Marian Knight MBE FMedSci

Director, National Perinatal Epidemiology Unit, University of Oxford

As I write this, the release of the first reflections from the chair of the latest government investigation into maternity and neonatal services in England has sparked alarming newspaper headlines about the state of health services for pregnant women and their newborn babies. It is a timely moment, therefore, to look to the future and where the opportunities lie to improve maternal and perinatal health, and how research in Oxford and elsewhere could transform lives in the future. It is a sobering statistic that, globally, a mother or newborn baby dies every seven seconds, showing the huge potential to drive change. It is likely that everyone reading this article recognises that saving those women’s and infants’ lives will take more than medical advances; the position of women in society and political will to prioritise their health will be needed too.

Over my lifetime in medicine, the overall health of women giving birth in the UK has changed substantially. Women giving birth now, compared with thirty years ago, tend to be older and have more physical, mental and social co-morbidities. This is partly due to socio-demographic changes, including trends towards choosing to give birth at older ages, but also lifestyle trends increasing the proportions of women living with overweight and physical inactivity, as well as a reflection of successful medical care as women with previously life-limiting conditions now survive to reproductive age. These trends mean we must consider not only how we provide seamless care for women with complex intersecting needs during pregnancy, but how we intervene before pregnancy to decrease risk, and after pregnancy and birth to maximise lifelong health.

Pre-pregnancy health

When should pre-pregnancy care begin, to maximise future maternal and perinatal health? Establishing healthy lifestyles and an understanding of how dietary and other choices can impact not only your own health but those of your future children can start early. We know that epigenetic modifications because of diet and other exposures affect both eggs and sperm as well as the developing fetus, leading to predisposition to cardiovascular disease, overweight and obesity in the next generation. In the “Lifelab” project at the University of Southampton, education and health researchers work together to empower children and young people to make healthy choices through understanding the science which underpins health messages. Such cross-disciplinary methods are increasingly needed to develop the preventive approaches needed to maximise future maternal and perinatal health.

The Oxford Local Policy Lab is another example of how bringing together researchers across disciplines and with charities and local government could have a transformational impact. Local sustainable travel policies, reducing pollution and improvements to the built environment all have the potential to improve pre-pregnancy, pregnancy and post-pregnancy health, yet we rarely think that broadly when considering either research or policy to improve outcomes for mothers and babies. Recognising the wide range of ways in which we can be working to change future health beyond solely pregnancy care is an important step. 

Nevertheless, pre-pregnancy medical and nursing care will remain essential to ensure treatment of women’s physical and mental health co-morbidities are appropriately optimised and discussions about risk management and preventive interventions such as vaccination take place. It is a sad fact that in the UK investigations into maternal and perinatal deaths, every year we continue to see women and babies dying because medications have been stopped inappropriately or they have not received effective vaccinations. Ensuring women have the right advice about planning for pregnancy is an important responsibility whatever branch of medical care we practice.

Driving innovation in pregnancy care

What opportunities exist then to drive pregnancy care towards a more individualised model, in recognition of women’s breadth of intersecting needs? With the expansion of linked electronic health records alongside artificial intelligence and machine learning methods, the potential for future data-driven approaches to enable personalised care is huge. Development of tools to enable discussion of choices around planning pregnancy and birth based on individual information will allow for nuanced care pathways beyond simple “low risk” and “high risk” categorisation. Ongoing assessment of patterns of vital signs, laboratory parameters and imaging results throughout pregnancy could enable us to identify concerns much earlier. The Defining, Recognising and Escalating Maternal Early Deterioration (DREaMED) programme at Oxford, for example, will develop a new early warning system using detailed electronic hospital record data to identify women whose condition is worsening, enabling rapid intervention to prevent severe complications or death. Other Oxford research is developing next generation ultrasound technology, not only improving the ability to detect pregnancy problems, but also to expand the technology to enable use by a wider range of staff in the UK and globally, ensuring the benefits to women in low- and middle-income country settings. Oxford research has been central to recognising and addressing disparity in maternal and perinatal outcomes between women from different minoritised or more deprived groups.

Historically, pregnant and breastfeeding women have largely been excluded from clinical trials, which has led to an extremely slow pipeline of innovation and what has been termed a “drug drought in maternal health”. As we look to the future, however, the introduction of new World Health Organisation Guidance on Best Practices for Clinical Trials is an encouraging development. It emphasises that we should be moving to a default position of inclusion of pregnant and breastfeeding women in clinical trials where they have the potential to benefit, and appropriate safeguards are in place. The Recovery trial, led from Oxford, showed how this can be done, and the new WHO framework could mark the start of a new era of clinical trial evidence to drive improvements in maternal and perinatal health.

Lifelong health post-pregnancy

We know that many maternal conditions are a marker for lifelong health. Pre-eclampsia and other hypertensive disorders of pregnancy, as well as conditions such as gestational diabetes, identify women who are at greater risk of future cardiovascular events. However, we are only just beginning to recognise the window of opportunity pregnancy represents to improve long-term health. Personalised and data-driven approaches, coupled potentially with genomics and the use of novel imaging, could allow women’s experiences in and around pregnancy to reset their future health. Across many conditions in later life, women are diagnosed later and have poorer outcomes than men with the same conditions. Recognising risk and advising about prevention following pregnancy could begin to address some of this inequity.

Women’s post-pregnancy health impacts not only on them but the health of the whole family. Nowhere is this more evident than when considering maternal mental health. Up to one in five women will experience a mental health problem in the year following pregnancy; effects on mother baby-bonding and wider family relationships can be significant and long-lasting. In the UK although there has been an increasing focus on maternal mental health, services remain patchy and research is still needed to work out the best models of care, especially for women from stigmatised, minoritised or deprived communities. Globally the gap between maternal physical and mental health care remains wide and has to be an important future focus; while suicide is recognised as the leading direct cause of maternal death in the year after pregnancy in the UK, in many countries maternal suicides are not even counted and therefore the basic evidence on how to prevent women’s deaths is not available. As much research is needed on mental health as on physical health to equitably improve future maternal and perinatal health.

Political will

Mahmoud Fathalah, then president of the International Federation of Gynecology and Obstetrics (FIGO) said in 1988, when I was a medical student, “women are not dying because of diseases we cannot treat but because societies have yet to make the decision that their lives are worth saving”. In many ways that remains as true today as it was then. However, if we work to develop ways to optimise pre-pregnancy health, leverage the benefits of data-driven, AI and machine learning approaches to pregnancy care, take advantage of pregnancy as a window of opportunity for improving life-long health, and above all, bring policy-makers with us, in thirty years’ time today’s medical students may be able to say something different.