|Ahead of print publication
Does provision of antenatal care, post-natal care and perinatal care reduce maternal, neonatal and child mortality? With special attention towards bangladesh situation in global perspective
Badar Uddin Umar1, Adnan Abdullah2, Kona Chowdhury3, Rahnuma Ahmad4, Mainul Haque2
1 Oxford College of Arts, Business and Technology, Scarborough, ON, Canada
2 Unit of Occupational Medicine (AA), and Pharmacology (MH), Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia, Kem Perdana Sugai Besi, Kuala Lumpur, Malaysia
3 Department of Pediatrics, Gonoshasthaya Samaj Vittik Medical College and Hospital, Dhaka, Bangladesh
4 Department of Physiology, Medical College for Women and Hospital, Dhaka, Bangladesh
|Date of Submission||06-May-2022|
|Date of Decision||16-May-2022|
|Date of Acceptance||19-May-2022|
|Date of Web Publication||08-Jul-2022|
The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur 57000
Source of Support: None, Conflict of Interest: None
The present review was intended to explore the effectiveness of perinatal services such as antenatal care (ANC) and post-natal care (PNC) on the health indicators such as maternal, child and neonatal mortality. Globally, indicators are considered very important in determining the health status and the overall performance of a country's healthcare system. A literature search was conducted using maternal mortality, child mortality, neonatal mortality, ANC and PNC in the PubMed, Google, Academia, The Lancet and Journal of the American Medical Association databases. Globally, implementing integrated perinatal care services has brought positive changes in the maternal, child and neonatal mortality indices. The United Nations (UN) is committed to improving the overall living conditions in all countries, significantly improving the population's health status. The UN came up with eight Millennium Development Goals in 2000, aiming to eliminate poverty and increase development in member states. The World Health Organization was a partner in implementing these goals. Later, the UN introduced 17-fold Sustainable Development Goals in 2015 as a blueprint for peace and prosperity for all citizens towards a better future by 2030. As a result, many countries have experienced positive changes in most indicator areas, including service utilisation, maternal mortality and child mortality. Some Sub-Saharan African and South Asian countries are progressing, however, slowly.
Keywords: Antenatal care, maternal mortality, millennium development goal, neonatal mortality, primary healthcare, South Asia, Sub-Saharan Africa, sustainable development goal
|How to cite this URL:|
Umar BU, Abdullah A, Chowdhury K, Ahmad R, Haque M. Does provision of antenatal care, post-natal care and perinatal care reduce maternal, neonatal and child mortality? With special attention towards bangladesh situation in global perspective. Adv Hum Biol [Epub ahead of print] [cited 2022 Aug 11]. Available from: https://www.aihbonline.com/preprintarticle.asp?id=350327
| Introduction|| |
Since the Alma-Ata conference in 1978, the World Health Organization (WHO) and countries worldwide have seen substantial development in primary healthcare (PHC). The concept of 'Primary Healthcare' emerged from the meeting as the central theme, and the slogan 'health for all by 2000' was adopted to bring about a drastic change in the healthcare delivery system across the world. Despite the WHO's initiatives to eliminate the gaps in the health status of people across the globe, the programme was not very successful in achieving its target, and the disparity still prevails, especially in developing countries., PHC encompasses a wide range of health services for the community, including health promotion, disease prevention, treatment, rehabilitation and palliative care. To reach the goals of 'Health for All by the year 2000', the United Nations (UN) announced the 8 Millennium Development Goals (MDGs), which were to be achieved by 2015. The MDGs, the MDG 4 and 5, were focused on reducing child mortality by two-thirds and improving maternal health, respectively. Providing skilled antenatal or pre-natal care to pregnant mothers during pregnancy, childbirth and post-natal care (PNC) could save maternal and newborn lives during the first few weeks following birth. MDGs were later superseded by the Sustainable Development Goals (SDGs). The UN came up with 17 ambitious goals through SDGs by 2030. Among the child-related SDG indicators, target 3.1 aims at reducing the global maternal mortality rate (MMR) to <70/100,000 live births by 2030. SDG goal-3, Target 3.2 aims to reduce the neonatal mortality rate (NMR) to around 12 deaths/1000 live births and under-5 mortalities to at least as low as 25/1000 live births by 2030.,
