Arquivo de etiquetas: Saúde Materno Infantil

Maternal and Child Health V

The Long Shadow of Childhood Undernutrition

In some of the previous chapters of this lecture, we’ve spoken of how maternal mortality and child mortality are influence also by the state of nutrition during pregnancy, prior to pregnancy and what happens to children in terms of their own nutritional status and probability of their succumbing to illness before the age of five. So we now recognize that childhood under-nutrition is a very critical element in global health. Not surprisingly it was positioned as one of the millennium development goals to be targeted for a substantial reduction in the prevalence of childhood under-nutrition across the world. Even a report as recent as the global nutrition report of 2014 lists that about two billion people are estimated to be deficient in one or more macronutrients, when we are really talking about macronutrient deficiency, we are really talking about ultimately being under-nourished due to deprivation of calories or energy. But we also now recognize that it’s not just calories or energy, it’s the quality of diet that matters in multiple ways. So we are looking at nutritionally balanced diets as well. And that is where we find the problems are probably even more than this particular estimate. We also know that about more than three billion people are afflicted globally with micronutrient deficiencies, whether it’s iron deficiency, vitamin A deficiency, or iodine deficiency, or a combination of all of these. When we look at the global profile of low birth weight and under-five malnutrition and look at what the magnitude is in different parts of the world in comparison to the standard, conventional, geographical atlas, the picture is really very different. Countries of south Asia, particularly India and its neighboring south Asian countries like Bangladesh and Nepal have a huge burden of under-nutrition, as do some of the countries in sub-Saharan Africa. Whereas in many other parts of the world, childhood under-nutrition is no longer a challenge and indeed, does not figure as a part of their own agenda for implementation of the millennium development goals. Despite all the progress that has been attained because of the millennium development goals and even to some extent the period preceding that, we have seen that there are huge disparities, even among the low and middle income countries in terms of the prevalence of underweight in childhood. While Brazil, China and Thailand have been models of great success with prevalence less than 10%. Indeed in Brazil, about 2%. In the countries of south Asia we find the picture very different. India, even in 2011 in a global nutrition report of the World Health Organization was reported to have 43% underweight below the age of five years. Bangladesh, 41% prevalence. And Nepal, 39% prevalence. Even in sub-Saharan Africa, which is better off than south Asia, there was a 28% prevalence of underweight children under the age of five. And these have profound effects. There is impaired physical growth, particularly linear growth among these children who are underweight and under-nourished. There’s a much greater susceptibility to infections, whether it is measles or respiratory infections or diarrheal diseases. Most of the infections can take a toll and even chronic infections like tuberculosis are far more often in the setting of under-nutrition. At the same time, it has an impact on cognitive and intellectual functions. The brain power of these children is substantially reduced as compared to what their potential would have been if they were well-nourished. And while it is certainly a tragedy for the child, in terms of not being able to obtain their full developmental potential, it’s also a huge problem for the countries in terms of the cumulative loss of brain power which they could have otherwise utilized for productive growth. At the same time, because education is also affected of these children because under-nourished children are sickly. They don’t learn very well. And they do not advance well to higher education; therefore their employment opportunities are also substantially decreased. They have reduced ability to participate in sports and other recreational activities and therefore their ability to really be important members of a large peer group, whether in schools or in society is also decreased over a period of time. But even more importantly this link carries on to pregnancy also. Imagine a girl child who’s under-nourished and anemic, growing on to become an anemic and rather underweight adolescent with a limited pelvic size. And when that adolescent girl then becomes pregnant soon thereafter we find that the small pelvic size also results in a small placental size that creates a problem in terms of the pregnancy outcome for the mother, but in the same time the reduced blood flow also results in under-nourished children, particularly when the baby in the womb is not able to get enough blood flow from the small placenta. So it has an impact on the mother, it has an impact on the child. And you may have maternal mortality or child mortality, particularly neonatal mortality, or you may even have a child who has been born successfully but is small size and then there is a further penalty to be paid thereafter. There are also a fair amount of negative effects on the risk of adult chronic disease like cardiovascular disease, diabetes, and even to some extent, some cancers. There are intergenerational effects not only between the child who becomes the mother and her own child, but sometimes these intergenerational effects can spill over to subsequent generations as well. So there is this intergenerational disadvantage of childhood under-nutrition that can carry on to subsequent generations. And we see this long shadow of childhood under-nutrition being cast into adult life when we look at the impact of rebound adiposity in a child who has been born small in size and low in birth weight, but gains in weight between the ages of two and twelve years. That doesn’t actually translate to an increased muscle mass. It translates much more into body fat, especially fat deposited in the abdomen and around the vital organs in the abdomen. And this sets the stage through metabolic programming for onset of high blood pressure, early onset of diabetes, and heart disease in, in these children as they grow into adulthood. And even in fairly early adulthood, you can find diabetes and heart attacks claiming a huge toll of health on these children. And we have evidence of this from multiple countries, but here is an example from India, from what’s called the New Delhi Birth Cohort. And this cohort that’s been followed up from birth to adult life what was determined was that while in the first two years of life the children in the lowest birth rate range were reasonably well protected against acquiring a lot of body fat, by the time they cross two years of age and started having a compensatory nutritional intake, their percentage of body fat markedly increased. And it is these children who had low birth weight under the age of two, but who had rebound adiposity or relative obesity. It was not actually obesity or overweight, it was relative obesity compared to their low birth weight in the beginning who turned out to have much higher incidence of diabetes by the time they became adults. So it was this problem that set the stage for adult diabetes. And it’s not surprising therefore to see that India, which had such a huge burden of childhood under-nutrition in the earlier pictogram, now in this pictogram also it has one of the highest burdens of diabetes in the world. So these are fairly interlinked, at least in the south Asian subcontinent. But these effects are not only limited to the life of one child or even the offspring of that child. When we look at a woman who is now pregnant and who is carrying the consequences of her own impaired nutrition from childhood, we must recognize that the female fetus that is in the womb also is having eggs which will result in her own children when she becomes a mother later on in life. And those are also affected in terms of their gene expression by the childhood under-nutrition that the mother suffered. So at least three generations are linked by this intergenerational transmission of nutritional disadvantage. And perhaps even more as we understand epigenetics, we recognize that some of these disadvantages can be carried into multiple generations. So we need insure that childhood under-nutrition is corrected, not only because we want to protect the present generation or the immediate next generation, but truly in the spirit of sustainable development we want to prevent some of these disadvantages accruing to as yet unborn generations. There are interventions that we need to adopt in order to insure that childhood under-nutrition can be successfully tackled by countries. And some of these are nutrition-sensitive interventions. They do not lie in the form of nutritional supplementations or specific nutrition related or diet related interventions, but they have a profound effect on nutrition because they impact the level of nutrition both in terms of intake as well as in terms of absorption and utilization. Water for example