Maternal health

Maternal health refers to the health of women during pregnancy, childbirth, and the postpartum period. It encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to reduce maternal morbidity and mortality.^[1]

Preconception care can include education, health promotion, screening and other interventions among women of reproductive age to reduce risk factors that might affect future pregnancies. The goal of prenatal care is to detect any potential complications of pregnancy early, to prevent them if possible, and to direct the woman to appropriate specialist medical services as appropriate. Postnatal care issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding, and family planning.

Problems

Maternal health clinic in Afghanistan (source: Merlin)

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.^[2] 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.^[3] 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.^[4]

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.^[2] In 2008 342,900 women died while pregnant or from childbirth worldwide.^[5] 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.^[6]

One specific disease that causes significant maternal health problems is HIV/AIDS. Mother to child transmission of HIV in the developing world is a large concern; approximately 45% of infected mothers transmit the disease to their children^[2] and HIV is a major cause of maternal mortality, causing 60,000 maternal deaths in 2008. HIV rates are especially high in Sub-Saharan and Eastern Africa, where maternal mortality rates are on the rise.^[6]

Maternal health problems also include complications from childbirth that do not result in death. For every woman that dies during childbirth, approximately 20 suffer from infection, injury, or disability^[7]

Almost 50% of the births in developing countries still take place without a medically skilled attendant to aid the mother, and the ratio is even higher in South Asia.^[2] Women in Sub-Saharan Africa mainly rely on traditional birth attendants (TBAs), who have little or no formal health care training. In recognition of their role, some countries and non-governmental organizations are making efforts to train TBAs in maternal health topics, in order to improve the chances for better health outcomes among mothers and babies.^[8]

Proposed solutions

The World Bank estimated that a total of 3.00 US dollars per person a year can provide basic family planning, maternal and neonatal health care to women in developing countries.^[9] Many non-profit organizations have programs educating the public and gaining access to emergency obstetric care for mothers in developing countries. The United Nations Population Fund (UNPFA) recently began its Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), focusing on providing quality healthcare to mothers. One of the programs within CARMMA is Sierra Leone providing free healthcare to mothers and children. This initiative has widespread support from African leaders and was started in conjunction with the African Union Health Ministers.^[10]

Improving maternal health is the 5th of the 8 United Nations' Millennium Development Goals, targeting a reduction in the number of women dying during pregnancy and childbirth by three quarters by 2015, notably by increasing the usage of skilled birth attendants, contraception and family planning.^[11] The current decline of maternal deaths is only half of what is necessary to achieve this goal, and in several regions such as Sub-Saharan Africa the maternal mortality rate is actually increasing. 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:^[12]

"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."

Developed countries had rates of maternal mortality similar to those of developing countries until the early 20th century, therefore several lessons can be learned from the west. During the 19th century Sweden had high levels of maternal mortality, and there was a strong support within the country to reduce mortality rate to fewer than 300 per 100,000 live births. The Swedish government began public health initiatives to train enough midwives to attend all births. This approach was also later used by Norway, Denmark, and the Netherlands who also experienced similar successes.^[13]

Increasing contraceptive usage and family planning also improves maternal health through reduction in numbers of higher risk pregnancies. In Nepal a strong emphasis was placed on providing family planning to rural regions and it was shown to be effective.^[14] Madagascar saw a dramatic increase in contraceptive use after instituting a nationwide family planning program, the rate of contraceptive use increased from 5.1% in 1992 to 29% in 2008.^[15]

Global Situation

Maternal Mortality Rate worldwide, as defined by the number of maternal deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management, excluding accidental or incidental causes.^[16]

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.

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. ^[17]

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. ^[18]

Worldwide, the Maternal Mortality Ratio (MMR) has decreased, with South-East Asia seeing the most dramatic decrease of 59% and Africa seeing a decline of 27%. There are no regions that are on track to meet the Millennium Development Goal of decreasing maternal mortality by 75% by the year 2015.^[19]

Oral health

Maternal oral health has been shown to effect the well-being of both the mother and her unborn fetus.

Oral health has long been considered an arena of its own, distinct from general health, but there has been a recent push to bring together these two fields. The 2000 Surgeon’s General Report stresses the interdependence of oral health on the overall health and well being of an individual.^[20] Oral health is essential to overall health, especially during perinatal period and the future development of their children.^[21] 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.^[22] 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. ^[23]

Connection between oral health and general health

Oral health has numerous implications on overall general health and the quality of life of an individual. The Surgeon General’s Report lists that various systemic diseases and conditions have oral manifestations.^[20] 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. Diet, nutrition, sleep, psychological status, social interaction, school, and work all can be affected by poor oral health. For example, oral-facial pain can result in sleep deprivation, depression, and other adverse psychological outcomes. Ultimately, impaired oral health can have a profound impact on the general well being of individuals, including the quality of their life.

Benefits and effects

Protection and control of oral health and diseases safeguards a woman’s health and quality of life before and during pregnancy. Also, it has the potential to decrease the transmission of pathogenic bacteria that occurs from mother to child.^[21] 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.^[22] It also causes indirect damage through bacterial induction of both inflammatory and immune responses of the host.^[24] 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.^[25] Other studies have also found an association between periodontal disease and development of pre-eclampsia and preterm births.^[24]

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.^[24] Dental carries are transmitted from mother to child vertically; colonization of carcinogenic bacteria primarily occurs from mother to child through saliva-sharing activities. Maternal oral flora can ultimately foretell oral flora in offspring.^[26] In addition, other maternal factors such as social, behavioral, and biological factors can predispose a child’s experience with tooth-decay.^[24] 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.^[22] 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.^[20] 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

Collaboration and education

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.^[22] 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.^[21] 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. 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. 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.^[20] 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.^[21] 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.^[20] 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.

See also

References

External links

• "5. Improve maternal health". Millenium Development Goals. UNICEF. 
• "Maternal Health". World Health Organization. 
• WHO Making Pregnancy Safer Country profile on maternal and newborn health
• Jhpiego - Innovating to Save Lives
• United Nations Millennium Campaign | Goal 5: Maternal health
• White Ribbon Alliance for Safe Motherhood
• Family Care International
• Partnership for Maternal, Newborn, and Child Health
• Safe Motherhood
• UNICEF Maternal Health Databases
• March of Dimes
• EngenderHealth Maternal Health Care: Saving Women's Lives
• Rotary Maternal Health Projects in Nigeria Reduction of Maternal and Child Mortality — Prevention and Treatment of Obstetric Fistula
• Women Deliver
• Maternal Health Taskforce
• The Collaborative on Quality Care for Pregnancy & Childbirth
• Breastfeeding Nutrition
• Astarte, an initiative of JSI Research & Training Institute
• The Global Library of Women's Medicine Safer Motherhood
• Women and Children First