work focuses on developing
community health networks to deliver essential health services in sub-Saharan
African countries affected by conflict, including the Democratic Republic of
Congo, Rwanda, Sierra Leone, and South Sudan. His interests include the
development of alternative models for rebuilding health systems and the use of
information technology in infrastructure-poor countries. He is author of the
forthcoming Community Case Management Essentials Manual. Emmanuel
holds degrees from Yale, Johns Hopkins, and Harvard and completed his
pediatric residency at the Children’s Hospital of Philadelphia. He is a member of

the board of the CORE Group.
Mary Dillon, Ed.D., MSW, is an adjunct professor at the University of
Oklahoma, School of Social Work, and has been working in the social services
field since the late 1980s. Her current research focus is on the effects of protective
services on girls and women who present with the co-occurring disorders of
mental illness and substance abuse. Her interest in teenage pregnancy and
women’s issues in general began in the 1980s when she was the program
director at a day shelter for homeless women and children. Later, she worked
as the executive director of a nonprofit afterschool program for at-risk
adolescent girls and their families. Her research and interest in teenage
pregnancy and the impact of drug and alcohol abuse led to the publication of
two books. She coedited and wrote several chapters in Adolescent and Teen
Pregnancy: A Global View (Greenwood Press, 2001) and Abuse of Alcohol and
other drugs: A Global View (Greenwood Press, 2002). Mary received her Master
of Social Work degree from Barry University in Miami, Florida, in 1993, and her
doctorate in Education and Human Services from Nova Southeastern University
in 2007.
Emmanuel Ezedinachi, MD, DTMH, is a professor of Medicine and consultant
physician at the University of Calabar Teaching Hospital, Calabar, Nigeria. He
is also founder and pioneer director of the Institute of Tropical Diseases
Research and Prevention, the University of Calabar Teaching Hospital,
Calabar, Nigeria. His research focuses on tropical and emerging diseases,
especially malaria, HIV/AIDS, and tuberculosis. He was the national
professional officer the World Health Organization’s Roll Back Malaria
(RBM) program between 2000 and 2007. Dr. Ezedinachi has published many
articles and made numerous national and international presentations on malaria
and other tropical diseases and continues to provide technical assistance to
United Nations agencies. He obtained his medical degree from the University
Düsseldorf, Germany, in 1974 and a diploma in Tropical Medicine & Hygiene
from the Tropical Medicine Institute, Hamburg, Germany, in 1978.
Nancy Gerein, Ph.D., M.Sc., is a senior lecturer and deputy head, Nuffield Centre
for International Health and Development. She has worked extensively in health
planning, and health sector reforms in many countries, including India,
Cameroon, Indonesia, and Bangladesh. As a health advisor for the Canadian
International Development Agency (CIDA), she was responsible for the
planning, management, and evaluation of health programs in Africa and Asia.
She joined the Nuffield Centre for International Health and Development at the
University of Leeds in 1999. Her teaching, research, and consultancy interest is
focused in the areas of reproductive health, health systems development, and
monitoring and evaluation. Nancy holds a Ph.D. in Healthcare Epidemiology
from the London School of Hygiene and Tropical Medicine, England, and an
M.Sc. in Health Policy and Planning from the University of British Columbia in
Canada.
Robert Gilman, MD, DTMH, is a Professor in the Department of International
Health, Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, Maryland. He is also a Research Professor at the Universidad
Peruana Cayetano Heredia. His research focuses on tropical diseases including

parasitic diseases such as Cysticercosis and Cyclospora cayetanensis. He has also
published widely on various aspects of tuberculosis and is best known for his
development of the diagnostic technique of Microscopic Observation and
Detection and Susceptibility (MODS) for use in tuberculosis. He continues to
spend at least six months each year in Peru working on locally endemic diseases,
including tuberculosis, Chagas and cysticercosis. Dr. Gilman received his
medical degree from Downstate Medical School in 1965 and his Diplomate of
Internal Medicine and Fellowship in Infectious Diseases from the Department of
Medicine, University of Maryland Hospital in 1973.
Andrea Gottsegen Asnes, MD, MSW, is an assistant professor in the Department
of Pediatrics, Yale University School of Medicine. Her area of expertise is
medical evaluation of suspected child maltreatment. Her research focuses on
the forensic evaluation of children who disclose sexual abuse and the experience
of nonoffending parents of sexually abused children. Dr. Asnes also teaches
communication skills and professionalism. She obtained her medical degree
from the Mount Sinai School of Medicine, her MSW from New York
University, and is a graduate of the Robert Wood Johnson Clinical Scholar’s
Program at the University of Michigan.
Andrew Green, MA, Ph.D., is head of the Nuffield Centre for International
Health and Development, a member of the Senior Management Team for the
Institute of Health Sciences, and chair of the International Management
Committee at the University of Leeds, England, UK. His research interests are
in health planning and policy, health sector reform, health economics, and
nongovernmental organizations; he has published widely in these areas. His
book An Introduction to Health Planning for Developing Health Systems
(published by Open University Press, 3rd Edition, 2007) is a well-known text
on the subject. He has carried out numerous consultancies for various
organizations including the Department for International Development
(DFID), London, the World Bank, and the World Health Organization.
Dr. Green holds a Ph.D. from the University of Leeds, England, and an MA in
Development Economics from the University of Sussex, England.
Anne Hyre, CNM, MSN, MPH, is a certified nurse-midwife with experience in
strengthening midwifery education and clinical practice in 15 countries. She has
more than 15 years of experience in strategic planning, program design,
implementation, and program evaluation for maternal and reproductive health
in the United States and abroad. She also has a solid record of success in business
development with donors, foundations, and corporations. She currently works
as the director of Global Outreach for the American College of Nurse-Midwives
(ACNM). Prior to joining ACNM, she spent 15 years with Jhpiego, including
8 years based in Jakarta, Indonesia. With Jhpiego, she provided technical
leadership and support to programs in preservice education, training systems
development, human resource capacity building, and clinical performance
improvement.
Monir Islam, MD, MPH, FRCOG, is director of the Department of Making
Pregnancy Safer, World Health Organization, Geneva, Switzerland. He
graduated with a degree in medicine from Dhaka University, Bangladesh, and
received his MPH from the Royal Tropical Institute, University of Amsterdam,
the Netherlands. He is a fellow of the Royal College of Obstetricians and
Gynaecologists (FRCOG), UK. Prior to joining the Making Pregnancy Safer
at WHO, Geneva, he was the director of Family and Community Health at the
WHO Regional Office for South-East Asia, New Delhi, India.
Albrecht Jahn, MD, Ph.D., is scientific officer, European Commission Directorate
General for Research, Brussels, Belgium. Prior to joining the European Commission,
he was a senior lecturer in the Department of Tropical Hygiene and Public Health
at the University of Heidelberg, Germany. With specializations in obstetrics and
gynecology, public health, and tropical infectious diseases, Dr. Jahn worked for
several years in rural hospitals in Kenya and Tanzania focusing on mother and
child health, including malnutrition. After establishing an interdisciplinary research
group at Heidelberg University, his research collaborations extended to Pakistan,
Nepal, Burkina Faso, Cape Verde, and South Africa with a focus on assessing
and improving maternity-related health systems and services as well as related
procedures and technologies.
Chuks Kamanu, MBBCh, FWACS, FICS, is an honorary consultant and head of
the Department of Obstetrics and Gynecology, Abia State University Teaching
Hospital, Aba, Nigeria. He is also a senior lecturer in the College of Medicine,
Abia State University, Uturu. He is actively involved in medical education at
both the undergraduate and postgraduate levels, and is an external examiner for
several Medical Schools in Nigeria. His research focuses on to reduce maternal
morbidity and mortality. He is involved in grassroots advocacy against harmful
traditional practices on women, and is a coveted speaker in academic and
religious conferences on this issue. Presently, he is working on a research
publication for the Surgery in Africa Review on destructive operations in
obstetrics (set of operations carried out in neglected obstructed labor when the
fetus is dead). Dr. Kamanu obtained his medical degree from the College of
Medicine, University of Calabar, Nigeria, where he also received his specialist
training in Obstetrics and Gynecology. He is a fellow of the West African College
of Surgeons and a fellow of the International College of Surgeons.
Andrzej Kulczycki, Ph.D., is an associate professor in the Department of Health
Care Organization and Policy, University of Alabama at Birmingham (UAB).
His research and teaching focus on strengthening reproductive health systems
and demography. He has published on various aspects of abortion, including a
landmark comparative study of abortion practice and policy centered on the
transnational dimensions involved (The Abortion Debate in the World Arena;
London: Macmillan; New York: Routledge). He obtained his Ph.D. from the
University of Michigan and also holds degrees from the Universities of London
and Durham, United Kingdom.
Claudio F. Lanata, MD, PPH, is a senior researcher at the Nutritional Research
Institute in Lima, Peru, which he joined in 1983, after his postgraduate training in
the United States. His research focuses on the relationship between poverty and
maternal and child health. He has led in Peru, an extensive research in child
health and nutrition focusing on diarrheal and respiratory diseases,
micronutrients, and vaccine development. His work has resulted in one book,
23 chapters, and more than 80 journal publications, mostly in major
international journals. An active collaborator with World Health Organization

and the Pan American Health Organization, he has served as a trustee of the
International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)
and continues to participate in several expert committees on diarrheal diseases
and vaccine development. Dr. Lanata is a member of the Child Health
Epidemiology Reference Group (CHERG), the Food-borne Epidemiology
Reference Group (FERG) of the World Health Organization, and founder of
the Child Health and Nutrition Research Initiative (CHNRI) in Switzerland.
John M. Leventhal, MD, is a professor of Pediatrics at the Child Study Center,
Yale University School of Medicine and an attending pediatrician at Yale-New
Haven Children’s Hospital. At the Children’s Hospital, he is medical director of
the Child Abuse Prevention Programs. Dr. Leventhal has worked in the field of
child maltreatment for over 25 years. From 2001 to 2006, he served as editor-in-
chief of Child Abuse & Neglect, The International Journal. During his tenure as
editor, he developed a ‘‘midwife’’ program to help international authors improve
their manuscripts so that they would be suitable for publication. His research has
focused on the epidemiology of child maltreatment, risk factors for abuse and
neglect, and distinguishing abusive from unintentional injuries. He has published
over 125 peer-reviewed articles and chapters.
Julian Lob-Levyt, MBChB, DRCOG joined the GAVI Alliance in January 2005
as the executive secretary of the GAVI Alliance, and CEO and president of the
GAVI Fund. Prior to this, he worked with UNAIDS as senior policy advisor to
the executive director. His career in global health has included work with both
bilateral and multilateral organizations. He was chief health advisor at the UK
Department for International Development (DFID) from 2000 to 2004. His
other key posts include regional health advisor for the European Commission
(EC) in Zimbabwe (1998–1999) and health sector reform coordinator for WHO
in Cambodia (1994–1997). Dr. Lob-Levyt represented the United Kingdom as a
founding board member of the Global Fund to Fight AIDS, TB and Malaria. He
is currently a board member of the International AIDS Vaccine Initiative (IAVI)
and the Global Health Workforce Alliance.
Elizabeth Lule, M.Sc., is manager of the AIDS Campaign Team for Africa
(ACTafrica), which is responsible for policy direction and coordination of the
World Bank’s HIV/AIDS work in Africa. She oversees implementation of the
Multi-Country HIV/AIDS Program (MAP) for Africa that has committed over
US $1.7 billion in more than 30 countries. Prior to 2006, she was the World
Bank’s advisor for Population and Reproductive and Child Health. Before
joining the World Bank, Elizabeth was Africa regional vice president for
Pathfinder International. She also worked with USAID in Nigeria as program
manager and technical advisor for the health, nutrition, and population
program. She taught Statistics and Demography at the University of Swaziland
and worked as epidemiologist with the Ministry of Health in Nigeria. Elizabeth
has advanced degrees from the London School of Hygiene and Tropical
Medicine and the London School of Economics.
Colin Mathers, Ph.D., is the coordinator for Epidemiology and Burden of Disease
in the Information, Evidence and Research Cluster at the World Health
Organization, Geneva, Switzerland. He manages the WHO’s work on global,
regional, and country-level estimates of mortality and burden of disease. His

principal research interests are in the measurement and reporting of population
health and its determinants, the burden of disease methods and applications, the
measurement of health-state prevalences, and cross-population comparability.
Colin graduated with an honors degree and University Medal in Physics from
the University of Sydney in 1975 and received his Ph.D. in Theoretical Physics
from the same institution in 1979.
Martin Meremikwu, MBBS, M.Sc., FMCPed, is professor of Child Health &
Consultant Pediatrician in the Department of Pediatrics, University of Calabar
Teaching Hospital (UCTH), Calabar, Cross River State, Nigeria. He obtained
his medical degree from the University of Nigeria, Nsukka, and also holds a
Master of Science degree in Mother and Child Health from the Institute of Child
Health (ICH), University of London, England. Dr. Meremikwu contributes
actively to assessment of the evidence base of maternal and child health
interventions and programs in developing countries, working as an editor with
the Cochrane Collaboration (Infectious Diseases Group), based at the Liverpool
School of Tropical Medicine, England. He has authored several Cochrane
systematic reviews of key issues in maternal and child health and has supported
the development of several others. He served on the Board of the Cochrane Child
Health Field and is head of the Evidence-based Medicine and Clinical Trials Unit
at the Institute of Tropical Diseases Research, University of Calabar Teaching
Hospital, Nigeria. He serves as a consultant to several national governments,
nongovernmental organizations, and international development agencies. In the
past 5 years, he has provided technical assistance to WHO’s programs on
integrated management of childhood illnesses (IMCI), and monitoring and
evaluation of malaria control, including management of malaria in pregnancy.
Caroline J. Min, MPH, DrPH, is research associate in the Dean’s Office,
Mailman School of Public Health, Columbia University. Prior to this, she
served as a research scientist at the New York City Department of Health and
Mental Hygiene, senior legislative assistant, FH/GPC Healthcare Practice,
Washington, DC, and senior program assistant, Management Sciences for
Health (MSH), Boston, MA. Caroline has an MPH in Population and Family
Health from Columbia University and a DrPH in Population, Family and
Reproductive Health from Johns Hopkins University.
Tolib Mirzoev, MD, MA, is a lecturer in International Health Systems at the
Nuffield Centre for International Health and Development, University of Leeds,
England. Before joining the University of Leeds, Tolib practiced medicine in
Russia and worked with the National Ministry of Health on health reform
projects where he developed expertise in the areas of health planning, health
reforms, human resources, health management information system, and project
management in the context of Tajikistan. He also has interest in health sector-
wide approaches (SWAps). Dr. Mirzoev received his medical degree from the
University of Saint Petersburg (Russia) and also holds a master’s degree from the
University of Leeds.
Nancy Mock, DrPH, currently serves as the interim executive director of the
Newcomb College Center for Research on Women and is an associate professor
of International Health and International Development at Tulane University.
Dr. Mock has over 30 years of experience in humanitarian and development

