pregnancy risk essay

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The Other Pregnancy Depression

I wanted this baby. i planned for this baby. why wasn’t i happy.

For eight months, I tirelessly tracked my periods, stockpiled ovulation strips and pregnancy tests, and even borrowed a busty fertility statue curvy enough to make a Kardashian jealous. After putting our toddler to bed, wearing a stained nightshirt and messy topknot, I’d tap my fatigued husband on the shoulder with a raised eyebrow, tilting my head toward the bedroom—the epitome of romance. I brought home the sample cup and informed him what he might have to do with it, or rather, in it. I’d begun entertaining the pros and cons of IUI vs. IVF; had tests to confirm I was still ovulating; and agreed that, at my next appointment, they should push dye through my fallopian tubes to check for blockage. It’s a miracle anyone gets pregnant by accident.

“I just don’t know how we’ll afford another one,” my husband moaned. Child care is expensive and time is scarce for two full-time working parents who moonlight as a writer and a musician.

A part of me agreed that two children were too many. I imagined myself underslept and overstimulated, racing between soccer and ballet. I could picture the manic orchestration of two packed lunches instead of one; all those emotional negotiations, doubled. (Cheese string or cheese cube? Banana peeled or unpeeled? But you just asked for … )  I was also not particularly excited by the idea of repeating the postpartum period ever again, complete with its bloody nipples and night sweats, rageful fits, and submarine-size mesh underwear. But I had no idea about the emotional deluge that awaited me.

My first pregnancy, at 37, was a product of decision fatigue. I didn’t ache for a baby, but my curiosity poked at me. We conceived without much effort, and I was immediately at peace with the decision. I came to understand that I’m the kind of person who’d never be satisfied not knowing the dark, expansive truth about motherhood. Writers are addicts, too; motherhood was abundant with new material.

This time, I was about to turn 40. As I considered the question, my OB-GYN spoke to me as if getting pregnant “at my age” would be a holy miracle worthy of its own biblical passage. Two of my closest friends had been in yearslong battles with second-child infertility. I saw the money they’d spent and the disappointment they’d weathered. But, I have a brother and I’ve always found it deeply comforting to have one other person who will always speak the language of my childhood. So I persisted, like some baby-obsessed sadist.

“I know, I know ,” I said to my husband. “But finances change. Biology doesn’t.”

Then, on a Tuesday morning in May, while waiting patiently on the seat of my toilet, I finally saw the two pink lines. I burst into tears. They were not happy tears.

A sick, sticky feeling of regret rose up to the base of my throat. Dread arrived in the pit of my stomach. I was having the kind of stark realization that comes after you push a red button and immediately understand the deep, eternal consequence of your actions. Instantly I began to mourn my nightly eight hours of sleep, my early-morning writing time, the work I’d done to repair a fragile relationship to my changing body, and the dissolution of my little family of three.

When you have a second child, people say things like, “You know what to do now! You’ve been here before!” And yet, this is exactly where my fear stemmed from. The first time, I only had my own optimism to rely on. This time I knew exactly what to expect, and I knew it wasn’t always pretty.

First came the depression-crying, the kind of tears that run like a faucet, unprovoked and without warning. Nothing prompted them, and I couldn’t attach their overflow to any particular emotion. The crying just … happened. In the car, at my desk, while cooking dinner. I felt sadness as if it were a vague, misty concept that came knocking, uninvited in its hazmat suit, to fumigate my entire body.

Next came the anxiety, a certainty that something would be wrong: with me, the baby, my pregnancy. I feared that because I was less excited about this pregnancy—more distracted, lethargic—that I would somehow damage the baby by osmosis. I got a therapist. She tried to assure me this was not possible and that I was experiencing something called “cognitive dissonance.” I had already created an alternate reality for myself with no basis in fact. Colored by my past experiences and deepest fears, I fabricated a false truth that did not exist. Too bad hormones don’t care about logic—or psychology.

Soon I began to obsess over the postpartum period, certain I would suffer from debilitating postpartum depression. If it’s this bad now, I thought. Aside from some white-hot postpartum rage, I’d managed to evade this common disorder—the subject, lately, of so many articles , books , and movies —after my daughter’s birth, but I remember seeing it from afar. It loomed just out of my periphery; if I’d taken just one wrong turn, I could have been enveloped into its blackness.

This fear only made the tears come harder. I imagined long, mind-numbing days at home, sobbing while the baby shrieked its tinny, incessant wails. I tried not to entertain what sort of intrusive thoughts I might have. I feared I would resent my new baby for taking me further from my writing, my body, my relationships, my daughter. That the baby would sense this anger and grow up to be the subject of one of the true-crime documentaries my husband and I often watched.

More than anything, however, I was caught off guard. I was officially middle-aged, a mother for three years now, and I didn’t consider that I could be this sad during my pregnancy. Especially a pregnancy I planned—and thought I wanted. I was drowning in the emotional quicksand of my own making.

Begrudgingly I’d deliver the news to friends, knowing they’d respond with squeals of joy and congratulations. I didn’t know how to explain that I did not feel like celebrating. I simply told them the truth, that I was sad, that it wasn’t like this last time, that I’m working on it, because people need resolutions. Then one day, a friend sent me a life raft.

“I got on Zoloft as soon as I hit the second trimester. First time in a decade,” she replied in a text.

You can do that? A small, invisible weight was lifted from my shoulders.

Another friend said something similar. She didn’t take one photo of herself pregnant, she told me. She cried often and struggled to be the mom she wanted to be for her 2-year-old. This friend also happens to be a clinical psychologist. I was relieved to hear her personal anecdotes, but I also wanted to know her professional point of view: Why aren’t more people talking about this? Are they? And I’m just left out of the conversation? I asked her to speak with me, not as my friend, but as Dr. Rebecca Lesser Allen.

“Statistically, antenatal depression is almost as common as postpartum depression,” Allen told me. “There’s increased awareness about postpartum depression. You get screened for it by your OB and your pediatrician, and they talk to you about it at the hospital, but no one really addresses antenatal depressive disorders, and I have no idea why that is.”

According to the Cleveland Clinic Journal of Medicine, 1 in 7–10 women will develop a depressive disorder during pregnancy. For reference, 1 in 5–8 women will experience depression postpartum. That’s more than a half million women each year who will confront a depressive disorder at some point during or after gestation.

We can (finally) talk about depression and anxiety after the baby’s born, but not while we’re pregnant? Since it’s not commonly discussed outside of mom circles, does the stigma around it run deeper? Logically, I knew that I had no reason to be ashamed of my emotional downward spiral. Intellectually, I understood that hormones are a racket and it’s OK to feel something other than elation about a pregnancy. The reality of motherhood can be joyful but also brutal. But why is this nuance so hard for us as a culture?

“We have this expectation that people are supposed to feel a consistent, simple way about something as enormous as creating and giving birth to and raising a baby, and that’s not fair,” Allen said. “It’s a huge thing.” Even for those who’ve gone to extensive lengths to get pregnant, it’s not so black and white. “Going through IVF and fertility issues is challenging, complicated, and traumatic, and so there becomes this huge expectation, but the reality is that being a mom is hard,” Allen said.

Allen points to Brooke Shields’ memoir, Down Came the Rain , published in 2005, which contained the story of Shields’ postpartum depression, and the subsequent press in which she promoted it. In the early aughts, such confessions were still new, and Shields received a great deal of criticism for openly sharing stories of her thoughts of infanticide, and for taking medication. Today that kind of vulnerability might receive much more support—but even in 2024, it depends on what side of the aisle you sit.

“Back [in the early 2000s], people believed that postpartum depression definitively meant that you didn’t want to be a mother. Now we know that’s just not accurate,” Allen continued. “I think because there hasn’t been the same normalization of depression during pregnancy, we assume it must mean that you don’t want the baby, simply because we don’t have enough practice talking about it.”

Still. I’m a woman who was born in the Deep South in the early 1980s. The patriarchal, puritanical voices I’d grown up around still speak to me, wanting me to believe that these fears were all my fault. I wanted this, right? So why am I so sad? I explained my fear to Allen: If I admit I feel anything less than elation, I’m afraid I won’t only feel guilty, I’ll somehow be punished.

“It reflects your internalization that this is not allowed,” she said. “And when we feel depressed or anxious during our pregnancy, it creates so much shame because we think, ‘I’m so lucky, people struggle to get pregnant, I’m selfish.’ It’s a bad way to feel.”

What’s even more bleak is that I can’t help but assume that this dead zone in conversation simply reflects our nation’s priorities. Does the silence confirm our lack of concern for women’s mental health? (I feel like I know the answer.)

Part of me wonders if we put less emphasis on maternal health during pregnancy because there is no baby yet. Do we care more about the mother’s mental health after the baby’s born because, in society’s mind , If she’s incapacitated, who else will take care of the baby ?! If you look at current public policy, it appears that all religious conservatives want is for the baby to be born, full stop, regardless of the financial, emotional, or physical toll this takes on a mother.

Allen is now out of the haze of newborn-toddler life. As for me, my son was born on Jan. 29. From behind a blue sheet and beneath the lucent glow of an operating light, I heard his first cries, a piercing shriek through air and liquid. For the first time in nine months, I felt pure and simple relief. You could even call it unbridled joy. I thought of Allen, who told me that as soon as her daughter was born, the fear and anxiety she’d carried along her pregnancy melted away. As I cradled my second child to my chest, I cried because he was finally here. I cried because, in that moment, I did not resent him. I cried because I know it doesn’t always happen like that for people with prenatal depression.

I still worry about the chaos of my new life with a newborn and a toddler. I wonder how I will maintain my writing practice, as well as excel in my full-time job, with two children. Ultimately, I find ease in knowing I’m not the only person who’s ever asked such questions. In her memoir, You Could Make This Place Beautiful , poet Maggie Smith writes, “I wonder: How will my children feel if they think that being seen as a mother wasn’t enough for me? What will they think of me, knowing I wanted a full life—a life with them and a life in words, too?”

What will my son think when he finds out that I felt pangs of sadness at his positive pregnancy test? That I struggled with the decision to bring him into our family? That I was overwhelmed by all that I wanted in life? I hope he’ll see an imperfect woman who isn’t afraid to tell the truth. Someone who wants to ask difficult questions. A woman who believes in the beautiful mess of an honest life, nuance and all.

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Overview of High-Risk Pregnancy

, MD, Main Line Health System

In a high-risk pregnancy, the mother and/or the fetus or neonate are at increased risk of morbidity or mortality before, during, or after delivery.

High-risk pregnancies are characterized by conditions that potentially pose a threat to the health of the mother and/or the fetus or neonate. Risks can result from various factors such as chronic disease, multiple gestation, previous pregnancy complications, or nonobstetric or obstetric complications that arise during a pregnancy.

Clinicians should discuss potential risk factors, including preexisting medical conditions (eg, diabetes, hypertension, thyroid disorders, psychiatric disorders), previous pregnancy complications, and genetic factors. Clinicians review the patient's medications and nutritional supplements to address drug safety in pregnancy Drug Safety in Pregnancy Medications may be required for various indications during pregnancy. The most commonly used medications include antiemetics, antacids, antihistamines, analgesics, antimicrobials, diuretics... read more and determine if any medications or supplements need to be discontinued, adjusted, or changed. Disease management should be optimized for conditions that are known to cause adverse fetal or maternal effects if poorly managed (eg, diabetes, hypertension, hypothyroidism). Modifiable risk factors, such as smoking, alcohol and drug use, and weight management, should be discussed. If either potential parent has a known or suspected genetic abnormality, the couple should be referred for genetic counseling and testing Preconception or Prenatal Carrier Testing of Parents Carrier testing is part of routine prenatal care and is ideally done before conception. The extent of carrier testing is related to how the woman and her partner weigh factors such as The probability... read more . Additionally, counseling should include discussions on the importance of folate supplementation, immunizations, and optimizing overall health before conception.

High-risk pregnancies require close monitoring, specialized care, and a multidisciplinary medical team, and sometimes referral to a perinatal center. Perinatal centers offer many specialty and subspecialty services provided by maternal, fetal, and neonatal specialists ( 1 General reference In a high-risk pregnancy, the mother and/or the fetus or neonate are at increased risk of morbidity or mortality before, during, or after delivery. High-risk pregnancies are characterized by... read more ). Close monitoring throughout the pregnancy may involve management of chronic diseases and increased frequency of prenatal visits, blood tests, and ultrasonography and other types of fetal monitoring. Communication with the pregnant woman and her family is essential to involve the patient in shared decision-making, develop a care plan, and provide emotional support.

General reference

1. American College of Obstetricians and Gynecologists : Levels of maternal care: Obstetric care consensus No. 9. Obstet Gynecol 134(2):428-434, 2019. doi: 10.1097/AOG.0000000000003384

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An Update on Research Issues in the Assessment of Birth Settings: Workshop Summary (2013)

Chapter: 3 assessment of risk in pregnancy.

Assessment of Risk in Pregnancy

R isk assessment in pregnancy helps to predict which women are most likely to experience adverse health events and enables providers to administer risk-appropriate perinatal care. While risk assessment and the challenge of defining “low risk” was a topic that was revisited several times during the course of the workshop, this chapter summarizes the Panel 2 workshop presentations which focused exclusively on the topic and included suggested topics for future research. See Box 3-1 for a summary of key points made by individual speakers. The panel was moderated by Benjamin Sachs, M.D., Tulane University, New Orleans, Louisiana. Also summarized here is the combined Panel 1 and 2 discussion with the audience (i.e., on topics covered both here and in Chapter 2 ).

IDENTIFYING LOW-RISK PREGNANCIES 1

The steady declines in maternal and neonatal mortality across the United States illustrated in Figure 3-1 are among the greatest public health achievements of the 20th century (CDC, 1999). The declines were driven by many technical and political changes, starting in 1933 when the first maternal and child morbidity and mortality reviews were convened. The shift from home to hospital births that occurred during the 1940s, coupled with the use of antibiotics and transfusions in the 1950s, drove further declines, bringing maternal mortality down to about 7 per 100,000 by 1982

______________________________________

1 This section summarizes information presented by Kimberly Gregory, M.D., M.P.H., Cedars-Sinai, Los Angeles, California.

BOX 3-1 Assessment of Risk in Pregnancy: Key Points Made by Individual Speakers

• Kimberly Gregory noted while the steady declines in maternal and neonatal mortality across the United States are among the greatest public health achievements of the 20th century, the maternal mortality rate has been increasing in recent years.
• Gregory emphasized the dynamic nature of low risk: the risk associated with childbirth can change at any point, often unexpectedly. She also emphasized the contextual nature of risk, for example with risks of both maternal and neonatal events being low in collaborative care situations where events are triaged appropriately.
• Gregory urged a greater focus on identifying conditions that call for different levels of care. Just as high-risk women need to be cared for in appropriate facilities with appropriate resources, the same may be true of low-risk women given that care of low-risk women in high-risk or high-intervention sites is associated with increased adverse events.
• Elizabeth Armstrong observed that numerous sociological and anthropological studies have identified control and safety as being especially important for the birth experience. However, control and safety have different meanings for different women. For some women, a technology-intensive birth in a hospital imparts a desired sense of control. For others, the same situation makes them feel out of control.
• Armstrong described contemporary American culture as a “risk society,” one that views birth as a high-risk and dangerous endeavor. Some social scientists believe that the attempt to classify births into varying levels of risk itself emphasizes the pathology inherent in birth rather than the normal physiology of birth.
• As described by Kathryn Menard, the purpose of risk assessment is to predict which women are most likely to experience adverse events, to streamline resources to those who need them most, and to avoid unnecessary interventions.
• Identifying low obstetric risk is a difficult challenge. Menard elaborated on how low risk is defined differently by different researchers, making it difficult to compare outcomes across settings. She emphasized the need for more consistent and evidence-based criteria of low obstetric risk and called for a greater understanding of predictors of both neonatal and maternal complications to guide decisions about level of care and a better understanding of predictors that should prompt maternal transfer.

(from greater than 800 per 100,000 in 1900). However, more recently, based on data from the Maternal, Child and Adolescent Health Division of the California Department of Public Health, there is very clear evidence that the maternal mortality rate is increasing (see Figure 3-2 ). In the mid-

FIGURE 3-1 (A) Maternal mortality rate per 100,000 live births by year, United States, 1900-1997. (B) Infant mortality rate per 1,000 live births by year, United States, 1915-1997. SOURCE: CDC, 1999.

FIGURE 3-2 Maternal mortality rate, California and the United States, 1999-2010. NOTES: HP2020, Healthy People 2020; ICD, International Classification of Diseases. State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths ≤42 days postpartum) was calculated using ICD-10 cause-of-death classification (codes A34, O00-O95, O98-O99) for 1999-2010. U.S. data and Healthy People 2020 Objective were calculated using the same methods. U.S. maternal mortality data are published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. rates from 2008-2010 were calculated using NCHS Final Death Data (denominator) and Centers for Disease Control and Prevention Wonder Online Database ( http://wonder.cdc.gov ) for maternal deaths (numerator). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April 2013. SOURCE: California Department of Public Health, 2013.

2000s, the national rate was about 13 deaths per 100,000. In California, it was about 16 per 100,000.

What Is Low Risk?

Tasked to identify low-risk pregnancies, Kimberly Gregory began by searching the scientific literature, restricting her search to publications since 1996 and to developed countries. She searched using several combinations of terms: “low risk” and “pregnancy”; “risk assessment” and “pregnancy”; “levels of care” and “pregnancy”; and all of those same terms crossed with “midwives,” “family practice,” “birth centers,” and “home births.” Later, she updated her search to include maternal transfers. Gregory also considered discussions of low risk in consensus statements issued by representative

organizations and on the websites of the American Congress of Obstetricians and Gynecologists (ACOG), American College of Nurse-Midwives (ACNM), American Academy of Family Physicians (AAFP), and American Association of Birth Centers (AABC).

Gregory observed that the history of risk assessment in obstetrics began in 1929, in the United Kingdom (UK), when Dr. Janet Campbell implied, “the first requirement of a maternity service is effective supervision of the health of the woman during pregnancy” (Dowswell et al., 2010). Thereafter, the UK Ministry of Health set antepartum exams to begin at 16 weeks, to occur again at 24 and 28 weeks, and then to occur monthly to 36 weeks and weekly thereafter. Examiners were advised to check fundal height, fetal heart, and urine. It was advised that medical officers conduct the week 32 and 36 exams. These standards form the basis for current antenatal care, although additional screening interventions for identifying “high risk” have been added over time. Mead and Kornbrot (2004) defined the “standard primip” 2 eligible for midwifery care in the United Kingdom as a woman who is Caucasian, 20-34 years old, taller than 155 centimeters, with a singleton and vertex pregnancy greater than 37 weeks, with the delivery setting occurring as planned, and with no medical complications.

