Prenatal control of pregnant women in the First Level of Care

Vitamins and minerals are essential for normal fetal development. The World Health Organization (WHO) recommends supplementation with iron, folic acid, vitamin A, calcium, and iodine during pregnancy. The American College of Obstetricians and Gynecologists also recommends supplementation with choline and vitamins B6, B12, C, and D. Prenatal vitamins do not have a standard formulation. However, most contain calcium, iodine, omega-3 fatty acids, zinc, and vitamins A, and also eat more iron and B vitamins and about twice as much folic acid as multivitamins (8).

Regarding prenatal factors, studies have shown that poor maternal exercise, exposure to tobacco smoke and secondhand smoke, unhealthy dietary pattern, maternal BMI before pregnancy, maternal weight gain during pregnancy, as well as poor birth outcomes, such as low birth weight or small for gestational age and preterm birth, are associated with an increased likelihood of childhood obesity (9).

Preterm birth remains a global epidemic, with a global incidence of 15 million births annually. Globally, preterm birth is the leading cause of death in children under 5 years of age. According to data from several countries, premature births have increased. According to the WHO, around 1 million children are estimated to die each year due to complications of preterm birth (10).

Prenatal care providers are encouraged to assess maternal weight at each prenatal visit, monitor progress toward meeting weight gain goals, and provide individualized counseling if significant deviations from a woman's goals occur. Currently, nearly 50% of women exceed their weight gain goals, and overweight and obese women have the highest prevalence of excessive weight gain. The risks of inadequate weight gain include low birth weight and failure to initiate breastfeeding. In contrast, the risks of excessive weight gain include cesarean deliveries and postpartum weight retention for the mother and large-for-gestational-age babies, macrosomia, and childhood overweight or obesity for the offspring. Prenatal care providers have many resources and tools they can use to incorporate weight counseling and other health behaviors health in their routine prenatal practices. Because many women are motivated to improve their health behaviors, pregnancy is often considered the optimal time to intervene in eating habits and physical activity issues to prevent excessive weight gain. Weight gain during gestation is a potentially modifiable risk factor for some adverse maternal and neonatal outcomes, and meta-analyses of randomized controlled trials report that diet or exercise interventions during pregnancy may help reduce excessive weight gain. However, health behavior interventions for gestational weight gain have not significantly improved other maternal and neonatal outcomes and have limited effectiveness in overweight and obese women (11, 12).

Since 1990, exposure to air pollution has been one of the significant health risks influencing the global burden of disease and injury, and the trend has been increasing. Globally, only 7% of children live in environments with air pollution levels, according to WHO guidelines, indicating a lifetime impact of air pollution exposure on most children. In addition, the increasing prevalence of allergic diseases in recent decades represents a significant challenge for children's Health and imposes a global economic burden. Emerging evidence indicates that specific forms of ambient air pollution, such as particles 2.5 or 10 mm in diameter, sulfur dioxide, nitrogen oxides, nitrogen dioxide, and oxides of nitrogen, are associated with the development of asthma in the pediatric population. Besides direct inhalation exposure during childhood, prenatal ambient air pollution exposure during the fetal stage might increase the risk of childhood asthma (13).

There is increasing evidence that prenatal environmental exposure to chemicals affects pubertal development. Many chemicals are present in the environment because of their extensive use, resistance to biological and chemical degradation, and bioaccumulation in the food chain. Exposure to these persistent organic pollutants continues for long periods after their production and use have been prohibited by law. Humans are exposed to environmental chemicals through food, drinking water, and air. POPs include polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers, dichloroethane, pentachlorophenol, hexabromocyclorodecane, and others. PCBs are chemicals produced between 1929 and 1985 for application in various products, including refrigerants in heat transfer systems and lubricants in plastics. The prenatal period is vulnerable because many developmental processes are initiated, and disruption of these processes can influence outcomes in later life. Prenatal exposure to polychlorinated biphenyls has been shown to interfere with children's neurological, immunological, metabolic, and endocrine development. Development is a multifaceted process under the control of various hormonal mechanisms; PCB exposure could interfere with pubertal development. Evidence shows that hormone disruptors can advance or delay puberty (14).