work, where she has concentrated on the problems of difficult to reach and
especially vulnerable populations. She has worked in more than 30 countries in
Africa, Asia, Latin America, and Eastern Europe including Angola,
Mozambique, Russia, Rwanda, Guatemala, and Sudan. She is the codeveloper
of a partnership between universities and private voluntary organizations to
combine efforts to address the problems of children in especially difficult
circumstances. She works extensively in Rwanda on the problem of HIV/AIDS
and Orphans and Vulnerable Children. She has published more than 30 peer-
reviewed articles and more than 50 technical reports. She has organized and co-
organized major conferences on Gender, Conflict, and HIV/AIDS; the
psychosocial aspects of complex emergencies; and best practices in
programming related to Orphans and Vulnerable Children. Dr. Mock has a
doctoral degree in Public Health from Tulane University. She received her
Bachelor of Science degree from Yale University.
David Moore, MD, is reader in Infectious Disease and Tropical Medicine at
Imperial College London, England. He is a Wellcome fellow in Clinical Tropical
Medicine. He lives in Peru, where his work is focused on the development,
evaluation, and implementation of novel diagnostic tests and testing strategies
for tuberculosis and multidrug-resistant tuberculosis (MDRTB). He has
published widely in this area, including breakthrough work in the New England
Journal of Medicine on the MODS assay. David received his medical degree from
the University of Birmingham, England. He also has an M.Sc. in Epidemiology
from the London School of Hygiene and Tropical Medicine where he holds an
honorary lecturer position. He is a principal investigator in the Peruvian
nongovernmental organization AB PRISMA and an associate in the
Department of International Health at Johns Hopkins Bloomberg School of
Public Health. He is currently chair of the subgroup for culture-based diagnostics
of the New Diagnostics Working Group of the STOP TB Partnership.
Olaf Müller, MD, Ph.D., is a professor of public health and head of the
interdisciplinary working group on Disease Control in Disadvantaged Populations,
Department of Tropical Hygiene and Public Health, Medical Faculty, Ruprecht-
Karls-University of Heidelberg, Germany. He studied biology, medicine,
and public health at the Technical University of Hannover and the Free
University of Berlin, Germany, and received his Ph.D. in Tropical Medicine
in 1990. Before being employed at the Heidelberg University, he was trained
in pediatrics and internal medicine at the University Hospital in Berlin/
Germany. Afterward, he worked in the field of infectious disease control
for several organizations including the International Red Cross in Kampala/
Uganda, the German Federal Health Office in Berlin/Germany, the GTZ in
Kinshasa/Zaire and Eschborn/Germany, and the British Medical Research
Council Laboratories in Farafenni/The Gambia. His research interests are
in the areas of tropical infectious disease control, particularly malaria and
HIV/AIDS, but also in the area of neglected tropical diseases and
malnutrition. He was and is the principal investigator of a number of
health facility and community-based clinical trials, mainly in the field of
malaria control interventions in Africa.
Marianne Nichol, M.Sc., is an epidemiologist working in the area of chronic

disease surveillance at Queens University, Kingston, Canada. Her research
focuses on effects of the built environment on physical activity among
adolescence. She holds a master’s degree in Epidemiology from Queen’s
University, Kingston, Canada.
Mary Ann Pass, MD, MPH, is a research professor in the Department of
Health Care Organization and Policy, University of Alabama at
Birmingham (UAB). Her research and teaching focus on infectious
diseases, children with special health-care needs, global health, and public
health practice. She has served as a local and regional health officer in
Alabama and consultant for Alabama state agencies on MCH services. She
obtained her medical and public health degrees from the University of
Alabama at Birmingham.
Rebecca Pass, MPA, was most recently a fellow with the United Nations
World Food Programme in Dakar Senegal. A graduate of Columbia
University’s School of International and Public Affairs with a degree in
Environmental Science and Policy, she has worked as a health-care
consultant for hospitals, health systems, and medical schools. Her research
interests include the ability of gene–gene interactions to buffer an organism
against environmental perturbations. She received an AB from Princeton
University in 2002.
Stephen Pearson, Ph.D., is a senior research fellow at the Nuffield Centre for
International Health and Development, University of Leeds, England. He is a
social scientist and demographer with specialization in qualitative and
quantitative research on men’s and young people’s reproductive health. He has
extensive experience as a consultant to several global health and development
agencies, including the Population Council, New York, and WHO, Geneva. He
received his Ph.D. in Environmental Science from the University of
Southampton, England.
William Pickett, BSc, MSc, PhD, is Associate Professor in the Department of
Community Health and Epidemiology at Queen’s University, Kingston,
Ontario, Canada. He teaches epidemiology in both the graduate school and
medical school at Queen’s. He and his colleagues have an active and
international research program that focuses upon children and their health,
with a special emphasis on injury, trauma and their prevention. Areas of
special focus include adolescent risk-taking and its effects on injury, pediatric
trauma on farms, and youth violence. This program of research is funded by the
Canadian Institutes of Health Research, the Public Health Agency of Canada,
and the National Institutes of Health in the United States.
Susan Purdin, RN, MPH, is Deputy Health Director, International Rescue
Committee, New York. She also holds an adjunct faculty position in
Columbia University’s Forced Migration and Health Program, teaching
courses on program planning, reproductive health, and HIV/AIDS
prevention in situations of forced migration. In 1999, she received the
Global Health Council’s award for ‘‘Best Practice in the Field of Global
Health’’ for providing field-based, on-site, technical assistance to

reproductive health projects in conflict settings.
Joanna Raven, MCommH, Ph.D., is a research associate in health systems
research in the International Health Group at the Liverpool School of Tropical
Medicine, England. Her research interests are maternal and reproductive health
and vulnerability, quality of care, and health systems. She has extensive
experience of working with partners from Europe, China, and Vietnam to
design and conduct research projects on maternal health, health insurance, and
health systems development. She is a registered midwife and holds a master’s
degree in Community Health from the Liverpool School of Tropical Medicine,
England.
Krishna Reddy, MD, is a resident in internal medicine at the Massachusetts
General Hospital in Boston, USA. He was an NIH Fogarty International
Clinical Research Scholar in Peru, where he conducted research on novel
methods of diagnosing tuberculosis. Krishna obtained his medical degree from
Harvard Medical School.
Nigel C. Rollins, MB, BCH, MRCP, MD, is a professor and head of the
Department of Maternal and Child Health at the University of KwaZulu-
Natal, South Africa. His research focuses on risk of HIV transmission
associated with exclusive breastfeeding. He is involved in a multicenter trial
of maternal highly active antiretroviral therapy (HAART) and postnatal
transmission of HIV. He is also principal investigator of a health systems
improvement intervention project that is aimed at improving the quality of
prevention of mother-to-child transmission (PMTCT) services at the district
level, as well as PMTCT surveillance projects in South Africa. Dr. Rollins is
chair of the WHO Technical Advisory Group on HIV and Nutrition and is a
member of several national and international professional committees,
including the South Africa National PMTCT Steering Committee, Research
Ethics Committee of the University of KwaZulu-Natal, and Executive
Committee, Commonwealth Association of Paediatric Gastroenterology and
Nutrition. He is an honorary senior lecturer at the Institute of Child Health,
University College, London (UCL), England. He joined the Department of
Child and Adolescent Health of WHO in July 2008 to work on PMTCT,
infant feeding, and broader pediatric HIV issues, particularly nutrition. A
member of the UK Royal College of Physicians, Dr. Rollins obtained his
MB, BCH, and MD degrees from Queen’s University, Belfast, in Northern
Ireland.
James Rosen, MS, is an independent consultant and economist by training who
has worked for over two decades in the field of global health. Jim’s most recent
work has focused on mainstreaming adolescent pregnancy concerns into safe
motherhood strategies, analyzing user-fee systems for sexual and reproductive
health care, making sure HIV programs include a proper focus on young people,
identifying ways to mainstream youth issues in poverty-reduction strategies,
measuring the impacts of health sector reform, and searching for sensible and
cost-effective linkages between HIV and other reproductive health programs.
Before becoming an independent consultant in 2000, he worked for 5 years as a
senior research associate at Population Action International, Washington, DC.
He previously held positions at Development Associates, Inc., Southborough,

MA, the Population Council, New York, and the World Bank, Washington, DC.
Jim has worked in over 20 less-developed countries, providing technical
assistance to health programs and policy makers and carrying out research and
program evaluation. He received his master’s degree in Economics from the
University of Wisconsin.
Allan Rosenfield, MD, was emeritus professor at Columbia University,
New York until he passed away in 2008. He was Delamar professor of Public
Health Practice and dean of the Mailman School of Public Health at Columbia
University for more than 20 years. He wrote extensively (with over 140 published
articles) on major domestic and global issues in the field of maternal and child
health. World renowned for his work on women’s reproductive health and
human rights, Dr. Rosenfield was among the first to draw attention to the
burden of maternal mortality in less-developed countries. He established the
pioneering Averting Maternal Death and Disability program, supporting more
than 85 projects to improve obstetric care in 50 countries. His publication
‘‘Maternal Mortality: A Neglected Tragedy: Where is the M in MCH?’’ (Lancet
1985, 2: 83–85), which questioned the neglect of maternal health in global
maternal and child health programs, drew considerable debate and attention to
reduction of maternal mortality during the child survival revolution era of the
1980s and 1990s. He was the 2007 recipient of the United Nations (UN)
Population Award, an award that recognized his high-level advocacy efforts,
having served on the boards of many organizations and advisory groups
including those of the UN Millennium Project and the World Health
Organization. He was also a recipient of the reproductive health movement’s
highest award, the Planned Parenthood Federation of America’s Margaret
Sanger Award. Dr. Rosenfield obtained his medical degree from Columbia
University, New York.
Jeffrey M. Smith, MD, Ph.D., is assistant professor in the Department of
Gynecology and Obstetrics, Johns Hopkins University School of Medicine. He
is also an assistant professor in the Department of Population and Family
Health. He currently works as the technical director for Jhpiego based in
Bangkok, Thailand. He is one of the key contributors to the manual
‘‘Managing Complications in Pregnancy and Childbirth (MCPC): A Guide for
Midwives and Doctors’’ published by the WHO in partnership with the World
Bank, the United Nations Children’s Fund (UNICEF), and the United Nations
Fund for Population Activities (UNFPA). He has written numerous national
and international strategic policy documents related to reproductive health and
human capacity development.
Alan Tita, MD, MPH, Ph.D., is assistant professor in the Divisions of Maternal-
Fetal Medicine and International Women’s Health in the Department of
Obstetrics and Gynecology at the University of Alabama at Birmingham
(UAB). He is also an investigator in the Center for Women’s Reproductive
Health, which houses UAB’s site for the NICHD Maternal-Fetal Medicine
Units Network. His research activities focus on improving maternal and
perinatal health globally, with a focus on preterm birth, obstetric infections,
obstetric and medical complications of pregnancy, evidence-based maternal
and child health, and epidemiology. He has written several peer-reviewed

publications and book chapters in these areas. He previously worked as a
medical officer in both the governmental and the NGO sectors in Cameroon,
Africa. Dr. Tita holds an MD degree from the University of Yaoundé,
Cameroon, an MPH (International Health) from the University of Leeds, UK,
and a Ph.D. in Epidemiology from the School of Public Health, University of
Texas Health Sciences Center at Houston. He is trained in obstetrics and
gynecology (Baylor College of Medicine, Houston) and maternal-fetal
medicine (UAB). He is a diplomate of the American Board of Obstetrics and
Gynecology.
Sally Theobald, MA, Ph.D., is a senior lecturer in social science and
international health in the International Health Research Group, Liverpool
School of Tropical Medicine (LSTM), England. She has been at LSTM since
1999, with a 2-year secondment to work as technical advisor to the Research
for Equity and Community Health (REACH) Trust in Malawi. Her current
research interests are captured under the umbrella of equitable and gender-
sensitive health development, especially in relation to TB, HIV, and sexual
and reproductive health. She has experience in designing and implementing
gender-sensitive qualitative research projects in health and has worked
collaboratively on qualitative research projects on HIV, tuberculosis, sexual
and reproductive health, maternal and child health, and health systems in
Thailand, South Africa, Burkina Faso, Malawi, and Kenya. She holds a BA
in Geography from the University of Newcastle Upon Tyne, England, and an
MA and PhD in Gender, Health, and Development from the University of
East Anglia, England.
Rachel Tolhurst, PhD, is a Lecturer in Social Science and International Health in
the International Health Research Group at the Liverpool School of Tropical
Medicine. UK. She gained her MA in Gender Analysis in Development at the
University of East Anglia and her PhD from the Faculty of Medicine at the
University of Liverpool. Her research interests and experience centre on
qualitative research on gender and equity issues in relation to health systems
development, including health financing, maternal health and communicable
disease (with a focus on malaria, tuberculosis and HIV). She has been working
on gender and health for 10 years, and has designed, conducted and supported
research in China, Ghana, Malawi, and Vietnam. She has also provided technical
assistance on mainstreaming gender in Sector Wide Approaches in Ghana and
Bangladesh.
L. Lewis Wall, MD, D.Phil., is an obstetrician–gynecologist and medical
anthropologist who has been active in the field of obstetric fistula surgery for
many years. He studied at the Institute of Social Anthropology in Oxford,
England, as a Rhodes Scholar and carried out anthropological field research
in northern Nigeria. This work was subsequently published as Hausa Medicine:
Illness and Well-being in a West African Culture’’ (Duke University Press, 1988).
The author of many peer-reviewed medical articles and book chapters in the
field of urogynecology and reconstructive pelvic surgery, he was named
national ‘‘Continence Care Champion’’ by the National Association for
Continence (NAFC) in 2005. He is president of The Worldwide Fistula Fund
(a not-for-profit charity), which is currently building a model fistula surgery