In the United States, identification of obstetric “low risk” is made more complicated than it is in the United Kingdom by questions such as, at low risk for what? Most risk-assessment models are for preterm birth, perinatal morbidity and mortality, Cesarean delivery, or vaginal birth after Cesarean or uterine rupture. No risk-assessment models, or tools, specifically address the risk of maternal morbidity and mortality. Because no such tools exist, and given that home and birth center births are supposed to be low risk, Gregory examined criteria used to identify candidates for home and birth center births as a means of identifying “low risk.”

According to criteria posted on the Open Door Midwifery website, 3 in order to be a candidate for home birth, exam and laboratory tests must be within normal limits and show no evidence of chronic hypertension, epilepsy or seizure disorder, HIV infection, severe psychiatric disease, persistent anemia, diabetes, heart disease, kidney disease, endocrine disease, multiple gestation, or substance abuse.

According to the American Public Health Association (APHA) Guidelines for Licensing and Regulating Birth Centers (APHA, 1982), birth centers themselves should specify criteria for establishing risk status in their policy and procedure manuals and clearly delineate and annually review medical and social risk factors that exclude women from the low-risk antepartum group. Referencing several older papers (Aubry and Pennington,

2 Primip is a woman who is having her first baby.

3 See http://www.opendoormidwifery.com/criteria.html .

1973; Hobel et al., 1973, 1979; Lubic, 1980; March of Dimes, Committee on Perinatal Health, 1976; Sokol et al., 1977), the APHA guidelines identify some specific high-risk conditions: recurrent miscarriage, history of still birth, history of preterm birth hypertension, diabetes, cardiac disease, anemia or Rh disease, renal disease, thyroid disease, toxemia, macrosomic infant, multiparity, “multiple problems,” systemic conditions like sarcoid or epilepsy, drug or alcohol use, and venereal disease. Gregory noted that the APHA guidelines emphasize continual evaluation through the prenatal, intrapartum, and postpartum periods. However, again, their focus is on perinatal risk, not maternal risk.

“High-risk” conditions are usually what Gregory described as a “sign of the times.” That is, they change over time. For example, Aubry and Nesbitt (1969) included tuberculosis in their list of high-risk conditions, along with bacteriuria, uterine anomalies, and other conditions. Today, in addition to many of the same conditions listed elsewhere, the American Academy of Pediatrics (AAP)/ACOG Guidelines for Perinatal Care , 7th edition (AAP and ACOG, 2012), include some new conditions: prior deep vein thrombosis or pulmonary embolism, chronic anticoagulation, and family history of a genetic disorder. Like the 1982 APHA guidelines, the AAP and ACOG 2012 guidelines emphasize ongoing risk assessment. They also emphasize referral and consultation among institutions that provide different levels of care.

So what is “low risk”? “It is the opposite of high risk,” Gregory said. She paraphrased Supreme Court Justice Potter Stewart: “I imply no criticism of … [the literature] which in those days was faced with the task of trying to define what may be undefinable…. I shall not today attempt further to define the kinds of material I understand to be embraced within that short hand description; concluding perhaps, I could never succeed in intelligibly doing so. But, I know it when I see it.”

Given Low Risk, What Happens to You?

Outcomes for low-risk mothers depend on where they deliver and who takes care of them. Villar et al. (2001) evaluated patterns of prenatal care and found no difference in risk of Cesarean, anemia, urinary tract infections, or postpartum hemorrhage between midwife, general practice, and obstetric care. They reported a trend toward lower preterm birth, less antepartum hemorrhage, and lower perinatal mortality with midwife and general practice care; significant decreases in pregnancy-induced hypertension (PIH) and eclampsia with midwife and general practice care; a significant increase in failure to diagnose malpresentation with midwife and general practice care; and a similar or higher satisfaction with midwife and general practice care.

Other studies have shown wide variation in care for healthy women, but more consistent care with complicated deliveries (Baruffi et al., 1984). Care is dictated by the structure, process, and culture where that care is being administered. For example, Gregory said evidence suggests that, for low-risk women, midwife-led care is better (i.e., results in fewer interventions) in freestanding or integrated birth centers where midwives have autonomy and where they are practicing in a small-scale setting. Midwives in integrated centers tend to incorporate the risk culture of the environment at large, such that midwives in units with high intervention rates perceive intrapartum risk to be greater and underestimate the likelihood to progress normally (Mead and Kornbrot, 2004). Gregory explained midwives in high-intervention environments are more likely to “risk out” a patient than are midwives working in low-intervention environments.

Approximately 20 percent of laboring women are transferred out of midwifery care, based on the Walsh and Devane (2012) and Hodnett et al. (2010) reviews. Lynch et al. (2005) reported an intrapartum transfer rate from hospitals without Cesarean delivery capabilities of 9.5 to 12 percent. Stapleton et al. (2013) reported that, of 18,084 women accepted for birth center care (of 22,403 who planned a birth center birth on entry to prenatal care), 13.7 percent (2,474) were transferred antenatally to a medical doctor for medical or obstetrical complications (primarily postdates, malpresentation, PIH, and nonreassuring fetal heart rate) and 0.2 percent (36) never presented to the birth center in labor. Thus, a total of 15,574 women planned and were considered eligible for birth center care at onset of labor. Of those, 4.5 percent transferred at the onset of labor but still prior to admission; another 12 percent (of those still on track for a birth center birth) were transferred intrapartum (e.g., because of arrest, nonreassuring fetal heart rate, diagnosis of breech, bleeding, PIH, cord prolapse, or seizure). Of note, less than 1 percent of the intrapartum transfers were emergency transfers, which Gregory interpreted to mean that there was plenty of time to make arrangements for getting the women safely to a nearby hospital. Also of note, 82 percent of the intrapartum transfers were for nulliparous women . Finally, another 2 percent (of those who actually delivered in the birth center) were transferred postpartum, primarily because of postpartum hypertension or postpartum hemorrhage. But again, only less than 0.5 percent of those transfers were emergency transfers, alluding to the fact that there was plenty of time to ensure that women were receiving appropriate levels of care. The researchers concluded that fetal and neonatal mortality rates among the birth center births were consistent with those of low-risk births reported elsewhere in other settings, including hospital births.

In her search for additional information to help guide the identification of obstetric low risk, Gregory identified Baskett and O’Connell (2009) as another relevant study. The researchers examined a 24-year period (1982-

2005) of maternal transfers for critical care from freestanding birth units. They identified 117 transfers out of 122,000 deliveries (so 1 in 1,000). Eighty percent of the transfers (95/117) were for intensive care unit (ICU) care and the other 20 percent (24/117) were for medical or surgical care not available at the obstetrics unit. Most transfers (101/117) were postpartum, the remainder (16/117) antepartum. Hemorrhage and hypertension accounted for 56.4 percent of indications for transfer. Overall mortality was fairly low (only 5 deaths out of 122,000 deliveries), with a death-to-morbidity ratio of 1 to 23.

In Gregory’s opinion, available data and guidelines suggest that the 30-minute rule of “decision to incision” for emergency Cesarean delivery might not be good enough (Minkoff and Fridman, 2010). She suggested that there might be specific conditions under which care providers should be thinking in terms of “golden minutes.” These include placenta previa/accreta, abruption, cord prolapse, and uterine rupture. She acknowledged, however, that, as Lagrew et al. (2006) pointed out, “most emergent Cesarean deliveries develop during labor in low-risk women and cannot be anticipated by prelabor factors” (p. 1638).

In conclusion, Gregory defined low risk as singleton, term, vertex pregnancies, and the absence of any other medical or surgical conditions. Low risk is a dynamic condition, one subject to change over the course of the antepartum, intrapartum, and postpartum periods. The change can be acute and unexpected.

Low risk can also be defined regionally or locally within the context of collaborative care. Rates of neonatal and maternal adverse events are low if events are triaged appropriately with skilled clinicians. Recognizing that 39 percent of deliveries occur in hospitals where there are fewer than 500 deliveries per year, or fewer than approximately two deliveries per day, clearly not all hospitals can provide the same standard of care. While volume is usually associated with outcome, this is not true of midwifery care. Small-scale midwifery care is associated with better outcomes in terms of fewer interventions.

Gregory urged an evaluation of risk-appropriate care within the context of both risk (low risk versus high risk) and alternate birth settings. More data are needed regarding conditions that call for high-level care, such that high-risk women and/or conditions are cared for in appropriate facilities with appropriate resources. For example, what maternal conditions require delivery at Level III (specialty) or IV (regional site)? Low-risk women may also need to be cared for in appropriate facilities with appro-

priate resources, given that care of low-risk women in high-risk or high-intervention sites is associated with increased adverse events.

SOCIOLOGICAL PERSPECTIVE ON RISK ASSESSMENT IN PREGNANCY 4

Looking beyond historical trends in childbirth and who chooses which settings, Elizabeth Mitchell Armstrong examined factors that drive women’s decisions about where to give birth. More specifically, what drives a woman’s understanding of risk? She looked through three different “lenses” on, or frameworks, for understanding, risk: (1) cultural views of risk and birth, that is, the sociocultural perception of birth in contemporary American society; (2) women’s perceptions, expectations, and experiences of birth and, in particular, the ways some women’s assessments of risk differ from those of their providers; and (3) structural conditions that affect risk.

Sociocultural Views of Risk and Birth in Contemporary American Society: The Notion of a “Risk Society”

Contemporary American culture views birth as a high-risk endeavor. The dominant cultural view of birth among medical professionals, as well as among laypersons, is that birth is inherently risky, even dangerous. Birth is depicted in popular movies like Knocked Up and in television shows like Birth Story as a chaotic, bloody affair involving lots of urgency, running around, and yelling. The model mood is one of panic. The birthing woman herself is depicted as irrational and out of control and the men around her as incompetent. Thus, birth is depicted in the media as a full-blown crisis, with vanishingly few planned home births depicted at all. In television and the movies, the only births occurring outside hospitals are precipitous ones; often, no one is in charge, and the birth resembles nothing so much as an unmitigated disaster. Also in the media, extreme pain is depicted as something with no other solution but drugs. Armstrong said, “No wonder women fear birth.”

Yet, a historical perspective on childbirth suggests that birth should be less terrifying than in the past. Today, virtually all women and babies survive birth, with the birth of a child often an emotional high that many women and men report as being among the happiest of their lives.

How has American culture come to regard birth, a natural and intrinsic part of life and human society, with such trepidation, fear, and loathing? Armstrong suspects that the answer lies, in part, in a broader set of cultural

4 This section summarizes information presented by Elizabeth Mitchell Armstrong, Ph.D., M.P.A., Princeton University, Princeton, New Jersey.

shifts that have transformed modern society and in the evolution of what Beck (1992, 1999) calls a “risk society.” A risk society is one where the notion of risk overshadows all social life and where the identification and management of risk are the principle organizing forces. Beck (1999) argues that modern society has become a risk society “in the sense that it is increasingly occupied with debating, preventing, and managing the risks that it, itself, has produced” (Beck, 2006). As both Beck (1992, 1999) and Giddens (1999) argue, modern life is increasingly perceived in terms of danger and organized around the pursuit of safety. This increased awareness of risk has led to a pervasive sense of uncertainty and attempts to control the future.

Based on theories of risk articulated by Beck (1992, 1999) and Giddens (1999), Armstrong shared some insights that she deems relevant to risk assessment at birth. First, many of the risks being considered are what Beck calls “manufactured risks,” that is, risks created by human intervention, as opposed to risks created by weather or other natural events. Second, the omnipresence of risk in modern society has led to the emergence of a collective risk consciousness and a prevailing ethos of risk avoidance. Beck notes that much of this is organized around “attempt[ing] to anticipate what cannot be anticipated” (Beck, 2006). Third, the relationship between risk and trust is inverse; that is, science and technological expertise have become more important in society and at the same time the public has lost trust in both the content and conduct of science. Fourth, as Beck (1999) contends, some social actors have greater authority than others to define risk.

It is this fourth phenomenon, that some social actors have greater authority than others to define risk that leads to what anthropologist Brigitte Jordan calls “authoritative knowledge” (Jordan, 1997; Jordan and Davis-Floyd, 1992). According to Armstrong, Jordan argues that in any particular domain of human life there may be several knowledge systems or ways of understanding the world. Some of these ways of understanding may carry greater weight than others, either because they explain the state of the world better or because they are associated with a stronger power base, or for both reasons. As one kind of knowledge begins to dominate, other knowledge systems are delegitimized and dismissed (Jordan, 1980, 1997). For example, in his description of the evolution of American medicine, Paul Starr (1982) points to the tremendous “cultural authority” accorded one form of medical practice, allopathic medicine, to the exclusion of other forms of medicine that flourished in the late 19th century. The important thing to keep in mind about authoritative knowledge, Armstrong explained, is that it is socially constructed. Yet, it is viewed as being a natural order, with many people failing to recognize the ways it is socially constituted. In the realm of birth, obstetrics embodies authoritative knowledge. As such, obstetrics crowds out other ways of knowing and other ways of birth, limiting women’s awareness of alternative modes of birth.

When birth is viewed through this lens of a “risk society,” it is easier to understand the climate of fear, not confidence, that surrounds American birth and how it is that we think of birth as dangerous. Contemporary organization of maternity care reflects our “risk society.” According to Armstrong, Ray De Vries (2012) has noted that even our attempt to classify births into varying risk levels is itself a powerful reframing of birth, one that emphasizes the pathology inherent in birth, rather than the normal physiology of birth.

Another force shaping the way women perceive the risk of birth is the polarization (Declercq, 2012) in views of birth, which are often characterized as the medical versus midwifery models of birth. Different attributes are associated with the different models (e.g., pathology with the medical model, physiology with the midwifery model), with the two models often considered to be “diametrically opposed.” In Armstrong’s opinion, this polarization of views of birth not only obscures the fact that birth is a physiological process with the potential for pathology (i.e., it is not “either/or”), but also affects cultural perceptions of risk and structures the options available to women.

Women’s Views of Risk

Numerous sociological and anthropological studies of contemporary American childbirth demonstrate that women’s experiences of birth are marked by a range of sometimes contradictory feelings. Women express fear while putting emphasis on being safe or feeling safe. Additionally, both women and their providers voice varying levels of trust and distrust in the female body. Finally, the desire for control is paramount in many discussions of birth. Armstrong identified control and safety as being particularly important.

Control can have different meanings and different implications. In a qualitative study of women’s birth experiences, Namey and Lyerly (2010) documented the multiple meanings of control in the context of birth and concluded that control matters but its meaning varies widely among women and can have implications for their choice of birth setting. Armstrong said, for some women, technology-intensive birth in the hospital imparts a desired sense of control. But for other women, that same situation makes them feel out of control.

Safety too can have different meanings and different implications. The prevailing cultural view is that the hospital is the safe place to give birth. Indeed, in Armstrong’s opinion, most women trust modern medical care to ensure safe births. Yet, studies show that many women who birth in hospitals end up very dissatisfied with their birth experiences (Declercq et al., 2002, 2006). The very high rate of routine interventions is part of why

they end up so dissatisfied. A desire for safety drives many women’s choices to birth outside of a hospital. Precisely what historically sent women to the hospital to birth in the first place—a desire to avoid risks and to experience a safer birth—is what motivates some women to avoid the hospital for birth today. If women choose birth outside the hospital, it is not because they are reckless or heedless of risks. Rather it is because their understanding of risk and safety is very different.

A number of studies have assessed women’s decision making around home birth and have identified a common set of themes (Boucher et al., 2009; De Vries, 2004; Klassen, 2001). Some women choose home birth for religious reasons (Klassen, 2001). Armstrong speculated that perhaps the higher rates of home births in Pennsylvania and Indiana, which were evident on one of the maps shown by MacDorman, reflect the Amish populations in those states. Yet, even among women for whom religious beliefs are a primary motivation for choosing home birth, many of those women report some of the same ideas about birth that other women who choose home births for nonreligious reasons report. That is, they perceive home as being a place where they can feel in control and where they will feel safe. In addition to feelings about control and safety, trust appears to be another determinant of home birth choice. Women who choose home births often report that they trust their body’s ability to birth and that they have a deep level of trust with their care provider.

The Role of Structure

Debates about home birth typically do not consider a structural perception of risk. Yet, in Armstrong’s opinion, it is an important perspective to consider. That is, what systems support or impede women’s decisions about birth settings? By examining systems of transport and transfers, one can begin to see the ways that institutional arrangements can actually increase risks for low-risk women delivering outside the typical setting. According to Armstrong, numerous studies, as well as court cases, have demonstrated “the trouble with transport” (Davis-Floyd, 2003). In Armstrong’s opinion, that we have failed to develop a system of transport and transfer that protects women and babies from adverse outcomes is not just a failure of infrastructure. It is also morally fraught because of the deep polarizations that exist in thinking about birth (as physiology versus pathology) and because of deep levels of mistrust among provider communities. So not only do we lack the infrastructure for transport and transfer, we lack cultural consensus to develop that infrastructure and ensure its smooth functioning. Armstrong noted that in other societies where home birth is a viable option for women, most notably in the United Kingdom and in the Netherlands, systems have evolved for assessing risk and ensuring smooth transfer—thus

reducing risk and ensuring safety for women who choose to birth outside of the hospital.

Areas for Future Social Science Research

In conclusion, Armstrong identified several areas where social scientists can contribute to gaining a better understanding of birth settings. First, they can help to achieve a better understanding of the notion of “good birth.” What is a good birth? Where (setting) and how (under the care of which providers) can good births happen as often as possible? Second, they can help to achieve a better understanding of women’s decision-making processes (e.g., where do expectations of birth come from?) and ways to foster trust between women and maternity care providers. Finally, they can explore ways to change the structural landscape around birth and develop high-functioning systems of transport and transfer.

PRESENTATION ON ASSESSMENT OF RISK IN PREGNANCY 5

By way of disclosure, Kathryn Menard began her talk by describing what she called her “vantage point.” She is the mother of three children and maternal fetal medicine specialist and educator; she works in a perinatal regional center at the University of North Carolina at Chapel Hill where about 3,700 babies are delivered annually. The center has a “24-7” midwifery practice that is well integrated into the care plan such that women can transition seamlessly from the midwifery practice to the generalist or maternal-fetal medicine practice. Many of her complicated antepartum patients choose midwifery-style births, with intrapartum care provided under the direct supervision of midwives but with physician backing. She noted that there is a freestanding birth center in town, just a couple of miles away from the hospital.

Why Assess Risk?

The purpose of risk assessment is to predict which women are most likely to experience adverse health events. The predictions can be used to streamline resources to those who need them most and avoid overuse of technology and intervention. Focusing resources on those who need them most and avoiding unnecessary interventions can lead to better care, better health, and lower cost.

