What can be done to improve the situation in developing countries like India?

There is lot that needs to be done to address the issues of maternal health in India but we will be targeting a few of the issues that we think are achievable and can have a great impact in improving the maternal health (and the developing baby’s health) in India.

TARGET ADOLESCENTS

The adolescents need to be educated about safe sex and the use of contraceptives. So educating adolescents in schools about such things can make a difference.

There is a need for national campaigns to spread awareness about the current health issues so as to delay childbearing till the maternal age of 20 years or more, having at least 2 years gap between subsequent pregnancies, improving nutrition during pregnancy and encouraging use of maternal services when pregnant. All these issues are preventable and therefore, spreading awareness about these can actually make a difference. 

HAVING THE APPROPRIATE HEALTH FACILITIES

Having the appropriate health facilities (management, midwifes) across all areas in India and other developing countries (or just upgrading the available facilities). The government should be encouraged to invest more money into the health systems and especially maternal health.

Also providing early detection of pregnancy, regular check-up of blood pressure, haemoglobin and foetal growth free of cost for poor people in rural and urban areas can improve maternal and child health outcomes for the nation. There should also be a meeting point for poor mothers across all areas to check their progress every month.

This can really make a difference.... 

Check this out ----- UNICEF

So what does the future look like in the attempt to encourage modifiable behaviours during pregnancy in developed countries?

In the last few posts on maternal modifiable behaviours in developed countries, what have we established?

One of the most prevalent modifiable behaviours in developed countries is maternal obesity and subsequent overnutrition of the fetus.^1,2

Other modifiable behaviours that still have a serious impact on fetal health and development is smoking and alcohol intake.^3,4

Such behaviours can cause death and a spectrum of physical and mental disabilities of the child.^5-8

Epigenetics is a mechanism that changes the expression of our genes in our DNA. This mechanism is heavily influenced by obesity, overnutrition, smoking and alcohol.^9-11 

Pregnant women of lower socioeconomic status (SES) show a greater incidence of each three modifiable behaviours as compared to women of higher SES.¹²

Low level education, poor financial status and poor access to health care and related health services contribute significantly to a poorer SES value and are factors that contribute to unhealthy perinatal choices.^12,13

Western society is characterised by high energy foods and a sedentary lifestyle – dangerous risk factors for obesity.¹⁴

We have established that we are advocating for a cohort of humans that do not have a voice or a choice!

HOW CAN A MOTHER BE SUPPORTED TO MAKE BEHAVIOURAL CHOICES THAT WILL BENEFIT HER UNBORN CHILD?

As you know our aim is to advocate for the unborn child, we have decided to specifically focus on modifiable behaviours of the mother during pregnancy.

There have been many campaigns for mothers to stop smoking and drinking alcohol during pregnancy. The effort in these areas has not been wastes and has decreased the prevalence of these behaviours. Psychosocial interventions have aided in the reduction of stillbirth, low birth rate and other smoking associated pathologies.¹⁵

Quit now

Drinkwise

There have also been an increase in strategies targeting obesity during pregnancy. Reducing weight during pregnancy has beneficial outcomes for both mother and child. Change in diet and nutrition has the biggest effect on reducing maternal weight which is really a two pronged benefit. Maternal weight loss which has a range of benefits for the fetus and at the same time change is nutrition leads to further beneficial results for the unborn child.^7,16

^{Healthy Eating}

Raising children

What do we think needs to happen?

An increase in health promotion specifically about the danger of maternal obesity and overnutrition during pregnancy must be a focus. Research has indicated that although many people regard behaviours like smoking, alcohol and drug use as potentially effecting the development of a child, only a small minority were aware of the danger of obesity and overnutrition during pregnancy!^17,18

We believe that behaviours and attitudes of a person are not localised and often are a reflection of wider community beliefs and attitudes. We believe a greater focus on community intervention strategies that engage the maternal population on a social level in a friendly, educational and cooperative approach. To provide the resources and support to make beneficial behavioural choices that will have beneficial ramifications for fetal health. Obesity is a pathology of our modern western lifestyle we foresee tremendous generational effects from this epidemic and believe it will pose a huge challenge to combat for many years to come.