and training center in Danja, Niger. Dr. Wall also has a master’s degree in
Bioethics and writes frequently in medical journals about issues of social and
ethical concern.
Sarah Wamala, B.Sc., M.Sc., Ph.D., is the newly appointed director general of
the Swedish National Institute of Public Health by the Swedish government.
Prior to this, she worked as the head of Department of Health Promotion and
Disease Prevention at Stockholm Centre for Public Health. She has also
previously worked as research manager and head of Unit of Social
Epidemiology at the Swedish National Institute of Public Health. She is
associate professor and senior lecturer in Public Health at Karolinska Institute.
Dr. Wamala is trained in economics, public health, and epidemiology at various
universities including Makerere University (Uganda), Stockholm University
(Sweden), Karolinska Institute (Sweden), Tufts University (USA), and
Cambridge University School of Public Health (UK). She was the 2000
recipient of the Knut and Alice Wallenberg’s Award for promising young
scientists. Dr. Wamala (together with Dr. Ichiro Kawachi at Harvard School
of Public Health) is among the first to edit a text book on globalization and
health (by Oxford University Press, New York), including a critical analysis of
the benefits and shortfalls of globalization for health. She is also the principal
investigator of one of the first international research projects empirically
investigating the effects of globalization on women’s health in sub-Saharan
Africa.
Amy T. Wilson, Ph.D., is associate professor and director of the International
Development Programs at Gallaudet University, Washington, DC. Her
research focuses on how Northern governments and global health agencies
can best bring development assistance to people living with disability in less-
developed countries. Amy has traveled globally to work with and evaluate the
work of American federal agencies, American and foreign nongovernmental
organizations, faith-based organizations, and foreign development assistance
agencies. Dr. Wilson recently completed a 2-year, eight-country evaluation of
an American NGO’s work with children who have multiple disabilities.
Sarah Windle, MPH, is a specialist in global maternal and child health with an
interest in social determinants of health and the development of theory-based
interventions for the promotion of sexual and reproductive health among women
and adolescents. She recently facilitated the development of sexual health
training materials for Réseau Matoutou, a nonprofit health promotion agency
in French Guiana, South America. Sarah received a Bachelor of Science degree in
Psychology from McGill University, Canada, and an MPH with specialization in
international maternal and child health from the University of Alabama at
Birmingham, USA.
Victor Y.H. Yu, AM, MBBS, M.Sc. (Oxon.) MD, FRACP, FRCP (Lond.),
FRCP (Edin.), FRCP (Glasg.), is professor and clinical director of the Ritchie
Centre for Baby Health Research. He is also professor of neonatology at Monash
University, Australia, president of the Australian Perinatal Society, president of
the Federation of Asia-Oceania Perinatal Societies, and vice president of the
World Association of Perinatal Medicine. He has been invited as visiting
professor and guest speaker to lecture in 44 countries on over 250 occasions. He is

a consultant to the World Health Organization and to the Singapore and Hong
Kong Governments on issues related to perinatal health. He has published 10
books, 170 book chapters, 270 papers, and 370 abstracts. He has supervised
neonatal training for about 200 pediatricians from 41 countries other than
Australia. Victor graduated from Hong Kong University Medical School in
1968. He went to Oxford University in England in 1972 and McMaster
University in Canada in 1975 for his postgraduate neonatal training and
became the founding director of the Neonatal Intensive Care Unit at Monash
Medical Centre in Melbourne, Australia, in 1977.
Michel Zaffran, M.Sc., is the deputy executive secretary and chief technical and
policy officer, GAVI Alliance. A French national, Michel received his
engineering degree from Ecole Centrale, France, and Technische Hochschule,
Darmstadt, Germany, with subsequent training in Tropical Epidemiology at the
Heidelberg University. After 2 years in Morocco with the French Government,
he joined GRET, a French NGO for which he worked in Burkina Faso and the
Democratic Republic of Congo. He then spent 18 years with WHO Vaccines and
Immunization Department, in cold chain and logistics, overseeing the work on
quality of immunization services and as program manager in charge of the
departmental strategic planning. His last assignment with WHO was as
coordinator of the Access to Technologies team where he led efforts in Vaccine
Quality, Vaccine Management, Vaccine Supply, and Immunization Financing.
From 1998 to 2003 he was the WHO representative on the Working Group which
helped to design and launch GAVI.
Index
A influences, 437–439
Abortion, impact on maternal health, 191 injury and health risk behaviors, 353
demography, 194–195 malaria, 211–212
global and regional incidence of mortality, 194 malarial nephropathy and splenomegaly, 212
history, 192 monitoring and research, 457–458
in India, 386 policy, 457
laws for, 192–193 problem
mortality and morbidity, 193–194 death and disability, 439–440
origin, 192 diet, nutrition and exercise, 442–443
reasons for, 195–196 GBV, 450
technologies used, 196–197 HIV/AIDS, 275–277, 448–449
women characteristics, undergoing, 196 intentional and unintentional injuries, 441–442
AbouZahr, C., 313, 314, 403 mental disorders, 440–441
Absenteeism, in health care services, 412 sexual and reproductive health, 444–448
See also Safe pregnancy, challenges tobacco and alcohol use, 443–444
Abstinence, be faithful, use condoms (ABC), 275 Advanced Market Commitment, 417–418, 422, 423
Abu-Elyazeed, R., 228 Affolder, R., 417–431
Acheson, D., 77 Africa
Acquired immune deficiency syndrome (AIDS), 271 diarrheal disease prevalence, 229
ACTs, see Artemisinin based combination treatments HIV transmission, 273
Acute lower-respiratory-tract infections, 296 malaria control programs, 215–216
Acute respiratory infections (ARI), 104, 497, 498 tuberculosis trends, 249
Adeyi, O., 442 unsafe abortion in, 445, 447
Adolescent Family Life Act, 379 African Development Foundation, 334–335
Adolescent health, 435 African Development Fund (AfDF), 424
disabilities, health challenges, 323–326 Afsana, K., 157, 163
DALY, 326–327 Afshar, H., 142, 144
definition of disability, 326 Aggleton, P., 275
in developing countries, 328–330 Agita Sao Paulo physical activity program, 304
health care for disabled poor, 333–337 Aglobitse, D. M., 282
ICIDH, 327–328 Agreement on Trade-Related Aspects of Intellectual
negative social beliefs, 331–333 Property Rights (TRIPS), 141
poverty and disability, 330–331 Agricultural chemicals, health effect, 103
importance, 435–437 Agugua, N. E., 175
improvement Ahmad, A., 486, 489
cost-benefit intervention, 456 Ahman, E., 445, 447
health programming, 451 Ahmed, T., 309
intentional injury, 452 Ahmed, Y., 407
mental disorders, 450–451 AIDS impact, in developing countries, 271–272
nutrition and physical activity, 453 children health
road traffic injuries, 452–453 care of orphans, 282
sexual and reproductive health, 454–456 epidemiology, 277
tobacco and drug use, 453–454 impact, 277–278
561
562 Index
AIDS impact, in developing countries (cont.) Ashton, J., 537

management, 278 Asia–Oceania region, PMR in, 46, 47
pMTCT, 278–279 See also Perinatal health, global promotion
treatment, 279–280 Askew, I., 538
impact on families health, 280–281 Atwine, B., 486, 489
mothers health Australia
adolescents, 274–275 mortality decline, 536
causes, 271–272 prenatal care system, 73
health service inadequacies, 275–277 Averting Maternal Death and Disability (AMDD), 365
HIV in women, 272 Awases, M., 519
pregnant women, 277 Ayaya, S. O., 484, 485, 486, 488
women vulnerability to HIV, 273–274 Azubuike, M. C., 87, 156, 158
people affected, 272
prevention of infection, 282
AIDS orphans B
care for, 282 Bachou, H., 252
defined, 481 Bacille Calmette–Guérin (BCG) vaccine, 246, 250, 260
in Mauritania and Zimbabwe, 482 Baden, S., 156, 157, 158, 160, 162
Aiken, L. H., 517 Balk, D., 178
Akin, A., 391 Baltazar, J. C., 233
Alcohol addiction, in adolescents, 443–444 Bang, R. A., 520
Alcohol and tobacco usage, intervention, 453–454 Bangladesh
Alcohol use disorders, in adolescents, 29 diarrheal disease, 231
Ali, M., 509 poverty level, 293
Alikasifoglu, M., 469 Bangladesh Rural Advancement Committee (BRAC), 8
Aliyu, M. H., 155, 402 Bankole, A., 384
Alma Ata Declaration Baqui, A. H., 228, 232
limitation, 537 Barber, S., 316, 517
of primary healthcare, 498, 503, 504 Barendregt, J., 24
requirement, 538 Barnes, K. K., 109
Almroth, L., 175, 180 Barreto, M., 227
Amazigo, U., 389, 390 Barrientos, S., 142, 144
AMCs, see Advanced Market Commitment Barros, F. C., 232
Amin, R., 235 Barstow, D. G., 170
Amoxicillin, 369 Barthauer, L. M., 469
Anand, K., 232, 233 Bartlett, L. A., 410
Anarfi, J. K., 484, 486 Bartlett, S. N., 342, 343, 350, 351
Andre, F., 418, 419 Basic Support for Institutionalizing Child Survival
Andrew, L., 375–394 (BASICS), 504
Anemia Battered child, 466
in adolescent girls, 442, 443 Bayoumi, A., 179
in children and adolescents, 211–212 Bearinger, L., 445, 448
and MND, 295 Beaver, S., 535
and VADD, 296 Becher, H., 291
Annual risk of infection (ARI), 251 Beegle, K., 484
Anopheles gambiae, 205 Begum, S., 292, 293
Antenatal care, in pregnancy, 399–400, 407–409 Behr, M. A., 252
See also Safe pregnancy, challenges Behrentz, E., 104
Antimalarials, 215–217 Behrman, J. R., 439, 442, 456
Antiretrovirals (ARVs), 275, 279, 424 Belsey, M. A., 282
Anyanwu, E., 141, 148, 167–186 Belsky, J., 472
ARI, see Acute lower-respiratory-tract infections Bendib, A., 232
Arifeen, S. E., 508 Benger, J. R., 475
Armstrong Schellenberg, J. R., 535 Benson, J., 197
Arney, W., 379 Bergen, B., 379
Aronson, N. E., 261 Berman, S., 249
Arredondo-Garcia, J. L., 264 Bern, C., 226, 233, 234, 533
Arrowsmith, S., 312, 314 Bernloehr, A., 70
Artemisinin based combination treatments, 213–215 Betrand, W. E., 235
Articles 25 and 26 of the UN Convention for the Rights of Bhagwati, J., 289
People with Disabilities, 325 Bhandari, N., 236, 279
Index 563
Bhore Commission, in India, 536 Canadian healthcare system, 74

Bhutta, Z. A., 50, 298, 304, 305, 308, 309 Cantwell, M. F., 245, 258, 265
Bicego, G., 483 Cape, S. P., 281, 400, 406
Bichmann, W., 538 Carpenter, D. O., 108
Bierrenbach, A. L., 256 Carter, E. J., 263
Bill and Melinda Gates Foundation, 420, 424 Cash, R. A., 8, 56, 94, 157, 305
Billings, D. L., 197 Castro, R., 402, 414
Bindman, A. B., 61, 66 CATALYST Consortium, of reproductive
Binkin, N. J., 245, 258 health, 198–199
Birbeck, G. L., 142 Cates, W., 194
Birth weight measurement, 44 Caulfield, L. E., 236, 287, 288, 289, 291, 292, 294, 295,
Bisphenyl A (BPA), 103 296, 297, 498
Bistrup, M. L., 101 Cauthen, G. M., 251
Bjerkedal, T., 264 Cawson, P., 468
Black, D., 77 CBAE, see Community-Based Abstinence Education
Black, G. F., 261 CBR, see Community-Based Rehabilitation
Black, R. E., 153, 154, 225–240 CD4 counts, in women, 274
Black Death, prevalence, 272 CDC rate, of unintentional injury, 347
Bland, R. M., 279 CEDC, see Children in Especially Difficult Circumstances
Block, R., 264 Central America, teenage pregnancy, 386–388
Blondel, B., 61 Cephalopelvic disproportion and obstetric fistulas, 314
Blume, S., 419, 420 See also Obstetric fistulas, global burden
Bonita, R., 145 Cervical cancer, mortality in, 426, 427
Bor, D., 527 Chapko, M. K., 155
Boschi-Pinto, C., 225–239 Chavasse, D. C., 228
Bossemeyer, D., 526 Chen, H., 371
Boyle, P., 426 Chen, K. C., 228
Brabin, B. J., 402 Chen, L., 274, 375, 529
Braddy, C. M., 175, 176, 177, 178, 179, 182 Chen, L. C., 369
Bradley, A. K., 232 Chen, X. K., 375
Brady, M., 175 Cherry, A. L., 375–394
Braveman, P., 426 Chetna, M., 369
Breastfeeding, in overweight protection, 303–304 Child, I. G., 53–78
Breman, J. G., 209, 210, 211 Child abuse and neglect
Briand, V., 212 consequences, 470–472
Briggs, C. J., 506 prevention, 473–474
Briggs, D., 105, 106, 107 risk factors for, 472
Brison, R. J., 350 worldwide scope of, 468–470
Brookfield, S. D., 524 See also Child maltreatment
Brost, B. C., 264 Childbirth worldwide, complications, 403
Brown, A., 6 Child environmental health, international recognition,
Brown, C. A., 407 100–101
Brown, K. H., 291 Child Health Epidemiology Reference Group
Browne, E. N., 214 (CHERG), 225
Brugha, R., 538 Childhood illness, complexity, 498
Brundtland, G. H., 215 Childhood injury
Bryce, J., 87, 91, 93, 225, 501, 504, 506, 509 external causes, 347–348
Buckley, R., 384 prevention, 354–355
Burger, J. L., 428 social disparities and vulnerable population, 348–350
Burk, J. R., 265 Child interventions, current evidence-based, 369–370
Buse, K., 89 Child labor, defined, 470, 481
Byers, L., 375–394 Child maltreatment, 463–465
child abuse and neglect
consequences, 470–472
C prevention, 473–474
Cagatay, N., 143 risk factors, 472
Campbell, H., 498, 535 worldwide scope, 468–470
Campbell, O., 402, 403 defined, 464
Campbell, O. M., 372, 519 emotional abuse, 467
Campbell, O. M. R., 365, 519 exploitation, 467–468
Campos, G., 232, 233, 235 family factors, 472
564 Index
Child maltreatment (cont.) high-income countries and population health,

