OWSD NIGERIA NATIONAL CHAPTER PRESENTS MATERNAL HEALTH CARE; IMPROVING THE WORKFORCE

May 11, 2022

OWSD Nigeria National Chapter University of Port Harcourt Branch Series of Scientific Communications: Olusayo A. Shorinwa on MATERNAL HEALTH CARE; IMPROVING THE WORKFORCE

MATERNAL HEALTH CARE; IMPROVING THE WORKFORCE.

Olusayo A. Shorinwa Ph.D

                                      Department of Experimental Pharmacology and Toxicology,

                                                    Faculty of Pharmaceutical Sciences,

                                                             University of Port Harcourt,

                                                         Port Harcourt, Rivers State, Nigeria.

                    Email: Olusayo.shorinwa@uniport.edu.ng sayoshorinwa@yahoo.com

                                              Telephone: +234 803 313 0810

Introduction

Maternal health can be simply defined as the state of health of women during pregnancy, childbirth and the postnatal period. Maternal health care is to ensure that women and their babies attain their full potential for health and well-being.

Maternal health is a very important aspect of public health because it affords the opportunity to prevent premature or unnecessary death among women by paying adequate attention and improving their quality of life. The well- being of women has a way of influencing the health of the future generation and can serve as a template for the prediction of likely future public health challenges that can arise in families, communities and the healthcare system.

WHO millennium development goal 5 is ‘’ improving maternal health” to save the lives of more than half a million women who die because of complications from pregnancy and childbirth each year. Improving maternal health is crucial to saving the lives of more than half a million women who die because of complications from pregnancy and childbirth each year (1). It has been reported that 810 women approximately, die every day from preventable causes related to pregnancy and childbirth (2). Pregnancy can expose existing health risks in women.

Factors affecting maternal health:

1. Maternal age
2. Parity
3. Education and marital status
4. Family size
5. Economic status
6. Place of residence
7. Environmental and social factors e.g., access to healthcare
8. Nutritional status
9. Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes.

The factors that influence maternal health also determines pregnancy outcomes, infant and child health.

 Maternal health challenges.

The most common health challenges associated with maternal injury and death are haemorrhage (excessive blood loss), infection, hypertension (high blood pressure), unsafe abortion, and obstructed labour. Haemorrhage can lead to anaemia while hypertension can ultimately lead to cardiovascular diseases. Malaria is also linked to maternal health problems.

1. Postpartum haemorrhage.

World Health Organization (WHO) defined post-partum  haemorrhage as blood loss in excess of 500 ml after delivery of the baby from a variety of sites: uterus, cervix, vagina and perineum1. Blood loss during the first 24 h after delivery is known as primary PPH, whereas blood loss from 24 h up to 6 weeks after delivery is termed late or secondary PPH (3).  

Risk factors:

Uterine atony, or lack of effective contraction of the uterus, is the most common cause of postpartum haemorrhage. Postpartum haemorrhage in a previous pregnancy is also a significant risk factor. Women with placenta previa (occurs when a baby's placenta partially or totally covers the mother's cervix — the outlet for the uterus) or overdistended uterus are also at risk (4).

There are 4 Ts of postpartum haemorrhage are tone, trauma, tissue, and thrombin. Some cases will require an emergent hysterectomy.

Prevention and treatment of postpartum haemorrhage.

1. Oxytocin is the drug of first choice for the prevention and treatment of postpartum haemorrhage even if it had been used earlier to induce labour (www.aafp.org › afp. Oxytocin is a hormone that is used for labour induction or strengthen uterine contractions or decrease blood flow through the uterus after the delivery of the baby (5)

Oxytocin is also used to stimulate uterine contractions in a woman with an incomplete miscarriage.

2. Ergometrine or methylergometrine or the fixed dose combination of oxytocin and ergometrine or oral misoprostol (600 μg) can be recommended if oxytocin is unavailable or ineffective.
3. Antibiotics such as gentamicin, ampicillin and clindamycin can be administered to women with retained placenta after normal vaginal delivery.

