chapter tnree great expectations: making pregnancy safer This chapter argues that the three most important components of care during pregnancy are first, providing good antenatal care, second avoiding or coping with unwanted pregnancies, and third building societies that support women who are pregnant. Despite increasing coverage in the last decade, antenatal care can only continue to realize its considerable potential by improving responsiveness breaking down the barriers to access and refocusing on effective interventions. Given the extent of unintended pregnancy and the unacceptably high levels of unsafe abortion around the world, continuing efforts to provide family planning services, education information and safe abortion services to the extent allowed by law-are essential public health interventions. Tackling the low status of women, violence against women and lack of employment rights for pregnant women is vital in helping to build societies that support pregnant women Pregnancy is not just a matter of waiting to give birth. Often a defining appropriate antenatal care during pregnancy to promote phase in a womans life, pregnancy can be a joyful and fulfilling period, health and cope with problems, by taking measures to for her both as an individual and as a member of society. It can also avoid unwanted pregnancies, and by making sure that be one of misery and suffering, when the pregnancy is unwanted or pregnancies take place in socially and environmentally mistimed, or when complications or adverse circumstances compro- favourable conditions. Women around the world face mise the pregnancy, cause ill-health or even death. Pregnancy may be many inequities during pregnancy. At this crucial time natural, but that does not mean it is problem-free women rely on care and help from health services, as Rarely is a pregnancy greeted with indifference. When a pregnancy well as on support systems in the home and comm occurs, women, their partners and families most often experience a Exclusion, marginalization and discrimination mixture of joy, concern and hope that the outcome will be the best of severely affect the health of mothers and that of all: a healthy mother and a healthy baby. All societies strive to ensure babies that pregnancy is indeed a happy event. they do so by providing
41 chapter three great expectations: making pregnancy safer This chapter argues that the three most important components of care during pregnancy are first, providing good antenatal care, second, avoiding or coping with unwanted pregnancies, and third, building societies that support women who are pregnant. Despite increasing coverage in the last decade, antenatal care can only continue to realize its considerable potential by improving responsiveness, breaking down the barriers to access and refocusing on effective interventions. Given the extent of unintended pregnancy and the unacceptably high levels of unsafe abortion around the world, continuing efforts to provide family planning services, education, information and safe abortion services – to the extent allowed by law – are essential public health interventions. Tackling the low status of women, violence against women and lack of employment rights for pregnant women is vital in helping to build societies that support pregnant women. Pregnancy is not just a matter of waiting to give birth. Often a defining phase in a woman’s life, pregnancy can be a joyful and fulfilling period, for her both as an individual and as a member of society. It can also be one of misery and suffering, when the pregnancy is unwanted or mistimed, or when complications or adverse circumstances compromise the pregnancy, cause ill-health or even death. Pregnancy may be natural, but that does not mean it is problem-free. Rarely is a pregnancy greeted with indifference. When a pregnancy occurs, women, their partners and families most often experience a mixture of joy, concern and hope that the outcome will be the best of all: a healthy mother and a healthy baby. All societies strive to ensure that pregnancy is indeed a happy event. They do so by providing appropriate antenatal care during pregnancy to promote health and cope with problems, by taking measures to avoid unwanted pregnancies, and by making sure that pregnancies take place in socially and environmentally favourable conditions. Women around the world face many inequities during pregnancy. At this crucial time women rely on care and help from health services, as well as on support systems in the home and community. Exclusion, marginalization and discrimination can severely affect the health of mothers and that of their babies
