Global health inequality and women – beyond maternal health

“We have promises to keep and miles go before we sleep”Robert Frost Global health, or the health of populations in a global context, seeks transcend borders, eliminating inequalities disease prevention healthcare worldwide [1]. The concept first appeared 1970–80s but gained prominence when it assumed centre stage at 2000 United Nations summit. At this meeting, eight millennium development goals were identified as major challenges these ambitiously earmarked for eradication by 2015 [2]. Goal five was improve maternal health. Since UN summit, many changes taken place women's some more predictable than others. Maternal mortality, an important indicator decreased 44% between 1990 2015. Whilst impressive, decrease falls short original goal set UN, which proposed 75% reduction mortality ratio during period. A recent World Health Organization report states that, 2017, 800 women still dying daily from preventable causes related pregnancy childbirth (www.who.int/data/gho/data/themes/maternal-and-reproductive-health). Decreasing is undoubtedly worthy goal. However, average woman spends less 5 years life being pregnant 20 middle-aged older. Focusing solely on childbearing symbolises traditional devaluation outside age who do not children. It also underplays importance co-existing pregnancy, such gestational diabetes induced hypertension how impacts woman's later [3]. Globally, suffer leading excess all periods life. Furthermore, there often focus within maternity care outcomes, low- middle-income countries. important, reality, inequality that interplay gender poverty divide. Women lower socio-economic status are highest risk, every group part globe [4]. with low levels education, members minority groups migrant should raise red flag provider, they most likely present medical late, long-standing yet undiagnosed conditions complications treatment [4, 5]. Therefore, needs address issues countries around world. Moreover, influence increasingly recognised factor inequity. sex genetic, differing little societies, refers socially construed roles influenced ethnicity, culture environment. same may vary respect biological This suggests urgent need further research into biological, behavioural social mechanisms involved ‘inequality’ ‘sexes’ ‘genders’. Addressing gender-based has all-encompassing implications personnel. As world shrinks national boundaries fade, its effects take ramifications. Domains anaesthetist now wide reaching including peri-operative care, critical illness pain management, encounter areas where face inequity, examples outlined detail below. Causes death peripartum period directly (e.g. haemorrhage, pre-eclampsia), indirectly sepsis, exacerbation heart disease, stroke) coincidental trauma). Regardless cause, leads quality antenatal received higher overall rate pregnancy-related [6]. disparity timely access regular delayed referral patients diabetes, converting what could been ‘routine cases’ high-risk pregnancies [7]. Undiagnosed obstetric pre-eclampsia exacerbated poor prenatal inability disinclination refer [8]. Access adequate analgesia labour delivery unequal highly variable [9]. compounded inequity developed developing nations their knowledge attitudes towards [10]. Encouragingly, initiatives ‘No delivery’ helped counter misconceptions safety analgesia, resulting rates caesareans, episiotomies, postpartum blood transfusions better neonatal outcomes approximately 55,000 deliveries China [11]. In ideal world, be accompanied professional relevant experience training environment equipped respond emergencies. Worldwide, attended midwives are, can significant variation midwifery practice, regulation education [12]. variability extend anaesthetic interventions, especially middle- low-income Sobhy et al. provide robust estimates risks anaesthesia regions: accounted 2.8% deaths, 3.5% direct deaths 13.8% after caesarean section. Exposure general increased risk compared neuraxial anaesthesia, nearly double managed non-physician anaesthetists physician [13]. settings, very attitude providers actually deters seeking help. Yet, despite growing recognition sometimes abusive disrespectful childbirth, consensus define measure occurrences lacking level [14]. worrying issue lack family planning, birth control, abortions, HIV women. These issues, alongside teenage taboo subjects, parts Apart cultural divide, known about special subset patients, frequently acute eclampsia, reaction injury cervix uterus, pelvic infection secondary haemorrhage. Long-term infertility, ectopic cervical incompetence weight infants, surgery [15]. agenda continues evolve, notable variations remain genders heavily biased gender. Although increasing awareness, factors prevent free make similar choices men overlooked across globe. situation worse hurdles faced accessing affordable infrastructure [16]. last two decades, main morbidity shifted infectious diseases reproductive non-communicable diseases. shift cause prominent high-income countries, communicable previously prevalent. Even Africa, proportion attributed rose 24% 39% 2019. estimated 2019 just over 19 million globally diseases; 8.5 died cardiovascular 4 cancer 1.8 succumbed respiratory (www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death). lead disability-adjusted globally, namely ischaemic disease; back neck pain; stroke; depressive disorders; chronic obstructive pulmonary [17]. All risk-factors co-exist woman. Highlighting changing nature problems facing women, emphasised, post-2015 framework, move beyond life-course approach For example, discussed de Marvao supplement; yet, even delays longer time-frames diagnosis severity cardiac opposed [18]. delay will living country use [19]. intersectionality status, extends numerous other demonstrate healthcare. Female undergoing dialysis spend time central venous catheter transition permanent [20]. abdomen referred gynaecologist, missing life-threatening non-obstetric causes; gender-linked presentation seen stroke, presenting chest pain. Women, those susceptible depression, anxiety mental issues. disability due remained constant 30 years. occur lifespan impacting each impact her structures. Vulnerability, stigma resources, resource-poor burden particularly (http://dcp-3.org/gender/improving-women's-mental-health). grapple opioid epidemic, contrast, 80% population deprived moderate severe Basic analgesics, morphine, hard procure 150 There both differences relating clinical demonstrating threshold tolerance pain, response analgesics postoperative postsurgical [21]. female-specific cancers. Despite breakthroughs several fronts (such screening, molecular treatment) scale, breast 50 geographic, racial, ethnic possibly diversity terms genetic predisposition [22]. hormone-receptor positive (HR+) subtypes cancer, best prognosis types, show greatest survival Greater system factors, late-stage availability systemic therapy. Cervical vaccination curable if detected early. Incidence twice high three times Availability prophylactic vaccines; innovative cost-effective approaches screening treating; novel surgical training, expected becomes target elimination (www.who.int/news-room/events/detail/2020/11/17/default-calendar/launch-of-the-global-strategy-to-accelerate-the-elimination-of-cervical-cancer). Surgical account 30% 70% lacks safe care. decade, led effort increase surgery. Medically provided key component improved globally. Increasing patient campaign intended awareness regarding professionals worldwide. Training opportunities Federation Society Anesthesiologists, well advocacy minimum standards improving capacity implement (the Lifebox foundation, Safe Africa). must recognise management gender- sex-linked resulted substantial disadvantages [23]. come long way recognising issue. next step policymakers, equality potential only benefits, economic gains. Anaesthetists role physicians various play pivotal identifying addressing No competing interests declared.