Abstract
The special collection on Maternal Health Considerations offers a comprehensive exploration of critical issues surrounding maternal well-being across diverse contexts and disciplines. Recognising that maternal health extends beyond the physiological realm, this collection delves into the multifaceted dimensions of maternal well-being, including physical, mental, and socio-ecological factors. The collection comprises a series of interdisciplinary studies that investigate various facets of maternal health, from conception to postpartum stages. It addresses the complex interplay between biological, psychological, and socio-cultural determinants that influence maternal health outcomes. By adopting a holistic approach, the contributors shed light on the interconnectedness of maternal well-being. Key themes explored within this collection include the impact of prenatal care on maternal and neonatal health outcomes, as well as the role of mental health in shaping maternal experiences. In addition, the collection presents innovative recommendations to enhancing maternal well-being, such as community-based interventions, technological advancements, and future policy considerations. Furthermore, the special collection emphasises the significance of culturally sensitive care in promoting maternal health. It highlights the need for tailored interventions that respect the diversity of maternal experiences across different ethnic, racial, and socioeconomic groups. Contributors to this collection employ a range of methodologies, including qualitative and quantitative research case studies, which provide an intricate overview of the current state of maternal health research. The collection also offers valuable insights for policymakers, healthcare practitioners, researchers, and advocates working towards improving maternal health outcomes worldwide. It serves as a vital resource for contributing to our understanding of the complexities surrounding maternal well-being. It offers a platform for critical dialogue and collaborative efforts aimed at promoting holistic maternal health.
Introduction
In the wake of the global pandemic, uncertainty has prompted reflections on our priorities. The surge of ‘lockdown’ babies1,2 underscores the closeness forged during challenging times, juxtaposed against the deliberative decisions to defer or postpone family planning. In light of these circumstances, an intensified focus on maternal health research is certainly warranted. The landscape is evolving rapidly, marked by unprecedented strides in fertility treatments, a growing trend of women choosing to delay pregnancy, and an increasing awareness of holistic health considerations.3 –5 It is imperative that we propel maternal health to the forefront of our collective consciousness, transcending disciplinary boundaries and permeating diverse sectors such as exercise physiology, obstetrics/gynaecology, psychology, nutrition/dietetics, telehealth, and public health interventions.6 –8
While existing research has made commendable strides in monitoring foetal health,9 –11 a significant gap persists in our understanding of maternal health, particularly throughout the various phases of family planning, conception, and birth.12 –14 In essence, a pressing need exists for researchers and practitioners, from both academia and industry, to unravel the nuances of maternal health and offer pragmatic, translatable recommendations for the future.15 –17 This special collection aspires to be a catalyst for fostering the latest innovative developments in maternal health across the globe, encompassing studies that navigate the complexities of pregnancy and the postpartum period. This initiative strives to elevate the discourse surrounding maternal health, fostering a collaborative environment that transcends boundaries and empowers both research and practice in this domain.
Maternal experiences and their mental health and well-being
Postpartum depression is a recognised public health challenge, and in particular for mothers living with human immunodeficiency virus (HIV). As Yeboa et al. 18 explain, the diagnosis impacts upon their engagement in care, HIV disease progression, and elevates the risk of mother-to-child transmission of HIV. A cross-sectional quantitative research design was utilised to evaluate nearly 300 participants in Uganda. Yeboa et al. 18 noted that postpartum depression had a prevalence of 15.9% in their examined cohort. After adjusting for other variables, participants also reported inadequate male partner support which was significantly more likely to indicate the woman experienced postpartum depression compared to those with sufficient support. The findings underscore the importance of routinely assessing mothers living with HIV for depression and the crucial role of male partner support. Healthcare providers for HIV-infected women should devise strategies to promote such support, contributing to enhanced maternal, infant, and HIV treatment outcomes.
