Medicosnext
The months leading up to the birth of a child are crucial for both the mother and the child. Nepal has been making a lot of effort to improve maternal and infant health, and has steadily been improving the care that mothers and infants receive during this time. Nepal Demography and Health Survey data by the Ministry of Health shows that maternal mortality ratio in Nepal has decreased from 539 maternal deaths per 100,000 live births to 239 maternal deaths per 100,000 live births between 1996 to 2016, and the country has seen a 25% increase in the number of expectant mothers seeking antenatal care from 2011 to 2016.
To learn more about these crucial months and the care required for the expectant mother and child during this time, we sat down with Dr. Deepti Dwa (Shrestha), a gynecologist at Prasuti Griha who has been practicing for the past 12 years.
What is antenatal care and what does it include?
Antenatal care is the systematic examination and supervision of a woman during pregnancy to monitor the progress of the fetal growth and to ascertain the well-being of the mother and the fetus. It includes indentifying the risk of the pregnancy, whether it is a high risk pregnancy or not, prevention and management of pregnancy related disease, educating the pregnant woman about her health, and promoting the health and well-being of the mother and fetus.
Why is antenatal care necessary?
To put it simply, ante-natal care is done to ensure a healthy baby from a healthy mother. The goal of antenatal checkup is detection and prevention of health complications, and education and counseling of the expectant parents. It includes early detection of high risk patients; prevention, detection, and treatment at the earliest symptom of any complication; immunization to be taken during the pregnancy; and education of the mother about the physiology of pregnancy and labor, so as to remove any fear she may feel. It includes counseling the mother about the diet to be taken and hygiene to be maintained during the pregnancy, counseling the couple about the place time and mode of delivery so that they can prepare early, and counseling the expectant parents about the care of a newborn. Finally, it also includes motivating the couple about the means and mode of family planning that they may use after the delivery of the child.
What can an expectant mother expect during her antenatal care?
In Nepal, we follow WHO recommendations for antenatal care. First of all, early detection of the pregnancy is sought. In cities, people often use a pregnancy kit as soon as they miss their periods, so early detection of pregnancy is easy. WHO recommends a visit to the doctor every four weeks till 28 weeks, every two weeks till 36 weeks, and every week till delivery after the 36th week of pregnancy. After the checkup of the pregnant woman, the doctor recommends medications to be taken. If the pregnancy is planned, it is recommended that the pregnant woman start taking folic acid tablets four weeks prior to conception. If the woman visits the doctor after pregnancy, we recommend folic acid till fourteen weeks after pregnancy. After three months of pregnancy, iron and calcium supplements are recommended. Besides supplements, the pregnant woman also needs to be immunized. We immunize the woman with tetanus toxoid between 16 to 24 weeks of pregnancy. It includes two doses taken 6 weeks apart.
What are the medical investigations that are done during the pregnancy?
As soon as the pregnant woman visits her gynecologist, we conduct some basic investigations, which include blood and urine tests. During blood tests, we look at the hemoglobin, blood group, CBC, platelet count, serology, etc. Serology in Nepal includes Hepatitis B, HIV, and venereal diseases, which can cause anomaly in the fetus. Ultrasound is done within the first 8 weeks to confirm pregnancy, to determine if it is a single or multiple pregnancy (twin, triplets, etc.) and to ensure that the pregnancy is not a molar or ectopic pregnancy. Molar pregnancy is when a non-viable egg implants into the womb, and ectopic pregnancy is when the fetus is implanted outside the womb. Within 13 to 18 weeks, another ultrasound is done to evaluate the possibility of Down syndrome. The next ultrasound takes place between 18 to 20 weeks to detect any fetal anomaly, i.e. to ensure that the baby’s limbs and internal organs are developing normally. And, finally, ultrasound is done at 34 weeks to evaluate the size of the fetus, position of the placenta, amniotic fluid index, etc.
What are the do’s and don’ts for a pregnant woman to follow during pregnancy?
There are many things that a pregnant woman must consider during her pregnancy. First is hygiene. She should wash daily, especially her genital and auxiliary area. But, she must avoid hot bath, as it can cause lethargy and fainting attacks. Another important aspect is breast care. She should wash her breasts with tap water, but she should not massage her breast, as it can release oxytocin, which is a hormone that induces contraction. We also teach dental care, as well as clothing to be worn during pregnancy. She must not wear tight clothes or belts around her abdominal area.
A lot of patients also ask about traveling during pregnancy. During early pregnancy, unless she has a history of miscarriage or abortion, traveling is not restricted. But, during late pregnancy, i.e. during the third trimester, traveling is not recommended, as there are chances of the mother going into pre-term labor. We also get asked a lot about sexual activity during pregnancy. Sexual activity is allowed in moderation, unless she has a history of miscarriage, abortion, vaginal bleeding, etc.
