Maternal health

According to a UNFPA report, social and economic status, culture norms and values, and geographic remoteness all increase a maternal mortality, and the risk for maternal death (during pregnancy or childbirth) in sub-Saharan Africa is 175 times higher than in developed countries, and risk for pregnancy-related illnesses and negative consequences after birth is even higher.[8] Poverty, maternal health, and outcomes for the child are all interconnected.[9]

Women living in poverty-stricken areas are more likely to be obese and engage in unhealthy behaviors such as cigarette smoking and drug use, are less likely to engage in or even have access to legitimate prenatal care, and are at a significantly higher risk for adverse outcomes for both the mother and child.[10] A study conducted in Kenya observed that common maternal health problems in poverty-stricken areas include hemorrhaging, anemia, hypertension, malaria, placenta retention, premature labor, prolonged/complicated labor, and pre-eclampsia.[11]

Generally, adequate prenatal care encompasses medical care and educational, social, and nutritional services during pregnancy.[12] Although there are a variety of reasons women choose not to engage in proper prenatal care, 71% of low-income women in a US national study had difficulties getting access to prenatal care when they sought it out.[12] Additionally, immigrants and Hispanic women are at higher risk than white or black women for receiving little to no prenatal care, where level of education is also an indicator (since education and race are correlated). Adolescents are least likely to receive any prenatal care at all. Throughout several studies, women and adolescents ranked inadequate finances and lack of transportation as the most common barriers to receiving proper prenatal care.[13]

Map of countries by fertility rate (2020), according to the Population Reference Bureau

Income is strongly correlated with quality of prenatal care.[13] Sometimes, proximity to healthcare facilities and access to transportation have significant effects on whether or not women have access to prenatal care. An analysis conducted on maternal healthcare services in Mali found that women who lived in rural areas, far away from healthcare facilities were less likely to receive prenatal care than those who lived in urban areas. Furthermore, researchers found an even stronger relationship between lack of transportation and prenatal and delivery care.[14] In addition to proximity being a predictor of prenatal care access, Materia and colleagues found similar results for proximity and antenatal care in rural Ethiopia.[15] Also, inadequate and poor quality services contributes in increasing maternal morbidity and mortality.[16]

Maternal HIV rates vary around the world, ranging from 1% to 40%, with African and Asian countries having the highest rates.[17] Whilst maternal HIV infection largely has health implications for the child,[18] especially in countries where poverty is high and education levels are low,[19] having HIV/AIDS while pregnant can also cause heightened health risks for the mother.[20] A large concern for HIV-positive pregnant women is the risk of contracting tuberculosis (TB) and/or malaria, in developing countries.[17] 28% of maternal deaths are from obstructed labour and indirect causes, meaning diseases that complicate pregnancy or that are complicated by pregnancy(malaria, anemia, HIV/AIDS), and cardiovascular diseases).[4]

During pregnancy, women of an average pre-pregnancy weight (BMI 18.5-24.9) should expect to gain between 25–35 pounds (11–16 kg) over the course of the pregnancy.[21] Increased rates of hypertension, diabetes, respiratory complications, and infections are prevalent in cases of maternal obesity and can have detrimental effects on pregnancy outcomes.[22] Obesity is an extremely strong risk factor for gestational diabetes.[23] Research has found that obese mothers who lose weight (at least 10 pounds or 4.5 kg) in-between pregnancies reduce the risk of gestational diabetes during their next pregnancy, whereas mothers who gain weight actually increase their risk.[24] Women who are pregnant should aim to exercise for at least 150 minutes per week, including muscle strengthening exercises.[25]

Maternal Oral Health has been shown to affect the well-being of both the expectant mother and her unborn fetus.