When campaigning for lifestyle change it is important to gain support and change from the environment around a person. So health promotion that incorporates the partner to further facilitate positive lifestyle alterations is another area health strategies must be directed.¹⁹ We also believe access to appropriate health care is critical in developed countries particularly for those of low SES, we see this as a particularly complex and difficult outcome to attain in the future.

The obesity epidemic has well and truly settled into western life and maternal health advocates face a serious challenge in approaching this issue. It is vital that a women understands that even though losing weight is often an immensely difficult and lengthy battle; even seemingly minor alterations in nutrition have colossal benefits for the unborn child in later life.

The challenge to continue to address smoking and alcohol intake by pregnant women in developing countries is not over yet. In particular, generating health strategies for specific subpopulations in developed countries like the Australian Indigenous population is a monumental problem at present and will be for some time to come.

With these thoughts in mind we can continue to make baby steps towards optimising a child’s biological start in life……MATERNAL HEALTH MATTERS! 

References

1.  Muhlhausler BS, Ong ZY. The fetal origins of obesity: early origins of altered food intake. Endocr Metab Immune Disord Drug Targets. 2011 Sep 1;11(3):189-97.

2.  Dyer JS, Rosenfeld CR. Metabolic imprinting by prenatal, perinatal, and postnatal overnutrition: a review. Semin Reprod Med. 2011 May;29(3):266-76.

3.  Bailey B. Alcohol consumption in early and late pregnancy is associated with poor child reading and writing ability at 8-9 years of age. Evid Based Nurs. 2013 Dec 4.

4.  McCarthy FP, O'Keeffe LM, Khashan AS, North RA, Poston L, McCowan LM, et al. Association between maternal alcohol consumption in early pregnancy and pregnancy outcomes. Obstet Gynecol. 2013 Oct;122(4):830-7.

5.  Waller DK, Mills JL, Simpson JL, Cunningham GC, Conley MR, Lassman MR, et al. Are obese women at higher risk for producing malformed offspring? Am J Obstet Gynecol. 1994 Feb;170(2):541-8.

6.  Aro T. Maternal diseases, alcohol consumption and smoking during pregnancy associated with reduction limb defects. Early Hum Dev. 1983 Dec;9(1):49-57.

7.  Blomberg MI, Kallen B. Maternal obesity and morbid obesity: the risk for birth defects in the offspring. Birth Defects Res A Clin Mol Teratol. 2010 Jan;88(1):35-40.

8.  Martinez-Frias ML, Bermejo E, Rodriguez-Pinilla E, Frias JL. Risk for congenital anomalies associated with different sporadic and daily doses of alcohol consumption during pregnancy: a case-control study. Birth Defects Res A Clin Mol Teratol. 2004 Apr;70(4):194-200.

9.  Cutfield WS, Hofman PL, Mitchell M, Morison IM. Could epigenetics play a role in the developmental origins of health and disease? Pediatr Res. 2007 May;61(5 Pt 2):68R-75R.

10.  Martinez JA, Cordero P, Campion J, Milagro FI. Interplay of early-life nutritional programming on obesity, inflammation and epigenetic outcomes. Proc Nutr Soc. 2012 May;71(2):276-83.

11.  Lucassen PJ, Naninck EF, van Goudoever JB, Fitzsimons C, Joels M, Korosi A. Perinatal programming of adult hippocampal structure and function; emerging roles of stress, nutrition and epigenetics. Trends Neurosci. 2013 Nov;36(11):621-31.

12.  Oddsberg J, Jia C, Nilsson E, Ye W, Lagergren J. Maternal tobacco smoking, obesity, and low socioeconomic status during early pregnancy in the etiology of esophageal atresia. J Pediatr Surg. 2008 Oct;43(10):1791-5.

13.  Fontaine KR, Robertson HT, Holst C, Desmond R, Stunkard AJ, Sorensen TI, et al. Is socioeconomic status of the rearing environment causally related to obesity in the offspring? PLoS One. 2011;6(11):e27692.

14.  Ford ES, Mokdad AH. Epidemiology of obesity in the Western Hemisphere. J Clin Endocrinol Metab. 2008 Nov;93(11 Suppl 1):S1-8.

