Actions needed to improve maternal health

2.1. Preconception and prenatal care 

Many of the risk factors can be mitigated or prevented with good preconception and prenatal care. Preconception screening and counseling offer an opportunity to identify and mitigate maternal risk factors before pregnancy begins. During preconception counseling, healthcare providers can refer women for medical and psychosocial or support services for any risk factors identified. Counseling needs to be culturally appropriate and linguistically competent. Prenatal visits offer an opportunity to provide information about the adverse effects of substance use during pregnancy, including alcohol and tobacco, and serve as a vehicle for referrals to treatment services. The use of timely, high-quality prenatal care can help to prevent poor birth outcomes and improve maternal health by identifying women who are at high risk and taking steps to mitigate risks, such as the risk of high blood pressure or other maternal complications. Interventions targeted at prevention and cessation of substance use during pregnancy may be helpful in further reducing the rate of preterm delivery and LBW. Promotion of folic acid intake can help to reduce the rate of NTDs. Other actions taken after birth can significantly improve neonatal health and chances of survival. Breastfeeding has been shown to reduce rates of infection in infants and to improve long-term maternal health.

2.2. Reduce the occurrence of spina bifida and other neural tube defects 

Approximately 50% of pregnancies that are affected by NTDs could be prevented with adequate consumption of folic acid from 1 month before conception through the first 3 months of pregnancy. In 1998, the Institute of Medicine recommended that to reduce the risk of an NTD-affected pregnancy, all women capable of becoming pregnant should consume 400 μg of folic acid daily, from fortified foods or supplements or a combination of the two, in addition to consuming folate-rich foods, such as orange juice, green vegetables, and beans. Most grain products (including enriched flour, breads, breakfast cereals, rice, and pasta) are now fortified with folic acid. However, the amount of folic acid that some segments of the reproductive-aged population receive through their diet may not adequately meet the recommended daily amount. However, an important study by Wald et al. [4] in 2001 affirmed that an increase to 5 mg daily was more effective in reducing the occurrence of NTDs. The supply of folic acid and docosahexaenoic acid (DHA) has been associated with a positive effect on pregnancy and infant outcome [5].

2.3. Increase the proportion of mothers who achieve a recommended weight gain during pregnancy 

Current evidence indicates that gestational weight gain, particularly during the second and third trimesters, is an important determinant of fetal growth [6], [7]. Inadequate weight gain during pregnancy is associated with an increased risk of low weight and infant death. Obesity is associated with an increased risk for adverse reproductive health outcomes, such as infertility, gestational diabetes, pregnancy-induced hypertension and pre-eclampsia, macrosomia (>4500 g), cesarean delivery, and prolonged labor [8], [9]. Maternal weight gain is susceptible to intervention and represents an opportunity to prevent poor birth outcomes. The Institute of Medicine's 1990 guidelines [10] for weight gain in pregnancy recommend a graduated level of weight gain based on a woman's prepregnancy body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) (Table 1).

Table 1. Maternal weight gain recommended in pregnancy based on prepregnancy body mass index.

	Body mass index a	Weight gain, kg
	Low<19.8	12.5–18
	Normal 19.8–26.0	11.5–16
	High 26.0–29.0	7–11.5

a BMI calculated as weight in kilograms divided by height in meters squared.

Prevention is the best way to treat this problem. Because pregnancy is the worst time to lose weight, women with a high BMI should be encouraged to lose weight prior to conceiving, using lifestyle changes if possible. During pregnancy, weight gain should be limited and physical activity encouraged.

During preconception counseling, women should be educated about the complications associated with high BMI. Obese women should also be screened for hypertension and diabetes mellitus.

2.4. Eliminate the use of some drugs or medications 

Many drugs can cross the placenta and adversely affect the developing child. Physicians and parents have become increasingly concerned about the potentially harmful effects of drugs on the developing embryo and fetus. One of the most dramatic reasons for this concern was the discovery in the 1960s of the gross anatomical defects caused by thalidomide, which many women had taken during pregnancy. Many other drugs are suspected of producing birth defects when taken during pregnancy; substances that produce such effects are called teratogens. Known or suspected teratogens include legal drugs (alcohol, nicotine, caffeine); prescription drugs (some antibiotics, hormones, steroids, anticoagulants, anticonvulsants, tranquilizers, methadone); illegal drugs (cocaine, heroin, marijuana); and environmental pollutants (organic solvents, including lead, methylmercury, and polychlorinated biphenyls).