When thinking about risk-appropriate perinatal care, it is important

5 This section summarizes information presented by M. Kathryn Menard, M.D., M.P.H., University of North Carolina at Chapel Hill, North Carolina.

to consider the entire continuum of care: preconception/interconception care (i.e., identifying modifiable risk factors and emphasizing prevention), antepartum care, intrapartum care, and neonatal care. Menard focused her comments on intrapartum care (care of the mother during labor and delivery).

Regionalization of Perinatal Care

Menard emphasized the role of regionalization within the context of perinatal care (care of the fetus or newborn from the 28th week of pregnancy through the 7th day postdelivery). In 1970, reports from Canada emphasized the importance of integrated systems that promote delivery of care to mothers and infants based on level of acuity; the reports showed that neonatal mortality was significantly lower in obstetrics facilities that had neonatal instensive care units (NICUs). In 1976, TIOP I (Toward Improving the Outcome of Pregnancy) described a model system for regionalized perinatal care that included definitions for varying levels of perinatal care based on both neonatal and maternal characteristics (March of Dimes, Committee on Perinatal Health, 1976). The early perinatal regional centers focused on education, dissemination of information, and referral resources and systems for maternal transport.

Evidence indicates that regionalization saves lives. For example, Lasswell et al. (2010) reported that infants smaller than 1,500 grams born at Level I or II hospitals had increased odds of death (38 percent versus 23 percent), compared to similarly sized infants born at Level III hospitals. Similarly, infants born at less than 32 weeks gestation in Level I or II hospitals had increased odds of death (15 percent versus 17 percent), again compared to similarly preterm infants born at Level III hospitals.

While the regionalization of systems, combined with advances in technology, has contributed to improvements in neonatal survival rates, there is not much information about other benefits of regionalized systems, including how regionalization impacts maternal mortality or morbidity. Nor is there much information about the potential harm of regionalization.

Early regionalization efforts emphasized both maternal and neonatal care. In 2012, the AAP issued a new policy statement regarding levels of perinatal care. The maternal characteristics that were included in the earlier policy statements (i.e., TIOP I) were removed, such that the policy statement contains no reference whatsoever to maternal care (Barfield et al., 2012). Likewise, the new Guidelines for Perinatal Care , 7th edition (AAP and ACOG, 2012), contains minimal reference to maternal care indicators. The current climate (2012) is also characterized by an emphasis on value-based health care, that is, an emphasis on increased quality at decreased

cost, an increased emphasis on patient-centered care, and greater recognition of a woman’s right to choose her site of birth.

What We Know About Neonatal Care in Different Settings

Menard remarked that while outcomes associated with different birth settings would be the topic of detailed presentations to follow, she wanted to provide a context for those talks (see Chapter 4 for a summary of that more detailed discussion). She mentioned the Wax et al. (2010) meta-analysis, which reported that planned home birth delivery of term babies is associated with less medical intervention but a two- to threefold increase in neonatal mortality. Data on delivery of term babies in freestanding birth centers is limited, so similar claims cannot be made. The Hodnett et al. (2012) Cochrane review reported that delivery of term babies in alternative hospital settings, that is, colocated midwifery units, are associated with higher rates of spontaneous vaginal delivery, more breastfeeding, more positive views of care, and no difference in either neonatal or maternal outcomes (all compared to conventional hospital settings). That review was based on 10 randomized controlled trials (N = 11,795). Finally, with respect to the delivery of term babies in a hospital setting, Menard mentioned Snowden et al. (2012), who reported that a higher delivery volume may be associated with lower neonatal morbidity. Very little is known about collaborative care models within the hospital environment and whether such models impact either neonatal or maternal outcomes.

What We Know About Maternal Care in Different Settings

Because maternal mortality is an uncommon event, examining maternal mortality is like “looking at the tip of the iceberg,” in Menard’s opinion. And while severe maternal morbidity is an active area of conversation today, it is not measured in a consistent manner. Much of the conversation revolves around how to define and monitor severe maternal morbidity. Nor are factors that predict the need for a higher level of care well defined. The scientific basis for making those decisions is limited, with different predictors being used in different circumstances.

“Low Obstetric Risk”

Different researchers define “low obstetric risk” differently. Menard gave four examples. First, in a randomized trial conducted in Australia (the COSMOS trial) on primary midwifery continuity care versus usual care within a tertiary care center, McLachlan et al. (2012) used these inclusion criteria: singleton, uncomplicated obstetric history (no stillbirth, neonatal

death, consecutive miscarriages, fetal death, preterm birth <32 weeks, isoimmunization, gestational diabetes), no current pregnancy complications (e.g., fetal anomaly), no precluding medical conditions (no cardiac disease, hypertension, diabetes, epilepsy, severe asthma, substance use, significant psychiatric disorder, BMI >35 or <17), and no prior Cesarean.

Second, in a randomized controlled trial of simulated home birth in the hospital (midwife-led care) versus usual care in the United Kingdom, MacVicar et al. (1993) used very different inclusion and exclusion criteria: nulliparous 6 and multiparous 7 women were included, but women with prior Cesareans were not; their definition of exclusionary maternal illness was more loosely defined (“no maternal illness such as diabetes, epilepsy, and renal disease”); and, while their definition of past obstetrical history was not as specific (no prior stillbirth, neonatal death, or small for gestational age), they included a history of elevated maternal serum alpha-fetoprotein.

Third, Bernitz et al. (2011) used yet another set of inclusion and exclusion criteria in their randomized controlled trial of three hospital levels in Norway. Their inclusion criteria were healthy, low-risk women without any disease known to influence pregnancy; singleton; cephalic; BMI <32; smokes <10 cigarettes/day; no prior operation on the uterus; and 36 weeks, 1 day to 41 weeks, 6 days gestation. Finally, a randomized controlled study in Ireland on midwifery care versus consultant-led care (Begley et al., 2011) used yet another entirely different set of exclusion criteria (e.g., BMI <18 or >29; smoking ≥20 cigarettes per day).

Menard emphasized the need for consistent and evidence-based criteria of “low obstetric risk” so that valid comparisons across settings can be made and our understanding of birth settings advanced.

Research Needed to Describe “Risk”

In addition to developing uniform definitions of risk factors, several other research steps need to be taken in order to advance our understanding of risk. Menard called for a greater understanding of essential resources for each of the various birth settings, predictors of neonatal complications to guide decisions about level of neonatal care (i.e., predictors beyond the context of birth weight, which is how most current neonatal care criteria are based), predictors of maternal complications to guide decisions about level of maternal care, and predictors that should prompt maternal transport.

With respect to determining predictors of maternal care, Menard remarked that the concept of levels of maternal care (i.e., birth center versus Level 1 [basic] versus Level 2 [specialty] versus Level 3 [subspecialty] versus

6 A woman who has never given birth.

7 A woman who has given birth two or more times.

Level 4 [regional perinatal center]) is being developed and promoted as a strategy to expand regionalized perinatal care. Ideally, the strategy will be applied uniformly across all states so that surveillance can be standardized. But doing so, she opined, will require a complementary set of predictors of maternal complications to guide decisions about which level of care a woman should receive.

With respect to predictors that should prompt maternal transport, the question is, if a woman has a birth experience in a birth center or a facility with a lower level of care, what are the important signs and symptoms that indicate she should be moved to a higher level of care?

Menard identified several additional research topics that would help to define “risk”: uniform definitions of maternal and neonatal morbidity; definitions of family perceptions and satisfaction with care; the role of the care provider and the role of continuity of care; the role of the care “system” and how to optimize that system (i.e., interprofessional working relationships, consultations, hand-offs, transfer of care); cultural issues, such as threshold for intervention in high-level facilities; and patient perception of risk and the influence of her perception of risk on birth outcomes and perception of care.

DISCUSSION WITH THE AUDIENCE 8

Following Menard’s presentation, the workshop was opened to questions and comments by members of the audience. Topics addressed included international birth setting trends and risk guidelines; perception of risk among women entering pregnancy and how it varies depending on age, culture, and other factors; the large proportion of non-Hispanic black women who deliver unplanned out-of-hospital births; the increasing rate of home births in the United States; how economic factors drive birth setting decisions; the need for infrastructure in states without birth center regulations; and the challenge of transfer (legal and professional mistrust issues).

International Birth Setting Trends and Risk Guidelines

The audience raised two separate sets of issues related to birth setting assessment outside of the United States. First, it was suggested that there might be lessons to be learned from antepartum risk guidelines being used in the United Kingdom, including the fact that the guidelines were created by conducting a systematic review of the international evidence and reaching consensus among a stakeholder panel.

8 This section summarizes the discussion that occurred at the end of Panels 1 and 2, immediately following Kathryn Menard’s presentation.

Second, a remark was made about the increasing percentage of women in the Netherlands who are choosing hospital deliveries. Specifically, according to a workshop participant, the number of women in the Netherlands choosing hospital deliveries has increased from 23 to 38 percent over the past 20 years. The participant emphasized that this is very different than what is happening in the United States, where a growing percentage of women are seeking home deliveries. He also emphasized that the trend is occurring in a country, the Netherlands, with a long history of home births. “I want the record to show,” he said, “that [in the Netherlands] it is considered a privilege to have a hospital birth.” Elizabeth Armstrong agreed that, yes, more women in the Netherlands are seeking hospital births, but she warned that the reasons for the trends are complex and that the trend does not necessarily mean that women feel unsafe in home birth settings. Another participant who identified herself as being from the Netherlands agreed with Armstrong that the reasons for the increasing trend in hospital births are complex. They include demographic changes, that is, more older women entering pregnancy, as well as more primips; media portrayal of pregnancy as something to be feared; increased prenatal testing; and a diverse immigrant population, with varying cultural perceptions of pregnancy. She noted primary care in the Netherlands is midwife-led care, adding that the rate of home birth in the Netherlands is about 19 percent, with another 12 percent of women giving birth in a hospital but with their midwives and without attendance by obstetricians.

Perception of Risk and How It Varies Depending on Age, Culture, and Other Factors

A participant suggested that perception of risk might be changing as the percentage of older women entering pregnancy increases. The implication was that older women are not as healthy as younger women and therefore may perceive pregnancy as a riskier experience than younger women do. Kathryn Menard agreed that women entering pregnancy are less healthy than in the past because they are older and suggested that perhaps the increasing maternal morbidity and mortality trends being observed in the United States are related to that demographic change. She emphasized the importance of maternal morbidity and mortality surveillance.

More generally on the issue of perception of risk, Nigel Paneth observed, “The question about risk is always: what can you control?” Centuries ago, losing a child in infancy was considered normal and unpreventable. Changes in infant (and maternal) mortality over time have changed what women consider as unpreventable, or uncontrollable. For example, the likelihood of a woman dying during pregnancy dropped 100-fold during the

20th century. Today, the risk of a woman dying during pregnancy is more controllable than it was in the past.

An audience member commented on the role of culture and how a woman’s perception of risk might reflect her own place of birth. Armstrong replied that, while there has not been much research addressing the role of place of birth in perception of risk, women who have experienced other maternity care systems enter the U.S. system with a certain set of expectations. This is true even of primips who have not actually delivered themselves but nonetheless have an understanding of how birth works in the culture they come from.

Armstrong further observed that social disadvantage can also impact choice of birth setting. Some socially disadvantaged women, whether it is because of race or ethnicity, socioeconomic status, or immigrant status, perceive medicalized, high-technology hospital birth as being of a higher status and therefore more desirable than home birth. That perception is not necessarily related to risk or safety.

Disparity in Outcomes Among Ethnicities

The panelists were asked why as many as 66 percent of home deliveries by non-Hispanic black women are unplanned and what research is needed to find the answer(s). Marian MacDorman clarified that the incidence of home births in general is much lower for non-Hispanic black women, perhaps because fewer non-Hispanic black women have access to care providers that allow that option, and that the proportion of unplanned home births is high but the absolute numbers are low. With respect to research, she emphasized the importance of directly asking women about their preferences and experiences. She also suggested promoting more services in areas and neighborhoods where non-Hispanic black women live and training more minority care providers.

Another audience member speculated that at least some of the large percentage of African American women who report on birth certificates that their home birth was “unplanned” reflects a growing preference in free birthing, which is birthing without the assistance of a care provider. She noted that free birthing is on the rise in places like Maryland where Medicaid provisions for home birth have been removed, and that many women who choose free birthing report “unplanned” on their birth certificates because they think it will draw less attention.

Paneth observed that the “big monster in the room” is not that 66 percent figure, rather the “huge health disparity between black and white infant mortality.” That, in his opinion, is the greater research challenge. What is causing such extreme preterm birth among African American women? While many research teams are pursuing answers, the question remains.

Why the Percentage of Home Births in the United States Is Increasing

The panelists were asked to reflect on why the percentage of home births in the United States is increasing. MacDorman replied that birth certificate data do not reveal why certain birth options are chosen, or not chosen. She referred to the large number of studies in the medical literature based on having directly asked women why they chose home births. Women who choose home births express desire for low-intervention physiologic births in environments where they feel comfortable and more in control over which interventions will be induced, and they express concern about the high rates of Cesarean delivery and other interventions in hospital settings.

Another audience member asked whether there might be a correlation between change in percentage of home births and increased access to licensed midwifery offering the option of transfer. That is, do states exhibiting greater increases in percentage of home births provide greater access to licensed midwifery offering the option of transfer? MacDorman agreed that the question would serve as an excellent topic for future research.

Economic Factors Driving Birth Setting Choice

An audience member commented on the role of health insurance in birth setting choice and observed that a significant number of women who would choose to deliver outside of the hospital are not able to do so because their insurance will not cover out-of-hospital deliveries. The audience member also mentioned liability insurance and observed that in some states Medicaid will not cover a home birth midwife unless the midwife carries a level of liability insurance that most home birth midwives do not carry. Panelist MacDorman agreed that economic factors contribute to the complexity of the issue of choice. She remarked that studies have shown that the cost of a home birth is about one-third the cost of a hospital birth, but in fact home births cost women much more than hospital births if they are not covered by insurance.

The Need for Infrastructure in States with Birth Center Regulations

In response to remarks made by Nigel Paneth about a birth center in Michigan closing after a breech delivery, an audience member commented on the fact that Michigan is one of the few states without licensure for freestanding birth centers. Breech deliveries are outside of the national standard for birth centers. The implication was that states without regulations, such as Michigan, need infrastructure to help avoid this type of problem.

The Challenge of Transfer

A participant observed that transfer is legally fraught for liability reasons. For example, in Virginia, midwives are licensed and practice legally. Yet, some hospitals report each and every transfer to the state licensing board, which presents a real challenge for the midwives. She asked the panelists if any of their research points to a way forward. Armstrong added that the patchwork of state laws that govern who can attend births compounds the legal challenge. However, she cautioned that moving forward will require more than legal reform. Addressing the challenge of transfer will require a multipronged approach, one that also involves rebuilding trust among the different communities of care providers. She described the mistrust that currently exists among communities of care providers as “endemic and corrosive.” MacDorman agreed that trust is a core issue.

Two other participants echoed concerns about liability and the important role that state legislation plays in either restricting or promoting collaboration during transfer. For example, malpractice carriers telling physicians that they cannot provide midwifery backup significantly restricts collaboration. The state of Washington has been very forward thinking in its requirement that insurers who provide malpractice insurance provide such insurance to midwives, thereby promoting collaboration.

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More than 30 years ago, the Institute of Medicine (IOM) and the National Research Council (NRC) convened a committee to determine methodologies and research needed to evaluate childbirth settings in the United States. The committee members reported their findings and recommendations in a consensus report, Research Issues in the Assessment of Birth Settings (IOM and NRC, 1982). An Update on Research Issues in the Assessment of Birth Settings is the summary of a workshop convened in March, 2013, to review updates to the 1982 report. Health care providers, researchers, government officials, and other experts from midwifery, nursing, obstetric medicine, neonatal medicine, public health, social science, and related fields presented and discussed research findings that advance our understanding of the effects of maternal care services in different birth settings on labor, clinical and other birth procedures, and birth outcomes. These settings include conventional hospital labor and delivery wards, birth centers, and home births. This report identifies datasets and relevant research literature that may inform a future ad hoc consensus study to address these concerns.

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Pregnancy Complications

Complications of pregnancy include physical and mental conditions that affect the health of the pregnant or postpartum person, their baby, or both. Physical and mental conditions that can lead to complications may start before, during, or after pregnancy. It’s very important for anyone who may become pregnant to get health care before, during, and after pregnancy to lower the risk of pregnancy complications.

If you are pregnant or gave birth within the last year, talk to your health care provider about anything that doesn’t feel right. If you have an urgent maternal warning sign  during or after pregnancy, get medical care immediately.

Reducing Your Risk

• Common Pregnancy Complications

Heart Conditions

High blood pressure (hypertension), hyperemesis gravidarum.

• Related Links

Living a healthy lifestyle and getting health care before, during, and after pregnancy can lower your risk of pregnancy complications.

• Before you get pregnant, eat healthy, stay at a healthy weight, take care of your mental health, avoid tobacco products, and limit or avoid alcohol. Preconception health care can also help you be as healthy as possible before you become pregnant.
• Once you’re pregnant, start prenatal care early and talk to your health care provider about health conditions you have now or had in the past. If you are being treated for a health condition or taking certain medicines, your provider might recommend changing the way your health condition is managed. Be sure to also discuss problems you had in any previous pregnancies.
• After pregnancy, see your health care provider for postpartum care. Be sure to discuss anything that doesn’t feel right, including not just physical symptoms, but also feelings of sadness, anxiety, and exhaustion that make it hard to take care of yourself, your baby, or others. You may need to see multiple different health care providers to be as healthy as possible after pregnancy.

The Hear Her campaign supports CDC’s efforts to prevent pregnancy-related complications and deaths by sharing potentially life-saving messages about urgent warning signs .

Common Complications

The following are some common conditions that can happen before, during, or after pregnancy. You can help prevent and manage them by seeing a health care provider regularly before, during, and after your pregnancy.

Anemia is having lower than the normal number of healthy red blood cells. People with anemia may feel tired and weak. You are more likely to get iron-deficiency anemia during pregnancy because your body needs more iron than normal. Your health care provider will check your number of red blood cells during your pregnancy. Treating the underlying cause of the anemia, if possible, can help restore the number of healthy red blood cells. Your provider may also recommend you take iron and/or folic acid supplements to help prevent and manage anemia.

Anxiety disorders are common before, during, and after pregnancy. If you have an anxiety disorder, you may struggle with uncontrollable feelings of anxiety, nervousness, fear, worry, and/or panic. These feelings can be intense and may last a long time. They can also interfere with relationships and daily activities, such as work or school. Anxiety disorders often occur with depression . Getting treatment for anxiety before, during, and after pregnancy is important. Talk to your health care provider as soon as possible if you think you have an anxiety disorder.