neglect, 467 535–536
parent factors, 472 recommendations for new strategy, 536–539
physical abuse, 465–467 role of medicine, 534
sexual abuse, 467 tuberculosis in, 245–249
societal factors, 472–473 clinical pattern, 252–253
Children in Especially Difficult Circumstances, 479 diagnosis, 253–257
Children health extrapulmonary, 257–258
care, historical perspectives, 3, 5 global burden, 249–250
diarrhea in and HIV co-infection, 258–259
clinical pattern, 226 multidrug-resistant, 259–260
etiology, 235 and nutrition, 252
morbidity and mortality, 226–234 pathogenesis, 251–252
prevention and treatment, 236–239 preventive chemotherapy, 261
risk factors, 235–236 risk factors, 250–251
with disabilities, health challenges, 323–326 spectrum, 253
DALY, 326–327 treatment, 261
definition of disability, 326 vaccination, 260–261
in developing countries, 328–330 unintentional injuries, 341–342
health care for disabled poor, 333–337 behavioral risk factors, 351–352
ICIDH, 327–328 causes, 347–351
negative social beliefs, 331–333 child development terms, 342
poverty and disability, 330–331 disease burden, measures of, 343
environmental health risks, 99–100 economic costs of injury, 346
air pollution, 104 fatal childhood injuries, 343
in chemical usage, 102–104 injury pyramids, 344–346
children’s environmental health, 100–101 nonfatal childhood injuries, 344
health indicators, 105–107 PYLL, 346
lack of clean water and sanitation, 104–105 strategies for prevention, 352–355
policy frameworks, 107–109 and VADD, 295–296
precautionary principles approach, 113–114 See also Child maltreatment; HIV impact, in developing
research priorities, 109–113 countries
vulnerability of children, 101–102 Child Survival Collaborations and Resources, 503, 504
evidence-based, 366–369 Child survival programs and malnutrition, 294
gender impact, 158 Child Survival Revolution, 7–9, 417, 419
health in difficult circumstances, 479–480 China
categories estimation methods, 482–488 child labor issue, 491
definition and methodological issues, 480–481 HBV, 426
health consequences of living, 488–489 maternal mortality, 406
health risks, 484–487 Chintu, C., 250, 258
policies and strategies, 489–493 Chloroquine (CQ), 217
problems magnitude, 481–482 Chopra, M., 143
HIV impact Chow, F., 257
epidemiology, 277 Chowdhury, A. M. R., 8
impact, 277–278 Christian, P., 174, 179, 390, 402
management, 278 Chronic obstructive pulmonary disease, 37, 38, 110
pMTCT, 278–280 C-IMCI, see Community IMCI
treatment, 280 Civil society organizations, 5, 95, 96
improvement, MDG, 370 Clasen, T., 108, 371
interventions, 371 Cleland, J., 195
malaria, 211–212 Cluver, L., 486, 489
malarial nephropathy and splenomegaly, 212 Cochrane, A. L., 363, 364
malnutrition, 287–290 Cochrane Database, role, 366, 370
MND, 295–299 Coercive sex and HIV infection, 274
obesity, 299–304 See also AIDS impact, in developing countries
PEM, 290–295, 297–299 Coghlan, B., 121, 122, 123, 125
mental health, risk factors, 439 Cohen, S. A., 383
and PEM prevalence, 290, 291 Colditz, G. A., 260
policy characteristics, 89 Collaborative Eclampsia Trial, 365, 372
policy, in developing countries, 533 Collazos, J. A., 273
health problems consequences, 534–535 Collins, C. D., 90
Index 565
Collins, C., 90, 293 Cravioto, A., 228

Commercial sexual exploitation, of children, 468 Crawley, J., 212
See also Child maltreatment Crosby, R. A., 378
Commercial sex workers and HIV/AIDS infection, 273, 274 Cruz, J. R., 227
Community-Based Abstinence Education, 380 CSOs, see Civil society organizations
Community-based organizations (CBOs), 504 Curative services, for MCH, 87
Community-based rehabilitation, 334–335 Currier, J. S., 274
Community IMCI
care seeking and compliance, 503
complementary process, 504–506 D
disease prevention, 502–503 DAC, see Development Assistance Committee
elements, 504 Dahlberg, L., 452
home care, 503 Dailard, C., 380
issues, 505 DAILY, see Disability-adjusted life year
physical and mental growth, 502 Dairo, A. E., 282
principles, 503–506 Daley, C. L., 258
Community inputs, in MCH improvement, 85 Danel, I., 406
Community risk assessment, role, 106 Darmstadt, G. L., 49
Comparative Risk Assessment, 20, 25 Darnton-Hill, I., 299
Complementary feeding, importance, 291 Daroh, D., 465
Comstock, G. W., 261 Darroch, J. E., 378, 382
Conflict, in children, 479–480, 489 Dasgupta, S., 104
See also Children health Datta, M., 260
Conflicts/wars impact, on maternal and child health De Brouwere, V., 5, 10, 400, 406, 411
advocacy, 130 Debt Buy-Down program, 418
causal model for, 125 de Burbure, C., 113
changing nature of conflict, 123–124 Decentralization, for health services, 90–91
countries with, highest child mortality and conflict Declaration of Alma-Ata, 6–7
status, 122 limitation, 537
displacement, 126 of primary healthcare, 498, 503, 504
DR Congo, mortality and conflict in, 123 requirement, 538
economic collapse, 125–126 De Francisco, A., 232
health services decline, 126–127 Dejong, J., 390, 391
impaired food availability, 125 de Koning, K., 162, 163
injury caused, 124–125 Delbanco, S., 378
millennium development goals and, 130 Delisle, H., 442, 453
mitigation of impact, 127–129 Delphi method, role, 102
prevention of, 129–130 Demographic and Health Surveys, 24, 227–229, 480, 482, 483
Sub-Saharan African countries, child mortality Dennison, R. A., 113
rate in, 123 de Onis, M., 287, 290, 292, 299, 300, 303, 306
Congenital tuberculosis, 265 Derman, R. J., 528
Congo, maternal and child deaths, 122–123 de Savigny, D., 91
Connell, J., 145, 519 De Silva, S., 175, 176, 179, 180, 181, 183, 186
Contact tracing, for childhood TB diagnosis, 257 Developing countries
Convention on the Rights of the Child, 489 antenatal care services, 400
Cooper, R. S., 40 child health policy, 533
Coovadia, H. M., 271–283 health problems consequences, 534–535
COPD, see Chronic obstructive pulmonary disease high-income countries and population health,
CORE, see Child Survival Collaborations and Resources 535–536
Cornia, G. A., 136 recommendations for new strategy, 536–539
Corporal punishment, 464 role of medicine, 534
Correa, C. M., 141 childhood injuries, 350–351
Corruption Index (Transparency International 2002), 55 children mortality, 146, 289, 503
Costa, M. C., 66, 234, 406, 536 chronic hunger, 306
Costello, A., 308 disability, 328–330
Couper, I. D., 527 EBF, 279
Coury, D., 281 HIV-positive children, 277
Coutsoudis, A., 279 malnutrition, 287
Cowan, F. M., 275 NMR estimation, 47
Coyne, E. T., 299 overweight percentage, 299
CRA, see Comparative Risk Assessment percentage of mental and physical disabilities, 323, 329
566 Index
Developing countries (cont.) Dollar, D., 136, 305

perinatal mortality rate, 46 Dorkenoo, E., 179
prevalence of overweight, 301 Dorrington, R. E., 272
teenage pregnancy, 387–388 Douthwaite, M., 528
tuberculosis Doveren, R. F., 264
diagnosis, 254 Dovlo, D., 412, 527
trends, 249–250 Dowell, S. F., 489
underweight and stunting percentage, 291 Dowswell, T., 352
See also Perinatal health, global promotion DPO, see Disabled People’s Organizations
Development Assistance Committee, 54 Dubois, C. A., 518
De Vogli, R., 142 Dubos, R., 99
Dhakal, S., 403 Duerr, A., 491, 492
Dhar, J., 178 Duley, L., 365
d’Harcourt, E., 121–130 Dumont, A., 314
DHS, see Demographic and Health Surveys Duncan, T., 168, 178
Diabetes, in women, 34–35 Dunn, P. M., 50
Diallo, K., 529 Durrant, J. E., 473
Diarrhea and PEM prevalence, 294 Dussault, G., 518
Diarrhea, in children, 104–105, 225, 235 Duyar, I., 484
clinical patterns, 226 Dwork, D., 3, 5
definition and clinical manifestations, 226
etiology, 235
morbidity and mortality, 226–229 E
age distribution, 231–233 3E and injury prevention, 352
assessment, 233–234 Eamranond, P., 253, 254
geographic distribution, 229–231 East Asia and the Pacific, teenage pregnancy in, 383–385
prevention and treatment, 237–239, 296 Education and HIV/AIDS reduction, 273
exclusive breastfeeding, 236–237 Edwards, P., 349, 350
Oral rehydration therapy (ORT), 237 Egwuata, V. E., 175
zinc supplements, 237, 296 Egypt
risk factors, 235–236 maternal mortality in, 406
trend in diarrhea mortality, 233–234 teenage pregnancy in, 391–393
Diaz de Leon, G., 4, 324, 388 Ehiri, J. E., 53–77, 108, 156, 167–186, 205–221, 232, 274, 305,
Dibley, M. J., 228 341–356, 361–371, 497–512, 525, 526, 533–540
Digges, D., 391 Eide, A. H., 329
Dilatation and curettage (D&C), 196 Ejemot, R. I., 108, 236, 371
Dillon, M., 375–394 Ekanem, E. E., 232
Directly Observed Therapy Shortcourse (DOTS), 246, Eke, N., 175
256, 261 Ekwempu, C. C., 311
Dirie, M. A., 175, 179, 186 El Arifeen, S., 508
Disability Elbert, T., 486
causes, 324 Elder, L., 453
defined, 326 Elkins, T. E., 317
and poverty, 324, 330–331 Elmusharaf, S., 178
Disability-adjusted life year, 20–21, 102, 289, 442, 444 El-Rafie, M., 233
calculations by, 326–327 Elwan, A., 329
purpose of, 326 Emergency obstetric care (EmOC), 10
Disabled People’s Organizations, 324, 326, 333, 335 Emotional abuse, in children, 467
Disabled poor, health care for See also Child maltreatment
achievements, limitations and risks of CBR approach, 334 Enarson, D. A., 261
community-based rehabilitation, 334–335 Enarson, P. M., 261
MDG strategies, 337 England
prevention and advocacy, 333–334 abortion law, 193
strategies in, 335–337 teenage pregnancy, 380–382
See also Adolescent health Ennew, J., 480
Disease and mortality, risk factors, 24–25 Entomologic inoculation rate (EIR), 205
Disease control programs, 6–7 Environmental exposures, 110–112
DisMod, role, 24 Environmental health indicators, 105–107
DISTAT, see United Nations Disability Statistics Database Environmental health policy frameworks, 107–109
Djankov, S., 130 Environmental health risks, in MCH, see Maternal and
Dolea, C., 313, 314 child health
Index 567
Environmental injustice, defined, 107 intervention in Ethiopia, 183–185

Environmental Protection Agency (EPA), 113 Navrongo FGM experiment, 183
EPI, see Expanded Programme on Immunization origin and prevalence
EPZs, see Export Processing Zones in religion and country, 174
Ertem, I. O., 472 in urban or rural residence, 173
Erythromycin, 369 policy and practice, implications, 179
Esamai, F. O., 484, 485, 486, 488 for children and adolescents, 181–182
Esin, M. N., 486 health, social and economic sectors, 182–183
Espinal, M. A., 267 intervention community participation, 183, 184–186
Esrey, S. A., 236 for practitioners, 180–181
Ethiopia, for FGM intervention, 183–185 programming for parents, 181
See also Female genital mutilation Tostan community empowerment program,
Eugenic Protection Law, 384 185–186
European Union (EU), chemical regulatory programs, Fergusson, D. M., 468
103–104 Ferlay, J., 426, 427
Europe, mortality decline, 536 Fernandez, H., 317
Evans, J. R., 539 Ferreccio, C., 227
Evidence-based practice, for MCH, 361 Fesseha, G., 492, 493
advantages, 361–362 Fetal death, defined, 44
collaborative Eclampsia and the Magpie Trial, 365 Fetal development and folic acid, 295
defined, 361 FGC, see Female genital cutting
criticisms, 362–363 FGM, see Female genital mutilation
health promotion interventions, 368–369, 371 Fidler, D., 145
MCH resources, 367 Figueroa-Damian, R., 264
research methods and hierarchy for, 363 Fikree, H., 154, 295
USPSTF grading, 363 Files, J. A., 175, 176, 177, 178, 179, 182
Exclusive breastfeeding (EBF), 236, 279 Filmer, D., 136
Expanded Programme on Immunization, 8, 417, 419 Finer, L. B., 196, 377, 379
Exploitative child labor, defined, 468 Fingerhut, L. A., 345, 346
See also Child maltreatment Finkelhor, D., 469
Export Processing Zones, 142 Finkelstein, E. A., 346
Extrapulmonary tuberculosis, 257–258 Fisher, R. G., 280
Ezedinachi, E., 205–222 Fistula, defined, 312
Ezzati, M., 20, 25, 114, 469, 471 Fistula repair, steps, 318
Fistula surgery, 318
Flanigan, C., 377, 378
F Flavin, M. P., 347, 348
Faith-based organizations (FBOs), 492 Fleck, J., 538
Falkingham, J., 406 Flynn, P., 275
Family and community, HIV/AIDS impact, 280–281 Fogarty, L. A., 522
See also HIV impact, in developing countries Folate supplementation, in pregnancy, 368
Fariyal, F., 295 Folic acid deficiency, 295
Fassa, A. G., 486 Food insecurity, defined, 302
Fatal childhood injuries, 343 Fonn, S., 162
See also Children health Fontaine, O., 236
Fawzi, W. W., 236, 297 Foreign direct investment, 136
FDI, see Foreign direct investment Forster, L. M., 486
Feachem, R. G., 236 Fortney, J. A., 401
Federal Children’s Bureau, of 1912, 5 Foster, M., 422
Federal District, in Mexico, 388 Foth, H., 103
Fekadu, D., 486 Fourcroy, J. L., 170
Felitti, V. J., 471 France, healthcare system, 72–73
Female Foeticide Law, 385 Franchi, L. M., 257
Female genital cutting, 168 Franco, M., 302
Female genital mutilation, 156, 167, 273–274 Freedman, L. P., 288
attitude towards, 185–186 Freedman, L., 13, 157
caring, 177 Freedom Index (Heritage Foundation 2008), 55
classification, 168–170 French pregnancy management program, 1971, 72
complications, 176 Frenk, J., 87, 135
factors to practice, 177–179 Friel, S., 302, 303, 304
health outcomes, 175–177 Fritzen, S. A., 525
568 Index
G Global Alliance for Vaccines and Immunization, 8, 417,