Against the backdrop of the joyous postpartum period, postpartum depression emerges as a significant concern. This mood disorder, characterised by a spectrum of symptoms, poses additional challenges for those concurrently managing HIV. Based on reports from Yeboa et al., 18 the global prevalence of postpartum depression in the general population of women is estimated at 13%, but the figure rises to 19.8% in developing countries. Varying prevalence rates are reported for women living with HIV in different nations, with this study addressing the knowledge gap specifically in Uganda. The research delves into the prevalence and associated factors of postpartum depression, shedding light on a critical aspect of maternal health in the context of HIV.
Another article about child feeding practices and malnutrition in rural Malaysia was explored by Chee Din et al. 19 in a case-control methodology in a cohort of just over 100 participants. The researchers investigated the association between child feeding practices, maternal depression, and malnutrition among young children in a rural Malaysian community. Structured questionnaires were administered to Malay mothers of malnourished children and mothers of well-nourished children. The findings revealed that depressed mothers ceased exclusive breastfeeding earlier than non-depressed mothers. Binary logistic regression analysis indicated that maternal depression significantly increased the risk of child malnutrition, with each additional child in the family further elevating this risk. The study underscores the importance of early screening for maternal depression, potentially during the first trimester, to mitigate the risk of child malnutrition by addressing associated feeding practices and maternal mental health.
In a separate study explored by Fleay et al., 20 breast cancer has a particularly notable occurrence during pregnancy or the postpartum period. This pregnancy-associated breast cancer is on the rise, paralleling the increasing trend of women delaying their first pregnancies. Those undergoing treatment for pregnancy-associated breast cancer face the dual challenge of contending with both the rigours of cancer and its treatment and the unique circumstances of pregnancy or the postpartum period. Often, individuals in this scenario confront symptoms commonly associated with cancer diagnosis and treatment, such as nausea, pain, and fatigue, all while navigating the complexities of pregnancy or early motherhood. Despite exercise being linked to a myriad of benefits for both pregnancy health and breast cancer outcomes, these experiences can pose significant barriers to engaging in physical activity. Fleay et al. 20 therefore evaluated the existing body of literature concerning recommendations and outcomes related to engaging in exercise for individuals grappling with pregnancy-associated breast cancer. While many studies recognise advantages of exercise utility, a consensus regarding appropriate exercise programmes for this specific population remains elusive.
Aligned with the breast cancer theme was another Australian protocol looking at a comprehensive randomised controlled trial investigating nurse-led Tai Chi aimed at improving a range of mental health and well-being outcomes along with physical functioning in women with breast cancer by Wang et al. 21 This protocol outlines an interventional trial aiming to assess the therapeutic effects of a Tai Chi programme on breast cancer management. The study will involve 40 participants diagnosed with breast cancer, randomised into either a Tai Chi programme or a waiting list control group. The Tai Chi programme will consist of 12 weeks of group sessions held twice a week, focusing on improving mental well-being, physical function, and quality of life. Primary outcomes include potential enhancements in quality of life, while secondary outcomes encompass improvements in mental well-being and physical function, assessed through self-administered online assessments and physical examinations. If successful, this research could highlight Tai Chi as a safe and effective exercise for empowering breast cancer patients in self-management and improving their overall well-being, with findings disseminated through various channels to inform both patients and healthcare professionals. Of note, pregnancy and/or history of pregnancy are not explicitly inclusive or exclusive criteria which would lend itself well to considerations around breast cancer and maternal health more generally.
A systematic review and meta-analysis by Maleki et al. 22 enabled the international team of researchers to examine studies from the last decade which were focused on key features of maternal stress and even nursing strategies for mother empowerment. While targeting neonatal intensive care, the clear take-home messages included the call to action for nursing strategies targeting emotional as well as practical support. The aim of this systematic review and meta-analysis was to compile and analyse global knowledge on nursing strategies for supporting mothers of preterm infants in the neonatal intensive care unit (NICU), focusing on emotional and practical assistance. Twenty studies published from 2010 to 2021 were included and categorised into three main themes: nursing strategies related to mothers’ emotions and attachment with their infants, strategies for maternal empowerment, and strategies facilitating mothers’ participation in caregiving and support processes. Among the interventions analysed, including educational programmes, spiritual care, and skin-to-skin contact, significantly lower maternal stress was observed in the intervention groups compared to controls. Key nursing strategies identified for supporting mothers of preterm infants encompassed family-centred care, parent education and support programmes, interpersonal psychotherapy, and telenursing, underscoring the importance of holistic support approaches in NICU settings.