Everyone feels sad sometimes, but these feelings usually pass in a few days. Depression interferes with daily life and may last for weeks or months at a time. Some people have depression before, during, or after pregnancy. Symptoms of depression include:

• Lasting sad, anxious, or “empty” mood.
• Feelings of hopelessness or pessimism.
• Loss of energy.
• Trouble falling asleep or sleeping too much.
• Overeating or loss of appetite.
• Feelings of irritability or restlessness.
• Problems concentrating, recalling details, and making decisions.
• Feelings of guilt, worthlessness, or helplessness.
• Suicidal thoughts or suicide attempts.

If you have many of these symptoms together, and they last more than 2 weeks, you may have depression. Depression during pregnancy can make it hard for you to care for yourself and your pregnancy. Having depression before or during pregnancy is also a risk factor for postpartum depression , which is depression that occurs after pregnancy. Getting treatment is important for both mother and baby. Talk to your health care provider as soon as possible if you think you have depression. If you have thoughts of harming yourself or your baby, seek medical care immediately. More information is available at Depression During and After Pregnancy .

Diabetes is a disease that affects how your body turns food into energy. There are three main types of diabetes: type 1 , type 2 , and gestational diabetes . For pregnant people with type 1 or type 2 diabetes, high blood sugar around the time of conception increases the risk of birth defects , stillbirth , and preterm birth . Among people with any type of diabetes, high blood sugar throughout pregnancy can also increase the risk of preeclampsia , cesarean delivery, and the baby being born too large. To manage your diabetes, see your doctor as recommended, monitor your blood sugar levels, follow a good nutrition plan developed with your provider or dietician, be physically active, and take insulin, if directed. Managing diabetes can help you have a healthy pregnancy. If you have diabetes before pregnancy or develop it during pregnancy, it’s important to continue seeing your health care provider after pregnancy to monitor your blood sugar and overall health.

Heart conditions, such as coronary artery disease, heart attack, cardiomyopathy, and congenital heart defects , impact the heart and blood vessels. Making healthy food choices, limiting your alcohol intake, quitting smoking if you smoke, and managing any other chronic conditions can help reduce your risk for many heart conditions. Not everyone has symptoms, but you may feel neck, jaw, chest, belly, or back pain if you have a heart condition. Many people with heart conditions have healthy, uneventful pregnancies, but pregnancy can put stress on the heart of people with some types of heart conditions. Having a heart condition may increase the risk of severe illness and death during and after pregnancy.

If you have a heart condition, it’s important to see your health care provider, ideally before pregnancy or as soon as possible after becoming pregnant. During your first prenatal care visit, let your provider know if you have a heart condition. If you are diagnosed with a heart condition during pregnancy, you may also need to be monitored by your provider earlier or more often after pregnancy. More information can be found at Heart Health and Pregnancy .

You may be at increased risk for other heart conditions in the future if you have some heart conditions, preeclampsia , or gestational diabetes during or shortly after pregnancy. Work with your health care provider to monitor your risk or manage your heart condition before, during, and after pregnancy.

High blood pressure is a common heart condition occurring when your blood pressure is higher than normal . Chronic hypertension means having high blood pressure before you get pregnant or before 20 weeks of pregnancy. Gestational hypertension  is high blood pressure that first occurs after 20 weeks of pregnancy. Preeclampsia happens if you previously had normal blood pressure and suddenly develop high blood pressure and protein in your urine or other problems after 20 weeks of pregnancy. If you have chronic hypertension, you can also get preeclampsia.

High blood pressure increases the risk of preterm delivery, and low birth weight, plus more serious issues such as eclampsia , stroke, and placental abruption (the placenta separating from the wall of the uterus). High blood pressure may be prevented and is treatable . These 7 strategies to live a heart-healthy lifestyle , plus at-home self-measured blood pressure monitoring with support from your health care provider, can help you manage your high blood pressure. If you are at high risk for preeclampsia, your provider may recommend low-dose aspirin after 12 weeks of pregnancy. Learn more about High Blood Pressure and Pregnancy .

Many pregnant people have some nausea or vomiting, or “morning sickness,” especially in the first 3 months of pregnancy. Hyperemesis gravidarum, however, is more extreme than “morning sickness.” It refers to persistent nausea and vomiting during pregnancy. This can lead to weight loss and dehydration and may require intensive treatment. If you are concerned about your symptoms, call your health care provider. If you have severe nausea (e.g., you are unable to drink for more than 8 hours or eat for more than 24 hours), seek medical care immediately.

Infections can complicate pregnancy and may have serious consequences. Being screened and treated for infections, such as HIV and other sexually transmitted infections (STIs) and getting recommended vaccines can prevent many bad outcomes. Easy steps, including hand washing and avoiding certain foods, can also help protect you from some infections. Your health care provider can help you stay up to date with your vaccines. To learn more about different infections and how to protect your health, visit the following CDC pages:

• Pregnancy and HIV, Viral Hepatitis, STI & TB Prevention
• Vaccines During Pregnancy FAQs
• COVID-19 Vaccines While Pregnant and Breastfeeding
• Food Safety During Pregnancy
• 10 Tips for Preventing Infections Before and During Pregnancy

One common bacterial infection during pregnancy is a urinary tract infection (UTI). Your health care provider will likely test your urine early in pregnancy to see if you have a UTI and treat you with antibiotics, if necessary. Treatment will make it better, often in 1 or 2 days. Although not everyone with a UTI has symptoms, you may have a UTI if you have:

• Pain or burning when you pee.
• Fever, tiredness, or shakiness.
• An urge to pee often.
• Pressure in your lower belly.
• Pee that smells bad or looks cloudy or reddish.
• Nausea or back pain. Top of Page

Starting pregnancy at a healthy weight can help reduce the risk of preeclampsia , gestational diabetes , stillbirth , and cesarean delivery. If you are underweight [PDF – 1 MB]  or overweight, talk to your health care provider about ways to reach and maintain a healthy weight before you get pregnant. Gaining a healthy amount of weight during pregnancy is also important for your health during and after pregnancy. Learn about pregnancy weight gain recommendations and steps to help you meet your pregnancy weight gain goal .

• CDC Pregnancy Learn about tips to get ready for pregnancy, giving your baby a healthy start in life, and keeping yourself and the baby healthy after birth.
• Pregnancy Complications Learn more about conditions that may complicate pregnancy from the March of Dimes.
• Pregnancy Complications Learn more about pregnancy complications from Womenshealth.gov.
• Severe Maternal Morbidity Health care professionals and researchers interested in learning more about severe pregnancy complications may visit the CDC Severe Maternal Morbidity page.

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• Maternal and Infant Health Data and Statistics
• Preconception Care
• CDC’s National Center for Birth Defects and Developmental Disabilities

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Physical exercise in pregnancy: benefits, risks and prescription

The aim of this article is to provide a comprehensive literature review, gathering the strongest evidence about the risks and benefits and the prescription of physical exercise during pregnancy.

Regular physical exercise during pregnancy is associated with numerous benefits. In general women are not adequately advised on this matter. Along with their concerns regarding the potential associated risks, it contributes to the abandonment or refusal to start exercising during pregnancy. A systematic review was conducted in MEDLINE including articles considered to have the highest level of scientific evidence. Fifty-seven articles, including 32 meta-analysis, 9 systematic reviews and 16 randomized controlled trials were included in the final literature review.

Exercise can help preventing relevant pregnancy related disorders, such as gestational diabetes, excessive gestational weight gain, hypertensive disorders, urinary incontinence, fetal macrosomia, lumbopelvic pain, anxiety and prenatal depression. Exercise is not related with an increased risk of maternal or perinatal adverse outcomes. Compliance with current guidelines is sufficient to achieve the main benefits, and exercise type and intensity should be based on woman’s previous fitness level.

Exercise in pregnancy is safe for both mother and fetus, contributing to prevent pregnancy related disorders. Exercise type and intensity should be adapted to woman’s previous fitness level, medical history and characteristics of the ongoing pregnancy.

Introduction

Physical exercise, defined as a planned, structured physical activity performed to improve one or more components of physical fitness is a key element of a healthy lifestyle, contributing to the prevention and treatment of several diseases [ 1 ]. Pregnancy is a great time to start exercising, since it is associated with an increased motivation to maintain or start a healthy lifestyle, and an increased frequency of medical appointments, which facilitates physical exercise monitoring [ 2 ].

Regular physical exercise during pregnancy is associated with numerous benefits, such as decreased incidence of gestational diabetes, hypertensive disorders, operative deliveries, excess weight gain and weight retention in the postpartum period, postpartum depression, among others [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ].

The fact that pregnant women are not properly advised on this matter together with concerns regarding the potential risks associated with exercise contribute to the abandonment or refusal to start exercising during this period [ 8 , 9 ].

Pregnancy is associated with physiological adaptions. The energy cost increases proportionally to maternal weight gain, affecting weight bearing activities (e.g. walking) but not weight supported (e.g. stationary cycling) [ 10 ]. A maternal-fetal temperature gradient is established, to promote fetal heat loss, raising concerns about the possibility of reversing this mechanism under strenuous exercise, endangering fetal well-being [ 11 ]. Resting heart rate is increased, but maximal heart rate is decreased, leading to a reduced heart rate reserve, reducing woman’s capacity to adapt to exercise-related stress [ 12 ]. Measuring maternal heart rate is therefore a less precise way of estimating exercise intensity and to guide exercise prescription - it overestimates the intensity of lower work rates, underestimating the intensity of higher work rates [ 12 ]. After the 20th week, the cardiac output is affected by positional changes (specially on supine position), as the gravid uterus may obstruct the aorta and the inferior vena cava, potentially influencing the type of exercise women can do [ 13 ].

The aim of this review is to gather the strongest scientific evidence to date about physical exercise’s risks, benefits and prescription, according to woman’s individual characteristics, medical history and characteristics of the ongoing pregnancy.

Materials and methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols (PRISMA-P) recommendations were used to guide this review [ 14 ].

This review aimed to include studies focusing on the practice of physical exercise during the gestational period and their respective maternal and fetal outcomes. Meta-analyses, Systematic Reviews, Randomized Controlled Trials (RCTs) and Prospective Studies were considered. Case reports, case series and narrative reviews were excluded.

A search on MEDLINE was conducted using the following queries: “pregnancy AND (physical exercise OR physical activity) AND outcome”. All studies identified were screened for these inclusion criteria: (1) published in English or Portuguese, (2) between January 1990 and December 2020, (3) with full-text available, (4) maternal and fetal outcomes related to physical exercise during pregnancy. Articles found by cross-referencing that met the inclusion criteria were also included. Studies focusing on long-term post-gestational follow-up or pre-gestational period were excluded.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the quality of evidence across studies for each considered outcome [ 15 ]. Evidence from randomized controlled trials was first rated as “high” quality of evidence, and was graded down if a risk of bias, indirectness, inconsistency, imprecision or risk of publication bias was detected. Evidence from all non-randomized interventions and observational studies was first rated as “low” quality of evidence. If there was no cause to downgrade, the studies could be upgraded if there was (1) a large magnitude of effect, (2) evidence of dose–response effect, (3) all residual confounding factors would decrease the magnitude of effect.

The search strategy resulted in 266 articles. Two additional articles were added by cross-referencing. Two duplicates were identified, remaining 266 articles. After examining title and abstract to determine those that met the inclusion criteria, 136 articles were excluded. The remaining 134 articles were accessed and analyzed for eligibility, and 77 articles were further excluded, for the following reasons: long-term post-gestational follow-up (n = 9), focus on pre-gestational period (n = 5), and no relevant outcomes recorded (n = 63). Fifty-seven articles were finally included in this review. A PRISMA diagram of the search results is shown in Figure 1 .

Flow-chart of the literature research (PRISMA-P).

The review included 32 meta-analysis, nine systematic reviews and 16 RCTs. The main characteristics of each study are described in Supplementary Material Tables 1–12 .

Benefits associated with exercise during pregnancy

A summary of the evidence concerning the evaluated outcomes is presented in Table 1 .

Benefits of exercise, summary of evidence.

GWG, gestational weight gain; EGWG, excessive gestational weight gain; PPWR, postpartum weight retention; GDM, gestational diabetes mellitus; GC, glucose control; LGA, large for gestational age; CD, cesarean delivery; ID, instrumental delivery; VD, vaginal delivery; LD, labor duration; GH, gestational hypertension; PE, preeclampsia; BP, blood pressure; LP, lumbopelvic pain; UI, urinary incontinence; PPD, postpartum depression; PD, perinatal depression; PA, perinatal anxiety.

Gestational weight gain, excessive gestational weight gain and postpartum weight retention

The Institute of Medicine has established recommendations for weight gain during pregnancy, according to women’s weight prior to their pregnancy [ 63 ]. An excessive gestational weight gain (EGWG) is considered if these recommendations are exceeded. It is estimated that almost 50% of pregnant women exceed their goals, being previous overweight and obesity important risk factors [ 64 ]. Moreover, EGWG is associated with an increased risk of gestational diabetes, cesarean section, birth canal trauma, large-for-gestational-age infants and postpartum weight retention, [ 64 ].

Seven meta-analysis [ 16 , 17 , 20 , 21 , 26 ], [ 27 ], [ 28 ] and four systematic reviews [ 23 , 35 , 36 , 38 ], analyzing various types of exercise interventions in women without contraindications to exercise, found a significantly reduced GWG in the exercise groups. Total GWG mean deviations (MD) between groups ranged from −1.61 kg (95% CI = −1.99 to −1.22, p<0.01) [ 28 ] to −0.61 kg (95% CI = −1.17 to −0.06, p = 0.03) [ 26 ]. Additionally, Wang et al. [ 16 ] found, in their subgroup analysis, that this effect was greater with exercise interventions conducted at least 3 times a week, 30–45 min per session and throughout the entire pregnancy. Chan et al. [ 35 ] added that a greater effect on the improvement of pregnant women’s level of physical activity was seen among supervised exercise classes.

This relationship was also sought among overweight and obese pregnant women [ 17 , 25 , 65 ], and all studies confirmed this hypothesis when exercise interventions were structured, either supervised or home-based (MD −1.14 kg, 95% CI = −1.67 to −0.62, p<0.0001 [ 17 ] and −0.91 kg, 95% CI = −1.76 to −0.06, p = 0.035 [ 25 ]). Exercise interventions that included only counseling and encouragement were not effective [ 65 ].

An identified limitation was the fact that all the included studies measured total body weight difference, instead of body fat. This is particularly important in exercise interventions that included muscle training/resistance exercises, since women may have increased their global muscle mass independently of the body weight variation.

EGWG was evaluated in four meta-analysis [ 20 , 21 , 23 , 36 ], and three RCTs [ 30 , 31 , 33 ], with the majority [ 20 , 23 , 31 , 33 , 36 ] (n = 5) finding a significant better weight gain control in the exercise groups. The decrease in the odds of having EGWG with exercise varied between 18% (odds ratio (OR) = 0.82, 95% CI = 0.68 to 0.99 [ 21 ]) and 61% (OR = 0.39, 95% CI = 0.17 to 0.89 [ 31 ]). Nobles et al. [ 30 ], who did not find a significant correlation, prescribed an unsupervised exercise intervention, without indicating a specific type of exercise to be performed, which may have hampered the efficacy of the intervention. However, Da Silva et al. [ 33 ] included an individually supervised exercise intervention, and also did not find significant results.

On the other hand, other systematic reviews and meta-analysis did not find significant effects of exercise interventions on GWG [ 18 , 19 , 37 ], along with three RCTs [ 29 , 32 , 33 ]. These studies analyzed GWG and not EGWG. In fact, Bacchi et al. [ 31 ] found no significant difference in mean GWG, but found significantly reduced odds of EGWG in the intervention group (OR = 0.39, 95% CI = 0.17 to 0.89, p = 0.02). Also, most of the studies’ populations included mainly previously healthy women – so, if only a small proportion of women gained more weight than expected, significant differences between groups could have been overlooked. A correlation between type of exercise, program duration and mean GWG results could not be drawn, since a great variety of exercise interventions were included in each review.

Considering postpartum weight retention (PPWR), a meta-analysis [ 20 ] related exercise during pregnancy with reduced PPWR (MD = −0.92 kg, 95% CI = −1.84 to 0.00, p = 0.05), together with two RCTs [ 29 , 34 ]. All the studies included aerobic exercises and were performed for at least 20 weeks, finishing at the end of the third trimester.

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is considered the most common metabolic disorder during pregnancy [ 66 ]. Indeed, GDM is associated with many adverse outcomes, such as higher risk of preeclampsia, macrosomia and birth trauma, neonatal hypoglycemia, diabetes later in life, among others [ 66 ]. A known modifiable risk factor for developing GDM is obesity [ 67 ], along with a sedentary lifestyle [ 66 ], all possibly influenced by physical exercise.

Several meta-analysis [ 6 , 17 , 22 , 28 , 39 , 40 , 43 , 44 ], two systematic reviews [ 21 , 37 ] and one RCT [ 47 ] evidenced that exercise during pregnancy had a beneficial effect on GDM, reporting a risk reduction between 28% (RR = 0.72, 95% CI = 0.58 to 0.91) [ 43 ] and 59% (RR = 0.41, 95% CI = 0.24 to 0.68) [ 44 ]. This benefit was found across different populations - obese and overweight women (RR = 0.71, 95% CI = 0.57 to 0.89) [ 17 ] and previously healthy women [ 6 , 21 , 22 , 28 , 37 , 39 , 40 , 43 , 44 , 47 ].

Davenport et al. [ 6 ] found a dose-dependent correlation between exercise and GDM prevention: to achieve a 25% reduction, it was necessary to perform 140 min per week of moderate-intensity exercise. Cordero et al. [ 47 ] reported that engaging in physical exercise 150–180min per week during pregnancy reduced the odds of developing GDM by 90% (OR = 0.103, 95% CI = 0.013 to 0.803, p = 0.009), comparing to standard care.

Furthermore, physical exercise can also play a role in disease control [ 36 , 41 , 42 , 46 ]. A RCT [ 46 ] with pregnant women previously diagnosed with GDM showed that structured aerobic and resistance exercise lowered postprandial glucose at the end of pregnancy (4.66 ± 0.46 mmol/L exercise group (EG) vs 5.30 ± 0.47 mmol/L control group (CG), p<0.001), but no difference was found regarding fasting glucose. Harrison et al. [ 42 ] found that exercise interventions significantly lowered both postprandial levels (MD = −0.33 mmol/L, 95% CI = −0.49 to −0.17) and fasting blood glucose levels (MD = −0.31 mmol/L, 95% CI = −0.56 to −0.05), among women previously diagnosed with GDM. Accordingly, a meta-analysis [ 41 ] described that both acute and chronic exercise were able to reduce maternal glucose values, and the sensitivity analysis showed that this reduction was driven mainly by women previously diagnosed with diabetes (MD = −2.76 mmol/L, 95% CI = −3.18 to −2.34, p<0.00001). On the other hand, the insulin requirement was not significantly different between groups.

