Globally, more than eight million of the 136 million women giving birth each year have excessive bleeding after childbirth. [ 94 ]  This condition—medically referred to as postpartum hemorrhage (PPH)—causes one out of every four maternal deaths that occur annually and accounts for more maternal deaths than any other individual cause. [ 94 ]  Deaths due to postpartum hemorrhage disproportionately affect women in developing countries.


For every woman who dies from causes related to pregnancy, an estimated 20 to 30 encounter serious complications. [ 62 ]  At least 15 per cent of all births are complicated by a potentially fatal condition. [ 62 ]  Women who survive such complications often require lengthy recovery times and may face lasting physical, psychological, social and economic consequences. Although many of these complications are unpredictable, almost all are treatable. Findings from a 2023 systematic review of the literature have found a relationship between health insurance coverage and postpartum outcomes, suggesting that those with little to no coverage have increased negative postpartum health outcomes. [ 95 ]                                     .


During the  postpartum period , many mothers breastfeed their infants. Transmission of HIV/AIDS through breastfeeding is a huge issue in  developing countries , namely in African countries. [ 93 ]   The majority of infants who contract HIV through breast milk do so within the first six weeks of life, [ 96 ]  despite that antiretroviral treatment (during pregnancy, delivery and during breastfeeding) reduces transmission risk by >90%.  However, in healthy mothers, there are many benefits for infants who are breastfed.  The World Health Organization recommends that mothers breastfeed their children for the first two years of life, whereas the American Academy of Pediatrics and the American Academy of Family Physicians recommend that mothers do so for at least the first six months, and continue as long as is mutually desired. [ 97 ]  Infants who are breastfed by healthy mothers (not infected with HIV/AIDS) are less prone to infections such as  Haemophilus influenza, Streptococcus pneunoniae, Vibrio cholerae, Escherichia coli, Giardia lamblia , group B streptococci,  Staphylococcus epidermidis , rotavirus, respiratory syncytial virus and herpes simplex virus-1, as well as gastrointestinal and lower respiratory tract infections and otitis media. Lower rates of infant mortality are observed in breastfed babies in addition to lower rates of sudden infant death syndrome (SIDS). Decreases in obesity and diseases such as childhood metabolic disease, asthma, atopic dermatitis, Type I diabetes, and childhood cancers are also seen in children who are breastfed. [ 97 ]


Following up on the women who have given birth is a crucial factor as it helps check on maternal health. Since healthcare facilities have records of the women who have given birth, when the women are followed to monitor the progress of their babies as well as their health, it becomes easy to put them on a follow-up and ensure they are doing well as the baby grows. Follow-up is accompanied by nutritional advice to ensure both the mother and her baby are in good condition. This prevents sickness that may affect the two and deteriorate their health.


Additionally, longitudinal followup must include mental health support and screening, as roughly 15% of women will experience  postpartum depression , also known as "baby blues", within the first year of birth, although it typically starts in the first 1–3 weeks after birth. [ 98 ] [ 99 ] [ 100 ]


Maternal health care and care of the fetus starts with prenatal health. The World Health Organization suggests that the first step towards health is a balanced diet which includes a mix of vegetables, meat, fish, nuts, whole grains, fruits and beans. [ 43 ]  Additionally, iron supplements and folic acid are recommended to be taken by pregnant women daily. These supplements are recommended by the US Surgeon General to help prevent birth complications for mothers and babies such as low birth weight, anemia,  hypertension  and pre-term birth. [ 101 ] [ 43 ] [ 102 ]  Folic acid can aid neural tube formation in a fetus, which happens early in gestation and therefore should be recommended as soon as possible. [ 103 ]  Calcium and Vitamin A supplements are also recommended when those compounds are not available or only available in low doses in the natural diet but other supplements such as Vitamins D, E, C, and B6 are not recommended. [ 103 ]  The WHO also suggests that low impact exercise and reduction of caffeine intake to less than 330 mg/day can help to reduce the likelihood of neonatal morbidity. [ 43 ]   Light exercise should be continued for pregnant mothers as it has been recommended to combat negative health outcomes, side effects and birth complications related to obesity. [ 101 ]  The overturned advice that pregnant women's heartate should not exceed 140 as of 2012 was still popularly believed. [ 104 ] [ 105 ]  Should possible side effects of a pregnancy occur, such as nausea, vomiting, heartburn, leg cramps, lower back pain, and constipation; low intensity exercise, balanced diet, or natural herb supplements are recommended by the WHO to mitigate the side effects. [ 43 ]  the US Surgeon General recommends abstaining from consuming alcohol or nicotine in any form throughout the duration of one's pregnancy, and to avoid using it as a way to mitigate some of the side effects of pregnancy mentioned earlier. [ 106 ]


In the case of a healthy vaginal birth, mothers and babies typically are recommended to stay at the hospital for 24 hours before departing. This is suggested to allow time to assess the mother and child for any possible complications such as bleeding or additional contractions. The WHO recommends that babies should have checkups with a physician on day 3, day 7-14 and 6 weeks after birth. [ 43 ]  At these follow-up appointments the emotional well-being of the mother should also be considered. Special attention to the possibility of  postpartum depression , which affects 10-15% of mothers in 40 countries is also recommended by the WHO. [ 107 ]  At these check ins mothers also have the opportunity to seek consultation from a physician about starting the breastfeeding process. [ 103 ]


Maternal health problems include complications from childbirth that do not result in death. For every woman that dies during childbirth, approximately 20 develop  infection ,  injury , or  disability . [ 108 ]  Around 75% of women who die in childbirth would be alive today if they had access to pregnancy prevention and healthcare interventions. [ 109 ]  Black women are more likely to experience pregnancy related deaths as well as receiving less effective medical care during pregnancy. [ 110 ]


Women who have chronic  hypertension  before their pregnancy are at increased risk of complications such as  premature birth ,  low birthweight  or  stillbirth . [ 111 ]  Women who have high blood pressure and had complications in their pregnancy have three times the risk of developing  cardiovascular disease  compared to women with normal blood pressure who had no complications in pregnancy. Monitoring pregnant women's blood pressure can help prevent both complications and future cardiovascular diseases. [ 112 ] [ 113 ]


Almost 50% of the births in developing countries still take place without a  medically skilled attendant  to aid the mother, and the ratio is even higher in South Asia. [ 114 ]  Women in Sub-Saharan Africa mainly rely on  traditional birth attendants  (TBAs), who have little or no formal health care training. In recognition of their role, some countries and non-governmental organizations are making efforts to train TBAs in maternal health topics, in order to improve the chances for better health outcomes among mothers and babies. [ 115 ]


Breastfeeding provides women with several long-term benefits.  Women who breastfeed experience better glucose levels, lipid metabolism, and blood pressure, and lose pregnancy weight faster than those who do not. Additionally, women who breastfeed experience lower rates of breast cancer, ovarian cancer, and type 2 diabetes. [ 97 ]  However, it is important to keep in mind that breastfeeding provides substantial benefits to women who are not infected with HIV.  In countries where HIV/AIDS rates are high, such as South Africa and Kenya, the virus is a leading cause of maternal mortality, especially in mothers who breastfeed. [ 93 ]  A complication is that many HIV-infected mothers cannot afford formula, and thus have no way of preventing transmission to the child through breast milk or avoiding health risks for themselves. [ 96 ]  In cases like this, mothers have no choice but to breastfeed their infants regardless of their knowledge of the harmful effects.


Worldwide, the  Maternal Mortality Ratio (MMR) , which is defined as deaths per 100,000 live births per time-period, has decreased, with South-East Asia seeing the most dramatic decrease of 59% and Africa seeing a decline of 27%.  There are no regions that are on track to meet the Millennium Development Goal of decreasing maternal mortality by 75% by the year 2015. [ 117 ] [ 118 ]


In a September 2016 ACOG/SMFM consensus, published concurrently in the journal  Obstetrics & Gynecology  and by the  American College of Obstetricians and Gynecologists  (ACOG), they noted that while they did not yet have a "single, comprehensive definition of severe maternal morbidity" (SMM), the rate of SMM is increasing in the United States as is maternal mortality. Both are "associated with a high rate of preventability." [ 10 ] [ 119 ]


The U.S.  Joint Commission on Accreditation of Healthcare Organizations  calls  maternal mortality  a " sentinel event ", and uses it to assess the quality of a health care system. [ 11 ]


Maternal mortality data is said to be an important indicator of overall health system quality because pregnant women survive in sanitary, safe, well-staffed and stocked facilities. If new mothers are thriving, it indicates that the health care system is doing its job. If not, problems likely exist. [ 120 ]


According to Garret, increasing maternal survival, along with life expectancy, is an important goal for the world health community, as they show that other health issues are also improving. If these areas improve, disease-specific improvements are also better able to positively impact populations. [ 121 ]


Maternal mortality rates are extremely high worldwide. However, most women who die during or after pregnancy live in low and lower-middle income countries. Specifically, in 2017, 94% of all maternal deaths occurred in low and lower-middle income countries. The MMR in low-income countries was 462 in 2017 signifying that 462 mothers died during childbirth for every 100,000 live births. [ 122 ]  In many low and lower-middle income countries complications of pregnancy and childbirth are the leading causes of death among women of reproductive age. According to the World Health Organization, in its World Health Report 2005, poor maternal conditions account for the fourth leading cause of death for women worldwide, after HIV/AIDS, malaria, and tuberculosis. [ 123 ]   In low-income countries, most maternal deaths and injuries during pregnancy and labor are due to preventative issues that have been largely eradicated in higher income countries including postpartum hemorrhaging, hypertensive disease, and maternal infections. [ 124 ]  For example, postpartum hemorrhaging is the leading cause of maternal death globally; however, 99% of postpartum hemorrhages occur in low and lower-middle income countries. [ 125 ]


The MMR is extremely high in low-income countries; however, it is necessary to acknowledge the reduction in MMR that has occurred over the past two decades. The MMR has drastically declined in low-income countries since 2010. [ citation needed ]  In low and lower-middle income countries, the average decline rate of the MMR is about 2.9% since 2000. [ citation needed ]  This improvement was caused by lower pregnancy rates in some countries; higher income, which improves nutrition and access to health care; more education for women; and the increasing availability of "skilled birth attendants"—people with training in basic and emergency obstetric care—to help women give birth. Despite this immense progress, there is still lots of work that must be done in order for low-income countries to meet the goal of the WHO organization of an MMR of less than 130 by 2030. Looking forward, the MMR in low and lower-income countries must continue to decline through improving access to skilled birth attendants to perform cesarean sections and other necessary procedures, increased access to family planning, and increased access to hospital facilities. [ 124 ]


Until the early 20th century developed and developing countries had similar rates of maternal mortality. [ 126 ]  Since most maternal deaths and injuries are preventable, [ 10 ]  they have been largely eradicated in the developed world.