2.5. Promote abstinence from alcohol to reduce fetal alcohol syndrome 

Overall rates of alcohol intake during pregnancy increased during the 1990s, and the proportion of pregnant women using alcohol at higher and more hazardous levels has increased substantially.

Alcohol crosses the placenta easily and stays in the fetus's system longer than the mother's. Alcohol can create a spectrum of fetal effects, including any or all of the following: fetal death; various degrees of mental impairment; physical abnormalities; hyperactivity; autistic tendencies; and failure to thrive. Heavy alcohol use is associated with FAS [11].

Fetal alcohol syndrome is one of the leading preventable causes of mental impairment and a leading cause of birth defects, including growth deficiency and microcephaly. Alcohol-related birth defects and alcohol-related neurodevelopmental disorders are thought to occur 3 to 4 times more often than diagnosed cases of FAS. Because of these lifelong effects, and because a safe level of alcohol consumption during pregnancy has not been identified, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) recommend that women who are pregnant or are planning a pregnancy abstain from the use of alcohol [12].

2.6. Promote abstinence from smoking 

Despite medical advice, 20%–30% of female smokers continue to smoke during pregnancy. Cigarette smoke contains more than 4000 harmful substances that both mother and fetus are exposed to [13]. While smoking a cigarette, carbon monoxide is inhaled. This means that the amount of oxygen available to the fetus through the umbilical cord is reduced. This makes the fetal heart beat more rapidly, and increases overall stress on its body. Recent research suggests that cigarettes can also reduce the flow of blood in the placenta, which limits the amount of nutrients that reach the fetus. Smokers have a greater risk of ectopic pregnancy and miscarriage. This risk is 4-times greater in smokers than nonsmokers, and 6-times greater in women who smoke more than 20 cigarettes a day. Tobacco is also associated with a higher risk of having a preterm labor, complications during labor, and a low birth weight neonate [13], [14]. If the mother quits in the first 3 months of pregnancy, the risk of having an LBW neonate will be similar to that of a nonsmoker. The risk of sudden infant death syndrome is increased in mothers who smoke during pregnancy. Infants exposed to tobacco smoke after birth also have an increased risk of the syndrome.

Epidemiological studies have associated maternal smoking with increased risk of obesity and type-2 diabetes in the offspring. One recent study has shown a direct association between fetal nicotine exposure and offspring metabolic syndrome with early signs of dysregulation of adipose tissue and pancreatic development [15].

2.7. Promote abstinence from illicit drugs 

Substance abuse in pregnancy is on the increase worldwide. Simultaneously, there is great variability in prevalence rates in different countries and in different ethnic groups. Substance abuse in pregnancy is associated with significant maternal and fetal morbidity [16]. Risk factors suggesting substance abuse in pregnancy include lack of prenatal care, history of premature labor, and cigarette smoking [16]. ACOG also acknowledges that some states consider intrauterine fetal drug exposure to be a form of child neglect or abuse under the law [17].

Use of cocaine during pregnancy is associated with maternal hypertension and increased chances of miscarriage, stillbirth, and placental abruption. Neonates are often born small for gestational age and experience a significant withdrawal syndrome. There is also a higher risk for preterm labor. It is now recommended that all neonates born to mothers who have used cocaine undergo a scan to detect cerebral infarcts, since there is a significantly increased risk of this occurring. Cocaine is harmful throughout all stages of pregnancy and many perinatal deaths are associated with maternal cocaine use [16].

Exposure to marijuana in utero may be associated with LBW, preterm birth, and neurobehavioral functioning. However, isolating the effects of marijuana use on neonates is difficult because users of the drug often use alcohol and tobacco as well. Self-reported use of illicit drugs, such as cocaine and marijuana, is quite rare, with 98% of pregnant women reporting abstinence from these drugs. Rates of abstinence from harmful substances during pregnancy appear to be declining slowly. Abstinence syndrome can also occur in the neonate.

2.8. Reduce infection transmission from mother to fetus 

Some infections suffered by the mother can damage the infant when the disease organisms cross the placental barrier. Screening tests are available for a group of infections known by the acronym TORCH, which stands for Toxoplasma gondii, other viruses (HIV, measles, and more), rubella, cytomegalovirus, and herpes simplex. All of these infections are due to teratogens.

