Current Women's Health Reviews - Volume 5, Issue 4, 2009

In this issue a striking article by P. Barate and M. Temmerman gives valuable information about the silent tragedy of maternal mortality worldwide showing that the Millennium Development Goal (MDG) 5, i.e. reduction of maternal mortality, is the most “off track” goal of the MDGs. These authors mentioned that since the launch of the Safe Motherhood Initiative in 1987, most of the appalling statistics on number of maternal deaths have remained relatively unchanged for 20 years; according to facts, which are deeply shocking, almost all cases of maternal mortality are preventable. Furthermore, information about the indicator is so poorly collected that we are faced to deal with a relative uncertainty in the estimates. Barate and Temmerman mentioned that too many actors have been trying to guide or influence policymaking in developing countries, with lack of cohesion and loss of performance as a consequence; and that donors often dictate the rules, since most governments and organisations lack the necessary resources, mandate or full-range expertise to deal comprehensively with the maternal and neonatal health issues. The provision of appropriate maternal care is a human right. We know that lack of provision of effective interventions is a violation of human rights. E. Silva Miranda and C. Garcia Serpa Osorio-de-Castro provide a thoughtful review about malaria in pregnancy. Advances have been achieved in the control of the mosquito but still research is needed in the development of safe, effective and affordable drugs that are acceptable to pregnant women and in adequate training and encouragement for adherence to treatment guidelines by health professionals. We are very grateful to Dr. Watanabe for the work on leading and assembling articles in such a relevant subject as maternal nutrition. This subject has been a steady concern for obstetrician and midwives. We remember a period about counselling restriction of maternal weight increase based on misconception about the prevention of preeclampsia. Authors of the articles in this issue show the complexity of the situation, since maternal malnutrition is a current problem. Transition shows an increase in women obesity as data provided by Li and Haung in China and the peculiar situation in Japan of lean women in young age showed by Itoh and Kanayama. Around 27 million children are born every year with intrauterine growth restriction, 97% of them in low-and-middle income countries (LMIC) [1]. The possibility of being born with a below-standard weight in LMICs is 24%, compared to 7% in high income countries. These children have a higher risk of death, health complications, impairment in growth and mental development, and when women higher risk of having children with fetal growth restriction and metabolic impairment in the next generation. Also, they have a higher risk of suffering chronic health problems like hypertension, diabetes and obesity. In their article Itoh and Kanayama gave valuable information about the consequences and mechanisms linking poor fetal nutrition and chronic consequences, mainly obesity. Maternal nutrition previous and during pregnancy is a major determinant of fetal growth. Watanabe et al. and Everette articles in this issue provide relevant information about how to improve maternal nutrition previous and during pregnancy. In their comprehensive reviews information is provided to better manage women nutrition and consequently ameliorate consequences in the progeny of such malnutrition. An issue of the Journal showing the relevance of the need to improve maternal health, the diversity of situations in the countries of the world and the need of conjunction of basic, clinical and epidemiological researchers looking for feasible interventions to improve maternal health. But also the need of joining global actors to work together with similar approaches and objectives.

Overweight and obesity have become a serious global public health issue in the world. More than one third of the reproductive age women are overweight. Adequate gestational weight gain contributes to better perinatal short- and long-term health outcomes in both mother and infants. In women of reproductive age, high prepregnancy BMI, overweight and obesity, are risk factors for adverse pregnancy outcomes, such as gestational diabetes, preeclampsia, cesarean delivery, and having a macrosomic infant. On the other hand, some industrialized countries face rising rates of underweight women of reproductive age. Low prepregnancy BMI and low gestational weight gain are associated with increased risk of low birth weight and small gestational age infants. Animal studies suggest that a combination of undernourishment in utero and normal or high levels of nutrients in the neonatal period plays a critical role in connecting a low birth weight with obesity in later life. In 1990, the IOM issued new guidelines for pregnancy weight gain. It has been the standard for weight gain and is followed worldwide by obstetricians and midwives in many countries. In a large sample study, only 34 percent of women gained weight within, and nearly 40 percent of women gained weight above the recommended IOM range. This standard has been slightly changed since 1990. Pregnancy can be an opportune time to improve nutrition, and presents an ideal time for health promotion activities. Some studies reported that pregnant women do not have an opportunity to get adequate and appropriate nutrition education for antenatal care. Most of them expect advice on general dietary improvements, with the remainder seeking advice on helping to promote their quality and quantity of nutritional intake. All women of reproductive age should be encouraged to follow the government recommendation and eat a well-balanced diet. Health care providers need to ensure that pregnant women are aware of the positive and negative effects of poor maternal nutrition status. We need to discuss the effective weight gain management and nutritional education throughout pregnancy to improve both maternal and infant's health.