is absolutely important. Unless you have clean drinking water, you can get diarrheal disease and that can wash out a good part of the nutrition that has been taken in. For the same reason, sanitation and hygiene are absolutely important, because infectious diseases, because of poor sanitation and hygiene, again, can drain away much of the limited nutrition that children in low and middle income countries get. And at least 50% of under-nutrition in India has now been ascribed to lack of sanitation. In terms of agriculture and food security, that becomes absolutely important, because we do need to produce enough dietary diversity through crop diversity as well as healthy food products to ensure that every citizen has calorically adequate but also nutritionally appropriate diet at each stage of life. And therefore these systems are to become better aligned to the need of nutrition of all society but particularly from the point of view of preventing child under-nutrition which is such a crying shame. Now we need social safety nets because if there are huge income disparities and also in terms of access to diets because of poor living conditions in low income communities, then we are going to see under-nutrition being perpetuated. So we do need some social safety nets as well. We need a greater focus on early development of children. We need focus on better schooling. Again, education fosters better nutrition. At the same time, midday meal schemes in different countries are also helping to improve some of the nutritional problems, especially micronutrient deficiencies among children. And we need child protection. We need maternal and mental health to be looked at, because if the mother is mentally stressed, she cannot feel a young infant or even the growing child properly. We need women’s empowerment. Having more income and more social status and political power for women insures that children grow up much better. At the same time we need access to health and family planning services because if you have an early pregnancy in an under-nourished adolescent girl being pushed into early marriage. And of the subsequent spacing of pregnancies also is very small, you are bound to get children who are under-nourished. And that is going to have an adverse influence later on as well. So we do require a large number of nutrition sensitive interventions. But we also need to incorporate nutrition specific interventions such as insuring adequate food and nutrient intake at each stage of life as appropriate to that age. And the specific requirements which may vary based on the level of physical activity, based on whether the person is at that point in time undergoing an illness or not and so on. Now we also particularly need to focus on promotion of exclusive breastfeeding at least for the first six months of life. That is absolutely mandatory for good nutrition as well as building of the immunity of the child. And this is very critical but unfortunately not widely practiced even in low and middle income country settings where one would have considered it to be a traditional cultural norm. But it is not. And we also need to promote the right complimentary feeding practices and responsive feeding practices when the children require food. So all of these actually are built in in earlier infancy and childhood. In fact while exclusive breastfeeding is required up to six months, continual breastfeeding should be carried on as long as possible even up to two years, if it’s possible. At the same time, good feeding practices are very important in the growing child. When we talk about the catch up growth happening because of compensatory nutritional feeding, getting ultimately converted not into real good, linear growth with muscle mass, but into a lot of body fat, we must recognize that high carbohydrate diets with low physical activity may be responsible for that. So we need better diets which also are combined with rigorous physical activity in the children, which can ensure that the catch up linear growth is translating into actually a better physical stature in terms of linear growth, but also more muscle mass rather than just body fat. So we need to pay attention to what kind of food we are giving. At the same time, caregiving and parenting practices are important in the entire area of child nutrition, control of infectious diseases is critical because we said; diarrheal diseases can drain away nutrition. Other infections can also reduce the appetite, reduce the absorptive capacity. So control of those infectious diseases, even treating intestinal worms which actually make the child malnourished, that’s also very important. Now we need to look at multiple micronutrient supplementation as a possible additional element, though that cannot be the sole pathway for good nutrition. We have to depend upon natural foods for good nutrition. The use of ready-to-use therapeutic foods has been recommended, particularly in treatment of severe forms of childhood under-nutrition. This is a little controversial because it appears to be pushed sometimes by the industry. But they may have a limited space in the treatment of the severe forms of malnutrition. In terms of the impact of various programs, we have also seen success stories which we can learn from and other countries can emulate. Thailand has been a poster child for such a success. If you see what has happened in the three Southeast Asian countries of Thailand, Philippines and Indonesia, between 1980 and 1990, Thailand had a marked decrease in the prevalence of underweight children. There was a bit of a spike thereafter when all of these countries were facing economic challenges because of some of the financial crises that their country’s faced but nevertheless we noticed that Thailand’s success continues to be commendable. And this has been a feature ever since thereafter. Indonesia has shown a slower growth, but even there we are finding a considerable amount of success. Philippines on the other hand till recently hasn’t had much success, but now it’s beginning to record some gains. What succeeded in Thailand and what is it that we can learn from there? That Thailand adopted the basic minimum needs approach, which looked at some of the social determinants like housing and environment. They brought in family planning and reproductive health services. They encouraged community participation. They also utilized spiritual and ethical development as a platform for promoting healthy nutrition and good eating habits. So they combined all of this and the effective linkages between services in various sectors with community level action mediated by community mobilizers who were interfacing with families, brought nutrition from the abstract policy level into very much of the home habit. Now when you look at how the Thailand model worked, they looked at services and brought in government, NGO action into health, education, agriculture and other sectors. But they also brought in facilitators who worked with community mobilizers, provided supervision, training, information and support. And these  mobilizers acted with the families and that interface involved counseling, organizations, supplies, referral for prenatal care, child care practices, growth monitoring, supplementation of micronutrients when needed. All of this happened at the community level. And the communities also became active participants in planning, implementation and monitoring. So this has been Thailand’s prescription for a successful program which reduced childhood under-nutrition in a very short space of time. And that is where other countries can actually learn from. What we recognize now is that childhood under-nutrition is not an aberration that comes in because of poor feeding in the limited space between birth and five years of age. It is sometimes a carryover effect of poor nutrition during pregnancy. It sometimes is a carryover effect of the poor nutrition that the mother herself had as a child and as an adolescent. But we also recognize that there are factors in infancy and early childhood which again need better attention, particularly to reduce the risk of various ill health conditions which can affect the child but also trying to prevent some of the later problems of adult chronic disease. And the stage there is set between birth and two years and between two years and twelve years. We also need to look at adolescence as a very important period of life. We don’t want anemic mothers resulting from anemic adolescent girls. We want to make sure that they also have good nutrition so that they can grow up well and bear healthy children later on. Even male adolescents too require healthy nutrition rather than becoming obese or having poor nutrition otherwise. This again needs to be carried over into adult life because again, if nutrition suffers in pregnancy, the child is bound to suffer again. So the idea of building  nutrition into a life course model is absolutely critical. Even if we target childhood under-nutrition and monitor specific metrics related to childhood under-nutrition, when we plan programs and frame policies, we have to have the life course model. And we have to look up, look upon it as a multi-sectorial societal responsibility. And that is where it fits into sustainable development.