In developed countries, Black (non-Latina) women have higher maternal mortality rates than White (non-Latina) women. According to the  New York City Department of Health and Mental Hygiene - Bureau of Maternal, Infant and Reproductive Health , it was found that from 2008 to 2012, Black (non-Latina) women have a pregnancy-related mortality rate twelve times higher than White (non-Latina) women. [ 127 ]  The U.S. has the "highest rate of maternal mortality in the industrialized world." [ 128 ]  It is also estimated that 50% of the deaths are from preventable causes. [ 129 ]  It was found that Black women were experiencing higher rates of maternal mortality from cardiomyopathy, complications from hypertension, and hemorrhage. [ 130 ]  Black women were also found to be at an increased risk for experiencing preeclampsia, abrupt placentae, placenta prevue, and postpartum hemorrhage when compared to white women. [ 130 ]  Even though these obstetric complications could also occur in white women, black women were more likely to experience fatality and adverse outcomes from these complications.


Since 2016,  ProPublica  and  NPR  investigated factors that led to the increase in maternal mortality in the United States. They reported that the "rate of life-threatening complications for new mothers in the U.S. has more than doubled in two decades due to pre-existing conditions, medical errors and unequal access to care." [ 128 ]  According to the United States  Centers for Disease Control and Prevention  (CDC), c. 4 million women who give birth in the US annually, over 50,000 a year, experience "dangerous and even life-threatening complications." [ 128 ]  Of those 700 to 900 die every year "related to pregnancy and childbirth." A "pervasive problem" is the rapidly increasing rate of "severe maternal morbidity" (SMM), which does not yet have a "single, comprehensive definition". [ 10 ]  The U.S healthcare system is in need of great improvement to reduce the rates of maternal mortality. With the shortage of primary care providers, including access to midwives and obstetricians, pregnant women are experiencing a delay in receiving prenatal care.  [ 131 ]  This is of even greater concern for pregnant women that have chronic conditions prior to pregnancy, such as hypertension or diabetes, that need to have their pregnancies closely monitored.  [ 131 ]


According to a report by the CDC, in 1993 the rate of SMM rose from 49.5 to 144 "per 10,000 delivery hospitalizations" in 2014, an increase of almost 200 percent. Blood transfusions also increased during the same period with "from 24.5 in 1993 to 122.3 in 2014 and are considered to be the major driver of the increase in SMM. After excluding blood transfusions, the rate of SMM increased by about 20% over time, from 28.6 in 1993 to 35.0 in 2014." [ 132 ]


In the context of the  Sustainable Development Goals  (SDG), countries have united behind a new target to accelerate the decline of maternal mortality by 2030.  SDG 3  includes an ambitious target: "reducing the global MMR to less than 70 per 100 000 births, with no country having a maternal mortality rate of more than twice the global average".


The WHO estimates that the cost to provide basic family planning for both maternal and neonatal health care to women in developing countries is US$8 per person a year. [ 133 ]  Many non-profit organizations have programs educating the public and gaining access to emergency obstetric care for mothers in developing countries. The United Nations Population Fund (UNPFA) recently began its Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), focusing on providing quality healthcare to mothers. One of the programs within CARMMA is Sierra Leone providing free healthcare to mothers and children. This initiative has widespread support from African leaders and was started in conjunction with the African Union Health Ministers. [ 134 ]


Improving maternal health is the fifth of the United Nations' eight  Millennium Development Goals  (MDGs), targeting a reduction in the number of women dying during pregnancy and childbirth by three quarters by 2015, notably by increasing the usage of skilled birth attendants, contraception and family planning. [ 135 ]  The current decline of maternal deaths is only half of what is necessary to achieve this goal, and in several regions such as Sub-Saharan Africa the maternal mortality rate is actually increasing. However, one country that may meet their MDG 5 is Nepal, which has it appears reduced its maternal mortality by more than 50% since the early 1990s. [ 136 ]  As the 2015 deadline for the MDG's approaches, an understanding of the policy developments leading to the inclusion of maternal health within the MDG's is essential for future advocacy efforts. [ 137 ]


According to the  UNFPA , maternal deaths would be reduced by about two-thirds, from 287,000 to 105,000, if needs for modern family planning and maternal and newborn health care were met. [ 15 ]  Therefore, investing in family planning and improved maternal health care brings many benefits including reduced risks of complications and improvement in health for mothers and their children. Education is also critical with research showing "that women with no education were nearly three times more likely to die during pregnancy and childbirth than women who had finished secondary school." [ 15 ]  Evidence shows that women who are better educated tend to have healthier children. Education would also improve employment opportunities for women which results in improving their status, contributing to family savings, reducing poverty and contributing to economic growth. All of these invests bring significant benefits and effects not only for women and girls but also their children, families, communities and their country.


Developed countries had rates of maternal mortality similar to those of developing countries until the early 20th century, therefore several lessons can be learned from the west. During the 19th century Sweden had high levels of maternal mortality, and there was a strong support within the country to reduce mortality rate to fewer than 300 per 100,000 live births. The Swedish government began public health initiatives to train enough midwives to attend all births. This approach was also later used by Norway, Denmark, and the Netherlands who also experienced similar successes. [ 126 ]


Increasing contraceptive usage and family planning also improves maternal health through reduction in numbers of higher risk pregnancies and by lowering the  inter-pregnancy interval . [ 138 ] [ 139 ] [ 140 ]  In Nepal a strong emphasis was placed on providing family planning to rural regions and it was shown to be effective. [ 141 ]  Madagascar saw a dramatic increase in contraceptive use after instituting a nationwide family planning program, the rate of contraceptive use increased from 5.1% in 1992 to 29% in 2008. [ 142 ]


Family planning has been reported to be a significant factor in maternal health. Governments should invest in their national healthcare to ensure that all women are aware of birth control methods. The government, through the ministry of health, should liaise with the private healthcare as well as the public healthcare division to ensure that women are educated and encouraged to use the right family planning method. The government should invest in this operation as when the rate of underage, as well as unplanned pregnancies, are reduced the healthcare cost stand a chance to drop by up to 8%. Healthcare will, therefore, be in a position to handle the other women who give birth. This will result in an improvement in maternal health. [ 143 ]


Four elements are essential to maternal death prevention. First, prenatal care. It is recommended that expectant mothers receive at least four antenatal visits to check and monitor the health of mother and fetus. Second, skilled birth attendance with emergency backup such as doctors, nurses and midwives who have the skills to manage normal deliveries and recognize the onset of complications. Third, emergency obstetric care to address the major causes of maternal death which are hemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour. Lastly, postnatal care which is the six weeks following delivery. During this time bleeding, sepsis and hypertensive disorders can occur and newborns are extremely vulnerable in the immediate aftermath of birth. Therefore, follow-up visits by a health worker is assess the health of both mother and child in the postnatal period is strongly recommended. [ 144 ]


A  maternal near miss  ( MNM ) is an event in which a pregnant woman comes close to  maternal death , but does not die – a " near-miss ".  Traditionally, the analysis of maternal deaths has been the criterion of choice for evaluating women's health and the quality of  obstetric  care.  Due to the success of  modern medicine  such deaths have become very rare in developed countries, which has led to an increased interest in analyzing so-called "near miss" events.


Maternal mortality is a  sentinel event  to assess the quality of a health care system.  The standard indicator is the  Maternal Mortality Ratio , defined as the ratio of the number of  maternal deaths  per 100,000 live births. Due to improved health care the ratio has been declining steadily in developed countries.  For example, in the UK 1952-1982 the ratio was halving every 10 years. [ 1 ]   In the European Union the ratio has now stabilized at around 10 to 20. [ 2 ]


The small number of cases makes the evaluation of maternal mortality practically impossible [ 2 ] [ 3 ]   Historically, the study of negative outcomes have been highly successful in preventing their causes, this strategy of prevention therefore faces difficulties when if the number of negative outcome drop to low levels.  In the UK, for example, the most dramatic decline in maternal death was achieved in  Rochdale , an industrial town in the poorest area of England.  In 1928 the town had a Maternal Mortality Ratio of over 900 per 100,000 live births, more than double the national average of the time. An enquiry into the causes of the deaths reduced the ratio to 280 per 100,000 pregnancies by 1934, only six years later, then the lowest in the country. [ 4 ]


The very low figures of maternal mortality have therefore stimulated an interest in investigating cases of life-threatening obstetric  morbidity  or  maternal near miss .  There are several advantages of investigating near miss events over events with fatal outcome


The growing interest is reflected in an increasing number of systematic reviews on the prevalence of near miss. [ 8 ] [ 9 ]   The studies and reviews span


The World Health Organization defines a maternal near-miss case as "a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy."


According to the World Health Organization, if a woman presents any of the conditions below during pregnancy, childbirth or within 42 days of termination of pregnancy and survives, she is considered as a maternal near miss case. [ 10 ]

 Cardiovascular dysfunction
	a)	Shock
	b)	Cardiac Arrest
	c)	Severe hypoperfusion (lactate >5 mmol/L or >45 mg/dL)
	d)	Severe acidosis (pH<7.1)
	e)	Use of continuous vasoactive drugs
	f)	Cardio-pulmonary resuscitation
 Respiratory dysfunction
	g)	Acute cyanosis
	h)	Gasping
	i)	Severe tachypnea (respiratory rate>40 breaths per minute)
	j)	Severe bradypnea (respiratory rate<6 breaths per minute)
	k)	Severe hypoxemia
			(O2 saturation <90% for ≥60min or PAO2/FiO2<200)
	l)	Intubation and ventilation not related to anaesthesia
 Renal dysfunction
	m)	Oliguria non responsive to fluids or diuretics
	n)	Severe acute azotemia (creatinine >300 μmol/ml or >3.5 mg/dL)
	o)	Dialysis for acute renal failure
 Coagulation dysfunction
	p)	Failure to form clots
	q)	Severe acute thrombocytopenia (<50,000 platelets/ml)
	r)	Massive transfusion of blood or red cells (≥ 5 units)
 Hepatic dysfunction
	s)	Jaundice in the presence of pre-eclampsia
	t)	Severe acute hyperbilirubinemia (bilirubin>100 μmol/L or >6.0 mg/dL)
 Neurologic dysfunction
	u)	Prolonged unconsciousness or coma (lasting >12 hours)
	v)	Stroke
	w)	Uncontrollable fit / status epilepticus
	x)	Global paralysis
 Uterine dysfunction
	y)	Hysterectomy due to uterine infection or haemorrhage


Maternal–fetal medicine  ( MFM ), also known as  perinatology , is a  branch of medicine  that focuses on managing health concerns of the  mother  and  fetus  prior to, during, and shortly after  pregnancy .