The 2000 Surgeon's General Report stressed the interdependence of oral health on the overall health and well-being of an individual.[26] Oral health is especially essential during perinatal period and the future development of the child.[27] Proper management of oral health has benefits to both mother and child. Furthermore, lack of understanding or maintenance of good oral health for pregnant women may have adverse effects on them and their children. Hence, it is imperative to educate mothers regarding the significance of oral health. Moreover, collaboration and support among physicians across various fields, especially among family practitioners and obstetricians, is essential in addressing the concerns for maternal oral health.[28] In 2007, the Maternal Oral Health Project was developed to provide routine oral care to low-income pregnant women in Nassau County, NY. Since its inception, the program has treated more than 2,000 pregnant women, many of whom had significant gum and/or tooth problems.[29]

Oral health has numerous implications on overall general health and the quality of life of an individual. The Surgeon General's Report lists various systemic diseases and conditions that have oral manifestations.[26] The oral cavity serves as both a site of and a gateway entry of disease for microbial infections, which can affect general health status. In addition, some studies have demonstrated a relationship between periodontal diseases and diabetes, cardiovascular disease, stroke, and adverse pregnancy outcomes. Furthermore, the report establishes a relationship between oral health and quality of life, including functional, psychosocial, and economic indicators. Poor oral health can affect diet, nutrition, sleep, psychological status, social interaction, school, and work.

Protection and control of oral health and diseases safeguards a woman's health and quality of life before and during pregnancy.[30] Also, it has the potential to decrease the transmission of pathogenic bacteria that occurs from mother to child.[27] Along with pregnancy, come physiological changes for a woman. The changes, including fluctuating hormones, increase the woman's susceptibility to oral infections such as periodontal disease. This disease impairs the body's ability to repair and maintain soft tissues.[28] It also causes indirect damage through bacterial induction of both inflammatory and immune responses of the host.[31] During pregnancy, mild inflammation of the gums, "pregnancy gingivitis", is quite common and if left untreated can lead to periodontal disease. There have been an increased number of studies establishing associations between, periodontal disease and negative health outcomes, which include tooth loss, cardiovascular disease, stroke, poor diabetes control, and adverse birth outcomes. For example, one such study found that moderate or severe periodontal disease early in pregnancy was associated with delivery of small-for-gestational-age infant.[32] Other studies have also found an association between periodontal disease and development of pre-eclampsia and pre-term births.[31]

Another notable oral disease pertinent to maternal child health is dental caries. Dental caries is the process of tooth decay, and the development of what is commonly known as cavities.[31] Dental caries are transmitted from mother to child vertically; colonization of cariogenic bacteria primarily occurs from mother to child through saliva-sharing activities. Maternal oral flora can ultimately foretell oral flora in offspring.[33] In addition, other maternal factors such as social, behavioral, and biological factors can predispose a child's experience with tooth-decay.[31] Some of these factors include the lack of knowledge a mother possesses concerning oral health, which can influence the development of caries among her children. Compared to children whose mothers have good oral health, children whose mothers have bad oral health are five times as likely to have poor oral health.[28] Poor maintenance of oral health has profound implications on the development of children. As mentioned in the Surgeon's General Report, oral health affects the quality of life, especially children, with respect to functional, psychological, economic, and overall emotional well-being of an individual.[26] To demonstrate the adverse effects of poor oral health, take for example the consequences a simple cavity can have on a child. First, it is painful. This might cause a child to miss school or have poor concentration, eventually compromising school performance. In addition, due to the pain, it might result in poor weight gain or growth. Also, children may exhibit reduced self-esteem because of cosmetic issues. Furthermore, it can affect language and impair speech. Impaired speech development can also result in low self-esteem. Finally, cavities although easily preventable, can pose a financial burden of a family. Public dental services are scarce and costly to individuals who lack dental insurance. It may also result in unwarranted visits to emergency department. Poor oral health permeates into other aspects of life, posing threats to overall well-being, if not handled timely and effectively