Maternal and Child Health IV

The Sexual and Reproductive Health Agenda

Maternal health shall be always a core health priority in any nation. It shall always be part and parcel of the universal health coverage, whatever the model. Indeed, MDG V also had a sub-target which espoused ensuring universal access to reproductive health as its horizon. And we still have to achieve this. Maternal mortality is an indicator of how well health systems are functioning. In well-functioning health systems, maternal mortality is extremely low, as low as less 20. Negligible.

443 And in ensuring universal coverage for mothers and women would require access to quality reproductive health services, but not just that, it would also require financial protection without which this access is not possible without impoverishment. When we move toward examining challenges post-2015, then one of the bottlenecks is the problem of poor quality and poor access to data, in the context of maternal health. Only 11 of the 75 countries have information, good enough information on maternal health indicators. And 85% of the global population lives in areas where cause of death data, as basic as the cause of death data are of poor quality and therefore one of the endeavors as we move towards post-2015 framework says, to set up maternal morbidity indicator frameworks and capacity worldwide. And such an initiative has been launched by the World Health Organization. We must remember that maternal mortality, the death of a woman related, occurring as a result of, or a complication of pregnancy is just the tip of the iceberg. For every maternal death, there are 20 to 30 other women, other pregnant women who experience acute or chronic morbidity. And this emanates from a near death that they just managed to avert. Or, non-severe obstetric complication, but can be very devastating, such as uterine prolapse or a fistulae. So we move from reduction in mortality, that’s one aspect, but we also have to take care of this part of obstetric morbidity and the near misses that continue to occur in a very large number of women, even now. sexual and reproductive health continues to need greater attention in the development agenda.451It’s a fundamental pillar of core development of a nation and a society. Unsafe sex is among the top ten causes of disability and death globally. It’s a key toward bad outcomes. And addressing this is the pathway to overall better health, overall sustainable health and sustainable communities. More than 120 million couples continue to have unmet need for contraception. More than 120 million couples. And even today 80 million pregnancies are unintended each year on the globe. This has to be addressed. We’re still far away from an optimum reproductive health scenario in the world today.

452Our efforts to intensify this and in particular to address the younger women, the adolescent girls and women and mothers in marginalized societies. Poor households, poor communities, rural or urban, has to be an important endeavor even in the post-2015 scenario. Family planning promotion has the potential to reduce poverty and hunger and avert almost a third of all maternal deaths, because the number of pregnancies comes down, the mother is able to cope with pregnancies much better. And also family planning can reduce childhood deaths by 10%. Women’s health cannot be optimally addressed without addressing the social determinants such as the status of women in the society and the level of their empowerment, education, and connectivity with the environmental sustainability. In the post-2015 frameworks an important priority for women’s health shall be addressing the problem of unsafe abortions. Each year there are 19 to 20 million unsafe abortions in the world. Almost all of them take place in countries that are low or middle income. And they are particularly so in countries with restrictive, conservative abortion laws. Very disturbingly each year there are 40,000 deaths of adolescent girls and women each year in the world who do unsafe abortions. We have the overarching picture of the abortion laws. The green color depicts liberal abortion laws where the choice is offered to the woman, to under…undertake an abortion.

453The red colors indicate those countries where the abortion laws are restricted and there are conditionalities to undergo abortion. In the second map that how appears on the screen, you would see that areas where there are restrictive abortion laws the burden of unsafe abortions is high. Thus, in Latin America and in sub-Saharan Africa, where the laws related to abortion are restrictive, conservative, the prevalence of unsafe abortions is very high. The take is that if you wish to curb unsafe abortions, the abortion laws should be liberal and pro-choice as far the women and the girls are concerned. I’d like to move toward the unfinished agenda of sexually transmitted illnesses in the context of post-2015 priorities. The STI, the sexually transmitted illnesses are the second most common cause of healthy lives lost in women after the pregnancy resolves. Our focus has been on gonorrhea, chlamydia, syphilis and trichomonas and it remains a challenge.

454HIV is also a sexually transmitted illness and it could be put here as a part of STIs. But we also have human papillomavirus infection, herpes simplex virus infection, hepatitis B infections. And somewhat less troublesome, problems such as scabies and pubic lice that need to be addressed. You will see that the Americas in the developed parts of the world have a huge challenge of sexually transmitted illnesses. So that’s one major area is the Americas, then Asian countries are the other major hub of STIs. And this needs to be put on the high priority agenda in the post-2015 scenario. STIs have a huge impact on not only women, but also on the fetus and the child. STIs cause premature delivery, newborn deaths, birth defects, infections in children. They are contributing toward infertility in women. And they also of course are associated very importantly with rejection of the women by the families and disempowerment. STIs must be addressed optimally and among all women in the world as we move on. Then we look at other challenges in women’s health post-2015. One problem stands out very clearly and that is the issue of violence against women. Not fully understood, often hidden, but we now know from large studies and one particular one done by WHO that the prevalence of violence against women, often by the intimate partner, the husband or the partner is extremely high. Non-sexual as well as sexual violence.Sexual abuse before the age of 15 is quite significantly prevalent across nations. Across societies. At times, transactional sex is common in some regions. And pays for education among the girls. Women who experience violence lose their sexual and reproductive choices because they are forced. They lose their rights. Intimate partner violence is common cause of unintended pregnancies. And this happens in the confines of the home. Thus there are multifarious impacts of this…this problem, affecting a large number of women in the world today. And this must be addressed as a health problem, this must be addressed as a social problem. One form of violence against women is the practice of female genital mutilation, which occurs as a traditional practice in some parts of the world, particularly Africa and some Asian countries.

