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
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
great expectations: making pregnancy safer 47 out the location of the closest appropriate care facility. It also involves securing funds for birth-related and emergency expenses, finding transport for facility-based birth and identifying compatible blood donors in case of emergency. Birth planning has en used in many developed countries for more than a decade with beneficial effects (68-70), and has been introduced with success in developing countries as well, albeit on too limited a scale so far Third, the antenatal care consultation is an opportunity to prepare mothers for parenting and for what will happen after the birth. Women and their families can learn how to improve their health and seek help when appropriate, and, most importantly, how to take care of the newborn child. Advice on parenting skills is particularly important for pregnant adolescents and women with low self-esteem(71), and improve the care that newborns and children will receive in the future(72). It helps to build a healthy family environment that is responsive to the child's needs Critical directions for the future Antenatal care started out in the first half of the 20th century as a means to educate ignorant"women with an emphasis on the welfare of the infant and child. This was a response to what had been identified as inadequate devotion to maternal duty result- ing in the poor physical stock of nations(73 ) In the 1950s it was used as an instru- ment for screening, so that women at higher risk of complications could be identified Although antenatal care turned out to be a poor screening instrument, few people would deny that many pregnancy complications, concurrent illnesses and health prob lems can be dealt with in an antenatal care consultation that focuses on effective interventions Antenatal care has come a long way, but can go much further. Four directions are critical: to rationalize the rituals of care, to roll out antenatal care as a platform for a number of other key health programmes, to establish communication with women more effectively, and to avoid the overmedicalization that can do more harm than good Most importantly, the unfinished agenda of reaching all women who are pregnant should be tackled All too often, antenatal care is still more a guestion of ritual than of effective interventions. Many of the tests and procedures carried out during a traditional antenatal consultation have very little scientific merit(74). Many ineffective interventions, such Box 3.3 Violence against women pm against women by a partner is a global rates of abuse during pregnancy are between ing her to find solutions. Experience shows, health problem and a human rights 4%and 11%. Violence during pregnancy can however, that this identification is only use olation. This violence often persists and kill: in Pune, India, 16% of all deaths during ful when appropriate support and/or referral sometimes may start during pregnancy, with pregnancy in 400 villages and seven hospitals can be provided Health workers must not only serious implications for the health of the mother were attributed to partner violence (55). Apart be sensitive to the subject, but also need to and child. In studies from countries such as from physical trauma, violence increases the know how to deal with it. Physicians, nurses, Egypt, Ethiopia, India, Mexico and Nicaragua, likelihood of premature labour, low birth weight, midwives and others involved in the care of 14-32% of women report having been anaemia, sexually transmitted infections, pregnant women have to be specifically trained ysically or sexually abused during pregnancy. urinary infections, substance use, depression to recognize and know how to ask about inti The perpetrator is usually their partner (53). In and other mental health problems (56) mate partner violence, provide information in Peru. 15% of women in Lima and 28% in the ntenatal care provides an opportunity for a confidential and non-judgemental way, and Department of Cusco have experienced physical the identification of instances of violence dur- provide care and support, reden, Switzerland and the United Kingdom, support to the expectant mother and help-
great expectations: making pregnancy safer 47 out the location of the closest appropriate care facility. It also involves securing funds for birth-related and emergency expenses, finding transport for facility-based birth and identifying compatible blood donors in case of emergency. Birth planning has been used in many developed countries for more than a decade with beneficial effects (68–70), and has been introduced with success in developing countries as well, albeit on too limited a scale so far. Third, the antenatal care consultation is an opportunity to prepare mothers for parenting and for what will happen after the birth. Women and their families can learn how to improve their health and seek help when appropriate, and, most importantly, how to take care of the newborn child. Advice on parenting skills is particularly important for pregnant adolescents and women with low self-esteem (71), and can improve the care that newborns and children will receive in the future (72). It helps to build a healthy family environment that is responsive to the child’s needs. Critical directions for the future Antenatal care started out in the first half of the 20th century as a means to educate “ignorant” women with an emphasis on the welfare of the infant and child. This was a response to what had been identified as