**3. Poverty, inequality and disparity in reproductive health: evidences about the Chilean case**

The concept of health inequalities has been defined as "the differences that in health are not only unnecessary and avoidable, but also are considered unfair" [20–23] and, inequity is considered as any reducible difference or inequality, related to heterogeneous life conditions tied up with incomes differences, even when the poorest have equality of access to health services [21, 24, 25]. The perspective of social, cultural and political determinants of health has allowed to understand the mechanism underlying as substratum in the "causes of the causes" and in the routes or production processes of the inequities [22, 26]. That is how it is detected the interaction between health and the social circumstances within the

#### *Poverty, Reproductive Health and Public Health Policies in Chile DOI: http://dx.doi.org/10.5772/intechopen.96100*

area where people live, where poverty has been described as the most potentially toxic risk factor for the population health, effect which shows from early ages, reproduce during adult life and transfer to following generations [10, 23, 24, 27]. Scientific evidences have demonstrated that there is a relation between the income gap between rich and poor and the mortality rate and physical and mental health problems [10, 28], which affects the possibilities and opportunities for people development. There is an unequal distribution of the mortality rate in Chile, because the child mortality in children born to mothers with no education have significantly lower survival rates than those born to mothers with secondary or higher education [29]. Is one of the reasons that justifies that medicine alone cannot solve people's health problems, since 56% of the variations of health conditions are explained by social and ecological factors [23, 30].

The condition of women is a political, economic, and social issue and the inequalities registered must be explained by social, economic, and cultural phenomenon [31]. The inequality consists of a systematic exclusion from power, resources, and opportunities [17, 31]. The attempt to identify the factors that explain women social and economic vulnerability should start examining first the impact of developing models, and some of their components, on the gender social inequalities [31].

In the 1960s, the standard of living of the richest and the poorest people was compared and it turned out that the poor lived thirty times worse than the rich. At the end of the 1990s, the poor already lived eighty-two times worse than the rich. The differences between the rich and the poor are constantly increasing. They appear already on a family level, but they are also reflected on the fate of children and, especially, women. The efforts to visualize the inequalities between men and women are more recent [17]. The study of differentiated impacts that economic policies on men and women have had, and currently have, has demonstrated that regardless of women's social group, they have created a continue discrimination of women compared to their male colleagues [17]. The income distribution is based on an imposed cultural contract, which highly values motherhood and naturalizes the unpaid domestic work of women.

Global incomes separated by sex show that, although the gap is growing [19], the earning capacity remains minor for women, while their contribution to the reproduction continues in the dark statistics [32]. There is a welfare and mercantilist concept of the economic models that create a strong "feminization of poverty" and exclusion of the incorrectly called "ethnic minorities". Women represent an increasing percentage of those people considered to be poor. In a world that is heading towards the globalization, women's poverty creates enclaves of people in need in the midst of wealth and originates growing pressure on the developed world, whether generating expensive humanitarian crisis or trigger–-for the first time in history–-a surge of women migrating without their husbands and children to look for a job in richest countries, which has a significant impact in the family and society. The available evidence suggests that the proportion of poor is higher among the family groups with a female head of the household, especially when the woman has small children. In Latin America, single female-headed families are largest in the category of low incomes (homeless) [33].

Regarding reproductive health, women's greater social vulnerability and economic precariousness during pregnancy is associated to higher stress levels and anxiety and, as a consequence, higher incidence of prematurity, low birth weight, early weaning, poor child care quality, higher rates of disadvantage, child developmental delay, poor child care quality, attention deficit and hyperactivity, language problems, poor social competences and lifelong behavior problems, which is the first link in the transmission and reproduction of inequalities of health, welfare

and human capital [34–36]. In addition, it has been pointed out that coronary heart disease, type 2 diabetes, vascular accidents, hypertension, and higher rates of adult mortality are related to the history of fetal malnutrition and low birth weight [35]. Moreover, the reproductive, neonatal, mental, and family health deteriorate when women have precarious employments and pregnancies without social security, informal and insecure houses, low schooling, psychosocial risk, absence of partner at home and high dependency rate [35].

In Chile, through surveys performed in vulnerable women's groups, it was possible to obtain an in-depth knowledge of the experience of motherhood in extreme vulnerability conditions [37]. The women's stories showed a motherhood perceived as a negative event, unexpected, assumed with resignation and anguish which, for some authors, generate internal disorganization, break of bonds and depression [37]. Feelings such as discomfort, despair and loneliness emerged, both for being an unforeseen pregnancy and for being unexpected and that is consistent with the precariousness of the social support to teach women on how to take care in a context of social vulnerability [37, 38]. Women describe a life condition where the social construction of hopelessness, invisibility and social exclusion have been naturalized, a condition which affects the practice of motherhood, childcare and sexual and reproductive rights [37, 39]. The situation of invisibility is not an isolated fact, because it occurs in a condition of poverty with a gender perspective. Women perceive a distance between them and health personnel, which they feel as lack of understanding of their condition of vulnerability and poverty, due to the asymmetrical power relations and stigmatization of guilty for their pregnancy [39]. The more difficult it is for a woman to carry out motherhood and children care, the further she is from a project that justify the exercise of her reproductive rights [40, 41].

In the context of reproductive health and poverty, some relevant facts for women are domestic violence (DV), unplanned pregnancy, immigrant status, Mapuche ethnicity and teenage motherhood.

#### **3.1 Violence against women**

Is a global public health problem [42] and its prevalence is higher in developing countries [43]. Pregnancy is an especially vulnerable period in terms of violence, affecting women's reproductive capacity [44], since pregnant women have an increased risk than no pregnant women [45]. Prevalence studies about DV have reported figures varying from 0,9% to 41,6,0%, being more severe or moderate post birth [42, 46]. One out of every five pregnant teenage women and one out of every six pregnant adult women have reported violent experiences during pregnancy. Violence during pregnancy becomes four times probable if the pregnancy was unexpected or unplanned [47].

The impact of domestic violence on the results of reproductive and neonatal health may be explained by the existence of indirect mechanisms that induce risks like psychological and social stress, which would be like underlying factors of adverse obstetric and neonatal results. It has been reported that biomedical risks, for women with experience of domestic violence, are related to pregnancy hypertensive states (PHS), intra-hepatic cholestasis of pregnancy (ICP), and in case of current violence with urinary tract infection, intrauterine growth restriction, preterm delivery and ICP [48]. Other associated risks are poor weight gain, vaginal, cervical or kidney infections, abdominal trauma, bleeding, exacerbation of chronic diseases, complications during labor, delay in the prenatal care, depression, suicide attempt and, even death [42, 43, 46]. At the same time, violence determines disturbances in the interaction between mother and son, which increases the possibility of negligence, abuse and neglect during the first year of life. The Biomedical risks

for neonatal health related to domestic violence are low rate of gestational age, and higher variability of anthropometric indicators such as weight and length at birth. It was observed 2.8 higher risk of small for gestational age newborns in relation to those of women without recognizing experiences of violence [48].
