A new publication by the WHO has produced 49 recommendations on antenatal care for a positive pregnancy experience. Death in pregnancy remains a scourge that we have the power to address, and this report can be a catalysed for doing so. Every year, around 300,000 women and adolescent girls die as a result of pregnancy and childbirth-related complications. Furthermore, approximately 2.6m babies were stillborn in 2015 alone. Of these unnecessary, and wholly preventable deaths, 99% occur in developing countries. It is a sad fact that the likelihood of a woman dying during or directly after pregnancy in the course of her lifetime is 1 in 13 in Nigeria. This same likelihood is reduced to an average of 1 in 3,300 in developed countries where antenatal care is widespread and of higher quality.
For this reason, the 49 prescriptions from the WHO have touched a chord within my Wellbeing Africa Foundation - we directly support antenatal care across Nigeria and have seen, first hand, the immediate affect good care can have on pregnant women. We have looked through the WHO recommendations and identified 5 that we feel are particularly transformative in improving maternal health outcomes in developing countries.
1. Nutrition education on increasing daily energy and protein intake is recommended for pregnant women to reduce the risk of low-birth-weight infants; good nutrition during and after pregnancy is paramount for the health and wellbeing of both mother and child. The production of breast milk, for example, is impeded in the absence of sufficient nutrition and calorie intake of the mother. Exclusive breastfeeding (that is, the practice of feeding an infant up to 6 months old exclusively on mothers' breast milk) has innumerable benefits, spanning from boosting a child's immune system to brain development and earning power. In 2015 only 27% of babies in West and Central Africa received exclusive breastfeeding, rendering this region the lowest in the world. The human body provides the exact composition of nutrients and water in a mother's milk. Yet a mothers' ability to produce milk is restricted without a sufficiently nutritious diet. Nutrition education is therefore a priority for improving maternal and child health.
2. Clinical enquiry about the possibility of intimate partner violence should be strongly considered at antenatal care visits; this less predicable WHO recommendation is a consequence of widespread and largely unreported gender violence that affects women and children across the globe. The UN estimates that globally 1 in 3 women are subject to sexual or gender violence by an intimate partner at some point in their lifetime, of which it is suggested that up to 90% of cases go unreported. Formal and clinical enquiry in to this horrific crime is therefore a necessary tool to expose incidents, deterring similar occurrences in the future.
3. Screening and treatment for diseases such as TB, Malaria, and HIV; this WHO prescription is most relevant to Africa, which accounts for 26% of global TB, 88% of malaria and more than 2 thirds of cases of HIV worldwide. Screening for these diseases is important to ensure the protection of a child, and in the case of HIV, the prevention of transmission. Screening is not traditionally a part of antenatal care, and is thus often ignored. It is therefore of heightened importance that the WHO emphasises the point to draw attention to this overlooked aspect of care.
4. Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women's experience of care; this is perhaps the most significant of all the recommendations, and one which the WBFA hold particularly dear. The WHO highlights that eight or more contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000 births when compared to 4 visits. The evidence is undeniable but the problem remains that developing countries lack the infrastructure and funds to facilitate the implementation of such antenatal care models. The WBFA provides free antenatal care to thousands of women across West Africa. But this is not enough, and the private and NGO sector cannot sufficiently counter this problem alone.
5. For this reason, our final recommendation could be no other than this: Policy makers should consider educational, regulatory, financial, personal and professional support interventions to recruit and retain qualified health workers in rural and remote areas; in the absence of government support, a woman's right of access to all the above recommendations cannot be realised. Without a firm and realistic commitment from governments to improving maternal health outcomes, the injustice that denies so many of the right to a safe pregnancy will endure.
The recommendations from the WHO provide a comprehensive list of prescriptions based on research and evidence from developing countries. The challenge now is how to implement such prescriptions across the developing world, urban and rural, to ensure that every mother and child have the best chances in pregnancy and early life.
Greater emphasis on antenatal care is needed to apply added pressure on governments to increase the portion of the budget on public health, specifically in terms of obstetrics and midwifery. Greater leverage for health organisations to manoeuvre governments to comply with the needs of pregnant women is accelerated by the work of the WHO and other organisations, but research can only go so far. Progress requires political will, which could prove the most difficult to attain of all. But the lives that can be saved through relatively clear and achievable antenatal care improvements should be impetus enough for governments to act. The WHO should be commended for mapping out these improvements - the next step is scaling up implementation.