Promoting health to reduce complications in newborns and mothers

Maternal and newborn health begins before a woman gets pregnant. It begins when she decides to have, or not have, children. Contraceptive and family planning methods are one way for women and girls who do not want to have children, or who do not want to have children right then, to control their fertility. The health benefits of appropriate timing and spacing of pregnancies are numerous; Pregnancies that are spaced by at least two years after a live birth and six months after a miscarriage or induced abortion can reduce the risk of complications and adverse maternal and newborn outcomes. Additionally, when possible, it is recommended to delay first pregnancy until after age 18, as studies have shown that both newborns and mothers have the healthiest outcomes when mothers are older than 18. Adolescents, regardless of marital status, should have access to contraceptive methods.

All family planning methods, whether they’re modern or traditional, are effective with correct and proper use. Some are more effective than others.

Proper health care during pregnancy, including nutrition and mental health, can reduce adverse outcomes for mother and baby, and reduce the risk of miscarriage and stillbirth. In planned pregnancies, pregnancy care can begin before pregnancy. Women who plan to get pregnant can begin focusing on proper nutrition, including folic acid and iron supplementation, and mental health, to prepare for the emotional and hormonal shifts that come with pregnancy. Additionally, all women who plan to get pregnant should know their HIV status; women who test HIV positive should begin antiretroviral therapy (ART) as soon as possible, and remain on ART during and after their pregnancy. Even if a pregnancy is unplanned, it is never too late for women to begin prioritizing their nutrition and mental health, and to test for HIV.

Quality, timely antenatal care remains one of the best interventions for identifying maternal and newborn complications before they become fatal. While quality medical care has always been a key component of antenatal care (ANC), the World Health Organization (WHO) developed a new model for ANC that ensures a positive pregnancy experience by providing additional support in a respectful, appropriate manner. This new model increases the number of recommended visits from four to eight during pregnancy and includes counseling on nutrition, physical activity, substance use (including tobacco), malaria and HIV prevention, tetanus and other vaccinations, and other context-appropriate interventions. In many contexts, this can be achieved by integrating ANC services with other health services, including child vaccinations, malnutrition treatment, and antimalarial interventions. This allows for mothers and their families to receive support and care for multiple needs in one visit. This integration can be especially helpful at reaching pregnant adolescents, who often delay attending their first ANC. Additionally, some components of ANC can be provided by lower-level cadres of healthcare providers, such as community health workers, on an outreach basis.

Regardless of the number or quality of ANC visits and care during pregnancy, there is always a risk of complications and emergencies. It is critical to get to a facility as soon as complications arise , so educating mothers, their partners, and their families on how to identify danger signs must be part of all pregnancy care. Delays in identifying complications, getting to a facility, or receiving care at the facility, (the Three Delays), can increase the risk of mortality and morbidity. Once arriving at the facility, basic emergency obstetric and newborn care (BEmONC) or comprehensive emergency obstetric and newborn care (CEmONC) must be available 24 hours a day, seven days a week, and be provided in a timely manner. BEmONC includes seven key services, or signal functions, with two additional services included in CEmONC. Cesarian section is included in CEmONC.

These signal functions are key medical interventions that treat the majority of maternal complications, including postpartum hemorrhage, sepsis, and eclampsia.

Complications from unsafe or incomplete abortion are also included in BEmONC and CEmONC. Unfortunately, coverage of BEmONC and CEmONC services varies widely across the globe, especially in low- and middle-income countries; improving coverage would go a long way to reducing maternal and newborn mortality worldwide.

If a woman is at risk of premature delivery, administering antenatal corticosteroids (ACS) can accelerate fetal lung development and reduce risk of brain hemorrhage and other prematurity complications in the newborn. The WHO recommends administering ACS when certain conditions are met. It is crucial that health systems and providers prioritize proper training and quality of care to increase survival and health outcomes for preterm newborns and their mothers, and this quality care includes appropriate use of ACS for threatened imminent preterm delivery.

The actions taken in the minutes and hours immediately following birth can have a long-lasting affects on the newborn; proper care can set them up for success throughout their life. The interaction between skilled healthcare workers and mothers before, during, and just after labor is critical for saving lives and ensuring good, healthy birth outcomes. Best practices include ensuring mothers are involved in the decision-making (including where they will give birth) and are provided with supportive care at all stages and that the birth proceeds without intervention as long as labor progresses normally and the woman and baby are well.

