1 CLIMATE AND ENVIRONMENTAL CHANGES AFFECT THE HEALTH OF VULNERABLE INDIVIDUALS, IN PARTICULAR WOMEN AND THEIR CHILDREN

It has been demonstrated that healthier women and their children contribute to more productive and better-educated societies (Onarheim et al., 2016). Therefore, protection and promotion of women's health have an important impact on the development and economic performance of nations (Sen & Grown, 1987). Supporting healthy mothers before, during, and after childbirth certainly promotes a cycle of positive societal development (Barker et al., 2018).

The effects of climate and environmental changes (CEC) are being felt globally with serious consequences for health (Rocque et al., 2021); more susceptible individuals such as women and children are particularly impacted. Furthermore, disadvantaged people, including those at low- and middle-income countries (LMICs) are more vulnerable to the health impacts of climate change and the least likely to adapt (https://www.epa.gov/climateimpacts/climate-change-and-human-health-whos-most-risk).

A systematic analysis for the Global Burden of Disease Study (GBD 2015 DALYs and HALE Collaborators, 2016) showed that an inadequate diet, maternal malnutrition, air pollution, and unsafe water, all factors associated with CEC, were the leading health risks for women, largely contributing to disability-adjusted life-years associated with cardiovascular, respiratory, gastrointestinal, and other common infectious diseases. While CEC have a huge impact on human health across the world, this impact is not being felt equally (Adepoju et al., 2021; Berberian et al., 2022). A report commissioned by the Global Gender and Climate Alliance, an UN-NGO alliance focused on gender and climate change, found that women and girls often face disproportionately high health risks from the impacts of climate change when compared to men and boys in 68% of the 130 peer-reviewed studies analyzed (https://wedo.org/wp-content/uploads/2016/11/GGCA-RP-FINAL.pdf). These impacts include death and injury from extreme weather; food insecurity; infectious disease; and poor reproductive and maternal health (https://wedo.org/wp-content/uploads/2016/11/GGCA-RP-FINAL.pdf). Even more women and girls living in disadvantaged socioeconomic conditions are more susceptible to climate change effects (Onwutuebe, 2019).

CEC impact women's health at different levels (Girardi & Bremer, 2022; Figure 1). Specifically, CEC may significantly affect women's health during the preconception period, pregnancy, and the postpartum and lactation periods, compromising the health not only of the mother but also the offspring. Infertility, adverse pregnancy outcomes, changes in milk composition, exacerbated menopause symptoms have also been associated with CEC (Girardi & Bremer, 2022; Figure 1). Furthermore, prenatal exposure to air and water pollution showed negative effects on neonates' neurobehavioral development, suggesting transgenerational effects of CEC (Wang et al., 2019). Extreme temperatures have been associated with adverse pregnancy outcomes such as miscarriages, premature birth, stillbirth, low birthweight, and congenital abnormalities (Girardi & Bremer, 2022; Rekha et al., 2023). Heat waves, and cold snaps can be especially dangerous for pregnant women with underlying health conditions (Rekha et al., 2023).

Extreme cold and hot temperatures were also found to be significantly associated with an increased risk of mortality from coronary heart disease, with women being more at risk (Tian et al., 2012). An acute effect of ambient temperature on stroke and myocardial infarction risk has also been described with women at increased risk of stroke at colder temperatures (Lavados et al., 2018).

Climate change is also worsening air quality, which can exacerbate respiratory problems such as chronic obstructive pulmonary disease and asthma (Duan et al., 2020; Makrufardi et al., 2023). Women are more likely to have asthma than men and weather events more prominently increase the risk of asthma morbidity and mortality in women (Duan et al., 2020). Furthermore, poor air quality has been associated with the development and exacerbation of autoimmune diseases, thus affecting women more than men (Adami et al., 2022).

CEC are also increasing the spread of vector-borne illnesses such as malaria, dengue fever, and Zika virus, which are linked to adverse maternal and neonatal outcomes. In low and middle income countires (LMICs), women are usually responsible for collecting and managing water for their households, and they are also more likely to be pregnant or breastfeeding, which makes them also more vulnerable to the health effects of waterborne diseases such as cholera, typhoid, and E. coli infections (O'Kelly & Lambert, 2020). In addition, extreme weather events such as hurricanes, floods, and droughts can displace women from their homes, disrupt access to healthcare, and increase exposure to infectious diseases (https://www.niehs.nih.gov/research/programs/climatechange/health_impacts/weather_related_morbidity/index.cfm).