455Female mutilation, female circumcision has no medical benefit or value. This is an unacceptable practice. There are problems related to psychological trauma and the impact it has in future reproductive live. But there are also acute problems such as infections and hemorrhage, which can potentially kill the woman. And there is also likelihood of chronic morbidity, obstetric problems, fistulae, which can ruin the life of, of the girl, of the woman. Female genital mutilation has to be curbed in the post-2015 frameworks. If required there has to be laws against this depraving practice and if required, there has to be a major social movement to, to address this menace. We must also remember that women’s health is not just about reproductive health or pregnancy or maternal health, there is also a huge importance of mental health in the context of healthy women, healthy mothers. Suicides are among top causes of deaths in peri-natal period in the developed world. And this would happen increasingly so in developing countries as we move toward better, so-called better care. Often the conversation around the mental health is focused on post-natal depression and that’s fortunately getting new attention. But other psychiatric illnesses in peri-natal period also need to be paid attention to. So peri-natal mental health is an important emerging agenda for the global community to address. Other priorities that await focus, are the breast cancer and cervical cancer. And infertility in its own right, not only are we concerned about excess fertility, but we are also concerned about women’s choice and the families or the couple’s choice to have children. And infertility is equally devastating to individuals and families. So this is waiting attention and this should be a priority in the post-2015 agenda. My key messages in this lecture are the following. First, we have made progress in regard to reduction in maternal mortality. And we are proud of it, even though we would miss the MDG V but the, the progress made is remarkable. Maternal mortality has declined by 50% since 1990 and this is the effect of the MDG initiative. Although the current burden, as we have stated earlier is unacceptable and we need to take care of this unfinished agenda, we must always remember that 99% of all maternal deaths are really in the developing countries. It’s the agenda of the poor. It’s the agenda of the developing nations and emerging economies. Maternal health is at the heart of development agenda and it’s at the heart of our quest toward universal health coverage. As we move beyond 2015, we have to take care of the unfinished task of averting all preventable maternal deaths. But we also need to focus clearly on the near misses and the obstetric morbidity that may not result in mortality. We have a huge unfinished reproductive health agenda, huge unmet family planning and need has to be addressed. Unsafe abortions have to be tackled. These are needless deaths and needless morbidity and needless risk to the women. Sexually transmitted illnesses have to be a focus for us to eliminate them, bring them down to a negligible level in years to come. The new agendas on the table are violence against women, peri-natal mental health, and other conditions such as cancer and infertility that affect women and mothers of the world.

Maternal and Child Health III

The Global Maternal Health Scenario

We now turn our attention to global maternal health. We will examine the progress made in reducing maternal mortality and also look at the issues which will be the focus beyond 2015. 421Let me first define two terms. Maternal death and maternal mortality ratio because these two terms would be used repeatedly in this particular lecture. Maternal death is defined as the death of a woman while pregnant or within 40 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management. Thus, maternal death is a death of a woman related to pregnancy and its complications. Maternal mortality ratio is defined as number of maternal deaths per 100,000 live births. Please note that this is a ratio where maternal deaths are the numerator and live births, babies born live after pregnancy are in the denominator. Where do we stand in regard to the status of maternal mortality? Maternal mortality has been the focus of our endeavors, worldwide. It used to be extremely high and it continues to be high, at an unacceptable level. Although we have made progress and we’ll come to that in a moment. Even today however, approximately 800 women die from preventable causes related to pregnancy and childbirth. In 2013, 289,000 women died during and following pregnancy and childbirth. More remarkably almost all of these deaths, 99% of them occurred in developing countries. There are hardly any maternal deaths in the developed world. This is the quantum of preventable mortality among women who go through pregnancy in the natural course of their lifetime. This map shows the distribution of maternal mortality ratio in various parts of the world in the year 2013. The reds and the oranges are high MMR where are the blues and the light blues are the lower maternal mortality rates. The deepest blue is just a rate of less than 10 per 100,000 maternal mortality ratio and you can see that that color is present only in the best of the, of the developed world. The deep red is a maternal mortality ratio of 500 per 100,000 live births.

422Extremely high. Fifty times that in the blue zones that you notice. It’s also obvious from this map that the highest rates of MMR prevail in sub-Saharan Africa. Indian subcontinent and other parts of Africa are somewhere in the middle where the rates are between 200 to 300 per 100,000 live births. So the agenda of maternal mortality reduction is the agenda of poor nations of sub-Saharan Africa and relatively poor nations of Asian subcontinent. The Millennium Development Goal number V relates to improving maternal health. And its specific focus is reduction in maternal mortality. And the target of MDG V is reduction in MMR or maternal mortality ratio by three-quarters, 75% from the 1990 baseline, to 2015 as the timeline. So MDG V is about reducing maternal mortality ratio by 75%, between 1990 and 2015. Let’s see what progress has been made in the context of MDG V since 1990. Between 1990 and 2013, and 2013 is a year for which we have the most updated data, maternal mortality worldwide has dropped by 50%. So if you notice, the number of maternal deaths on the right side, 1990, 523,000 and in 2013 maternal deaths are down to 289,000. It’s about 50% reduction. If you look at the ratio, the maternal mortality ratio, it declined from 380 per 100,000 live births as we defined shortly ago, from 210 globally in the year 2013. It’s again, an outstanding reduction, close to about 50%. More importantly the MDG initiatives have been a trigger for faster reduction in maternal mortality ratio. Between the year 1990 and 2005, the average annual percent change in MMR was the reduction of 2.2% each year. And this accelerated to 1.5 times in the time period of 2005 to 2013 to 3.3%.

441There is no doubt that the political commitment, increased resources, better monitoring and better and higher scale up of effective interventions triggered by the Millennium Development Goals, has resulted in saving additional lives of mothers. However, only 10 high burden countries of the 75 will achieve the MDG V. The rest of the world and the world as a whole would unfortunately still fail to achieve MDG V. And that’s the unfinished agenda that we carry beyond 2015. But let’s look at the regional progress and inequities in maternal mortality ratio. As you would see from this graph, the global community as a whole reduced MMR from 380 to 210 between 1990 and 2013. A decline of 45%. This decline was greater in South Asia, the middle two bars, from 530 to 190. The sub-Saharan Africa, where we see the highest rates also made a significant reduction, the blue is much bigger than the red. And this decline was 48%. So there has been progress all across the world, including the tough places like the African continent and the Indian subcontinent. The progress has been uneven and this needs to be corrected. So there are inequities where we need to invest in order to make sure that there is more even progress and faster progress in time to come. When we look at the causes of maternal deaths and try to derive lessons for averting maternal deaths, something very clear emerges. Thirty-five percent, more than one-third of maternal deaths occur because of hemorrhage or bleeding, triggered by childbirth. High blood pressure, eclampsia accounts for 18% of maternal mortality. Infections, 8%. Unsafe abortion, unsafe abortions account for 9% of maternal deaths.