Contraindications of oxytocin:

Administration of oxytocin should be discontinued in the presence of foetal distress, foetal prematurity, abnormal foetal position (including unengaged head), placenta previa, cervical cancer etc.

Combinations of antibiotics and oxytocin have a significant effect on many infectious processes (mastitis, para proctitis, endometritis etc.

2. Urinary tract infection

Symptoms include pain, burning and urgent need to urinate. A minor urinary tract infection can result in kidney or blood infection if not urgently taken care of.

Treatment: Antibiotics such as:

1. Trimethoprim/sulfamethoxazole.
2. Nitrofurantoin.
3. Fosfomycin.
4. Fluoroquinolones such as ciprofloxacin are drugs of choice.

3. Malaria in pregnancy.

Prevention and treatment

WHO recommendation for malaria in pregnancy is as follows:

1. Intermittent preventive treatment in pregnancy {IPTp}.
2. Sulfadoxine-pyrimethamine should be administered as early as possible during the second trimester of gestation. Each dose should be at least one month apart with a minimum of four antenatal visits.

Caution:

Sulfadoxine-pyrimethamine can be taken on an empty stomach with or without food. Co-administration of folic acid at a daily dose equal or greater than 5 mg with sulfadoxine-pyrimethamine should be avoided so as not to reduce the antimalarial efficacy.

Iron (30-60 mg of elemental iron) and folic acid (0.4 mg) intake is recommended in pregnant women to decrease the risk of low-birth-weight infants, maternal anaemia and Iron deficiency at term. Co-administration of sulfadoxine-pyrimethamine with cotrimoxazole prophylaxis is contraindicated in women (6, 7).

iii. Insecticide‐treated nets (ITNs): ITNs should be made available to women very early in pregnancy (8).  

Treatment

Malaria illness in pregnant women must be effectively managed. However, treatment should not commence until a proper diagnosis by microscopy or rapid diagnostics tests (RDTs) has been carried out. Treatment because of clinical suspicion can only be done when parasitological diagnosis is not accessible or available (9).  Effective management of malaria illness for all pregnant women in malarious areas must be assured (10).  

Uncomplicated malaria in pregnant women

First trimester:

Quinine plus clindamycin should be administered for seven days or quinine monotherapy if clindamycin is not available. Artesunate plus clindamycin for seven days is recommended in case of treatment failure. An ACT can be given when there are patient compliance issues with the seven-day treatment.

Second and third trimesters:

ACT such as artemether-lumefantrine or artesunate plus clindamycin for 7 days or quinine plus clindamycin can be administered.

Dihydroartemisinin plus piperaquine should be avoided due to insufficient information on second and third trimesters of pregnancy.

Artesunate can be given alone if clindamycin is not available. 

Pregnant women with HIV infection:

This class of women should be treated as outlined above but sulfadoxine-pyrimethamine should not be given to those taking co-trimoxazole (trimethoprim plus sulfamethoxazole) as prophylaxis.  

Complicated malaria:

Pregnant women with severe malaria should be promptly treated with parenteral artesunate  in the second and third trimester . This is because of the recurrent hypoglyceamia that is associated with quinine. However, artesunate or artemether or quinine can be used based on their availability, Safety considerations are higher in first trimester for artesunate even though it’s able to reduce deaths from severe malaria.

Dosages:

Artemether plus lumefantrine (ALu): a fixed‐dose tablets containing 20 mg of artemether and 120mg of lumefantrine. The recommended treatment is a 6‐dose regimen over a 3‐day period (twice a day for 3 days).

Quinine treatment:

A loading dose of quinine (i.e. 20 mg salt/kg body weight – twice the maintenance dose) followed by the maintenance dose of (10 mg salt/kg body weight) is administered at 8‐hour intervals, starting 8 hour after the first dose. Treatment with an effective oral ACT (e.g. artesunate plus amodiaquine or artemether plus lumefantrine or dihydroartemisinin plus piperaquine) or artesunate (plus clindamycin or doxycycline) or quinine (plus clindamycin or doxycycline) (9).  

4. Iron deficiency anaemia

Pregnancy increases the risk of iron deficiency anaemia.

