Maternal Health

Definition and Importance

Maternal health refers to the health of women during pregnancy, labor, and the postpartum period. It is a critical aspect of public health, as complications during these stages can have significant consequences for both mother and child.

• Maternal mortality remains a global concern, with over 700 women dying daily from preventable causes related to pregnancy and childbirth in 2023.

• Care by skilled health professionals before, during, and after childbirth is essential for saving lives.

Global Trends in Maternal Mortality

Statistics and Patterns

Maternal mortality ratio (MMR) is defined as the number of maternal deaths per 100,000 live births. Global trends show a decline, but disparities persist.

• Between 2000 and 2023, MMR dropped by about 40% worldwide.

• Over 90% of maternal deaths occur in low- and lower-middle-income countries.

• MMR stagnated or increased in some high-income countries, including the US.

Major Complications of Pregnancy

Leading Causes of Maternal Death

Nearly 75% of all maternal deaths are due to a few major complications:

• Severe bleeding (mostly after childbirth)

• Infections (usually after childbirth)

• High blood pressure during pregnancy (pre-eclampsia and eclampsia)

• Complications from delivery

• Unsafe abortion

Infection in Pregnancy

Maternal Physiological Changes and Risks

Pregnancy alters maternal physiology, increasing susceptibility to infections. Subtle shifts in immunity and hormonal changes place mothers at greater risk.

• High progesterone and decreased smooth muscle tone increase risk of urinary tract infections (pyelonephritis).

• The impact of infection depends on the type and timing during gestation.

Sepsis

Sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period.

• Sepsis is the third most common cause of death in pregnant women.

• Accurate assessment is complicated by underreporting of infections.

Bacterial and Viral Infections

• Bacterial: Group A strep (maternal sepsis), Group B strep (neonatal infection), Listeria (miscarriage, congenital infection), Hemophilus (meningitis, neonatal infection).

• Viral: Rubella (congenital defects), Measles (high maternal mortality), CMV (growth restriction), Parvovirus B19 (hydrops), Varicella (maternal pneumonia), Hepatitis B (miscarriage, death), Zika (microcephaly), Influenza (maternal morbidity), COVID-19 (increased maternal mortality).

Pre-eclampsia

Definition and Diagnosis

Pre-eclampsia is a pregnancy-specific condition occurring after 20 weeks, characterized by new-onset hypertension and proteinuria.

• Blood pressure >140/90 mmHg on two occasions at least 4 hours apart, or one reading >170/110 mmHg.

• New onset proteinuria is required for diagnosis.

Global Impact and Risk Factors

• Accounts for 14% of all maternal deaths globally.

• Associated with limited access to care, obesity, insulin resistance, and hypertension.

• Commonest cause of pre-term birth.

Pathophysiology

Pre-eclampsia is a two-stage disease:

1. Abnormal placentation in early pregnancy

2. Exaggerated maternal response after 20 weeks

• Failure of spiral arteries to adapt leads to decreased placental blood flow and uteroplacental ischemia.

Maternal and Fetal Complications

• Maternal: Hypertension, stroke, liver failure (HELLP syndrome), renal dysfunction, clotting disorders, cerebral edema.

• Fetal: Growth restriction, stillbirth, pre-term delivery, respiratory distress.

Reducing Risk and Management

• Aspirin 75mg daily and calcium supplements may reduce risk.

• Weight loss before pregnancy is recommended.

• Management includes treating hypertension, magnesium sulfate for seizure prevention, regular monitoring, thromboprophylaxis, and steroids for fetal lung maturation.

Postpartum Considerations

• 40% of eclamptic fits occur after delivery.

• Blood pressure should be monitored closely postpartum.

• Women with pre-eclampsia are at increased risk of hypertension later in life.

Labor and Delivery

Definition and Stages

Labor is defined as the onset of regular, painful uterine contractions with progressive cervical dilation and effacement.

• Three stages: First (onset to full dilation), Second (full dilation to delivery), Third (delivery of placenta).

• Active labor: Cervix 4-6 cm dilated, regular contractions.

Monitoring and Pain Relief

• Fetal heart rate monitoring (normal: 120-160 bpm).

• Maternal monitoring: heart rate, blood pressure, urine analysis, temperature, contractions, cervical dilation.

• Pain relief options: breathing techniques, water, hypnotherapy, TENs, nitrous oxide, narcotics, epidural.

Support and Outcomes

• Understanding labor, birth choices, pain relief, and support increases likelihood of successful vaginal delivery.

Complications in Labor

• Failure to progress, insufficient contractions, fetal distress, maternal hemorrhage.

• Skilled care is essential for recognition and management of complications.

Cesarean Section and Obstetric Fistula

Indications and Prevention

• Cesarean section indicated for obstructed labor, malposition, fetal distress, multiple pregnancy, previous cesarean, and other complications.

• Obstetric fistula is a preventable injury caused by prolonged obstructed labor without skilled care.

• Prevention requires access to emergency obstetric care.

Postpartum Hemorrhage

Causes and Management

Postpartum hemorrhage is the most common cause of maternal death worldwide.

• Blood loss >600ml, often due to uterine atony or retained placental tissue.

• Management: uterotonics, removal of retained tissue, manual compression, brace sutures, hysterectomy.

Care After Pregnancy

Postnatal Care

Postnatal care is crucial for screening complications, infections, postnatal depression, establishing breastfeeding, managing medical problems, and contraception.

• 63% of maternal deaths in the USA occur after delivery.

Reducing Maternal Deaths

Interventions and Social Determinants

• Interventions include access to care, contraception, structured antenatal care, birth spacing, skilled labor care, emergency drills, and postnatal care.

• Social determinants such as gender norms, violence, child marriage, and health system failures significantly impact maternal health outcomes.

Access to Contraception

• Contraception prevents pregnancy-related health risks and allows birth spacing.

• 77% of women aged 15-49 have their contraceptive needs met in 2024.

Summary Table: Major Maternal Complications

Conclusion

Maternal health is a multifaceted issue involving medical, social, and systemic factors. Addressing complications and reducing maternal mortality requires comprehensive interventions, skilled care, and attention to social determinants of health.