442This is the global scenario. How do the mothers survive the period of pregnancy and childbirth? One of the key things that we know that works is conducting delivery in safe hands. Providing care during labor and childbirth by a skilled health professional, a doctor or a nurse or a midwife. Therefore for MDG V, a key indicator is births attended by skilled health personnel. And if you look at the coverage of this, you will note that in high income countries, and even in upper middle income countries, the two bars on the right side, almost every birth is being attended by skilled personnel or skilled professionals. Every mother. On the other hand, on the extreme left, in low income countries, this proportion is less than 50%. And low and middle income countries are somewhere in the middle. You can see that further reduction in maternal mortality is related to how best we ensure that the labor and delivery is in the hands of skilled people. And, this inequity between the low income countries and the better off countries has to be bridged. This is the centerpiece of our strategies to improve maternal mortality. Skill care at delivery coupled with the emergency obstetric care which would involve emergency caesarian section and blood transfusion and manual evacuation of placenta. These interventions are at the heart of our efforts to reduce maternal mortality. Then unsafe abortion need to be addressed through legalization of abortion services and abortion as a, as a, as a domain and its acceptability in the society coupled with expertise to undertake safe abortion. These are the key approaches to addressing maternal deaths. In the context of maternal health MDG, namely the MDG V. This MDG is linked to very interestingly many other MDGs. It’s related to eradication of poverty, access to basic services. It is linked to improving the status of gender and empowering women and empowering communities. It’s linked to its impact on child mortality and child survival. The MDG IV, it is linked to universal education because educated women are less likely to, to have adverse pregnancy outcomes and maternal deaths. It’s also linked to the HIV related MDG because a part of mortality of mothers is linked to HIV. In some ways, it is at the heart of the entire MDG effort and we also view MDG V as a final common pathway and an indicator of overall development. And of course global partnerships, environmental sustainability are linked in ensuring empowerment of women, good health of mothers, and above all very, very low levels of maternal mortality.

Maternal and Child Health II

Child Health Post- 2015

Why do children die? First and foremost, about 50% of children’s deaths are related to complications that occur in newborn period. And these are preterm birth complications. Complication during the intra-partum period. We also call them as birth asphyxia, as a composite cause of death. That infections of newborn babies such as sepsis, meningitis and pneumonia and malformations, birth defects. In post-neonatal period the predominant causes are three: pneumonia, diarrhea and malaria. And they account for about a third of global child mortality burden. It’s also important to know that nutrition plays a very important part in determining the child survival. Under-nutritional state, whether in the form of wasting, stunting or low birth weight has a bearing on at least half of under-five child mortality. And we need to correct under-nutrition in a significant way to make an overall progress towards better child survival. We have well established evidence based affordable effective interventions to save lives of children. Neonatal life can be saved with good care of the mother in ante-natal period. Skilled care at birth. Skilled care in labor and at and soon after birth will save many child lives. Resuscitation of the baby who doesn’t breathe at birth. Kangaroo mother care for a small baby who needs warmth and access to breastfeeding. Antibiotics. Supportive care. Beyond the newborn period, immunization. We talked about measles, but we also have haemophilus influenzae and pneumococcal vaccine and rotavirus vaccine which avoid pneumonia and diarrhea. And if diarrhea does occur, effective treatment is possible through the use of oral rehydration solution and the zinc. And for pneumonia, if it does indeed occur, antibiotic therapy will save most children. In the recent times we have been able to package these interventions into programs. So integrated management of childhood illness combines these interventions into a package which is delivered by the health workers after training and insuring that there is a supply chain of treatments out there in the field where the babies and children are. Home based newborn care. Facility based care of sick newborns and children. These packages of services will save most lives. It must also be stated that safe water, sanitation and hygiene are also crucial in improving the health outcomes of children, particularly in preventing illnesses. And nutrition is fundamental to child survival. Exclusive breastfeeding in the first six months of life. Timely and appropriate introduction of complimentary food. Addressing moderate under-nutrition and addressing severe, acute malnutrition aggressively are the building blocks of a good nutrition program in a nation. If we have interventions they must reach children, women and households. If they do not reach, these interventions cannot save children. So when we examine the coverage of various interventions we find that there are gaps. For instance, breastfeeding which does so much good to children is, covered to only about 40% of the global population. Exclusive breastfeeding rates in the first six months of life at just about 40% globally. This should be 90%-plus. Oral rehydration solution should be accessible to every child with diarrhea,100% coverage. But what we have is 30%. And antibiotics for pneumonia which should be accessible to any child with pneumonia, is at the present rate is only 50% coverage. The gap amounts to deaths. And this gap has to be bridged therefore. The interventions must be taken to scale and every child should receive the intervention that he or she deserves. It’s not just about access to interventions alone. Interventions to be delivered through an efficient, and a quality mechanism. So quality of services is also extremely important. For instance if you just close the quality gap and newborn care, we can save additional two million newborn lives. So it’s not only about reaching, but reaching effectively, reaching with quality, that will lead to optimum survival of children. Access to intervention is also linked to mechanisms that connected the babies, that target children, target mothers, target infants to the intervention. In Rwanda performance based payment to community workers led to a better connect of this nature, that children accessed care and services. In Bangladesh engagement with NGOs and commercial partners led to disconnectivity of increasing access by the, the children, by the families to the live-saving interventions. And in India, conditional cash transfers to families and to health workers led to a phenomenal increase in facility births from 40% to 80% in a span of five to seven years. There are drivers of change that lead increased uptick of interventions on scale that we should learn from, adapt them, and implement them if appropriate contextually. What is the agenda of child health beyond 2015? First and foremost we still have to end all preventable child deaths. There are still too many child deaths happening, particularly among newborn babies as we stated. For this, the global community has now set 2035 as the horizon, by which time we all as a global community end all preventable child deaths. And this translates to bringing down under-five mortality rate to 20 per 1000 or less by this timeline. Just to remind you, the current rate is 46 per 1000 live births. So our endeavor is to reduce it by more than half beyond 2015 and up to 2035, a span of about two decades. Likewise, global newborn mortality rate is now targeted to be brought down to single digit by 2035. Current rate being 20 per 1000 live births. So this is the new set of goals and targets that the global community has set for itself and that’s the direction that 2015 onwards we will take as a global community. There are other priorities beyond survival for children. Over-nutrition is looming large. Too many children are becoming obese because of changes in lifestyle. In some ways the ill effects of so-called development. Diabetes, childhood cancer, childhood kidney diseases, birth defects that requires surgical corrections. And very importantly, psycho-social issues, autism, abuse and disabilities are increasingly important to be tackled even in the lesser resource settings and nations. There is also an area of insuring intact survival that is the expectation of the society of today. There’s another important area which is calling for attention, now and beyond 2015. And this is the domain of developmental origins of health and disease. We now know very well that the physiology prevailing in fetal life, distresses and the well-being as fetus has a profound implication in regard to growth, development, health, ill health, abnormal physiology in adolescence and adulthood. The nine months within the womb of the mother have profound programming that determines how the life goals of individual is as an adult. We now know very clearly that if the fetus is constrained, restricted in growth and in terms of well-being in utero, that this baby is predisposed to obesity, hypertension, heart disease, diabetes and so on. So we have an interesting situation here that we have a baby who was deprived in utero. If he survives, comes out as a small baby. And then if he does well and moves into adulthood, he has a second jeopardy and that is the risk of diseases such as the heart disease, hypertension, dyslipidemia, stroke and so on. Can this be modified? Can this be changed? Can this be averted? That babies not only are healthy in utero, not only they are healthy as fetuses, but also as children, also as adult. This is a Holy Grail in child health and adult health in…and in the context of non-communicable disease today. And post-2015, as it is now, this will be a major area of attention for all of us by way of research, by way of intervention design and by way of scaling up these interventions to, to avert this catastrophic pathway that you…that we now know operates in a very significant way in our lives. Health we believe is a driver of development. And that’s at the heart of the global and the national agendas beyond 2015. But healthy children of today are healthy adults of tomorrow. So if adults will drive development, then they have to be healthy. And healthy adults, the beginning is made by being healthy children. So beyond 2015, we have one part of the agenda of ending preventable deaths. And in this context we have summarized the, the…the trend and the situation by making a statement that child mortality has been halved since 1990. Further progress is linked to acceleration in newborn survival in particular and we offered reasons for it. Universal coverage of interventions with quality is the key to end preventable child mortality that stands today. Birth defects will need attention. Their prevention and correction should be a priority. As we move beyond survival, in post-MDG IV scenario we have to ensure that babies not only survive, but they’re intact in terms of their potential for growth and in terms of their neuro-development abilities. Childhood disability, autism, neuro-developmental problems will be an important priority in this period. Under-nutrition will continue to plague us for quite some time, but we now have an epidemic of over-nutrition in children looming large. And we need to apply our attention to both these areas of nutrition. Chronic pediatric diseases such as cancer and systemic iseases will require attention. And a huge effort will be required to find ways of insuring that fetal origins of adult disease could be averted or could be modified. So that children who survive the fetal life and early neonatal life eventually do…do not pick up non-communicable diseases such as heart disease, hypertension and diabetes. And this would be a very major challenge that we will have to put our heads together to energize the science and epidemiology and operations research to, to tackle this emerging area of a huge problem which will be a very important focus post-2015.