Essential newborn care (ENC) refers to the key routine newborn care practices all newborns should receive and include early initiation and exclusive breastfeeding, thermal care, and safe hygiene practices. Early initiation and exclusive breastfeeding involves putting the newborn to the breast, and only feeding breastmilk, within the first hour of life. Continued exclusive breastfeeding through the first six months is more likely when breastfeeding is initiated early. Thermal care, including prompt drying and covering at birth, maximizing skin-to-skin contact, delayed bathing, and maintaining the “warm chain”, keeps the newborn warm and reduces the risk of hypothermia, especially in premature newborns. Skin-to-skin contact is especially important, and recent guidance encourages immediate skin-to-skin contact between mother and newborn within the first hour for all infants, regardless of birthweight. Safe hygiene practices for newborn care goes beyond hand washing; it also includes umbilical cord care. Proper umbilical cord care can prevent life-threatening sepsis and cord infections and avert preventable neonatal deaths. It includes using clean, sterile blades and ties, keeping the stump clean using soap and water, and drying thoroughly with a clean cloth after getting wet. In most settings, proper clean, dry umbilical cord care is sufficient to prevent infection. In some settings, where harmful traditional substances are placed on the cord, the WHO recommends using chlorhexidine digluconate (CHX) in addition to clean, dry cord care.

All women should know their HIV status, especially if they intend to become pregnant, as there is a risk of transmitting HIV to their newborn during pregnancy, delivery, or while breastfeeding. This vertical transmission, or mother-to-child transmission, is the leading cause of infection among children under 15 globally, and eliminating vertical transmission in low- and middle- income countries has been slow. Between 15 and 45 percent of infants born to HIV-positive women will become infected, if no preventative action is taken. Antiretroviral therapy (ART) can significantly reduce the risk of vertical transmission, as it decreases viral levels and makes it less transmittable. All pregnant women should be tested for HIV at their first antenatal visit, especially those in HIV-endemic regions, and all pregnant women living with HIV should be supported to initiate or continue ART during pregnancy. All children born to HIV-positive mothers should receive preventative antiretroviral drugs, with regular testing at two months and after the cessation of breastfeeding.

Proper post-delivery care, or the care a newborn receives immediately following birth, is crucial. While all newborns should receive essential newborn care, most newborns have specific needs that go above and beyond these essential services. Small and/or sick newborns (SSNB), or those who are born weighing below 2,500 grams or become ill, require specific interventions to prevent long-term morbidity or mortality. As nearly 80% of all newborn deaths occur in low-birth-weight (LBW) newborns, timely, appropriate, and quality interventions can save lives. Most small and sick newborns require special inpatient care, which can only be provided in a health facility. Intensive care in a high-level referral facility is only required by a third of sick newborns.

Newborns that are born small (from prematurity or intrauterine growth restriction) or become ill are at high risk of dying or becoming disabled; an estimated 1 million of survivors in this group survive with a long-term disability. Specialized care is necessary for these small and/or sick newborns (SSNBs).

The first hours and days after birth are the riskiest for both mothers and newborns. All mothers and newborns should remain at the facility for 24 hours after birth to ensure stability and establish healthy practices. Even in uncomplicated births, there are important interventions and practices during this period that can reduce the risk of further complications and support the health of mothers and newborns. Postnatal care (PNC) builds upon antenatal care to continue counseling and health education on newborn care and care-seeking for danger signs in the postnatal period. This support may be especially important in settings where births still take place at home. It can also include assessment and counseling provided to the mother before discharge after giving birth in a health facility, as well as later contacts during home visits by community health workers or postnatal visits to a health facility.

The quality and duration of this care is also important. The WHO recommends PNC continue for the first 42 days, or six weeks, following birth. It encourages care provided by kind, competent health care workers operating in a health system with a robust referral network, to ensure timely care in case of complications requiring facility-based treatment. These visits can occur in facilities, or at home through community-based delivery systems, such as community health workers. PNC should be provided in a respectful manner, and emphasize the unique challenges of the postnatal period for women. As much as 24% of women experience postpartum anxiety, and nearly 17% experience depression. Screening for maternal mental health issues should be included in PNC visits as part of this human-centered approach.