Of timely concern was the work produced by Ross et al. 23 in which the psychological impact of COVID-19 testing was evaluated in a Canadian context. Incredible disruption was made throughout the healthcare system to respond to the coronavirus outbreak and subsequent variants of concern internationally. These anecdotal and documented public health measures included routine testing to enable access to hospitals and the admission of birth partners and supports were heavily scrutinised at one of the most vulnerable times in a woman’s life. Ross et al. 23 further describe the concern of infecting others and how that stress and strain were also among healthcare workers in obstetrics as well. While it was an important step in maintaining health, it may have amplified an already stressful time in the lives of those involved. Obstetric patients expressed concerns about transmitting COVID-19 to their newborns and partners but reported relief and support from the testing programme. They also believed the testing initiative helped reduce anxiety and contributed to research benefitting others. Healthcare workers experienced increased job stress during the pandemic, with the testing programme causing minor additional stress, particularly among nurses. However, the majority of healthcare workers viewed the testing initiative positively and valuable for research purposes. Overall, the study suggests that universal SARS-CoV-2 testing can be beneficial in estimating COVID-19 prevalence without significantly increasing stress levels among patients and healthcare workers.
Aligned with the impact on healthcare workers, Wissemann et al. 24 focused on midwives and the importance of the availability and impact of mentoring programmes for staff retention and quality of care. This review aimed to analyse the effectiveness of mentoring programmes for midwives with over a year of clinical experience, given the challenges like job dissatisfaction and limited support contributing to midwifery attrition globally. Conducted through a five-step integrative review process, the study identified eight relevant articles. Four main themes emerged, highlighting the impact of mentoring on midwives’ work environment, relationships with peers and management, and the overarching organisational support. The findings suggest that organisational backing is crucial for effective mentoring programmes to enhance midwifery staff retention. Understanding midwives’ perspectives on mentoring can guide the development of tailored mentoring programmes, potentially addressing workforce retention issues in midwifery practice.
Prenatal care and maternal and neonatal health outcomes
Cardiometabolic markers and placenta status were the feature from the Spanish research team investigating foetal sex in a sample of over 100 women. 25 This cross-sectional study aimed to investigate variances in maternal-neonatal metabolic markers and placental status based on foetal sex among Caucasian pregnant women and their newborns. Analysis of serum cardiometabolic markers revealed that mothers carrying male foetuses exhibited higher triglyceride levels during late pregnancy, while male newborns had greater levels of total and low-density lipoprotein cholesterol compared to females. Furthermore, mothers of male infants and male newborns had higher uric acid levels at birth. Placentas from female infants showed higher placental-newborn weight ratios, manganese content, and fibroblast growth factor-2, with slightly longer telomeres. Despite these subtle differences, the study suggests the potential for a more personalised approach to prenatal care based on foetal sex, considering the observed variations in cardiometabolic markers and placental status.
Another addition to this special collection was from Wallace et al. 26 in which antenatal and parenting education in an online mode of delivery was scrutinised from an Australian sample. This study aimed to explore the experiences and perceptions of new parents engaging in online antenatal education classes, given the evolving landscape of prenatal education. Conducted with 294 participants from various online antenatal and early parenting education programmes in Australia, the study employed a mixed-methods approach. Through qualitative analysis of responses, three main themes emerged: control and content of videos, accessibility, and support throughout the programme. Participants expressed a desire for trustworthy and accurate information delivered in a framework aligned with adult-learning principles, emphasising the importance of the diversity of families and learning styles among expectant parents. These findings offer valuable insights for the development of online antenatal education programmes, catering to the preferences and needs of millennial parents and informing maternity care policy and practice.
