Why Do Women Seek Antenatal Care Late? Perspectives From Rural South Africa

Despite the widespread availability of free antenatal care services, most women in rural South Africa attend their first antenatal clinic late in pregnancy and fail to return for any followup care, potentially leading to avoidable perinatal and maternal complications. Using interviews with pregnant women from the rural Hlabisa district of South Africa, we documented perceptions of health and health care during pregnancy and investigated factors shaping the utilization of antenatal care. Our findings indicate that most women in this setting do not perceive significant health threats during pregnancy, and in turn view more than one antenatal care visit as unnecessary. In contrast, women perceive labour and delivery as a time of significant health risks that require biomedical attention, and most women prefer to give birth in a health facility. This paradox, in which health care is important for childbirth but not during pregnancy, is embodied in most women's primary reason for seeking antenatal care in this setting: to receive an antenatal attendance card that is required to deliver at a health facility. Health education programs promoting antenatal care are required to explain the importance of effective antenatal care toward maternal and child health.     

心脏病史女性孕前保健和管理

心脏病女性在妊娠期易发生心血管并发症,是孕产妇非产科因素死亡的重要原因,应加强孕前保健和管理。结合患者病史和检查进行孕前风险评估,能够手术矫正者建议其孕前手术治疗,不宜妊娠者应建议其避孕,允许继续妊娠者孕期应联合多学科管理,提高妊娠分娩安全性。     

Pregnancy and autoimmune diseases

Autoimmune diseases (AID) are more prevalent in women than in men, and pregnancy-related factors such as hormonal modulation and fetal microchimerism may influence the future risk of maternal AID. For women with AID, optimizing reproductive health requires a continuum of multidisciplinary care that initiates well before the desire for pregnancy is articulated. Family planning is essential so that pregnancy can be timed when disease is stable and to allow for appropriate medication adjustments. When contraception is used, the choice of method needs to take into consideration underlying disease and laboratory features. For females undergoing gonadotoxic therapy, options for preserving ovarian health and fertility warrant consideration, even among those who are not contemplating future pregnancy. Both maternal and fetal outcomes are optimized with multispecialty care as well as close monitoring during pregnancy and the postpartum period and when treatment regimens compatible with pregnancy are maintained to control underlying disease activity.     

UNINTENDED PREGNANCY: Consequences and Solutions for a Worldwide Problem

Unintended pregnancy is a worldwide problem that affects women, their families, and society. Unintended pregnancy can result from contraceptive failure, non-use of contraceptive services, and, less commonly, rape. Abortion is a frequent consequence of unintended pregnancy and, in the developing world, can result in serious, long-term negative health effects including infertility and maternal death. In many developing countries, poverty, malnutrition, and lack of sanitation and education contribute to serious health consequences for women and their families experiencing an unintended pregnancy. Regardless of the cause, unintended pregnancy and its negative consequences can be prevented by access to contraceptive services including emergency contraception, safe and legal abortion services, and a society that allows women to determine their own reproductive choices. Addressing unintended pregnancy and its substantial human and dollar costs should be a priority in every country. The availability of reliable contraception for all, regardless of age or ability to pay, is an essential first step. Women and adolescents require access to age-appropriate and culturally sensitive reproductive health care services, including emergency contraception. Access to safe, legal abortion services is necessary to impact the staggering maternal mortality rates worldwide. Midwives throughout the world provide the majority of care for women of reproductive age. It is essential to identify those at risk for unintended pregnancy, provide the services they require, and remain diligent to ensure that those women and their families have safe options to consider when faced with an unintended pregnancy. In 1920, Magaret Sanger said, “No women can call herself free who does not control her own body.” Although great strides have been made to improve the health and status of women since Ms. Sanger spoke those words, there remains much work to be done.     

The 1988 National Maternal and Infant Health Survey: Design,Content, and Data Availability

ABSTRACT: The 1988 National Maternal and Infant Health Survey was conducted by the National Center for Health Statistics to study factors related to poor pregnancy outcome, such as adequacy of prenatal care; inadequate and excessive weight gain during pregnancy; maternal smoking, drinking, and drug use; and pregnancy and delivery complications. The survey is a nationally representative sample of 11,000 women who had live births, 4000 who had late fetal deaths, and 6000 who had infant deaths in 1988. Mothers were mailed questionnaires based on information from certificates of live birth, reports of fetal death, and certificates of infant death. Information supplied by the mother, prenatal care providers, and hospitals of delivery was linked with the vital records to expand knowledge of maternal and infant health in the United States. Data collection from the Longitudinal Followup of mothers in the survey began in January 1991. It provides information on health and development of low- and very low-birthweight babies, child care and safety, maternal health, maternal depression, and plans for adoption and foster care. Both surveys will provide useful data for clinicians in maternal and child health.     

