Pregnancy Limit: How Many Are Safe?

Pregnancy is a life-changing experience, but it's important to remember that it also comes with potential risks and challenges. While continuing a pregnancy and giving birth is generally considered a safe process, it's not without its complications. The risks associated with pregnancy vary depending on various factors, and it's crucial for individuals to be aware of these factors to make informed decisions regarding their reproductive health.

Pregnancy complications and maternal mortality rates

Maternal mortality refers to deaths due to complications from pregnancy or childbirth. The World Health Organization defines a maternal death as "the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, excluding accidental or incidental causes." Common causes of death for pregnant women include emboli (blood clots affecting the heart and brain), eclampsia (high blood pressure complications), heavy bleeding, sepsis (severe infection), and anesthesia-related deaths. These causes account for 80% of all deaths relating to pregnancy. Additionally, women with chronic severe diseases are at a greater risk of death than healthy women.

In 2020, approximately 287,000 women died during and following pregnancy and childbirth worldwide. Almost 95% of these deaths occurred in low and lower-middle-income countries, and most could have been prevented. Sub-Saharan Africa and Southern Asia accounted for around 87% of global maternal deaths, with Sub-Saharan Africa alone contributing to 70%. The maternal mortality ratio (MMR) in low-income countries was significantly higher than in high-income countries, with 430 per 100,000 live births versus 13 per 100,000.

Certain factors can increase the risk of pregnancy complications and maternal mortality. Pre-existing health conditions, pregnancy-related health conditions, lifestyle factors (such as smoking or drug use), and age can contribute to a high-risk pregnancy. Pregnant individuals under the age of 17 or over the age of 35 are considered high-risk and may require extra care before, during, and after giving birth. Additionally, people with pre-existing conditions such as autoimmune diseases, high blood pressure, mental health disorders, or polycystic ovary syndrome (PCOS) are also at increased risk.

To reduce maternal mortality and improve pregnancy outcomes, access to skilled health professionals, quality care, and contraception is essential. Early and thorough prenatal care is critical for detecting and managing high-risk pregnancies. Additionally, addressing social determinants of health, such as income and education, and challenging gender norms that devalue women's access to reproductive health care are crucial steps towards ensuring safer pregnancies.

Risk factors for high-risk pregnancies

While all pregnancies carry some risks, a high-risk pregnancy is one that involves increased health risks for the pregnant person, the foetus, or both. A high-risk pregnancy may require extra care before, during, and after birth to reduce the possibility of complications. Here are some risk factors that can contribute to a high-risk pregnancy:

• Age: Pregnant people under the age of 17 and over the age of 35 are considered high risk. Younger pregnant people are at higher risk of premature labour or birth and may be less likely to receive thorough prenatal care. Older pregnant people are more likely to experience complications such as early pregnancy loss, gestational diabetes, and pregnancy-related high blood pressure.
• Pre-existing health conditions: Autoimmune diseases (such as lupus or multiple sclerosis), high blood pressure, polycystic ovary syndrome (PCOS), blood clotting disorders, kidney disease, mental health disorders, and thyroid disease can increase the risks during pregnancy.
• Pregnancy-related health conditions: Certain conditions that develop during pregnancy, such as gestational diabetes, preeclampsia, eclampsia, and birth defects or genetic conditions in the foetus, can pose risks to both the pregnant person and the foetus.
• Multiple gestation: Pregnancies with more than one foetus (such as twins or triplets) are considered high risk due to the increased likelihood of premature birth and other complications.
• Previous pregnancy complications: A history of preterm labour, birth, or other complications with previous pregnancies can increase the risk of a high-risk pregnancy.
• Lifestyle factors: Smoking, drug addiction, alcohol abuse, and exposure to certain toxins can negatively impact the health of the pregnant person and the foetus.

It is important to note that even with a high-risk pregnancy, many people experience healthy pregnancies and normal labour and delivery. Early and regular prenatal care is crucial for managing and reducing the risks associated with a high-risk pregnancy.

Abortion safety and accessibility

Firstly, it is essential to recognise that abortion restrictions and impeded access can have detrimental consequences. Restrictive laws and requirements that are not medically justified, such as criminalisation, mandatory waiting periods, and biased counselling, pose significant barriers. These barriers can lead to increased risks and threaten patient safety. The risk of death associated with abortion increases with pregnancy progression, making timely access crucial. Additionally, restrictive abortion regulations can cause distress and stigma, impacting the human rights of women and girls, including privacy, non-discrimination, and equality.

Secondly, unsafe abortions are a significant concern and a preventable cause of maternal deaths and morbidities. Approximately 45% of abortions are unsafe, resulting in physical and mental health complications and imposing social and financial burdens. Inaccessible quality abortion care can lead to unsafe abortion practices, such as procedures performed by untrained individuals using dangerous and invasive methods. This lack of access to safe abortion care not only affects women's physical and mental well-being but also violates their human rights, including the right to life, health, and reproductive freedom.

To address these issues, comprehensive abortion care is essential. This includes providing information, abortion management, and post-abortion care. A supportive legal and policy framework, along with accessible and accurate information, plays a vital role in ensuring safe and respectful abortion care. Additionally, a well-functioning health system with trained health workers who can provide a range of abortion care options is crucial.

