2021/03/07 by S. N. Myatra, Sheila Nainan Myatra, S. Tripathy +3 · 5 citations
Medicine · Health Professions · #Global Maternal and Child Health #Global Health Care Issues #Global Health and Surgery
paper · pdf · doi:10.1111/anae.15431
“We have promises to keep and miles to go before we sleep”Robert Frost Global health, or the health of populations in a global context, seeks to transcend borders, eliminating inequalities in disease prevention and healthcare worldwide [1]. The concept of global health first appeared in the 1970–80s but gained prominence when it assumed centre stage at the 2000 United Nations summit. At this meeting, eight millennium development goals were identified as major challenges and these were ambitiously earmarked for global eradication by 2015 [2]. Goal five was to improve maternal health. Since the UN summit, many changes have taken place in women's health, some more predictable than others. Maternal mortality, an important global indicator of women's health, decreased by 44% between 1990 and 2015. Whilst impressive, this decrease falls short of the original millennium goal set by the UN, which proposed a 75% reduction in the maternal mortality ratio during this period. A recent World Health Organization report states that, as of 2017, more than 800 women were still dying daily from preventable causes related to pregnancy and childbirth (www.who.int/data/gho/data/themes/maternal-and-reproductive-health). Decreasing maternal mortality is undoubtedly a worthy goal. However, an average woman spends less than 5 years of life being pregnant and more than 20 years being middle-aged or older. Focusing solely on childbearing women symbolises the traditional devaluation of women outside of childbearing age and of women who do not have children. It also underplays the importance of co-existing disease during pregnancy, such as gestational diabetes and pregnancy induced hypertension and how this impacts on a woman's health in later life [3]. Globally, women suffer healthcare inequalities leading to excess mortality in all periods of life. Furthermore, there is often a focus within global women's health on maternity care and outcomes, in low- and middle-income countries. Whilst important, in reality, the global health inequality that women suffer is an interplay between the gender and the poverty divide. Women of a lower socio-economic status are at highest risk, in every age group and in every part of the globe [4]. Women with low levels of education, women members of minority groups and migrant women should raise a red flag for every healthcare provider, as they are the women most likely to present for medical care late, present with long-standing yet undiagnosed medical conditions and suffer complications of treatment [4, 5]. Therefore, global health needs to address these issues in all countries around the world. Moreover, the influence of gender on disease is increasingly being recognised as an important factor in global health inequality and inequity. Whilst sex is genetic, differing little between societies, gender refers to socially construed roles that are influenced by ethnicity, culture and the socio-economic environment. The same disease may vary with respect to biological sex and gender [3]. This suggests that there is an urgent need for further research into the biological, behavioural and social mechanisms involved in the global ‘inequality’ of disease between the ‘sexes’ and the ‘genders’. Addressing gender-based inequality in global health has all-encompassing implications for medical personnel. As the world shrinks and national boundaries fade, disease and its effects take on global ramifications. Domains of the anaesthetist are now wide reaching including peri-operative care, critical illness and pain management, all of which encounter areas of health where women face inequity, some examples of which are outlined in more detail below. Causes of critical illness and death during pregnancy and the peripartum period are directly related to the pregnancy (e.g. haemorrhage, pre-eclampsia), indirectly related to the pregnancy (e.g. sepsis, exacerbation of heart disease, stroke) and coincidental to the pregnancy (e.g. trauma). Regardless of cause, lower socio-economic status leads to a reduction in the quality of antenatal care received and a higher overall rate of pregnancy-related complications [6]. A global disparity in timely access to regular antenatal care often leads to delayed referral of patients with hypertension or gestational diabetes, converting what could have been ‘routine cases’ to high-risk pregnancies [7]. Undiagnosed obstetric conditions such as pre-eclampsia are often exacerbated by poor prenatal care and inability or disinclination to refer to medical care [8]. Access to adequate analgesia during labour and delivery is unequal and highly variable worldwide [9]. This is compounded by an inequity between women of the developed and developing nations in their knowledge and attitudes towards labour analgesia [10]. Encouragingly, global health initiatives such as the ‘No pain labour and delivery’ have helped counter misconceptions around the safety of labour analgesia, resulting in lower rates of caesareans, episiotomies, postpartum blood transfusions and better neonatal outcomes in approximately 55,000 deliveries in China [11]. In an ideal world, delivery should be accompanied by a medical professional with the relevant experience and training and in an environment equipped to respond to emergencies. Worldwide, many deliveries are still not attended by midwives and when they are, there can be significant variation in midwifery practice, regulation and education [12]. This variability can also extend to anaesthetic interventions, especially within middle- and low-income countries. Sobhy et al. provide robust estimates of the risks of anaesthesia in these regions: anaesthesia accounted for 2.8% of all maternal deaths, 3.5% of direct maternal deaths and 13.8% of deaths after caesarean section. Exposure to general anaesthesia increased the risk compared with neuraxial anaesthesia, with the rates of death being nearly double when managed by non-physician anaesthetists compared with physician anaesthetists [13]. Furthermore, in some settings, the very attitude of the healthcare providers actually deters women from seeking help. Yet, despite growing recognition of the sometimes abusive and disrespectful treatment of women during childbirth, a consensus on how to define and measure these occurrences is lacking at a global level [14]. A significant and worrying issue is lack of access to family planning, birth control, abortions, HIV treatment and sex education in all women. These issues, alongside teenage pregnancy, are often taboo subjects, especially in many parts of the developing world. Apart from the socio-economic and cultural divide, there is also little known about anaesthetic and medical care for this special subset of patients, who frequently present with acute complications such as eclampsia, sepsis, a reaction to anaesthesia, injury to the cervix or uterus, haemorrhage, pelvic infection and secondary haemorrhage. Long-term complications such as infertility, ectopic pregnancy, cervical incompetence and low birth weight infants, all have