The World Health Organization (WHO) chose World Health Day 7 April 2005 to focus on mothers and children. Their slogan was: ‘Make every mother and child count’. Other global initiatives such as ‘The Millennium Development Goals’, ratified by more than 189 nations, have set targets to reduce maternal deaths by 75% and child deaths by two-thirds by 2015 (WHO 2005). The goal of such initiatives is not only to reduce mortality, but also to ensure access to appropriate health care services during pregnancy and childbirth (WHO 2004).

The decline of mortality rates in developed countries is due to improved sanitation, nutrition, standards of living, and level of education along with advances in medicine, improved access to health care, and better surveillance and monitoring of disease (Center for Disease Control and Prevention 1999, Detels et al 2002). Because of the low incidence of death, an additional indicator, ‘severe maternal illness/morbidity’, has been established which ‘places a woman at serious risk of death but is not fatal’ (Public Health Agency of Canada 2006).

The reasons that women die vary from country to country. Canada has one of the lowest maternal mortality rates and one of the best early childhood survival rates in the world. The European fetal death rate ranges from 3.7 to 7.3 per 10000 births (Zeitlin et al 2003). In Canada, the leading causes of direct maternal death are pulmonary embolism and pre-eclampsia/pregnancy-induced hypertension, amniotic fluid embolism, and intracranial haemorrhage. The leading cause of indirect maternal death is cardiovascular disease (Gilbert & Harmon 1993, Health Canada 2004).

In 1997 the leading causes of direct maternal death globally were haemorrhage, infection and unsafe abortion. The leading causes of indirect maternal death were anaemia, malaria and cardiovascular disease (WHO 2005).

For information on mortality and morbidity rates in specific countries, check websites for the World Health Organization and for governing bodies related to maternity healthcare within the therapist’s location (e.g. SOGC, ACOG, RCOG, CDC).

The realities for therapists working in developing countries are different. In these countries, women are often younger, have many more children and may live in difficult conditions. They may not have access to basic facilities such as water, let alone healthcare or bodywork.

Some of the pregnancy outcomes related to these factors are low gestational weight gain, pre-term birth, small for gestational age births, intrauterine growth restriction, pregnancy-induced hypertension, gestational diabetes, higher risk of maternal death, as well as a range of adverse infant health outcomes including congenital anomalies (Public Health Agency of Canada 2006).

There are wide-ranging implications for pregnancy and birth outcomes related to the severity of the risk issue and how it is managed or treated. In some cases, for example with a multiple pregnancy, or with age as the ‘risk factor’, thorough monitoring is the outcome as opposed to a specific treatment and there may be no actual complication. It is important to remember that: ‘Only 10 to 30 percent of women who are labelled high risk actually end up having the outcome for which they are at increased risk’ (Pearson 1997).

One of the most important components for a healthy pregnancy outcome is adequate prenatal care. Many tests and observations are available to help assess risk factors, prevent complications from developing and assist with diagnosis and treatment.

Working with the higher-risk population requires additional skills, training and experience compared to working with the low-risk population. The therapist needs to know the specific adaptations and precautions including those on home or hospital bedrest.

Prior to undertaking bodywork, there needs to be a solid understanding of the circumstances which result in a woman being considered ‘higher risk’. This includes: the woman’s general and maternity health history, knowledge of the type of primary care she is receiving, liaising with primary caregivers if relevant, the specifics of the health issue and an evaluation of the type of bodywork which would be safest and most beneficial. Complete contraindications to bodywork are rare, except in the obvious case of medical emergency or an unstable health situation. Once the situation has stabilised, bodywork can be a useful adjunct to the recovery process.

Some bodywork texts suggest that higher-risk clients should not receive any therapy, or advocate modifications that are not based on clinically researched documentation. These recommendations are often based on fear or concern for litigation rather than clear evidence-based practice. There are no existing collected data to suggest that bodywork is harmful in higher-risk situations, particularly if it is done according to sound training and careful clinical application. On the other hand, there have been numerous clinical programmes within antenatal hospital settings, some for over a decade, with wide-ranging positive effects for patients, hospital staff, and the professional and student massage therapists who have participated in the sessions.

These may be exacerbated or improved by the changes in the endocrine system. Depending on the symptom presentation, therapists may need to adapt their bodywork or work. Energy work would include Extraordinary Vessel work.