Gagain, J. R., 130 420–422, 424–426, 518
Gakidou, E., 147 Global Burden of Disease (GBD) study, 19, 20, 25–27
Gamble, C., 214 for adolescents, 29–32
Ganatra, B., 386 causes of disease burden, by income group among
Ganesh, D., 378 adolescents, 31
Gardner, F., 486, 489 in children, burden of disease, 27–29
Garner, P., 217, 294, 506 disease burden from risk factors, 24–25
Garrett J., 301, 302, 304 methods and approaches, 21–24
Garrib, A., 232 mortality causes, by income group among children, 28
Garrison, K., 525 mortality levels and death cause estimation, 24
GATS, see General Agreement on Trade in Services outcomes, 38–40
GATT, see General Agreement on Tariffs and Trade risk factors for mortality and burden of disease
Gatti, D., 387 in adolescents, 32
GAVI, see Global Alliance for Vaccines and Immunization in children, 29
Gender analysis frameworks, 161–162 role, 25
Gender-based violence (GBV), 450 women, mortality and disease burden in, 32–34
Gender inequity, impact on Maternal and child health, among aged 20 years and over, 38
151–154, 158 among aged 60 years and over, 35–38
advocacy efforts for, 159–160 YLD estimation, 24
concepts and definitions in, 152 Global cooperation, in maternal and child heath care, 4
disability, 159 child survival revolution, 7–9
ethnicity and caste role, 158–159 future perspectives, 14–15
gender-based violence, 156 maternal health care, 9–10
gender impact, 156–158 newborn survival and continuum of care, 13–14
gender mainstreaming approach for, 160–163 primary health care, 6–7
geographic and regional variations, 159 safe motherhood initiative, 10–12
health promotion and health- seeking behavior, 155–156 Global distribution, of malaria transmission risk, 209
inequity in nutrition, 153 Global Fund for AIDS, Tuberculosis and Malaria, 306
marriage and pregnancy in adolescence, 154–155 Global Immunization Vision and Strategy, 421
multisectoral approaches, 160 Globalization, impact on population health
research priorities, 163 advantages, 135–136
and sexual relations in adulthood, 155 changes in food production and consumption, 143–144
and socioeconomic determinants, 158 and changing occupational roles, 142–143
Gender mainstreaming approach, role, 160–163 commercialization of health services, 139–142
Gender-sensitive community participation, role, 163 features, 138
General Agreement on Tariffs and Trade, 139 ‘‘Feminization of employment’’, 143
General Agreement on Trade in Services, 146 healthcare professional migration, 145
Genser, B., 114 impact on maternal and child health, 136–137
Georgia, abortion rate, 195 MDGs goal achievement, 145–147
Gerais, A. S., 179 and migration, 143–145
Gerein, N., 83–97 SAP and public services, 142
Germany, healthcare system, 72 Global malaria control strategies
Gertler, P., 517 drugs, 214–218
Gestational age estimation, 44 human-vector contact prevention, 214
Getchell, W. S., 255 progress and limitation, 219–220
GFATM, see Global Fund for AIDS, Tuberculosis and vaccines, 218
Malaria vector control, 214
Gharaibeh, M., 486, 487 Global trends, of Tuberculosis, 249–250
Ghosh, J., 144 See also Tuberculosis (TB)
Giardia lamblia, 235 Goiter prevalence and iron deficiency, 295
Gilad, J., 274 Goldenberg, R., 76
Gilles, H. M., 232 Gómez-Dantés, O., 135
Gilman, R., 245–266 González-Cossı́o, T., 295
Gilroy, K., 509 Good, J. T., 264
Gilson, L., 92, 539 Goodburn, E. A., 528
Gini Coefficient (World Bank 2008), 55 Gordon, B., 103, 105, 110, 111, 112
GIVS, see Global Immunization Vision and Strategy Gordon, D., 363, 393
Glanz, K., 298 Gove, S., 498, 535
Glass, R. I., 237 Goyaux, N., 402
Gleick, P. H., 142 Graham, W. J., 89, 93, 95, 365, 410, 411, 519
Index 569
Granja, A. C., 402 delivery, 86

Grant, J. P., 4, 7, 99 financing, 92
Grassly, N. C., 483 governance, 89
Gray, G., 278 health policy, planning and management, 89–90
Green, A., 83–96, 276 human resources management, 91
Greenough, W. B., 237 information system, 93
Greenwood, B. M., 209, 212, 219 infrastructure and transportation, 92–93
Gregson, S., 485 institutions, ownership, 88
Greksa, L. P., 484 location, 87
Grisolle, A., 263 medical supplies, 93
Groce, N., 331 quality assurance systems, 88
Gross, R., 291, 484 relationships, 87
Gross Domestic Product (GDP), 55 resources and support systems, 91
Gross National Product (GNP), 49 types and levels, 86–87
Growth monitoring, oral rehydration, breastfeeding, and Health-care system improvement, in IMCI, 502
immunization (GOBI), 7, 419 See also Integrated management of childhood illness
Gruenbaum, E., 177, 178, 179, 183 Health center intrapartum care strategy, 519
Gruskin, S., 526 Health insurance, in OECD healthcare financing, 59
Gülmezoglu, A. M., 217 Health Management Information System, 90, 93
Guerrero, M. L., 227 Health planning, defined, 89
Guimaraes, Z. A., 229, 233 Health services decline, reasons for, 126
Guirgis, W., 391 Health staff planning and management, 91
Gupta, D. N., 228 Health system, objective, 85
Gurgel, R. Q., 235, 236 Health worker
Gutierrez, G., 233, 235, 237 density and child mortality, 517, 518
and population ratio, 517
typology, 520
H Health Workers for Change program, 162
HAART, see Highly active antiretroviral therapy Heavily Indebted Poor Countries Initiative, 418, 423, 424
Haemophilus influenzae b (Hib), 419 Hedvall, E., 263
Hagemann, F., 480, 481 Heimbach, D., 385
Haider, R., 279 Heinicke, M. K., 335
Halsey, N. A., 261 Heise, L., 156
Halving hunger, recommendations for, 307–308 Helfer, R. E., 465
Hammer, G. P., 232 Helicobacter pylori, 257
Haney, D. Q., 389 Henao, A. M., 428
Harare, maternal mortality in, 407 Henrieka, E., 178
Hardon, A., 419, 420 Henshaw, S. K., 66, 377, 379
Harromoës, P., 113 Hepatitis B Vaccination Project, 426
Hart, P. D., 260 Hepatitis B virus (HBV), 426
Hathout, H. M., 170, 175 HepB3, immunization, 421
Hawkes, C., 136, 143 Herman-Giddens, M. E., 469
Hayes, A., 103 Hernlund, Y., 168, 178
HC-SC, see Health Canada–Santé Canada Herpes virus 2 and HIV infection, 275
HDI, see Human Development Index Hershfield, E., 249
Health Canada–Santé Canada, 74 Hesseling, A. C., 249, 254
Healthcare financing mechanisms, in OECD countries Highly active antiretroviral therapy, 275
healthcare expenditures and processes, 60–61 High production volume chemicals, 113
health insurance, 59 Hillard, P. J., 177, 181
human resources, 61, 66 HIPCI, see Heavily Indebted Poor Countries Initiative
out-of-pocket payments, 59–60 Hirsch, B., 214
private insurance, 59 Hirschhorn, N., 233, 237
public taxation, 56 Hirve, S., 386
social programs, 56 HIV/AIDS
Health care services and maternal mortality, 400 in adolescent, 448–449
Healthcare system and MCH in children, 479
elements, 85–86 intervention, in adolescent, 454–456
framework, 84–85 mortality
health services development in children, 27
community inputs, 94 in women, 32–33
decentralization, 90–91 See also Adolescent health
570 Index
HIV impact, in developing countries, 271–272 ICPD, see International Conference on Population and
children health Development
epidemiology, 277 IDA, see International Development Association
impact, 277–278 IDD, see Iodine deficiency disorders
management, 278 IFF, see International Finance Facility
pMTCT, 278–279 IFFIm, see International Finance Facility for Immunization
treatment, 279–280 ILO, see International Labor Organization
families health impact, 280–281 ILO Convention No. 138 and 182, 491
mothers health ILO Convention 182 on Worst Forms of Child Labor, 489
adolescents, 274–275 IMCI, see Integrated management of childhood illness;
causes of, 271 Integrated Management of Childhood Infections
health service inadequacies, 276–277 Immunization challenge, global, 417–421
HIV in women, 272 equity in, 426–427
pregnant women, 277 funding in, 421–424
women vulnerability to HIV, 273–274 generic categories of vaccines, 423
people affected, 271–272 new vaccine administration routes, 428
HMIS, see Health Management Information System sustainability in, 424–426
HMM, see Home management of malaria vaccine management, 429–430
Hoeman, S., 486, 487 vaccines research and development, 427–428
Hoffman, S. D., 377, 378 Immunization, technologies, 429
Hogan, D., 323 Impairments, causes, 327
Holme, A., 311 See also International Classification of Impairments
Holmes, C. B., 262 INCHES, see International Network on Children’s Health,
Holtgrave, D. R., 378 Environment and Safety
Holton, J., 471 India
Home management of malaria, 216–217 abortion, 386
Homicide and adolescent health, 442 diarrheal disease, 229
Honduras, maternal mortality, 406 teenage pregnancy, 385–386
Horizontal integration, defined, 87 India’s National Family Planning, 386
Hosken, F. P., 170 Indonesia case study, for maternal mortality reduction, 523
House, W., 383 Industrial chemicals, risk, 103
Household surveys and orphans population estimation, 483 Infant health, evidence-based, 367–369
See also Children health Infant interventions, current evidence-based, 369–370
Houwert, K. A., 254 Infant mortality
Howard-Jones, N., 5 rate, 401
Howell, E. M., 61 in United States, causes, 66, 68
HPI, see Human Poverty Index Ingle, G. K., 369
HPV chemicals, see High production volume chemicals Injury
Huerta-Franco, R., 388 in childhood
Huffman, S. L., 295, 297 external causes, 347–348
Huicho, L., 229, 233 prevention, 354–355
Huiming, Y., 371 social disparities and vulnerable population, 348–350
Human Development Index, 55 defined, 342
Human immunodeficiency virus (HIV), 271 economic costs of, 346
and malaria, 213–214, 217 pyramids, 344–346
and tuberculosis, 251, 258–259 surveillance, defined, 342
Human papilloma virus (HPV), 276, 426, 448–449, 455 See also Children health
Human Poverty Index, 55 Insecticide-treated bed nets, 213
Hunger, defined, 288 Integrated management of childhood illnesses, 9, 91, 108,
Hunt, J. M., 73 294, 497–500, 535
Huntington, D., 392 C-IMCI, 502–503
Huttly, S. R., 236 principles of, 503–506
Huynen, M. M. T. E., 137, 139, 140 criticism, 501
Hyre, A., 515–530 evidence base for, 506–507
future of, 509–511
global health system reform, 511
I health-care system improvement, 502
ICD, see International Classification of Diseases health system reforms, 511
ICF, see International Classification of Functioning, health workers skills improvement, 500–501
Disability and Health implementation of, 507–509
ICIDH, see International Classification of Impairments policy environment, 510
Index 571
principles of, 500 Japan

scope of, 499 healthcare system, 74–75
Integrated Management of Childhood Illnesses, 369 teenage pregnancy, 384
Intentional injuries Jaramillo, E., 253, 254
in adolescents, 441–442 Jayasekera, C. R., 484, 489
defined, 342 Jayatissa, R., 484
See also Adolescent health Jefferson, T., 371
Intentional injury treatment, in adolescent, 452 Jeffery, G. M., 216
Intermittent preventive treatment, 217 Jenkins, R., 135
International Classification of Diseases, 21, 55, 535 Jewkes, R. K., 402
International Classification of Functioning, Disability and Jha, P., 443, 453, 454
Health, 327, 328 Jinadu, M. K., 232
International Classification of Impairments, 327–328 Johansson, A., 385
International Conference on Chemical John, C. C., 211, 212
Management, 104 John, P. B., 486, 489
International Conference on Financing for Development, Johnson, B. R., 402
417, 420 Johnson, C. F., 467
International Conference on Population and Development, Jones, C. A., 265
12, 192, 458 Jones, G., 236
International Conference on Primary Health Care, 6 Jones, R. K., 196
International Development Association, 424 Jones, S. D., 156, 175, 177, 178, 179, 180, 186
International Federation of Gynecologists and Obstetricians Julian Lob-Levyt, 417–431
(FIGO), 175 Justin, R. G., 380
International Finance Facility, 422 Jutla, R. K., 385
International Finance Facility for Immunization,
417, 422
International Labor Organization, 470, 480 K
definition of child labor, 481 Kabra, S. K., 371
definition of child work, 481 Kader, A., 392
International Leadership Forum, 334 Kairys, S. W., 467
International Monetary Fund (IMF), 7, 142, 423, 424 Kamali, A., 485, 489
International Network on Children’s Health, Environment Kamanu, C., 167–186
and Safety, 101 Kaminsky, D. C., 227
International recognition, of child environmental health, Knowledge, attitude, and practices (KAP), 403
100–101 Kapilashrami, M. C., 386
International Sanitary Conferences, 5 Kar, N., 486, 489
International Society for Prevention of Child Abuse and Karamagi, C. A., 273
Neglect, 464, 465, 473 Katz, J., 404, 405
International Union Against Tuberculosis and Kawachi, I., 136, 147
Lung Disease, 249 Kawai, V., 260
Intrauterine device (IUD), 385, 392 Keegan, J., 121
Iodine deficiency disorders, 295 Keeps, E. J., 526
Iodine fortification, 297 Kelly, E., 177, 181
IPT, see Intermittent preventive treatment Kelly, J. M., 509
Iron Kempe, C. H., 463, 465, 467
deficiency in pregnant women, 295 Keusch, G. T., 237
sources, 295 Khan, P. S., 10, 172, 403
Islam, M., 399–414 Khanna, R., 162
ISPCAN, see International Society for Prevention of Child Khasnabis, C., 335
Abuse and Neglect Kim, J., 157
ITNs, see Insecticide-treated bed nets King, E., 438
IUATLD, see International Union Against Tuberculosis King, J. F., 363
and Lung Disease Kinoti, S. N., 412
Kirby, D., 438, 444, 454
Kirkhorn, S. R., 486, 488
J Klugman, K., 280
Jackson, T. D., 264 Knippenberg, R., 50
Jafar, T., 299 Knowles, J. C., 456
Jaffar, S., 233 Knutson, J. F., 329
Jahn, A., 287–308 Koblinsky, M. A., 236, 407, 409
Jana, N., 265 Koblinsky, M., 91, 158
572 Index
Kohli, H. S., 147 Loeb, M. E., 329