implications for anaesthesia and surgery [15]. As the agenda of global health continues to evolve, notable variations in access to and outcomes of healthcare remain between genders [3]. In many societies, access to healthcare is heavily biased by sex and gender. Although there is increasing awareness, factors that prevent women from being free to make similar healthcare choices as men are frequently overlooked across the globe. However, the situation is undoubtedly worse in low- and middle-income countries where the social and cultural hurdles faced by women in accessing affordable healthcare are compounded by poverty and poor infrastructure [16]. Globally, in the last two decades, the main causes of morbidity and mortality in women have shifted from infectious diseases and reproductive health to non-communicable diseases. This shift in the cause of deaths is more prominent in low- and middle-income countries than in high-income countries, where communicable diseases have previously been more prevalent. Even in Africa, the proportion of women's deaths attributed to non-communicable diseases rose from 24% in 2000 to 39% in 2019. The World Health Organization estimated for 2019 that just over 19 million deaths in women globally were attributed to non-communicable diseases; including approximately 8.5 million women who died from cardiovascular disease, 4 million died from cancer and 1.8 million succumbed to respiratory diseases (www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death). Furthermore, non-communicable diseases lead the causes of disability-adjusted life years for women globally, namely ischaemic heart disease; low back and neck pain; stroke; major depressive disorders; and chronic obstructive pulmonary disease [17]. All the risk-factors leading to these causes of morbidity and mortality often co-exist in the same woman. Highlighting the changing nature of the health problems facing women, especially in low- and middle-income countries, the World Health Organization has emphasised, as a post-2015 framework, the need to move the women's health agenda beyond the focus on reproductive health issues and to take a life-course approach to women's health. For example, cardiovascular disease is increasingly recognised in women, as discussed by de Marvao et al. in this supplement; yet, even in high-income countries, there are delays in women seeking medical care and longer time-frames for diagnosis and recognition of the severity of cardiac disease in women as opposed to men [18]. This general delay in access to treatment in women will likely be further compounded by living in a low- or middle-income country where there is low use of secondary prevention for cardiovascular disease [19]. This intersectionality between socio-economic status, sex and gender extends to numerous other examples that demonstrate inequity in healthcare. Female patients undergoing dialysis spend a longer time with a central venous catheter and are less likely to transition to permanent access than men [20]. Women with an acute abdomen present later than men and are often referred to a gynaecologist, missing life-threatening non-obstetric causes; this gender-linked delay in presentation and diagnosis has also been seen in patients with stroke, cancer and in women presenting with chest pain. Women, especially those from low- and middle-income countries, are more susceptible to depression, anxiety and other mental health issues. Globally, death and disability in women due to mental health issues has remained constant over the last 30 years. Furthermore, it can occur across a lifespan impacting not just at each stage of a woman's life but also impact on her family and social structures. Vulnerability, social stigma and lack of access to resources, especially in resource-poor settings, make this burden particularly acute (http://dcp-3.org/gender/improving-women's-mental-health). Whilst high-income countries grapple with an opioid epidemic, in contrast, approximately 80% of the global population is deprived of access to treatment for moderate or severe pain. Basic analgesics, such as morphine, may be hard to procure in as many as 150 countries. There are both sex and gender differences relating to the experience of pain with clinical research demonstrating women have a lower threshold and tolerance to pain, less response to analgesics and are at increased risk of increased postoperative pain and developing chronic postsurgical pain [21]. There are global differences in women's health related to female-specific cancers. Despite breakthroughs on several fronts (such as screening, molecular diagnosis and treatment) on a global scale, the mortality of breast cancer has not decreased over the last 50 years. There may be geographic, racial, ethnic and possibly cultural diversity in terms of genetic predisposition and mortality of breast cancer [22]. The hormone-receptor positive (HR+) subtypes of breast cancer, which are also the best prognosis types, show the greatest differences in survival across the globe. Greater mortality in low- and middle-income countries has been attributed to health system factors, late-stage presentation at diagnosis and lack of availability of systemic therapy. Cervical cancer is both preventable with vaccination and curable if detected early. Incidence is twice as high and mortality is three times higher in low- and middle-income countries as compared with high-income countries. Availability of prophylactic vaccines; innovative cost-effective approaches to screening and treating; and novel surgical training, is expected to decrease this global inequality in disease burden as it becomes a target for global 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 diseases account for 30% of the global burden of disease and 70% of the global population lacks access to safe anaesthesia and surgical care. In the last decade, the World Health Organization has led a global effort to increase the safety of surgery. Medically provided anaesthetic care is a key component of improved surgical outcomes globally. Increasing recognition of the importance of anaesthesia to patient outcomes has led to a campaign intended to raise awareness regarding the need for anaesthesia professionals worldwide. Training opportunities have been increased by the World Federation of Society of Anesthesiologists, as well as advocacy for minimum safety standards and improving the capacity to implement these standards (the Lifebox foundation, Safe Africa). However, training must recognise that peri-operative care, critical care and pain management are areas where these gender- and sex-linked differences have resulted in substantial disadvantages for women [23]. The world has come a long way in recognising health as a global issue. The next step for all those involved in women's health, from medical professionals to policymakers, is to recognise that gender equality in global health has the potential to lead not only to health benefits, but also to social and economic gains. Anaesthetists in their role as peri-operative physicians have an important role in improving safety and surgical outcomes at various levels and can play a pivotal role both in identifying and addressing these inequalities early. No competing interests declared.