Health of women and children is central to covid-19 recoveryBMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n899 (Published 14 April 2021) Cite this as: BMJ 2021;373:n899
- Neena Modi, professor of neonatal medicine1,
- Mark Hanson, British Heart Foundation professor
- 1Imperial College London, Chelsea and Westminster campus, London SW10 9NH, UK
- Institute of Developmental Sciences and NIHR Biomedical Research Centre, University of Southampton, Southampton, UK
- Correspondence to: N Modi
Covid-19 has widened longstanding health and socioeconomic inequalities affecting women and children. The effects will be seen for many years because the wellbeing of women and children is central to population health and resilience across generations, which in turn affects sustained economic recovery.
Scientists, societies, and economists have long marginalised the health and wellbeing of women and children, but the pandemic has forced new behaviours and ways of working and brought about the collapse of industries that previously seemed invincible. This has led to a questioning of previous norms and provides a window of opportunity for change. Here, we examine the scientific, rights based, and economic rationale for post-pandemic investment in the health and wellbeing of women and children.
Follow the science
Before covid-19, governments around the world were waking to the financial and humanitarian costs of worsening population health from non-communicable diseases (NCD). Research over recent decades shows clearly that parents’ nutrition and health and a child’s early life experiences and exposures play an important part in establishing risks for later NCD.1 These exposures alter the biology of the developing fetus and child through mechanisms that may have promoted survival in our evolutionary past but are counterproductive in the face of the sedentary lifestyles and fast food challenges of our contemporary world.2
The effects are substantial. Children born too soon, too small, or to a mother who is underweight, overweight, or has diabetes are 1.5-6 times more likely to develop NCD than those born full term with a healthy birthweight or to a healthy mother.3 Globally, preterm birth rates range from 5-15% and are rising, around 10% of full term babies are growth restricted, and in many countries, 50% of pregnant women are overweight or obese.4 Thus overall, about half of all births represent children placed at risk of NCD from early life.
Early life circumstances also matter. For example, a child born full term in the most deprived areas has a similar likelihood of having a speech and language problem as an extremely premature baby in the most affluent areas.5 We are already beginning to see the consequences of a suboptimal start to life on population health, with life expectancy in the United States, for example, now falling, reversing historical trends.6
These fundamental biological processes during early development shape us all, initiating individual trajectories of health and resilience.7 However, insufficient recognition is holding back policies to improve the health and wellbeing of women and children that should lie at the heart of NCD reduction. Current national and global policies to reduce NCD focus on treatments rather than establishing healthy lifecourse trajectories.8 Thus, for example, the global action plans for NCD sponsored by the World Health Organization and the World Bank give little attention to the developmental origins of NCD and the role of maternal and child health.910 This is despite evidence from previous global socioeconomic crises of the detrimental consequences of poor maternal and child health on population health.11 Intergenerational physical and mental ill health leads to progressively poorer population health, reduced productivity, rising costs, and adverse economic impact.
Gender, age, and other societal inequities are part of the wider rights issues raised by the pandemic. Containment measures have disrupted children’s education, safety, and food security, leading Unicef to publish a six point plan for government actions to avert a “lost covid generation.”12 The effects on black and minority ethnic communities have also been widely discussed. However, the broader effects of widening gender based inequities seem insufficiently recognised, and their discussion in many respects reflects an outdated, paternalistic view of social justice. Thus, the Lancet Covid-19 Commission13 flagged the gender dimension in terms of the need to protect vulnerable women, not as an issue of fundamental human rights, let alone the centrality of women to economic recovery.
Another salutary example is that despite longstanding recognition of the importance of including pregnant and breastfeeding women and children in research,14 initial covid-19 vaccine trials excluded these groups.15 The consequence is that the efficacy and safety of the vaccines remains uncertain for a large proportion of the population. Moreover, as women of reproductive age form a large part of the healthcare workforce, and children can be vectors of transmission, the failure to include them in research is likely to have multiple adverse downstream consequences.
Many commentators have likened the challenge of economic recovery from covid-19 to the aftermath of the second world war, which led to the formation of WHO and the International Covenant on Economic, Social and Cultural Rights and established the right to health as a universal principle. However, current policy seems to regard health primarily as the product of healthcare and has led to the call for “universal healthcare” taking precedence over “being healthy.”16
Being healthy involves many factors, of which healthcare is arguably the least important. It starts in early life and forms part of the transmission of opportunity, or disadvantage, across generations. The injustices and inequities that exacerbate the likelihood of poor physical and mental health through poor education, parenting, air quality, diet, and environmental toxins interact, are additive, and are often perpetuated and amplified across generations. Sadly, the focus on healthcare, rather than being healthy has allowed policy makers to avoid investing in policies that deal with these wider determinants that can improve the health and wellbeing of women and children and break the pathway of transmission of disadvantage.