This is likely to be a cause of infertility, ectopic pregnancy and miscarriage, due to the presence of endometrial tissue outside the uterine cavity. Energy work can be done to support the Extraordinary Vessels and Spleen, Liver and Kidney.

This may be related to the immune mechanism involved – if the disorder involves alterations in T _h1 responses which decrease in pregnancy or T _h2 responses which increase (Formby 1995).

Approximately 3% of women have a developmental anomaly of the genital tract (Llewellyn-Jones 1990). Examples of such conditions are: double uterus (with or without a double cervix and vagina), bicornuate uterus or septate uterus and/or abnormalities of genital tract, cervix, vagina, malformation of the kidney and ureters (Rabinerson et al 1992, Tindall 1987).

A uterine malformation increases the risk of fetal malpresentation, spontaneous abortion and pre-term labour by four times (Llewellyn-Jones 1990). Some malformations may cause complications in labour.

Cervical incompetence is also common. The use of ultrasound scanning will usually reveal a uterine abnormality. However, if the cervix and vagina are structurally normal, the woman is usually fertile.

Women may also have displacements of the uterus, such as retroverted uterus or prolapsed uterus, which may cause complications. These may be indicated by severe abdominal pain.

Although these practices are illegal in many western countries, including the UK and Canada/USA, they are often carried out by a traditional birth attendant illegally or young girls may be sent back to their country of origin for the circumcision. Types 1 and 2 present fewer complications, particularly for the maternity period; however, type 3 may cause major issues. The procedure itself carries a high risk of mortality from haemorrhage and sepsis. Lifelong morbidity from urinary infection, pelvic inflammatory disease, endometriosis and renal damage is common. Cervical smears cannot be obtained and psychological trauma and marital disharmony are common (Jordan 1994).

In pregnancy urinary tract infection is more likely. During labour, progress cannot be assessed by vaginal examination and second stage labour may be prolonged because of the rigidity of the scar tissue. This may result in fetal hypoxia and brain damage (Thompson 1989). An episiotomy may be needed. If the perineum is not meticulously repaired then faecal incontinence may result, there is likely to be severe damage to the pelvic floor and uterine prolapse is not uncommon. The caregiver must not repair the labia to restore the infibulated state, which is illegal, although they may face pressure from relatives to do so.

This is severe nausea and vomiting, which may be accompanied by ptyalism (excessive salivation) and is pathological. Its exact cause is unclear although it is thought to be related to the endocrine and hormonal changes of pregnancy. The client can become dehydrated and, more seriously, suffer electrolyte disturbances, ketosis and weight loss. Hospitalisation may be necessary if the woman is unable to retain fluids and nutrition and needs to receive them intravenously; otherwise, her condition could deteriorate resulting in liver and renal damage.

It is more likely to occur during the first trimester, although for some women it remains an issue throughout the pregnancy.

Pre-eclampsia is a multi-system disorder that complicates 3–5% of all pregnancies. It usually arises after 32 weeks but may occur as early as 20–24 weeks (Dietl 2000, Higgins & de Swiet 2001).

The SOGC guidelines define pre-eclampsia as ‘a hypertensive disorder most commonly defined by new-onset proteinuria, and potentially, other end-organ dysfunction’.

Oedema used to be included as one sign of pre-eclampsia but now is considered a feature of normal pregnancy, although it is a different type of oedema when linked with pre-eclampsia. Weight gain is also not included in the definition of pre-eclampsia.

Pre-eclampsia may develop into eclampsia. However, with adequate monitoring and treatment it rarely reaches this level of severity. Once an initial assessment has been made, through elevated blood pressure and proteinuria, further tests are undertaken to assess renal function, thrombocytopenia and liver enzymes.

Eclampsia is assessed with extreme oedema occurring throughout the body including the face, eyelids and neck and onset of headaches, visual disturbances, followed by seizures. The onset of convulsions (although in 38% cases there were no signs of pre-eclampsia) in the UK occurs about once in every 2000 births and represents severe risks to mother and fetus. Of these, 1 in 50 women died and 1 in 14 babies also died (Douglas & Redman 1994).

Eclampsia is characterised by decreased perfusion to all organ systems secondary to vasospasm (narrowing of the blood vessels). There is arteriolar vasoconstriction and disseminated intravascular coagulation (DIC). The effects are seen in the kidney, liver and placental bed. Other features of PET may include central nervous system irritability and at times coagulation or liver function abnormalities.