The significance of oral health is apparent, however, many women do not receive dental services before, during, and after pregnancy, even with obvious signs of oral disease.[30] There are several factors at play regarding pregnant women not seeking dental care, including the role of the health care system and disposition of the woman herself. There is a common misconception that it is not safe to obtain dental services while pregnant. Many prenatal and oral health providers have limited knowledge about the impact and safety of delivering dental services; hence they might delay or withhold treatment during pregnancy.[27] Moreover, some prenatal providers are not aware of the importance of oral health on overall general health, thus failing to refer their patients to dental providers.[30] First and foremost, the misconception regarding the impact of dental services while a woman is pregnant needs to be purged. There is a consensus that prevention, diagnosis, and treatment of oral diseases are highly beneficial and can be performed on pregnant women having no added fetal or maternal risk when compared to the risk of providing no oral care.[30] Equally important is establishing collaboration among clinicians, especially maternal health providers, with other dental providers. There should be coordination among general health and oral health providers, especially because of the interdependence of the two fields.[26] Thus, it is imperative to educate and train health providers of the significance of oral health, designing methods to incorporate in their respective practices. Providers most provide education to pregnant women addressing the importance of oral health, because these women ultimately control the fate of themselves and their offspring. For example, providers can illustrate to mothers how to reduce cavities by wiping down the gums of their children with a soft cloth after breastfeeding or bottle-feeding.[27] Bestowing knowledge and practical applications of good oral health maintenance measures to mothers can help improve overall health of the mother and child. There are still other factors in play when analyzing the low use of dental services by pregnant women, particularly prevalent among ethnic and racial minorities. A major factor is the lack of insurance and or access to dental services.[26] For this reason, more data needs to be collected and analyzed so that programs are set up to effectively to reach all segments of the population.

The pregnancy related mortality ratio (PRMR) represents the number of deaths per 100,000 live births resulting from pregnancy or pregnancy related causes. Analysis of the Pregnancy Mortality Surveillance System, conducted by the Center for Disease Control and Prevention (CDC), indicates significant racial and ethnic disparities in pregnancy related deaths.[34] Specifically, A 2019 report from the CDC shows that the PRMRs of Black women and American Indian women in the United States are 3-4 times higher than that of White women. For White women during 2019, there were an approximate 13 maternal deaths per 100,000 live births. For Black and American Indian women, there were 41 and 30 maternal deaths per 100,000 live births respectively. The majority of these deaths were due to preventable diseases associated with pregnancy related mortality, such as hypertension. While the fatality rate of these diseases was higher among Black and American Indian women, the initial prevalence was generally the same across all races.[35] Although lower than that of Black and American Indian women, the PRMR for Asian and Pacific Islander women was found to be higher than that of White women (with a disparity ratio of 1.1).[35] The PRMR for Hispanic women has shown a decline in recent years. However, state specific reports show that Hispanic women face high rates of maternal morbidity.[36]

The CDC cites multiple possible causes for the racial gap in maternal mortality. They say that most pregnancy related deaths are the combined result of 3-4 contributing factors. For Black and American Indian women, this can include issues of implicit racial bias held by healthcare providers, which affects the quality of care given to treat or prevent a fatal disease. These factors can also be more structural (e.g. the gap in access to primary and preventative care in minority communities). In the CDC report, economic status is not cited as a leading cause of maternal mortality. While economic status and education level is a possible contributing factors to maternal mortality, the racial gap is shown to persist across all economic and education levels.[35]

There are many factors that influence maternal health and the access of resources. One of these factors that recent studies have highlighted is religion. For example, one such study stated that, due to the insensitivity and lack of knowledge that physicians showed immigrant Muslim women in Canada, their health information and treatment suffered.[37] The health care that they received from physicians did not provide information in respect to their religious or cultural practices and did little to provide cultural adjustments and emotional support.[37] In order to provide a safer and more comfortable environment for Muslim women, it was proven that they needed more support that would connect with the immigrant community and health-related information.[37] Discrimination based on religion is a factor that effects the maternal health care of women from different backgrounds. There is not a lot of discussion on the studies that reflect the hardships that women go through in terms of their religion and maternal care. Stigmatizing certain maternal and reproductive practices is common within the context of religion. For example, in a study that focused on interviewing women who have had abortions, one participant used the word “guilt” 16 times in her one hour interview.[38] She cited that the cause of her guilt was because of her Catholic upbringing.[38] The overall data showed that there was a strong relationship between religion and self-stigma.[38] Among the women who identified as a practicing Christian, 65% made statements that proved self-stigma effects.[38] There is a lot of stigma and norms regarding religion that, in turn, place women at risk when receiving health-care.[39] Other religious practices and traditions have shown to influence maternal health in a negative way. Practitioners of apostolicism in Zimbabwe have been associated with higher maternal mortality.[40] Results of a study showed the dangerous associations that religion may have on maternal health.[40] The general trend shows that Apostolicism promotes high fertility, early marriage, non-use of contraceptives and low or non-use of hospital care.[40] There are delays in recognizing danger signs, deciding to seek care and receiving appropriate health care.[40] Future studies can look at how societal traditions or expectations such as gender roles may combine with religion to result in poorer maternal health care.