Konje, J. C., 314 Loewenson, R., 143, 144
Korenromp, E. L., 213, 219 Loncar, D., 314, 440, 443
Korte, R., 529 Lopez ,A. D., 20, 21, 24, 25, 288
Kosek, M., 226, 227, 233, 533 Loudon, I., 399, 405
Kothari, A., 265 Louis, G. B., 102
Kotzee, T., 527 Low-birth-weight (LBW), 287
Kraay, A., 136 Lowenstein-Jensen medium, usage, 256
Krawinkel, M., 288, 290, 291, 292, 293, 294, 295, 296, Lucas, D., 535
297, 298 Lule, E., 153, 435–459
Krieger, N., 77 Lumley, J., 73
Krishnan, S., 274 Luo, C., 258
Krug, E., 452 Lynch, E., 379
Krug, E. G., 343, 466, 468, 469, 471, 472
Kuehn, B. M., 145
Kulczycki, A., 191–200 M
Kumar, D., 258 Mabiala-Babela, J. R., 486
Kun, K. E., 175 McArthur, J. W., 306, 308, 521
Kuo, A. A., 75 McCarthy, J., 400, 402
Kusiako, T., 404, 405 McIntyre, D., 92, 539
Kwashiorkor, 292 McIntyre, J., 276, 278
Kyle, A. D., 105, 106 MacKay, J., 443
McKeown, T., 77, 534, 535
McMichael, P., 143
L Magnani, R., 437
Labonte, R., 137, 146 Magnussen, L., 136, 534, 536
Ladner, J. L., 213 Magpie Trial, 364, 365
Lalande, M., 77 Mahler, H., 10, 364
Lalloo, D. G., 209 Maine, D., 9, 11, 159, 316, 365, 367, 400, 402
Lalor, K. J., 487, 488 Maklouf, H., 392
Lanata, C. F., 225–239 Malaria
Lancet Maternal Health Steering Group, 365 burden, 208–209
Landrigan, P. J., 102 cause, 205
Langsten, R., 232 chemoprophylaxis, disadvantage of, 218
Larson, U., 175, 179, 181, 182, 235, 238 in children and adolescents, 211–212
Latin American countries, abortion law, 193 clinical patterns and consequences of, 209–212
Lauren, W., 281 global control strategies
Lawn, J. E., 13, 47, 407, 410 drugs in, 214–218
Lawson, J. B., 175, 180 human-vector contact prevention, 214
Laycock, H. T., 177, 180, 181, 182 progress and limitations, 219–220
Lazzerini, M., 371 vaccines, 218
Lee, K., 136, 147 vector control, 214
Lengeler, C., 220, 371 and HIV co-infection, 212–214
Leslie, J., 158 keyterms in, 206–208
Leventhal, J. M., 463–475 nephropathy and splenomegaly, 212
Levine, R., 422 during pregnancy, 212–213
Levonorgestrel, usage, 369 transmission, 205, 208
Lewis, T., 142 Malnutrition
Lifesaving emergency care, in pregnancy, 409 defined, 287
See also Safe pregnancy, challenges determination of, 290
Lightfoot-Klein, H., 176, 182 and disease prevalence, 288
Limpaphayom, K., 522 factors contributing micronutrient deficiencies and, 298
Lindblade, K. A., 484 infection and nutrition, interdependence, 291
Lindenmeyer, L., 5 keyterms used, 288
Lindmark, G., 175, 179, 186 life cycle and, 293
Live birth, defined, 44 in maternal and child health, 287–290
Llewelyn, M., 264 MND, 295–299
Lloyd, J., 429 obesity, 299–304
Lobstein, T., 288, 299, 301, 302, 303, 304 PEM, 290–295, 297–299
Lockhat, H., 178 interventions affecting undernutrition in, 305
Lockman, S., 256 and mortality rate, 288
Index 573
nutrition deficiencies, 287 disability, 159

obesity and poverty, 302 ethnicity and caste, 158–159
poverty and, 289 gender-based violence, 156
and tuberculosis, 252 gender impact, 156–158
See also Maternal and child health (MCH) gender mainstreaming approach, 160–163
Mann, G., 159 geographic and regional variations, 159
Manual vacuum aspiration, 196 health promotion and health-seeking behavior,
Marais, B. J., 250, 253, 254, 256 155–156
Marasmus, 292 marriage and pregnancy in adolescence, 154–155
Margono, F., 265 multisectoral approaches, 160
Marion Sims, J., 318 research priorities, 163
Marmot, M., 77 and sexual relations in adulthood, 155
Marston, C., 195, 438 and socioeconomic determinants, 158
Martines, J., 50 global cooperation, 3, 5
Mason, J. B., 289, 294, 305 child survival revolution, 7–9
Masuy-Stroobant, G., 410 future perspectives, 14–15
Masvingo, maternal mortality, 407 maternal health care, 9–10
Maternal and child health (MCH), 515 newborn survival and continuum of care, 13–14
abortion, 191 primary health care, 6–7
characteristics of women, 196 safe motherhood initiative, 10–12
demography, 194–195 globalization impact, 135–142
laws, 192–193 changes in food production and consumption,
mortality and morbidity, 193–194 143–144
new technologies, 196–197 and changing occupational roles, 142–143
origin, 192 determinants of population health, 137–138
reasons, 195–196 healthcare professional migration, 145
community level, 528–529 migration, 143–145
conflict and wars impact, 121–123 SAP and public services, 142
advocacy, 130 health-care workers deployment, 524–525
changing nature, 123–124 health services development
displacement, 126 community inputs, 94
economic collapse, 125–126 decentralization, 90–91
health services decline, 126–127 delivery, 86
impaired food availability, 125 elements, 85–86
injury caused, 124–125 financing, 92
Millennium Development Goals, 130 framework, 84–85
mitigation, 127–129 governance, 89
prevention, 129–130 health policy, planning and management, 89–90
crisis of human resources, 516–519 human resources management, 91
diarrhea in children information system, 93
clinical pattern, 226 infrastructure and transportation, 92–93
etiology, 235 institutions, ownership of, 88
morbidity and mortality, 226–234 location, 87
prevention and treatment, 236–239 medical supplies, 93
risk factors, 235–236 quality assurance systems, 88
environmental risks, 99–100 relationships, 87
air pollution, 104 resources and support systems, 91
in chemical usage, 102–104 types and levels, 86–87
children’s environmental health, 100–101 health workers performance, 526
health indicators, 105–107 health workforce development and planning, 521–522
lack of clean water and sanitation, 104–105 high-quality clinical practice sites, 522–523
policy frameworks, 107–109 and malaria
precautionary principles approach, 113–114 in children and adolescents, 211–212
research priorities, 109–113 drugs, 214–218
vulnerability of children, 101–102 and HIV co-infection, 212–214
evidence-based, 363–366 human-vector contact prevention, 214
current, 366 in pregnancy, 212–213
knowledge gaps and MDGs, 366 vaccines, 218
and gender inequity, 152–154 vector control, 214
advocacy efforts, 159–160 malnutrition, 287–290
on children’s health, 158 MND, 295–299
574 Index
Maternal and child health (MCH) (cont.) Mental disorders

obesity, 299–304 in adolescents, 440–441
PEM, 290–295, 297–299 treatment, 450–451
newborns and children health care, 519–521 See also Adolescent health
in OECD countries Meremikwu, M., 497–512
antenatal care, national approaches, 70–75 Merson, M. H., 226, 233
child care, 75–76 Methotrexate drug, 368
healthcare financing mechanisms, 56–66 Metts, R., 327, 329
healthcare systems, 54–55 Metz, H. C., 388, 389
health status indicators, 66, 68–69 Mexico, teenage pregnancy, 387–388
and international inequality, 56 Mhalu, F. S., 534
services delivery, 69–70 Microbiological diagnosis, of TB, 256–257
social determinants of health, 76–77 Micronutrient deficiencies, 287
policy and learning materials, 522 burden of disease, 295–296
postabortion care, 197–199 defined, 288
promotion intervention, 368–369 factors contributing, 297–299
qualified teachers and trainers, 523–524 management and control, 296–297
training programs, 522 Micronutrient fortification, 297
tuberculosis, 262–263 Microscopic observation drug susceptibility (MODS),
clinical presentation and diagnosis, 263–264 247, 256
congenital and perinatal, 265 MICS, see Multiple Indicator Cluster Surveys
extrapulmonary, 265 Middle east and North Africa, teenage pregnancy,
perinatal and maternal outcomes, 264–265 390–393
in pregnancy, 263 Midwife, defined, 516
treatment, 264 Midwifery care, in childbirth, 404, 405
workers integration and support, 525–526 Mifepristone drug, 196–197, 369
workers retention, 527–528 Milaat, W., 393
See also Maternal mortality Millennium Development Goals, 12–13, 305, 306, 329,
Maternal and newborn mortality reduction, 404–407 361, 417
See also Safe pregnancy, challenges adolescent health improvement, 436–437
Maternal and Safe Motherhood Program, 46 child health improvement, 370
Maternal mortality and globalization, relationship
defined, 401 child mortality reduction, 145–146
rate, 400 maternal health improvement, 146–147
in Egypt, 406 recommendations for health workers, 516
in Thailand, 405 in safer pregnancy monitoring, 411
ratio, defined, 401 for TB, 245
reasons, 9–10, 316, 403 and United Nations Millennium Declaration, 420
risk factors, 403 vaccines for HIV, 424
Mates, S., 263 See also Conflicts/wars impact, on maternal and child
Mathers, C. D., 314, 440, 443 health
Mathers, C., 19–40 Miller, C. M., 484, 489
Matheson, N. J., 371 Miller, F. C., 375
Matsudo, S. M., 304 Miller, P., 233, 237
Mauldon, J., 378 Minilaparotomy, usage, 368
Maulik, P., 333 Minimum Initial Service Package (MISP), 127
Mauritania, AIDS orphans, 482 Min, C. J., 3–15
May-Chahal, C., 468 Mirzoev, T., 83–96
Mayhew, S., 157 Misoprostol drug, 368, 369
MCH, see Maternal and child health Miyazaki, T., 384
MDG, see Millennium Development Goals Mkandawire, T., 142
MDRI, see Multilateral Debt Relief Initiative Mmari, N. K., 437
MDR-TB, see Multidrug-Resistant Tuberculosis MND, see Micronutrient deficiencies
Mehta, S., 384 Mochizuki-Kobayashi, Y., 444
Measles aerosol vaccine, 428 Moerman, M. L., 315
Melanovic, B., 146 Mohan, P., 509
MEME, see Multiple exposures multiple effects Mohanthy, S., 385
Mendez, M. A., 301 Mølbak, K., 227
Mendie, K., 216 Moore, D. A., 245–266
Mensah, G. A., 443 Moore, J., 382
Mensch, B. S., 444 Moore, K. A., 382
Index 575
Moore, S. A., 228 Neonatal deaths

Mor, T. S., 428 estimation, 45, 46–47, 48
Morris, K., 176, 186 limitations in study, 48–50
Morris, S. S., 226, 227 rate, 43, 47
Moscow, teenage pregnancy, 382–383 See also Perinatal health, global promotion
Mosley, W. H., 369 Neonatal mortality rate, 401, 404
Mota, H. F., 229, 233 Neumann, C. G., 227
Mothers health, HIV impact Neupane, S., 158
adolescents, 274–275 Nevirapine (NVP), 279, 368
causes, 271 Newborn mortality reduction, 407
health service inadequacies, 275–276 See also Safe pregnancy, challenges
HIV in women, 272–273 Newell, M. L., 278, 281, 371, 456
pregnant women, 277 Newman, R. B., 264
women vulnerability to HIV, 273–274 New Zealand, mortality decline, 536
See also HIV impact, in developing countries NHS, see National Health Service
Motshei, M., 157 NICE, see National Institute for Health and Clinical
Moulding, T., 252 Excellence
Msall, M., 323, 328 Nichol, M., 341–356
Mukadi, Y. D., 258, 259 Nigeria
Mull, L. D., 486, 488 diarrheal disease, 232
Muller, M., 275 obstructed labor in women, 316
Müller, O., 287–309 teenage pregnancy in, 389–390
Multidrug-Resistant Tuberculosis, 259–260 Nkanginieme, K. E., 175
Multilateral Debt Relief Initiative, 418, 423, 424 NMR, see Neonatal mortality rate
Multiple exposures multiple effects, 106, 107 Nolan, C. M., 261
Multiple Indicator Cluster Surveys, 24, 239, 482, 483 Nonfatal childhood injuries, 344
Mung’Ala-Odera, V., 211 See also Children health
Murphy, S. C., 211 North Africa and Middle East, teenage pregnancy in,
Murray, C., 87 390–393
Murray, C. J. L., 20, 21, 25, 40 North America
Murray, J. E., 72 mortality decline, 536
Murtha, A. P., 264 teenage pregnancy in, 377–380
MVA, see Manual vacuum aspiration North Atlantic Free Trade Agreement (NAFTA), 141
Mwaba, P., 249, 250 Norton, R., 453
Mwinga, A., 249 Nour, N. M., 175, 177, 179
Mycobacterium tuberculosis, 245, 250–251 Novelli, V., 249
See also Tuberculosis (TB) NPC, see National Population Commission
Nutritional deficiencies, in adolescents, 442–443
See also Adolescent health
N Nyonator, F., 527
Naficy, A. B., 228
Nahlen, B., 212
Nanda, G., 163 O
Napravnik, S., 274 Oberhelman, R. A., 255, 256, 257
Nasiru, I., 383 Obesity
National Clinical Training Network, 523 burden of disease, 299–303
National Family Health Survey of India, 385–386 defined, 288
National Health Service, 70 factors affecting, 290
National Institute for Health and Clinical Excellence, 70, 71 management and control, 303–304
National Population Commission, 389 O’Brien, K. L., 261
National Research Council (NRC), 112 Obstetric complications, defined, 401
Natural maternal mortality, defined, 401 Obstetric fistulas, global burden, 311
NCTN, see National Clinical Training Network development, 315
Necochea, E., 526 epidemiology, 313–314
Needle-free injections, importance of, 429 injuries, 314
See also Immunization challenge, global keyterms in, 312
Needleman, H., 100 obstructuve labor and consequences, 311–313
Neilson, J. P., 361, 362 pathways, 315
Nelson, L. J., 245, 250 prevention, 319–320
Nemer, L., 294 social causes, 314–317
Nemir, R. L., 265 treatment, 317–319
576 Index
Obstructed labor Ozcebe, H., 391