PHC aimed at eight services. Maternal and childcare with family planning were among the top priorities. Many countries' introduction of PHC-related projects brought promising health indicators. There have been visible changes in the neonatal, child and maternal health indicators due to all the efforts and campaigns at national and international levels. These morbidity and mortalities have improved sustainably in many developed and developing countries. The most important factors influencing these changes are the quality and quantity of antenatal care (ANC) and PNC. ANC is the care provided by trained or skilled healthcare providers to pregnant mothers ensuring safe delivery and the best health outcomes for the newborn and the mother., The care given to the expectant mother during pregnancy and before delivery focuses on the mother's physical, psychological, emotional and social well-being. Specific nutritional needs of the pregnant woman, treatment of hypertension and immunisation needs are ensured in the ANC. ANC visits also decrease the risk of neonatal mortality.,,
A literature search was conducted using the keywords: maternal mortality, child mortality, neonatal mortality, antenatal care and post-natal care in the PubMed, Google, Academia, The Lancet, and Journal of the American Medical Association databases to review the state of perinatal care services concerning mortality indices. Several themes emerged in the search pertaining to the utilisation of perinatal care services. Socioeconomic, familial, educational, cultural, religious and healthcare system efficiency were identified. Availability of facility delivery, transportation and distance from health centres, poor infrastructure, lack of skilled care providers, the attitude of staff and family members, availability and accessibility of various services, cost, convenience, women's decision-making capacity, gender inequality with women's status in the society, autonomy and place of residence were also among some of the other essential factors.
| Perinatal Care|| |
Perinatal care comprises the care of the pregnant mother during pregnancy, childbirth and after childbirth. Hence, it includes ANC and PNC. These services are considered essential to eliminating the risks of maternal and child mortality.,,,, Although the WHO recommended at least four ANC visits earlier, the policy has been updated and endorses eight ANC visits, especially in low-income settings.,, However, Bangladesh's country guidelines follow the older approach of four ANC visits. Quality services such as skilled birth attendance, delivery in healthcare facilities and universal access to basic maternal healthcare are important to reduce mortality and morbidity. There is ample evidence for the effectiveness of these services.,,, There is substantial evidence that receiving ANC determines whether a mother will seek PNC and ultimately get the positive outcomes of both.,,, PNC comprises care provided to both the newborn and the mother after birth or delivery. The post-natal period is crucial, specifically in the first 42 days. PNC services can reduce the risk of maternal and neonatal death.,,,, The WHO recommends the first PNC visit by a healthcare provider as soon as possible (within an hour) if a baby is born in the healthcare facility and within 24 h if delivered at home., There should be repeated follow-up visits starting from 1 to 6 weeks. Even with unskilled PNC, neonatal death is significantly decreased.,
| Maternal Mortality|| |
In 2017, global MMR was 211/100,000 live births, and about 810 women died daily from pregnancy and childbirth-related problems, which could have been prevented. MMR declined by 38% worldwide during the previous 7 years, but most of these deaths occurred in the low and lower-middle income countries. The majority of these countries are from Sub-Saharan Africa and South Asia. This reflects inequalities in access to quality healthcare services in those regions [Figure 1] and [Figure 2]. If looked back in history, between 1750 and 1850, the MMR was above 1000/100,000 live births in many countries. Henceforth, the rate started declining slowly. The United Kingdom and the United States were the first countries to record such health statistics. The decline was more prominent in the higher-income countries than the lower- and middle-income countries. By 2000, the higher-income countries' MMR was reduced to below 40/100,000 live births [Figure 3]. With the League of Nations established in 1919, maternal health started gaining attention. Ultimately, the WHO was established in 1949. By another 40 years of its establishment, the first Safe Motherhood Conference was held in Nairobi, Kenya, in 1987.