15.  Chamberlain C, O'Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2013;10:CD001055.

16.  Thangaratinam S, Rogozinska E, Jolly K, Glinkowski S, Duda W, Borowiack E, et al. Interventions to reduce or prevent obesity in pregnant women: a systematic review. Health Technol Assess. 2012 Jul;16(31):iii-iv, 1-191.

17.  Shub A, Huning EY, Campbell KJ, McCarthy EA. Pregnant women's knowledge of weight, weight gain, complications of obesity and weight management strategies in pregnancy. BMC Res Notes. 2013;6:278.

18.  Buschur E, Kim C. Guidelines and interventions for obesity during pregnancy. Int J Gynaecol Obstet. 2012 Oct;119(1):6-10.

19.  Edvardsson K, Ivarsson A, Eurenius E, Garvare R, Nystrom ME, Small R, et al. Giving offspring a healthy start: parents' experiences of health promotion and lifestyle change during pregnancy and early parenthood. BMC Public Health. 2011;11:936.

The way forward for maternal health in Australia

The Australian Government recognizes the inequities in maternal health within the nation and has implemented a series of initiatives to address the issue.

YEAR	FUNDING	INITIATIVE
2004	$4.3 million over three years	Increased funding to combat smoking during pregnancy through encouragement of health professionals to advise pregnant women of the adverse outcomes.1 Additionally, antenatal clinics now make smoking cessation advice and program referral information widely available.2
2004	$1.69 million over three years	Increased funding to “develop and trial locally appropriate family, family friendly, evidence based sustainable models of service delivery which include a strong health promotion and prevention focus”.1
2008	$490 million over six years	Funding of the Indigenous Early Childhood Development National Partnership to improve maternal and child health, increase access to maternal and child care services for Indigenous families and improve pre-pregnancy and teenage sexual and reproductive health.3
2009-10	$120.5 million over four years	Funding of the Improving Maternity Services Budget Package which increased services for rural communities.3 The Government also planned to address the issues of lifestyle risks in pregnant women.3

Unfortunately, despite these initiatives, the inequities are still significant. This is also demonstrated in the general success with the Nationwide anti-smoking campaigns, which have failed to reach those Australians with “less capacity to respond to health promotion messages and related information”.^4(p2)

What we want…

Community empowerment. Funding needs to be directed towards development of the local rural and Indigenous health workforce and towards initiatives led and managed by the local community (for example Aboriginal Community Controlled Health Organisations). From this platform, maternal health promotion will be appropriate, acceptable and effective.

Targeted interventions. Interventions must increase awareness of the damage caused to the unborn child and provide adequate support services to assist pregnant women in achieving their health goals. We need:
Targeted campaigns to reduce number of women smoking during pregnancy
Targeted campaigns to reduce drinking during pregnancy
Establishment of support networks and facilities specific to achieving preventative maternal health goals
Increased access to contraceptives for teenagers in the rural setting
Increased awareness of the consequences of poor maternal health on infant heath outcomes

Continued momentum toward a focus on prevention…

“It is in the national interest to allocate a greater proportion of total health resources to health promotion and illness prevention – and given the particular characteristics of people in rural and remote areas, the returns from this investment will be substantial in those places”. ⁴

National legislation supporting the rights of the unborn child. Every child has the right to the best possible start in life.

1.  Australian Government Department of Health. Maternal and Infant Health. Commonwealth of Australia [cited 2014 Mar 01]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-maternal-index

2.  Australian Institute on Health and Welfare. Australia's Mothers and Babies 2011 [Internet]. Canberra: University of New South Wales; 2011 [cited 2014 Mar 01]. AIHW cat. no. PER 59. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129545698

3.  Australian Government Department of Health. Taking Preventative Action – A Response to Australia: The Healthiest Country by 2020 – The Report of the National Preventative Health Taskforce [Internet]. Commonwealth of Australia; 2010 [cited 2014 Mar 23]. Available from: http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/1671CBF53AA5E030CA2579540005F1C3/$File/6588%20DoHA%20Health%20Strategy_120510.pdf

4.  National Rural Health Alliance Inc. Fact Sheet 5: Health Promotion in Rural Australia [Internet]. 2011 [cited 2014 Mar 09]. Available from: http://ruralhealth.org.au/sites/default/files/fact-sheets/fact-sheet-05-health%20promtion%20in%20rural%20australia_0.pdf