A few days ago, Alana had a posting about the relationship between antenatal care and maternal mortality on her Global Health Change.org blog. Her post, my comments, and a question from another reader got me thinking about about what do we know about the relationship between antenatal care and maternal mortality. I am actually doing some work right now on the effectiveness of the Safe Motherhood set of strategies in developing countries, and although I am most interested in the role of skilled delivery with my own work, I have read a bit about the role of antenatal care as well. I was going to post this as a comment on Alana’s blog, but figured my comments would be too extensive and would likely warrant its own posting. So while I am not an expert on these things, here is my take.
Antenatal care is one of the four pillars of the Safe Motherhood strategy developed over the past 20 years and implemented in most developing countries to reduce maternal mortality. However, just because something is advocated by the WHO and most international health agencies does not mean that it has ever been properly evaluated or even if we know if it works. Sad to say. Much of what we recommend to improve global health has never been subjected to rigorous evaluation. The evidence around antenatal care is believed to be effective based on what I will call “intuitive evidence”. It makes a lot of sense that it would work – who can object to making sure women visit the doctor before giving the birth? – so we advocate for it. But there is little good evidence that is suggests that it does all that much to reduce maternal mortality (there could be lots of other benefits from antenatal care, many of which we likely care a great deal about, but I will set these aside for the moment).
Although in general it is actually hard to say anything about maternal mortality, because it is perhaps the major health indicator that is among the hardest to measure, what we do know is that maternal mortality dropped relatively quickly from about the mid 1880s to mid 1990s in most developed countries, and more recently in some of the middle income countries in the world (e.g. Thailand, Malaysia). These drops happened around the same time as a number of other very important changes, so it is hard to isolate the main driver of these declines. The other trends include declines in fertility rates, declines in infectious diseases, increases in access to midwives and maternity services, increases in access to emergency obstetric care, increases in institutional deliveries, the development of new medicines, such as antibiotics and oxytocic medicines, increases in maternal eduction, and of course increases in access to antenatal coverage. They all could have contributed in some way, but today maternal mortality rates are generally a few order of magnitudes (about 100 times) higher in developing countries than in developed countries. Perhaps the greatest injustice in global health.
In 1932, an article was published in the Lancet that observed that although there had been significant attention given to antenatal care to reduce maternal mortality in the UK, there had been no measured decline in mortality. In fact, one of the conclusions of the author was that it may have even increased mortality due to increased rates of unnecessary caesarean sections and early induced labors. A survey of antenatal guidelines across European countries has shown that there is a great deal of variation between the prescribed number of visits, without any observed variation in mortality rates. To my knowledge, there have not been good studies that have been able to isolate the individual contribution of antenatal on maternal mortality directly, but it seems unlikely that antenatal coverage was the main driver of declines in maternal mortality seen in developing countries.
The bulk of maternal mortaltiy is concentrated during the labor, delivery, and immediate postpartum periods (basically 2-3 days around the birth event) so interventions focused on this time period are believed to play a bigger role in reducing maternal mortality (although even this is not well established). One of the goals of antenatal care is to screen and identify patients who are at high risk of having complications, and it seems that its ability to do this is not very good. There are few good predictors, other than previous complications, that predict future complications (and if you had complications before, then you don’t need antenatal care to tell you that you are at high risk for future complications).
So while there is little evidence to either support or refute the role of antenatal care in reducing maternal mortality, it seems unlikely that it does. Does that mean that we should not focus on providing antental care in developing countries? Of course not. There may be lots of good reasons for providing these services, such as providing education and other services. Does it mean that if we get high coverage of antenatal services we should wipe our hands thinking we have solved maternal mortality. Absolutely not. Many countries in sub-Saharan Africa actually have quite high levels of antenatal coverage and persistently high levels of maternal mortality. Antenatal services supposedly take up large portions of the reproductive health budgets in many countries, leaving less available for other types of reproductive health services. Should countries spend more of these resources on other types of reproductiv health services? Maybe. Should donors provide more money for reproductive health, in particular non-antenatal reproductive health services? Maybe. How would I spend an additional dollar to reduce maternal mortality? I don’t know. These are all questions that warrant more attention from researchers before they can conclusively be answered, but I am willing to bet it is not antenatal care that will be the final answer.Share on Facebook