On the contrary, a systematic review from Perales et al. [ 38 ] found only a weak level of evidence between exercise interventions and a reduced incidence of GDM. Correspondingly, no significant difference between groups was found by Han et al. [ 45 ] (OR = 1.10, 95% CI = 0.66 to 1.84), Nascimento et al. [ 36 ] or by Da Silva et al. [ 33 ] (OR = 1.0, 95% CI = 0.6 to 1.9).

Regarding glucose control studies, a recognized limitation was the inability to detect the interference of insulin or other glucose sensitizing agents on the presented results. As for the studies focused on GDM risk, different applied diagnostic criteria for GDM is considered a constraint.

The great majority of the presented studies analyzed only previously healthy pregnant women. However, other populations such as overweight or obese women have a greater risk of developing GDM. Thus, it is possible that a diminished ability to detect significant differences between groups may have resulted from a selection bias.

Excessive fetal growth

Excessive fetal growth includes definitions such as macrosomia – a birth weight superior to 4000–4500 g, and large-for-gestational-age (LGA) – a birth weight equal or superior to the 90th percentile for a given gestational age [ 68 ]. Approximately 7.8% of all newborns in the United States are born with 4000 g or more [ 69 ]. An increased birth weight is associated with an increased likelihood of operative deliveries, shoulder dystocia, birth trauma and postpartum hemorrhage [ 68 ].

The exercise potential positive impact on excessive fetal growth was confirmed by five meta-analysis [ 7 , 21 , 27 , 48 , 49 ] and a systematic review [ 38 ]. Risk reduction regarding macrosomia varied between 4% (RR = 0.96, 95% CI = 0.94 to 0.98) [ 48 ] and 61% (RR = 0.41, 95% CI = 0.25 to 0.68) [ 49 ]. As for LGA infants, it was found a risk reduction between 19% (RR = 0.81, 95% CI = 0.69 to 0.96) [ 49 ] and 49% (RR = 0.51, 95% CI = 0.30 to 0.87) [ 21 ]. All studies included women without contraindications to exercise, and no specific subgroup analysis was made. Pastorino et al. [ 48 ] found a significant correlation only when exercise was performed during late pregnancy, rather than during early pregnancy, possibly indicating a greater contribution of exercise interventions for this outcome when carried out during the late second and third trimesters. This is in line with the physiological fetal weight gain in the second half of pregnancy.

Two meta-analysis [ 17 , 45 ] and two systematic reviews [ 23 , 38 ] found no significant difference in the odds of delivering a macrosomic infant between exercise and standard antenatal care groups. This was verified across different study populations, including overweight/obese women [ 17 ] and previously healthy women [ 23 , 38 , 45 ]. Bennett et al. [ 49 ] did not find significant differences between groups regarding LGA risk (RR = 1.13, 95% CI = 0.54 to 2.36), as opposed to macrosomia risk (RR = 0.41, 95% CI = 0.25 to 0.68). A correlation between type of exercise, program duration and macrosomia/LGA results could not be drawn, since a great variety of exercise interventions were included in each review.

Delivery mode and labor duration

Regarding cesarean delivery (CD), three meta-analysis [ 27 , 44 , 50 ] and one RCT [ 51 ] showed a significant reduction in the group who exercised during pregnancy. Sanda et al. [ 51 ] analyzed an exercise intervention of moderate-to-vigorous intensity, and found 67% reduced odds of CD (OR = 0.33, 95% CI = 0.11 to 0.97, p = 0.044). In Poyatos-León et al. [ 50 ] this effect was significant when exercise was performed during the second and third trimesters [ 50 ] (RR = 0.78, p = 0.105 vs RR = 0.66, p = 0.028) regardless of the type of exercise. This finding is in line with Pastorino et al. [ 48 ], who found a decreased risk of macrosomia when exercise was performed during the third trimester. However, four meta-analysis [ 5 , 17 , 28 , 45 ], two systematic reviews [ 23 , 38 ] and one RCT [ 32 ] did not find significant differences in CD rates. This was verified with different populations, namely obese and overweight women [ 17 ], previously healthy women [ 5 , 23 , 38 , 45 ] and previously inactive women [ 32 ]. Types of exercise, frequency and session’s duration were largely diverse across interventions. Thus, a correlation between different samples, interventions and CD outcomes could not be drawn.

Two meta-analysis [ 44 , 50 ] and one RCT [ 51 ] evaluated the impact of exercise in vaginal delivery rates. All found an increase in vaginal births in the exercise groups (RR = 1.09, 95% CI = 1.04 to 1.15 [ 44 ], RR = 1.12, 95% CI = 1.01 to 1.24 [ 50 ] and OR = 2.69, 95% CI = 1.02 to 7.09 [ 51 ]).

Instrumental delivery (ID) had a lower prevalence in the exercise group of one meta-analysis [ 5 ]. A reduction of 24% on the odds of ID (OR = 0.76, 95% CI = 0.63 to 0.92, p = 0.004) was found among previously healthy pregnant women [ 5 ]. On the other hand, two RCTs [ 51 , 53 ] and two meta-analysis [ 44 , 50 ] did not find any significant differences in ID. In terms of delivery duration, evidence is not consensual. Sanda et al. [ 51 ], Perales et al. [ 38 ] and Agur et al. [ 53 ] found no differences in labor duration; on the other hand, Barakat et al. [ 52 ] reported that the intervention group had a shorter first stage (409.15 ± 185.74 min (EG) vs 462.83 ± 208.37 min (CG), p = 0.01) and a shorter total duration of labor (450.74 ± 188.64min (EG) vs 507.19 ± 2.16.06min (CG), p = 0.01). Included populations were diverse (i.e. previously inactive women [ 50 ], women with antenatal bladder neck mobility [ 53 ], normal-weight women and previously healthy women [ 45 , 51 , 70 ]), however, none included overweight or obese women, conditions related to a slower labor progression and an increased need for ID [ 71 ], possibly underestimating the effect of exercise on these outcomes.

Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy include Gestational Hypertension (GH) and Preeclampsia (PE). 70 These disorders are relatively common during pregnancy - PE complicates 2–8% of pregnancies worldwide. Furthermore, hypertensive disorders are related to 16% of maternal deaths, as well as other adverse outcomes, such as inadequate fetal growth, preterm delivery and perinatal death [ 72 ].

A systematic review [ 37 ] and three meta-analysis [ 6 , 44 , 55 ] showed a significant risk reduction of GH and PE among previously healthy women who exercised during pregnancy. Davenport et al. [ 6 ] found a 39% reduced risk of developing GH (RR = 0.61, 95% CI = 0.43 to 0.85, p = 0.003) and 41% reduction of PE (RR = 0.59, 95% CI = 0.37 to 0.90, p = 0.03). Furthermore, a meta-regression analysis revealed that these benefits were achieved when exercise interventions were performed ≥3 days per week, at least 25 min per session, and with a higher compliance, which was found in supervised programs [ 6 ]. Additionally, a RCT investigated the effect of exercise during pregnancy on blood pressure [ 56 ], among previously inactive women, showing a significantly reduced systolic blood pressure (MD = 7.5 mmHg, p = 0.013).

Contrarily, a meta-analysis [ 17 ] and two systematic reviews [ 33 , 54 ] found no significant differences on PE and GH risk between groups. Comparing the three studies, two considered a population with an increased risk of developing hypertensive disorders (i.e. women at risk of developing PE [ 54 ] and overweight/obese women [ 17 ]), which can sustain that exercise may be only effective in preventing GH and PE among women without a previously increased risk for these conditions. However, these findings need to be interpreted with caution, since in Meher et al. [ 54 ] the sample size was considered too small to draw reliable conclusions.

Lumbopelvic pain

Lumbopelvic pain (LP) is a prevalent condition among pregnant women, with more than 50% of them experiencing it [ 73 ].

Two systematic reviews [ 35 , 36 ] found a beneficial effect of exercise during pregnancy on lumbopelvic pain. Chan et al. [ 35 ] reported a significant effect on pain intensity of low back and pelvic pain, but findings regarding pain prevalence were inconsistent. Nascimento et al. [ 36 ] also related exercise interventions with decreased lumbopelvic pain intensity, but not with lumbopelvic pain prevalence. Exercise interventions varied on type, frequency, intensity and duration, hindering a possible association of specific types of exercise interventions with these outcomes.

Urinary incontinence

Urinary incontinence (UI) is a prevalent pathology in the prenatal and postpartum period, affecting 18–75% of women in late gestation [ 74 ] and one-third of women after childbirth [ 75 ]. Literature is not consensual, but high-impact activities, due to intra-abdominal pressure increase, are described as potential risk factors for pelvic floor weakening [ 76 ]. Nevertheless, aerobic exercise during pregnancy has been correlated with the prevention of EGWG and LGA infants, known important risk factors for prenatal and postnatal UI.

UI benefited from exercise during pregnancy [ 36 , 38 , 57 , 58 ]. Considering its prevention, in Davenport et al. [ 57 ], exercise reduced the odds of UI by 52% during pregnancy (OR = 0.48, 95% CI = 0.32 to 0.73, p = 0.0005) and by 39% in the postpartum period (OR = 0.61, 95% CI = 0.48 to 0.77, p<0.0001). However, exercise did not show a beneficial effect regarding UI treatment [ 57 ].

Most exercise interventions included pelvic floor muscle training (PFMT) [ 36 , 57 , 58 ]. Hence, PFMT appears to play an important role on UI prevention in pregnancy and postpartum period. On the other hand, a systematic review [ 38 ] described a strong level of evidence for the combination of aerobic plus resistance exercise programs, possibly indicating that exercise in general can have a beneficial effect on UI prevention. Studies’ samples included previously healthy women, and one RCT [ 58 ] focused on pregnant women with pelvic floor weakness (women with antenatal bladder neck mobility). It would be also important to investigate the effect of exercise interventions on overweight and obese pregnant women. Indeed, since overweight is a modifiable risk factor for UI, perhaps exercise interventions could be effective in reducing its prevalence in this population.

Psychological outcomes: postpartum depression, perinatal depression and anxiety

Depression during pregnancy and in the postpartum period affects approximately 13% of women, and anxiety up to 39% [ 77 , 78 ]. Pregnant women tend to report more negative feelings than non-pregnant individuals [ 79 ], evidencing pregnancy as a potential vulnerable period for women’s psychological well-being.

Exercise during pregnancy was related to a significant beneficial effect on prenatal depression in a meta-analysis [ 3 ] and three systematic reviews [ 35 , 36 , 62 ]. In fact, Davenport et al. [ 3 ] reported a 67% reduction on the odds of prenatal depression (OR = 0.33, 95% CI = 0.21 to 0.53). Likewise, several studies [ 3 , 35 , 36 , 62 , 80 ] revealed that symptom severity was reduced with exercise. Haakstad et al. [ 60 ] found a significant difference only when results were analyzed per-protocol, pointing out that exercise compliance is an important aspect to achieve any benefit on psychological outcomes.

Concerning postpartum depression, a systematic review [ 36 ] found positive effects on depressive symptoms severity, but no strong evidence was found considering its prevalence. Still, two RCTs [ 59 , 61 ] and one meta-analysis [ 3 ] found no significant differences on symptom severity [ 3 , 59 , 61 ] or prevalence [ 3 , 59 ]. Exercise programs were only performed during the prenatal period, which may indicate that, for exercise to have a beneficial effect on postpartum depression, it should also be performed in the postpartum period.

Regarding anxiety symptoms, a significant reduction was shown in two systematic reviews [ 35 , 62 ] and one RCT [ 60 ]. Haakstad et al. [ 60 ] added that feelings of sadness, hopelessness and anxiety had a significant improvement with exercise when women had complete exercise adherence (p = 0.01). On the other hand, Davenport et al. [ 3 ] found no evidence supporting the benefits of exercising on anxiety prevalence or symptom severity.

Risks associated with exercise during pregnancy

A summary of the evidence concerning the evaluated outcomes is presented in Table 2 .

Risks of exercise, summary of evidence.

PTB, preterm birth; LBW, low birth weight; SGA, small for gestational age; PM, perinatal mortality; MCT, maternal core temperature; CA, congenital anomalies.

Preterm birth

Preterm birth (PTB) is a leading cause of perinatal morbidity and mortality, occurring in approximately 10% of all live births worldwide, and in about 6% of all live births in Europe [ 85 ]. Physical activity was thought to be related to an increased risk of PTB, as it could reduce placental circulation, and increase the release of catecholamines, which stimulate myometrial activity [ 86 ]. On the contrary, exercise may have a protective effect by preventing pregnancy complications such as PE, obesity or GDM [ 87 ], which in turn are related to an increased PTB risk.

The risk of PTB among women who exercised during pregnancy was shown not only not to be increased [ 7 , 17 , 23 , 32 , 33 , 36 , 39 , 44 ] but also to be reduced [ 18 , 21 , 37 , 81 ]. Da Silva et al. [ 21 ] found a 20% reduction in the odds of PTB (OR = 0.80, 95% CI = 0.70 to 0.91). Considering specific types of populations, PTB was not related to exercise among overweight and obese women [ 17 ], previously inactive women [ 32 ] or normal weight women [ 44 ].

Most studies evaluated this outcome among previously healthy women, with only observational studies considering a broader and less restricted population. Consequently, the level of evidence regarding populations with a higher PTB risk is low to moderate.

Inadequate fetal growth

Small-for-gestational-age (SGA) - a birth weight below the 10th percentile for the GA, and low birth weight (LBW) – a birth weight inferior to 2500 g [ 88 ], are important predictors of neonatal morbidity and mortality [ 89 ]. Substrate use during exercise, together with increased insulin sensitivity and redirection of blood flow to the working muscles, can possibly hamper the energy demands required by the fetus [ 90 ].

Seven studies, including meta-analysis [ 7 , 18 , 44 , 49 ], systematic reviews [ 36 , 37 ] and a RCT [ 32 ], evaluated the effect of exercise on the risk of delivering a LBW infant. In all articles, the incidence of LBW was not increased, regardless of the population, intervention type or gestational age.

Similarly, all the systematic reviews [ 82 ] and meta-analysis [ 7 , 17 , 18 , 21 , 27 , 45 , 48 , 49 ] that examined the impact of exercise during pregnancy on the risk of delivering SGA infants found no significant differences. In particular, Wiebe et al. [ 27 ] performed a subgroup analysis considering women with different comorbidities. In all groups, including overweight and obese women (OR = 0.90, 95% CI = 0.31 to 2.63, p = 0.85 [ 27 ]) and women with chronic hypertension or a history of PE (OR = 0.75, 95% CI = 0.28 to 1.98, p = 0.56 [ 27 ]), exercise did not significantly increase the odds of SGAs.

An inadequate GWG may impair fetal growth, increasing the risk of SGA and LBW infants [ 91 ]. In this sense, Bennett et al. [ 49 ] included in their review only studies designed to reduce GWG. Although a small reduction in infants’ birthweight was noticed, exercise did not increase the risk for SGA (RR = 0.38, 95% CI = 0.01 to 15.0) or LBW (RR = 0.88, 95% CI = 0.60 to 1.29).

Thus, the available evidence supports the safety of exercise during pregnancy regarding the risk of SGA and LBW infants, including low, moderate and vigorous intensity exercise.

Miscarriage and perinatal mortality

Miscarriage is a common adverse outcome, occurring in approximately 15% of all pregnancies [ 92 ]. Perinatal mortality (PM) rates in the United States are around six per 1,000 live births [ 93 ]. Obesity, hypertension and diabetes are known risk factors [ 93 ], conditions that can possibly be attenuated by regular exercise.

The risk of miscarriage in women who exercise during pregnancy was assessed by a meta-analysis [ 4 ] and a systematic review [ 37 ], and neither found a significant correlation (OR = 0.69, 95% CI = 0.40 to 1.22, p = 0.20) [ 4 ], suggesting that exercise is not associated with this outcome. However, in Davenport et al. [ 4 ], most of the evaluated studies included pregnancies after the eighth week of gestation, when the risk of miscarriage is smaller. Furthermore, amount, intensity or frequency of exercise did not seem to alter the odds of PM or miscarriage [ 4 ]. The maximum session duration registered was 60 min, at moderate intensity and, therefore, it is not possible to infer about the safety of more intense and prolonged exercise exposures.

Similarly, regarding PM, none of the analyzed studies [ 4 , 82 ] found significantly increased odds associated with exercise.

Maternal hyperthermia

One systematic review [ 84 ] and one meta-analysis [ 83 ] evaluated the exercise effect on maternal core temperature. Ravanelli et al. [ 84 ] included trials with exercise performed in different conditions: land-based and water immersion exercise. In neither studies women exceeded the threshold of 39 °C (highest Tcore = 38.9 °C [ 84 ]), nor changed core temperature more than 1.5 °C (MD = 0.26 °C, 95% CI = 0.12 to 0.40 [ 83 ]). Thus, a safe zone was defined regarding exercise intensity and conditions: land-based exercise for up to 35 min (80–90% of maximum heart rate, 25 °C and 45% relative humidity), and water immersion exercise for up to 45 min (≤33.4 °C), irrespective of pregnancy stage.

Davenport et al. [ 83 ] also assessed the odds of congenital anomalies and found no significant differences between groups (OR = 1.52, 95% CI = 0.54 to 4.32). However, exercise was performed in most studies after 12 weeks gestation (as is well established the risk of developing congenital abnormalities is greater in the first trimester).

It is currently not possible to infer conclusions concerning exercise performed at different intensities, durations and environmental conditions other than those included in these trials. Accordingly, the safety of more vigorous exercise or exercise performed at more critical conditions remains unknown.

Prescription

Exercise prescription is addressed by several international guidelines [ 94 ], [ 95 ], [ 96 ], [ 97 ], [ 98 ]. Regarding its frequency and duration, it is advised to accumulate 150–300 min of exercise per week, with sessions in most days of the week (≥3 days) of at least 20–30 min [ 94 ], [ 95 ], [ 96 ].

Women’s previous fitness level should always be considered to decide about exercise intensity. Although previously active pregnant women can be advised to exercise at moderate intensity, previously sedentary women should start their exercise program with light intensity exercise, followed by a more gradual progression [ 94 ]. Considering exercise at higher intensities, research is limited, but there is no evidence so far suggesting that vigorous exercise is harmful (in women with a previously high fitness level) [ 96 ].