Walking is the ideal exercise during pregnancy, but it is better to avoid long walks or standing for a long time, as it predisposes to varicose vein. She should also avoid sitting in cross-legged position, as it will impede blood circulation.
A pregnant woman should get eight hours of sound sleep at night and take a one- to two-hour nap during the day. Natural sedatives, such as warm bath or walk milk, can also be used to induce sleep.
What are the common mistakes pregnant women make during pregnancy?
Most pregnant women are conscious about their health during the pregnancy. But, in Nepal, when it comes to household work, often due to their domestic and social circumstances, they feel compelled to do household chores, which can lead to complications limke contractions and pre-term labor.
What are the risk factors that can affect pregnancy?
First of all, we have to look at how many pregnancies she has had in the past. If she has had past miscarriage or abortion, she is categorized as high risk. Then, during our systematic examinations, we have to consider if she has a history of hypertensive disorder (high blood pressure) or diabetes. If that is the case, the pregnancy is immediately categorized as high risk. If she has had a C-section before, she needs special care. We have to look at the cause of previous C-section and evaluate whether she’ll need C-section again. If she a systemic disease, it needs to be treated, so that it does not affect the health of the mother or the fetus.
Some health issues are only detected during the pregnancy. Sometimes, the patient is already predisposed to hypertension, but it is only detected during pregnancy examinations. Some patients get gestational diabetes mellitus, where a woman with no history of diabetes becomes diabetic during pregnancy. In such cases, she needs special care as per her condition.
During pregnancy, what kind of education does the husband and the family of the pregnant woman need to care for the pregnant woman?
First of all, the husband must be alert and conscious about the pregnant state of his wife. We counsel the husband about regular ante-natal checkup, what occurs during the antenatal checkup. He must be made conscious that a pregnant woman and a non-pregnant woman are not the same, so she must be restricted from certain activities. He should be told about the danger signs that he should be conscious of. These danger signs include leakage of fluid, vaginal bleeding, distressing abdominal pain, headache, blurring of vision, lack of movement of the fetus, fever, rigor, and excessive vomiting. In such cases, he needs to bring her to the hospital immediately.
The husband also needs to be counseled on sexual activities during pregnancy, as they are not always conscious about what can or cannot take place during pregnancy. The husband should be conscious about where and how the delivery should take place. Some might want the mother to deliver at home or at a health post. In such case, we have to counsel them to have the delivery at a hospital with all the facilities available. They also often ask about the cost and details of the procedure, which is explained to the husband and the family.
What are some fears that pregnant women have during pregnancy?
They are usually scared of labor pain. Many of them have also heard of a lot of cases where the mother or the baby passed away due to complications. In such circumstances, we have to counsel them that that not all cases are dangerous, and that ante-natal checkup is vital to decrease the possibility of such fatal incidences. We also counsel them on the danger signs to be alert for, and in which cases they must get immediate medical attention.
Is the comprehensive antenatal care you have prescribed possible in rural areas of Nepal, where fully-equipped hospitals are not easily accessible?
In cases where healthcare is not easily accessible, the pregnant mother must be educated on what they should and should not do during pregnancy and the danger signs to look out for. Once they are made aware, they will take necessary precautions. They must also be prescribed the necessary medications needed during pregnancy. In rural areas, although hospitals may not be available, there will often be a health post with a health worker. They can visit the health post. If visiting weekly is not possible, they can visit every two weeks, or once a month, and if the health worker sees any symptoms of a possible complication, they can refer them to a doctor. This way, she will be safe.
In Nepal, in many rural areas, there are still many women who have children when very young, and in urban areas, women are starting to have children much later in life. What kind of effect can that have on the pregnancy and antenatal care?
We get a lot of cases where girls as young as 14 or 15 years old come from outside the valley to see us after becoming pregnant. Up to 17 years, if a girl is pregnant, we immediately classify her as a high-risk pregnancy. In cases of pregnancy in early age, we need to make sure that their organs are developed enough to go through the pregnancy. At their tender age, their social and economic status is also not strong enough, so we need to counsel them accordingly. In early age pregnancy, there is a risk to the mother’s health, whereas in case of pregnancy in older age, there is higher risk of complication to the fetus. Pregnancy where the mother is 35 years or older is considered high risk. In such case, we need to monitor for fetal abnormalities like Down syndrome. We conduct special tests, including genetic test, tests for neural defects, etc.
What kind of improvement do you see as necessary in the health sector of Nepal?
In urban areas, the development is going well. The women are also well-informed. But, the main problem we see is in rural areas, where women feel shy to say that they are pregnant, and many of them have home delivery. If they feel hesitant to access healthcare during their pregnancy, the government needs to ensure their health, even if the health workers have to go door to door to provide the service and thus reduce maternal mortality.
