Population Action International

Having a safe pregnancy must be a right, not a privilege.

Pregnancy and childbirth and their consequences remain the leading causes of death and disability among women of reproductive age in developing countries today.1 Millions of women around the world do not have the means to either prevent unwanted pregnancies, or to prevent complications and disease in pregnancy.

The global increase in antenatal care2 coverage saves newborns' lives. Coverage is greater than or equal to 90 percent in 20 developing countries, although coverage rates alone do not indicate the quality of care women receive.3 The majority of these countries are in the Caribbean or South America. Still, antenatal care coverage remains notably low in Africa and parts of Asia.

Money and location determine babies' chances of survival. Across regions, the use of antenatal care is significantly influenced by wealth, and there are vast disparities in access to antenatal care between rural and urban areas. Women in urban areas are, on average, twice as likely as those in rural areas to receive four antenatal visits, but in general, these disparities are greatest in areas where use of antenatal care is low overall.4

Women's status is a strong determinant of access to services. For example, a WHO survey found that in some settings women in abusive relationships were significantly less likely to have received antenatal care.5

Antenatal care is a core component of maternal and child health care. In many developing countries, these services receive the largest share of budgetary allocations among reproductive health services.6 However, there are conflicting notions of what the content of care should be and the degree to which antenatal care improves health outcomes for women. A trend analysis of antenatal care coverage found that in many countries, blood and urine testing need to be increased to diagnose conditions such as preeclampsia, severe anemia and sexually transmitted infections (STIs).7

Antenatal care coverage can be used as a measure of women's exposure to the health system. Women who receive at least four antenatal care visits are about 3.3 times more likely to deliver in a medical facility than other women.8 Women who receive antenatal care are also most often associated with receiving postpartum care.9 However the relationship between antenatal care and skilled attendance at delivery is weakest in sub-Saharan Africa, where maternal mortality is highest.10

Aside from serving as an entry point to the health system in general, antenatal care can be a key entry point for family planning, nutrition and TB services, and prevention and care for HIV and other sexually transmitted infections (STIs). A study in Rakai, Uganda, found that pregnant women are twice as likely to become infected with HIV than non-pregnant or lactating women, indicating a critical need for HIV-prevention services as well as testing, care and PMTCT services (See PMTCT Box).11 Due to its generally wide coverage, antenatal care has an enormous potential to expand access to a wide range of interventions.12 For example, it is critically important for introducing preventative treatment and bednets for malaria. Every year, roughly 50 million women living in malaria-endemic countries become pregnant, and 10,000 of them and 200,000 of their infants die as a result.13 Antenatal care and provision of the information about reproductive risk factors and how to deal with them can also play an important role in engaging men in reproductive health issues. When and where possible, encouraging joint decision-making among couples can improve health outcomes for both partners overall.


Preventing Mother-to-Child Transmission of HIV

In 2006, an estimated 530,000 children were newly infected with HIV, contributing to an estimated 2.3 million children living with HIV worldwide.14 The majority of these infections occurred in sub-Saharan Africa and were acquired from mothers during pregnancy, labor, delivery or breast-feeding.

To prevent HIV infection in infants, United Nations agencies recommend a four-pronged approach15 that includes:

  1. preventing primary HIV infection in women;
  2. preventing unintended pregnancy among women with HIV infection;
  3. preventing transmission of HIV from infected pregnant women to their infants; and
  4. providing care, treatment and support to HIV-infected women.

Prevention of primary HIV infection in the general population is the foremost strategy for preventing mother-to-child transmission. Recent research shows that lowering HIV infection rates among sexually active adults by 1 to 5 percent can, in fact, achieve the same reduction in infant HIV infections as interventions administering Nevirapine to infants.16

All women, including HIV-positive women, should be enabled to reach their desired fertility and avoid unintended pregnancy. Emerging research on the relationship between pregnancy and HIV suggests that pregnancy can pose risks to HIV-positive women. HIV infection in pregnancy increases the risk of obstetric complications,17 18 and HIV-related illnesses such as anemia and tuberculosis might be aggravated by pregnancy.19 Pregnancy may also place women at a higher risk of contracting HIV; a study in Uganda found that women's susceptibility to HIV acquisition doubled during pregnancy.20

