Reducing risks to the unborn child.

If clinicians are to play a leading role in reducing risks to the fetus, they have to think outside the box. Improved pregnancy outcomes require that medical and health professionals, including midwives and nurses, work with others far beyond the confines of the antenatal clinic and the delivery room. For the WHO-estimated 200 million plus conceptions globally each year, mostly among disadvantaged groups in disadvantaged (at-risk) areas, the first nine months of life are vulnerable to risks. These risks are not just medical, but also employment, agricultural, security, energy and climate risks. Improving care to reduce these varied risks to the fetus inside the womb challenges us to accept a very broad concept of integrated health – drawing from expertise far outside the traditional medical specialties. It is important to grasp this challenge. David Barker et al. suggest that it is the creation of resilience (the ability to recover quickly from illness, change or misfortune) in the fetus while inside the womb, that prepares everyone, particularly those living and working in deprived and food insecure conditions, to face the vicissitudes and stresses of later life outside the womb. On the one hand, nutritional and hormonal factors may create resilience in the womb. On the other, social and environmental risks and hazards (whether from the husband’s job loss, an earthquake or from the sedative, thalidomide), affecting the mother-baby dyad during pregnancy, may reduce the resilience of the child in the next stages of life’s journey. There is a definitional oversight in which the life of the child is inadvertently cut into two: the fetus or the ‘child inside’ and the ‘child outside’ the womb. This segmented definition should be replaced by a new inclusive way of thinking about ‘the unborn child’. The world has to be reminded that traditionally birth, or bher, as in child – ‘bearing’, began from the time of conception, when a mother bears a new life – a life at considerable risk. Obstetric and gynaecological care for the fetus at risk inside the womb has considerable prospective implications after the child leaves the womb. Retrospectively, paediatric care has the remit of the ‘child’, or kilpei – meaning womb, and therefore the risks that affect the emergent child in the mother’s womb. Economic decision-makers may better understand the essence of the problem and opportunity here, by using the term ‘the unborn child’ for the ‘child inside the womb’. In one light, economists have made major strides in both following and supporting the fetal origins hypothesis. They have described how the stress of a mother’s deprivation affects fetal outcomes. In turn, they show how these outcomes are strongly associated with long-term health risks in both childhood and adulthood. Economists have demonstrated the high returns on funding investments for improving pregnancy outcomes like increased birth weight in low-income countries. They have shown that reduced birth weights not only affect the length of life, but also the quality of life in terms of health, cognition, educational attainment, employment and productivity. They have shown the many societal benefits for ‘outside the uterus life’, which are affected by the quality of the in utero experience. In another light, however, economists continue to estimate their key poverty indicator, ‘life expectancy’, not at the time of the conception of life, but at the time of birth. This anachronistic, economic definition of life expectancy unfortunately hardens the clinicians’ dichotomy of ‘fetus inside the womb, and live child outside the womb’. It also focuses only on the duration of life rather than the quality of life after birth. Most importantly, it hides the risks to the fetus. This cover-up of risks to the unborn child is particularly iniquitous for children born in areas increasingly at risk to disasters and already disadvantaged by poverty, hunger and social deprivation. Unless the World Bank rethinks its poverty indicator to include the life of the unborn child, millions of lives will continue to be unnecessarily maimed or killed through their definitional oversight. An emotive exemplar of this issue is provided by an anthropologist’s op-ed, entitled: ‘Letter from an