|Figure 1: MMR in selected African Countries/100,000 live births from 2000 to 2017. MMR: Maternal mortality rate.|
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|Figure 2: MMR in SAARC Countries/100,000 live births from 2000 to 2017. MMR: Maternal mortality rate.|
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|Figure 3: MMR in selected high-income countries/100,000 live births from 2000 to 2017. MMR: Maternal mortality rate.|
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The WHO defined maternal mortality as 'the death of a woman while pregnant all within 42 days of the termination of pregnancy, irrespective of the duration and site of pregnancy from any cause related to or aggravated by the pregnancy or its management except the accidental causes'. Various government and local government programmes could impact the MMR,,, as evident by the Mother Care Nigeria program, Midwives Service Scheme and Free Maternal and Child Health Services. All such interventions in Nigeria could contribute to an almost 75% decline in MMR. Although this rate was far from the MDG target, this decline was promising. Like Pakistan, some regions in South Asia have the highest MMR of 260/100,000 live births. Every day, about 30,000 women die from birth-associated complications. There are many factors contributing to these high maternal and neonatal deaths. According to the WHO, severe bleeding after delivery (post-partum haemorrhage), infections/sepsis, hypertension or pre-eclampsia, eclampsia, obstructed labour and complications and unsafe abortion are the major causes of maternal mortality associated with childbirth. Maternal education, sociocultural factors, household income, women's decision-making capacity and service utilisation patterns are also worth mentioning.,,,,,,,,
| Under-five Mortality, Child Mortality and Neonatal Mortality|| |
Neonatal mortality is the death of a newborn during the first 28 days of life. NMR is the number of neonatal deaths/1000 live births in a given year or period, and early neonatal death is the death of a newborn during the first 7 days of life. Under-five mortality rate (U5MR) is an MDG indicator. It is defined as the probability of a child dying before reaching the age of five, born in a specific year or period. In 2020, 5 million children under 5 years of age died, meaning 13,800 children died every day in this age group. Primary causes are infectious diseases such as pneumonia, diarrhoea and malaria, besides pre-term birth and birth-related complications. The Global U5MR declined by 61% from 1990 to 2020 (93/1000–37/1000 live births, respectively).
Despite a 54% decline in neonatal deaths since 1990, on average, 17 out of 1000 newborns died within the first 28 days of their life in 2020. Global neonatal mortality declined from 4.6 million in 1990 to 3.3 million in 2009, but in the latter decade, the decline was slow. Globally, 2.4 million children die in their 1st month of life, accounting for approximately 6700 newborn deaths daily, 7% more than the 1990's rate for all under-5 mortalities. Similar to maternal mortality, the NMR is 9–10 times higher in the South Asian and Sub-Saharan African countries, respectively [Figure 4] and [Figure 5]. Compared to child mortality among children of 1–11 months or 1–4 years, neonatal mortality declined much slower globally [Figure 6]., In 2019, most neonatal mortality was caused by pre-term birth, birth asphyxia, infections and congenital disabilities. To achieve MDG-4, an annual decrease rate of 4.4% in the under-5 mortality rate is required. However, between 1990 and 2015, the global under-5 mortalities decreased at an annual rate of 3%. Fifty-eight countries either met or exceeded the required rate to meet the MDG-4. Twenty-eight countries did not achieve the 4.4% rate, and many countries have a higher absolute level of under-5 mortalities, especially 11 countries recording more than 100/1000 live births in 2015. The decline in the under-5 mortality rates reduced infectious diseases, including lower respiratory infections, diarrhoeal diseases, measles and malaria. In South Asia, the NMR exceeded the mortality rate for other child age groups (29.8/1000 live births) [Figure 7]. In Western and Central Sub-Saharan Africa, the mortality rate for children aged 1–4 years was higher. In 2015, India had the highest number under-5 mortality rates at 1.3 million, followed by Nigeria at 726,600 and Pakistan at 341,700. The Central African Republic and Pakistan had a NMR of about 40.2/1000 live births [Table 1] and [Figure 8].