Maternal and Child Health I

Trends and Progress in Child Health

In this lecture we shall examine the trends in child survival and look at the priorities beyond 2015. The Millennium Development Goal IV relates to reducing child mortality. And the indicator for child mortality is the under-five mortality rate which is the number of deaths under the age of five per 1000 live births. So the target for MDG IV is to reduce by two-thirds the level of under-five mortality rate between the year 1990 as the base and 2015 as the timeline.


This is MDG IV which has triggered a great deal of action in saving children. And we made remarkable progress in reducing child deaths in recent times. Although the challenge continues to be huge, but there are successes that we can celebrate. Under-five deaths worldwide have declined by 50%.They have been halved between the year 1990 and the year 2013. In the year 1990 there were 12.7 million under-five child deaths. And this number now stands at 6.3 million in the year 2013. And we must be proud to, to appreciate the fact that despite population growth, there are 17,000 fewer children dying every day in today’s time.

But the other side of the challenge is that another 17,000 children under the age of five continue to die every day till this date. When we examine the progress in the context of MDG IV we also note that there are huge inequalities. Most child deaths occur in sub-Saharan Africa and South Asia. Children from poor families are twice as likely to die as those from rich families. And social determinants such as mothers’ education influence child mortality in a very, very big way. And diarrhea and pneumonia, two causes of child death which are eminently amenable to prevention and treatment continue to kill as many as two million under-five children in the world today.


Let’s examine the effect of the Millennium Development Goals on child mortality, which is truly phenomenal because global under-five mortality rate is falling faster than at any other time in the history of humankind during the last two decades. Since the year 1990, the under-five mortality rate worldwide has dropped by 49%. There were 90 deaths per 1000 live births in 1990 which is down to 46 per 1000 live births in the year 2013. And all regions except sub-Saharan Africa and Oceania have reduced the under-five mortality rate by 52% or more.

That’s very remarkable. And if you examine the global annual rate of decline in under-five mortality rate it is notable that there has been more than tripling in the annual rate of reduction in the under-five mortality rate. It was 1.2% annual decline between 1990 and ’95. It has now risen to 4% decline in the time segment of 2005 to 2013. And this has happened because the Millennium Development Goals triggered political commitment, greater resources for child health enabling research and evidence and above all a monitoring framework which drove action.413

We can see in this graph that there has been progress post-MDG in reduction in child mortality in all the regions of the world. But overall, despite these gains we as a global community shall not be able to reach the intended MDG IV goal. Only eight of the 60 burden countries would achieve the MDG IV goal in 2015 and that’s the unfinished agenda which will be now carried over to post-2015 scenario. This picture shows the distribution of under-five mortality rate worldwide. The blues are the regions with low under-five mortality rate, typically below 20. And the orange and red indicate areas where under-five mortality rate is very high. The red indeed is an under-five mortality rate of 100 per 1000 live births which is extremely high. You would see that globally areas with high under-five mortality rate are located in sub-Saharan Africa. And then there are intermediate areas in South Asia, the India subcontinent and parts of Africa. And the developed nations have much lower under-five mortality rate as you would expect. It’s also important to know that about half of under-five deaths occur in just five countries: India, Nigeria, Pakistan, DR Congo and China. And India and Nigeria put together account for one-third of the entire global burden. Clearly in order to address the unfinished agenda of child mortality there has to be a focus in five nations and in particular, India and Nigeria. It must be stated that immunization has had a vital role in bringing down child mortality in recent times.

414It’s estimated that since 2000 measles vaccine alone has averted as many as 14 million under-five child deaths. There is an important issue within the child health survival paradigm and that relates to the complexity of tackling neonatal mortality. Neonatal period is the period of infancy less than 28 days of life. The first four weeks of life are the newborn period or neonatal period. Neonatal mortality is the number of deaths per 1000 live births in the first four weeks of life. And this as you would note is a part of the overall under-five mortality as a sub-segment of that. Now neonatal mortality is tougher to tackle because it is influenced a great deal by maternal health and the care that the mother and the baby receive at childbirth,which is quite different from the care that is required for a child with diarrhea or pneumonia. Neonatal mortality has also declined in all parts of the world, as is obvious on this graph. The neonatal mortality rate in the year 1990 was 33 per 1000 live births, which is down to 20 in the year 2013. The absolute number of newborn deaths in the year 1990 was 4.7 million. It’s down to 2.8 million. That’s remarkable. So we have made progress in this regard. However when we see the progress in neonatal period vis-a-vis progress in reducing mortality after the neonatal period, the post-neonatal period something very significant stands out. That the progress in post-neonatal mortality reduction has been more remarkable, faster than that in the neonatal period. So it’s notable that the decline in neonatal mortality is lower than that in post-natal period. That means we have made less progress in reducing deaths occurring in the first four weeks of life. And that is therefore important for us to focus on as we move beyond 2015 agenda. We also note an epidemiological phenomenon that neonatal mortality component of under-five mortality has risen with time. Therefore future progress in child survival is linked to our progress in saving lives of infants in the earliest period of life, which is the riskiest period in humankind.

