Reproductive risk manages to be conceptualized by the interaction between the definition of risk and risk factors during reproductive life of women having as a result fatal maternal death and / or death of the fetus or newborn. Therefore, to achieve adequate reproductive health is essential that health personnel manage the risk approach, as not all women have the same chance of getting sick and dying; whose livelihood is the proper understanding of the definition of reproductive risk and their classification (preconception risk, risk obstetrics and perinatal risk) to identify individual needs at every stage of reproductive life in a way so that they are benefiting women and their families.
Keywords: reproductive risk, maternal mortality, reproductive health
This document aims to review the definition of risk, risk factors and the definition of maternal death, conceptualizing risk as the probability of an event occurring that includes various probability measures regarding adverse consequences1; risk factors, defined as those factors that are related to the disease under investigation by their presence or absence, or may be the cause which favors its appearance in certain people2, ie, those who are aimed to the prediction of mortality future; belonging to different levels of organization: social (eg unemployment, illiteracy, poverty) and biological (age, immune status, genetic characteristics, etc.)3 defining maternal death: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management4 understanding that the relationship in these definitions are reproductive risk factors explaining them as the probability of harm during the reproductive process, it will affect mainly the mother, the fetus or newborn but also the father and family mostly. The estimate of the probability of an adverse outcome when one or more reproductive risk factors are present, measuring their interactions as predictors and calculating what would happen in the health of the population if they are removed, modified or so fewer controls; makes possible the implementation of reproductive risk in preventive medicine.5
The identification of reproductive risk factors may allow early influence on them and effectively6 to ensure that women of childbearing age get pregnancy in good health; with minimization of the different risk factors present in the couple from the preconception stage7,8 to achieve the prevention and reduction of maternal death in this case.
Reproductive health according to the World Health Organization (WHO) is: state of mental and social physical well-being in all matters relating to the reproductive system, its functions and processes with the right to receive appropriate services that allow pregnancy and childbirth safely.9 Pan American Health Organization (PAHO) from 1996 describes that there must be management with risk approach whose analytical approach varies from the mathematical calculation of the probability of risk with statistical estimates of their likely future behavior, to a qualitative analysis of the context in the risks that occur in different types of populations.10
This approach is based on the observation that not all women have the same probability or risk of disease and death, but for some of them, this probability is greater. This difference establishes a gradient of care needs ranging from a minimum for those with low risk, up to a maximum required only for those with high possibility of future changes in their health.11
It is the probability or degree of danger that both women of childbearing age and their potential product have, to suffer from illness, injury or death in the event of a pregnancy.12, 13
When unifying the concept of reproductive risk with the reproductive stages of women, it is possible to make the distinction before, during and after conception. Thus, resulting in the classification of reproductive risk: risk preconception (before pregnancy), obstetrical risk (during pregnancy and childbirth) and perinatal risk (which runs until the first week of life of the newborn).5
Preconception reproductive risk
The concept applies to women of reproductive age in non-gestational periods. The aim is to classify nonpregnant women of childbearing age according to the risk that a future pregnancy would result in the health of her fetus or newborn.
It is known that women who are at high risk preconception possibly present a high-risk obstetrics, in the case of gestating; and these last ones are more likely to suffer from damage during the reproductive process. For this reason, it is imperative to act in the preconception period in order to identify women at high risk to provide them with more complex care, according to rules and procedures.5
The preconception reproductive risk factors are many: illiteracy, poverty, malnutrition, live in marginal urban or rural areas with inadequate health services, etc. These factors vary between countries and between different regions thereof. However, there are some factors that persist regardless of social status or geographical area in which women live. Among these, four are the most recognized:
They can also be classified in groups according to: a) socio-demographic factors; b) medical and reproductive history background.12
It will be outlined some relevant data only related to reproductive risk factors, even if, as already described, these are many and vary according to the geographic region (urban and rural):
Obstetric risk
It is understood as all those external or intrinsic factors to women, which can lead any complications during the course of pregnancy, development of delivery, postpartum or likely to alter in any way the normal development or survival of the product. Risk factors at this stage are virtually the same as were described in the preconception stage, with the difference that if not intervened at that stage, here the risk is increased by the same gestation. Obstetrical risk assessment allows us to plan the characteristics, the intentionality that prenatal monitoring must have in each case, in particular to identify risk factors, health education and early detection of complications.34
Perinatal reproductive risk
Ranging from the 28th week of gestation until the first week of life of the newborn. It not only considers the maternal risk, but also includes risks to the fetus or newborn5, which may be presented during pregnancy, childbirth, postpartum period.
Panorama of maternal mortality in Mexico and in Hidalgo state.