CEC-related stress can also impact women's mental health (Figure 1). Across the world, women are more likely to suffer from mental illness following extreme weather events (Cruz et al., 2020). Mental health professionals use the term eco-anxiety to refer to the stress and grief many feel about the climate and environmental crisis (Rothschild & Haase, 2023). Women tend to be more susceptible to the development of eco-anxiety, depression, and posttraumatic stress disorders associated with CEC than men (Heeren et al., 2022). According to the World Health Organization (WHO), women are the largest single group of people to be affected by posttraumatic stress disorder (PTSD) (https://www.who.int/news-room/fact-sheets/detail/violence-against-women). It is widely known that during climate disasters, women also suffer increased domestic violence, sexual intimidation, human trafficking, and rape, contributing to PTSD (https://www.un.org/en/chronicle/article/womenin-shadow-climate-change; https://wedo.org/wp-content/uploads/genderequaladaptation.pdf). According to a recent study, low socioeconomic status, poverty, scarce economic and social resources, and lack of social support also contribute to the exacerbation of preexisting mental health problems and the development of new mental disorders after facing a traumatic event due to climate change (https://www.un.org/en/chronicle/article/womenin-shadow-climate-change). In addition, socially, and culturally, mental health is still stigmatized in many parts of the world exacerbating mental health issues related to the climate crisis (Pescosolido et al., 2013).

Women's vulnerability to climate change stems from a number of factors—social, political, economic, and cultural (https://www.un.org/en/chronicle/article/womenin-shadow-climate-change; Arora-Jonsson, 2011; Fatouros & Capetola, 2021). According to a United Nations (UN) report, 70% of people living in conditions of poverty are women, and in urban areas 40% of the poorest households are headed by women (https://www.un.org/en/chronicle/article/womenin-shadow-climate-change). Women also face the major responsibility for water supply and energy for cooking and heating, and food security for their household, but only a small percentage, less than 10% of them, are landowners. Furthermore, women have limited access to and control of environmental goods and services (clean air, clean water); they also have little participation in decision-making and are not involved in the distribution of environment management benefits (https://www.un.org/en/chronicle/article/womenin-shadow-climate-change). In many societies, socio-cultural norms and childcare responsibilities prevent women from training and education. Illiteracy coupled with inaccessibility to resources and decision-making processes results in limited mobility and disproportionate effects of climate change on women's health (https://www.un.org/en/chronicle/article/womenin-shadow-climate-change). Consequently, women are less able to confront climate change, mitigate its effects, and adapt, all of which increase the vulnerability of women to the effects of CEC (Arora-Jonsson, 2011; Fatouros & Capetola, 2021; Figure 1).

In the United States, climate change is clearly exacerbating existing inequalities in women's health, particularly in communities with socioeconomic inequalities. People of color are more vulnerable to heatwaves, extreme weather events, and environmental contaminants (https://www.nytimes.com/2021/04/28/climate/air-pollution-minorities.html; Berberian et al., 2022; Butler et al., 2022; Deivanayagam et al., 2023; Tessum et al., 2019). Discriminatory policies and social, political, and economic inequalities also contribute to health disparities in women of color (Butler et al., 2022). Environmental racism, the unequal access to a clean environment and basic environmental resources based on race, has also been associated with adverse health in pregnant people and their offspring (Tessum et al., 2019). In the United States, Afro-American and Latinx people, who are more likely to live in areas with heavy pollution, are disproportionately victimized by these environmental hazards (Tessum et al., 2019). This “pollution inequity” affects women and children disproportionally and might explain in part the adverse pregnancy and neonatal outcomes observed in the affected groups (Bekkar et al., 2020). While air pollutants have been extensively associated with adverse pregnancy outcomes, a significant association was found between temperature increase and preterm delivery with the strongest associations observed in Black and Asian mothers (https://www.scientificamerican.com/article/heat-and-racism-threaten-birth-outcomes-for-women-of-color/). Historical disinvestment, discriminatory practices and policies, structural and environmental racism, and inadequate access to healthcare all uniquely and synergistically contribute to CEC-associated adverse health outcomes in women and their babies (Segal & Giudice, 2022).