Although factors of religion can negatively influence maternal health care, other studies show the necessity of understanding different religious beliefs and practices. In Ghana, interviews of women showed the benefits of transparent religious beliefs and practices while pregnant and in labor.[41] Spiritual interventions done by pastors in pregnancy included prayer, revelations, reversing negative dreams, laying of hands and anointing women.[41] Religious artifacts used among the women during pregnancy and labor were anointing oil, blessed water, stickers, blessed white handkerchief, blessed sand, Bible and Rosary.[41] The women made many connections to these practices and to their religion such as God having the capability to reduce labor pain and to provide a safe and successful delivery.[41] The results concluded that spirituality is an integral part of the care of pregnant women in Ghana.[41] In order to ensure the safety of these women, their religious practices should not be in secrecy.[41] The presence of artifacts infer that women do not have the freedom to practice their religion at home.[41] It was concluded that pastors should be sensitive to their role in the labor process and that revelations and spiritual interventions should not lead to pregnancy or labor complications.[41] Future studies in religion and maternal health care will focus on the role of pastors, familiar support, and the views of midwives or health care professionals in different societies around the world.

Prenatal care is an important part of basic maternal health care.[42] It is recommended expectant mothers receive at least four antenatal visits, in which a health worker can check for signs of ill health – such as underweight, anaemia or infection – and monitor the health of the foetus.[43] During these visits, women are counseled on nutrition and hygiene to improve their health prior to, and following, delivery. They can also develop a birth plan laying out how to reach care and what to do in case of an emergency.

Poverty, malnutrition, and substance abuse may contribute to impaired cognitive, motor, and behavioral problems across childhood.[44] In other words, if a mother is not in optimal health during the prenatal period (the time while she is pregnant) and/or the fetus is exposed to teratogen(s), the child is more likely to experience health or developmental difficulties, or death. The environment in which the mother provides for the embryo/fetus is critical to its wellbeing well after gestation and birth.

A teratogen is "any agent that can potentially cause a birth defect or negatively alter cognitive and behavioral outcomes." Dose, genetic susceptibility, and time of exposure are all factors for the extent of the effect of a teratogen on an embryo or fetus.[45]

Prescription drugs taken during pregnancy such as streptomycin, tetracycline, some antidepressants, progestin, synthetic estrogen, and Accutane,[46][47] as well as over-the-counter drugs such as diet pills, can result in teratogenic outcomes for the developing embryo/fetus. Additionally, high dosages of aspirin are known to lead to maternal and fetal bleeding, although low-dose aspirin is usually not harmful.[48][49]

Newborns whose mothers use heroin during the gestational period often exhibit withdrawal symptoms at birth and are more likely to have attention problems and health issues as they grow up.[50] Use of stimulants like methamphetamine and cocaine during pregnancy are linked to a number of problems for the child such as low birth weight and small head circumference and motor and cognitive developmental delays, as well as behavioral problems across childhood.[51][52][53][54] The American Academy of Child and Adolescent Psychiatry found that 6 year-olds whose mothers had smoked during pregnancy scored lower on an intelligence test than children whose mothers had not.[55]

Cigarette smoking during pregnancy can have a multitude of detrimental effects on the health and development of the offspring. Common results of smoking during pregnancy include pre-term births, low birth weights, fetal and neonatal deaths, respiratory problems, and sudden infant death syndrome (SIDS),[45] as well as increased risk for cognitive impairment, attention deficit hyperactivity disorder (ADHD) and other behavioral problems.[56] Also, in a study published in the International Journal of Cancer, children whose mothers smoked during pregnancy experienced a 22% risk increase for non-Hodgkin lymphoma.[57]

Although alcohol use in careful moderation (one to two servings a few days a week) during pregnancy are not generally known to cause fetal alcohol spectrum disorder (FASD), the US Surgeon General advises against the consumption of alcohol at all during pregnancy.[58] Excessive alcohol use during pregnancy can cause FASD, which commonly consist of physical and cognitive abnormalities in the child such as facial deformities, defective limbs, face, and heart, learning problems, below average intelligence, and intellectual disability (ID).[59][60]