Comparison of Perception of Pregnancy Risk of Nulliparous Women of Advanced Maternal Age and Younger Age

Introduction : Over the last 3 decades, the proportion of women who have delayed childbearing into their mid 30s and early 40s has been increasing. Because advanced maternal age (AMA) is associated with several adverse maternal, fetal, and neonatal outcomes, these pregnancies are considered to be “high risk.” Research indicates that pregnancy risk perception is an important factor in pregnant women's health care use and decision making during pregnancy. The objectives of this study were to compare risk perception in pregnant women of AMA (aged 35 years or older) with that of younger women and to explore the relationship between perception of pregnancy risk and selected variables. Methods : A sample of 159 nulliparous pregnant women (105 aged 20‐29 years and 54 aged 35 years or older) was recruited from a variety of settings in Winnipeg, Manitoba, Canada. Women were asked to complete questionnaires to assess perception of pregnancy risk, risk knowledge, pregnancy‐related anxiety, perceived control, health status, and medical risk. Results : Women of AMA had higher education levels, were more likely to work during pregnancy, and had higher medical risk scores than younger women. Women of AMA perceived higher pregnancy risk for both themselves and their fetuses than did younger women. They rated their risks of cesarean birth, dying during pregnancy, preterm birth, and having a newborn with a birth defect or one needing admission to a neonatal intensive care unit higher than those of younger women. There were no significant differences between the 2 age groups in pregnancy‐related anxiety, knowledge of risk, perceived control, and health status. Discussion : Women of AMA have a higher perception of pregnancy risk than younger women, regardless of their medical risk. This evidence suggests that incorporating discussions of pregnancy risk into prenatal care visits may assist pregnant women of AMA to make more informed choices, reduce anxiety, and avoid unnecessary interventions.     

HIV-INFECTED WOMEN AND INFANTS

The utilization of health care by HIV-seropositive pregnant women and their infants was studied in an indigent urban population. Ninety HIV-seropositive women delivered 99 HIV-exposed infants at the Johns Hopkins Hospital from August 1, 1988, to April 1, 1991. Repeat pregnancies occurred in 17 (18.9%) women during the study period. Completion of the primary immunization series by age nine months was the criteria for infant adherence to medical care. Of all infants, 72.9% achieved adequate immunization status by nine months. However, only 41 (45.6%) women reported ever seeking HIV-related health care. Factors associated with maternal adherence with HIV-related health care included HIV status of her infant, maternal drug use, and incarceration. Number of living children, maternal age, educational level, marital status, and repeat pregnancy were not associated with mothers seeking HIV-related health care. Despite low adherence to HIV-related health care in this sample of HIV-seropositive women, the majority of their infants did receive adequate immunizations, one proxy measure of adequate infant health care.     

Determinants of Maternal Mortality in the Developing World

Maternal mortality is the culmination of a series of detrimental events in a woman's life, pregnancy being the last one. The underlying pathology is the lack of education, sanitation, accessible health care, as well as poor nutrition and poverty. These affect women during pregnancy and childbirth when they are more vulnerable. This 10-year review of literature from the developing world focuses on, and discusses the determinants of maternal mortality. Methods of reducing maternal mortality through policy addressing health care needs are touched on.     

Postnatal care in low-income urban African American women: relationship to level of prenatal care sought.

OBJECTIVE: This study examined the relationship between level of prenatal care utilization and postnatal patterns of health care behavior among high-risk minority women. The primary hypothesis was that prenatal care utilization predicts subsequent levels of both the maternal and child health services used in the postnatal period. METHODS: The study population consisted of 297 low-income African American women who were recruited at delivery at an urban tertiary medical center in the Mid-Atlantic region. They were followed monthly for 1 year using telephone interviews to determine their use of maternal and child health services. Four levels of prenatal care were identified retrospectively based on reviews of health records and screening interviews using the Kessner Index. Data regarding pregnancy outcomes, maternal postnatal visits, and well-child and acute care child visits were collected. RESULTS: Women who sought inadequate or no prenatal care had greater infant morbidity and mortality in the postnatal period and significantly lower levels of attendance at maternal postnatal visits, well-child visits, immunization completions, and acute care visits. CONCLUSION: This study confirms that the level of prenatal care is indicative of the level of postnatal care women seek for themselves and their children in the first year after delivery.     