|Table 1: Top 10 countries with the highest under-five mortality rate, 2019|
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|Figure 4: Under-5 child mortality rate in SAARC Countries/1000 live births from 1960 to 2019. U5MR: Under-5 mortality rate.|
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|Figure 5: Under-5 child mortality rate in selected African Countries/1000 live births from 1960 to 2019. U5MR: Under-5 mortality rate.|
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|Figure 6: Neonatal mortality rate as per World Regions/1000 live births between 1990 and 2019.|
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|Figure 7: Under-5 child mortality rate in SAARC countries/1000 live births from 2018 to 2019. NMR: Neonatal mortality rate.|
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|Figure 8: Under-5 child mortality rate in selected World Regions and Countries/1000 live births from 1960 to 2019.|
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| Perinatal Mortality and Effect of Perinatal Care|| |
Reviewing several mortality indices over the past 3–4 decades shows that there has been substantial progress in areas of maternal, neonatal and under-5 child mortality worldwide.,, The WHO's 2010 Countdown Decade Report showed that achieving MDGs 4 and 5 were eminent with political and financial commitments. Out of 68 countries, 19 were on track to reduce child mortality by 2015. Most study countries did not reduce maternal mortality., These failures were mainly due to a lack of infrastructure, trained staff and adequate quality care.,,, SDG target for global neonatal deaths/1000 live births is 12 or fewer deaths by 2030, and in 2020, it reached 17 from 31/1000 live births in 1990. Some regions and countries made substantial development, while others had little progress towards 2030 SDG targets. Sub-Saharan Africa (28/1000 live birth) and South Asian countries (25/1000 live births) made minor progress and were still far from the target. However, apart from Afghanistan (22) and Pakistan (37), most South Asian countries showed promising improvements in this indicator [Table 2].
|Table 2: Historical progress towards Sustainable Development Goal targets 2030|
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SDG 2030 target for U5MR is 25 deaths/1000 live births. The global average of under-5 mortalities in 2020 reached 37 from 93/1000 live births in 1990. Most world regions made substantial development in the indicator U5MR, apart from Sub-Saharan Africa and South Asian regions., Afghanistan (54) and Pakistan (59) made the most Negligible Development by 2020 [Table 2].
Considering maternal mortality indicators, SDG 2030 target for MMR is 70/100,000 live births. The global average of MMR in 1990 was 385/100,000 live births, which declined to 152/100,000 live births in 2020. This rate is still far from the 2030 target. High-Income, Central and East Europe, and the Central Asian countries had been able to reduce MMR to much lower rates than that of the target by 2020. However, multiple Sub-Saharan African and South Asian areas still need to do a lot to bring the MMR rates to an acceptable level.,,, Among South Asian countries, Afghanistan (348), Nepal (239), Pakistan (189), Bhutan (187), Bangladesh (169) and India (130) had a very high MMR in 2020 [Table 2].