inadequate devotion to maternal duty resulting in the poor physical stock of nations (73). In the 1950s it was used as an instrument for screening, so that women at higher risk of complications could be identified. Although antenatal care turned out to be a poor screening instrument, few people would deny that many pregnancy complications, concurrent illnesses and health problems can be dealt with in an antenatal care consultation that focuses on effective interventions. Antenatal care has come a long way, but can go much further. Four directions are critical: to rationalize the rituals of care, to roll out antenatal care as a platform for a number of other key health programmes, to establish communication with women more effectively, and to avoid the overmedicalization that can do more harm than good. Most importantly, the unfinished agenda of reaching all women who are pregnant should be tackled. All too often, antenatal care is still more a question of ritual than of effective interventions. Many of the tests and procedures carried out during a traditional antenatal consultation have very little scientific merit (74). Many ineffective interventions, such rates of abuse during pregnancy are between 4% and 11%. Violence during pregnancy can kill: in Pune, India, 16% of all deaths during pregnancy in 400 villages and seven hospitals were attributed to partner violence (55). Apart from physical trauma, violence increases the likelihood of premature labour, low birth weight, anaemia, sexually transmitted infections, urinary infections, substance use, depression and other mental health problems (56). Antenatal care provides an opportunity for the identification of instances of violence during pregnancy – a first step towards providing support to the expectant mother and helpViolence against women by a partner is a global public health problem and a human rights violation. This violence often persists and sometimes may start during pregnancy, with serious implications for the health of the mother and child. In studies from countries such as Egypt, Ethiopia, India, Mexico and Nicaragua, 14 –32% of women report having been physically or sexually abused during pregnancy. The perpetrator is usually their partner (53). In Peru, 15% of women in Lima and 28% in the Department of Cusco have experienced physical violence during pregnancy (54). In Canada, Sweden, Switzerland and the United Kingdom, ing her to find solutions. Experience shows, however, that this identification is only useful when appropriate support and/or referral can be provided. Health workers must not only be sensitive to the subject, but also need to know how to deal with it. Physicians, nurses, midwives and others involved in the care of pregnant women have to be specifically trained to recognize and know how to ask about intimate partner violence, provide information in a confidential and non-judgemental way, and provide care and support, including through appropriate referral (57–63). Box 3.3 Violence against women
The World Health Report 2005 as routine weighing of the woman at each consultation to assess maternal well-being and fetal growth, could be dispensed with(75). They take up valuable time which could be more usefully dedicated to counselling women on healthy lifestyles and health problems such as the detection and management of existing diseases This interaction between antenatal care and coping with women's circumstances and pre-existing diseases is the most underestimated aspect of care in pregnancy The potential for antenatal care to be much more far-reaching in this respect has not been fully exploited. As a platform for other health programmes such as HIv/ AIDS and other sexually transmitted infections, malaria, TB and family planning the resource of antenatal care is invaluable. WHO guidelines are readily available (42 )to advise on care, prevention and treatment of diseases during pregnancy. Moreover, pregnancy is a time when a dialogue about health and relevant social issues can be established between women and health services staff. establishing communication with women and linking up the medical and social worlds will make care more human, and ultimately more responsive A frequently forgotten issue is that of supply-driven overmedicalization of normal pregnancies, sometimes for reasons of financial gain. Overmedicalized care can needlessly damage the health of both mothers and babies and expose households to unnecessary expenditure. All too often, sophisticated investigations such as ultrasound scanning are performed without justification at every antenatal visit, while useful procedures such as blood pressure measurement are neglected and the establishment of birth plans and counselling on existing health problems are omitted. This has gone to extremes in some countries, where ultrasound is used to detect female fetuses for the purposes of sex-selective abortion. In terms of coverage, there is some way to go to provide at least four care contacts during each pregnancy, starting early enough to ensure that effective interventions are used. Women need providers who are skilled enough to offer care that is linked into a health care system that has continuity with childbirth care. The barriers to extending coverage are twofold. First, in some areas no services are offered, implying the need for outreach or services that can be physically accessed. Second, services are often not responsive enough. Complaints of unhelpful and rude health personnel, unexpected and unfair costs, unfriendly opening hours and the lack of involvement of male partners e not