defined, 312 Ozener, B., 484
injury complex and injuries, 313, 314 Ozler, S., 143
Odoi, A. T., 170, 175, 176, 177, 178 Ozumba, B. C., 175
OECD countries, maternal and child healthcare, 53, 351
antenatal care, variations in national approaches
Australia, 73 P
Canada and Japan, 74–75 PAC, see Postabortion care
France, 72–73 Padmanabhan, B. S., 486, 489
Germany, 72 PAF, see Population attributable fraction
Sweden, 73–74 Palme, I. B., 259
UK, 70–72 Pan American Health Organization (PAHO), 386
child care, 75–76 Pan American Sanitary Bureau (1902), 5
financing mechanisms Panpanich, R., 484, 485
insurances and direct payment, 59–60 Papiernik, E., 73
taxations and social programs, 56–58 Parashar, U. D., 237
healthcare systems, 54–55 Parasite rates, usage, 205
expenditures and processes, 60–61 Park, M. M., 259
health status indicators Parker, R. G., 274
low birth rates, 69 Parkhurst, J. O., 88
mortality rates, 67 Parkin, D. M., 449
pregnancy termination and outcomes, 67–68 Parraga, I. M., 298
health systems’ human resources in, 61–66 Pass, M. A., 99–115
and international inequality, 56 Pass, R., 99–115
member countries and healthcare systems, 53–54 Patel, V., 438, 439, 441, 450, 451
services delivery, 69–70 Pathmanathan, I., 404, 406, 407
social determinants of health, 76–77 Patterns of injury, defined, 342–343
See also Maternal and child health (MCH) See also Children health
OEEC, see Organization for European Economic PCP, see Primary care physician
Cooperation Pearce, V., 475
Office International d’Hygiène Publique (1907), 5 Pearn, J., 486, 487
O’Hare, D., 265 Pearson, S., 83–96
Okonofua, F. E., 175, 179, 181, 182 Peden, M., 453
Oladipo, L. A., 314 Pelletier, D. L., 236, 498
Oleke, C., 489 Pelly, T. F., 252
Olivera, O., 142 People living with HIV/AIDS, 492
Olumole, D., 94 Pereira, C., 11
Oni, G. A., 227 Pérez-Schael, I., 228
Onolemhemhen, O. D., 311 Perinatal health, global promotion, 43–44
Oral rehydration salts (ORS), 237 evidence-based, 363–366
Oral rehydration solution (ORS), 533 future perspectives, 48–50
Oral rehydration therapy, 7–8, 225, 237, 369 limitations
Organization for Economic Cooperation and Development neonatal deaths, 48
(OECD), 53 perinatal deaths, 47
Organization for European Economic Cooperation, 54 stillbirths, 48
Ormerod, P., 264, 265 outcomes
Orne-Gliemann, J., 279 estimation, 44, 46–47
Orphans and Vulnerable Children, 479, 480 neonatal deaths calculation, 47
health conditions, 489 stillbirth rate estimation, 47
policies, 490–491 promotion intervention, 368–369
population of, 481 See also OECD countries, maternal and child
practices, 492 healthcare
ORT, see Oral rehydration therapy Perinatal interventions, current evidence-based, 366
Osrin, D., 308 Perinatal mortality
Out-of-pocket payments, in OECD healthcare financing, defined, 43, 401
59–60 in developing countries, 47
OVC, see Orphans and Vulnerable Children limitations in study, 47
Overweight See also Perinatal health, global promotion
defined, 288 Perinatal mortality rate, 43
factors affecting, 290 Perinatal tuberculosis, 265
Oxaal, Z., 156, 157, 158, 160, 162 PHC, see Primary health care
Index 577
Physical abuse, in children, 465–467 Pritchett, L., 136

See also Child maltreatment Private insurance, in OECD healthcare financing, 59
Picken, S. D., 384 Promotive services, for MCH, 86–87
Pickett, W., 341–356 Protein-energy malnutrition (PEM), 287, 297–299
Pinto, J. A., 485, 487, 488 burden of disease, 290–293
Piot, P., 276 defined, 288, 292
Plasmodium falciparum, 205, 212 management and control, 293–295
Plasmodium vivax, 205, 212 Prowse, J. M., 108, 232, 305, 308, 498, 534, 537
Plotkin, S., 418, 419 Prüss-Üstün, A., 102, 103, 104, 105
PLWHA, see People living with HIV/AIDS PTSD, see Post-traumatic stress disorder
PMR, see Perinatal mortality rate Public taxation, in OECD healthcare financing, 56
PMTCT, see Prevention of mother-to-child transmission Punyaratabandhu, P., 228
Pneumonia prevention and zinc intake, 296 Purchasing Power Parity, 55
Polybrominated diphenyl ethers (PBDEs), 103 Purdin, S., 121–132
Polychlorinated biphenyls (PCBs), 103 Purified protein derivative (PPD) skin test, 255
Polyvinyl chloride (PVC), 103 PYLL, see Potential years of life lost
Po, Z., 387
Pompey, F., 141
Pond, K. P., 108 Q
Ponnighaus, J. M., 260 Qayed, M., 392
Population attributable fraction, 25
Population census and orphans population estimation, 483
See also Children health R
Population Reference Bureau, 173 Raatikainen, K., 401
Porto, S. O., 485 Rabbani, F., 136
Postabortion care, 197–200 Radelet, S., 422
essential elements, 198 Ragan, N. B., 103, 111
See also Abortion, impact on maternal health Ragheb, S., 391
Post-neonatal mortality rate, defined, 401 Rahaman, M. M., 235
Postpartum and postnatal care, 409–410 Rahaman, M., 235
See also Safe pregnancy, challenges Rahman, A., 178
Post-traumatic stress disorder, 489 Rahmathullah, L., 228
Potential years of life lost, 343, 346 Ramirez-Cardich, M. E., 258, 259
Poverty Ramphele, M., 281
child health problems, 534–535 Randomized controlled trials (RCTs), 364
childhood injuries, 351–352 Ransom, E., 404
child maltreatment, 472–473 Rasch, V., 275
disability, 324, 330–331 Rasheed, S., 324
HIV/AIDS infection, 281 Raven, J., 151–164
malnutrition, cycle of, 289 Ravindran, T. K. S., 88, 92
obesity, 302 Ravoira, L., 379
See also Child health; Child maltreatment Razzell, R., 536
PPP, see Purchasing Power Parity REACH, see Registration, Evaluation, and Authorization of
PRB, see Population Reference Bureau Chemicals
Pregnancy, see Safe pregnancy, challenges; Teenage Read, J. S., 371
pregnancy Recommended home fluids (RHFs), 237
Prenatal care services, provision, 69–70 Rectovaginal fistula, defined, 312
Prenatal care system Reddy, K., 245–266
in Australia, 73 Registration, Evaluation, and Authorization of Chemicals,
in France, 72–73 103
in Germany, 72 Rehm, J., 444
in Sweden, 73–74 Reitman, V., 384
in United Kingdom, 70–72 Report of the Sanitary Commission of Massachusetts, 539
Prenatal screenings, in United Kingdom, 71 Reproductive health and rights, defined, 13
Preston, S. H., 536 Reynal-Querol, M., 130
Prevention of mother-to-child transmission, 163, 276, Rice, A. L., 288
278–280 Richter, L., 281
Preventive chemotherapy, for tuberculosis, 261 Ridde, V., 92
Preventive services, for MCH, 87 Rimba, K., 484
Primary care physician, 74 Risk for injury, defined, 342
Primary health care, 6–7, 86 See also Children health
578 Index
Rivers, K., 275 Sarker, M., 484

Road traffic accidents, in adolescents, 29 Sazawal, S., 296
Road traffic injuries prevention, in adolescent, 452–453 SBA, see Skilled birth attendant
See also Adolescent health SBR, see Stillbirth rate
Rodriguez, L., 252 Scanlon, T. J., 484–485
Rodriguez-Garcia, R., 279 Schaaf, H. S., 260
Roe, D., 113 Schaal, S., 486
Roe vs. Wade 1973, 379 Schaefer, G., 264
Rogan, W. J., 130, 111 Schaefer, L., 516
Roll Back Malaria (RBM) strategy, 219–220 Schaller, J. G., 278
Rollins, N. C., 271–283 Schecter, G. F., 267
Romanow, R. J., 77 Schellenberg, A., 504
Ronfani, L., 371 Schellenberg, D., 211
Ronsmans, C., 89, 93, 95, 402, 402, 410, 411 Schellenberg, J. R., 535
Rosen, J., 435–459 Schneider, H., 91
Rosenfield, A., 3–15, 365, 367 Schoen, C., 61
Ross-Fowler, G., 388 Schor, E. L., 75
Rossi, P. H., 483 Schorling, S. K., 228
Rowe, A. K., 535 SCT, see Social Cognitive Theory
Ruel, M. T., 301, 302, 304 sdNVP, see Single-dose nevirapine
Ruiz-Palacios, G. M., 237 Secondary health care, of health services, 86
Rural areas, health services, 6 Sedgh, G., 445, 447
Rushwan, H., 175, 181, 186 Sen, A., 386
Russia, abortion rate, 195 Sen, B., 292, 293
Russian Federation, teenage pregnancy, 382–383 Senanayake, M. P., 486–487
Rwanda, maternal and child deaths, 122 Senderowitz, J., 274
Senlet, P., 197
SES, see Socio economic status
S Severe Acute Respiratory Syndrome, 428
Sachs, J. D., 306, 308, 521 Sexual abuse, in children, 467
Sackett, D. L., 361, 362 See also Child maltreatment
Safe Drinking Water Act, 109 Sexual and reproductive health, in adolescent, 444–448
Safe Motherhood Initiative, 10–12, 364, 365 See also Adolescent health
Safe Motherhood Technical Consultation, 11 Sexually transmitted diseases (STDs), 488
Safe pregnancy, challenges, 399–400 Sexually transmitted illnesses, 379
antenatal care services, 407–409 Sexually transmitted infections, 379
challenges, 411–413 Seymour, H., 537
keyterms used, 201 Shafer, R. W., 258
lifesaving emergency care, 409 Shah, I., 445, 447
magnitude of problem, 400–404 Shaha, K. K., 385
maternal and newborn mortality reduction, 404–407 Shamebo, D., 231
MDGs, 411 Shandall, A. A., 175, 181
micronutrient supplementation, 297 Shane, B., 390
mother and newborn outcomes, 404 Sharief, E. H., 178
postpartum and postnatal care, 409–410 Sharpe, M., 101
rich-poor divide, 410–411 Shaw, E., 176, 182
VADD in, 295–296 Shawky, S., 393
Sagan, L. A., 534 Shell-Duncan, B., 168, 178
Sahar, E., 391 Shen, J. J., 66
Saito, M., 256 Sherman, S. S., 487
Sala, F., 428 Shingadia, D., 249, 255
Salaam, T., 487, 489 Shirk, M., 384
Salazar, G. E., 252, 253, 254, 258 Sibley, L. M., 402, 528
Sallam, S. A., 392 Sickle cell disease, 212
Samara, R., 383 Sierra Leone, maternal and child deaths, 122
Sanchez, P. A., 305 Silberschmidt, M., 275
Sanderson, L. P., 170 Simonds, F., 5
Santelli, J., 379 Simpson, K., 357
Santiago, E. M., 256, 295 Singh, S., 155, 382, 383, 389, 484, 489
SAPs, see Structural Adjustment Programs Single-dose nevirapine, 279
SARS, see Severe Acute Respiratory Syndrome Singleton, T., 334
Index 579
Sipe, T., 528 Sub-Saharan Africa (SSA), 287, 305