Regarding exercise type, there are certain activities that were found to be safe in pregnancy, such as walking, stationary cycling, aerobic dancing, resistance exercises (using light weights, body weight, elastic bands), stretching exercises, swimming and water aerobics [ 94 , 96 ]. Moreover, a variety of aerobic and resistance exercises should be performed for greater benefits [ 95 ]. Specific PFMT exercises should also be performed to prevent UI [ 36 , 38 , 57 , 58 ]. Contact activities and sports with increased risk of trauma should be avoided [ 97 ]. Exercise in the supine position should be addressed carefully, avoiding long periods of training, especially after the first trimester [ 95 , 96 ].

Additionally, all women should also be informed of the warning signs that should motivate them to stop: vaginal bleeding, abdominal pain, regular uterine contractions, amniotic fluid leakage, persistent excessive shortness of breath, dizziness, headache, severe chest pain, muscle weakness, calf pain or swelling [ 94 ], [ 95 ], [ 96 ].

Contraindications

Before recommending an exercise program, a thorough clinical evaluation should be conducted, to secure that there are no medical or obstetrical reasons to either avoid exercise or modify exercise routines [ 94 , 97 ]. According to the 2019 Canadian Guidelines, absolute contraindications to exercise are: ruptured membranes, premature labor, unexplained persistent vaginal bleeding, placenta praevia after 28 weeks’ gestation, PE, incompetent cervix, intrauterine growth restriction, high-order multiple pregnancy (e.g. triplets), uncontrolled type I diabetes, uncontrolled hypertension, uncontrolled thyroid disease and other serious cardiovascular, respiratory or systemic disorders [ 95 ]. Additionally, relative contraindications are: recurrent pregnancy loss, history of spontaneous PTB, twin pregnancy after the 28th week, GH or mild/moderate cardiovascular or respiratory disease, symptomatic anemia, malnutrition, eating disorders, and other significant medical conditions [ 95 ].

Exercise proved to have a beneficial impact in all weight-related variables - GWG (low to high quality level of evidence, 13 studies [ 16 , 17 , 20 ], [ 21 ], [ 22 ], [ 23 ], [ 24 , 26 ], [ 27 ], [ 28 , 35 , 36 , 38 ]), EGWG (low to high quality evidence, five studies [ 20 , 23 , 31 , 33 , 36 ]) and PPWR (low to moderate quality of evidence, three studies [ 20 , 29 , 34 ]). Similarly, women who exercised during pregnancy had a lower risk of GDM (very low to high quality evidence, 11 studies [ 6 , 17 , 21 , 22 , 28 , 37 , 39 , 40 , 43 , 44 , 47 ]). In fact, risk factors for developing GDM are maternal overweight and obesity, which can be improved with exercise. A lower risk of macrosomia (very low to high quality evidence, four studies [ 7 , 38 , 48 , 49 ]) and LGA (low to high quality evidence, three studies [ 21 , 27 , 48 ]) was also found, possibly also related to the reduction of GDM risk. Both GH (very low to high quality evidence, three studies [ 6 , 37 , 44 ]) and PE (very low to high quality evidence, four studies [ 6 , 37 , 44 , 55 ]) risks were lower in women who exercised during pregnancy.

Exercise did not influence cesarean delivery rates (moderate to high quality evidence, seven studies [ 5 , 17 , 23 , 28 , 32 , 38 , 45 ]), labor duration (low to high quality evidence, three studies [ 38 , 51 , 53 ]) or instrumental delivery rates (moderate to high quality evidence, four studies [ 44 , 50 , 51 , 53 ]). However, a higher probability of vaginal delivery (moderate to high quality evidence, three studies [ 44 , 50 , 51 ]) was found in exercise groups. Heterogeneity among these findings may be related to the fact that operative deliveries are influenced by multiple variables (including maternal obesity that was not considered in many studies). Additionally, exercise can prevent fetal macrosomia, GDM and improve maternal cardiorespiratory capacity and fitness level, decreasing maternal exhaustion, but it does not influence aspects such as fetal breech presentation, uterine abnormalities, and obstetric emergencies such as cord prolapse, maternal request for a cesarean delivery or obstetrical protocols to treat labor dystocia.

Exercise showed a beneficial effect in UI prevalence (very low to moderate quality evidence, four studies [ 36 , 38 , 57 , 58 ]). The fact that exercise lowered LGA, macrosomia and EGWG risks, could also have influenced this outcome. Exercise type had an important role, since most studies that presented significant results included PFMT in their intervention. Also, lumbopelvic pain intensity had a better control in women who exercised during pregnancy (very low to low quality of evidence, two studies [ 35 , 36 ]), although pain prevalence was similar between groups. Among the included studies, pain intensity measurement tools varied plenty, hampering the establishment of firm conclusions. Anxiety and prenatal depression were reduced with exercise (very low to moderate quality of evidence, five studies [ 3 , 35 , 36 , 60 , 62 ]), although postpartum depression was not influenced by prenatal exercise (low to high quality of evidence, three studies [ 3 , 59 , 61 ]).

Overall, the level of quality of evidence was rated down mainly because of risk of bias and heterogeneity of the presented results in Supplementary Material Tables 1–12 .

Two studies [ 83 , 84 ] evaluated maternal core temperature changes with exercise, and concluded that it doesn’t rise to dangerous values (very low to moderate quality evidence). Evidence did not relate exercise to an increased risk of PTB (very low to high quality evidence, 12 studies [ 7 , 17 , 18 , 21 , 23 , 32 , 33 , 36 , 37 , 39 , 44 , 81 ]). More research is needed regarding women with increased risk for PTB (e.g. history of a previous PTB). Low-birth-weight risk (very low to high quality evidence, seven studies [ 7 , 18 , 32 , 36 , 37 , 44 , 49 ]) and SGA risk (very low to high quality evidence, nine studies [ 7 , 17 , 18 , 21 , 27 , 45 , 48 , 49 , 82 ]) were uniformly unaltered with exercise interventions across studies.

Overall, the level of quality of evidence was rated down mainly because of risk of bias, heterogeneity of results and indirectness of evidence in Supplementary Material Tables 1–12 .

Analyzing dose-response relationships of physical exercise and pregnancy outcomes, in general, greater health benefits are seen with more intense and frequent exercise sessions [ 6 , 16 , 47 , 80 ], and most benefits can be achieved with compliance to current international guidelines [ 94 ], [ 95 ], [ 96 ]. Interventions that consisted only in counseling were not as effective, probably due to an increased adherence to supervised and structured exercises.

Concerning exercise safety limits, the available evidence states that low, moderate and vigorous intensity physical exercise is safe. In studies evaluating miscarriage, the maximum registered session duration was 60 min, at moderate intensity, with no negative outcomes reported. Exercise for up to 35 min at moderate intensity, 25 °C and 45% relative humidity, and water immersion (≤33.4 °C) exercise for up to 45 min, are safe, irrespective of pregnancy stage. It is currently not possible to infer conclusions concerning exercise performed at different intensities, durations and environmental conditions other than those included in these trials.

Strengths and limitations

There are some limitations to this review. First, it has only considered studies in English and Portuguese, possibly inducing a publication bias. Mainly RCTs and systematic reviews were included, which may have limited its comprehensiveness. Secondly, the fact that several different types of exercise interventions were considered for each outcome may have influenced the significance of the results. Another important issue is that some articles included interventions not limited to exercise (such as diet and lifestyle counseling) and this also may have induced some bias. Finally, there is lack of strong evidence for some of the included outcomes, such as LP, PM, miscarriage and congenital anomalies (very low to low quality evidence, n = 3 studies).

The strengths of the current review include the synthesis of evidence from 15 countries and five different continents, and the application of the GRADE methodology to evaluate the quality of evidence. Additionally, the chosen study design of the included articles provided a strong level of evidence, since only RCTs, systematic reviews and meta-analysis were included.

This review provides an important insight to exercise prescription in clinical practice. On one hand, it reassures and increases the confidence in the prescription of exercise during pregnancy - exercise generally improves maternal and fetal outcomes, in the absence of significant harmful effects. On the other hand, based on international guidelines and dose-response analysis, it was possible to find an appropriate duration, frequency and intensity to be advised as a goal for most pregnant women. In addition, these results can help to improve women’s motivation to comply with exercise programs.

In future studies, more attention should be paid to the impact of specific types of exercises, timing of initiation and total duration on pregnancy outcomes. Moreover, program compliance should be monitored more rigorously, and factors that may influence participants’ retention and compliance should be accessed. Also, it would be important to access the effects of a sedentary lifestyle during pregnancy. There is a necessity to better define an upper-safe-limit of exercise intensity, frequency and duration, to better advise previously active women, namely professional athletes and exercise enthusiasts.

Conclusions

Exercise can help to prevent important pregnancy related disorders, such as GDM, GH and PE. Conditions that have an impact in maternal quality of life, such as anxiety, prenatal depression, LP and UI are also prevented and may be improved with exercise. Exercise was not found to be related with an increased risk of miscarriage, CA, PTB, PM, or inadequate fetal growth (SGA and LBW). Considering exercise prescription, most of the described benefits can be achieved with compliance to the current international guidelines. Exercise intensity should be adapted to women’s previous fitness level. Specific types of exercise and their particular effect in each maternal and perinatal outcome as well as exercise in women with specific comorbidities need more extensive research.

Research funding: None declared.

Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

Competing interests: Authors state no conflict of interest.

Informed consent: Not applicable.

Ethical approval: Not applicable.

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106 Topics about Teenage Pregnancy Essay Examples, & Tips

Want to know how to write an essay about teenage pregnancy? This issue is very hot, sensitive, and controversial. Numerous articles and researches focus on its causes and effects.

❗ Teenage Pregnancy Essay: How to Write?

🏆 top 10 topics about teenage pregnancy, 🥇 best teenage pregnancy essay examples & topic ideas, 📌 interesting teenage pregnancy research paper topics, 👍 good research topics about teenage pregnancy, ❓ research questions on teenage pregnancy.

We’ve collected a list of topics about teenage pregnancy, as well as a number of tips on outlining your essay, writing an introduction, and formulating a teenage pregnancy thesis statement. Get inspired with us!

Whether approaching the subject from a demographic or medical point of view, the interest in a teenage pregnancy essay heavily roots itself in the issues of today.

With a multitude of topics dealing with different sides, from mothers and children to the government, creating a unique essay that will get you a good grade is a matter of adequately constructing your argument.

• Choose a single theme that you will address. All teenage pregnancy essay topics center on one problem but concern themselves with different facets of it. Thus, you have to decide whether you want to write about government-supported methods of pregnancy prevention or the repercussions of an increase in the number of teenage mothers.
• Carry out your research process and compile your findings into a bibliography. You should use book and journal titles to demonstrate your in-depth knowledge of the issue, properly referencing your sources within your paper when you use them. The more you understand your chosen problem from the viewpoint of different researchers and their studies, the more you can hope to write a comprehensive essay.
• Write an outline. By doing so, with or without using topic sentences, you can see how many sub-themes you touch upon and how inclusive your work is. This action will help you save time by writing and rewording the better part of your paper, as you will see potential structural issues early on.
• Construct a title. As the first thing a potential reader sees, it should be both engaging and thought-provoking. However, teenage pregnancy essay titles should grab their readers’ attention without a shock factor, intriguing them with information but not demeaning their topic. Regardless of your opinion regarding the issue, remember that you are writing about living people who deserve fair treatment.

You should draft your paper traditionally with an introduction, body, and conclusion. You can start your first paragraph with an interesting fact or statistical number to gain your audience’s attention. However, do not forget to write a thesis statement, as well as a hook.

Your introduction and conclusion should reflect each other, and that may become possible only if your first paragraph gives your reader an idea of what your stance is and what you plan to achieve in your paper. Without a thesis, you can neither expect readers to get interested in your work nor write an excellent conclusion yourself.

Understand what your teenage pregnancy essay body needs, and include only information that will help you advance your main argument.

For example, if you are writing a paper from a sociology studies perspective, then you may see that you may gain an advantage by writing from a statistical or socioeconomic perspective.

Remove any sentences that do not link to your thesis statement, directly or indirectly. Your central argument should be pivotal to your paper, as exciting as the various facts that you find may be.

Superb structure comes from reading up on even better examples. You can easily find a teenage pregnancy essay example or two and use them to get inspired. Do not forget to assess these sample papers on technique and information included, gauging which methods you can uplift into your own work.

However, remember that you cannot and should not plagiarize, as copying and pasting information is an academic offense. Safeguard your paper’s grade by remaining academically honest.

Teenage Pregnancy Thesis Statement

Early pregnancies remain one of the most acute social problems in the world. Still, formulating a teenage pregnancy thesis statement might be a challenge. To make it easier for you, we’ve prepared some examples.

• The complications associated with early pregnancies are the main cause of death for 15-19-year-old girls in the world; therefore, the problem of teenage pregnancy needs to be addressed on the governmental level worldwide.
• Teenage pregnancies have severe health, social, and economic implications both in developed and developing countries.
• Sex education in schools is the best way to prevent early pregnancies.
• Reducing social pressure on girls to marry and bear children early is the best way to lower the levels of teenage pregnancies in the least developed countries.

Are you still confused by your assignment? Let IvyPanda help you with any topic!

• Teenage pregnancies in developed countries
• How to prevent teenage pregnancies?
• Adolescent pregnancies in various regions of the world
• Teenage pregnancy as a cause of death
• Early pregnancies and health consequences
• Early childbearing and severe neonatal conditions
• Social and economic effects of teenage pregnancies
• Adolescent pregnancies in developing countries
• Causes and effects of teenage pregnancy
• Sex education as a way to prevent early pregnancies
• Teenage Pregnancy Causes and Effects In addition to this, the modern society allows the teenagers to have a lot of time and space with the opposite sex on their own, which results to instances of pregnancy at teenage hood.
• Teen Pregnancy: Causes, Effects and Prevention Teenage pregnancy is the pregnancy of underage girls during their adolescent period, normally between the ages of 13 to 19 but this range varies depending on the age of the menarche and the legal age […]
• Teenage Pregnancy Concept and Problems This becomes potentially dangerous to the teenage girls due to the lack of prenatal care and the fact that her body is not fully developed to carry a pregnancy.
• Teenage Pregnancy Major Causes and Solutions Thus, one of the manifest functions of the family is to be the meaningful unit which supports the accepted social order and is a support of the state.
• Positive Impacts of Sex Education on Teenage Pregnancies Failures of Sex Education in reducing teenage pregnancies According to the article by Stobbe, education has not achieved much in terms of helping students change their attitudes and behavior on sex and use of birth […]
• Increasing of Sex Education in Schools to Curb Teenage Pregnancy Increased sex education is important because it emphasizes on the need to abstain and use of contraceptives. It is therefore important to increase sex education in schools to avert cases of teenage pregnancies.
• Teenage Pregnancy and Abortion: Articles Evaluation The article highlights the importance of coming up with sexual health services and contraception methods, which are community-based for the benefit of the young people in a bid to counter the seemingly never-ending menace of […]
• Social Aspects of Teenage Pregnancy In recent years, both in the USA and in European countries, the number of pregnant women among minors has been increasing due to a decrease in the age of sexual debut, an increase in sexual […]
• Improving Health Care Delivery: Teenage Pregnancy Due to the absence of proper support, these young individuals lack timely prenatal care and skills to support their developing fetuses.
• Teenage Pregnancies in California Socioeconomic position, teens’ surroundings, their family, and the number of resources accessible epitomize some of the teenage pregnancy causation. The Maternal, Child, and Adolescent Health Program is a different initiative from the State of California […]
• Teenage Pregnancy and Quality of Care Therefore, the most effective method of ensuring the quality of care, patient safety, and costs is conducting campaigns to prevent teenage pregnancies.
• The National Campaign End Teenage Pregnancy in Ohio The dream of most parents is to ensure their children lead to a successful future which may be affected by the occurrence of unplanned teenage birth.
• Teenage Pregnancy Problem and Decision-Making Tool The first option is the birth of a new person and the opportunity for the young mother to love and raise him.
• Teenage Pregnancy in America The WHO says that many teenage pregnancies that end in birth often lead to poor emotional and physical health for the new mothers. The same research also reveals that increasing access to effective contraception is […]
• Teenage Pregnancy in New Jersey This paper aims to address the issue of teenage pregnancy in New Jersey and identify the parties that influence young people’s decisions related to sexual behavior.
• Teenage Pregnancy: Statistics, Factors, and Strategies One of the causes of the high levels in teen pregnancies is attributed to poverty and the social inequalities in both Britain and America.
• The Problem of Teenage Pregnancy Marx, Fleur Hopper Faith-Based versus Fact-Based Social Policy: The Case of Teenage Pregnancy Prevention published in Social Work, Volume 50, 2005, is dedicated to the idea of teenage pregnancy in the United States.
• Psychological Causes of Teenage Pregnancy They are not settled in their lives and are not able to bear the responsibility of a child. Abortion is also justified in the unfortunate event of teenage marriage and pregnancy.
• Teenage Pregnancy Rates and Prevention Programs The purpose of this paper is to study the adolescent pregnancy rates in the US, identify the risk factors, list health and mental risks of teenage pregnancy, and find existing and other possible solutions to […]
• Teenage Pregnancy, Abortion, and Sex Education According to, some individuals in the society particularly the religious ones see abortion as a vice affecting every corner of the world.
• Sex Education Role in Preventing Teenage Pregnancy In a bid to survive, the teens resort to prostitution as a means of earning a livelihood, which in turn leads to teenage pregnancies.
• The Ways to Reduce Teenage Pregnancies Although teen pregnancy is an ongoing problem, it can be reduced with good education, parental support, and birth control Over the last couple of years, the United States of America has woken up to the […]
• The Major Factors of Teenage Pregnancy Mooney, Knox, & Schacht, states that low self-esteem is often associated with abused children and are one of the factors that shape teenagers’ sexual behavioral patterns and lead to teen pregnancy.
• Teenage Pregnancy and Its Consequences to the Society The opportunities of mother and the child to build a future are further depleted by these risks. Education to the youthful teens would be a valuable tool to curb early pregnancies.
• Popular Culture and Teenage Pregnancy Among Americans This has been the case particularly in regards to the Western society of the early to the middle 20th century and the up-and-coming international normalcy of the late 20th and 21st century.
• Teenage Pregnancy in the Modern World Teenage pregnancy rate in America is among the highest among the developed nations; although the teen pregnancy rate is said to be dropping in the past years in the developed world, in the US, rate […]
• The Rise of Teenage Pregnancy Rates in the United States of America
• Teenage Pregnancy: Keeping Healthy Relationships With All Involved
• Children and the Issues of Teenage Pregnancy and Gangs
• The Importance of Condom Distribution in Schools to Prevent the Rise of Teenage Pregnancy
• The Misunderstanding of Contraceptives: The Rising Teenage Pregnancy Rates Around The Globe
• Understanding Teenage Pregnancy in Society
• Sexual Education: Teenage Pregnancy a Global View by Andrew Cherry
• The Issue of Teenage Pregnancy in America and the Alternatives to Legal Abortion
• Teenage Pregnancy and The Role of Health Professionals
• Physical and Mental Effect of Teenage Pregnancy
• The Failures of the Abstinence-Only Education to Curb Teenage Pregnancy in the United States
• Teenage Pregnancy and Parenthood as a Social Problem
• Why Hollywood’s Perception of Teenage Pregnancy Is Flawed
• Teenage Pregnancy and Adolescent Pregnancy
• The Effect of Minimum Legal Drinking Age Restrictions on Teenage Pregnancy and Pregnancy Outcomes
• The Serious Issue of Teenage Pregnancy in America and the Reasons for the Rise of the Social Problem in the Country
• The Relationship of Childhood Sexual Abuse to Teenage Pregnancy
• The Cause and Prevention of Teenage Pregnancy in the United States
• The Serious Issue of Teenage Pregnancy in the Philippines and in Developed Countries Around the World
• The Central Issues of Teenage Pregnancy and Out-Of-Wedlock Childbearing
• The Social Problem of Teenage Pregnancy in the Philippines
• The Impact of Teenage Pregnancy on the Health Care System and Population Subgroups
• Teenage Pregnancy and Parents Were Not Ready for Kids
• Psychosocial Development and the Effects of Teenage Pregnancy
• Teenage Pregnancy and the Role of the Fathers
• The Issue of Teenage Pregnancy in Dysfunctional American Families
• The Determinants of Teenage Pregnancy Using the Seedhouse
• Relationship Between Delinquency and Teenage Pregnancy
• The Introduction of Teenage Pregnancy in Frank Furstenberg’s Unplanned Parenthood
• The Social Issue of Teenage Pregnancy in High Schools in America
• Why Comprehensive Sex Education Can Help Prevent Teenage Pregnancy in Philadelphia
• Teenage Pregnancy : Protecting Our Youth Through Abstinence
• The Health Issues and Risk of Teenage Pregnancy in Philadelphia
• The Effects of Teenage Pregnancy on Teenage Mothers
• Teenage Pregnancy and Its Effect on Children
• The Different Social Factors That Influence Teenage Pregnancy Among American Teenagers
• The Significance of the Introduction of Birth Control for Teens to Prevent Teenage Pregnancy
• The Socio-Economic Effects of Teenage Pregnancy on Girls in Secondary School
• The Teenage Pregnancy Versus Parental Consent in Regards to Unwanted Abortion
• The Issue of Sexual Activity Among Teenagers and Teenage Pregnancy in the United States
• What Cultural Factors Contribute to the Spread of Teenage Pregnancy?
• Why Does Reducing the Risk of Teen Pregnancy Matter?
• What Are the Statistics on Teenage Pregnancy in the United States?
• What Is the Incidence of Teenage Pregnancy Among Blacks and Hispanic Teens?
• How Does Sex Education Affect Teen Pregnancy?
• What Is the Role of the Media in Raising Awareness of the Social Issue of Teenage Pregnancy?
• How Does Socioeconomic Status Affect Early Adolescent Pregnancy?
• What Social and Personal Factors Affect Adolescent Pregnancy?
• How Teenage Pregnancy Changes Lives Forever?
• What Are the Causes and Effects of Teenage Pregnancy?
• How Does Teen Pregnancy Affect Academic Performance?
• What Caused the Teenage Pregnancy Epidemic?
• How to Prevent Health Problems During Teenage Pregnancy?
• What Can You Do to Reduce Teen Pregnancy Rates?
• How Does Developing Gender Expression Affect Teen Pregnancy?
• What Causes Social Isolation in Teen Pregnancy?
• How to Prevent Stress and Depression in Teen Pregnancy?
• What Are the Physical and Mental Implications of Teen Pregnancy?
• How Teenage Pregnancy Stops Students From Finishing What They Started?
• What Facts About Teen Pregnancy Should You Know?
• How Can Teenage Pregnancy Be Prevented?
• What Are the Implications of Teenage Pregnancy?
• How Can Society Prevent and Avoid Unwanted Teenage Pregnancy?
• How Teenage Pregnancy Affects the High School Dropout Rate?
• What Is the Role of Health Care Professionals in Preventing Teenage Pregnancy?
• How Can Comprehensive Sexuality Education Help Prevent Teen Pregnancy in Philadelphia?
• Why Has the Teenage Pregnancy Rate Been on the Rise for Many Years?
• Do Certain Economic Factors Affect Abortions in Teenage Pregnancy?
• What Is the Dilemma of Teenage Pregnancy in Indonesia?
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Middle East crisis — explained

