great expectations: making pregnancy safer 4 Classic complications of pregnancy include pre-eclampsia and eclampsia which affect 2.8%of pregnancies in developing countries and 0. 4% in developed countries (12), leading to many life-threatening cases and over 63 000 maternal deaths worldwide every year. Haemorrhage following placental abruption or placenta praevia affects about 4% of pregnant women(13). Less common, but very serious complications include ectopic pregnancy and molar pregnancy Diseases and other health problems can often complicate, or become more severe during, pregnancy. Malaria worsens during pregnancy, for example, and together with anaemia is responsible for 10 000 maternal deaths and 200 000 infant deaths per year (see Boxes 3. 1 and 3. 2). Mortality from Hiv/AIdS during pregnancy can be significant in areas where prevalence is high. Tuberculosis is frequently encountered among pregnant women and is responsible for 9%of all deaths of women of reproductive age. Maternal malnutrition is a huge global problem, both as protein-calorie deficiency and as micronutrient deficiency. Paradoxically, obesity is also increasingly becoming an issue and leads to diabetes and birthing difficulties(45) Mental ill-health in pregnancy appears to be more common than previously recognized Although pregnancy has been regarded as a period of general psychological well- being for women (46), high rates of psychiatric morbidity in pregnant women have been reported, for example in Uganda (47). Pre-existing psychological disturbances can easily surface as depression, substance abuse or attempts at suicide, particularly when combined with a pregnancy that is unwanted. Rates of depression are at least high, or higher, in late pregnancy than during the postpartum period (48-51 In addition, many pregnant women are exposed to risks that are directly related to their way of life. Unhealthy lifestyles, including consumption of alcohol, tobacco and drugs, are dangerous for both mother and fetus, as they may lead to problems such as premature detachment of the placenta, sudden infant death syndrome, fetal alcohol syndrome and childhood developmental problems(52). Gender-based violence or exposure to hazards in the workplace may not be readily recognized by pregnant women as problems that health workers can help to resolve, but constitute major and underestimated public health problems(see Box 3.3) Box 3.2 Anaemia- the silent killer Anaemia is one of the world's leading causes women are less able to withstand blood loss Pregnancy and childbirth series (42-44) of disability (35)and thus one of the most (39)and may require blood transfusion which he strategy for control of anaemia in serious global public health problems. It is not always available in poor countries and egnant women includes: detection and nearly half of the pregnant women in not without risks. Anaemia during pregnancy appropriate management; prophylaxis against Id 52% in non-industrialized countries is also associated with increased stillbirths red with 23% in industrialized perinatal deaths, low-birth-weight babies and iron and folic acid; and improved obstetric countries(36). The commonest causes of prematurity (40). In malaria-endemic countries, care and management of women with severe anaemia are poor nutrition, iron and other anaemia is one of the commonest preventable anaemia. micronutrient deficiencies, malaria, hookworm causes of death in pregnant women and also in Successful delivery of these cost-effective and schistosomiasis. HIV infection(37) children under five years of age (41). Reducing interventions requires the integrated efforts and haemoglobinopathies make important the burden of anaemia is essential to achieve of several health programmes-particularly additional contribution the Millennium Development Goals relating to those targeted at pregnant women and young Anaemia during pre maternal and childhood mortality. The greatest children-and the strengthening of health sy cal consequences. It is associated burden of anaemia falls on the most "hard-to- tems, increased community awareness, and risk of maternal death, in particular reach"individuals WHO has published clinic orrhage(38). Severely anaemic pregnant guidelines in its Integrated Management of
great expectations: making pregnancy safer 45 Classic complications of pregnancy include pre-eclampsia and eclampsia which affect 2.8% of pregnancies in developing countries and 0.4% in developed countries (12), leading to many life-threatening cases and over 63 000 maternal deaths worldwide every year. Haemorrhage following placental abruption or placenta praevia affects about 4% of pregnant women (13). Less common, but very serious complications include ectopic pregnancy and molar pregnancy. Diseases and other health problems can often complicate, or become more severe during, pregnancy. Malaria worsens during pregnancy, for example, and together with anaemia is responsible for 10 000 maternal deaths and 200 000 infant deaths per year (see Boxes 3.1 and 3.2). Mortality from HIV/AIDS during pregnancy can be significant in areas where prevalence is high. Tuberculosis is frequently encountered among pregnant women and is responsible for 9% of all deaths of women of reproductive age. Maternal malnutrition is a huge global problem, both as protein-calorie deficiency and as micronutrient deficiency. Paradoxically, obesity is also increasingly becoming an issue and leads to diabetes and birthing difficulties (45). Mental ill-health in pregnancy appears to be more common than previously recognized. Although pregnancy has been regarded as a period of general psychological wellbeing for women (46), high rates of psychiatric morbidity in pregnant women have been reported, for example in Uganda (47). Pre-existing psychological disturbances can easily surface as depression, substance abuse or attempts at suicide, particularly when combined with a pregnancy that is unwanted. Rates of depression are at least as high, or higher, in late pregnancy