Skaine, R., 170 AIDS orphans, 482
Skilled birth attendant, 516, 521 diarrheal disease prevalence, 229
Skinner, D., 479, 480 malaria control measures, 219–220
Sloan, F. A., 408 teenage pregnancy, 388–390
Smallpox eradication program, 6 Suellentrop, K., 377, 378
Smallpox vaccine, origin, 418–419 Suk, W. A., 101
Smellie, W., 312, 313 Suligoi, B., 274
Smith, E., 159 Sullivan, P. M., 329
Smith, J. M., 515–529 Sullivan, R., 516
Smyth, L., 123 Sulphadoxine–pyrimethamine (SP), in malaria treatment,
Snow, R. W., 205, 208, 213, 214, 215, 219, 220 217
Snyder, J. D., 226, 233 Summerbell, C. D., 304
Soares-Weiser, K., 371 Sunguya, B. F., 534
Social beliefs and disabilities, 331–333 Supakankunti, S., 139
See also Adolescent health Supple, C., 329
Social Cognitive Theory, 298 The Survey Assessment of Vietnam Youth, 385
Social programs, in OECD healthcare financing, 56 Sutherland, I., 260
Social Security Act, 379 Swaminathan, M. S., 305
Socioeconomic status (SES), 144, 402 Sweat, M. D., 279
Sodemann, M., 238 Sweden, healthcare system in, 73–74
Solorzano, E., 486
South Africa and HIV infections, 272
South Africa, childhood TB, 250, 254–255 T
South America, teenage pregnancy, 386–388 Taft, C., 350, 351
South Asia, teenage pregnancy, 385–386 Tandon, B. N., 229
South Korea, abortion rate, 195 Tanumihardjo, S. A., 289, 299, 302, 304
Spady, D. W., 345 Tanzania, childhood TB, 250
Spleen rates, usage, 205 Tanzania Essential Health Interventions Project, 90–91
Springer, K. W., 471 Task Force on Child Health and Maternal Health, role,
Stanton, B., 232 12–13
Stanton, B. F., 275 Task Force on Child Survival and Development, 8
Stanton, C., 46 Tawfik, L., 412
Starke, J. R., 250, 258 TBAs, see Traditional birth attendants
Starrs, A., 11 Technology for Primary Healthcare (PRITECH) program,
Stegen, G., 255 498
Stegen–Toledo Criteria, for childhood TB Teenage pregnancy, 375–377
diagnosis, 255 adolescent fertility rates, 377
Steketee, R. W., 213 defined, 376
Sterne, J. A., 261 regional and country-specific perspectives
Stevens-Simon, C., 378 Central and South America, 386–388
Stewart, P., 74 East Asia and the Pacific, 383–385
Stillbirth, defined, 401 Europe and Central Asia, 380–383
Stillbirth rate, 43 middle east and North Africa, 390–393
estimation, 48 North America, 377–380
limitations in study, 49 South Asia, 385–386
See also Perinatal health, global promotion sub-Saharan Africa, 388–390
Stilwell, B., 145, 518, 529 See also Adolescent health
STIs, see Sexually transmitted illnesses; Sexually Ter Kuile, F. O., 213, 214
transmitted infections Tertiary health care, of health services, 86
Stockwell, T., 454 Tetanus toxoid (TT), 429
Stolovitch, H. D., 526 TFR, see Total fertility rate
Street children, 480, 481 Thaddeus, S., 159, 316
defined, 480 Thailand, maternal mortality, 405
health conditions, 488 Theobald, S., 151–163
policies for, 490 Thind, A., 238
Strobino, D., 77 Thomas, J. C., 227
Structural Adjustment Programs, 135, 139, 142 Thomlinson, R., 536
See also Globalization, impact on population health Thurman, T. R., 485
Stunting, defined, 288, 291 Thyroid-stimulating hormone (TSH), 295
Subbarao, K., 281 Ticconi, C., 407
580 Index
Timæus, I. M., 488 UK Consortium on AIDS and International

Tinker, A., 158, 404 Development, 490
Tita, A. T., 363, 366 Umeh, O. C., 274
Tita, A., 361–372 UNAIDS
TNCs, see Transnational corporations HIV prevention in adolescent, 454, 456
Tobacco addiction, in adolescents, 443–444 model based orphans estimation, 488
Tobacco and alcohol usage, intervention, 453–454 UN Convention on the Rights of the Child, 101
See also Adolescent health Undernourishment
Toledo, A., 255 and child mortality, 289
Tolhurst, R., 151–163 defined, 288
Toole, M. J., 484, 489 See also Malnutrition
Torgerson, R., 137 Understanding Children’s Work, 491
Tostan Community Empowerment Program, 185–186 Underweight, defined, 288, 291
Total fertility rate, 401 UNFPA, see United Nations Fund for Population Activities
Toubia, N., 178 Unintended pregnancies, 195
Toumbourou, J. W., 454 Unintentional injuries
Towner, E., 352 in adolescents, 441–442
Traditional birth attendants, 3, 10–11, 405, 409, 520–521, in children, 341–342
528, 529 behavioral risk factors, 351–352
Traditional practices and impact on women’s health, causes, 347–351
see Female genital mutilation (FGM) child development terms, 342
Trafficked children, defined, 481 disease burden, measures, 343
See also Children health economic costs of injury, 346
Transnational corporations, 135, 142 fatal childhood injuries, 343
Trauma, defined, 342 injury pyramids, 344–346
Tripathy, S. N., 263, 264 nonfatal childhood injuries, 344
Tripp, J., 378, 380 PYLL, 346
Tuberculin skin test (TST), 251, 255 strategies for prevention, 352–355
Tuberculosis (TB), 245, 246–248 defined, 342
in children See also Adolescent health; Children health
BCG vaccination, 260 United Kingdom
clinical pattern, 252–253 healthcare system, 70–72
diagnosis, 253–257 maternal mortality, 405
extrapulmonary, 257–258 United Nations Children’s Fund, 419
global burden, 249–250 United Nations Convention for the Rights of People with
and HIV co-infection, 258–259 Disabilities, 323–325
inaccuracy causes, tuberculin skin test, 255 United Nations Development Programme (UNDP), 8
multidrug-resistant, 259–260 United Nations Disability Statistics Database, 329
and nutrition, 252 United Nations Fund for Population Activities, 364, 528
pathogenesis, 251–252 United Nations International Children’s Emergency Fund
preventive chemotherapy, 261 (UNICEF), 5, 367, 497
risk factors, 250–251 estimation of child soldiers, 480
spectrum, 253 estimation of sexual exploitation in child, 480
Stegen–Toledo criteria for clinical diagnosis, 255 vulnerable children definition, 481
treatment, 261 United Nations International Seminar on Measurement of
vaccination, 260–261 Disability, 330
latent infection versus disease, 251 United Nations Millennium Declaration, 420
in women, 262–263 United Nations Millennium development goals, 14
clinical presentation and diagnosis, 263–264 United Nations Millennium Summit, 329, 417
congenital and perinatal, 265 United Nations Population Fund (UNFPA), 10
extrapulmonary, 265 United Nations Statistics Division, 330
perinatal and maternal outcomes, 264–265 United States Agency for International Development, 5, 498
in pregnancy, 263 United States of America
treatment, 264 abortion in
See also Maternal and child health (MCH) characteristics of women, 196
Tulloch, J., 9 law, 193
rate, 194–195
maternal mortality, 405
U MCH recognition, 5
UCI, see Universal Childhood Immunization teenage pregnancy, 377–380
UCW, see Understanding Children’s Work tuberculosis trends, 250
Index 581
United States Preventive Services Task Force, 363 Walsh, J., 537
Universal Childhood Immunization, 419 Wamala, S., 135–147
The Universal Declaration of Human Rights, 5 Wang, C. T. T., 471
UN Millennium Project, 306 Wang, Y., 288, 299, 301, 302, 303, 304
UN Millennium Summit, 12, 420 Ward, P., 528
The Uruguay Round of Multilateral Trade Warner, M., 345, 346
Negotiations, 139 Warren, K. S., 7
USAID, see United States Agency for International Warren, K., 537
Development Wasting, defined, 288, 291
USPSTF, see United States Preventive Services Task Force Waszak, C., 392
Ussery, X. T., 258 Watts, H., 484, 489
Webb, P., 291
Weil, O., 317
V Weiser, S. D., 273–274
Vaccination Wellings, K., 381, 382
for diarrhea, 236–237 Wells, C. D., 245, 250
discoveries, timeline, 418 Werner, D., 331
in global health, 417 West, A., 485
importance, 417 Western Pacific Region (WPR), 504
for malaria, 218 Westoff, C., 195
management, 429–430 WFCL, see Worst Forms of Child Labor
research and development, 427–428 Whalen, C., 258
See also Immunization challenge, global WHO’s Programme for the Control of Diarrheal
Vaccine administration routes, 428 Diseases, 8
VADD, see Vitamin A deficiency disorders Willett, W., 453
Valent, F., 104 Williams, C. D., 3, 108
Vallejo, J. G., 251 Wilson, A. T., 323–338
Vallely, A., 217 Wilson, A., 335
Vallely, L., 217 Wilson, M. E., 260
van de Walle, E., 536 Winch, P., 504
van den Hazel, P., 101 Windle, S., 167–186
Van der Hoek, W., 228 Winkler, J., 197
van Egmond, K., 402, 403 Wittig, M., 481
Van Lerberghe, W., 5, 10, 400, 406, 411 Wojdyla, D., 10
Vargas, D., 257 Wolfensohn, J. D., 329
VCT, see Voluntary counselling and testing Wolff, P. H., 492, 493
Ventura, SJ., 377, 379 Women
Vertical integration, defined, 87 with disabilities, health challenges, 323–326
Verzin, J. A., 175, 177, 179 DALY, 326–327
Vesicovaginal fistula, 312, 313 definition of disability, 326
Vesikari, T., 237 in developing countries, 328–330
Viboud, G. I., 228 health care for disabled poor, 333–337
Victora, C. G., 8, 226, 233, 237, 369, 533 ICIDH, 327–328
Vietnam, teenage pregnancy, 384–385 negative social beliefs, 331–333
Villa, S., 233 poverty and disability, 330–331
Villar, J., 402, 408 HIV, 272, 273–274
Viner, R., 378, 380 HIV infections prevention, 282
Vitamin A deficiency disorders, 295–296 pregnancy and HIV, 277
Vogeltanz, N. D., 469 sexual health and HIV prevalence, 273–274
Volmink, J., 278, 371 vulnerability to HIV, 273–274
Voluntary counseling and testing, 163, 275 See also Maternal and child health (MCH)
Woodruff, T. J., 104
Woodward, C. A., 527
W Woodward, D., 137
Waldman, R. J., 484, 489 Woolf, A. D., 486
Waldman, R., 13 Working children
Wall, L., 311–320 health conditions, 488–489
Walls, T., 255 policies, 490
Walmus, B. F., 235 World Health Assembly challenge, 419
Walraven, G., 295 World Health Organization Reproductive Health
Walsh, J. A., 7 Library, 366
582 Index
World Health Organization (WHO), 5, 139–141, Worseley, A., 170, 178

168, 497 Worst Forms of Child Labor, 481, 489
adolescent mortality estimation, 443–444 Wyrsch, M., 228
adolescents definition by, 435
Alma Ata’s Declaration of Primary Health Care, 537
child mortality, estimation X
by homicide, 469 Xaba, M., 162
by injury, 347
by malnutrition, 497
definition, of child maltreatment, 464 Y
definition, of persistent diarrhea, 226 Yap, K. L., 228
definition, of physical abuse, 465–467 Yassin, K. M., 232
Delphi method, 102 Yayori, M., 384
disabilities estimation, 329 Yeager, B. A., 227, 235
estimate of stillborn, 404 Yeager, B. A. C., 236
evaluation of IMCI, 507 Years Lived with Disability (YLD), 24
FGM prevention, 180, 182 Yellow fever, immunization for, 421
health workforce investment estimation, 518 Yoon, K. H., 303
infant mortality estimation in Nigeria, 389–390 Yoon, P. W., 236
malaria control program, 214–218
Maternal and Safe Motherhood Program, 46
maternal mortality estimation, 400 Z
mental and physical disability estimation, 323 Zaba, B. A., 278
poverty and child health problems, 535 Zaba, B., 281
recommendations for antenatal care in pregnancy, Zablotska, I. B., 273
407–408 Zaffran, M., 417–431
road traffic injuries in adolescents, estimation, 442 Zar, H. J., 256, 257
role in TB prevention, 245, 261 Zidovudine (AZT), 278, 368
sexual violence estimation, 469 Zimbabwe, AIDS orphans in, 482
smallpox eradication, 417 Zinc
strategy for public health, 304 deficiency and pregnancy, 296
See also Adolescent health; Global Burden of intake and diarrhea prevention, 296
Disease (GBD) study; Maternal and child supplementation, for diarrheal treatment, 237
health (MCH) Zodgekar, A. V., 386
World Summit for Children, 9 Zwarenstein, M., 262
Worldwide Fistula Fund, 311 Zwi, A. B., 122

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John Ehiri

Maternal and Child Health

Foreword by Paul Garner

ISBN 978-0-387-89244-3 e-ISBN 978-0-387-89245-0

Library of Congress Control Number: 2009932149

# Springer ScienceþBusiness Media, LLC 2009

Printed on acid-free paper

Springer is part of Springer ScienceþBusiness Media (www.springer.com)

sanitation, immunization, improved nutrition, and access to basic health-care

Part I The World’s Heterogeneity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Part II Politics, Power, and Maternal and Child Health. . . . . . . . . . . . . . 119

11 Abortion and Postabortion Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Part III Specific Disease Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Part IV Programs, Policies, and Emerging Concerns . . . . . . . . . . . . . . . . 359

28 Planning, Development, and Maintenance of the MCH Workforce . . . 515

Rebecca Affolder The GAVI Alliance, Geneva, Switzerland

Anne Hyre Jhpiego, Johns Hopkins University, Baltimore, Maryland, USA

Jeffrey M. Smith Jhpiego/Johns Hopkins University, Baltimore, Maryland,

With increasing globalization, inequity, and escalating poverty, application of

A significant proportion of the United Nation’s Millennium Development Goals

Rationale and Target Audience for the Book

information on evidence-based maternal and child programs and policies; and

Content and Layout

Part I: The World’s Heterogeneity

Part II: Politics, Power, and Maternal and Child Health

Part III: Specific Disease Concerns

tuberculosis, malnutrition, and injuries. It also includes chapters on obstetric

research on the topic as well as clinical features and diagnosis of TB among

Part IV: Programs, Policies, and Emerging Concerns

cross-national themes, trends, progress, and challenges. They highlight the

Allan Rosenfield and Caroline J. Min

J.E. Ehiri (ed.), Maternal and Child Health, DOI 10.1007/b106524_1, 3

Box 1.1 Milestones in Global Cooperation in MCH

Box 1.2 Declaration of Alma-Ata

Box 1.3 Oral Rehydration Therapy

Box 1.4 Definition of Reproductive Health and Reproductive Rights

Box 1.5 United Nations Millennium Development Goals

Goal 1: Eradicate extreme poverty and hunger.

Alma-Ata Declaration International Monetary Fund Integrated Management of

J.E. Ehiri (ed.), Maternal and Child Health, DOI 10.1007/b106524_2, 19

2002, with annual assessments published in Annex

Table 2.1 (continued)

Colon and rectum cancer 0 3 1 37 299 2,684 622 5,817

Low and middle income countries High income countries

Child 0–4 years Child 5–9 years Adolescent 10–19 years

Women 20 years and over Men 20 years and over

Low and middle income countries High income countries

Europe and Central Asia Respiratory infections

East Asia and Pacific

0 500 1000 1500 2000 2500 3000 3500

Fig. 2.3 Mortality Per cent of total global deaths

Global climate change

High income HIV/AIDS and TB

0 50 100 150 200 250 300

High income HIV/AIDS and TB

Other infectious and parasitic

Latin America and Caribbean Neuropsychiatric conditions

Middle East and North Africa Road traffic accidents

Other unintentional injuries