In a separate Australian cohort, research by Beetham et al. 27 used a longitudinal study design and evaluated physical activity and maternal and infant outcomes. Conducted with 1657 pregnant women aged 28–39 years, participants reported their physical activity levels in each trimester and completed surveys regarding pregnancy and childbirth outcomes within 3 years post-birth. Physical activity levels were classified by frequency and described by categories of ‘Nil’, ‘Low’, ‘Moderate’, and ‘High’. The study found no significant association between physical activity during pregnancy and infant birthweight, prematurity, gestational diabetes, hypertension, or antenatal depression. However, there was a lower prevalence of antenatal anxiety among women with low or moderate physical activity levels compared to those with no activity. These findings suggest that while different volumes of physical activity during pregnancy did not impact measured adverse health outcomes, engaging in low to moderate physical activity may contribute to reducing antenatal anxiety.
Aligned with the exercise theme was research from a team in Norway investigating an Italian sample of pregnant women and their engagement in regular physical activity and exercise during the antenatal period. 28 The objective of this study was to investigate the facilitators and barriers to regular exercise among Italian pregnant women and to assess their social support regarding maternal exercise. Conducted with 513 healthy pregnant women in their third trimester, the study utilised a self-administered questionnaire regarding regular exercisers (⩾150 min/week) or not regular exercisers (<150 min/week). Only 4.6% of participants met exercise guidelines, with ‘insufficient time’ being the predominant barrier. Facilitators included relaxation, prevention of health issues, enjoyment, and weight management. Exercising with others significantly predicted regular exercise, while receiving advice on exercise from healthcare professionals correlated with higher exercise rates. The study highlights internal motivations for exercise among Italian pregnant women and underscores the importance of social support and healthcare guidance in promoting regular exercise during pregnancy.
Physical inactivity and other risk factors were investigated by Fondjo et al. 29 in the pursuit of understanding postpartum preeclampsia. Postpartum preeclampsia poses significant risks globally, including hospital readmissions and maternal complications. Understanding its risk factors is crucial for prevention and management strategies. This case-control study, conducted in Ghana, aimed to identify such factors. Among 65 postpartum preeclamptic women and 65 normotensive mothers, physical inactivity, infrequent antenatal visits, analgesic use, and caesarean delivery were significantly associated with both new-onset and persistent postpartum preeclampsia. Contraceptive use was linked to new-onset cases, while low-birthweight babies increased the risk of persistent preeclampsia. The findings underscore the importance of screening, close monitoring, and follow-up care post-delivery to manage postpartum preeclampsia effectively.
Discussion
The special collection of articles serves to illuminate the nuances and disparities that persist in maternal health. In an era of heightened global connectivity, there has been a commendable surge in awareness regarding the unique challenges faced by women in the realm of maternal health. No longer confined to the boundaries of specific regions, this awareness transcends borders and cultures. It is a rallying call, urging societies around the world to recognise and address the multifaceted needs of women during their maternal journey.
Nestled within these articles are revelations that have pragmatic applications and recommendations included. They delve into the intricacies of maternal health, not just at a superficial level but by peeling back the layers to expose the profound implications on mental and physical well-being. These articles are a testament to the evolving nature of healthcare, urging us to reevaluate and recalibrate our approach to women’s health. While strides have indeed been made in the field of women’s health, there remain expanses of uncharted territory. These articles, collectively, serve as a compass, directing our attention to the areas around the globe and the topics where knowledge is sparse and where further quality research is needed. It is a call to action for the scientific community, urging them to contribute to a deeper understanding of women’s health.
Within this opportunity for inclusivity lies an imperative to amplify the voices that have been historically marginalised. The experiences of women who have been on the fringes of society, whether due to socioeconomic factors, cultural differences, or other determinants, must be brought to the forefront. These articles emphasise the importance of creating spaces where every voice is not only heard but also valued, contributing to a richer and more holistic understanding of women’s health.
Footnotes
Acknowledgements
Dr Fox-Harding would like to extend acknowledgements to each of those author contributions to the special collection, the women involved as participants in the respective studies, and future women who will benefit from the research conducted therein.
