Effective Antenatal Interventions to Prevent Maternal and Newborn Mortality

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By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

Compared to intrapartum care, antenatal care (ANC) has been largely neglected as an opportunity for intervention despite its potential to greatly impact the health of mothers and newborns. For many women around the world, particularly in low- and middle-income countries, ANC is their first adult contact with the formal health care system. ANC coverage has expanded over the last fifteen years: the proportion of women in developing countries receiving at least one ANC visit increased from 64% in 1990 to 83% in 2014. While this increase in utilization is a step in the right direction, content and quality of ANC are equally important factors.

A recent study published as part of the MHTF-PLOS Collection, “Neglected Populations: Decreasing Inequalities & Improving Measurement in Maternal Health,” reviews the current state of evidence on a number of antenatal interventions designed to reduce adverse maternal and newborn health outcomes. The authors analyze 21 types of interventions that fall into three categories: nutrition, infection and obstetrical/other. Key findings from the review and areas needing further research are summarized below.

Nutrition

Immediate and exclusive breastfeeding: There have been a number of interventions aimed at educating and supporting women to initiate breastfeeding and adopt optimal breastfeeding behaviors. Improving breastfeeding practices can help to reduce neonatal mortality, especially in low-resource settings.

Antenatal iron supplementation and anemia screening/treatment: Universal antenatal iron supplementation is safe and effective for combating maternal iron deficiency and anemia. There is limited evidence suggesting a possible impact on maternal mortality and morbidity, low birth weight and infant mortality, but further investigation is needed to examine these outcomes.

Multi-micronutrient supplementation: While a number of trials have found an association between multi-micronutrient supplementation and reduced risk of low birth weight, some evidence suggests a possible increased risk of neonatal death in some settings. There is no evidence illustrating an association with reduced risk of stillbirth.

Calcium supplementation: Available evidence suggests an association between calcium supplementation and reduced risk of maternal death from pre-eclampsia/eclampsia among women with low calcium intake. Some research has also demonstrated that calcium supplementation contributed to a modest reduction in preterm birth risk, and one large trial found a reduction in risk of all-cause neonatal mortality.

Antenatal vitamin A supplementation: There is mixed evidence on the relationship between antenatal vitamin A supplementation and maternal mortality, and there is no evidence that it is associated with reduced infant mortality, stillbirth, preterm birth or increased birthweight. However, despite the questionable benefit, ensuring adequate vitamin A intake is important. Available evidence supports the current recommendation to screen for maternal night blindness during pregnancy, a potential consequence of vitamin A deficiency during pregnancy.

Advance distribution of vitamin A for administration to the newborn: Results from randomized controlled trials suggest that vitamin A supplementation for newborns may reduce the risk of infant mortality, but only in settings with significant maternal vitamin A deficiency.

Iodized salt use: Available evidence does not illustrate a significant association between salt iodization and maternal and newborn mortality, stillbirth, prematurity or intrauterine growth restriction. However, adequate intake of iodized salt may help to prevent long-term cognitive disability.

Balanced protein-energy supplementation: Studies have been conducted in diverse settings, many with relatively small sample sizes, which limits the interpretation of results. However, available evidence suggests that balanced protein-energy supplementation can reduce the risk of low birth weight, particularly among women with poor nutrition status.

Infection

Deworming: While studies in non-pregnant populations with anemia have illustrated a benefit of deworming, there is no clear evidence that it prevents maternal and newborn mortality, stillbirth, prematurity or intrauterine growth restriction. Further evidence is needed to determine if deworming offers benefits to pregnant women and newborns.

Intermittent presumptive treatment of malaria and use of insecticide-treated nets: Evidence suggests that both of these interventions during pregnancy can dramatically reduce the risk of low birth weight. Malaria accounts for approximately 10% of maternal deaths in high-risk areas, but there is no direct evidence that the two interventions reduce the risk of maternal mortality. Weak evidence suggests a potential reduction in risk of newborn mortality, but further research is necessary. These two interventions should be implemented in areas with endemic malaria to improve maternal and newborn health outcomes.

Tetanus toxoid: Vaccination for tetanus toxoid in pregnant women almost always results in protection for the newborn and substantially reduces the risk of neonatal mortality caused by tetanus.

Advance distribution of chlorhexidine for application to the umbilical cord stump: Applying chlorohexidine to the umbilical cord stump is associated with substantial reduction in risk of neonatal death, often due to sepsis. An intervention giving chlorohexidine to pregnant women for application after home delivery is currently being implemented in Nepal.

Syphilis screening and treatment: Though evidence is limited, studies have demonstrated that timely screening and treatment of syphilis can substantially reduce syphilis-related stillbirths and neonatal deaths.

HIV screening/prevention of mother-to-child transmission (PMTCT): Transmission of HIV from mothers to babies is generally preventable through the use of combined antiretroviral therapy regimens. In order to maximize benefit, women must be screened and treated during pregnancy when receiving antenatal care.

Obstetrical and other

Advance distribution of misoprostol for use immediately after childbirth for preventing postpartum hemorrhage: Use of oxytocin is currently the gold standard for preventing postpartum hemorrhage (PPH). However, in settings where this option is not feasible, misoprostol can serve as an effective alternative. Available evidence suggests that use of misoprostol can prevent three out of four cases of PPH that would have otherwise been treated with oxytocin. Some observational studies have demonstrated that advance distribution of misoprostol by community health workers can be an effective strategy to safely prevent PPH.

Pre-eclampsia screening and treatment: Timely detection and treatment for pre-eclampsia can prevent a substantial number of maternal and newborn deaths related to pre-eclampsia/eclampsia. In order to maximize benefit, adequate infrastructure and functional referral systems for women with pre-eclampsia/eclampsia are crucial.

Clean delivery practices: The benefit of clean delivery practices is difficult to measure given the diversity of conditions and other contributing factors. However, available evidence suggests that interventions such as use of clean birth kits can improve maternal and newborn health outcomes in certain settings.

Thermal care: Measuring the effect of individual thermal care practices is difficult given that these practices are often done collectively. Thermal care practices can reduce the risk of newborn death from hypothermia. The effect size is probably substantial, but the evidence is inconclusive as to the proportion of newborn deaths that can be averted with good thermal care practices.

Birth preparedness ad complication readiness: A number of interventions under the “birth preparedness” umbrella have been designed and tested, many of which involve educating women about danger signs during pregnancy or labor. Some of these interventions have increased health service utilization, but not necessary emergency health care services. Certain interventions, particularly when birth preparedness is one component of a larger package, have been associated with a reduction in maternal mortality.

Tobacco and alcohol use: Some counseling and health education interventions have been associated with a modest reduction in smoking among pregnant women. There is not sufficient evidence demonstrating the success of interventions aimed at reducing alcohol consumption among pregnant women, though some psychological and educational interventions have been successful in some non-pregnant populations.

Family planning: Birth spacing is an important contributing factor to maternal and newborn health outcomes. Prenatal counseling has been associated with increased postpartum family planning usage in many settings around the globe.

As this review illustrates, a number of effective interventions exist for preventing adverse maternal and newborn health outcomes. However, the implementation of these interventions often requires resources such as skilled staff, medicines and equipment, physical infrastructure and financial means. Improving maternal and newborn health outcomes in low-resource settings requires a variety of strategies for implementing evidence-based practices.

Read more about the importance of antenatal care.

Watch a video of lead author Stephen Hodgins discuss this paper in a panel discussion to mark the launch of the MHTF-PLOS Collection, “Neglected Populations: Decreasing Inequalities & Improving Measurement in Maternal Health.”

Learn more about the MHTF’s collaboration with PLOS.