2.4 Promotion of fetal health and well-being
Preconception and prenatal interventions are what health professionals do in partnership with people to try to improve gestational parent and fetal well-being and outcomes. These strategies can be planned and implemented at an individual, family, group, community or population level.
Family-centred care recognizes that informed, respectful and individualized care of a pregnant individual is provided in the context of their larger support system, which often includes family. According to the Public Health Agency of Canada (2017a), one of the 17 underlying principles of Family-Centred Maternity and Newborn Care (FCMNC) is that “women and their families play an integral role in decision making”.
Preconception care
Listen as Dr. Maggie Morris describes the value of preconception care for an adolescent population from her medical perspective.
Watch as Morris expresses her ideas for how preconception care in a clinic setting could be improved.
How would you describe the interpersonal approach Morris advocates people use when working with an adolescent population?
Do you agree with this approach? Why or why not?
Read the World Health Organization (WHO, 2013) policy brief, Preconception Care: Maximizing the Gains for Maternal and Child Health, to discover more about a broad range of evidence-supported preconception strategies to improve numerous outcomes. Click on the “Preconception Care Policy Brief” link on the following WHO webpage to begin.
Prenatal care
In the next video, Morris outlines some of the physical challenges pregnant adolescents may experience.
Morris has a great deal of expertise as a practitioner in diagnosing, treating and educating the prenatal adolescent population she works with about sexually transmitted infections. Infection transmission can be significant to fetal well-being and outcomes. As an example, if a pregnant person is positive for the Human Immunodeficiency Virus (HIV), and untreated, the probability of transmitting this virus to the fetus is between 15 – 40% (Keenan-Lindsay et al., 2006). Read more about HIV testing, which is recommended in both prenatal care and preconception care, from the Caring for Kids website of the Canadian Paediatric Society.
Do you have ideas for how to reach a broader audience, including partners who may not be attending prenatal care visits, with important information about topics such as fetal risks from sexually transmitted infections?
Another principle of FCMNC (referred to earlier on the webpage) is that “the attitudes and language of health care providers have an impact on a family’s experience of maternal and newborn care” (PHAC, 2017a).
What qualities might make a health practitioner feel safe to an adolescent, thereby enabling easier disclosure and discussion around sexual health topics?
Also mentioned by Morris in the previous video is a higher risk for prematurity, particularly in the younger adolescent aged population. Read about ways pregnant individuals can reduce their risk factors for preterm labour on The Society of Obstetricians and Gynaecologists of Canada website.
Premature birth can occur even when there are no known risk factors. What may bring about the onset of labour is something still being uncovered through research. Listen as Dr. Stephen Lye describes the work in his lab related to the role the mother’s immune system may play in the initiation of labour.
Lye’s research about the role of the maternal immune system in the onset of labour has lead to further exciting research into three areas of clinical applications. He talks next about these areas which, when combined, have the potential to decrease not only the rates of premature birth, but also the rates of synthetic glucocorticoid treatments administered in situations where preterm labour turns out over time to have been symptoms of a “false” labour.
There are numerous complications during pregnancy, labour, or birth that can affect the health and well-being of the pregnant person, fetus or both. An infection caused by bacteria is an example of a complication that may contribute to negative outcomes. By way of illustration, maternal urinary tract infection caused by the bacteria Group B Streptococcus is associated with an increased risk for labour to begin prematurely and for fetal membranes which surround the fetus and amniotic fluid to rupture preterm prior to labour beginning (Duff, 2012, p.1140-1141).
Duff (2012) explains several factors increase risk for the development of an intra-amniotic infection called chorioamnionitis (to review how the placenta is connected with the fetal membranes, note the “Smooth chorion” and “Amnion” as labelled in the first diagram of the placenta on page 1.1 of the module). Significant risk factors for this type of infection according to Gibbs and Duff (as cited in Duff, 2012), include: first birth, low socioeconomic status, young gestational parent age, prolonged labour and ruptured membranes, numerous vaginal examinations and the presence of a lower genital tract infection (such as bacterial vaginosis). Chorioamnionitis may lead to serious complications for both the pregnant person and the fetus. In some cases, clinical symptoms such as gestational parent fever, uterine tenderness, pus in the amniotic fluid, and an elevated heart rate in the gestational parent and the fetus will be present along with the inflammation of the chorion and amnion. In preterm deliveries, the occurrence of this infection with or without symptoms is approximately 25% (Armer & Duff as cited in Duff, 2012). This compares to a rate of around 1% to 5% in full term pregnancies (Gibbs & Duff as cited in Duff, 2012, p.1144).