Methamphetamine Use in Pregnancy: A Call for Action

Substance use during pregnancy continues to be an area of concern in Canada. Rates of substance use appear to be increasing among women of childbearing age, and use during pregnancy may effect maternal and fetal outcomes. Little is known of the prevalence of methamphetamine use during pregnancy and its impact, but maternity care providers are encountering patients who use methamphetamines in their practices. These health care providers are asking for evidence-based recommendations for management and treatment. There is an immediate and urgent need to address this gap in order to improve the health of pregnant women and their babies.     

Excessive Gestational Weight Gain

Excessive gestational weight gain (GWG) is associated with an increasing incidence of maternal and neonatal complications, including hypertensive disorders of pregnancy, fetal macrosomia, and increased cesarean birth rates. In the United States, it is recommended that health care providers use an individualized approach to counsel a woman about pregnancy weight gain goals that is based on the woman's initial body mass index (BMI) and to track GWG throughout the pregnancy by evaluating maternal weight at each visit. Studies have shown that women entering pregnancy with a higher BMI are at increased risk for excessive GWG and postpartum weight retention. Research also demonstrates an increased risk of childhood obesity in children born to women with excessive GWG. Specific counseling about exercise and diet, as well as technology and motivational interviewing, are some tools prenatal care providers can use that have been shown to be effective in reducing excessive GWG. This article reviews the current research regarding maternal and neonatal risks associated with excessive GWG, as well as the interventions that have demonstrated promise for addressing this problem.     

Low use of rural maternity services in Uganda: impact of women's status,traditional beliefs and limited resources

In Uganda, lack of resources and skilled staff to improve quality and delivery of maternity services, despite good policies and concerted efforts, have not yielded an increase in utilisation of these services by women or a reduction in the high ratio of maternal deaths. This paper reports a study conducted from November 2000 to October 2001 in Hoima, a rural district in western Uganda, whose aim was to enhance understanding of why, when faced with complications of pregnancy or delivery, women continue to choose high risk options leading to severe morbidity and even their own deaths. The findings demonstrate that adherence to traditional birthing practices and beliefs that pregnancy is a test of endurance and maternal death a sad but normal event, are important factors. The use of primary health units and the referral hospital, including when complications occur, was considered only as a last resort. Lack of skilled staff at primary health care level, complaints of abuse, neglect and poor treatment in hospital and poorly understood reasons for procedures, plus health workers' views that women were ignorant, also explain the unwillingness of women to deliver in health facilities and seek care for complications. Appropriate interventions are needed to address the barriers between rural mothers and the formal health care system, including community education on all aspects of essential obstetric care and sensitisation of service providers to the situation of rural mothers.     

The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity

Reports from the UK Confidential Enquiries into Maternal Deaths and Morbidity are now published annually. In 2013–15, the maternal mortality rate was 8.8 per 100,000 maternities. Over two thirds of women died from medical and mental health causes and less than one third from obstetric causes. Cardiac disease remained the leading cause of maternal death in the UK. With the majority of women dying from pre-existing conditions, there remain multiple opportunities to reduce women's risk of complications in pregnancy through early and forward planning of the care of women with known pre-existing medical and mental health problems. Provision of appropriate advice and optimisation of medication prior to pregnancy, referral early in pregnancy for the appropriate specialist advice and planning of antenatal, intrapartum and postnatal care and effective postnatal provision of advice concerning risks and planning for future pregnancies are the key improvements needed to prevent women dying in the future.     

Disabled women׳s maternal and newborn health care in rural Nepal: A qualitative study

Objective

there is little evidence about disabled women?s access to maternal and newborn health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and care seeking. Our study explores disabled women?s experiences of maternal and newborn care in rural Nepal.

Design

we used a qualitative methodology, using semi-structured interviews.

Setting

rural Makwanpur District of central Nepal.