42 The World Health Report 2005 REALIZING THE POTENTIAL OF ANTENATAL CARE Meeting expectations in pregnancy A pregnancy brings with it great hope for the future, and can give women a special and ighly appreciated social status. It also brings great expectations of health care that is often willingly sought at this time. This explains, at least in part, the extraordinary success of antenatal care consultations. Women want confirmation that they are preg ant. At the same time they know that pregnancy can be dangerous, particularly in the developing world. In many countries pregnant women are likely to know of maternal deaths, stillbirths or newborn deaths among their own extended family or in their com- munity. It is natural that demand is high for health care that can provide reassurance, solve problems that may arise and confirm the status conferred by pregnancy In high-income and middle-income countries today, use of antenatal care by pregnant women is almost universal - except among marginalized groups such as migrants ethnic minorities, unmarried adolescents, the very poor and those living in isolated rural communities. Even in low-income settings, coverage rates for antenatal care-at least for one visit- are often quite high, certainly much higher than use of a skilled health care professional during childbirth There were noticeable increases in the use of antenatal care in developing countries during the 1990s. The greatest progress was seen in Asia, mainly as a result of rapid changes in a few large countries such as Indonesia(see Figure 3. 1). Significant increases also took place in the Caribbean and Latin America, although countries in these areas already had relatively high levels of antenatal care. In sub-Saharan Africa by contrast, antenatal care use increased only marginally over the decade(although levels in Africa are relatively high compared with those in Asia) While antenatal care coverage has improved significantly in recent years, it is generally recognized that the antenatal care services currently provided in many arts of the world fail to meet the recommended standards. a huge potential thus Figure 3. 1 Coverage of antenatal care is rising +15% +4% 11% South-East Asia Europe Mediterranean (6;96% (1:14%25:61%(17;46%)(1:8% 6;5 Number of countries and percentage of the regional population included in the analysis Data source: Multiple Indicator Cluster Surveys (UNICEF) and Demographic and Health Surveys
42 The World Health Report 2005 REALIZING THE POTENTIAL OF ANTENATAL CARE Meeting expectations in pregnancy A pregnancy brings with it great hope for the future, and can give women a special and highly appreciated social status. It also brings great expectations of health care that is often willingly sought at this time. This explains, at least in part, the extraordinary success of antenatal care consultations. Women want confirmation that they are pregnant. At the same time they know that pregnancy can be dangerous, particularly in the developing world. In many countries pregnant women are likely to know of maternal deaths, stillbirths or newborn deaths among their own extended family or in their community. It is natural that demand is high for health care that can provide reassurance, solve problems that may arise and confirm the status conferred by pregnancy. In high-income and middle-income countries today, use of antenatal care by pregnant women is almost universal – except among marginalized groups such as migrants, ethnic minorities, unmarried adolescents, the very poor and those living in isolated rural communities. Even in low-income settings, coverage rates for antenatal care – at least for one visit – are often quite high, certainly much higher than use of a skilled health care professional during childbirth. There were noticeable increases in the use of antenatal care in developing countries during the 1990s. The greatest progress was seen in Asia, mainly as a result of rapid changes in a few large countries such as Indonesia (see Figure 3.1). Significant increases also took place in the Caribbean and Latin America, although countries in these areas already had relatively high levels of antenatal care. In sub-Saharan Africa, by contrast, antenatal care use increased only marginally over the decade (although levels in Africa are relatively high compared with those in Asia). While antenatal care coverage has improved significantly in recent years, it is generally recognized that the antenatal care services currently provided in many parts of the world fail to meet the recommended standards. A huge potential thus Figure 3.1 Coverage of antenatal care is rising % of pregnant women 100 90 80 70 60 50 40 30 20 10 0 Eastern Mediterranean (6; 57%)a World (56; 55%)a Western Pacific (1; 8%)a Americas (17; 46%)a Africa (25; 61%)a Europe (1; 14%)a South-East Asia (6; 96%)a 1990 2000 +11% +34% +15% +6% +17% +4% +20% a Number of countries and percentage of the regional population included in the analysis. Data source: Multiple Indicator Cluster Surveys (UNICEF) and Demographic and Health Surveys
great expectations: making pregnancy safer 43 remains insufficiently exploited. Although progress has been made globally in terms of increasing access and use of one antenatal visit, the proportion of women who are obtaining the recommended minimum of four visits is too low(1). The first consultation is often late in pregnancy, whereas maximum benefit requires an early initiation of antenatal care. Antenatal care is given by doctors, midwives and nurses and many other cadres of health workers(2). Little is known about the capacities of non-professional workers such as traditional birth attendants to deliver the knowl effective interventions during pregnancy d'r It is October 2004 and bounlid, from the Lao People's Democratic Ive had no antenatal care and I don 't expect to have any for the rest Republic, is seven months pregnant and feeling tired. She is finding of my pregnancy. i plan to give birth at home, as i did with my other four it much harder to work and her family s income has slipped because children. It is too expensive for most people in my village to give birth brought in soon. When she goes to the fields she in their own, as she does not have the energy to deal with them and ounlid has not received any professional advice about the birth or work at the same time nutrition concerning the baby
