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  1. 1. CURRENT HEALTH CARE CHALLENGES IN ADULT WOMEN'S HEALTH Narendra Malhotra Jaideep Malhotra Neharika Malhotra Bora
  2. 2. Women’s Health Issues—From Womb to Tomb
  3. 3. LIFE CYCLE OF WOMEN & HEALTH ISSUES INFANCY AND CHILDHOOD(0-9 YEARS) • Sex selection • Genital mutilation • Discriminating nutrition • Discriminating Health care
  4. 4. ADOLESCENCE ( 10-15 YEARS) • Early child bearing and abortion • STD & HIV Infection • Undernutrition and Anemia • Increase substance abuse
  5. 5. REPRODUCTIVE AGE(20-44 YEARS) • Unwanted / Unplanned pregnancies • Abortions • STI & AIDS • Pregnancy Complications • Anemia
  6. 6. POST REPRODUCTIVE (45 YEARS & ABOVE) • Gynecological Malignancies • Cardiovascular diseases • Osteoporosis • Osteoarthritis • Diabetes Mellitus LIFE TIME • Gender Violence • Enviornmental and occupational hazards • Depression
  7. 7. CHILDHOOD • Sex selective abortion • Female mutilation • Nutrition problems • Neglect • Cannot benefit from the services ADOLESENT/ADULT • Unwanted pregnancies, STDs • Sexual harassment/abuse • Turnpike sex • Smoking and substance abuse OLDERS • Increase in morbidity /problems on quality of life • Violence • Social pressure • Increase in morbidity
  8. 8. Healthy is… • Living well despite your inescapable illnesses and diseases. Total Wellness is… • The balance and integration of the physical, intellectual, emotional, spiritual, occupational, environmental, and social aspects of the human condition.
  9. 9. 7 Dimensions of Wellness Occupational Spiritual Emotional Physical Intellectual environmental Social
  11. 11. Women’s health a major development task for us An unfinished agenda in our country Challenges include reducing  Maternal mortality  Unwanted fertility  Infertility  Sexually transmitted infection ( HIV, AIDS,HPV)  Cancers  Female feticide & Violence against women.
  12. 12. Gender Based Health What Remains to be Improved in Women’s Health?
  13. 13. HARD FACTS MATERNAL MORTALITY • India accounts for 20% of maternal deaths. • Every minute one women dies of pregnancy and childbirth. • MMR is 330/ 100,000 live births.(Improving) still we are far from M D GOALS • Greater than Bangladesh & Pakistan
  14. 14. HARD FACTS POPULATION • Indian population is 1.2 billion. • India occupies 2.4% of world land. • 17.5% of world population. • One out of 6 people in world live in India. • 35% population below the poverty line.
  15. 15. HARD FACTS • The total number of HIV Rose from 8 million in 1990 to 34 million in 2010 • Prevalence of HIV in children- 3.4 million • People newly infected in 2010- 2.7 million • India has population of 1 Billion out of which half in sexually active group • Total number of people with HIV in India is 23.9 lakhs in 2009 with children accounting for 3.5% • Parent to child transmission: 5.4% of all routes
  16. 16. HARD FACTS FEMALE FETICIDE / GENDER ISSUE • Sex Ratio 940/ 1000. • Deficit of 3 crore women. • 60 million girls missing. • 2000 girls aborted everyday in India. • A girl child is killed and disowned every hour. • 35% of girls sexually abused between 12 to 16 years.
  17. 17. KEY ISSUES, POLICY & INTERVENTIONS Complication of pregnancy and childbirth are major cause of death and disability among women of reproductive age leading to high maternal mortality in India. PREVENTION • Improving diet supplimentation of pregnant and lactating women. • Health care providers and skilled midwife. • Strengthening referral system for effective management of complications. • Tertiary level centers fully equipped.
  18. 18. • Uncontrolled fertility / Sexually transmitted infection Unequal power between men and women in sexual relationship exposes women to involuntary exposure to sex, sexually transmitted infections and unwanted pregnancy.
  19. 19. PREVENTION • Empowering women with education and employment. • Family planning and sexual counselling. • Sex education of young adolescents. • Promotion of mutual consent and condom uses.
  20. 20. • Female feticide, Domestic violence, rape and sexual abuse occur in all regions, class and age. Affects 30% women worldwide.
  21. 21. “Have a son and your name continues!”
  22. 22. “Last year only one girl child was born in our village. All other families had sons” Kristof, Nicholas D. 1993. "Peasants of China discover new way to weed out girls." The New York Times, 21 July, 1.