It is estimated that 800 women worldwide die from complications related to pregnancy35, although maternal mortality in Mexico has reduced its ratio from 53.8 in 2002 to 37.7 in 2012.36
According to the indicators of maternal mortality of the National Observatory of Maternal Mortality, a reduction of maternal mortality ratio was presented to 4.1 comparing years 2012 and 2013; Appearing 38.2 maternal deaths per 100,000 live births estimated in 2013; from which 22% of maternal deaths occurred between 20 and 24 years of age followed by women aged 25 to 29 years with 20.8%; 79.7% had stable partners; 11.3% spoke an indigenous language; 73.2% did not work; 32.3% had completed at least one year of high school, more than 50% affiliated to popular insurance.37
From the deaths occurred in Mexico in 2012, a third came from indirect obstetric causes which are the result of existing risk factors before pregnancy or disease that evolves during the same (as are patients with epilepsy, asthma, heart disease, pre-existing hypertensive disease, among others); not due to direct obstetric causes but aggravated by the physiological effects of pregnancy.38
In Hidalgo maternal death in the 2005 - 2010 period has maintained its absolute figures, the RMM shows stable trend and remains above the national average according to the Observatory of Maternal Mortality and Department of Epidemiology. From the deaths in the state of Hidalgo, 89.8% counted with an average age of 28.69 years. Basic education (79.6%) and illiteracy (10.8%) had the highest percentages, while living with a partner represented 86.4%. The maternal deaths , 81.8% were engaged in household, and 52.8% were not beneficiaries to any health service.39
Purpose of assessing reproductive risk
The importance of the approach of reproductive risk is that it identifies health needs, identify those social and medical conditions, both maternal and paternal, using the presence of risk factors as a guide for future action, in order to increase the chances of a favorable perinatal outcome40. Thus, it facilitates the redistribution of resources, increament of coverage, referral and counter-referral of patients, family care and elimination of the factors that prevent women from obtaining the knowledge that allows them to require prompt and adequate medical attention and to help them make autonomous decisions about reproduction.41
With the obtained data during the preconception reproductive risk assessment may be recommended to women, the most convenient time to plan pregnancy and protect the fetus during the first weeks of gestation.42
Consecutively, during antenatal care obstetrical risk factors are identified and managed adequately and timely so that maternal health benefits especially patients with deficiency or classified with high-risk obstetrics states.43 It should not be forgotten the evaluation of perinatal reproductive risk as this also affects the health of the fetus or newborn due to the fact that the greater the number of risk factors is, the greater the cognitive implications are that hinder the acquisition of learned processes.44
Tools for assessing reproductive risks
The reproductive risk approach has been used for many years and for evaluation, Nesbitt and Aubry came up with the idea of giving penalty points regarding the clinical significance and added all established a predictive prognosis; thus, they concocted the "risk tables" which consist of risk factors prior to the current pregnancy, and others remaining to be initiated or appearing during pregnancy.45 Which they are intended to help medical personnel to classify women according to their reproductive risk; and to guide the doctor in deciding whether a patient can continue or not prenatal care in a primary care or in a more complex level, regardless of whether the response of this level is that the patient can continue their prenatal care at the place that originated remission.46
Although the reproductive risk has been addressed and defined since 1996 by PAHO and for classification purposes, they based on the timing of the reproductive process of women; this fact suggests a conflict because the preconception risk, the obstetric risk, and perinatal risk , overlap and interact with each other and in spite the fact that a woman has been classified as a high risk woman (preconception risk and obstetric risk) and therefore the likely to suffer damage during the reproduction process will be higher for her than it would be for another woman who did not present these risk factors, there is no certainty that this will happen; therefore, the actions to take are varied; on one hand providing adequate information about their health status and associated risk factors, and on the other hand counseling on contraceptive methods if they do not want to gestate and if they intends to pregnancy or is in it, they should receive a special and some preferential care, as it will be a high risk pregnancy (obstetric and / or perinatal), not only with the intent of improving or maintaining maternal health but also the newborn.
The usefulness of the evaluation of reproductive risk is undeniable; it is of utmost importance for public health to allow compliance with the essential functions (prevention, surveillance, disease control, health promotion and health care for vulnerable and high-risk population)47 by recognizing each one of the parties that form a reproductive risk since identifying the preconception reproductive risk obstetrical reproductive risk and perinatal reproductive risk correctly, allows the application of various strategies focused either on primary prevention and / or secondary as the case. For the author, the evaluation of preconceptional risk is the most important because it could help to health service providers to make primary prevention. However, currently it is not necessary to wait that pregnancy happens to create health interventions, it can be developed a true primary prevention; and promoted the design of strategies for the implementation of health programs in line with the living conditions of women, where service providers are agents for change and allow woman to make informed decisions to protect their health48, with the firm intention that in Mexico complications in reproductive health of women and their potential impact on well-being of newborns would be minimized.
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[a] Department of Medicine [ICSA-UAEH].
Correspondence: Sandra Angelica Jimenez Oropeza. E-mail: orojim86@hotmail.com
Ex-Hacienda la Concepción, Actopan-Pachuca highway Tilcuautla s/n Hidalgo Mexico.