great expectations: making pregnancy safer 43 remains insufficiently exploited. Although progress has been made globally in terms of increasing access and use of one antenatal visit, the proportion of women who are obtaining the recommended minimum of four visits is too low (1). The first consultation is often late in pregnancy, whereas maximum benefit requires an early initiation of antenatal care. Antenatal care is given by doctors, midwives and nurses and many other cadres of health workers (2). Little is known about the capacities of non-professional workers such as traditional birth attendants to deliver the known effective interventions during pregnancy. It is October 2004 and Bounlid, from the Lao People’s Democratic Republic, is seven months pregnant and feeling tired. She is finding it much harder to work and her family’s income has slipped because of this. The rice-cropping season is starting and the rice needs to be brought in soon. When she goes to the fields she has to leave her children on their own, as she does not have the energy to deal with them and work at the same time. “I’ve had no antenatal care and I don’t expect to have any for the rest of my pregnancy. I plan to give birth at home, as I did with my other four children. It is too expensive for most people in my village to give birth with a skilled attendant at the clinic, which, in any case, has very basic facilities and no telephone or ambulance if there were complications.” Bounlid has not received any professional advice about the birth or nutrition concerning the baby. J. Holmes/WHO
44 The World Health Report 2005 Pregnancy-a time with its own dangers Antenatal care is not just a way to identify women at risk of troublesome deliveries (3, 4 While less prominent than the dangers that can occur during childbirth, those surrounding pregnancy are far from being negligible. Women expect that antenatal care will help them deal with the health problems that can occur during pregnancy itself. If left unchecked, some of these may threaten health and survival before the child is due to be born A substantial proportion of maternal deaths-perhaps as many as one in four-occur during pregnancy. Data on mortality during pregnancy, however, are very fragmentary (5). The proportion of maternal deaths during pregnancy varies significantly from country to country according to the importance of unsafe abortion, violence, an disease conditions in the area(6, 7). In egypt 9% of all maternal deaths occur duri the first six months of pregnancy and a further 16% during the last three months ( 8) Apart from complications of unsafe abortion, which can be prevented or dealt with by good post-abortion care, three types of health problems exist in pregnancy. First, the complications of pregnancy itself, second, diseases that happen to affect a pregnant an and which may or may not be aggravated by pregnancy, and third, the negative effects of unhealthy lifestyles on the outcome of pregnancy. All have to be tackled by antenatal care Pregnancy has many complications that require care (9). In Lusaka, Zambia, nearly 40%of pregnancy-related referrals to the university teaching hospital were related to problems of the pregnancy itself, rather than to childbirth: 27% for threatened abortion or abortion complications, 13% for illness not specific to pregnancy such as malaria and infections, and 9% for hypertensive disorders of pregnancy (10). In a recent study of six west African countries, a third of all pregnant women were shown to experience some illness during pregnancy, (not including problems related to unsafe abortion)of whom 2.6% needed to be hospitalized(11) Box 3.1 Reducing the burden of malaria in pregnant women and their children Each year, approximately 50 million women Interventions against malaria and anaemia are Intermittent preventive treatment in preg living in malaria-endemic countries throughout well known, and though not perfect, can do a nancy is the administration of a full therapeutic the world become pregnant. Around 10 000 of lot to reduce malaria morbidity and mortality. dose of an antimalarial drug(sulfadoxine these women and 200 000 of their infants die Maternal, neonatal and child health services pyrimethamine) at specified intervals in the a result of malaria infection, severe malarial are a prime vehicle for such interventions. second and third trimesters, regardless of aemia contributing to more than half of these Apart from prompt treatment of malaria whether or not the woman is infected. This deaths(14, 15). Malaria in pregnancy also infections (23), maternal, neonatal and child reduces maternal anaemia creases the risk of stillbirth, spontaneous health services can contribute by increasing and low birth weight by approximately 40% portion, low birth weight and neonatal death. the use of insecticide-treated nets and provid -(28-30). Intermittent preventive treatment is one of the most cost-effective strategies for pregnant women coinfected with HIV. Insecticide-treated nets limit the harm preventing the morbidity and mortality associ- More than 90% of the one million annual done by malaria: they reduce parasitaemia, ated with malaria (31, 32), and recent evidence deaths from malaria are among young African the frequency of low birth weight, and anae- suggests that it may be a useful strategy for children, as are most cases of severe malarial mia(24-26). These nets have been shown to the control of malaria and anaemia in lamia(16-18). Severe anaemia probably reduce all-cause mortality in young children by infants (33, 34). An Intermittent Preventive accounts for more than half of all childhood around one fifth, saving an average of six lives Treatment in Infants Consortium, comprising deaths from malaria in Africa, with case fatal- for every 1000 children aged 1-59 months WHO, UNICEF, and research groups in Africa rates of between 8% and 18% in hospitals protected each year (26 ). They represent a Europe and the USA, is tackling the outstand- (16-22 )and probably more than that in the highly cost-effective use of scarce health care ing research issues e sources