Human Rights and Gender Equality V

Gender Inequity 

Social inclusion is a challenge across groups racial groups, ethnic groups, linguistic groups. It’s a challenge across classes, especially when market forces and politics combine to widen the gap between the rich and the poor. And it is from time immemorial been a challenge, across the gender. Because from traditional societies until today in most parts of the world, women have faced massive barriers to their effective participation in the economy. To careers, to earning a living. To the right to own and inherit property, or to start businesses. Often this discrimination has been, legally imprinted, it’s in the books, in other words. Often it has been cultural barriers. Fortunately, this is changing and changing fast in many parts of the world. indeed, my own experience working in poor villages, in remote areas that are known to be traditional patriarchal communities where the men are in charge. Even in such places, one can observe dramatic social change before one’s eyes, where villages that, up until recent years, never contemplated that a young girl would complete a primary education and go on to secondary school are now actively pursuing, when given the opportunity, the education of their girls, not only through secondary school, but of young women into higher education, and then coming back as leaders of communities. And this in places with the reputation of being highly discriminatory in practice. So, we’re in an environment of flux, where age old practices of discrimination against girls and women are changing. Where ideas are changing, where economic demands are changing. And where economic possibilities for girls and women are changing in the right direction. Our purpose in sustainable development is to help that process to help insure that  societies make all opportunities open to girls and, and to women and thereby dramatically to improve their economic performance. Often this is a key step out of poverty. Often it’s a key step to overall sustainable development because when girls are educated, when women are empowered, many very important and powerful and wonderful things happen in society. That help not only the economic development and social equality, but also the environmental sustainability. And of course, the quality of governance in society. All of the aspects of sustainable development. The Millennium development goals, took on gender equality in a quite strong and direct way, MDG3, says that the goal was to promote gender equality, and empower women. And the specific target attached to that is in the education sector. To eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015. And this should be measured by the enrollment rates and the completion rates of girls compared to boys, and primary secondary and higher ducation. Let me emphasize the many many gains that will be achieved by honoring and fulfilling MDG3. First, of course is human rights. This is a basic question of human rights. Back in the Universal Declaration of Human Rights and in the International Covenant on Economic Social and Cultural Rights, as well as the International Covenant on Civil and Political rights. The rights of, girls and women are protected, absolutely as clearly and strongly as the, the rights of, boys and men. Gender equality is at the core of universal human rights from the very start. But the economic gains the practical implications of this, are enormously strong as well. And that’s why Jeremy Bentham, with his Utilitarian philosophy of the greatest good for the greatest number, would be the first champion of gender equality. Because, Jeremy Bentham’s utilitarian calculation would be very very clear that, it can’t work for society, as a whole to try to operate on half its brain power, half its human potential, half its investments in skills, training, and know-how. So the returns to investing in girls and women from a, quote unquote human capital point on view, the productivity of women in any sector of the economy, whether they’re farmers or workers in industry or workers, workers in the service sector. Of course, is greatly enhanced, as it is for men by more education, better literacy, numeracy,and advanced skills. But when investing in women, there’s a, an added dimension that is extremely important. Women are biologically and socially the main caregivers of children in the family. Of course, that’s a, a bit of a social phenomenon, but it’s also a very real phenomenon naturally, because the health of the mother in pregnancy, for example, is absolutely pivotal for the well being throughout the lifetime of of, of the child. We’re learning how intrauterine development, what happens to the, the fetus during pregnancy, can create the conditions for health or ill health throughout the, the entire subsequent, life. So if a mother faces discrimination, if she’s not eating properly, if she is not literate and able to secure access to antenatal care for example, the consequences can be devastating for the child. Of course, the mother then by best health practice, will be the exclusive provider of nutrition for the newborn for the first 6 months in breast feeding. And will play an important role of breast feeding and a complementary feeding basis, for another year or year and a half after that. Say for, the period from 6 months to 2 years. And so the mother’s health, her well-being, her knowledge of how to take care of the child is absolutely essential to the well being of the next generation. Invest in a girl, you’re investing in a mother. Investing in a mother, you’re investing in a child’s wellbeing in the next generation.  You are thereby having a fundamental role in intergenerational social mobility. And so that’s an added, decisive reason why gender equality is so essential, and why gender discrimination, discrimination against girls and women, has such a pernicious effect on societies, causing one of the most profound reasons why they may remain stuck in extreme poverty. We’ve also noted that, as the woman is empowered with more skills, as she is therefore enabled to enter the labor force, earn a decent income. It will be very much expected on a variety of reasons for the mother to have fewer children. To have a voluntary, rather quick reduction of the total fertility rate. One thing is that the woman herself will be empowered within the household. Sometimes, there’s a difference of opinion between the the, the mother and the father about how many children. The father says, as many as possible. The mother says, I’d rather have fewer, but in many traditional societies, the mother’s voice is very weak, in that negotiation if it even is a negotiation. But more importantly, both the husband and the wife very often agree completely, that if the mother is with skills, with education, especially, able to be in the labor force earning a decent income, then the opportunity cost of having more children is very, very high. The time taken out to raise the child may be very expensive in terms of lost income, and then it’s not a difference between the father and the mother, but rather an, an alliance of views that say, better to have fewer children, to invest more in the health, nutrition and education of that smaller family, and we’ve seen for so many reasons why that’s a better deal for the children themselves, and a better deal for the society in accelerating the end of extreme poverty. And in combining the economic development with the social inclusion in that next generation. We have new tools very good ones, and ever-improving tools to assess the state of gender inequality, and to make comparisons across societies in ways that can give good direction and impetus to societies to to do better.