Maternal–fetal medicine specialists are  physicians  who  subspecialize  within the field of obstetrics. [ 1 ]  Their training typically includes a four-year  residency  in  obstetrics  and  gynecology  followed by a three-year  fellowship . They may perform  prenatal tests , provide treatments, and  perform surgeries . They act both as a  consultant  during lower-risk pregnancies and as the primary obstetrician in especially  high-risk pregnancies . After birth, they may work closely with  pediatricians  or  neonatologists . For the mother, perinatologists assist with  pre-existing health concerns , as well as  complications caused by pregnancy .


Maternal–fetal medicine began to emerge as a discipline in the 1960s. Advances in research and technology allowed physicians to diagnose and treat fetal complications  in utero , whereas previously, obstetricians could only rely on  heart rate monitoring  and maternal reports of fetal movement. The development of  amniocentesis  in 1952,  fetal blood sampling  during  labor  in the early 1960s, more precise fetal heart monitoring in 1968, and  real-time ultrasound  in 1971 resulted in early intervention and lower  mortality rates . [ 2 ]  In 1963,  Albert William Liley  developed a course of intrauterine transfusions for  Rh incompatibility  at the National Women's Hospital in Australia, regarded as the first fetal treatment. [ 3 ]  Other antenatal treatments, such as the administration of glucocorticoids to speed lung maturation in neonates at risk for  respiratory distress syndrome , led to improved outcomes for  premature infants .


Consequently, organizations were developed to focus on these emerging medical practices, and in 1991, the  First International Congress of Perinatal Medicine  was held, at which the  World Association of Perinatal Medicine  was founded. [ 2 ]


Today, maternal-fetal medicine specialists can be found in major hospitals internationally. They may work in privately owned clinics, or in larger, government-funded institutions. [ 4 ] [ 5 ]


The field of maternal-fetal medicine is one of the most rapidly evolving fields in medicine, especially with respect to the fetus. Research is being carried on in the field of fetal gene and stem cell therapy in hope to provide early treatment for genetic disorders, [ 6 ]  open fetal surgery for the correction of  birth defects  like  congenital heart disease , [ 7 ]  and the prevention of  preeclampsia .


Maternal–fetal medicine specialists attend to patients who fall within certain levels of maternal care. These levels correspond to health risks for the baby, mother, or both, during pregnancy. [ 8 ]


They take care of pregnant women who have  chronic conditions  (e.g. heart or kidney disease,  hypertension ,  diabetes , and  thrombophilia ), pregnant women who are at risk for pregnancy-related complications (e.g.  preterm labor ,  pre-eclampsia , and  twin or triplet pregnancies ), and pregnant women with fetuses at risk. Fetuses may be at risk due to  chromosomal  or  congenital abnormalities , maternal disease, infections, genetic diseases and  growth restriction . [ 9 ]


Expecting mothers with  chronic conditions , such as high blood pressure, drug use during or before pregnancy, or a diagnosed medical condition may require a consult with a maternal-fetal specialist. In addition, women who experience difficulty conceiving may be referred to a maternal-fetal specialist for assistance.


During pregnancy, a variety of  complications of pregnancy  can arise. Depending on the severity of the complication, a maternal-fetal specialist may meet with the patient intermittently, or become the primary obstetrician for the length of the pregnancy. Post-partum, maternal-fetal specialists may follow up with a patient and monitor any medical complications that may arise.


The rates of maternal and infant mortality due to complications of pregnancy have decreased by over 23% since 1990, from 377,000 deaths to 293,000 deaths. Most deaths can be attributed to infection, maternal bleeding, and obstructed labor, and their incidence of mortality vary widely internationally. [ 10 ]   The Society for Maternal-fetal Medicine (SMFM) strives to improve maternal and child outcomes by standards of prevention, diagnosis and treatment through research, education and training. [ 11 ]


Maternal–fetal medicine specialists are obstetrician-gynecologists who undergo an additional three years of specialized training in the assessment and management of high-risk pregnancies. In the United States, such obstetrician-gynecologists are certified by the  American Board of Obstetrician Gynecologists  (ABOG) or the  American Osteopathic Board of Obstetrics and Gynecology .


Maternal–fetal medicine specialists have training in obstetric ultrasound, invasive prenatal diagnosis using amniocentesis and chorionic villus sampling, and the management of high-risk pregnancies. Some are further trained in the field of fetal diagnosis and prenatal therapy where they become competent in advanced procedures such as targeted fetal assessment using ultrasound and Doppler, fetal blood sampling and transfusion, fetoscopy, and open fetal surgery. [ 12 ] [ 13 ]


For the ABOG, MFM subspecialists are required to do a minimum of 12 months in clinical rotation and 18-months in research activities. They are encouraged to use simulation and case-based learning incorporated in their training, a certification in  advanced cardiac life support  (ACLS) is required, they are required to develop in-service examination and expand leadership training. Obstetrical care and service has been improved to provide academic advancement for MFM in-patient directorships, improve skills in coding and reimbursement for maternal care, establish national, stratified system for levels of maternal care, develop specific, proscriptive guidelines on complications with highest maternal morbidity and mortality, and finally, increase departmental and divisional support for MFM subspecialists with maternal focus. As Maternal–fetal medicine subspecialists improve their work ethics and knowledge of this advancing field, they are capable of reducing the rate of  maternal mortality  and maternal  morbidity . [ 14 ]


Maternal-fetal conflict,   also known as  obstetric conflict , occurs when a pregnant woman’s (maternal) interests conflict with the interests of the fetus. Legal and ethical considerations involving women's rights and the rights of the fetus as a patient and future child, have become more complicated with advances in medicine and technology. Maternal-fetal conflict can occur in situations where the mother denies health recommendations (e.g. blood transfusions, surgical procedures, cesarean section) that can benefit the fetus or make life choices (e.g. smoking, drinking alcohol, drugs, hazardous exposure) that can harm the fetus. [ 1 ]  There are maternal-fetal conflict situations where the law becomes involved, but most physicians avoid involving the law for various reasons.


Prior to technological advances and current obstetric practices, the fetus was viewed as part of the mother and they were viewed as one entity rather than separate entities. [ 1 ]  With advances in technology, healthcare providers are able to access the fetus directly (e.g. sampling fetal blood, urine, other tissue, etc. and high-resolution ultrasonography) resulting in the fetus being defined as a separate patient from its mother. [ 1 ]  This shift from a perspective of 'unity' (referred to as the maternal-fetal dyad) to 'duality' of the mother and fetus has created a maternal-fetal conflict. [ 2 ]  With this shift, fetal interest has been taken into consideration separately from the mother's interest. [ 3 ]  Since the fetus can only be accessed through the mother, this change in perspective has become more complicated. [ 3 ]   In the perspective of the mother and fetus as one patient (a dyad), it is necessary to consider if the combined benefits of the mother and fetus outweigh the combined burdens. [ 4 ]  When making these decisions from the perspective of 'duality', it is necessary to determine the burdens and benefits of the mother and fetus separately. [ 4 ]


While a woman's  right to privacy ,  right to autonomy , and  informed consent  are valued and prioritized during decision-making for the mother and fetus, [ 1 ]  there are various difficulties that arise with the perspective of the viability of a fetus, including " personhood ".  For example, the question of whether or not it is ethical to "gently  persuade " a woman to make a decision she may not want to make because she is pregnant. [ 1 ] [ 5 ]  In another example, a woman can receive a court-ordered cesarean section to save a fetus, but this is usually viewed as coercion, which is why most physicians avoid involving the court when helping make decisions for the mother and fetus. [ 6 ]


There are many factors that define whether a fetus is a patient of its own or an entity involving its mother including: the fetus's independent moral status, the future fetus as a child, and the viability of the fetus. [ 1 ]  One view is that a fetus has rights when it has an  independent moral status  from its mother, but some ethicists cannot agree on when this occurs. [ 1 ]  A fetus has the potential to become a child and the future of that child is taken into consideration when determining the independence of the fetus as a patient and in decision-making for the mother and fetus, [ 1 ]  (i.e. whether or not the health decisions will benefit the fetus when it becomes a child). [ 1 ]  A fetus can survive apart from its mother once it is  viable . The viability of a fetus separate from its mother may confer an independent moral status. Prior to viability of the fetus, the mother's autonomy and rights are prioritized. [ 1 ]


One perspective of decision making for maternal-fetal conflict is to prioritize the health of the mother and fetus, but it is difficult to determine what 'healthy' means for a fetus, especially without infringing on the basic rights of the mother. [ 2 ]  For those that define 'healthy' as 'perfect' or 'near-perfect' the implication is that a less than perfect fetus should not be born. [ 2 ]  Some of the people who are most opposed to prioritizing fetal rights are those with disabilities. [ 2 ]  The thought of a 'healthy' or 'perfect' child does not consider what a child with a disability would feel about how their mothers would be treated for choosing to bear them. [ 2 ]


With viewpoints shifting from the mother and fetus being a single unit to two individual units, understanding the mother's experiences and circumstances are necessary in decision-making. [ 2 ]  Not all women have direct control over their situation, which makes it difficult for a woman to make the best decision for their fetus. For example, a low-income mother may not be able to afford nutritious meals resulting in circumstance playing a role in maternal-fetal decisions. [ 2 ]  Instead of viewing the maternal-fetal relationship as a conflict, there are viewpoints that have shifted the perspective to maternal-fetal shared interest. [ 5 ]