  23. 23. Today, the vast majority in Asia, I in different populations, 60 million girls at least, otherwise expected to be alive, are missing due to gender selective abortion, infanticide or neglect .
  24. 24. Girl Boy 880 900 920 940 960 980 1000 1991 2001 945 927 1000 1000 Sex distribution for 0-6 years of age in India Girl Boy Oomman N, Ganatra BR., Sex selection: the systematic elimination of girls. Reprod Health Matters. 2002 May;10(19):184-8.
  25. 25. 117,4 116,7 90 95 100 105 110 115 120 Guangxi Zhejiang Sex ratio at birth in China- 1995 In CHINA: •21 of 31 (%67.7) provinces have higher ratio than 108.0 (expected sex ration at birth) •40 million single men by 2020 Gu B, Roy K. Sex ratio at birth in China, with reference to other areas in East Asia: what we know. Asia Pac Popul J. 1995 Sep;10(3):17-42.
  26. 26. PREVENTION • Law • Counselling • Support services • Medicare • Raise awareness • Mobilize support
  27. 27. Quality of care where health services are available and affordable NEEDS • Skilled staff / Professionals. • Effective client provider interaction. • Adequate supply of drugs. • Communication programmes. • Information to poor women and family • On health problems and importance of seeking care.
  28. 28. Focused Interventions • Ante- natal services • Basic Ante-natal care • Prompt detection/Management and referal of ante-natal complications • TT Injection • Iron and folic acid supplementation • Treatment of other associated infection
  29. 29. INTERVENTIONS • Strengthen the performance of overall health system specially district level. • Effective programs to promote increased utilization of maternal health services / EOC. • Women access to basic and comprehensive emergency obstetric care. • Availability of skilled birth attendant. • Information on maternal morbidity • Maternal death audits.
  30. 30. The Challenge of Obstetrics THE GREAT OBSTETRICAL SYNDROME
  31. 31. • Preterm labor • Preterm Rupture of membranes • Pre-eclampsia • SGA/IUGR • Fetal Death Obstetrical Disease
  32. 32. Disease Treatment Preterm labor Tocolysis Preterm PROM Expectant management Pre-eclampsia Antihypertensive agents IUGR Delivery
  33. 33. Safe Delivery • Skilled birth attendant • Timely detection and referral of intra-natal complications • Tertiary level Obstretics care Post-Partum Care • Family planning services • Monitoring for post-partum sepsis
  34. 34. Preventing unwanted pregnancy • Emergency contraception • Medical termination of pregnancy • Management of unsafe abortion complications • Post- abortal contraception planet earth is getting heavier
  36. 36. Today a basket of contraceptive choices available to women and various studies have shown that today even in the educated and developed world the first year failure rates are much higher in typical users than perfect users
  37. 37. “Contraceptives should be used at every conceivable occasion.” “It take many nail to build crib…only one screw to fill it…” What is the best way to prevent pregnancy?
  38. 38. Oral contraceptives • Perimenopausal women and oral contraceptives…can help smooth the ride of the ovarian roller coaster during perimenopause • Teenagers and young adult women…what’s old and what’s new in the world of oral contraceptives?
  39. 39. What are the benefits of OCs? Besides the obvious? • Reduce the risk of ovarian cancer • Treating dysmenorrhea • Treating endometriosis • Treating PCOS • Treating acne • Reducing estrogen deficiency symptoms in perimenopausal females • Continuous and extended cycle OCs may improve mood, reduce headaches and increase quality of life… • Long term effects of continuous regimens? Not known…fertility? Thromboembolism?
  40. 40. Sexually Transmitted Disease •Young women know very little information on STDs and because of the fear of being branded as sexual active they hardly try to learn information. • Woman equipping less power as a decision maker has resulted with late diagnosis and treatment.
  41. 41. Sex trade/tourism.. • 4 million people in sex abuse traffic is estimated in the world. • The revenue / year of organized criminal organizations is 7 billion dollars • 500,000 women and children for the sex trade is estimated to infiltrate into European Union countries in 1995.
  42. 42. Prevention of RTI & STI • Promotion of barrier contraception and distribution • Symptomatic management of RTI • Screening and treatment of sex-workers • Screening for cervical cancer
  43. 43. INTERVENTIONS • STI treatment education. • Social marketing of condoms. • Voluntary testing of HIV and counselling. • Women controllerd barrier methods for preventing STI / pregnancy.