2 ADDRESSING CLIMATE AND ENVIRONMENTAL CHANGES TO SUPPORT HEALTH EQUITY IN PREGNANT PEOPLE AND THEIR OFFSPRING

Transdisciplinary research to investigate the pregnancy exposome—all the external factors that a pregnant person is exposed to—may help address health disparities by identifying populations at greatest risk for adverse pregnancy and neonatal outcomes and for characterizing the underlying molecular mechanisms responsible for CEC-induced health complications. This approach can be scaled spatially and temporally to assist in developing and targeting interventions that are associated with local risk factors that underlie disparities in pregnancy-related morbidities and mortalities and other diseases. Moreover, geographically targeted interventions are needed to break the chain of disparity in marginalized populations and to support women's health decision-making practices and policies (Brown et al., 2019). Building political and economic power, as well as directly addressing CEC-related challenges, are also critical components of climate resilience (Brown et al., 2019). Actions focused on mitigation and adaptation are crucial and women are key to building climate resilience in communities (https://unfccc.int/news/five-reasons-why-climate-action-needs-women). Involving women is crucial to build climate resilience in communities. Effective communication and tailored methods to engage women in preventive strategies are necessary to ameliorate the deleterious effects of environmental and climate changes on women's health (Sbiroli et al., 2022). That communities are more successful in resilience and capacity-building strategies when women are part of the planning process has been reported by the UN (https://www.apha.org/-/media/Files/PDF/topics/climate/Guide_Section2.ashx).

It is time to increase awareness of the effects of CECs on women's health and their transgenerational effects in order to ensure that all people, regardless of race and ethnicity, are protected from the detrimental effects of CECs.

Climate change effects on women's health should be addressed with a focus on equity and inclusivity to ensuring that vulnerable and marginalized populations such as low-income communities, indigenous people, communities in developing countries, racial and ethnic minorities, refugees and displaced persons and persons with disabilities are not disproportionately affected (https://www.epa.gov/climateimpacts/climate-change-and-human-health-whos-most-risk).

To address the health impacts of CECs, the National Institutes of Health (NIH) recently launched the Climate Change and Health Initiative in response to Executive Order 14008: Tackling the Climate Crisis at Home and Abroad (https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/27/executive-order-on-tackling-the-climate-crisis-at-home-and-abroad/). The NIH Climate Change and Health (CCH) Initiative is a cross-cutting NIH effort to reduce health threats from climate change across the lifespan and build health resilience in individuals, communities, and nations around the world, especially among those at highest risk (https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/27/executive-order-on-tackling-the-climate-crisis-at-home-and-abroad/). The NIH CCH Initiative is led by an Executive Committee comprising the Directors of seven NIH Institutes and Center, one of which is the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

NICHD's presence on the NIH CCH Initiative Executive Committee and in the proceedings of the NIH CCH Initiative are intentional and serve to ensure the inclusion of pregnant people and children, as well as those with intellectual, developmental, and physical disabilities and those undergoing medical rehabilitation, in the Initiative's activities. Moreover, an important component of the CCH Initiative's Strategic Framework is an emphasis on health equity. The NIH as a whole and NICHD as an Institute purposefully recognize the special health vulnerabilities of certain populations such as children, older adults, persons with disabilities, and pregnant people. And as stated in the NIH CCH Initiative's Strategic Framework, “Prioritizing the needs of those who are most affected, often least able to effectively respond, and in large part, least responsible for the decisions that have led to this global environmental crisis, is vital to efforts to prevent or attenuate the most consequential health impacts of climate change” (https://www.nih.gov/sites/default/files/research-training/initiatives/climate-change/nih-climate-change-framework.pdf).

Importantly, a first-ever White House initiative on Women's Health Research was also recently announced. This initiative involves a transformative investment to close research gaps and improve women's health, particularly by addressing health disparities and inequities (https://www.whitehouse.gov/briefing-room/statements-releases/2023/11/13/fact-sheet-president-joe-biden-to-announce-first-ever-white-house-initiative-on-womens-health-research-an-effort-led-by-first-lady-jill-biden-and-the-white-house-gender-policy-council/).