There are different perspectives that value the protection of the fetus, but opposing viewpoints ask "what/whom is the fetus being protected from?" [ 2 ]  Most things a mother does can harm her fetus, even things that may not seem harmful (e.g. eating feta cheese or owning a cat). [ 2 ]  It is difficult to prove causality as development is multi-factorial, making it difficult to define what or who the fetus needs to be protected from. [ 2 ]  Although some may view the mother and fetus as separate entities, they are a unified dyad where the baby needs the mother to survive and their physiology is shared. [ 2 ] [ 5 ]  This mentality allows decision-makers to best understand both patients's perspectives, and acknowledge the best interests for both the mother and their fetus. [ 3 ]


The mother's autonomy and rights almost always are respected in decision-making. [ 3 ]  Decision-making is individualized based on prognosis, gestational age, and the pregnant woman's life and values. [ 3 ]  A variety of perspectives (e.g. pediatric, obstetric, etc.) are important to incorporate in decision-making process to best avoid being biased. [ 3 ]  Many ethicists have argued that women should have the same rights as non-pregnant women, which includes making decisions. [ 3 ]  It is also important to acknowledge that a mother generally will make the best decision for both herself and her fetus as she made the decision to have and continue the pregnancy. [ 5 ]  In cases where unwanted circumstances arise, it is difficult to blame a mother for uncontrollable, unfavorable fetal outcomes (e.g. birth defects) so giving the mother the benefit of the doubt is important. [ 3 ]  In order to make the best decisions for the mother and fetus, a physician-patient relationship is valuable as well as other maternal-fetal relationships (e.g. relationship to the father of the fetus, family members involved, etc.). [ 3 ]  Addressing the  gestational age  also affects decision making. [ 3 ]  Although, it's important to understand there is also very little information about early gestation periods, which makes it difficult to make decisions early on in the pregnancy. [ 3 ]


As an obstetrician and caregiver for the mother as a patient, it is important a physician acknowledges how their role and decisions affect both the mother and fetus, although the mother is ultimately their patient. [ 1 ]  Physicians must prioritize the mother's rights and autonomy as well as understand the value of  beneficence  and  non-maleficence . [ 1 ] [ 4 ]  Those that view the fetus and mother as one entity, acknowledge the overall benefit of a decision in regards to both the fetus and mother. [ 1 ]  Those that view the fetus and mother as separate entities, cannot overlook the mother's rights for the benefits of the fetus and vice versa. [ 1 ]  Other perspectives include overriding maternal autonomy if there is a more reliable option. [ 1 ]  For example, a cesarean section could save the baby and mother's life, but the mother wants a natural birth that will kill both entities so the mother's decision could be overruled. [ 1 ]  This is not always the case as there are other factors that are taken into consideration. [ 1 ]


Physicians are not allowed to harm one patient for the benefit of another patient (i.e. a physician cannot harm a mother for the sake of the fetus and vice versa). [ 4 ]  If there is harm to one patient, that patient must volunteer to take treatment and not be influenced by the physician's bias. [ 4 ]  This causes difficulty as the fetus cannot voluntarily take a treatment and the fetus must be accessed through the mother. [ 3 ]  To avoid issues, physicians always prioritize the pregnant woman's autonomy as the physician's obligation is to the mother. [ 7 ]  The physician should refrain from unwanted procedures and treatments mentioned by the mother. [ 7 ]  It is important to establish that her autonomy cannot harm others. [ 4 ]  In the viewpoint of a maternal-fetal dyad, the mother is both a  proxy  for the  best interest  of the fetus and also separately the decision maker for herself as a patient. [ 4 ]  According to Susan Mattingly, a mother who denies treatment that benefits the fetus can no longer be an appropriate proxy for the fetus, but physicians still have to respect her as a separate patient with her own rights and autonomy. [ 4 ]  In the viewpoint of a maternal-fetal relationship being a one-patient model, a mother would only be harming herself if she denies treatment for fetus that may benefit fetus. [ 4 ]  These situations are normally avoided because punishment based on how a woman behaves in regards to her fetus could make women avoid medical care. [ 5 ]  The best way to establish a patient-physician relationship is by following best practices, conducting informed consent discussions, preparing for any situation that may arise, offering an alternate provider, compromise, providing documentation (e.g. medical record of information, treatment options, recommendations, etc.), and providing supportive resources for both the physician and provider, if problems are to arise. [ 8 ]


Physicians are not required to obtain legal approval for decisions on mother and fetus, nor will a physician be in trouble with the law if they decide to make a decision on behalf of the mother and fetus. [ 6 ] [ 1 ]  There are legal obstacles that make it difficult for the law to be involved in decision making for maternal-fetal conflict, which include the fetus having no rights, court standards being vague and flexible, discrimination towards disadvantage women, and the inability to force a woman to do things that are not required from anyone else (e.g. non-pregnant women, men, etc.). [ 1 ]  Lawmakers find it difficult to make exceptions to the law just because someone is pregnant (e.g. lawmakers find it difficult to forbid alcohol during pregnancy when non-pregnant women are permitted to drink alcohol). [ 2 ]  Allowing the fetus to have rights is difficult when it's dependent on a mother who has her own rights and autonomy. [ 2 ]  Even in the case where court-ordered cesarean sections seem necessary, most physicians and law-makers avoid it altogether as court-orders can be deemed as coercion. [ 3 ]  Women who have decisional capacity should be able to use it and refuse treatment if wanted. [ 3 ]  Because of these legal obstacles, law-makers and judges tend to prioritize women's rights to make their own decision. [ 1 ]


The best interest of the fetus is established by the physician, but decided on by the mother. [ 6 ]  The problem is that there tends to be prejudices and inequalities when it comes to what is in the best interest of the fetus, especially in healthcare. [ 6 ]  According to Kelly Lindgren's journal,  Maternal–Fetal Conflict: Court-Ordered Cesarean Section,  “poor, minority women are affected most often by court-ordered c-section [...] which include: 47% Black Americans, 33% from Asia or Africa, and only 20% White.” [ 6 ]  It is also important to address that no other group of people are forced to do anything, so it is questioned why a woman who is pregnant should be forced. [ 6 ]  The court system is also reluctant to give the fetus and child the same rights. [ 6 ]   Women are burdened by laws resulting from their ability to be pregnant. [ 6 ]


"Good ethics begins with good facts." [ 3 ]  An ethical framework (e.g. principle-based theories, conflict-based theories,  feminist theory , and  ethics of care ) acknowledges the pregnant woman's competency to make her own decision for her and her body, including the fetus, but with the fetus’ well-being in mind. [ 3 ]  Acknowledging what happens after the fetus is delivered is the post-delivery perspective of pediatricians. [ 3 ]


Principle-based theory is defined as "respect for patient autonomy, beneficence non-maleficence, and justice to guide conflict resolution." [ 3 ]  Conflict-based theories emphasize women's rights to autonomy and the physician's moral obligation to both the woman and the fetus separately. [ 5 ]  Conflict arises as pregnancy is only unique to women, which is why it is necessary to prioritize women's autonomy and rights. [ 5 ]  When the fetal interest is prioritized, it imposes on social and racial equality. [ 5 ]


Feminist theory  (also known as  feminist ethics ) is a gender-based perspective, which acknowledges that women are treated differently in decision-making. [ 3 ]


Ethics of care  and relational ethics acknowledges human relationships (i.e. relationship of patient to fetus, physician, community, society, etc.) as well as a woman's life experiences (e.g. age, political view, religion, lifestyle, etc.) and how that affects a person's decision-making. [ 3 ] [ 5 ]  In terms of maternal-fetal conflict, it emphasizes understanding the patient's values and experiences to best support her decisions. [ 3 ]


M. C. Reid's journal, "The case of Medea—a view of fetal-maternal conflict" alludes to the Greek Myth of  Medea  as it addresses maternal-fetal scenarios. [ 14 ]  The myth of  Medea  is about a woman named Medea who killed her two children as revenge against her husband. [ 14 ]  M. C. Reid compares Madea to several maternal-fetal scenarios, those of Meilssa, Nada, and Olga through the use of  conflict theories  based on: [ 14 ]


There could be several reasons behind an act: is it inherently vicious (e.g. based on hatred, cruelty, greed, etc.); is it a morally commended act (e.g. based on respect, consideration, compassion, etc.); or is it a neutral act (e.g. based on no motives, accidental situations, etc.). [ 14 ]  Certain acts can seem good, but with vicious motives. For example, a surgeon does an intervention because they are sadistic, but the procedure helps the patient resulting in a good act, but with vicious intent. [ 14 ]  Reid argues that a mother would unlikely act purposely vicious toward her fetus. [ 14 ]


There are many different views of the maternal-fetal relationship:


Women have rights and autonomy; [ 14 ]  some argue that these rights are under threat during situations involving abortion. [ 14 ]  As long as a woman is competent to make decisions regarding her own body and fetus, she is considered eligible to make decisions and retain her autonomy and rights. [ 3 ]


The case of  Medea  uses  conflict theories  to address and compare  Medea's  story to three other fictional women: Melissa, Nada, and Olga. [ 14 ]


Mauriceau–Smellie–Veit maneuver  or  Mauriceau maneuver  (named after  François Mauriceau ,  William Smellie  and  Gustav Veit ) is an  obstetric  or  emergent  medical maneuver utilized in cases of  breech delivery . This procedure entails suprapubic pressure by one obstetrician on the mother/uterus, while another obstetrician inserts left hand in vagina, palpating the fetal maxilla using the index and middle finger and gently pressing on the maxilla, bringing the neck to a moderate flexion. The left hand's palm should rest against the fetus' chest, while the right hand can grab either shoulder of the fetus and pull in the direction of the fetus' pelvis. The combined neck flexion, traction on the fetus toward the hip/pelvis, and the suprapubic pressure on the mother/uterus allows for delivery of the head of a breech infant, granted prior breech delivery steps are followed and the infant's occipitus is rotated/facing anteriorly relative to the mother. [ 1 ] [ 2 ]


Meconium peritonitis  refers to  rupture  of the  bowel  prior to birth, resulting in fetal stool ( meconium ) escaping into the surrounding space ( peritoneum ) leading to inflammation ( peritonitis ). Despite the bowel rupture, many infants born after meconium peritonitis  in utero  have normal bowels and have no further issues.


Infants with  cystic fibrosis  are at increased risk for meconium peritonitis.


Twenty percent of infants born with meconium peritonitis will have  vomiting  and dilated bowels on  x-rays  which necessitates surgery. [ citation needed ]


Meconium peritonitis is sometimes diagnosed on prenatal  ultrasound [ 1 ]  where it appears as calcifications [ 2 ]  within the peritoneum.