  44. 44. Positive Health promotions • Public education program for – adequate nutrition – Decision on family size – Safer sex – Male participation – Education and employment • School Health Program – On reproductive health, dangers of substance abuse
  45. 45. The HPV vaccine in young women • Gardasil /Cervarix to prevent cervical cancer (HPV 16, 18) and genital warts (HPV-6 and11) • By the way there are over 100 types of HPV, 30 of which invade mucus membranes • Vaccinate girls between 9 and 26 • Is it 100% effective? HPV naïve, yes; already + HPV with above types? Not effective…
  46. 46. Can Gardasil /Cervarix prevent other cancers caused by HPV? • Squamous cell carcinoma of the rectum • Squamous cell carcinoma of the vagina • Squamous cell carcinoma of the mouth and throat When will boys get the HPV vaccine?
  47. 47. Before we leave the topic of STDs… • Forget teenagers for a moment… • The fastest rising group for STDs in U.S. is the over 60 crowd and now also in asian countries • HPV, HSV, HIV, GC, Syphilis • Why?
  48. 48. Violence and Women World scale: Today one of every 3 women are subjected to different forms of violence. (Heise, Ellsberg, Gottemoeller, 1999).
  49. 49. • "...any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their marital status, on a basis of equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field." (UN, CEDAW-1994) Discrimination against women
  50. 50. A systematic weapon : Rape • In South Africa every 83 second one woman is rapedA report by the U.N. (1996) • Special Rapporteur on Rwanda estimated that at least 250 000 women were raped during the genocide. • During the 1992-1995 conflict in Bosnia- Herzegovina between 20 000 and 50 000 women were raped WHO, Sexuel violence in conflict setting and the risk of HIV, 2004. Integrated Regional Information Networks (IRIN)
  51. 51. In the World • Completed rape at least once during the life of women completed rape USA 14-20% Canada: 40% • 12-25 percent of all adult women have been specified that they were victims of sexual haresment or attempted rape. Koss et al.,1997; Killpatrick et al.,1992; Randall and Haskell, 1995
  52. 52. Eradication of social problems • Law, public education and services to eradicate – Domestic violence – Sexual assault – Forced prostitution – Early childhood marriages • Strict regulation of use and abuse of medical technology
  53. 53. Let’s move into perimenopause… • Transitional state from reproductive years to postmenopausal years—length is variable--3 to 10 years • Ovary is on a roller-coaster ride • Variable menstrual cycles (greater than 7 days, different from normal) • FSH is rising • Late perimenopause—greater than 2 skipped cycles and an interval of amenorrhea (greater than 60 days)—vasomotor symptoms begin • Final menstrual period (hallelujah!)—no periods for a year • Welcome to your postmenopausal years
  54. 54. Older Ages and Women • The expected duration of life in our country, the birth (DIE-2000) -71.0 years for women -66.4 years for men • At least 35 countries in the world in the birth of the expected life span for women has reached 80 years. Women live average 6-8 years more than men. (WHO)
  55. 55. Older Ages and Women • A long way with diseases .. Health care access problems In our country, all illiterate population over 65 years is 24% and 74% are women. Elderly women than elderly men are poor and lack social protection.
  56. 56. Ladies! Expose yourself! And your kids!!! • 10-15 minutes every day or every other day! • Lighter skin? Less time. Darker skin? More time. • Obviously if you have had skin cancer or are at high risk for skin cancer, the prudent recommendation is to take vitamin D orally. • Other cancers that may be prevented by vitamin D? Colon cancer, ovarian cancer, prostate cancer • Tell your husbands to get those prostates out in the sun!
  57. 57. Don’t forget your calcium and vitamin D • The Coppertone girl
  58. 58. To summarise…… Women Health requires • Favourable health policies. • Strengthening and expanding health services. • Positive attitude and approach. • Long term basis … improvement in nutrition, education and employment opportunities for women for positive impact on health.
  59. 59. Vision Empowered people choose the number and timing of their births, using methods and providers of their choice. Women empowerment,education,employment,environment
  60. 60. some of our social initiatives
  62. 62. Helpful Websites  Go Red for Women  Centers For Disease Control  The Way To Eat  The National Women’s Health Information Center  The Mayo Clinic  National Cancer Institute  National Osteoporosis Foundation  Womens Health  American Heart Association  American Stroke Association  National Stroke Association  Susan G. Komen  SMRITI  FOGSI
  63. 63. Questions
  65. 65. THANK YOU