Furthermore, addressing societal disparities is vital to improving abortion safety and accessibility. For example, Black women in the United States face a maternal mortality rate three times higher than that of white women. By ensuring equitable access to abortion care, we can mitigate the impact of existing healthcare and social inequities on vulnerable communities.

In conclusion, abortion safety and accessibility are interconnected issues that require a multifaceted approach. By prioritising comprehensive abortion care, respecting human rights, ensuring accessible information, and addressing societal disparities, we can improve the safety and well-being of individuals seeking abortion services.

Pregnancy and mental health

Pregnancy is often associated with the myth that hormonal changes protect women from psychiatric disorders and promote emotional well-being. However, recent studies reveal that up to 20% of women struggle with mood or anxiety disorders during gestation and postpartum. The reported rates of depression in pregnant women vary from 5% to almost 30%, with anxiety disorders being equally prevalent.

The perinatal period, encompassing gestation and the first year after childbirth, is a critical time for a woman's mental health. It is characterised by significant physiological, hormonal, and emotional changes, as well as various stressors. These factors contribute to anxiety and depression, which are the most common emotional disturbances experienced by pregnant women.

The decision to manage mental health issues during pregnancy can be challenging. Many women choose to discontinue or avoid pharmacological treatment to reduce the risks of prenatal medication exposure to their unborn child. However, this decision may carry risks as well. Untreated psychiatric illnesses in the mother can lead to significant health risks for both the mother and the fetus, including poor nutrition, smoking, drinking, suicidal behaviour, prolonged or premature labour, and low birth weight.

To make an informed decision, it is crucial for pregnant women to be well-informed about the risks associated with both options and to consider their specific diagnosis and the recommendations of their healthcare provider. In mild cases of depression and anxiety, counselling, support groups, environmental manipulation, and healthy diversions like walking and social activities can be effective. For more severe cases that do not respond to these approaches, professional psychotherapy, brief hospital stays, intensive outpatient programs, or medication may be necessary.

Pregnancy and cardiovascular health

Pregnancy is a time of profound physiological changes, which can pose a challenge to the cardiovascular system. While most pregnancies proceed without cardiovascular complications, the presence of underlying heart conditions can significantly increase the risk of adverse outcomes for both the mother and the fetus. Here are some key considerations regarding pregnancy and cardiovascular health:

Cardiovascular Changes During Pregnancy:

During pregnancy, the body undergoes several adaptations to support the growing fetus. These changes include:

• Increased blood volume and cardiac output: There is a 30-50% increase in blood volume and cardiac output, which peaks during the second trimester.
• Decreased blood pressure: Blood pressure typically decreases by 10-15 mm Hg due to reduced systemic vascular resistance caused by the placenta and vasodilation.
• Increased heart rate: The heart rate rises by about 10-15 beats per minute.
• Hematological changes: The hematocrit level decreases due to a greater increase in plasma volume compared to red blood cell mass.

Pregnancy-Related Cardiovascular Risks:

Pregnancy can be challenging for women with pre-existing cardiovascular conditions. Some of the risks include:

• Valvular heart disease: Conditions such as mitral stenosis, aortic stenosis, and aortic regurgitation can worsen during pregnancy, leading to heart failure, arrhythmias, and ischemic events.
• Congenital heart disease: Advances in medical care have allowed more women with congenital heart disease to reach childbearing age. Pregnancy may be well-tolerated in some cases, but it can also lead to maternal and fetal complications, especially in those with complex lesions or cyanotic heart disease.
• Cardiomyopathy: Hypertrophic cardiomyopathy and peripartum cardiomyopathy can pose significant risks during pregnancy, including heart failure and arrhythmias.
• Coronary artery disease: Pregnancy increases the risk of myocardial infarction, especially in women with risk factors such as smoking, diabetes, and hypertension.

Management and Preconception Care:

The management of cardiovascular disease during pregnancy requires a multidisciplinary approach involving maternal-fetal medicine specialists, cardiologists, and other experts. Preconception counseling and risk assessment are crucial. Some key considerations include:

• Medical management: Medications such as beta-blockers, diuretics, and calcium channel blockers may be used to control symptoms and optimize cardiovascular function. Anticoagulation therapy in pregnant women with mechanical heart valves requires careful consideration due to the risks of fetal embryopathy and bleeding.
• Delivery planning: Vaginal delivery is generally preferred over cesarean delivery to minimize hemodynamic changes and blood loss. Epidural anesthesia is often recommended to avoid catecholamine-induced tachycardia.
• Fetal monitoring: Regular ultrasounds and fetal surveillance are essential to assess fetal growth and well-being, especially in high-risk pregnancies.

Cardiovascular Health After Pregnancy:

It is important to recognize that the cardiovascular demands of pregnancy can have long-term implications for a woman's cardiovascular health. Pregnancy-related conditions such as preeclampsia and gestational diabetes have been associated with an increased risk of future cardiovascular disease. Therefore, postpartum care should include ongoing cardiovascular assessment and management to optimize long-term health.

Frequently asked questions