Adhesiolysis
partial resection of pseudocyst
covering enterostomy. [ citation needed ]


Meconium peritonitis was first described in 1838 by  Carl von Rokitansky . [ citation needed ]


The role of men in childbirth in the  Western world  has become more participatory than it was in the past. More Western women want their male partners to give active assistance during  pregnancy  and  childbirth .


Until the concluding decades of the 19th century, an experienced  nurse midwife , who was considered to be knowledgeable about the birth process, typically helped to deliver a woman's baby. Birth typically took place in the home, and it was considered to be an event for females. It was a time for female friends and relatives to come into the home and care for the mother, her household, provide reassurance, and offer guidance. Birth was not considered to be a private event, but more of a social one, that also could create a strong bond among the participants and supporting attendees.


Physicians there warned that it was dangerous not to receive modern medical attention while delivering children. They also stated one in every thirty women was expected to die because of a lack of medical attention. Due to these warnings, many women favored going into labor with a physician as opposed to a midwife.  Physicians typically prohibited friends and relatives from participating or observing.  The birth process may have been regarded as private or even embarrassing to the patient or the doctor and there were issues of preventing infection. Around 1910,  some states began to outlaw the midwifery practice. Others enacted regulatory requirements which were difficult for many midwives to complete.
Since the 1920s, physician assistance has been predominant during childbirth. However, since the 1960s midwifery has returned and grown in popularity and societal acceptance.  Even during childbirth with a physician, it is now common for women to have their families, particularly their partners, in the delivery room with them.


To help their wives prepare for childbirth, many male partners participate in specialized childbirth classes, such as  Lamaze  or  Bradley method of natural childbirth . Men may give active assistance during childbirth by simply being present during his wife's labor or by coaching during childbirth. Many women find their partners' presence in the delivery room to be comforting.  If he is present the man may be able to assist in making decisions that may be required at various junctures in the childbirth process (for example, regarding the use of  epidural , accelerating delivery, dealing with medical problems and other matters).


Until the early 1960s men were typically excluded from the labour room.  However, during this decade there was an increasing pressure on hospitals to allow men into the labour room to provide support for their partners.  It was only by the 1980s that it became common and expected that men would be present when their partners gave birth.  The contemporary Australian experience is that men are expected to be present and support their partners. [ 1 ]


Many women find it soothing to have someone assist them during their pregnancies, making it more common for a woman's male partner to support her both before and during childbirth. [ 2 ]  The type and quality of a relationship between a man and a woman is what determines how, and if, the man will be active during his partner's pregnancy.


Some contend that when men are fearful or anxious regarding birth that they actually make the birth more difficult for their partner.  Their fear may be transmitted to their partner and this increases her  adrenaline  levels leading to  labor  stalling. In some circumstances this may require the use of medications such as  oxytocin  to restart labor and thus can sometimes lead to a cascade of intervention that can result in a  caesarean section . [ 1 ]


Two musicians have played or performed musical works during the delivery of a child of theirs.  Mickey Hart  recorded  Music to Be Born By  and played it back during delivery, and  Alfredo Rolando Ortiz  played  Paraguayan harp  at the birth of his child.


The  Mexican paradox  is the observation that Mexicans exhibit a surprisingly low incidence of  low birth weight  (especially foreign-born Mexican mothers [ 1 ] ), contrary to what would be expected from their  socioeconomic status  (SES). This appears as an  outlier  in graphs correlating SES with low-birth-weight rates. The medical causes of lower rates of low birth weights among birthing Mexican mothers has been called into question. [ 2 ]


The  Hispanic paradox  refers to the same phenomenon observed across the populations of South and Central America, where Mexicans remain the healthier. [ 3 ]


The results of a study showed that the mean birth weight of Mexican-American babies was 3.34 kg (7.37 lbs), while that of  non-Hispanic White  babies was 3.39 kg (7.48 lbs.). This finding re-emphasized the independence of mean birth weight and LBW. This however did not refute the discrepancies in LBW for Mexicans. The study also showed that the overall  preterm birth  rate was higher among Mexican Americans (10.6%) than non-Hispanic Whites (9.3%). In North Carolina, from 1996 to 2000, the infant death rate was 6.1 for Mexican-born infants, in comparison to 6.6 for White infants, and 15 for Black infants. [ 4 ]  The overall hypothesis of the authors was that this finding reflected an error in recorded  gestational age , described in a strongly  bimodal  birth-weight distribution at young gestational ages for Mexican-Americans. [ citation needed ]


Many external effects come into play, such as the Mexican diet, extended family ties, low levels of stress, strong religious beliefs and strong ties to their communities. A 1995 study suggested that the  Virgin of Guadeloupe  encouraged healthy births thanks to its iconic pregnancy symbolism. [ 4 ]  Another study suggested that resistance to changes in  diet  is responsible for the positive birth weight association for Mexican-American mothers. [ 5 ]  Yet another study showed that Mexicans blend traditional and modern medicine, a potential explanation for the paradox. [ 3 ]


It was also observed that, the longer Mexican women live in the United States, the more their infant mortality risks increased. [ 4 ] [ 6 ]  Lower occurrences of  periodontal disease  with Mexican-American women was also suggested as an explanation for the Mexican paradox. [ 7 ]  Another study revealed that, beyond healthy births, Mexican infants also have lower developmental outcomes in their development years. [ 8 ]


A 2014 study concluded that the Mexican paradox is disappearing slowly, most of the comparison data between Mexican infants and White infants being fairly similar in recent years. [ 1 ]  Another 2016 study showed that the Mexican paradox erodes in the third generation of the immigrated family. [ 9 ]


It was also verified that Mexicans have less high blood pressure, cardiovascular diseases and most cancers. than the US population in general. [ 3 ]


Mitochondrial replacement therapy  ( MRT ), sometimes called  mitochondrial donation , is the replacement of  mitochondria  in one or more cells to prevent or ameliorate disease. MRT originated as a special form of  in vitro fertilisation  in which some or all of the future baby's  mitochondrial DNA  (mtDNA) comes from a third party. This technique is used in cases when mothers carry genes for  mitochondrial diseases . The therapy is approved for use in the United Kingdom. [ 1 ] [ 2 ]  A second application is to use  autologous  mitochondria to replace mitochondria in damaged tissue to restore the tissue to a functional state. This has been used in clinical research in the United States to treat cardiac-compromised newborns. [ 3 ]


Mitochondrial replacement therapy has been used to prevent the transmission of mitochondrial diseases from mother to child; it could only be performed in clinics licensed by the UK's  Human Fertilisation and Embryology Authority  (HFEA), only for people individually approved by the HFEA, for whom  preimplantation genetic diagnosis  is unlikely to be helpful, and only with informed consent that the risks and benefits are not well understood. [ 4 ]


Relevant mutations are found in about 0.5% of the population and disease affects around one in 5000 individuals (0.02%)—the percentage of people affected is much smaller because cells contain many mitochondria, only some of which carry mutations, and the number of mutated mitochondria need to reach a threshold in order to affect the entire cell, and many cells need to be affected for the person to show disease. [ 2 ]


The average number of births per year among women at risk for transmitting mtDNA disease is estimated to approximately 150 in the  United Kingdom  and 800 in the  United States . [ 5 ]


Prior to the development of MRT, and in places where it is not legal or feasible, the reproductive options for women who are at risk for transmitting mtDNA disease and who want to prevent transmission were using an egg from another woman, adoption, or childlessness. [ 1 ] : 45


Autologous mitochondria extracted from healthy tissue and supplied to damaged tissue has been used to treat cardiac-compromised newborns. Alternatives to the approach include use of an  extracorporeal membrane oxygenator  (ECMO) or tissue or organ transplantation. [ 3 ]


In vitro  fertilization  involves removing  eggs  from a woman, collecting  sperm  from a man, fertilizing the egg with the sperm, allowing the fertilized egg to form a  blastocyst , and then transferring the blastocyst into the uterus. MRT involves an additional egg from a third person, and manipulation of both the recipient egg and the donor egg. [ citation needed ]


As of 2016 there were three MRT techniques in use: maternal spindle transfer (MST); pronuclear transfer (PNT); and the newest technique, polar body transfer (PBT). The original technique, in which mitochondria-containing cytoplasm taken from a donor egg is simply injected into the recipient egg, is no longer used. [ 1 ] : 46–47


In maternal spindle transfer, an  oocyte  is removed from the recipient, and when it is in the metaphase II stage of cell division, the spindle-chromosome complex is removed; some of the cytoplasm comes with it, so some mitochondria are likely to be included. The spindle-chromosome complex is inserted into a donor oocyte from which the nucleus has already been removed. This egg is fertilized with sperm and allowed to form a blastocyst, which can then be investigated with  preimplantation genetic diagnosis  to check for mitochondrial mutations, prior to being implanted in the recipient's uterus. [ 1 ] : 47–48


In pronuclear transfer, an oocyte is removed from the recipient and fertilized with sperm. The donor oocyte is fertilized with sperm from the same person. The male and female  pronuclei  are removed from each fertilized egg prior to their fusing, and the pronuclei from the recipient's fertilized egg are inserted into the fertilized egg from the donor. As with MST, a small amount of cytoplasm from the recipient egg may be transferred, and as with MST, the fertilized egg is allowed to form a blastocyst, which can then be investigated with  preimplantation genetic diagnosis  to check for mitochondrial mutations before being implanted in the recipient's uterus. [ 1 ] : 50


In polar body transfer, a  polar body  (a small cell with very little cytoplasm that is created when an egg cell divides) from the recipient is used in its entirety, instead of using nuclear material extracted from the recipient's normal egg; this can be used in either MST or PNT. This technique was first published in 2014 and as of 2015 it had not been consistently replicated, but is considered promising as there is a greatly reduced chance for transmitting mitochondria from the recipient because polar bodies contain very few mitochondria, and it does not involve extracting material from the recipient's egg. [ 6 ]