751The United Nations development program beginning in 2010, has began to construct a Gender Inequality Index, which is a, a very handy and useful tool, like its Human Development Index, the Gender Inequality Index combines several different dimensions on a weighted average basis to give a Quantified Assessment of gender inequality that can be compared across countries. In this index, there are 3 different categories that are included. First, reproductive health. If mothers face very adverse conditions in, reproduction, then this is scored as a high degree of gender inequality. Two sub-categories to reproductive health, one is the maternal mortality rate. That is the rate at which mothers die in child birth or pregnancy, more generally. And the second is the adolescent fertility rate. The rate at which adolescent girls are bearing children. An indication of girls being forced out of their education into early marriage, and early child bearing. The second big category in the gender inequality index is, empowerment. And this is measured 2 ways in the index. One is by the share of total parliamentary seats, held by women. And the second is by the enrollment rates of women in higher education. In the third big category, of the gender inequality index is the measure of inequality of labor market participation. In some societies till today, women are simply not allowed to work in many sectors of the economy. This is especially true in the Middle East. Where women even very educated women, can’t work with men alongside them, or, are not allowed to work at all in particular sectors of the economy. In other places, labor force participation by women is very, very high. Public Policy plays a role here, not only in barring or allowing women to participate in particular sectors, but also in facilitating that participation. In Scandinavian countries, for example, with the social democratic ethos and the social welfare state. Every woman is afforded the right to have access for their child, in a quality daycare, financed by the state. And that enables mothers, even poor mothers who might otherwise not be able to afford the child care, to leave the children with the high confidence in a, a very safe  preschool environment, and often a preschool environment which does an excellent job of helping to prepare that young child for primary school education. Well, the result of putting together these 3 factors of reproductive health, of empowerment, and labor force participation, gives us a world map that you see in, in front of you. And the color code, as always, gives us an indication of the relative rankings of, of countries. What you can see is that, again, not surprisingly, because we’ve seen it again and again, northern Europe, and especially Scandinavia, Sweden, and Norway, Denmark, stand right at the top of, of the world league tables, in having the lowest gender inequality. A strong   representation of women in parliament, very high labor force participation, excellent coverage of reproductive health services. Then you have many countries that are a bit in the middle of the pack, still high. But not as high as Scandinavia. My own country, the United States is an example of that where conditions are relatively good on a global basis, and this is after decades of improvements of the legal status and the social status of women in the society and in the labor force. And then there are countries that are clearly places where girls and women continue to face a tremendous amount of discrimination. And you see this in West Africa, where the index scores are low.

752And you see it especially in the places where the inequality ranks the highest. This is in the Middle East and in West Asia. Typically societies, Islamic societies where women are not allowed to have an economic role where strict separation by gender is often enforced. As in many aspects of Saudi society. And where women’s participation in the political process is extremely low. so, this gender inequality index is rather vivid, in highlighting on a multidimensional basis, where progress has been high, and where progress is still very much needed if society is to reap the benefits of gender equality. We can see in more detailed way, the underlying factors in this index. Shown here is the participation rate by women in parliament. We know that in much of the world women are not well represented. This is true in a lot of Africa. It’s true in the Middle East. It’s true in large parts of Asia. At the other extreme, again, is the very high representation in northern Europe, and especially in Scandinavia. Remember that Rwanda is a remarkably exciting exception, to the general trends because there’s very very high women’s, representation in the parliament. More than 50%, the very highest in the world. And I think, causally a factor in Rwanda’s, large strides in social progress and social indicators in recent years. The next picture shows the labor force participation, differences across the world. The highest rates of labor force participation again are in the Scandinavian countries with all of the support of the social welfare system.

753The lowest rates are in the Middle East and North Africa, and Western Asia.and, and in South Asia as well, where women are not in the labor force, either for legal or for cultural reasons that anywhere close to the rates in other countries. These are tremendous lost opportunities. I’ve worked in a number of countries in this region. Often households are quite poor. The woman is quite skilled, maybe even with a college education, but not in the labor force, because of the prevailing ideas within the family, that it’s not right for the woman to be out of the house, for example. And I find it a bit frustrating, to see the family and the children suffering poverty, even when the opportunities are there, the skills are there.754

And with both the legal and social empowerment, the women would definitely find opportunities and a very gainful employment. Even in the high income countries where labor force participation has remained higher or has become higher, I should say, because it’s reflected a lot of social change over the last half century, there are still some significant gaps in the earnings of men and women. Women may take time out from the labor market, during child bearing and raising young children and this can cause them to suffer a strong loss of earnings, companies may discriminate saying we’re not going to invest in, in the skills or the promotion of women because we think they’re going to leave to raise families or simply because of social norms. And I’ve been shocked, I have to say, by sometimes what I’ve heard from CEOs in some parts of the world who just assume, them being, they being men, that women do not have a place in top management. But there is progress, and it’s important progress.755

In education, and, I think, with the good impetus of the Millennium Development Goals, there has been a narrowing of the gap at the primary level, the gap has nearly been closed, or has been closed in most parts of the world. Girls in primary school age are in school, they are completing school, they have comparable enrollments to boys. In some parts of the world, the girls have overtaken boys at secondary and tertiary level. This is an exciting development. Sometimes I’m wondering what’s happening to those young men, because they’re dropping out, the girls are staying in university. Latin America, which had a tradition and, and a reputation as a Makismos Society male-oriented is a place where girls have really done very, very well at secondary and tertiary education. And the gaps have been narrowed or fully closed or more, more than cloth closed, in recent years. And this is a, a very exciting development.

What can be done? What should be done when gender inequality is high and society is bearing the heavy cost of that? It’s clear that as always, a multidimensional process needs to be deployed because some of these barriers are legal, some are cultural, some are a matter of tradition and inertia.

Legal reform is often remaining a very important factor. Can women run businesses? Can they own property? Can they inherit property? Shockingly, the answer is often no, still today in the 21st Century.

Women’s representation in politics. Sometimes it’s a matter of women running for office and this becoming a normal practice. Some societies have, added quotas, that say that certain proportion of the votes on a proportional representation list of a party, must be taken by women. And this can have a very powerful effect of changing ideas, changing norms, and changing policies when the women are represented.

Government financial support for families, for maternity leave, for child care, play a huge practical role in the places that have had most success, especially in the Scandinavian context. The rest to the world needs to learn from that example. Early childhood development activities where government ensures childcare, preschool, health and nutrition programs for young children, obviously for boys as well as girls, is a big help for gender equality, because otherwise, the mothers are the caregivers, the mothers that don’t then have the opportunities either to provide the care that their young children need, or to be able to rejoin the labor market.

And finally it bears emphasizing that around the world till today, women face a terrible, terrible unspoken burden of violence. Whether it’s rape and and the kind of violence that once in a while gets reported, or it’s husbands beating wives and we know that this is a part of the real world around the world, UNICEF and other UN agencies have undertaken heroic efforts to bring this kind of violence against women and girls to light. To help advocate and press for changes of laws, and when the laws are on the books but the enforcement is not, to press for proper enforcement, and public leadership so that these laws are taken seriously, and they are enforced. In many traditional societies women were the property of their husbands and the property to beat if that’s how they saw fit. This inhuman approach that is a most fundamental denial of human rights has got to come to an end. It is a core part of gender equality. It is a continuing reality that must be brought to a close.