In addition to preventing primary HIV infections and avoiding unintended pregnancies, reducing HIV infection in children depends upon secondary prevention. This includes identifying HIV-positive pregnant women and providing them with antiretroviral (ARV) prophylaxis and guidance on infant feeding. Worldwide, an estimated 2.2 million women living with HIV/AIDS give birth each year.21 However, PMTCT programs only reach an estimated 5 percent of the HIV-positive population.22

Reducing HIV infection in children demands a range of PMTCT strategies, with antenatal care remaining a critical, yet underexploited entry point for a continuum of services for HIV-positive mothers.23

Given that most women are unaware of their HIV status, the range of strategies to address PMTCT should account for the known influences of viral load; such strategies include prevention and control of STIs and malaria, exclusive breast-feeding and strengthened family planning programs.24 These services reduce the risk of PMTCT, as well as promote health among all pregnant women and their children, and should exist alongside scaled-up VCT and drug treatment.25

 

Notes

  1. WHO. 2005. World Health Report 2005. Geneva: WHO.

  2. Antenatal care is care for and during pregnancy, provided by skilled health personnel. The WHO recommends a minimum of four antenatal visits at specific times for all pregnant women.
  3. WHO and UNICEF. 2003. Antenatal Care in Developing Countries: Promises, achievements and missed opportunities. Geneva: WHO.
  4. Ibid.
  5. Garcia-Moreno, Claudia, et al. 2005. WHO Multi-country Study on Women’s Health and Domestic Violence against Women: initial results on prevalence, health outcomes and women’s responses. Geneva: WHO.
  6. Gay J, Hardee K, Judice N, et al. 2003. What works: a policy and program guide to the evidence on family planning, safe motherhood, and STI/HIV/AIDS interventions: safe motherhood module 1. Washington, DC: Policy Project.
  7. WHO and UNICEF. 2003. Antenatal Care in Developing Countries: Promises, achievements and missed opportunities. Geneva: WHO.
  8. Ibid.
  9. Fort, Alfredo L., Monica T. Kothari, and Noureddine Abderrahim. 2006. Postpartum Care: Levels and Determinants in Developing Countries. Calverton, Maryland, USA: Macro International Inc..
  10. WHO and UNICEF. 2003. Antenatal Care in Developing Countries: Promises, achievements and missed opportunities. Geneva: WHO.
  11. Gray, Ron H, Li X, Kigozi G, et al. 2005. “Increased risk of incident HIV during pregnancy in Rakai, Uganda: A prospective study.” The Lancet 366: 1182-1188.
  12. Ronsmans, Carine and Wendy J Graham. 2006. “Maternal mortality: Who, when, where and why.” The Lancet 368: 1189-1199.
  13. WHO. 2005. World Health Report 2005. Geneva: WHO.

  14. UNAIDS. December 2006 AIDS Epidemic Update. Geneva: UNAIDS.

  15. The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children. Geneva: 3-5 May 2004.
  16. Sweat M., et al. 2004. “Cost effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries.” AIDS 18:1661–71.
  17. Maiques-Montesinos V, et al. 1999. “Post-cesarean section morbidity in HIV-positive women.” Acta Obstet Gynecol Scand 78: 789–92.
  18. Bjorklund K, Mutyaba T, Nabunya E and Mirembe F. 2005. “Incidence of postcesarean infections in relation to HIV status in a setting with limited resources.” Acta Obstet Gynecol Scand 84: 927–28.
  19. Ronsmans, Carine and Wendy J Graham. 2006. “Maternal mortality: Who, when, where and why.” The Lancet 368: 1189-1199.
  20. Gray, Ron H, Li X, Kigozi G, et al. 2005. “Increased risk of incident HIV during pregnancy in Rakai, Uganda: A prospective study.” The Lancet 366: 1182-1188.
  21. WHO. 2005. World Health Report 2005. Geneva: WHO.
  22. USAID. 2004. Coverage of selected services for HIV/AIDS prevention, care and support in low and middle income countries in 2003. Washington DC: The Policy Project.
  23. WHO and UNICEF. 2003. Antenatal Care in Developing Countries: Promises, achievements and missed opportunities. Geneva: WHO.
  24. Iliff PJ, Piwoz EG, Tavengwa NV, et al. 2005. “Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival.” AIDS 19: 699–708.
  25. Holmes, Wendy. 2005. “Seeking rational policy settings for PMTCT.” The Lancet 366: 1835–36.