When chorioamnionitis is present, an inflammatory response may also develop within the fetus either from contact with infected amniotic fluid or from contact with inflammatory cells transferred from uteroplacental circulation (Galinksy et al., 2013, p. 2). Galinksy et al. (2013) state research is ongoing into how chorioamnionitis with an associated inflammatory response in the fetus may be involved in changes to the development and function of the fetal and premature newborn heart, lungs, brain, vision and kidneys (p.6).
AMPATH, which stands for Academic Model Providing Access to Healthcare, is an initiative to build capacity and improve primary health care in the area around Eldoret in western Kenya. The University of Toronto is one of a consortium of North American universities and health centres, (lead by Indiana University), that has partnered with Moi University and Moi Teaching and Referral Hospital in Africa to assist the Government of Kenya with these goals. In the mid-2000’s, under Dr. Alan Bocking’s leadership as then Chair of the University of Toronto’s Department of Obstetrics and Gynaecology, possibilities for the University of Toronto to enter the North American consortium were explored as a way of enhancing social responsibility and commitment – particularly on behalf of then medical residents in obstetrics and gynaecology. Listen as Bocking explains more about this process and the program itself.
Watch as Bocking reveals the strong impact that interventions in this geographic area have had on outcomes like maternal mortality.
Bocking mentions the concept of group prenatal care which allows for prenatal screening and education while fostering and valuing peer contributions in a group setting. Explore the Centering Healthcare Institute website to learn more about this group model of care within the North American context.
Were you aware of this type of prenatal care?
How might some of the determinants of health be further strengthened through this approach?
Delays in access to appropriate health care during pregnancy or labour and birth can have significant detrimental effects on gestational parent health and developmental outcomes for the next generation. Listen as Bocking outlines the four delays related to maternal mortality.
The fourth delay described by Dr. Bocking in the previous video relates to a community level of responsibility for maternal and child health. What does community accountability for the health of all gestational parents mean to you?
Do you think changes in community accountability where you live could improve gestational parent and fetal outcomes? If so, how?
The next reading from the Maternity Worldwide website provides a glimpse into some of the barriers women around the world may experience to accessing quality healthcare.
Prenatal education
According to the Best Start Resource Centre manual, Prenatal Education in Ontario: Better Practices (2015), prenatal education can be based on differing philosophies as well as various prenatal individual and group content needs. Meeting these educational needs can occur through myriad differing strategies, vehicles and settings which can make controlling for a number of factors in research about prenatal education challenging. The next reading is from the Best Start Resource Centre website. It summarizes research findings regarding the delivery of prenatal education in Ontario. Pages which may be of particular interest are 9-12 as well as 19-21. Note: reference is to page numbers within the document, and not the PDF itself.
In the next video Dr. Christine Ateah, vice-dean in the Faculty of Health Sciences and professor in the College of Nursing at the University of Manitoba, describes a survey she completed about prenatal education needs as well as an intervention she conducted following the survey. As you listen, consider how her work may link with the previous reading in which Ontario parents recommended including more postpartum content into prenatal education.
More about prenatal learning needs and the unique opportunities that exist when preparing for a first baby’s birth are revealed by Ateah below.
Next, Dr. Roos, assistant professor in the Department of Psychology at the University of Manitoba, discusses postpartum planning during pregnancy – suggesting this may be protective for mental health care later on.
If you are a parent, what prenatal education topics do you think would have been helpful to better prepare you for your first baby’s arrival and the postpartum period? If you are not a parent, interview someone who is one about what information they would have wanted to know prior to their first child’s birth.
Watch as Ateah explains her recommendations and future plans for research.
Ateah mentions a potential barrier to prenatal education access as cost. In the Best Start by Health Nexus (2019) reading earlier on this page, people with lower levels of income were identified as less likely to access prenatal education in Ontario. Read more in the document (pages 27 – 28) about barriers to accessing prenatal education and strategies prenatal educators have used to make services more accessible. Recommendations based on the data within the report are discussed on page 32. The report can be accessed above or with the following link.