Participants

we purposively sampled married women with different impairments who had delivered a baby in the past 10 years from different topographical areas of the district. We also interviewed maternal health workers. We compared our findings with a recent qualitative study of non-disabled women in the same district to explore the differences between disabled and non-disabled women.

Findings

married disabled women considered pregnancy and childbirth to be normal and preferred to deliver at home. Issues of quality, cost and lack of family support were as pertinent for disabled women as they were for their non-disabled peers. Health workers felt unprepared to meet the maternal health needs of disabled women.

Key conclusions and implications for practice

integration of disability into existing Skilled Birth Attendant training curricula may improve maternal health care for disabled women. There is a need to monitor progress of interventions that encourage institutional delivery through the use of disaggregated data, to check that disabled women are benefiting equally in efforts to improve access to maternal health care.     

HIV-infected women and infants: Social and health factors impeding utilization of health care

The utilization of health care by HIV-seropositive pregnant women and their infants was studied in an indigent urban population. Ninety HIV-seropositive women delivered 99 HIV-exposed infants at the Johns Hopkins Hospital from August 1, 1988, to April 1, 1991. Repeat pregnancies occurred in 17 (18.9%) women during the study period. Completion of the primary immunization series by age nine months was the criteria for infant adherence to medical care. Of all infants, 72.9% achieved adequate immunization status by nine months. However, only 41 (45.6%) women reported ever seeking HIV-related health care. Factors associated with maternal adherence with HIV-related health care included HIV status of her infant, maternal drug use, and incarceration. Number of living children, maternal age, educational level, marital status, and repeat pregnancy were not associated with mothers seeking HIV-related health care. Despite low adherence to HIV-related health care in this sample of HIV-seropositive women, the majority of their infants did receive adequate immunizations, one proxy measure of adequate infant health care.     

HIV and maternal mortality

The majority of the 17 million women globally that are estimated to be infected with HIV live in Sub-Saharan Africa. Worldwide, HIV-related causes contributed to 19 000–56 000 maternal deaths in 2011 (6%–20% of maternal deaths). HIV-infected pregnant women have two to 10 times the risk of dying during pregnancy and the postpartum period compared with uninfected pregnant women. Many of these deaths can be prevented with the implementation of high-quality obstetric care, prevention and treatment of common co-infections, and treatment of HIV with ART. The paper summarizes what is known about HIV disease progression in pregnancy, specific causes of HIV-related maternal deaths, and the potential impact of treatment with antiretroviral therapy on maternal mortality. Recommendations are proposed for improving maternal health and decreasing maternal mortality among HIV-infected women based on existing evidence.     

The Association of Inadequate and Intensive Prenatal Care With Maternal,Fetal, and Infant Outcomes: A Population-Based Study in Manitoba,Canada

ObjectiveLittle is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba.MethodsThis retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours.ResultsThe distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization.ConclusionInadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.     

Prenatal nutrition: a practical guide for assessment and counseling

Adequate nutrition during the periconceptional and prenatal periods is important for healthy pregnancy outcomes. By enhancing maternal nutritional status, health care providers can help pregnant women lower their risk of certain pregnancy complications and decrease their children's risk of adverse birth outcomes and later chronic disease. Use of evidence-based tools and recommendations will assist in the assessment of pregnant women's diets and streamline the counseling session to optimize their nutritional status. This article contains a review of the literature related to nutrition intervention studies during pregnancy that were designed to improve habits or achieve target weight gains and nutrition recommendations specific for the pregnancy state, as well as tools/resources for the health care provider for implementation of these recommendations into their busy practices.     

Comparison of selected outcomes of CenteringPregnancy versus traditional prenatal care

The purpose of this study was to assess the effect of traditional prenatal care versus a group model of care, CenteringPregnancy, on maternal knowledge of pregnancy, social support, health locus of control, and satisfaction. The CenteringPregnancy model of care gives patients extended time with the provider in a group setting. The study used a two-group, pretest/posttest design of pregnant women who elected either the traditional approach to prenatal care (n = 48) or the Centering approach (n = 50). The results of this study showed statistically significant differences between the groups on posttest in knowledge of pregnancy. For social support and health locus of control, the high scores at pretest contributed to a ceiling effect, which limited the potential for change. Additional research is needed to assess health status outcomes among women electing alternative approaches to prenatal care.