The conflict between Israel and Palestinians — and other groups in the Middle East — goes back decades. These stories provide context for current developments and the history that led up to them.

'Struggle, struggle, struggle.' What new and expecting mothers are facing in Gaza

Elissa Nadworny

A baby is looked after at the neonatal unit at Kamal Adhwan hospital in Beit Lahia in the Gaza Strip, where children are born with complications due to malnourished mothers. Omar El Qattaa for NPR hide caption

A baby is looked after at the neonatal unit at Kamal Adhwan hospital in Beit Lahia in the Gaza Strip, where children are born with complications due to malnourished mothers.

TEL AVIV, Israel — In Rafah, baby Manal has just woken up from a nap. "Have you made a poo-poo?" asks her mother, Likaa Saleh, 24, as she opens a flimsy diaper that was hard to find and is several sizes too small.

The 5-month-old begins to cry. The skin on her tush and legs has rashes and is peeling where the tight material of the diaper rubs — a skin irritation that won't go away. "No, no, no," Saleh soothes her. "I'll put some cream on you now and all the pain will go away. You're a good girl."

It's hardly the life Saleh imagined for her second child when she learned she was pregnant last year. Baby Manal is one of an estimated 20,000 children who have been born in Gaza since Israel began its bombardment of the enclave in response to the Oct. 7 attack by Hamas. Amid a spiraling humanitarian crisis, women who are pregnant or have recently given birth are confronting impossible conditions as they grapple with how to care for their newborns. In place of celebrations and nursery rhymes, they face airstrikes and ground fighting. Instead of bottles and baby food, they're fighting disease and a growing lack of food and water.

"I can't teach her to eat or feed her because there's no food, no vegetables, and there's not enough milk for her," Saleh says. "I can't sleep at night because all I'm doing is thinking and I'm heartbroken."

Saleh and her family used to live in an affluent area of Gaza City, a home with all the supplies she'd need to welcome her baby, who was due in late October. Instead, Manal's arrival by C-section came under air attacks a month after the war in Gaza began.

The circumstances of the birth was one of "the worst moments of my life," Saleh says. And each day since then over the past five months has gotten harder and harder. Now, sheltering in Rafah, a city with more than a million displaced Palestinians , she has trouble finding milk, food, diapers and baby clothes that fit.

A pregnant Palestinian woman (center) displaced from northern Gaza stands in a warehouse in Rafah, where she is taking shelter, on Feb. 29. About 5,000 women in Gaza are expected to give birth in the next month. AFP via Getty Images hide caption

A pregnant Palestinian woman (center) displaced from northern Gaza stands in a warehouse in Rafah, where she is taking shelter, on Feb. 29. About 5,000 women in Gaza are expected to give birth in the next month.

"Those who pay the highest price in war are mothers and kids," says Hiba Tibi, a country director for CARE, an aid organization that helps women and children in Gaza. "They are becoming less and less hopeful. They are giving up."

The United Nations estimates that in Rafah, where Saleh and baby Manal are living, a tenth of children under age 2 are suffering from the most severe malnutrition. But as you move farther north and farther away from the trickle of aid coming into Rafah, conditions worsen.

In northern Gaza, where Saleh is originally from, a third of children under 2 are experiencing a life-threatening lack of food, and an international committee of experts warns that famine is now "imminent." Gaza health officials say at least 23 children have died from malnutrition. CARE's partners in the north of Gaza report that women in shelters are burying their newborns who have died.

Goats and Soda

There's already 'catastrophic' hunger in gaza. who decides when to call it a 'famine'.

"They see in almost all the shelters, babies that are born and dying before even getting registered," says Tibi. "So they are not even counted in life."

She can't shake what one new mother told her recently. "She told me, 'I wish I never gave birth. I wish I didn't have this kid come to life.'"

"No electricity, no clean water"

In addition to women like Saleh who have given birth since the war, many more are still pregnant, suffering from malnutrition, infection and dehydration, and without access to medical care. According to the Gaza Ministry of Health, there are nearly 60,000 pregnant women in Gaza, with about 5,000 women expected to give birth in the next month.

A nurse tends to a baby at Kamal Adhwan hospital in Beit Lahia, Gaza. Omar El Qattaa for NPR hide caption

A nurse tends to a baby at Kamal Adhwan hospital in Beit Lahia, Gaza.

Only about a third of the territory's hospitals are still partially functioning, since Israel launched its assault on Gaza in response to the Oct. 7 Hamas attack that killed 1,200 people in southern Israel. The Israeli military's offensive in Gaza has killed more than 32,400 Palestinians, according to the Gaza Ministry of Health.

The war has seen several hospitals come under attack. In recent days, the Israeli military has conducted raids at Al-Shifa hospital , the largest in Gaza, as part of an operation that it says is designed to "thwart terrorist activity" at Al-Shifa. Equipment and supplies have been damaged, healthcare workers arrested and most hospital functioning has stopped, according to health officials in Gaza.

These are the circumstances that have driven pregnant women all across the enclave to find treatment at a health clinic in Deir al Balah, in central Gaza. Run by the U.S.-based aid organization Project Hope, the clinic sees up to 60 pregnant women a day. Nearly a quarter are malnourished, according to staff at the clinic.

"It's really bad and it's becoming worse and worse every day," says Maram Badwan, the lead physician at the clinic, who is also displaced from her home. "Most of the children and women [we treat] stay in tents and with no electricity, no clean water." In addition to malnutrition and dehydration, she and her staff see many cases of hepatitis A, anemia, lice and scabies.

Project HOPE's team in Gaza provides medical care at a short-term medical clinic in a school housing displaced families in Rafah on Feb. 9. Motaz Al Aaraj for Project HOPE hide caption

Project HOPE's team in Gaza provides medical care at a short-term medical clinic in a school housing displaced families in Rafah on Feb. 9.

The clinic has a limited supply of medicine and prenatal vitamins that it offers its patients, and it also gives free ultrasounds. Women come from all over Gaza. For many, it's the first doctor's visit in their pregnancy.

The risk of disease surrounds new and expecting mothers

That's the case for Rhonda Abd Al-Razeq, a pregnant 26-year-old who is living at a shelter in Deir al Balah. She fled her home in the northernmost area of Gaza, where she and her husband farmed mulberries, onions and potatoes. Over the last several months, they've stayed at different shelters, leaving after each one came under fire from Israeli airstrikes, she says. At her current shelter, 60 people are sleeping in the same room.

Abd Al-Razeq isn't sure how far along she is. Asked what defines her life right now, she responds, "Struggle, struggle, struggle."

People in Gaza are starving to death. 5 things to know about efforts to feed them

She caught hepatitis A, along with several members of her family, many of whom have fungal infections. "If there was cleanliness, would I have gotten hepatitis?" she asks, exasperated. "The water we drink is itself dirty. How would we not get a disease?"

In her visit with Badwan, Abd Al-Razeq learned she was also malnourished and hypertensive, and yet the ultrasound showed her baby's heartbeat was strong.

She also learned the baby's sex: a boy, a welcome joy at a time when she's constantly worried about where and how she'll give birth.

Giving birth in an overcrowded shelter

There aren't many safe places for Abd Al-Razeq and other pregnant women to give birth in Gaza. If they can't make it safely to the few remaining hospital beds, they're likely to have their deliveries in crowded shelters.

Arvind Das, who recently led a team of medics from the International Rescue Committee into Gaza, said that all across the enclave he witnessed women giving birth in overcrowded shelters, some with as many as 80,000 people crammed inside. .

Palestinian women and infants receive medical care at a clinic in Rafah, in the southern Gaza Strip, on Feb. 29. AFP via Getty Images hide caption

Palestinian women and infants receive medical care at a clinic in Rafah, in the southern Gaza Strip, on Feb. 29.

"There is no privacy. There is no dignity," he said, holding back tears. "You have literally 1.5 meters of space, and that's where pregnant women are meant to deliver the children."

CARE is one of several aid organizations training women to be midwives to help other women in the shelters give birth.

Sherehan Abdel Hadi, who gave birth to her son Sanad at the end of December, says delivering is just the beginning of many more challenges.

"My son needs milk," she says. "I am not having any healthy food."

While pregnant, Abdel Hadi and her family fled on foot from Gaza City. They're now living at an uncle's house in Deir El Balah.

"There are continuous bombardment and airstrikes," she says. "We are afraid all the time."

The noise from Israeli planes and drones makes it hard for Sanad to sleep, she says. So does their crowded living situation: Abdel Hadi, the new baby and her three older children are staying with relatives, a large extended family crammed in together, sleeping three on a mattress.

"Sanad is crying all of the time, no stop," she says. "I struggle with the hot water to bathe him, and his diapers are too big and leak a lot, so he needs to change clothes, but I don't have enough clothes."

Without access to hot water, and with the crowding at home, she's worried that baby Sanad will get sick.

Rua al-Sindavi, 24, expects to give birth in a tent due to insufficient medical facilities, and she had to migrate to Rafah in southern Gaza because of Israeli attacks. Pregnant with triplets, Sindavi is one of many women who suffer from malnutrition due to food shortages in the city. Anadolu via Getty Images hide caption

Rua al-Sindavi, 24, expects to give birth in a tent due to insufficient medical facilities, and she had to migrate to Rafah in southern Gaza because of Israeli attacks. Pregnant with triplets, Sindavi is one of many women who suffer from malnutrition due to food shortages in the city.

Back In Rafah, Likaa Saleh is trying to get young Manal to eat something. She's boiled potatoes because she doesn't have money to purchase anything else. With some coaxing, she gets her baby to stop crying and take a soft potato. She feels a moment of relief as Manal stops crying and eats — a momentary respite from her near-constant worry about her daughter's future and the world she's brought her into.

Abu Bakr Bashir contributed from London.

I thought my bloody stool during pregnancy was hemorrhoids. It was stage 3 colorectal cancer.

• Kelly Spill, 32, noticed blood in her stool when she was pregnant.
• Multiple doctors told her it was internal hemorrhoids.
• When her son was 8 months old, she was diagnosed with stage 3 colorectal cancer.

This as-told-to essay is based on a conversation with Kelly Spill . It has been edited for length and clarity.

At eight months pregnant with my son, Jayce, I felt like everything in my body was changing. So, when I noticed blood in my stool and started experiencing constipation, I wasn't too worried. I mentioned it to my doctor, but she told me it was normal. I had no idea what was going on in my body at that point, so I took her word for it.

After Jayce was born, I started feeling really bad. The bleeding and constipation continued, so I requested a second postpartum checkup. A different OB/GYN said I likely had internal hemorrhoids.

I was a new mom and planning to relocate from California to New Jersey to be closer to my family. I pushed my health concerns aside to focus on the move.

I had to go to the ER after filling the toilet with blood

Once I was settled on the East Coast, I started feeling even worse. I had no appetite and lost 10 pounds, which was significant for me. Because of the move and job changes, I didn't have good health insurance, so going to the doctor was difficult.

One day, I used the bathroom, and there was so much blood that it looked like I had my period — but I didn't. I took a photo and sent it to my mom, who told me to go to the emergency room. There, doctors again told me it was hemorrhoids and suggested I lay off the spicy food.

Related stories

Finally, I got my insurance sorted and saw a new doctor. At the clinic, a nurse gave me advice that might have saved my life. She said, "If you don't find your answers here and you still don't feel well, keep searching because you know your body best." That was so validating when people — doctors — were blowing off my concerns as soon as they heard I was a new mom.

I was diagnosed with stage 3 cancer, and needed fertility treatments

Finally, I found a doctor who took me seriously and ordered a colonoscopy. Shortly after I saw a specialist at Memorial Sloan Kettering Cancer Center who diagnosed me with stage 3 colorectal cancer . Jayce was 8 months old.

Not only was I facing a terrifying diagnosis, but the doctor immediately started talking about my fertility. I was only 28, but the protocol of chemotherapy, radiation, and surgery would likely leave me unable to conceive. I knew I wanted more kids, but talking about fertility right after being diagnosed with cancer was overwhelming.

I felt pummeled physically, mentally, emotionally, and financially. And this hadn't even really started.

At the last minute, I chose a clinical trial that could preserve my fertility

On the doctor's advice, I underwent fertility treatments and an egg retrieval soon after I was diagnosed and before treatment started. That was truly the worst part of this experience. Having swollen, bloated ovaries near my tumor was incredibly painful. But my husband and I ended up with four embryos — hope for the future family we envisioned.

The day I was set to begin treatment, a research nurse came in and explained I was eligible for a clinical trial run by Stand Up to Cancer and Memorial Sloan Kettering Cancer Center. It would use immunotherapy to treat colorectal cancer. Only three other people had the treatment. If it worked, it could cure my cancer while preserving my fertility. If I didn't, we'd go back to the typical treatment plan of chemo, radiation, and surgery.

I said yes right away. By the second treatment, I was feeling so much better. By the ninth and final treatment, my tumor was gone. In August, I learned I wouldn't need radiation or surgery because I didn't have cancer anymore. That was the best day of my life.

I got pregnant using the embryos I created before treatment

I wanted to get pregnant immediately. I left an appointment in tears after doctors explained I should wait two years while I was at the highest risk of relapse. I used those two years to process everything that had happened to me: becoming a mom, cancer patient, then survivor all at once.

When I was cleared to get pregnant, I knew we could try to conceive naturally. Yet I had worked so hard for those embryos I was determined to use them. That led to my daughter, Maya, who was born in 2023.

I want more kids in the future, and I would like to try to get pregnant the old-fashioned way. I'm so incredibly grateful for the nurse who told me to advocate for myself, the doctor who guided me to fertility treatments, and the research nurse who connected me with the clinical trial. They saved not only me but my family too.

Watch: How anti-abortion crisis pregnancy centers target women looking for abortions

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Francesca Farago is pregnant, expecting first baby with trans fiancé Jesse Sullivan

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Francesca Farago and her fiancé, Jesse Sullivan , are expanding their family.

The “Too Hot to Handle” alum and the trans TikToker shared in a joint announcement on International Transgender Day of Visibility that she is pregnant with their first child together.