44 The World Health Report 2005 Pregnancy – a time with its own dangers Antenatal care is not just a way to identify women at risk of troublesome deliveries (3, 4). While less prominent than the dangers that can occur during childbirth, those surrounding pregnancy are far from being negligible. Women expect that antenatal care will help them deal with the health problems that can occur during pregnancy itself. If left unchecked, some of these may threaten health and survival before the child is due to be born. A substantial proportion of maternal deaths – perhaps as many as one in four – occur during pregnancy. Data on mortality during pregnancy, however, are very fragmentary (5). The proportion of maternal deaths during pregnancy varies significantly from country to country according to the importance of unsafe abortion, violence, and disease conditions in the area (6, 7). In Egypt 9% of all maternal deaths occur during the first six months of pregnancy and a further 16% during the last three months (8). Apart from complications of unsafe abortion, which can be prevented or dealt with by good post-abortion care, three types of health problems exist in pregnancy. First, the complications of pregnancy itself, second, diseases that happen to affect a pregnant woman and which may or may not be aggravated by pregnancy, and third, the negative effects of unhealthy lifestyles on the outcome of pregnancy. All have to be tackled by antenatal care. Pregnancy has many complications that require care (9). In Lusaka, Zambia, nearly 40% of pregnancy-related referrals to the university teaching hospital were related to problems of the pregnancy itself, rather than to childbirth: 27% for threatened abortion or abortion complications, 13% for illness not specific to pregnancy such as malaria and infections, and 9% for hypertensive disorders of pregnancy (10). In a recent study of six west African countries, a third of all pregnant women were shown to experience some illness during pregnancy, (not including problems related to unsafe abortion) of whom 2.6% needed to be hospitalized (11). Interventions against malaria and anaemia are well known, and though not perfect, can do a lot to reduce malaria morbidity and mortality. Maternal, neonatal and child health services are a prime vehicle for such interventions. Apart from prompt treatment of malaria infections (23), maternal, neonatal and child health services can contribute by increasing the use of insecticide-treated nets and providing intermittent preventive treatment. Insecticide-treated nets limit the harm done by malaria: they reduce parasitaemia, the frequency of low birth weight, and anaemia (24–26). These nets have been shown to reduce all-cause mortality in young children by around one fifth, saving an average of six lives for every 1000 children aged 1–59 months protected each year (26). They represent a highly cost-effective use of scarce health care resources (27). Each year, approximately 50 million women living in malaria-endemic countries throughout the world become pregnant. Around 10 000 of these women and 200 000 of their infants die as a result of malaria infection, severe malarial anaemia contributing to more than half of these deaths (14,15). Malaria in pregnancy also increases the risk of stillbirth, spontaneous abortion, low birth weight and neonatal death. The risk of severe malaria is increased in pregnant women coinfected with HIV. More than 90% of the one million annual deaths from malaria are among young African children, as are most cases of severe malarial anaemia (16–18). Severe anaemia probably accounts for more than half of all childhood deaths from malaria in Africa, with case fatality rates of between 8% and 18% in hospitals (16–22) and probably more than that in the community. Intermittent preventive treatment in pregnancy is the administration of a full therapeutic dose of an antimalarial drug (sulfadoxinepyrimethamine) at specified intervals in the second and third trimesters, regardless of whether or not the woman is infected. This reduces maternal anaemia, placental malaria, and low birth weight by approximately 40% (28–30). Intermittent preventive treatment is one of the most cost-effective strategies for preventing the morbidity and mortality associated with malaria (31, 32), and recent evidence suggests that it may be a useful strategy for the control of malaria and anaemia in young infants (33,34). An Intermittent Preventive Treatment in Infants Consortium, comprising WHO, UNICEF, and research groups in Africa, Europe and the USA, is tackling the outstanding research issues. Box 3.1 Reducing the burden of malaria in pregnant women and their children