uncommon. Relatively straightforward changes to the arrangements of how antenatal care sessions are run( for instance not limiting antenatal care to one session per week) can sometimes make significant improvements to uptake. Adolescent girls are particularly vulnerable in this respect. Services that are responsive to them and young women will make a great contribution to the expansion of antenatal care. The question should not be " why do women not accept the service that we offer? ", but "why do we not offer a service that women will accept? (76) NOT EVERY PREGNANCY IS WELCOME Planning pregnancies before they even happer Many women intend to get pregnant. Each year an estimated 123 million succeed. But a substantial additional number of women- around 87 million- become pregnant unintentionally. For some women and their partners this may be a pleasant surprise but for others the pregnancy may be mistimed or simply unwanted(77). Of the esti- mated 211 million pregnancies that occur each year, about 46 million end in induced abortion (see Figure 3. 2)(78)
48 The World Health Report 2005 as routine weighing of the woman at each consultation to assess maternal well-being and fetal growth, could be dispensed with (75). They take up valuable time which could be more usefully dedicated to counselling women on healthy lifestyles and health problems such as the detection and management of existing diseases. This interaction between antenatal care and coping with women’s circumstances and pre-existing diseases is the most underestimated aspect of care in pregnancy. The potential for antenatal care to be much more far-reaching in this respect has not been fully exploited. As a platform for other health programmes such as HIV/ AIDS and other sexually transmitted infections, malaria, TB and family planning, the resource of antenatal care is invaluable. WHO guidelines are readily available (42) to advise on care, prevention and treatment of diseases during pregnancy. Moreover, pregnancy is a time when a dialogue about health and relevant social issues can be established between women and health services staff. Establishing communication with women and linking up the medical and social worlds will make care more human, and ultimately more responsive. A frequently forgotten issue is that of supply-driven overmedicalization of normal pregnancies, sometimes for reasons of financial gain. Overmedicalized care can needlessly damage the health of both mothers and babies and expose households to unnecessary expenditure. All too often, sophisticated investigations such as ultrasound scanning are performed without justification at every antenatal visit, while useful procedures such as blood pressure measurement are neglected and the establishment of birth plans and counselling on existing health problems are omitted. This has gone to extremes in some countries, where ultrasound is used to detect female fetuses for the purposes of sex-selective abortion. In terms of coverage, there is some way to go to provide at least four care contacts during each pregnancy, starting early enough to ensure that effective interventions are used. Women need providers who are skilled enough to offer care that is linked into a health care system that has continuity with childbirth care. The barriers to extending coverage are twofold. First, in some areas no services are offered, implying the need for outreach or services that can be physically accessed. Second, services are often not responsive enough. Complaints of unhelpful and rude health personnel, unexpected and unfair costs, unfriendly opening hours and the lack of involvement of male partners are not uncommon. Relatively straightforward changes to the arrangements of how antenatal care sessions are run (for instance not limiting antenatal care to one session per week) can sometimes make significant improvements to uptake. Adolescent girls are particularly vulnerable in this respect. Services that are responsive to them and young women will make a great contribution to the expansion of antenatal care. The question should not be “why do women not accept the service that we offer?”, but “why do we not offer a service that women will accept?” (76). NOT EVERY PREGNANCY IS WELCOME Planning pregnancies before they even happen Many women intend to get pregnant. Each year an estimated 123 million succeed. But a substantial additional number of women – around 87 million – become pregnant unintentionally. For some women and their partners this may be a pleasant surprise, but for others the pregnancy may be mistimed or simply unwanted (77). Of the estimated 211 million pregnancies that occur each year, about 46 million end in induced abortion (see Figure 3.2) (78)
great expectations: making pregnancy safer 49 Despite the large number of unintended pregnancies, many more women than ever before control their reproductive life by spacing their pregnancies more widely or limiting the number of pregnancies. Some 30 years of effort to bring contraceptive services within people's reach have not been in vain. In developing countries contraceptive prevalence has risen from around 10% in the early 1960s to 59%at the turn of the millennium (79). Despite falling international financial support, there has been a 1% annual increase in contraceptive prevalence over the last 10 years worldwide(80). A corresponding global drop in fertility has been seen, with the current average number of children per woman standing at 2.69, compared with 4.97 in the early 1960s (81) Nevertheless, as more women than ever before reach reproductive age, millions who