Women with a normal prepregnancy body mass index (BMI) and those who meet the recommended weight gains are healthiest and have healthier children. Adequate gestational weight gain contributes to better perinatal short- and long-term health outcomes in both mothers and infants. However, many key aspects of the health of women of childbearing age have changed, including a high prepregnancy BMI and advanced age, along with a high proportion of women from diverse ethnicities. Overweight and obesity have become major problems in the world. High prepregnancy BMI, overweight and obesity, are risk factors for adverse pregnancy outcomes, such as gestational diabetes, preeclampsia, cesarean delivery, and having a macrosomic infant. On the other hand, underweight is associated with a higher incidence of miscarriage, and the delivery of small for gestational age (SGA) and low birth weight (LBW) infant. Prepregnancy BMI and gestational weight gain show strong association with pregnancy outcomes. Their combined effects on maternal and neonatal outcomes, including short- and long-term health risks, are strong. Therefore, it is important that health providers help women implement lifestyle changes to achieve normal BMI levels preconception, avoid excess weight gain during pregnancy and eliminate postpartum weight retention.

Nutrition education is defined as any set of learning experiences designed to facilitate the voluntary adoption of eating and other nutrition-related behaviors, conducive to health and well being. Preconception, the period before pregnancy and usually encompassing teenaged years and early adulthood, was identified by the 1992 Institute of Medicine Report as an important period for intense nutrition education to achieve optimal prepregnancy nutritional status. The primary objective was to evaluate the effectiveness of nutrition education for reproductive-aged females. Studies, conducted in the United States and internationally, published between 1992-2009 were identified through a library search of databases and an examination of reference lists of relevant publications. Studies included those that involved adolescent and/or adult females and examined the impact of nutrition education intervention. Only articles published in peer reviewed journals in English were included in this review. Ten studies were identified that met the review criteria. Findings from this review suggest that there has been some progress since the 1992 Institute of Medicine Report; however long-term empirical evidence in this area is relatively scant. Therefore, there is the need for well-designed, evidencebased, peer-reviewed studies to determine program effectiveness and impact over the lifecourse of the reproductive aged female.

Objective: prevalence of obesity and associated diseases in women has increased rapidly in Mainland China. It is critical to identify nutrition risk factors in obesity prevention and control. Methods: This review analyzed nutrition risk factors relating to obesity epidemic in Chinese women by using data of The 2002 China National Nutrition and Health Survey (2002CNHS) and other publications. Results: high fat and unbalanced diet was noted. 22.7&percnt of adult women were overweight and 7.6&percnt were obese. The prevalence of hypertension, dyslipidemia, diabetes and metabolic syndrome in adult women was 18.0&percnt, 15.9&percnt, 2.66&percnt, and 11.4%, respectively. Chinese girls were in relatively lower prevalence of overweight and obesity than boys, in total, 3.9&percnt of 7-17year girls were overweight and 1.7&percnt were obese. But it was 6.6&percnt and 3.4&percnt in urban girls. The rapid increase of the prevalence is alarming. Urban women have higher risks than rural women. High fat and unbalanced diet, as well as sedentary lifestyle contributed to the obesity epidemic and the prevalent of non-communicable chronic diseases. Obesity prevention and control strategies and actions have progressed, but further evidence-based weight management programs both in individual and population are needed.

