Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action

Abstract

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs.

Keywords: LMIC; Pregnant; Vulnerability.

Fig. 1

Vulnerability trajectory as a net balance of risk effects (threats), barriers, and protective or recovery factors (reparative strategies). Footnote: figure illustrates typical vulnerability trajectories for pregnant women. Pre-existing threats (including inherent threats due to the pregnancy state) and barriers and weak reparation imply that the woman’s trajectory for health and well-being starts at a suboptimal state. Threats and barriers become cumulative due to repetition or reinforcement as pregnancy advances and are maximal around the time of birth. Adapted from Bill & Melinda Gates Foundation MNCH D&T Growth and Resilience Strategy (with permission).

Fig. 2

Vulnerability framework through which threats, barriers and reparations influence maternal and perinatal outcomes. Footnote: pregnancies where women have deficiencies or exposure to risks are high-risk pregnancies. Barriers and unmet needs can affect the quality of maternity care, predisposing to adverse outcomes. Effective repair mechanisms in place could prevent adverse outcomes. These vulnerability attributes shown in different colours, Threats, Barriers, and Repair, can influence care and outcome at multiple times during pregnancy through the postpartum continuum. This is illustrated by the arrows interlinking an attribute (T∗/B∗) to healthy or adverse outcomes based on whether an effective reparative strategy (R∗) is involved. Occurrence of an adverse outcome further reinforces threat (T∗) and barrier (B∗) leading to persistence of adverse outcomes during the pregnancy journey. For example, a teenager entering pregnancy with anaemia (T), if diagnosed early in pregnancy and treated (R), could have a healthy outcome. But if she faces barriers in accessing antenatal care because of disempowerment (B), she will likely have complications from worsening anaemia. However, if the high-risk status is recognised in the second or third trimester and reparative interventions are initiated, maternal and perinatal complications are likely to be averted. But, even when anaemia is effectively managed early in pregnancy if new barriers (B∗) arise in later pregnancy (e.g., homelessness), the woman is at increased risk of adverse outcomes (e.g., eclampsia and stillbirth due to lack of antenatal care and undiagnosed pre-eclampsia).