Cytoplasmic transfer was originally developed in the 1980s in the course of basic research conducted with mice to study the role that parts of the cell outside of the nucleus played in embryonic development. [ 2 ]  In this technique,  cytoplasm , including proteins,  messenger RNA  (mRNA), mitochondria and other organelles, is taken from a donor egg and injected into the recipient egg, resulting in a mixture of mitochondrial genetic material. [ 2 ]  This technique started to be used in the late 1990s to "boost" the eggs of older women who were having problems conceiving and led to the birth of about 30 babies. [ 2 ]  Concerns were raised that the mixture of genetic material and proteins could cause problems with respect to  epigenetic  clashes, or differences in the ability of the recipient and donor materials to effect the development process, or due to the injection of the donor material. [ 2 ]  After three children born through the technique were found to have developmental disorders (two cases of  Turner's syndrome  and one case of  pervasive developmental disorder  (an  autism spectrum  disorder), the FDA banned the procedure until a clinical trial could prove its safety. [ 2 ]  As of 2015 that study had not been conducted, but the procedure was in use in other countries. [ 2 ]


A related approach uses autologous mitochondria taken from healthy tissue to replace the mitochondria in damaged tissue. Transfer techniques include direct injection into damaged tissue and injection into vessels that supply blood to the tissue. [ 3 ]


Assisted reproduction  via MRT involves  preimplantation genetic screening  of the mother,  preimplantation genetic diagnosis  after the egg is fertilized, and  in vitro fertilization . It has all the risks of those procedures. [ 1 ] : 60


In addition, both procedures used in MRT entail their own risks. On one level, the procedures physically disrupt two oocytes, removing nuclear genetic material from the recipient egg or fertilized egg and inserting the nuclear genetic material into the donor unfertilized or fertilized egg; the manipulations for both procedures may cause various forms of damage that were not well understood as of 2016. [ 7 ] : 23


Maternal mitochondria will be carried over to the donor egg; as of 2016 it was estimated that using techniques current in the UK, maternal mitochondria will comprise only around 2% or less of mitochondria in the resulting egg, a level that was considered safe by the HFEA and within the limits of  mitochondrial variation  that most people have. [ 7 ] : 23–24


Because MRT procedures involve actions at precise times during egg development and fertilization, and involves manipulating eggs, there is a risk that eggs may mature abnormally or that fertilization may happen abnormally; as of 2016 the HFEA judged that laboratory techniques in the UK had been well enough developed to manage these risks to proceed cautiously with making MRT available. [ 7 ] : 33–34


Because mitochondria in the final egg will come from a third party, different from the two parties whose DNA is in the nucleus, and because nuclear DNA encodes genes that make some of the proteins and mRNA used by mitochondria, there is a theoretical risk of adverse "mito–nuclear" interactions. While this theoretical risk could possibly be managed by attempting to match the  haplotype  of the donor and the recipient, as of 2016 there was no evidence that this is an actual risk. [ 7 ] : 34–37


Because MRT is a relatively new technology, there are concerns that it is not yet safe for public use as there have been limited studies that used MRT in large animal models. [ 8 ]


Finally, there is a risk of  epigenetic  modification to DNA in the nucleus and mitochondria, caused by the procedure itself or by mito–nuclear interactions. As of 2016 these risks appeared to be minimal but were being monitored by long-term study of children born from the procedure. [ 7 ] : 38


In the United States in 1996  embryologist   Jacques Cohen  and others at the  Institute for Reproductive Medicine and Science ,  Saint Barnabas Medical Center  in  Livingston, New Jersey  first used cytoplasmic transfer in a human assisted reproduction procedure. [ 9 ]  In 1997 the first baby was born using this procedure. In 2001, Cohen and others reported that ten single babies, twins, and a quadruplet at his New Jersey clinic and a further six children in Israel had been born using his technique. Using modifications of his procedure, a baby had been born at  Eastern Virginia Medical School , five children at the Lee Women's Hospital Infertility Clinic in  Taichung, Taiwan . [ 10 ]  twins in Naples, Italy [ 11 ]  and a twins in India. [ 12 ]  In total as of 2016, 30–50 children worldwide had been reported to have been born using cytoplasmic transfer. [ 13 ]


In 2002, the US  Food and Drug Administration  (FDA) asked a Biological Response Modifiers Advisory Committee Meeting to advise on the technique of cytoplasmic transfer to treat infertility. This committee felt that there were risks at the time of inadvertent transfer of chromosomes and enhanced survival of abnormal embryos. [ 13 ]  The FDA informed clinics that they considered the cytoplasmic transfer technique as a new treatment, and, as such, it would require an  Investigational New Drug  (IND) application. Cohen's clinic started the pre-IND application, but the clinic then went private, funding for the application dried up, the application was abandoned, the research team disbanded, [ 14 ]  and the cytoplasmic transfer procedure fell out of favor. [ 15 ]  In 2016, 12 (out of the 13) parents of children born using cytoplasmic transfer at the Saint Barnabas Center participated in a limited follow-up inquiry via online questionnaire. Children whose ages then were 13–18 reported no major problems. [ 16 ]


In 2009, a team in Japan published studies of mitochondrial donation. [ 17 ]  In the same year, a team led by scientists at  Oregon Health & Science University  published results of mitochondrial donation in monkeys; that team published an update reporting on the health of the monkeys born with the technique, as well as further work it had done on human embryos. [ 18 ]


Human trials in 2010 by a team in Newcastle University and Newcastle Fertility Centre were successful in reducing transmission of mtDNA. The results of the study found the mean mtDNA carried over was on average under 2% in the experimental embryos. This was true for both the MI-SCC and PN transfer methods of MTR. This research did not extend past the blastocyst stage because of ethical concerns, and there are still concerns about whether results retrieved from the blastocyst stage are viable representations of whole embryos. Because of these speculations and to further the viability of MTR as a safe and effective technique, further research and clinical trials would need to be initiated to test the efficacy of MTR in the long term in human patients. [ 19 ]


In the United Kingdom, following animal experiments and the recommendations of a government commissioned expert committee, [ 20 ]  the Human Fertilisation and Embryology (Research Purposes) Regulations were passed in 2001 regulating and allowing research into human embryos. In 2004,  Newcastle University  applied for a license to develop pronuclear transfer to avoid the transmission of mitochondrial diseases, [ 21 ]  and was granted the license in 2005. Following further research by Newcastle and the  Wellcome Trust , [ 22 ] [ 23 ]  scientific review, [ 24 ]  public consultations, and debate, the UK government recommended that mitochondrial donation be legalized in 2013. [ 25 ]  In 2015 parliament passed the Human Fertilisation and Embryology (Mitochondrial Donation) Regulations, which came into force on 29 October 2015, making human mitochondrial donation legal in the UK. The  Human Fertilisation and Embryology Authority  (HFEA) was authorized to license and regulate medical centers which wanted to use human mitochondrial donation. [ 26 ] [ 27 ]  In February 2016, the US National Academy of Sciences issued a report describing technologies then current and the surrounding ethical issues. [ 1 ]


The HFEA Safety Committee issued its fourth report in November 2016 recommending procedures under which HFEA should authorize MRT, [ 7 ]  the HFEA issued their regulations in December 2016 [ 27 ] [ 4 ]  and granted their first license (to  Newcastle Fertility Centre ; Newcastle upon Tyne Hospital NHS Foundation Trust led by Dr Jane Stewart as Person Responsible to the HFEA) in March 2017. [ 28 ]  Between August 2017 and January 2019, the HFEA received 15 requests from women to undergo MRT, of which 14 were granted. [ 29 ] [ 30 ]  As of 2020, if children have been born from these procedures, the details have not been published because of the wishes of the parents. [ 31 ]


Douglass Turnbull , the driving force behind mitochondrial research at Newcastle University, was awarded a  knighthood  in 2016. [ 32 ] [ 33 ]


In 2016,  John Zhang  and a mixed team of scientists from Mexico and New York used the spindle transfer technique to help a Jordanian woman to give birth to a baby boy. The mother had  Leigh disease  and already had four miscarriages and two children who had died of the disease. [ 34 ]  Valery Zukin, director of the Nadiya clinic in  Kyiv , Ukraine, reported in June 2018 that doctors there had used the pronuclear transfer method of MRT to help four women give birth (three boys and a girl) and three women to become pregnant (one from Sweden); the team had 14 failed attempts. [ 35 ]   In January 2019 it was reported that seven babies had been born using MRT. [ 36 ]  The doctors had first gotten approval from an ethical committee and a review board of the Ukrainian Association of Reproductive Medicine [ 37 ] [ 38 ]  and the Ukrainian Postgraduate Medical Academy, under the auspices of the  Ukrainian Ministry of Healthcare ; [ 35 ]  there was no law in Ukraine against MRT. One of the first children, a boy, was born to a 34-year-old woman in January 2017, and genetic test results were reported as normal. [ 39 ] [ 40 ]  In August and October 2017 the British HFEA authorized MRT for two women who had a genetic mutation in their mitichondria that causes  myoclonic epilepsy with ragged red fibers . [ 41 ]  In January 2019, Embryotools, Barcelona, Spain announced that a 32-year-old Greek woman had become pregnant using the spindle transfer technique. MRT was not legal in Spain so they had performed the trial in Greece where there was no law against MRT. They were helped by the Institute of Life in Athens, Greece and had obtained approval from the Greek National Authority of Assisted Reproduction. The pregnant Greek woman had already had four failed  IVF  cycles and surgery twice for  endometriosis . [ 42 ]


In August 2017, in a letter to two clinics, including Zhang's, the  FDA  warned that the technique should not be marketed in the U.S. [ 43 ]


In June 2018 Australian Senate's Senate Community Affairs References Committee recommended a move towards legalising MRT, and in July 2018 the Australian senate endorsed it. [ 44 ]  Research and clinical applications of MRT were overseen by laws made by federal and state governments. State laws were, for the most part, consistent with federal law. In all states, legislation prohibited the use of MRT techniques in the clinic, and except for Western Australia, research on a limited range of MRT was permissible up to day 14 of embryo development, subject to a license being granted. In 2010, the Hon. Mark Butler MP, then Federal Minister for Mental Health and Ageing, had appointed an independent committee to review the two relevant acts: the  Prohibition of Human Cloning for Reproduction Act 2002  and the  Research Involving Human Embryos Act 2002 . The committee's report, released in July 2011, recommended the existing legislation remain unchanged. [ 45 ]  The Australian  National Health and Medical Research Council  issued two reports on legalising MRT in June 2020. [ 46 ] [ 47 ]  In 2022, Maeve's Law was passed by the Australian Parliament, legalising MRT under a specified mitochondrial donation licence for research and training, and in clinical settings. [ 48 ]


