Pregnancy, Childbirth, and Newborn Health

Research and data

Although the major causes of maternal and perinatal  mortality and morbidity have been identified and techniques developed to prevent them, information on causes of death for specific settings is often lacking. In 2004, WHO published Beyond the Numbers: Reviewing Maternal Deaths and Implications to Make Pregnancy Safer to guide researchers in investigating causes of deaths and severe complications of pregnancy and improving practices. In addition, the WHO-UNICEF-UNFPA Guidelines for Monitoring the Availability and Use of Obstetric Services (1997) present a series of process and impact indicators for assessing the availability, use and quality of obstetric services and as well as guidance on data collection and interpretation.  For more research ideas see Safe Motherhood Needs Assessment (1996), a tool kit for carrying out rapid assessments of health systems and community responses to maternal and newborn deaths that includes step-by-step guidelines for implementation, a model budget, and other materials such as survey schedules, sampling frames and data coding sheets. 

Estimates of maternal mortality for developing and developed countries and a review of the definitional and methodological challenges underlying these estimates can be found in Maternal Mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA (2003). Of special importance are the figures showing women's lifetime risk of dying from pregnancy-related causes in each country and the enormous disparities among them. These estimates are indispensable for policy makers and planners concerned with identifying essential health care needs and strengthening system capacity for reducing maternal deaths and improving the quality and accessibility of obstetric care.

Antenatal care in developing countries: Promises, Achievements and Missed Opportunities (2003) assesses the importance and content (useful or not) of antenatal care and reports on access to and use of skilled services. Data are presented for developing countries on trends in the percentage of women with at least one antenatal visit, the number and timing of visits and type of provider, socioeconomic and demographic correlates of the use of antenatal care, and its relation to skilled health care at delivery. The country data are useful for identifying gaps in preventive care.

Guidelines for Providers

WHO has an extensive list of publications in this area, in particular, the Integrated management of pregnancy and childbirth (IMPAC) set of tools and a toolkit for Strengthening Midwifery Services. Some relate to basic essential care at the primary level and others to the management of complications in more advanced (referral) facilities. The guidelines are intended for physicians, nurses, midwives, community outreach workers, and others involved in the provision of basic and emergency care and advice at various levels of service delivery. 

Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice (2003) is intended for primary level health care providers working in rural or urban health posts or in the home. Produced jointly by WHO, UNICEF and UNFPA, the guide includes detailed descriptions of routine and emergency diagnosis and referrals for antenatal care, labor and delivery, postpartum care, the care of newborns, and post-abortion care. It is designed for use as a clinical decision-making tool by a skilled attendant at the primary level and can be adapted to local situations with the help of an adaptation guide. Flowcharts and information and treatment charts in each of the clinical sections cover routine monitoring, early detection and management of complications, preventive measures, and advice and counseling. Additional sections include advice on HIV, support for women with special needs, community linkages, essential drugs, supplies and equipment, clinical record-keeping, and simple messages through all stages of the process for the woman, her partner and her family. See also Kangaroo Mother Care: A Practical Guide (2003) on the benefits of skin-to-skin contact for the survival and comfort of fragile and preterm newborns.

At a more advanced level, practitioners with higher level midwifery or obstetric skills who are based in facilities with the necessary equipment and supplies for handling emergencies should consult Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors (2000) and Managing Newborn Problems: A Guide for Doctors, Nurses and Midwives (2003). These comprehensive manuals are organized by symptom (e.g., shock, vaginal bleeding in early pregnancy, fetal distress in labor) to facilitate rapid assessment and decision-making in emergency situations. Each symptom is followed by recommendations for initial management with summaries of the main steps required for each procedure. A list of essential drugs for managing complications in pregnancy and childbirth is included. In addition, the Reproductive Health Database in the Reproductive Health Library includes dozens of items (reviews, commentaries and practical applications) relating to antenatal care, malaria in pregnancy, social support, hypertensive disorders, nutrition during pregnancy, prenatal diagnosis and fetal surveillance, preterm labor, fetal distress, the management of three stages of labor, postpartum care and breastfeeding, and neonatal disorders. Consult the Effectiveness Summaries for Decision-Making to view the latest evidence on the value of specific interventions