Value and values
The current focus of most governments is to restore prosperity after the economic recession caused by covid-19. Threats to the economy from climate change and environmental despoliation have also gained increasing attention over recent decades. Future generations will come to view this pandemic as a fundamental consequence of the Anthropocene era,17 linked to the long term damage caused by the extractive economic models and associated market driven policies of the 19th and 20th centuries. These included the marginalisation and exploitation of women and children, and extraordinarily, the negative valueplaced on their wellbeing by failing to recognise the relevance of this to population health. This continues—for example, women have been more likely than men to be furloughed18 and domestic violence against them has increased during lockdowns.19
The lockdown restrictions imposed to control covid-19 allowedmany people to work at home, exposing the importance and unequal distribution of unpaid domestic work. During lockdown women continued to carry more of the burden than men of home schooling, childcare, and other activities that are unremunerated but nonetheless support economies. Unlike paid work, breastfeeding and parenting are not included in gross domestic product (GDP), even though they are powerful determinants of long term health and wellbeing.20
An analysis by the Organisation for Economic Cooperation and Development suggests that the inclusion of unpaid household work alone would increase GDP by 15% to 70%, depending on the country and method of calculation.21 Such ideas are not new. They have been attributed to comments made by US senator Robert Kennedy in the 1960s22 and have a rich basis in feminist scholarship.23 Data from the latest Global Burden of Disease study24 emphasises that economic progress should be measured using the sociodemographic index, which relates to healthy life expectancy, rather than GDP.
The former governor of the Bank of England, Mark Carney, has recently argued that radical change is required to build economies and societies based on human values rather than market values.25 We suggest that human values, especially the value which societies put on maternal and child health, should define so called “market values.”
The basis for an economic framework that incorporates factors that strengthen maternal and child wellbeing already exists. For example, UN sustainable development goal 5 calls on governments to “recognise and value unpaid care and domestic work through the provision of public services, infrastructure and social protection policies.” However, the added clause “as nationally appropriate” allows policy makers to avoid commitment, especially during times of financial constraint.26 Countries also need to do more than “recognise and value” this work. Assigning unpaid work a monetary value would enable its inclusion in productivity metrics. This would make it visible and its worth to economies measurable. Recovery from the pandemic offers opportunity to avoid returning to the failed model and develop a new economic framework that measures and incorporates contributions to maternal and child wellbeing.
Bold new vision
Putting women and children first meets three important policy prerequisites. First, there is strong and undisputed scientific evidence for causal relationships between maternal and child health and population health. Second, there are powerful rights based justifications to end age and gender based inequities. Third, the importance of population health to the economy is clear.
The effect of the pandemic in widening inequalities has received wide attention in reports such as the Marmot review Build Back Fairer.27 However, history tells us inequalities are likely to persist unless policy makers understand the causal pathways between disadvantage, poor health, and damage to economic resilience and that they can be broken by improving maternal and child health. Achieving a future where governments see a healthy population as both a moral responsibility and the cornerstone of prosperity requires an economic framework that measures and assigns value to actions that initiate healthy life-course trajectories. The collapse of long established industries such as in the travel and hospitality sectors, as a result of covid-19 offers opportunity for bold new policies and investment predicated on an economic model fit for the 21st century.
Such ideas are surfacing.282930 The Pan-European Commission on Health and Sustainable Development (the Monti commission), which includes political, financial, economic, social, policy and medical expertise, will be delivering recommendations towards the end of 2021 on investments to improve the post-pandemic resilience of health and social care systems. The Wellbeing Economy Alliance (https://wellbeingeconomy.org) aims to shift global economies to focus on “sustainable wellbeing,”and the Hawaiʻi State Commission on the status of women has produced a plan for recovery that argues, “Rather than rush to rebuild the status quo of inequality, we should encourage a deep structural transition to an economy that better values the work we know is essential to sustaining us.”31 Medical and scientific communities can add to the case for replacing the destructive, inequitable economic and societal frameworks of the past with practices based on valuing health and wellbeing, recognising maternal and child health as a cardinal mediator of humankind’s resilience to challenges and chances for a sustainable future.
Strong scientific evidence exists for maternal and child health and wellbeing having a causal effect on trans-generational population health, adult prosperity, and societal resilience
All these factors are central to sustained economic recovery after covid-19, providing strong justification to end age and gender based inequities
The effect of the pandemic on longstanding industries offers opportunities to implement new policies and ways of working
These should be predicated on an economic framework that assigns measurable value to actions that improve the health and wellbeing of women and children
Contributors and sources: Both authors contributed equally to this paper, which arose out of discussions over several months. Both authors have been involved in research and policy initiatives relevant to mother and child health. NM is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: NM reports grants outside the submitted work from the National Institute for Health Research, Medical Research Council, British Heart Foundation, Health Data Research UK, HCA International, Nestle, Shire Pharmaceuticals, Prolacta Life Sciences, Chiesi Pharmaceuticals and March of Dimes. NM is a member of the Nestle scientific advisory board, the president of the UK Medical Women's Federation, vice-chair of the strategy and advocacy committee of the Medical Women's International Association, immediate past-president of the UK Royal College of Paediatrics and Child Health, president-elect of the British Medical Association, patron of Keep Our NHS Public, and trustee of the charities TheirWorld, David Harvey Trust, Action Cerebral Palsy and Academy of Medical Sciences. MH reports grants outside the submitted work for British Heart Foundation, European Union Horizon 2020 LifeCycle Programme, and The Royal Society. The views expressed are the authors’ own.
Provenance and peer review: Not commissioned; externally peer reviewed.
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