Although HIV/AIDS can be transmitted to offspring at different times, the most common time that mothers pass on the virus is during pregnancy. During the perinatal period, the embryo/fetus can contract the virus through the placenta.[45]

Gestational diabetes is directly linked with obesity in offspring through adolescence.[61] Additionally, children whose mothers had diabetes are more likely to develop Type II diabetes.[62] Mothers who have gestational diabetes have a high chance of giving birth to very large infants (10 pounds (4.5 kg) or more).[45]

Because the embryo or fetus's nutrition is based on maternal protein, vitamin, mineral, and total caloric intake, infants born to malnourished mothers are more likely to exhibit malformations. Additionally, maternal stress can affect the fetus both directly and indirectly. When a mother is under stress, physiological changes occur in the body that could harm the developing fetus. Additionally, the mother is more likely to engage in behaviors that could negatively affect the fetus, such as tobacco smoking, drug use, and alcohol abuse.[45]

Genital herpes can be passed to the offspring through the birth canal during delivery.[63][64] In pregnancies where the mother is infected with the virus, 25% of babies delivered through an infected birth canal become brain damaged, and 1/3 die.[45] HIV/AIDS can also be transmitted during childbirth through contact with the mother's body fluids.[45] Mothers in developed countries may often elect to undergo a caesarean section to reduce the risk of transmitting the virus through the birth canal, but this option is not always available in developing countries.[65]

Globally, more than eight million of the 136 million women giving birth each year suffer from excessive bleeding after childbirth.[66] This condition—medically referred to as postpartum hemorrhage (PPH)—causes one out of every four maternal deaths that occur annually and accounts for more maternal deaths than any other individual cause.[66] Deaths due to postpartum hemorrhage disproportionately affect women in developing countries.

For every woman who dies from causes related to pregnancy, an estimated 20 to 30 encounter serious complications.[43] At least 15 per cent of all births are complicated by a potentially fatal condition.[43] Women who survive such complications often require lengthy recovery times and may face lasting physical, psychological, social and economic consequences. Although many of these complications are unpredictable, almost all are treatable.

During the postpartum period, many mothers breastfeed their infants. Transmission of HIV/AIDS through breastfeeding is a huge issue in developing countries, namely in African countries.[65] The majority of infants who contract HIV through breast milk do so within the first six weeks of life.,[67] in despite of that Antiretroviral treatment (during pregnancy, delivery and during breastfeeding) Reduces transmission risk by >90% . However, in healthy mothers, there are many benefits for infants who are breastfed. The World Health Organization recommends that mothers breastfeed their children for the first two years of life, whereas the American Academy of Pediatrics and the American Academy of Family Physicians recommend that mothers do so for at least the first six months, and continue as long as is mutually desired.[68] Infants who are breastfed by healthy mothers (not infected with HIV/AIDS) are less prone to infections such as Haemophilus influenza, Streptococcus pneunoniae, Vibrio cholerae, Escherichia coli, Giardia lamblia, group B streptococci, Staphylococcus epidermidis, rotavirus, respiratory syncytial virus and herpes simplex virus-1, as well as gastrointestinal and lower respiratory tract infections and otitis media. Lower rates of infant mortality are observed in breastfed babies in addition to lower rates of sudden infant death syndrome (SIDS). Decreases in obesity and diseases such as childhood metabolic disease, asthma, atopic dermatitis, Type I diabetes, and childhood cancers are also seen in children who are breastfed.[68]

Following up on the women who have given birth is a crucial factor as it helps check on maternal health. Since healthcare facilities have records of the women who have given birth, when the women are followed to monitor the progress of their babies as well as their health, it becomes easy to put them on a follow-up and ensure they are doing well as the baby grows. Follow up is accompanied by nutritional advice to ensure both the mother and her baby are in good condition. This prevents sickness that may affect the two and deteriorate their health.