One of the most serious viral diseases during the first 3 months of pregnancy is rubella, the most teratogenic agent known. If primary rubella infection occurs during pregnancy, the virus may cross the placenta and induce fetal infection, depending upon the gestational period. The classic triad of defects associated with congenitally acquired rubella consists of cataracts, heart defects, and sensorineural deafness, but many other anomalies have also been described. The pathological potential of intrauterine rubella, the congenital rubella syndrome (CRS), has greatly expanded. Cases of CRS are still being reported in India, as in most other countries, despite the availability of the rubella vaccine since 1969 [18]. The treatment is only symptomatic. A pregnant woman can be tested to see whether she has already had rubella, but if she has not, she cannot be given the vaccine for rubella because it contains the live virus. Thus, it is best for a woman who is considering pregnancy to ascertain whether she has had rubella before she becomes pregnant, and to receive the vaccine at that time if she has not had it.

The rapid spread of the genital herpes virus among young adults poses another danger [19]. The incidence of herpes simplex virus (HSV) infection has been increasing steadily in recent decades, and concerns about perinatal HSV infection are growing among women of reproductive age because of the risk of virus transmission to their babies during pregnancy, with potentially devastating consequences to the fetus. Infection of the fetus with this virus usually occurs late in pregnancy, probably during delivery, and can result in severe neurological damage. When infection occurs several weeks prior to birth, a variety of congenital abnormalities can result. Previous studies have suggested that genital HSV infection acquired during pregnancy is associated with preterm labor, intrauterine growth restriction, and spontaneous abortion. Prompt medical intervention is necessary if the presence of herpes during pregnancy is suspected. The treatment consists of topical and oral acyclovir (200 mg every 6 hours for 7–10 days). Current data suggest that in the population treated in the first trimester there is no greater incidence of major congenital defects.

Sexually transmitted infections (STIs) are now the most common group of identifiable infectious diseases in many countries, especially among those aged 15–50 years and in infants. Their control is important considering the high incidence of acute infections, complications and sequelae, their socioeconomic impact, and their role in increasing transmission of HIV [20]. The worldwide incidence of major bacterial and viral STIs is estimated to be over 125 million cases yearly. STIs are hyperendemic in many low-resource countries. However, in industrialized countries, bacterial STIs such as syphilis, gonorrhea, and chancroid declined from their peak during World War II until the late 1950s, increased during the 1960s and early 1970s, and have again decreased since that time. In the industrialized world, diseases due to Chlamydia trachomatis, genital herpes virus, human papillomaviruses, and HIV are now more significant than the classical bacterial viruses; both groups remain major health problems in most low-resource countries. HIV infections have an equal sex ratio in Africa, with a younger age incidence in women and a high vertical transmission rate; while in Latin America, bisexual men, and increasingly, heterosexual transmission by intravenous drug users is reported. There is also an HIV-2 virus, whose virulence is in question, common in West Africa [20].

The incidence of syphilis has been increasing in recent years. Infection of the fetus with syphilis is not infrequent. Fortunately, the placental barrier does not permit passage of the spirochetes that cause syphilis until after the fourth or fifth month of pregnancy. Consequently, transmission of the spirochetes (which otherwise would take place in about 24% of cases) may be prevented if treatment begins early in pregnancy. When infection does occur, the spirochetes may produce spontaneous abortion or a weak, deformed, or mentally deficient newborn. HIV and hepatitis B and C are included in sexually transmitted infections.

If a mother develops hepatitis B during her pregnancy, there is a chance that the fetus may also become infected. If the mother develops acute hepatitis in the third trimester of pregnancy or the immediate postpartum period, the risk of infection for the neonate may be 60%–70%. It is vital that the neonate receives treatment immediately after birth to ensure as much protection as possible. Neonates infected with hepatitis B who do not receive treatment at the time of birth may have the virus for the rest of their lives and can spread the disease. There may be long-term effects from acquiring hepatitis B at such an early age. Approximately 90% of infants who acquire HBV infection at birth go on to become chronic carriers. An estimated 15%–25% of these carriers ultimately will die of liver failure secondary to chronic active hepatitis, cirrhosis, or primary hepatocellular carcinoma. A dose of hepatitis B vaccine has been shown to prevent 90% of perinatal infections if given within 12 hours of birth.