Women who have experienced genital cutting (also called female genital mutilation, or FGM) require special attention in pregnancy and delivery. For guidance on the best approaches see Management of Pregnancy, Childbirth and the Postpartum Period in the Presence of Female Genital Mutilation: Report of a WHO Technical Consultation (1998). WHO has also produced a series of guidelines for the care of HIV-positive pregnant women and new mothers: see Clinical Guidelines for the Management of Pregnant Women with HIV Infections (2001) and New Data on the Prevention of Mother to-Child Transmission of HIV and their Policy Implications: Conclusions and Recommendations (2001). Guides on feeding practices include Breastfeeding and Replacement Feeding Practices in the Context of Mother-to-Child Transmission of HIV (2001) and HIV and Infant Feeding Counselling: A Training Course (2000).

The strategic role of the skilled midwife in pregnancy, childbirth and newborn care cannot be overemphasized. WHO's Strengthening Midwifery toolkit builds on a set of training modules developed in 1996 that has been revised in line with new evidence. Listed in Part 3 under Section I, these include a foundation module on The Midwife in the Community as well as modules on managing postpartum hemorrhage, prolonged and obstructed labor, puerperal sepsis, eclampsia, and incomplete abortion (the last of which will be published later in 2004).

On a more general level, Working with Individuals, Families and Communities to Improve Maternal and Newborn Health (2003) is addressed to all global partners who are collaborating with WHO's Making Pregnancy Safer initiative. It presents a framework for developing interventions in four priority areas: developing people's capacities to stay healthy and to make healthy decisions and respond to obstetric and neonatal emergencies; increasing people's awareness of the rights, needs and potential problems related to maternal and newborn health; strengthening linkages for social support among men, women, families and communities and the health care delivery system; and improving the quality of care of health services with respect to their interface with women, men, families and communities. The document establishes a common vision and approach to empowering women, families and communities to increase their control over maternal and newborn health, to improving access to and use of high-quality maternal and newborn health services, and to ensuring a continuum of care throughout pregnancy, childbirth and the postpartum period.

Policies and strategic plans

First published in 1994, the Mother-Baby Package: Implementing Safe Motherhood in Countries remains a standard reference for planners. The package consists of 18 simple interventions with a scientifically demonstrated capacity to reduce maternal and infant mortality in resource-poor settings. Pragmatically and strategically designed, the package can be implemented within the existing health care system without significant additional investments in expensive drugs or equipment. To calculate the costs of adopting the 18 life-saving interventions, consult The Mother-Baby Package Costing Spreadsheet (1999), which explains each step in the process and includes a User Guide.

WHO is now calling for a global movement to ensure that every pregnant woman and her newborn have access to a skilled attendant.  Global Action for Skilled Attendants for Pregnant Women (2003) outlines the key elements of the global strategy. It identifies the responsibility of the health sector, highlights methods of mobilizing resources to increase access, and stresses the need to forge partnerships among health care professionals, women and their families, governments, the private sector and international agencies. An accountability framework lists useful examples of what doctors and their professional associations can do; what midwives and their associations can provide, what health service managers and planners can do, what women, families and communities can do; and what the private sector, national authorities and international technical assistance agencies (including WHO) can contribute. Each section includes a list of tools and monitoring indicators. Valuable appendices summarize many practices during pregnancy, delivery and newborn care according to whether they are demonstrably beneficial or not and specify the forms of care that practitioners and facilities at different levels can appropriately deliver. 

Whereas Global Action for Skilled Attendants is directed at what health systems can do, policy makers and women's health advocates concerned with creating a broader rights-based legal environment for maternal health at the national level should turn to Advancing Safe Motherhood through Human Rights (2001). Written by Rebecca J. Cook and Bernard M. Dickens, this important manual shows how governments, nongovernmental organizations (NGOs) and international agencies can create an enabling policy environment for safe motherhood by promoting compliance with basic international human rights agreements relating to health, survival and security, information and education, and nondiscrimination. Based on this work, WHO is currently developing a practical tool for use by governments called Using human rights for maternal and neonatal health: A tool for strengthening laws, policies and standards of care (forthcoming). The purpose of the tool is to help countries to use a human rights framework to identify and address legal, policy and normative barriers to women's access to and use of maternal and newborn health services. 

Tag it:

?