Module 4: Preconception and Prenatal Care for Women

Introduction: What is Preconception and Prenatal Care?

Prenatal care is perhaps the most important factor which determines the outcome of pregnancy. It has long been endorsed as a means of providing an array of available medical, nutritional, and educational interventions to reduce the risk of low birth weight and other adverse pregnancy conditions and outcomes; prenatal care is also important for identifying mothers at risk for delivering a preterm infant. Today, prenatal care typically is initiated in the first trimester of pregnancy and has an increasing schedule of visits as the pregnancy progresses. The content of this care usually includes screening for a variety of medical conditions, physical exams, and educational or counseling services.

Preconception care provides similar aspects but instead targets all women of reproductive age during adolescence and before the first pregnancy, as well as between pregnancies. The Center for Disease Control has defined preconception care as:

“Interventions that aim to identify and modify biomedical, behavioral and social risks to a woman’s health or pregnancy outcome through prevention and management by emphasizing those factors that must be acted on before conception or early in pregnancy to have maximal impact.”(1)

Preconception care includes assessing and identifying:(2)

• Nutritional status: fortification or supplementation of the diet with micronutrients such as iron, iodine, and folic acid;

• Preexisting medical conditions: treatment of conditions such as obesity, diabetes, epilepsy, hypothyroidism, and hypertension;

• Infectious diseases: vaccination against rubella, varicella, and hepatitis B; screening for HIV/AIDS and other sexually transmitted infections;

• Family planning for appropriately timed pregnancies;

• Genetic disorders: genetic risk assessment and preconception counseling to reduce the risk of birth defects.

Disparities in Preconception and Prenatal Care

In wealthy countries, the standard of care has risen to such an extent that maternal mortality has virtually disappeared. However, in many other parts of the world, the care of the mother before and during pregnancy may still be of low standard or may be nonexistent. This is evidenced by the fact that every year, approximately 300,000 women die of pregnancy-related causes, and 99% of these deaths occur in low- and middle-income countries.(3) WHO estimates that only 29-36% of African, 20-61% of Asian and 69-89% of South American births have maternity care.(4) Maternal mortality has decreased by almost half over the past few three decades, yet in low- and middle-income countries, the ratio of mothers that do not survive childbirth to those who do (maternal mortality ratio) is 14 times higher than in wealthy countries.(5) Furthermore, it is estimated that up to 15% of pregnant women develop complications related to pregnancy.(6) In areas of the world with limited access to and poor quality of medical care, about three-quarters of maternal deaths are considered “direct,” that is, due to pregnancy and its complications. The major direct causes of maternal mortality are hemorrhage, obstructed labor, sepsis, and hypertensive disorders of pregnancy. The methods to prevent these deaths are also well known and, while modern medical care is needed to prevent most of them, this care does not require highly technical interventions. The challenge today is to close these vast disparities in health outcomes for mothers by improving access to prenatal and preconception care.

Barriers to Care

Many factors interfere with needed preconception and prenatal care in the Global South, including a shortage of resources, geographic barriers, lack of education and awareness, and cultural beliefs.

Inadequate resources: In most low- and middle-income countries, there is gross shortage of doctors, midwives, and maternity units. The few medical workers available tend to practice in urban areas, leaving rural areas without access to care.

Widely dispersed population: In some places, particularly in rural areas, the population may be widely dispersed because villages are far apart, the people are nomadic in nature, or because many women spend a great part of the year in farms assisting their husbands and cannot easily reach maternity centers, especially where roads are bad or impassable.(7)

Literacy and financial status: Illiteracy and poverty are important factors which contribute to the poor prenatal and preconception care in many developing countries.(8)(9) There is evidence that literacy plays a more important role in determining the standard of antenatal care in such a community than the degree of wealth. A study in 47 countries in Africa, the Middle East and Asia showed that infant mortality rates associated far more with literacy rates than with gross national products.(10)

Cultural and traditional practices: The care of women during pregnancy is determined to a large extent by the influence of cultural and traditional factors. Many communities tend to adhere to the traditional belief that pregnancy and delivery is the province of traditional birth attendants. No prenatal care is performed in many of these cases. One study about the care of pregnant women in northern Nigeria showed that this influence is so strong in the population that even some educated patients do not go to the maternity centers during their pregnancy, preferring to remain at home and adopt traditional methods.(11)

In addition, the cultural pattern in some low- and middle-income countries is such that women occupy a subordinate position in the community. The acceptance of modern maternity practices may therefore depend on husbands, who may prefer their pregnant wives to assist in the farms or perform household duties rather than attend maternity clinics. Some traditional and cultural practices not only prevent a large number of women from utilizing maternity services but also can have harmful effects on patients.

Interventions

In order to eliminate disparities in health outcomes for mothers, increasing access and removing barriers to prenatal and preconception care is essential. Primary care should reach all women of reproductive age and incorporate the elements of preconception and prenatal care. Regardless of whether women are considering starting a family, it is important for them to be aware of the availability of services for preconception health.

Currently, there is a lack of understanding about how to reach all target populations with needed preventive interventions, and there is also a lack of funding and policy support. Coordinated action is necessary for the implementation of large-scale programs that address the issue of maternal health in low-income countries.

Footnotes

(1) Johnson, Kay, Samuel F. Posner, Janis Biermann, and José F. Cordero, comps. Recommendations to Improve Preconception Health and Health Care - United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. Rep. no. 55(RR06). Washington, DC, 2006. Centers for Disease Control and Prevention, 21 Apr. 2006. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm.

(2) Ibid.

(3) World Health Organization. Maternal Mortality Fact Sheet. http://www.who.int/mediacentre/factsheets/fs348/en/.

(4) Atrash, H. K., Alexander, S., & Berg, C. J. (1995). Maternal mortality in developed countries: not just a concern of the past. Obstetrics & Gynecology, 86(4), 700-705.

(5) United Nations. “Goal 3: Ensure healthy lives and promote well-being for all at all ages.” Sustainable Development Goals: 17 Goals to Transform Our World. http://www.un.org/sustainabledevelopment/health/.

(6) Walsh JA, Feifer CN, Measham AR, Gertler PJ. Maternal and perinatal health problems. In: Jamison DT, Mosley HW (eds). Disease ControlPriorities in Developing Countries. New York, NY: Oxford University Press; 1993.

(7) Adapted from: Nylander O, Adeyemi O. 10 Antenatal care in developing countries. Baillière's Clinical Obstetrics and Gynaecology. Volume 4, Issue 1, March 1990, Pages 169-186.

(8) Harrison KA (1985) The influence of maternal age and parity on child bearing with special reference to primigravidae aged 15 years and under. British Journal of Obstetrics and Gynaecology 92(supplement 5):23-31.

(9) Ekwempu CC (1988) The influence of antenatal care on pregnancy outcome. Tropical Journal of Obstetrics and Gynaecology 1: 67-71.

(10) Nortman DI & Hofstatter E (1985) Population and Family Planning Programmes. A Compendium of Data through 1978 10th edn, pp 4-11. New York: Population Council.

(11) Ekwempu CC (1988) The influence of antenatal care on pregnancy outcome. Tropical Journal of Obstetrics and Gynaecology 1: 67-71.