Singapore was also considering whether to permit the MRT in 2018. [ 49 ]


In 2018, researchers announced the use of MRT to restore function to heart tissue in cardiac-compromised newborns. The damaged heart cells absorbed mitochondria extracted from healthy tissue and returned to useful activity. [ 3 ]


As of February 2016, the United States had no regulations governing mitochondrial donation, and Congress barred the FDA from evaluating any applications that involve implanting modified embryos into a woman. [ 50 ]


The  United Kingdom  became the first country to legalize the procedure: the UK's chief medical officer recommended it be legalized in 2013; [ 25 ]  parliament passed The Human Fertilisation and Embryology (Mitochondrial Donation) Regulations in 2015, [ 51 ] [ 52 ]  and the regulatory authority published regulations in 2016. [ 27 ]


Despite the promising outcomes of the two techniques, pronuclear transfer and spindle transfer, mitochondrial gene replacement raises ethical and social concerns. [ 53 ]


Mitochondrial donation involves modification of the  germline , and hence such modifications would be passed on to subsequent generations. [ 54 ]  Using human embryos for in vitro research is also controversial, as embryos are created specifically for research and egg donors are induced to undergo the procedure by financial compensation. [ 55 ]


Mitochondrial donation also has the potential for psychological and emotional impacts on an offspring through an effect on the person's sense of identity. Ethicists question whether the genetic make-up of children born as a result of mitochondrial replacement might affect their emotional well-being when they become aware that they are different from other healthy children conceived from two parents. [ 56 ]


Opponents argue that scientists are " playing God " and that children with three genetic parents may suffer both psychological and physical damage. [ 57 ]


On the other hand,  New York University  researcher  James Grifo , a critic of the American ban, has argued that society "would never have made the advances in treating infertility that we have if these bans had been imposed 10 years" earlier. [ 58 ]


On February 3, 2016, the  Institute of Medicine  of the  National Academies of Sciences, Engineering, and Medicine  issued a report, commissioned by the  U.S. Food and Drug Administration , addressing whether it is ethically permissible for clinical research into mitochondrial replacement techniques (MRT) to continue. The report, titled  Mitochondrial Replacement Techniques: Ethical, Social, and Policy Considerations , analyzes multiple facets of the arguments surrounding MRT and concludes that it is 'ethically permissible' to continue clinical investigations of MRT, so long as certain conditions are met. It recommended that initially the technique should only be used for male embryos to ensure that DNA with potential mitochondrial disease would not be passed on. [ 1 ]


In 2018  Carl Zimmer  compared the reaction to  He Jiankui 's human gene editing experiment to the debate over MRT. [ 59 ]


Montevideo units  are a method of measuring  uterine  performance during  labor . They were created in 1949 by two physicians,  Roberto Caldeyro-Barcia  and  Hermogenes Alvarez , from  Montevideo ,  Uruguay . They are exactly equal to 1  mmHg  within 10 minutes. A standard adequate measurement is 200; this is generally equivalent to 27  kPa  of combined pressure change within 10 minutes.


Units are directly equal to pressure change in mmHg summed over a ten-minute window. It is calculated by internally (not externally) measuring peak uterine pressure amplitude (in mmHg), subtracting the resting tone of the contraction, and adding up the numbers in a 10-minute period. [ 1 ]  Uterine pressure is generally measured through an intrauterine pressure catheter.


Montevideo units can be more simply calculated by summing the individual contraction intensities in a ten-minute period, a process which should arrive at a result identical to the original method of calculation. [ 2 ]


Generally, above 200 MVUs is considered necessary for adequate labor during the active phase.


If, for instance:


55-10 = 45
50-10 = 40
45-10 = 35
65-10 = 55
50-10 = 40


45+40+35+55+40 = 215 MVUs


The  Moro reflex  is an  infantile reflex  that develops between 28 and 32 weeks of gestation and disappears at 3–6 months of age. It is a response to a sudden loss of support and involves three distinct components: [ 1 ]


It is distinct from the  startle response . [ 2 ]  Unlike the startle response, the Moro reflex does not decrease with repeated stimulation. [ 3 ]  The primary significance of the Moro reflex is in evaluating integration of the  central nervous system . [ 3 ]


Ernst Moro  elicited the Moro reflex by slapping the pillow on both sides of the infant's head. Other methods have been used since then, including rapidly lowering the infant (while supported) to a sudden stop and pinching the skin of the abdomen. Today, the most common method is the head drop, where the infant is supported in both hands and tilted suddenly so the head is a few centimeters lower than the level of the body. [ 3 ]


The Moro reflex may be observed in incomplete form in  premature birth  after the 25th week of  gestation , and is usually present in complete form by week 30 ( third trimester ). [ 1 ]  Absence or asymmetry of either abduction or adduction by 2 to 3 months age can be regarded as abnormal, as can persistence of the reflex in infants older than 6 months. [ 3 ]  Furthermore, absence during the neonatal period may warrant assessment for the possibility of developmental complications such as birth injury or interference with brain formation. [ 3 ]  Asymmetry of the Moro reflex is especially useful to note, as it is almost always a feature of root,  plexus , or nerve disease. [ 4 ]


The Moro reflex is impaired or absent in infants with  kernicterus . [ 5 ]


An exaggerated Moro reflex can be seen in infants with severe brain damage that occurred in-utero, including  microcephaly  and  hydranencephaly . [ 6 ]  Exaggeration of the Moro reflex, manifesting either as low threshold or excessive clutching, often occurs in newborns with moderate hypoxic-ischemic encephalopathy. The Moro reflex is also exaggerated in infants withdrawing from narcotics. [ 7 ]


Persistence of the Moro reflex beyond 6 months of age is noted only in infants with severe neurological defects, including  cerebral palsy . [ 8 ] [ 9 ]


The Moro reflex was first described in western medicine by Austrian  pediatrician   Ernst Moro  (1874–1951) in 1918. Moro referred to it as the Umklammerungsreflex (embracing reflex). [ 10 ]  In this publication, he stated: "When a young infant is placed on the examination table and one taps with hands on both sides of the pillow, there follows a rapid symmetrical extending abduction of both extremities, which approach each other in adduction immediately thereafter". According to him, this reflex should disappear after the infant's first 3–6 months of life. Since then, the Moro reflex has been used to detect early neurological problems in infants. [ 10 ]  Absence or prolonged retention of Moro reflex can be signs that the infants need neurological attention. [ 11 ]


The Moro reflex may be a survival instinct to help the infant cling to its mother. If the infant lost its balance, the reflex caused the infant to embrace its mother and regain its hold on the mother’s body. [ 12 ]  The Moro reflex might also be an alarm signal from the baby who is about to lose support, and the spread arms provide extremities for where to be grabbed by its handler to prevent a fall.  [ 13 ]


Newborn transport [ 1 ]  is used to move  premature  and other sick infants from one  hospital  to another, such as a medical facility that has a  neonatal intensive care unit  and other services. Neonatal transport services such as  NETS  use mobile intensive care incubators fitted with mechanical ventilators, infusion pumps and physiological monitors capable of being used in a mobile environment. [ 2 ]  These transport systems seek to emulate the environment of a neonatal intensive care and permit uninterrupted care to occur in a referring hospital and then during the journey by road or  air ambulance . Power and medical gas supplies are carried within the system as well as making use of external supplies; as available. Infant transport systems commonly weigh over 100 kg and present a challenge to vehicle operators in terms of weight, manual handling,  crashworthiness  and power consumption.  [ citation needed ]


Neonatal transportation was first started by the American physician  Joseph Bolivar DeLee  (1869 –1942). [ 3 ]   DeLee showed an intuitive interest in the care of preterm infants, recognising the necessity of a thermo-regulated environment during their transfer. [ 4 ]   The first organised neonatal transportation program began in New York in 1948 and was called the New York Premature Infant Transport Service. [ 5 ]   This remarkable system was created more than a decade before Neonatal Intensive Care Units (NICUs) were established, and incorporated many of the main characteristics of the modern neonatal transportation units.  In 1968, in the United Kingdom, neonatologist  Herbert Barrie  introduced the country’s first dedicated neonatal ambulance. [ 6 ]   Barrie obtained funding from the Variety Club charity for an ambulance that could collect babies requiring intensive care from maternity hospitals and bring them back to the neonatal intensive care unit at Charing Cross Hospital. [ 7 ] [ 8 ]


Normally, regular ambulance staff and their vehicles are not equipped to transport sick newborns and special newborn transport teams are provided from either particular hospitals (hospital-based) or established to serve many hospitals (regionally based). Team composition varies from one country to another, with options including various two or three person combinations of nurse, doctor and  respiratory therapist .   Access to neonatal transport also varies, particularly in developing countries. [ 9 ]


Typically, newborn transport teams spend some time stabilizing a baby's condition prior to transport. Without adequate stabilisation, a clinical deterioration en route may occur.


Wherever possible (and safe), in utero transfer is generally preferable to newborn transport. [ 10 ]  Transfer of the mother while still pregnant leads to improved survival and quality of survival for the baby.


Nitrazine  or  phenaphthazine  is a  pH indicator  dye often used in  medicine . More sensitive than  litmus , nitrazine indicates pH in the range of 4.5 to 7.5. Nitrazine is usually used as the disodium salt.


This test, however, can produce false positives. If blood gets in the sample or if there is an infection present, the pH of the vaginal fluid may be higher than normal. Semen also has a higher pH, so recent vaginal intercourse can produce a false reading.


An  Obstetric Flying Squad  is a form of medical retrieval team that is composed of an  obstetrician ,  anaesthetist ,  midwife  and other healthcare personnel who are on-call to attend to mothers with major obstetric complications occurring in the community.


The idea of having an Obstetric Flying Squad was suggested by Professor  E Farquhar Murray  who wrote that " instead of rushing a shocked and collapsed patient to hospital for nursing and specialist aid, the specialist and nurse should be rushed to the patient " (see Liang reference below). In the  United Kingdom  in the 1930s, the majority of births occurred in the home.


The first organised obstetric flying squad was started by H. J. Thomson in  Bellshill ,  Lanarkshire ,  Scotland  in 1933 to provide emergency back-up to  general practitioners  and  midwives  involved in  home births .


The commonest major problems dealt with by the squad were:


The mothers were frequently severely shocked and the baby was also likely to be in a precarious position. Many lives were saved during the early years of operation of the service. Other countries with high home-birth rates subsequently copied the idea and set up similar services.