The progress made by countries and world regions was possible because of interventions such as increased ANC coverage, availability of skilled birth attendance during childbirth, provision of quality and equitable maternal care and making evidence-based clinical practice guidelines. Studies in low and middle-income countries found that more than 4 ANC visits with skilled attendance reduced the MMR.,,,,, ANC contributes to this declining rate in MMR and NMR by ensuring healthcare services, including screening, early detection and treatment of health issues, besides health promotion advice regarding pregnancy and delivery care to the mothers.,, Similarly, PNC effectively reduces MMR and NMR.,,,,,,, That is why international organisations such as the UN, WHO and United Nations International Children's Emergency Fund prioritised reducing mortalities related to pregnancy and childbirth, which can be achieved through antenatal and PNC services., Ensuring the provision of quality care in a healthcare facility to all women and newborns, besides facility delivery, could save more than a million newborn lives as well as reduce healthcare costs by about US$ 4·5 billion/year. Better care starting before pregnancy (pre-conception) and then ANC and PNC services could forestall 71% of neonatal deaths and 54% of maternal deaths per year by 2025. Strengthening the healthcare system in resource-poor countries by expanding networks, increasing facility births, ensuring the availability of midwives and trained birth attendants and eliminating financial and social barriers are important strategies to remove the gaps in healthcare access. These interventions could effectively improve maternal and neonatal health.,
| Bangladesh Perspective|| |
Bangladesh Demographic and Health Survey 2017–18 key indicators showed that the economic condition in Bangladesh continues to improve with increased electricity access in rural areas. However, inequalities still exist in rural-urban differentials and financial states. Ninety-one per cent of the households in 2017 had access to electricity. Almost 94% of the households possessed a mobile phone. Education levels also increased, and 52% of the survey population had secondary education. Similarly, Bangladesh made visible improvement and child health indicators. In 2017, 82% of the women received at least one ANC visit from a healthcare provider, about 20% more than that in 2014. Women receiving four or more ANC visits increased from 31% to 47% during the same period and are expected to reach 50% by 2022. Fifty-three per cent of the births were attended by medical personnel in 2017, increasing facility deliveries. Half of the deliveries occur in the healthcare facilities (private 32%, public 14% and non-government organisations 4%). There is region-wise inequality in the use of the facility. Those belonging to the highest and lowest wealth quintiles and those in different country regions do not experience the same healthcare facilities. Half of the mothers and children received PNC services from a trained healthcare provider within 48 h of delivery. ANC and PNC services and their utilisation are essential tools to monitor maternal health, deliver care, identify complications and prevent adverse outcomes. Perinatal care and care during labour from a trained healthcare provider can critically reduce MMR and add NMR. During 2014–17, 53% of all deliveries were attended by either a doctor, nurse, midwife, family welfare visitor or community skilled birth attendant, besides 35% of deliveries were attended by dais or untrained attendants. Compared to neighbouring South Asian Countries, Bangladesh has not shown promising improvements in ANC and PNC service utilisation rates [Figure 9]. However, the country has made substantial progress towards the SDG 2030 target in MMR and child mortality index [Figure 7] and [Figure 10]. Between 2000 and 2019, global child mortality has reduced to half, but neonatal mortality did not make similar progress. Among 204 countries, 65 (32%) are not towards the 2030 SDG 3.2 goal, predominantly in Sub-Saharan African and South Asian countries. Besides poverty reduction, these countries need to strengthen essential services, vaccination, infection prevention, health equity and education.,, Another study explored the all-cause and cause-specific mortality data from 204 countries' projected values for 2030 based on present data and trends. These projections show that Bangladesh will be steeply improving in lowering the NMR and U5MR by 2030. It is also projected that 75% of the countries would have U5MR lower than the 2030 threshold of 25/1000 live births, and 68% of the nations will have reached lower than 12/1000 live births NMR threshold.,, A study done by Khan et al. predicted that with the current reduction trend, Bangladesh will achieve the SDG goal of a U5M rate before 2030. However, maternal high-risk fertility behaviours and poor healthcare services can impede our progress. Rahman et al., in their Lancet article in 2018, stated that despite the increase in the coverage of 4 ANC and PNC visits, facility-based delivery by skilled birth attendants and exclusive breastfeeding in Bangladesh, these services would not reach the projected target Universal Health Coverage (UHC) of 80% by 2030.