“We wanted to take this special day to celebrate this amazing milestone with all of you,” they wrote Sunday alongside a photo of Farago’s positive pregnancy test. “We’ve brought you with us through the loss, so we couldn’t wait to bring you along for the win.”

The reality star, 29, said she is “still pretty newly pregnant” and noted she and Sullivan 33, are so excited to have Arlo as the “coolest older sibling,” referring to Sullivan’s 15-year-old child.

“AHH IM PREGNANT!” she added.

Sullivan commented on the post, “I finally got her pregnant! So excited to be a dad to more world changers!”

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Sullivan also shared a TikTok video in conjunction with the announcement detailing the couple’s journey to conceive through IVF. Clips show Farago giving herself injections and undergoing various procedures as part of the process.

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“We’re pregnant! It’s been such a struggle to get here, but we felt like TDOV [Transgender Day of Visibility] was the perfect day to let you in on our celebration,” Sullivan captioned the video.

“I’m so proud of @Francesca Farago for fighting her way to get here, and I fall more in love with her every day.”

The former Netflix personality told Page Six exclusively in October 2023 that IVF had been “a lot more mentally and physically taxing than [either of them] realized.”

Sullivan, who has “been on testosterone for four years,” chose to stop his hormone therapy amid his IVF injections because “he wanted to give himself the best chance.”

“It’s extremely hard on your mental health. You’re freaking out, you feel terrible, you’re tired, you’re bloated, you feel depressed in a way,” Farago recalled.

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• v.10(3); 2021 Mar

A study on anemia and its risk factors among pregnant women attending antenatal clinic of a rural medical college of West Bengal

Anuradha sinha.

1 Department of Pathology, Purulia Government Medical College, Purulia, West Bengal, India

Moumita Adhikary

2 Department of Microbiology and Pathology, Rampurhat Government Medical College, Rampurhat, West Bengal, India

Jyoti P. Phukan

Sonal kedia.

3 Department of Anesthesiology and Gynecology and Obstetrics, Ramakrishna Mission Seva Pratishthan, Kolkata, West Bengal, India

Tirthankar Sinha

Background:.

Anemia is the commonest nutritional deficiency disorder in the world, particularly in developing countries. Though anemia is easily treatable and largely preventable disease if timely detected, it still continues to be significantly prevalent among pregnant women.

The aim of this study was to measure the extent of anemia in pregnancy and to assess the association of risk factors with anemia.

Study Design:

Hospital-based cross-sectional descriptive study.

Materials and Methods:

A total of 200 women were selected among pregnant women attending antenatal clinic. Sampling was done by selecting every fifth woman visiting antenatal clinic within the duration of two months on alternate days. Data were collected using a predesigned, pretested semi-structured schedule. Hemoglobin concentrations were also recorded for each patient. Data were analyzed using Chi-square test and 'T' test of significance. A value of P < 0.05 was considered significant.

We found overall prevalence of anemia to be 90% among pregnant women. Most of the anemic patients (60.5%) belong to moderate severity according to the World Health Organization classification. Three factors namely socioeconomic status, gravida and time of 1 st antenatal visit were significantly associated with prevalence of anemia in pregnancy ( P < 0.05).

Conclusion:

In this study, a high prevalence of anemia was found in pregnant women. Low socioeconomic status, multigravida and delayed visit to antenatal clinic were significantly associated with anemia in pregnancy. So, awareness and education programs should be generated to make people come to know about anemia, its complications during pregnancy and ways to prevent it.

Introduction

Anemia has been recognized as the most common form of nutritional deficiency worldwide, particularly in developing countries like India. Though anemia is easily treatable and preventable disease, it continues to be significantly associated with pregnancy. Diminished intake and increased demand, excess demand in case of multigravid woman and altered metabolism along with the background characteristics like low socioeconomic status, illiteracy, early age of marriage associated with increase in susceptibility to infectious diseases like hookworm infestations may serve to be the underlying factors associated with prevalence of anemia during pregnancy. According to the World Health Organization (WHO) prevalence of anemia among pregnant women varies from 14% in developed countries to 65%–75% in India.[ 1 ] In women, anemia may become the underlying cause of maternal mortality and perinatal mortality.[ 2 ]

Hemoglobin value <11 g/dL is defined as anemia in pregnancy by WHO.[ 3 ] Anemia in pregnancy can be further divided as mild, moderate and severe anemia for hemoglobin level 10.0–10.9 g/dL, 7–9.9 g/dL and severe <7 g/dL.[ 4 ]

Various studies showed an association between anemia and maternal mortality.[ 5 , 6 , 7 ] Apart from maternal mortality, anemia in pregnancy may result in intrauterine growth retardation, low birth weight, still-birth, and neonatal death.[ 8 , 9 , 10 , 11 ]

In view of low dietary deficiency of iron and folic acid, and high prevalence of anemia among pregnant women, India started the National Nutritional Anemia Prophylaxis Program (NNAPP) to prevent anemia among pregnant women.[ 12 ] Through this program 100 mg of ferrous iron and 500 mcg folic acid tablets distributed to pregnant woman through Urban Family Welfare Centers in urban areas and Primary Health Centers in rural areas. Despite of these preventive measures, anemia in pregnant women is still very much prevalent in India.[ 12 , 13 ]

The key for safe motherhood is reduction of maternal anemia. The risk factors of anemia particularly during pregnancy are multifactorial and complex.[ 14 ] So, knowledge of these risk factors and compliance of respondents towards implemented government program is very much essential to prevent anemia and its consequences.

Primary health care physicians are the first contact physician in the community who can play a very important role in identification and treatment of anemia.[ 15 ] Many issues associated with anemia can be assessed and modified at the primary care level such as dietary habits, multi parity etc.

Hence, this study was undertaken with the following aims and objectives:

• To determine the magnitude of anemia in pregnant women according to severity among study population, and
• To find out association of anemia with different socio-demographic factors.

Materials and Methods

Study subjects and study area.

This cross-sectional study was conducted in a rural teaching hospital of West Bengal, India for a duration of 2 months. This rural medical college is situated in a backward area of western West Bengal which caters mainly economically poor population. Data collected from 200 pregnant women (Cases). Every fifth patient was taken attending antenatal clinic (ANC) and first patient was selected randomly. A consent form was filled by each participant.

Inclusion and exclusion criteria

Inclusion criteria.

Pregnant women attending ANC who filled the consent form having their Hemoglobin (Hb) report. Confirmation of pregnancy was done by either urinary pregnancy test and/or by pelvic ultrasonography.

Exclusion criteria

Unwilling pregnant women and who did not have hemoglobin report with them were excluded from the study.

Ethical consideration

The study was approved by the institutional ethics committee before commencing the study. The study was done as a part of the Indian Council of Medical research short-term studentship program (ICMR-STS). It was obtained on 21/03/2012.

Data collection

Data were collected from every participant using a predesigned, pretested semi-structured schedule. Sociodemographic particulars and data regarding reproductive behavior were collected. Socioeconomic status was determined based on Tendulkar's committee poverty line where the income of less than rupee 673 per month was considered as low socio-economic status. Hemoglobin level is also recorded from the available investigation report. All hemoglobin levels estimated by the cyanmethemoglobin method.

Statistical analysis

Chi-square test and 'T' test of significance were used to show any association between risk factors and severity of anemia. A 'P' value <0.05 was considered statistically significant to show an association between the particular risk factor and severity of anemia.

Results and Observations

In our study, 200 pregnant women were included. The demographic characteristics of the pregnant women were shown in Table 1 . The most common age group in our study was 20-30 years (54.5%) and majority were of low socioeconomic status (58%) [ Table 1 ]. Maximum numbers of study subjects were Hindu (94.5%).

Distribution of pregnant women according to variable characteristics ( n =200)

Among the pregnant women, 90% suffered from anemia; majority had moderate anemia (60.5%), followed by mild anemia (29%). Only 1 woman was suffering from severe anemia while the rest had no anemia [ Table 2 ].

Distribution of severity of anemia among pregnant women according to WHO criteria

Hb=Hemoglobin

Association of anemia with low socioeconomic status was found to be 63.93%, 51.72% and 35% for severe and moderate, mild and no anemia respectively [ Table 3 ] which was statistically significant [P = 0.03]. However, no significant association of severity of anemia with the educational status of the pregnant women was detected.

Distribution of pregnant women according to socio economic status with respect to severity of anemia ( n =200)

χ 2 =7.002, P =0.030 (S). S=Significant

Also, severity of anemia is associated with time of first antenatal visit which is statistically significant [ Table 4 ]. However, severity of anemia with respect to age and religion were not significant.

Distribution of pregnant women according to time of 1 st antenatal visit with respect to severity of anemia ( n =200)

χ 2 =27.549, P =<0.001 (S). S=Significant

Anemia in pregnancy is a major health issue in India. The reason being low socioeconomic status, less dietary intake of iron and folic acid, short spacing of multiple pregnancies, excessive bleeding during labor, infections like malaria and hookworm infestations.[ 16 ]

In West Bengal, National Family Health Survey-3 found the prevalence of anemia among pregnant women of age group 15–49 years to be 62.6%.[ 17 ] This is less than our study, where we found it to be 90%; which is similar to other Indian studies done by Lokare et al ., Gautam et al ., Toteja et al . and ICMR Taskforce Multicenter Study[ 12 , 18 , 19 , 20 ] On the contrary, few recent studies done in African continent found the prevalence of anemia in pregnant women as low as 25.8% to 37.6%.[ 21 , 22 ] This variation may be due to various socio-demographic and comorbid conditions. Also, as our study participants are mainly poor from tribal population with low socioeconomic status, therefore the prevalence of anemia during pregnancy may be remarkably high.

Majority of cases in our study had moderate anemia (60.5%), mild anemia (29.0%) and one case of severe anemia which was found to be similar to Vindhya et al ., Mahamud et al ., Sarala V et al .[ 15 , 21 , 23 ]

There was no association found between age group and religion with anemia unlike Viveki et al . who found higher maternal anemia for age group above 26 years.[ 24 ] Studies done in Aurangabad city and New Delhi in India showed that severity of anemia decreases with higher per capita income, which is similar to our study.[ 12 , 19 ]

Time of ANC visit also plays an important role in reducing maternal anemia. 1 st Trimester visit with prescription of proper diet, iron and folic acid supplements have reduced severe anemia remarkably in our study which is like study done by Mangla et al .[ 25 ]

Still a remarkably high prevalence of anemia among pregnant women showed that anemia is endemic in this region irrespective of age, religion, education status, occupation etc., Various socio-cultural problems like taking vegetarian diet, having tea after food, open field defecation predisposing women to hook worm infestation and other associated infections may serve as important factor behind high prevalence of anemia in the pregnant women. Age of marriage didn't show any association with respect to severity of anemia in this study suggesting that multiple pregnancies, heavy menstrual blood loss or multiple abortions because of some false cultural belief like the desire to have a boy child may be the reasons behind high prevalence of anemia. Thus, gravida showed a significant association with severity of anemia.

In our study, we found that majority of pregnant women did not consume the minimum number of iron and folic acid tablets. This suggested lack of compliance or low efficacy of government policies to provide regular supplementation. Also lack of motivation and education towards utility of supplementation may be the cause to serve high prevalence of anemia. However mere use of this supplementation during pregnancy cannot solely serve the purpose, as other etiologies like hookworm infestations, malarial infection and other infections may be an issue which needs to be taken under consideration.

Limitations of the study

The study was conducted with a small sample size in a hospital which increases the possibility of error. If it would have been a longitudinal study rather than cross-sectional, then a better association between anemia and its risk factors could have been assessed. Mother's status of anemia could not be traced at different trimesters of pregnancy because of short duration of the study period. No test was done, or report was checked to find out any infectious disease like hookworm infestation or malaria and others to serve as etiology behind anemia. Morphology of red blood cell was also not recorded, which could help us to find its etiology.

Recommendations

Based on our study, we have the following recommendations to prevent and/or decrease the severity of anemia among pregnant women:

• Awareness and Education programs should be generated to make people come to know about anemia, its complications, and ways to prevent it.
• Especially adolescent girls should be educated to make them aware of the upcoming problem if not taken care since the same age.
• Woman of childbearing age should be motivated to take the required supplementation before conceiving and to continue with it till breastfeeding the baby.
• Education of the male partner regarding the complications of the disease and the utility of the supplementary diet during pregnancy may help the pregnant woman a lot to execute these policies in her daily life.
• To add support to supplementation food fortification with essential vitamins and minerals may serve the purpose. Iron fortification may be used in commonly used food like salt and sugar to build up iron stores and such things should be easily accessible and affordable by the common people. Mere cooking of food in cast iron utensil may reduce the severity of anemia.
• Advertisement programs should be generated to draw the attention of policymakers as anemia is one of the major global problems.

In summary, this study revealed a high prevalence of anemia in pregnancy, irrespective of age, religion, education status and occupation. Anemia is found to be endemic in this region, due to various unfavorable socio-demographic factors. As we all know, prevention is better than cure, therefore, these findings may help our policymakers and health care providers to change policies, add new strategies and educates the society to save from maternal anemia.

Financial support and sponsorship

Indian Council of Medical Research – Short Term Studentship (ICMR-STS).

Conflicts of interest

There are no conflicts of interest.

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What Is Going On in Pakistan?

By Ayesha Siddiqa

Ms. Siddiqa is an expert on Pakistan’s military.

For decades, Pakistan’s military has been the country’s most vital institution. Although it frequently intervened to oust elected governments, many Pakistanis saw this as salvation from the country’s blundering politicians. The army, it was thought, was the only force capable of holding the country together.

The question now is whether the generals can keep themselves together.

The military has suffered a catastrophic loss of prestige after the populist former prime minister Imran Khan directly challenged its influence. In response, Mr. Khan was ousted and jailed, and his party — despite winning the most parliamentary seats in a divisive February election — was shut out of a new civilian government that took power this month with the blessing of the military leadership. The country remains deeply polarized.

But an even greater concern for Gen. Syed Asim Munir, the army chief, is that the polarization extends into the military itself. It is common knowledge in Pakistani political circles that significant portions of the military leadership, powerful military families and rank-and-file officers are sympathetic to Mr. Khan’s right-wing, anti-American vision for the country, which included aligning Pakistan more closely with China and Russia. Whether this internal rift can be healed will ultimately decide the direction and stability of Pakistan, which has nuclear arms and is the world’s fifth most populous.

These divisions could hardly come at a worse time for Pakistan. The economy is near collapse , and General Munir is working to repair relations with Washington that were badly frayed by Mr. Khan’s politics. Pakistan is beset by political and security challenges on all sides, including by its archrival, India, under Prime Minister Narendra Modi, a Hindu nationalist, as well as Iran and the Taliban-held Afghanistan. Iranian forces launched airstrikes on targets in Pakistan in January, prompting Pakistani counterstrikes. This month Pakistani military posts were hit by militant attacks in the country’s south and along the border with Afghanistan.

The military, of course, bears much of the blame for the country’s predicament. After the decade-long military regime of Gen. Pervez Musharraf ended in 2008, Pakistan returned to a fragile democracy. But the army leadership began to fear that the two dominant political parties, the Pakistan Muslim League-Nawaz and the Pakistan People’s Party, were seeking to rein in military influence.

The generals faced other pressures, too. The United States imposed conditions on financial aid to Pakistan’s military in 2009 and killed Osama bin Laden on Pakistani soil in 2011. Later that year, 28 Pakistanis were killed in an accidental clash between NATO and Pakistani forces along the border with Afghanistan. A popular narrative gained ground, partly fanned by the army, that portrayed the United States as conspiring to undermine the nation’s sovereignty.

The military leadership sought a more cooperative political partner to help face these challenges and counterbalance the entrenched parties. It paired up with Mr. Khan, a popular cricket-star-turned-politician who had been a supporter of General Musharraf’s government and a harsh critic of Pakistan’s dynastic political families, which he accuses of corruption.

It backfired.

Mr. Khan, who was elected prime minister in 2018, inflamed Pakistanis with his calls to tear down the political establishment and reject American influence. But with inflation hitting double digits, he faced growing public criticism of his handling of the economy. He accused the military of conspiring with the United States to force him out, creating a rift. With a political crisis threatening to add to the economic problems, he was removed from office by a parliamentary no-confidence vote in April 2022 that bore the fingerprints of the military leadership.

When a high court ordered his arrest in May of last year, his supporters openly turned against the army, protesting in the streets and even attacking the residences of senior army officers and other military targets.

As last month’s elections approached, the military took steps to ensure Mr. Khan’s party would not win. He was sentenced just before the election to long prison terms on much-questioned charges of corruption and leaking state secrets, and severe restrictions were imposed on his party, Pakistan Tehreek-e-Insaf, that essentially barred its candidates from campaigning.

But Mr. Khan’s message — fanned by anger over the generals’ meddling — continued to resonate, and candidates aligned with his party stunned the military by winning the most seats in Parliament. The military kept them from power by engineering the current coalition government, which is headed by Prime Minister Shehbaz Sharif and includes traditional parties that the generals once sought to marginalize by aligning with Mr. Khan.

In addition to a withering economic and security landscape, that government now also faces large swaths of Pakistanis who feel the election was stolen. The military, which is propping up the government, is powerful enough that it might very well weather the damage to its reputation, but it needs to get its own house in order.

Serving and retired officers have explicitly called for General Munir to take a softer approach toward Mr. Khan, and it is widely known in Pakistan that members of some military families participated in last May’s protests over how Mr. Khan was being treated.

General Munir is busy trying to extinguish that fire, reminding officers that the violence last May targeted the military and moving to gag dissent within the armed forces to stop pro-Khan sentiments from spreading further.

He may succeed in the short term, but this story is far from over.

General Munir’s three-year term expires in November of next year, and many officers expect that his successor could be more sympathetic to Mr. Khan — the enmity between the two men is widely believed to stem from a personal rivalry — perhaps even leading to new elections and Mr. Khan’s return to the political stage. This would not be unprecedented: Pakistan has a history of backroom machinations resulting in ousted leaders being brought back. (The prime minister’s brother Nawaz Sharif was removed three times as prime minister and twice went into exile. He returned ahead of the February elections and is expected to exert behind-the-scenes influence over his brother’s government.)

This is where things could get dangerous for Pakistan. Mr. Khan has remained intransigent, refusing to negotiate with his rivals in the military and political establishment. Many fear where a vengeful Mr. Khan could lead Pakistan if he were to return. And yet if General Munir tries to extend his tenure to retain the status quo, military disunity could flare.

Army unity looks likely to hold for the time being. But all is not well in the military fraternity. Unless Pakistan’s generals can patch the rift over Mr. Khan, the country’s political stability, its security and its future will be difficult to predict.

Ayesha Siddiqa (@iamthedrifter) is a political scientist at King’s College, London, and the author of “Military Inc.: Inside Pakistan’s Military Economy.”

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