In most  developed countries  the majority of births now occur in hospitals and the  ambulance  services are well-developed, so the need for the service is extremely low. Less than 1% of births in the UK now occur in the home. The priority now is for rapid transport of distressed mothers to a hospital.


The original aim was to primarily manage obstetric complications on site, then secondarily transport the mother and child to hospital. This gradually evolved into primary on-site resuscitation than rapid transport to definitive care in a hospital. The concept of a hospital medical team going to retrieve patients continues in the concept of trauma retrieval teams.


The flying squad typically consisted of an  obstetrician ,  anaesthetist , midwife, and a helper such as a hospital orderly. The service was activated following a phone call for assistance, and the team members would 'fly' (meaning 'travel quickly') to the scene.


The anaesthetic equipment initially was quite simple and consisted of a  Schimmelbusch mask  to administer  chloroform . Later more sophisticated equipment was used. Of great importance was intravenous infusion equipment, intravenous fluids and later the provision of group O blood.


Obstetric medicine , similar to  maternal medicine , is a sub-specialty of  general internal medicine  and  obstetrics  that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant humans. [ 1 ]  It is closely related to the specialty of  maternal-fetal medicine , although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech. [ 2 ]


Obstetric physicians may provide care for chronic medical conditions that precede the pregnancy (such as epilepsy, asthma or heart disease), or for new medical problems that develop while the pregnancy is already in progress (such as gestational diabetes, and hypertension). [ 1 ]  By the 19th century, obstetrics had become recognized as a medical discipline in Europe and the United States. [ 3 ]  Formal training in obstetric medicine is currently offered in Australia, New Zealand, the United States, and Canada.


Obstetrics gains its origins from the observation that, throughout historical record, women have accompanied other women during the birthing stage of their pregnancy. Similar findings can be observed in Anthropological research of tribal birthing practices, ancient Egyptian depictions, and even scriptures in the Old Testament [ 4 ]  illustrate the presence of a woman figure, be it doctor or relative, present among the birthing of a baby.


During the 17th century, doctors were weary about the connection between  midwifery  and medicine, and thus failed to acknowledge its credibility. The practice of women assisting women through labor was viewed as uneducated. [ 5 ]  However, as time progressed, a new perspective among pregnant patients grew, where by they sought for mid-wives to deliver their babies. For example, [ 5 ]  in Wales and England, under 1% of people delivered their babies at home, which was a testament to the rise of midwives, that led to the present day professional field of Obstetrics. The roles of physicians in the process in delivering babies expanded as 17th century aristocrats utilized the best medical practitioners they could find. [ 3 ]


During this period, the medical field was still grappling with the idea of obstetrics and midwifery, which were activities thought to be practiced by uneducated females, as they were unable to form a connection between medicine and midwifery. These circumstances led to the mistreatment of pregnant women, who were often made to partake in experimental procedures and untested treatments, which led to harm on mothers and the fetus.


The purpose of the act was to improve training for midwives as well as regulating their practice. [ 6 ]  This meant that women who wanted to identify as "midwives" had to do so under the certification and verification of the Act. Penalties would incur on women who fraudulently claimed certification, with imprisonment possibly going up to 12 months. The caveat to this act was that a woman could practically engage in midwife duties, however they could not give them self the title of midwife or imply that they were affiliated with the title. However, the basis of the act was the acknowledgement of the field, creating an environment for people to gain professional knowledge about the field. This act was significant in leading to the present practice of obstetric medicine as it created a pathway for women to begin practicing with pre/post natal care, leading to the discovery of numerous methods in obstetric medicine.


Maternal mortality is an ongoing issue that is rising among pregnant women. A challenge facing many pregnant women is the lack of access to specialized obstetric care, often resulting in untimely deaths and an increasing rate of maternal morbidity. This lack of access offered to women has resulted in an outreach programs attempted by clinicians to reach women who are currently suffering from the consequences of reduced accessibility. This increased awareness is emerging during a time of "obstetric transition", [ 7 ]  where research is noticing a notable shift in patterns from instances of high maternal mortality to patterns of lower maternal mortality. These patterns depict instances of high maternal mortality associated with implicit obstetric cause, while instances of low maternal mortality are related to factors such as maternal age, non-communicable disease (NCD) and indirect causes of maternal death (not directly linked to obstetric care).


The total cost of having a child in a hospital is can total several thousand dollars, which can be an expensive hurdle depending on an individual's socioeconomic status. Many countries lack the funding required to provide women from low-income households with prenatal care needs. This poses a problem for many women who are uninsured, or do not have access to adequate insurance. For women who are completely uninsured, their only source of prenatal care can be from charities and programs run by public funds, which is not a reliable source of prenatal care that has to be done regularly. [ 8 ]  When considering couples who have children in their early 20s, with an annual income of $19,800, having a child that on average costs $4,800, [ 8 ]  is a financial burden. Numerous insurance companies do not cover maternity care, which indicates that possessing insurance does not immediately clear couples of debt.


During the 18th century, common methods of resolving obstructed labor often resulted in high mortality of the infant. These methods included pulling on the legs of the baby or using breeching hooks. William Smellie revolutionized child birth by writing works on how to use forceps in the assistance if childbirth. [ 9 ]  The practice of using forceps proved to be much more effective and less damaging to the baby.


By the 20th century, medicinal drugs were used to treat pregnant women, or to provide them with prenatal care. By the 1950s, women were having given contraceptive pills to begin regulating their hormones and fertility, [ 3 ]  which effectively allowed couples to have planned pregnancies. By the 21st century, women were being given medication for the induction and augmentation of labor.


Treating the ailments of pregnant mothers requires a unique approach, since medicines commonly used may have an adverse effect on the fetus. Some common ailments include, but are not limited to :


A common ailment of pregnant women is postpartum depression. Depression can cause pregnant women to have poor nutrition or inadequate strength to nurture herself and her baby. The result of this can be problems in development and health of the fetus. The use of medicine to treat postpartum depression is a subject for debate, since some research indicates that the use of antidepressants during pregnancy can lead to physical malformations and long-term health problems of the baby [ 10 ]  Other forms of treatment include support groups and psychotherapy.


Gestational diabetes is observed by elevated glucose levels in pregnant women who have never had diabetes. This form of diabetes occurs when placental hormones interfere with insulin produced by the mother, resulting in an excess of glucose in the blood. The excess glucose will cross the placenta and cause the baby's pancreas to produce extra insulin and store the excess glucose as fat. [ 11 ]  Gestational diabetes is treated by a diet and exercise regiment the goal of maintaining lower levels of glucose in the body. [ 12 ]   Gestational diabetes increases the risk of high blood pressure, preeclampsia, C-section or developing diabetes in the future. [ 13 ]  It is important to adapt to healthy habits if one has gestational diabetes. Intervention diet, becoming physically active and weight control all help reduce any health problems or risk in the future.


Gestational hypertension is characterized by high blood pressure during pregnancy. Chronic hypertension can lead to a severe condition called preeclampsia, which can result in damage to organs. Hypertension can cause the placenta to not receive enough blood and starving the fetus of oxygen. Hypertension is treated in pregnant mothers by adjusting their diet to contain less fat and salt, consuming enough water, and getting regular exercise. [ 14 ]


Maternal obesity is a rising epidemic among pregnant women, that is detrimental to both the health of the baby and the mother. Obesity leads pregnant women to develop gestational diabetes and preeclampsia, and increase the risk of stillbirth and numerous congenital anomalies. Studies have shown that prolonged sitting time, either before or during pregnancy, is a strong indicator of the risk for gestational diabetes. However, light physical activities like walking were not found to be associated with an increased risk of gestational diabetes mellitus. Beyond the immediate risks during pregnancy, the obesity of the mother tends to create a predisposition for the baby to have the inclination to develop conditions like heart disease and diabetes. [ 15 ]   During pregnancy, the rate at which nutrition is absorbed and conveyed to the fetus affects its physiology and metabolic regularity. Nutrition available in either abundance, or scarcity, both affect the overall outcome of the fetus, thus creating a precursor for future health developments. Typical treatment includes monitored consumption of food, as well as moderate exercise. It is well known that the practice of physical activtiy effectively prevents or reduces obesity. These benefits are also extended to pregnant women. While exercise is important and can help the mother lose weight, it is important to know that when it comes to obese mothers, the ultimate goal is not weight loss but, more so weight control. Extreme changes in diet can lead to significant and reproducible shifts in microbial composition.  [ 16 ]


A body mass index of 25 or higher as a pregnant woman is associated with an increased risk of offspring  macrosomia  (birth weight in excess of 4,000 grams or 8 pounds). This is further associated with moderate to severe obesity at school age, making it a predictor of offspring body composition. Children born to obese mothers are more prone to obesity and more prone to developing gastrointestinal and metabolic diseases later on in life.  [ 16 ]  Each additional kilogram of gestational weight gain increases the offspring’s risk of overweight or obesity by 1-23%. [ 17 ]  Maternal health status has a significant impact on the newborn's gut microbiota.  [ 16 ]  Breastmilk is important for the development and maintenance of the infant microbiota after birth. [ 16 ]  Once the baby is born, it is important for the mother to continue watching her health by staying on a diet and physically active.


Puerperal Sepsis is a bacterial infection that affects the genital tract, commonly occurring after the birth of a baby. The symptoms typically appear one day after pregnancy, however symptoms may appear earlier if the woman has had prolonged damage to the membranes in the vaginal tract. This was a leading factor in maternal mortality, as 80%-90% of women in some hospitals did not survive after receiving their diagnosis due to the rapidly spreading nature of the infection. Malnourished women, or with women with anaemia were susceptible to the infection. Some common symptoms included, but were not limited to: fever (temperature of 38 °C or more), chills and general malaise, lower abdominal pain, tender uterus, sub involution of the uterus purulent, and foul-smelling lochia. [ 18 ]


Out of the 2 million people in the world living with HIV, 90% of them contract it from their HIV-positive mother from either breastfeeding, pregnancy, or birth. [ 19 ]  HIV positive women who become pregnant require special types of treatment in order to prevent transmission from mother to fetus.  Antiretrovirals  are medications that reduce the  viral load  of the HIV virus in the mother's fluids and blood. It is ideal to start treatment as early as possible, even before conceiving. Reduction of the viral load reduces the chance of the baby to become infected. [ 20 ]