AIDS currently threatens the lives of a growing number of unborn and newborn babies. The percentage of women who have developed AIDS or ARC (AIDS-related complex) is rising rapidly. Mothers with AIDS can pass the virus to their babies, either across the placental barrier during pregnancy, during birth, or by breastfeeding. Pregnant women with HIV can pass it to their baby during pregnancy, labor, delivery, or breastfeeding. During pregnancy, there is a risk that HIV can pass through the placenta and infect the fetus. During labor and delivery, the neonate may be exposed to the virus in the mother's blood and other fluids. Breastfeeding also can transmit the virus because breast milk contains HIV. However, not all HIV-infected women infect their babies. Estimates of transmission vary from 10%–40%. Without treatment, 1 in 4 babies will become infected. The risk of passing HIV to the baby depends in part on the mother's viral load and CD4 levels that will be watched carefully during pregnancy. Both a high viral load and a low level of CD4 cells mean there is a greater risk of passing HIV to the fetus.

Neonates infected with HIV at birth are also more susceptible to opportunistic infections and rapid progression to AIDS, including a 50% chance of developing AIDS by 3 years of age and a 90% chance of dying by 10 years of age.

It is vital that all pregnant women are tested for HIV as early as possible in their pregnancies. Women who have not been tested for HIV during pregnancy are offered a rapid HIV test when they go into labor. Results of a rapid test are available in a few hours. It is important to have this test because the baby should receive treatment as soon as possible if the mother has HIV.

Antiretroviral therapy is now standard practice in the management of pregnant patients with HIV infection. If an HIV-positive woman has been taking medications to treat HIV, she should continue the treatment during pregnancy. If she has not been taking medication, she should usually wait until after the first trimester to start. The drugs help to keep the viral load low and make it less likely that the baby will get HIV. Like other drugs, medications used to treat HIV may affect the development of the fetus. But stopping treatment increases the risk of passing the virus to the baby [20].

Optimal antiretroviral therapy is to treat pregnant women infected with HIV the same as adults infected with HIV who are not pregnant, using clinical, virologic, and immunologic status to guide treatment decisions. One difference for pregnant women is to include zidovudine in every treatment regimen [21]. In addition to antiretroviral therapy, the mode of delivery can have an impact on vertical transmission of HIV. Approximately 65% of transmissions occur during labor [22]. In fact, during labor and delivery, the baby is exposed to body fluids that can spread the virus. When a woman goes into labor the amniotic sac breaks. Once this occurs the risk of HIV infection increases. Because of these issues, women with high viral loads are offered a cesarean delivery. A cesarean delivery decreases the risk of passing HIV to the baby during labor and delivery [22].

Neonates born to HIV-positive mothers will be treated with medication after birth to further decrease the chance of becoming infected. The first dose is given within 12 hours after delivery. Treatment continues for 6 weeks. Women who are HIV-positive should not breastfeed since this could pass the infection to their babies. Women who are HIV-positive can feed their babies infant formula with a bottle. Infant formula is a safe way of providing the baby with all of the nutrients needed to grow and thrive.

Prevention of STIs can be summarized in 5 key points. Firstly, the aggregate effect of radical and sustained behavioral changes in a sufficient number of individuals potentially at risk is needed for successful reductions in HIV transmission. Secondly, combination prevention is essential since HIV prevention is neither simple nor simplistic. Reductions in HIV transmission need widespread and sustained efforts, and a mix of communication channels to disseminate messages to motivate people to engage in a range of options to reduce risk. Thirdly, prevention programs can do better. The effect of behavioral strategies could be increased by aiming for many goals (e.g., delay in onset of first intercourse, reduction in number of sexual partners, increases in condom use, etc) that are achieved by use of multilevel approaches (e.g., couples, families, social and sexual networks, institutions, and entire communities) with populations both uninfected and infected with HIV. In particular, the best means to prevent the spread of and to protect against STIs is the condom. Fourth, prevention science can do better. Interventions derived from behavioral science have a role in overall HIV-prevention efforts, but they are insufficient when used by themselves to produce substantial and lasting reductions in HIV transmission between individuals or in entire communities. Finally, we need to get the simple things right. The fundamentals of HIV prevention need to be agreed upon, funded, implemented, measured, and achieved.