In the last half-century, obesity has constantly increased in Japanese adults except for women of childbearing age who often desire to be thin. Considering the lean composition of Japanese mothers and rather strict restrictions on maternal weight gain during pregnancy in Japan, there is concern that increasing numbers of young Japanese have been undernourished during the pre-conceptional as well as conceptional period. Indeed, increasing numbers of neonates have been born with low birth weights in Japan. Animal studies suggest that a combination of undernourishment in utero and normal or high levels of nutrients in the neonatal period plays a critical role in connecting a low birth weight with obesity in later life, leading to the concept of a ’thrifty phenotype‘ proceeding to ’mismatch‘ to high levels of nutrients after birth as a risk of obesity. Results obtained with rodent models have suggested that hypothalamic plasticity in the early developmental period plays a critical role in the mechanistic framework.

Maternal pregravid obesity is associated with adverse outcomes in pregnancy. There are many complications by maternal obesity during pregnancy, such as spontaneous abortion, congenital malformations, gestational hypertention, preeclampsia, gestational diabetes mellitus, fetal macrosomia, and so on. Also, at parturition, the prevalence of cesarean section and associated complications such as deep vein thrombosis, wound disruption, and infection increase. Furthermore, offspring of obese women increases the risk of adolescent components of the metabolic syndrome. To improve short- and long-term adverse outcome associated with obese pregnant women, we need to encourage obese women to lose body weight before pregnancy. During pregnancy, weight gain should be limited to Institute of Medicine guidelines.

It has been documented that there is a strong positive association between prepregnancy body mass index and the risk of preeclampsia. However, few papers have evaluated the role that additional anthropometric and body composition measurements may have in predicting preeclampsia risk. For the present review, studies were identified using MEDLINE Scientific Database. Large observational, case-control and cohort studies published between 1990 and 2008 were identified. Twelve studies met the inclusion criteria, nine reporting that anthropometric and body composition measurements could be used to predict preeclampsia risk during pregnancy. Waist, waist to hip circumference and total body water content, in particular, appear to correlate with preeclampsia risk. Further observational studies, using gold standard technologies for measuring body composition now need to be undertaken to build upon these preliminary findings.

More than two decades after the launch of the Safe Motherhood Initiative, maternal health in many developing countries has shown little or no improvement. Year after year, more than half a million mothers continue to die in silence. The specificities of the complex cross-cutting issue only partly explain why tireless efforts have led to insufficient progress so far. While some success stories prove that results can be obtained quickly, the dissensions and deficiencies the Initiative has encountered have strongly weakened its impact. However, recent developments over the past 3 years allow us to foresee the silence will soon be broken. While advocacy begins to subsequently raise awareness, more financial means are mobilized. As a consensus on the priority interventions has finally been reached (Women Deliver conference, London, October 2007), more coordinated actions and initiatives are being developed. The strive for the achievement of the Millennium Development Goals helps to create the political momentum the cause strongly needs to generate new leadership, develop and implement the adequate strategies. Sensible focus on resources and structure as well as innovative management will be crucial in that process.

Malaria is a widespread parasitic disease, with serious implications in pregnancy. To provide an overview of studies on interventions aimed at malaria control for pregnant women, the literature was searched for available studies published in the last 40 years, according to inclusion and exclusion criteria. Studies relaying control policies and interventions focusing on pregnancy were selected. The vast majority of studies (79.2%) were conducted in Africa. Only 5.5% of the studies were performed in the Americas, mainly in South America. Key issues presented dealt with: careseeking behavior, access to treatment, prevention and treatment, beliefs, perceptions and practices by patients and health professionals. The studies point to the need for prenatal monitoring, development of educational interventions for the general population and for health professionals, regular supply of essential medicines, and knowledge of health professionals' and patients' attitudes and beliefs concerning malaria. Because pharmacological interventions are the most effective strategy for combating the disease, the development of safe, effective and affordable drugs that are acceptable to pregnant women is imperative. Adequate training and encouragement for adherence to treatment guidelines by health professionals both deserve special attention.