than during the postpartum period (48–51). In addition, many pregnant women are exposed to risks that are directly related to their way of life. Unhealthy lifestyles, including consumption of alcohol, tobacco and drugs, are dangerous for both mother and fetus, as they may lead to problems such as premature detachment of the placenta, sudden infant death syndrome, fetal alcohol syndrome and childhood developmental problems (52). Gender-based violence or exposure to hazards in the workplace may not be readily recognized by pregnant women as problems that health workers can help to resolve, but constitute major and underestimated public health problems (see Box 3.3). women are less able to withstand blood loss (39) and may require blood transfusion which is not always available in poor countries and is not without risks. Anaemia during pregnancy is also associated with increased stillbirths, perinatal deaths, low-birth-weight babies and prematurity (40). In malaria-endemic countries, anaemia is one of the commonest preventable causes of death in pregnant women and also in children under five years of age (41). Reducing the burden of anaemia is essential to achieve the Millennium Development Goals relating to maternal and childhood mortality. The greatest burden of anaemia falls on the most “hard-toreach” individuals. WHO has published clinical guidelines in its Integrated Management of Anaemia is one of the world’s leading causes of disability (35) and thus one of the most serious global public health problems. It affects nearly half of the pregnant women in the world: 52% in non-industrialized countries – compared with 23% in industrialized countries (36). The commonest causes of anaemia are poor nutrition, iron and other micronutrient deficiencies, malaria, hookworm and schistosomiasis. HIV infection (37) and haemoglobinopathies make important additional contributions. Anaemia during pregnancy has serious clinical consequences. It is associated with greater risk of maternal death, in particular from haemorrhage (38). Severely anaemic pregnant Pregnancy and Childbirth series (42–44). The strategy for control of anaemia in pregnant women includes: detection and appropriate management; prophylaxis against parasitic diseases and supplementation with iron and folic acid; and improved obstetric care and management of women with severe anaemia. Successful delivery of these cost-effective interventions requires the integrated efforts of several health programmes – particularly those targeted at pregnant women and young children – and the strengthening of health systems, increased community awareness, and financial investment. Box 3.2 Anaemia – the silent killer 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
46 The World Health Report 2005 Seizing the opportunities Good antenatal care does more than just deal with the complications of pregnancy Women are the largest group of health care users actively and willingly seeking care at clinics. This offers enormous opportunities to use antenatal care as a platform for programmes that tackle nutrition, HIV/AIDS, sexually transmitted infections, malaria sis, among others. This and other opportunities have so far ficiently exploited. Three important opportunities during antenatal care should not be First, antenatal consultations offer an opportunity to promote healthy lifestyles that improve long-term health outcomes for the woman, her unborn child, and possibly have a positive impact on contraceptive use after birth. Some women actually prefer to discuss family planning methods during pregnancy or as part of postnatal care 65). Another example of an opportunity for prenatal health promotion is that of smoking cessation programmes in pregnancy, which appear to be successful (66) They reduce the risks of low birth weight and preterm birth, and improve the pregnant womans health in the long term as well Second, antenatal care provides an opportunity to establish a birth plan ( 67). Apart from planning the birth, making the plan is a chance to inform women and their families of the potential for unexpected events. Birth preparedness itself includes planning the desired place of birth, the preferred birth attendant and birth companion, and finding his young child in Niger is protected by an insecticide-treated bednet
46 The World Health Report 2005 Seizing the opportunities Good antenatal care does more than just deal with the complications of pregnancy. Women are the largest group of health care users actively and willingly seeking care at clinics. This offers enormous opportunities to use antenatal care as a platform for programmes that tackle nutrition, HIV/AIDS, sexually transmitted infections, malaria and tuberculosis, among others. This and other opportunities have so far been insuf- ficiently exploited. Three important opportunities during antenatal care should not be missed. First, antenatal consultations offer an opportunity to promote healthy lifestyles that improve long-term health outcomes for the woman, her unborn child, and possibly her family. The promotion of family planning is the foremost example of this and can have a positive impact on contraceptive use after birth. Some women actually prefer to discuss family planning methods during pregnancy or as part of postnatal care (64, 65). Another example of an opportunity for prenatal health promotion is that of smoking cessation programmes in pregnancy, which appear to be successful (66). They reduce the risks of low birth weight and preterm birth, and improve the pregnant woman’s health in the long term as well. Second, antenatal care provides an opportunity to establish a birth plan (67). Apart from planning the birth, making the plan is a chance to inform women and their families of the potential for unexpected events. Birth preparedness itself includes planning the desired place of birth, the preferred birth attendant and birth companion, and finding This young child in Niger is protected by an insecticide-treated bednet. P. Carnevale/WHO