3.1.1. Inadequate Access to Food Supplies at the Household Level

In the first case, severe malnutrition in pregnant women can occur because of climate change events such as droughts, flooding, and landslides. This malnutrition is because, under such severe weather conditions, the quantity and quality of food produced become constrained. The limited availability of nutritious food due to changes in agricultural production and low household income often creates an unpredictable environment for the foetus to grow and develop.

To cope with extreme cases of hunger, pregnant women in the Caribbean who are part of low-income households may change their consumption of foods to one which may be high in calories, but low in nutrients, also known as nutrient-poor foods because of their cheaper cost (Bloem et al. 2010; Darnton-Hill and Cogill 2010). Such an unexpected change in the quality of pregnant women's diet can lead to micronutrient deficiencies, which are associated with higher birthweight/large gestational age, maternal obesity, and gestational diabetes (Zhu et al. 2019).

The unpredictable nature of changes in the weather was also noted to affect pregnant women in rural Uganda, for example, who are part of indigenous communities. Even though there was a marked improvement in their access to antenatal healthcare, the overall maternal and child health amongst their people declined and worsened as food insecurity persisted when compared to non-indigenous women (Bryson et al. 2021). Nevertheless, regardless of the origin, such food insecurity will likely result in less diet diversity in the long run and a rise in maternal health disorders in the Caribbean, which are associated with poor diet and nutrition (Niles et al. 2021).

#### 3.1.2. Maternal Mental Health (MMH) Costs

In the second case, according to Engle (2009, p. 963S), maternal mental health is "a state of well-being in which a mother realises her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can

make a contribution to her community." Often conditions associated with extreme temperatures, such as heat stroke and dehydration, can exacerbate pre-existing mental health conditions experienced by some pregnant women, such as postpartum depression, maternal dysthymia, pregnancy, and postpartum anxiety and obsessive compulsive disorder (OCD), as well as birth- related Post-Traumatic Stress Disorder (PTSD) (Waqas et al. 2022).

In cases where such conditions exist, they can affect the developmental outcomes of the foetus in many direct ways, such as interrupting the bonding process between mother and baby, breastfeeding, and changes in the cognitive ability of the baby (Smith et al. 2022; Juvrud et al. 2021). Notwithstanding these factors, pregnant women and single parents from low-income households in the Caribbean may suffer from higher rates of MMH disorders. Pregnant women and single parents in the Caribbean reside in low-income households with more than one dependent relative and children. Household resources may be diverted from accessing additional forms of care, such as counselling and social services, to satisfy primary needs, such as paying utility bills and buying groceries.

In addition, pregnant women who suffer from MMH conditions may access less treatment because the topic of mental health in the Caribbean carries a great deal of stigma. Consequently, even though healthcare institutions in the Caribbean provide such services, and while it may be essential to maintaining the health of some pregnant women, these services may not be used due to fears of discrimination by family, peers, and community members. The internalisation of shame by pregnant women brought on by MMH disorders and the associated stigma can worsen these conditions, making the condition more prevalent in the Caribbean.

#### 3.1.3. Biological Infectious Diseases

In the third case, there is a class of diseases transmitted by biological vectors, which can also be transmitted from mother to baby. The World Health Organization (WHO) (2020) has listed nine vectors, that is, mosquitoes, aquatic nails, fleas, ticks, lice, blackflies, sandflies, tsetse flies, and triatome bugs, as being the primary cause of 27 diseases which can be manifested as either viral, bacterial, parasitic, or ectoparasitic diseases. According to Brand and Keeling (2017), temperature changes influence the life cycle of biting insects, including those listed above, which may cause these insects to bite more on warm days, leading to greater transmission of diseases.

Vector-borne diseases are known to cause distress amongst pregnant women, as the timing of such infections can be in utero like congenital Zika syndrome, leishmaniasis, and Chagas disease. These diseases can have adverse outcomes during pregnancy, such as low foetal birth weight, congenital deformities, and even pre-term labour, as they can be passed on congenitally (O'Kelly and Lambert 2020). In terms of child health, vector-borne diseases, along with water- and airborne diseases, some of which are caused by climate change events, are known to negatively affect

young children's health outcomes, causing conditions such as asthma and pneumonia (Akachi et al. 2009).

The emergence of vector-borne diseases such as the Zika syndrome in the Caribbean can pose a significant risk to pregnant women, even though the WHO (2022) indicates that the region had the lowest report of such diseases in 2020. This is because there has been a lack of reporting and sensitisation of the public by the health institutions of Caribbean countries. As a result, the extent to which this vector-borne disease impacts the foetuses of pregnant women in the Caribbean may not be known. Although it is not known, it is possible that women from low-income households may not be able to access the necessary medical attention or take precautions to safeguard the foetus's life, which makes them particularly vulnerable.

#### 3.1.4. Extreme Temperatures and Temperature-Related Diseases

In extreme temperatures such as heat waves, pregnant women in the Caribbean may become vulnerable to heat exhaustion, heat cramps, heat stroke, and dehydration, which can lead to premature labour. Extreme temperatures also make it more likely that wildfires in the Caribbean will occur more frequently and last longer. As a result, it is expected that the contents of the smoke, which may also include harmful chemicals from plastics and toxic fumes from waste materials, can also contribute to pre-term labour. This an important problem, as low-income households in the Caribbean may not be able to manage periods of hot weather in a resilient manner because their houses may not be designed with cooling measures such as air conditioning units, thermostats, ceiling fans, and attic and garage insulation (Flores-Larsen and Filippin 2021).

The smoke contents can reduce the blood volume, which causes the level of oxytocin to become more concentrated, thus leading to Braxton Hicks contractions, better known as false labour pains (Raines and Cooper 2022). Such contractions, while expected, can potentially cause distress to the foetus. Furthermore, extreme heat waves, which are known to cause pre-term deaths, neonatal deaths, and miscarriages, were also found to be associated with seasonal variations in the use of caesarean delivery for high-risk pregnancies. One example of such an occurrence is in Ghana, where high ambient heat and extreme temperatures led to a higher incidence of both caesarean deliveries and spontaneous abortions.

Under such circumstances, as the maternal heat exposure level rises, so too does pregnant women's likelihood of experiencing an abortion (Asamoah et al. 2018). In cases where a caesarean delivery and spontaneous abortions may become a reality for some pregnant women in low-income situations, this may become a financial and legal burden. These procedures are expensive but having an abortion in many Caribbean countries like Trinidad and Tobago in its Offences against the Person Act is currently illegal (Trinidad and Tobago 2016). Therefore, while some of these procedures may not be accessible through public health institutions, in instances where such procedures are necessary to preserve the mother's life, they can be

inaccessible to pregnant women and single parents from low-income households, which may lead to a rise in illegal abortions and maternal deaths amongst this population segment.

Apart from foetuses, young children under five years old are also vulnerable to high temperatures associated with extreme heat as they have little ability to thermoregulate, i.e., to regulate their body temperature. Studies such as Hu et al. (2019) have found that short-term changes in the outdoor temperature were strongly linked with high blood pressure in children, especially if the patient is female and has a low body mass index. In countries like the Caribbean, with a distinct dry weather season, the exponential growth in heat-related child mortality is likely to outweigh any improvements made to reduce child death from these conditions. This can be due to changes in population growth and the continued rise in global emissions (Chapman et al. 2022).