|Figure 9: Antenatal and post-natal service utilisation rates in SAARC Countries in recent years. ANC: Antenatal care, PNC: Post-natal care.|
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|Figure 10: Recent MMRs in SAARC Countries/100,000 live births. MMR: Maternal mortality rate.|
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| What Should be Done to Improve the Situation?|| |
According to the WHO, the content of ANC visits should include (1) measuring blood pressure, (2) urine analysis for bacteriuria and proteinuria, (3) blood tests to detect syphilis and severe anaemia and (4) weight and height measurement. Competent healthcare providers and a midwife should provide these services. Women expecting to become mothers would receive health education about health behaviours, pregnancy, childbirth warning signs and social, emotional and psychological support. An integrated and comprehensive maternal and neonatal care programme can enhance maternal, neonatal and child survival. Expanding the community and facility-based strategies to provide quality care during pregnancy, labour and the post-natal period is vital. Countries such as Nepal have shown success by prioritising neonatal care through an integrated community-based and facility-based approach. Having an adequate number of trained staff for providing natal and PNC, skin-to-skin contact immediately after birth, advanced resuscitation for birth asphyxia with timely breathing assistance after birth, umbilical cord care, early screening of congenital disabilities and treatment, treatment of sepsis and neonatal infections besides post-natal check-ups are among some effective strategies., Providing PNC services alone will not change the situation entirely. Eliminating the gaps among different population groups is also necessary, as evident by the Sri Lankan experience. The country has a very high PNC utilisation rate, but it is not universal. An innovative subsidised maternal and child health voucher scheme in Bangladesh effectively increased awareness and utilisation of ANC PNC and attended deliveries at facilities and homes. All of these led to the lowering of maternal and infant mortalities. This intervention helps in eliminating the financial barrier between availing maternity services in many lower economic settings. Utilisation rates for various services, including 3 ANC visits, significantly increased among subsidised groups than in the non-voucher receiving group., A country will not attain UHC unless it scales up the resources and interventions to strengthen the maternal and childcare delivery system. It also needs to allocate adequate funds for healthcare to eliminate gaps through nationalised health insurance models while expanding public funding and providing community-based healthcare delivery.
| Conclusion|| |
Several studies have proved that access to antenatal, perinatal and PNC services is crucial for improving maternal and child health. Bangladesh has made many improvements in most of the health indicators. Still, the target to reduce maternal mortality and utilisation of ANC and PNC services provided by skilled healthcare personnel has not been met. Although we could reduce infant mortality rate and overall U5MR, NMR still lags. Good strengthening of ongoing ANC and PNC services in Bangladesh will help us achieve our desired SDG goal by 2030.
Pregnant women need to be encouraged to avail themselves of ANC and PNC. Therefore, there is a need for community education of families, especially women, regarding the importance of these visits. Consequently, we recommend that such educational programmes that provide education concerning health behaviours, pregnancy, childbirth warning signs and social, emotional and psychological support should be implemented in the community. Also, to achieve effective ANC care as per the recommendation of WHO, the responsible authorities need to ensure that skilled healthcare providers are providing such services. An integrated and comprehensive maternal and neonatal care programme should also be in place to enhance maternal, neonatal and overall child survival. Expansion of the community and facility-based strategies to provide quality care during pregnancy, labour and post-natal period is also recommended. More studies regarding maternal and child healthcare need to be carried out.
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas, they took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted and decided to be accountable for all aspects of the work.
Consent for publication
The author reviewed and approved the final version and has agreed to be accountable for all aspects of the work, including any accuracy or integrity issues.
This is a review paper. Data utilised from open-access resources.
The authors show gratitude to Naufela Nafisa Ahmad, Master of Arts in English Language (Linguistics), Jalan Wangsa Delima 7, Wangsa Maju, 53300 Kuala Lumpur, Malaysia, for revising and providing her expert opinion about the quality of the English language of this article. The authors also express gratitude to Faizaan Binti Muzammil, Photographer and Editor, 7/16/1 South Mujadara Dhaka, Bangladesh, for her kind effort and time regarding image development and editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2]