In a September 2016 ACOG/SMFM consensus, published concurrently in the journal Obstetrics & Gynecology and by the American College of Obstetricians and Gynecologists (ACOG), they noted that while they did not yet have a "single, comprehensive definition of severe maternal morbidity" (SMM), the rate of SMM is increasing in the United States as is maternal mortality. Both are "associated with a high rate of preventability."[5][85]

The U.S. Joint Commission on Accreditation of Healthcare Organizations calls maternal mortality a "sentinel event", and uses it to assess the quality of a health care system.[6]

Maternal mortality data is said to be an important indicator of overall health system quality because pregnant women survive in sanitary, safe, well-staffed and stocked facilities. If new mothers are thriving, it indicates that the health care system is doing its job. If not, problems likely exist.[86]

According to Garret, increasing maternal survival, along with life expectancy, is an important goal for the world health community, as they show that other health issues are also improving. If these areas improve, disease-specific improvements are also better able to positively impact populations.[87]

Maternal health clinic in Afghanistan (source: Merlin)

Decreasing the rates of maternal mortality and morbidity in developing countries is important because poor maternal health is both an indicator and a cause of extreme poverty. According to Tamar Manuelyan Atinc, Vice President for Human Development at the World Bank:[88]

"Maternal deaths are both caused by poverty and are a cause of it. The costs of childbirth can quickly exhaust a family's income, bringing with it even more financial hardship."

In many developing countries, complications of pregnancy and childbirth are the leading causes of death among women of reproductive age. A woman dies from complications from childbirth approximately every minute.[80] According to the World Health Organization, in its World Health Report 2005, poor maternal conditions account for the fourth leading cause of death for women worldwide, after HIV/AIDS, malaria, and tuberculosis.[89] Most maternal deaths and injuries are caused by biological processes, not from disease, which can be prevented and have been largely eradicated in the developed world — such as postpartum hemorrhaging, which causes 34% of maternal deaths in the developing world but only 13% of maternal deaths in developed countries.[90]

Although high-quality, accessible health care has made maternal death a rare event in developed countries, where only 1% of maternal deaths occur, these complications can often be fatal in the developing world because single most important intervention for safe motherhood is to make sure that a trained provider with midwifery skills is present at every birth, that transport is available to referral services, and that quality emergency obstetric care is available.[80] In 2008 342,900 women died while pregnant or from childbirth worldwide.[91] Although a high number, this was a significant drop from 1980, when 526,300 women died from the same causes. This improvement was caused by lower pregnancy rates in some countries; higher income, which improves nutrition and access to health care; more education for women; and the increasing availability of "skilled birth attendants" — people with training in basic and emergency obstetric care — to help women give birth. The situation was especially led by improvements in large countries like India and China, which helped to drive down the overall death rates. In India, the government started paying for prenatal and delivery care to ensure access, and saw successes in reducing maternal mortality, so much so that India is cited as the major reason for the decreasing global rates of maternal mortality.[92]

Until the early 20th century developed and developing countries had similar rates of maternal mortality.[93] Since most maternal deaths and injuries are preventable,[5] they have been largely eradicated in the developed world.

In developed countries, Black (non-Latina) women have higher maternal mortality rates than White (non-Latina) women. According to the New York City Department of Health and Mental Hygiene - Bureau of Maternal, Infant and Reproductive Health, it was found that from 2008 to 2012, Black (non-Latina) women have a pregnancy-related mortality rate twelve times higher than White (non-Latina) women.[94] The U.S. has the "highest rate of maternal mortality in the industrialized world."[95] It is also estimated that 50% of the deaths are from preventable causes.[96]

Since 2016, ProPublica and NPR investigated factors that led to the increase in maternal mortality in the United States. They reported that the "rate of life-threatening complications for new mothers in the U.S. has more than doubled in two decades due to pre-existing conditions, medical errors and unequal access to care."[95] According to the Centers for Disease Control and Prevention, c. 4 million women who give birth in the US annually, over 50,000 a year, experience "dangerous and even life-threatening complications."[95] Of those 700 to 900 die every year "related to pregnancy and childbirth." A "pervasive problem" is the rapidly increasing rate of "severe maternal morbidity" (SMM), which does not yet have a "single, comprehensive definition".[5]

According to a report by the United States Centers for Disease Control and Prevention, in 1993 the rate of Severe Maternal Morbidity, rose from 49.5 to 144 "per 10,000 delivery hospitalizations" in 2014, an increase of almost 200 percent. Blood transfusions also increased during the same period with "from 24.5 in 1993 to 122.3 in 2014 and are considered to be the major driver of the increase in SMM. After excluding blood transfusions, the rate of SMM increased by about 20% over time, from 28.6 in 1993 to 35.0 in 2014."[97]