Cardiovascular Journal of Africa: Vol 27 No 2 (March/April 2016)

25 / 72

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016 AFRICA 79
Pre-conception counselling for key cardiovascular
conditions in Africa: optimising pregnancy outcomes
Liesl Zühlke, Letitia Acquah
Abstract
The World Health Organisation (WHO) supports pre-concep-
tion care (PCC) towards improving health and pregnancy
outcomes. PPC entails a continuum of promotive, preventative
and curative health and social interventions. PPC identifies
current and potential medical problems of women of child-
bearing age towards strategising optimal pregnancy outcomes,
whereas antenatal care constitutes the care provided during
pregnancy. Optimised PPC and antenatal care would improve
civil society and maternal, child and public health. Multiple
factors bar most African women from receiving antenatal care.
Additionally, PPC is rarely available as a standard of care in
many African settings, despite the high maternal mortality rate
throughout Africa. African women and healthcare facilitators
must cooperate to strategise cost-effective and cost-efficient
PPC. This should streamline their limited resources within
their socio-cultural preferences, towards short- and long-term
improvement of pregnancy outcomes.
This review discusses the relevance of and need for PPC
in resource-challenged African settings, and emphasises
preventative and curative health interventions for congenital
and acquired heart disease. We also consider two additional
conditions, HIV/AIDS and hypertension, as these are two
of the most important co-morbidities encountered in Africa,
with significant burden of disease. Finally we advocate
strongly for PPC to be considered as a key intervention for
reducing maternal mortality rates on the African continent.
Keywords: pre-conceptual counselling OR counselling, Africa,
sub-Saharan Africa OR Afric*
Submitted 1/9/15, accepted 2/3/16
Cardiovasc J Afr 2016; 27: 79–83
DOI: 10.5830/CVJA-2016-017
The World Health Organisation (WHO) recently stated that
four out of 10 women report that their pregnancies were
unplanned. As a result, 40% of pregnancies miss the essential
health interventions required prior to pregnancy. Despite the
laudable gains achieved by some countries in the United
Nations’ millennium development goal 5 target 5A, ‘Reduce by
three-quarters, between 1990 and 2015, the maternal mortality
ratio’, maternal morbidity remains a critical concern and public
health issue in Africa.1 The WHO strongly supports the need for
optimal pre-conception care (PCC) or counselling, followed by
comprehensive antenatal care.2
PCC is defined as the continuum of promotive, preventative
and curative health and social interventions.3 In addition to
health interventions, other sectors and stakeholders need to
be engaged to ensure universal access to PPC. PCC aims
at improving the health status of prospective parents and
reducing behaviours and individual and environmental factors
that contribute to poor maternal and child health outcomes. Its
ultimate aim is to improve maternal and child health, in both the
short and long term.
It is important to note that although PCC aims primarily at
improving maternal and child health, it brings health benefits
to adolescents, women and men as individuals in their own
right (not just as potential parents).4 Among others, PCC can
improve a variety of important health outcomes including:
reducing maternal and child mortality; preventing unintended
pregnancies, perinatal complications, reducing the vertical
transmission of HIV/STIs, and co-morbid infections such as
rubella; and reducing the risk of type 2 diabetes mellitus and
cardiovascular disease later in life. PPC identifies current and
potential medical problems of women of childbearing age, in
order to strategise optimal pregnancy outcomes.
The WHO has developed a package of PPC interventions
that focuses on information and perspectives on important
issues, target groups, delivery mechanisms and specific regional
considerations. These are focused around 13 areas and provide
an evidence-based package of interventions addressing the
following areas: nutritional conditions, vaccine-preventable
diseases, genetic conditions, environmental health, infertility/
subfertility, female genital mutilation, too early, unwanted and
rapid successive pregnancies, sexually transmitted infections,
HIV, interpersonal violence, mental health, psychoactive
substance abuse, and tobacco use (Table 1).2
It is clear that addressing non-medical and medical causes
and correlates of maternal morbidity and mortality will optimise
healthy pregnancy outcomes.5 Various authorities have studied
key non-medical issues, namely, women’s education and family
planning, which directly impact on the general welfare of
childbearing women and enhance pregnancy outcomes.6
Of note is the importance of key collaborations and multi-
sector engagement in order to devise a local strategy for PCC.
Such a strategy would need to be informed by an assessment of
the strengths and weaknesses of the PCC system in place. It will
need to be supported by key stakeholders and partnerships to
ensure political commitment, and it has to leverage on existing
public health programmes. It would also need to be adapted
to country priorities and target populations, while identifying
Departments of Paediatric Cardiology and Medicine,
Red Cross War Memorial Children’s and Groote Schuur
Hospitals, Cape Town, South Africa
Liesl Zühlke, MB ChB, DCH, FCPaeds (SA), Cert Cardiology
(Paeds), MPH, FESC, PhD,
Department of Medicine, Division of Hospital Internal
Medicine, Mayo Clinic Hospital, Saint Mary’s Campus,
Rochester, Minnesota, USA
Letitia Acquah, MD, MSc, FACP