do not want a child or who want to postpone their next pregnancy are not using any contraception(82 ) This growing unmet need may be due to the lack of acces to contraceptives, an issue in particular for adolescents, or it may result from women not using them. The most commonly given reason- in about 45% of cases- for not using a contraceptive method is a perceived lack of exposure to pregnancy. Fear of side-effects and cost is a reason for non-use in about one third of cases. Opposition to use is a lesser but still significant reason for non-use, frequently attributed to the husband (83 ) For all of these reasons, uptake of contraception is still very low in many parts of Africa, and patchy in other continents. According to recent survey data some countries are actually experiencing a reversal in family planning coverage Even if all the needs for contraception were met, there would still be many unwanted and mistimed pregnancies. Although most modern methods of contraception are highly effective if used consistently, advice and counselling on their correct use is often not available. If all users were to follow instructions perfectly, there would still be nearly 6 million accidental pregnancies per year. The fact is that with typical, real-life use of contraceptives, an estimated 26.5 million unintended pregnancies occur each year because of inappropriate use or method failure (84). In addition, dissatisfaction with methods can lead to discontinuation which is often associated with lack of choice incorrect use or fear of side effects all symptoms of poor quality family planning Figure 3.2 The outcomes of a years pregnancies counselling and services. What the research on unmet need for Miscarriages contraception and on contraceptive and stillbirths failure does not capture well is the role of unequal power relations between Live births 32 million men and women. These contribute 63% ubstantially to both unwanted sex and subsequent unwanted pregnancy (85) Young women are at particular risk of unwanted sex, or sex in unwanted conditions, particularly when there are large age differences between them and their partners(85). Between 7% and 48%of adolescent girls report that their first sexual experience was forced (86 87). Adolescent girls are more likely to be pressured into sexual activity at an
great expectations: making pregnancy safer 49 Despite the large number of unintended pregnancies, many more women than ever before control their reproductive life by spacing their pregnancies more widely or limiting the number of pregnancies. Some 30 years of effort to bring contraceptive services within people’s reach have not been in vain. In developing countries, contraceptive prevalence has risen from around 10% in the early 1960s to 59% at the turn of the millennium (79). Despite falling international financial support, there has been a 1% annual increase in contraceptive prevalence over the last 10 years worldwide (80). A corresponding global drop in fertility has been seen, with the current average number of children per woman standing at 2.69, compared with 4.97 in the early 1960s (81). Nevertheless, as more women than ever before reach reproductive age, millions who do not want a child or who want to postpone their next pregnancy are not using any contraception (82). This growing unmet need may be due to the lack of access to contraceptives, an issue in particular for adolescents, or it may result from women not using them. The most commonly given reason – in about 45% of cases – for not using a contraceptive method is a perceived lack of exposure to pregnancy. Fear of side-effects and cost is a reason for non-use in about one third of cases. Opposition to use is a lesser but still significant reason for non-use, frequently attributed to the husband (83). For all of these reasons, uptake of contraception is still very low in many parts of Africa, and patchy in other continents. According to recent survey data some countries are actually experiencing a reversal in family planning coverage. Even if all the needs for contraception were met, there would still be many unwanted and mistimed pregnancies. Although most modern methods of contraception are highly effective if used consistently, advice and counselling on their correct use is often not available. If all users were to follow instructions perfectly, there would still be nearly 6 million accidental pregnancies per year. The fact is that with typical, real-life use of contraceptives, an estimated 26.5 million unintended pregnancies occur each year because of inappropriate use or method failure (84). In addition, dissatisfaction with methods can lead to discontinuation, which is often associated with lack of choice, incorrect use or fear of side effects, all symptoms of poor quality family planning counselling and services. What the research on unmet need for contraception and on contraceptive failure does not capture well is the role of unequal power relations between men and women. These contribute substantially to both unwanted sex and subsequent unwanted pregnancy (85). Young women are at particular risk of unwanted sex, or sex in unwanted conditions, particularly when there are large age differences between them and their partners (85). Between 7% and 48% of adolescent girls report that their first sexual experience was forced (86, 87). Adolescent girls are more likely to be pressured into sexual activity at an Figure 3.2 The outcomes of a year’s pregnancies Live births 63% Induced abortions 22% Miscarriages and stillbirths 15% 32 million 46 million 133 million Source: (78)