Advocacy to improve health

Advocacy is ‘speaking out on behalf of a particular issue, idea, or person’, acting as a catalyst for change. To achieve the targets described in this book requires advocates and champions. It is therefore an essential component of the work of all health professionals to ensure that services work better for the population and for patients. Effective advocacy requires diplomacy, persistence, an understanding of how systems work, and an ability to work with disciplines outside medicine. The targets of advocacy have traditionally been healthcare focused, but considering the wider social determinants of health is essential. An understanding of social and political science is essential when thinking of the best ways to advocate for and improve a situation. In this chapter, we summarise a toolkit for how to advocate to improve health, and provide two real-life case studies on the commercialisation of infant feeding and child abuse in Mumbai.

Child injury, maltreatment, and safeguarding

Child maltreatment and intentional injuries are major public health challenges, incurring huge costs for both individuals and society. Violence is an abuse of power comprising acts of commission and omission, and can have lasting consequences for survivors. It includes abuse in the home and collective violence, resulting in children being orphaned or abandoned, forced to become child soldiers, ‘street kids’ or trafficked for domestic work or sexual exploitation. In addition to physical violence, emotional abuse can involve bullying and seeing or hearing the ill treatment of another, such as a child witnessing intimate partner violence. Child maltreatment rates are higher in countries affected by war, famine, social inequality, and economic transition and in communities with marginalised indigenous and disabled groups. Comprehensive interventions, based on child rights principles, are needed that focus on prevention, detection, and intervention.

Child nutrition

The ‘first 1000 days of life’, covering conception to age two, is recognised as a critical period for the growth and development of young children. Evidence suggests that good nutrition in early life can help adults become taller, stronger, healthier, and more intelligent and, thus, more economically productive, with many benefits for the next generation as well. The concept of a ‘window of opportunity’ is essential for designing intervention strategies. However, how to promote healthy growth in the first 2–3 years, without provoking excess weight gain and adiposity, is a major challenge to public health policymakers. This chapter addresses the global burden of childhood under and over-nutrition, highlighting the main public health interventions for improving child nutrition.

Congenital disorders

Congenital disorders encompass a wide range of conditions (e.g. genetic disorders, foetal disease, and developmental disorders) that occur before birth and are an important contributor to mortality and morbidity worldwide. Congenital disorders can be identified at different life stages and effective health services take a holistic approach to their care and prevention. This involves both population health and specialist services across the life course. Systematic collection of data on the types, prevalence, severity, and outcomes of congenital disorders, along with analysis and interpretation of data helps to inform appropriate planning of care and preventative services and activities. Important concepts in relation to congenital disorders, prevention activities, and key challenges to their effective delivery are described in this chapter.

Intrapartum-related events affecting the newborn

This chapter addresses the causes, burden, and interventions for intrapartum-related events, or ‘birth asphyxia’. Intrapartum-related neonatal deaths are among the leading causes of under-five child deaths, and account for 26% of all newborn deaths. An estimated one in ten babies will need some help to start breathing at birth. Approximately 98% of intrapartum deaths occur in low- and middle-income countries, as high rates of home births and unattended deliveries remain challenges. High-risk pregnancies should be monitored closely and deliver in facilities with capacity for obstetric and neonatal management. Here we present the evidence for interventions for primary and secondary prevention (including obstetric care, neonatal resuscitation), and tertiary prevention for infants with acute complications.

Strategies to improve maternal and reproductive health

Many single interventions are available to enhance access to and quality of maternal health services but none alone can significantly reduce the rate of maternal mortality in a population. Factors such as rapid urbanisation, political unrest, changes in fertility rates, or growing numbers of institutional births, change the scenario of maternal risk and call for reappraisal of a country’s maternal health strategy and programme priorities. Strategies to improve maternal health, such as the Global Strategy for Women’s and Children’s Health, act as a roadmap to ensure that every woman and her newborn survive. It is vital to consider both the whole reproductive, maternal, neonatal, child, and adolescent health continuum of care, and all levels of healthcare, from community to tertiary settings to improve maternal health. Furthermore, women must be empowered to take decisions about their own health and access to quality healthcare services must be improved.

Maternal morbidity

Maternal morbidity describes complications that have a significant effect on women during and after pregnancy, and are a leading cause of ill-health among women of reproductive age, especially in low- and middle-income countries. With the introduction of the new Sustainable Development Goals, the scope of global maternal health targets has been expanded, moving from a focus on preventing maternal mortality to formulating targets and emphasising the importance of maternal health and wellbeing. This chapter introduces the new concept of maternal morbidity, suggests how this relates to maternal mortality, and summarises what is known about the burden of maternal morbidity globally and what interventions and research are needed to improve maternal health during and after pregnancy, with an emphasis on the context of low- and middle-income countries.

Sexual and reproductive health

Ensuring sexual and reproductive health and rights (SRHR) and empowerment of girls and women are essential to improving individual-level and population-level outcomes globally, and to achieving the Sustainable Development Goals (SDGs). Target SDGs for SRHR include access to a range of (SRH) services, reproductive rights, and ending discrimination and violence against women and girls. SRH services should be provided in a holistic and integrated package to ensure increased access to modern contraceptives, maternity care, prevention, and appropriate treatment of infertility, comprehensive sexuality education and the prevention, diagnosis, and treatment of sexually transmitted infections, reproductive tract infections, and HIV. Addressing these is particularly crucial for ending the HIV/AIDS epidemic, where women are at greater risk of infection compared to men due to a greater physical vulnerability, which is further compounded by gender inequality, poverty, and violence.

Introduction to maternal and reproductive health

Pregnancy and childbirth have a huge impact on the physical, mental, emotional, and socioeconomic health of women and their families. Poor maternal health remains a significant problem both in developed and developing countries. While motherhood offers a rewarding experience, for too many women it is associated with suffering, ill health, and even death. Many women, including adolescents, die from preventable causes related to pregnancy and childbirth. Maternal deaths are classified as direct or indirect. Direct causes are those related to obstetric complications of pregnancy, labour, delivery, and the postnatal period, while indirect causes are those relating to pre-existing medical conditions that may be aggravated by the physiological demands of pregnancy. Opportunities to prevent and control diseases occur at multiple stages of life. Identifying which groups of women experience poorer physical and mental health, and understanding risk factors, will enable midwives and other health professionals to better support women before, during, and after pregnancy and childbirth.

Strategies to improve adolescent health

Adolescents have previously been neglected on the global health agenda, but recent progress has been made with the inclusion of adolescents in the UN Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016-2030), and the landmark 2017 document the from WHO and other agencies, AA-HA! Guidance, designed to support in-country implementation of strategies for adolescent health. Investing in adolescent programmes yields a triple return; improving the health of the adolescent, of their future selves as adults, and then of their children. As the main determinants of adolescent health are outside the specific remit of the health sector, interventions must be delivered by multiple sectors, including education, social protection, roads and infrastructure, and employment, and be targeted more widely at various levels of influence; the individual and family, community, school, media and technology, environment, and legal frameworks. Adolescent participation and engagement in programmes is key to their success.