Anaemia may present with such symptoms as fatigue, weakness, dizziness, shortness of breath, pale skin or rapid heartbeat, hypotension or difficulty with concentration when severe etc.

Treatment

1. Taking prenatal vitamins or iron supplements so as to have an in take of 27 mg of iron a day.
2. Good and adequate nutrition can also prevent iron deficiency in pregnancy.  Dietary sources of iron include poultry, fish, lean red meat, beans, dark green leafy vegetables. Iron derived from plant sources and supplements should be taken together with food or fruits with high vitamin C content such as oranges, tomatoes and strawberries.
3. You may also consult your healthcare provider (11).  

5. High blood pressure.

High blood pressure could be present either before pregnancy or develop during pregnancy.

Types of high blood pressure in pregnancy:

Gestational hypertension: This develops after 20 weeks of pregnancy without excess protein in the urine or organ damage.

Chronic hypertension: This is usually present before pregnancy or may occur before 20 weeks of pregnancy.

Chronic hypertension with superimposed preëclampsia: This occurs in women with chronic hypertension which gets worse as the pregnancy grows and is characterized with excess protein in the urine.

Preeclampsia: This occurs when hypertension develops after 20 weeks of pregnancy with signs of organ damage such as the liver, kidneys, blood or brain. Complications (such as seizures) may arise in the mother and baby, if left untreated.

Symptoms of hypertension:

These includes headache, nausea, vomiting, dizziness, blurred or double vision

nosebleeds, palpitations and breathlessness.

Effect of high blood pressure on pregnancy

1. Reduced blood flow to the placenta-may result in decreased oxygenation of baby tissues leading to reduced intrauterine growth, breathing problems and other complications for the baby.  
2. Placental abruption. Placenta separates from the inner wall before delivery causing heavy bleeding which may be life-threatening.
3. Organ damage-Poorly controlled hypertension can lead to organs such as the kidneys, brain, heart, lungs etc which may be life threatening.  
4. Premature delivery- this may arise as a preventive measure to life-threatening complications due to high blood pressure in pregnancy.
5. Cardiovascular disease risk-Preeclampsia or premature delivery due to hypertension is a risk factor for cardiovascular disease.

Classification of blood pressure.

Drug therapy of hypertension

Consult your healthcare provider. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers and renin inhibitors are generally avoided during pregnancy. 

How to reduce the risk of complications?

You must take the following steps to ensure that you are healthy during pregnancy:

1. Be regular at your prenatal visits.
2. Strictly adhere to your blood pressure prescriptions throughout the pregnancy period.
3. Engage in moderate physical activity subject to your healthcare provider approval.
4. Eat a healthy and nutritious diet.
5. Avoid alcohol, smoking and other illicit drugs. Avoid self-medication as much as possible (12).

Conclusion

The health of women is highly important in building a healthy and sound society. Good health-care interventions can prevent or reduce complications associated with health challenges encountered in motherhood.

Improving maternal healthcare ultimately imparts on the families, communities and even the entire society. This helps to increase participation of women in social and economic activities which greatly increases and improves the quality of life thereby improving the workforce.

References

1. https://www.fao.org › sustainable-development-goals › mdg
2. https://www. who.int
3. WHO. The prevention and management of postpartum haemorrhage. Report of a Technical working group. Geneva 3–6 July 1989. World Health Organization/Maternal and Child Health 90.7. Geneva: WHO, 1990.
4. https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-...(pluh,previa%2C%20you%20might.
5. https://www.cochrane.org
6. Updated WHO Policy Recommendation on Use of IPTp, October 2012
7. WHO Policy Brief for the Implementation of Intermittent Preventive Treatment of Malaria in Pregnancy using Sulfadoxine‐Pyrimethamine (IPTp‐SP) 11 April 2013).Buk
8. A Strategic Framework for Malaria Prevention and Control during Pregnancy in the African Region, WHO 2004.
9. Guidelines for the Treatment of Malaria, Second Edition, WHO 2010.
10. A Strategic Framework for Malaria Prevention and Control during Pregnancy in the African Region, WHO 2004.
11. https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-d...
12. https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-d...