Pregnancy is the psychologically most vulnerable period for women. During pregnancy, women are prone to varying degrees of stress due to changes in hormone levels and many other factors, such as brief bouts of fear, nervousness, and the possible long-term persistence of negative emotions. Negative emotions in women, such as stress, anxiety, and depression, are common during pregnancy. Negative emotions during the prenatal period can present potential risks to maternal Health and the Health of the newborn. Antenatal stress, anxiety, and depression are not only associated with fetal development and adverse pregnancy outcomes, such as low birth weight, preterm delivery, and fetal distress but also have more lasting effects, directly or indirectly, on growth and the development of children. Children of women who experience one or more negative emotions during pregnancy are more likely to have behavioral and emotional changes, attention deficit hyperactivity disorder, and autism in childhood. They are also more likely to have depression, impulsivity, and cognitive disorders in adolescence and suffer from schizophrenia in adulthood. In addition, women with prenatal symptoms of anxiety, depression, perceived stress, and post-traumatic stress disorder may experience more severe pain and be at higher risk of developing pregnancy complications, such as diabetes and preeclampsia, during childbirth and are more likely to of suffering from postpartum depression (15).

Prenatal maternal stress can arise from malnutrition, major life events, bereavement, catastrophic events, depression, or anxiety. Selye described stress as a physiological response pattern that occurs in response to an external or internal stressor and will last if the stimulus persists. The stress response is a homeostatic process and involved in this response is the neuroendocrine system called the hypothalamic-pituitary-adrenal (HPA) axis, which regulates various physiological processes, including energy expenditure and storage, digestion, the immune system, mood, and the emotional response to stress through the release of glucocorticoids. The acute stress response does not produce long-term changes in the stress response axis, whereas chronic stress can exert long-lasting effects. Dysregulation of the HPA axis caused by repeated or extreme exposure to stress is associated with elevated cortisol levels and may be related to the anxiety and pathology of depression. Maternal prenatal stress increases fetal plasma cortisol to levels that overwhelm the metabolic capacity of placental 11β-hydroxysteroid dehydrogenase. This enzyme usually protects the fetus from higher maternal glucocorticoid levels by converting cortisol to inactive cortisone. Elevated levels of circulating fetal cortisol bind to glucocorticoid and mineralocorticoid receptors that are expressed at high levels in multiple regions of the fetal brain, including the limbic system, hypothalamus, and cortex, where it impacts neurogenesis, gliogenesis, and synaptogenesis, suggesting its role in influencing cognitive, behavioral, and morphological development. These structures have been implicated in aggressive behavior, a phenomenon defined by Moyer (1971) as "overt behavior that is intended to inflict physical harm on another person" (16-19).

Exome sequencing (ES) is becoming increasingly available in prenatal diagnosis. However, data on its clinical utility and integration into clinical management remain limited. The BACs-on-Beads™ (BoBs) prenatal assay was introduced to rapidly detect abnormalities of chromosomes 13, 18, 21, X, and Y and nine specific significant microdeletion syndromes. According to the WHO, congenital disabilities affect 4 to 8% of births worldwide, and their incidence varies between countries. Non-invasive prenatal testing is widely used to detect common fetal chromosomal abnormalities. However, the ability of NIPT-Plus to detect copy number variation (CNV) is debatable (20). Skeletal dysplasia is a group of rare genetic disorders associated with cartilage and bone abnormalities. Skeletal disorders are clinically and genetically heterogeneous, with more than 350 genes that explain the diversity of phenotypes of these diseases. Non-invasive prenatal screening has the potential to detect the maternal X chromosome that causes X-linked ichthyosis and may guide prenatal diagnosis of ichthyosis and reflect the family history to improve the pregnancy as well as the management of the Health of children and family members. An optimal intrauterine environment is essential to maintain fetal development. Harmful regents have been identified to be associated with significant congenital malformations, primarily neurological and cardiovascular congenital disabilities. The current view suggests that various cardiovascular diseases in adulthood are related to prenatal exposure to toxins such as glucocorticoids, antibiotics, antidepressants, antiepileptics, etc. HBB-associated hemoglobinopathy, with its two general subtypes as thalassemia and abnormal hemoglobin (Hb) variants, is one of the most prevalent inherited Hb disorders worldwide. Fetal macrosomia is common in pregnancy and associated with several adverse maternal and neonatal prognoses. Although, the accuracy of the prediction of fetal macrosomia is still poor (21). Exposure to environmental stressors during pregnancy plays a vital role in influencing and later susceptibility to certain chronic diseases through the modulation of epigenetics, including DNA methylation. Diagnosis of a microdeletion of chromosome 22q11.2 and its associated deletion syndrome (22q11.2DS) is optimally made early. Definitive diagnosis by chorionic villus or amniocyte genetic testing using a chromosome microarray will detect clinically relevant microdeletions. Maternal genetic effects can be defined as the effect of a mother's genotype on her offspring's phenotype, regardless of the offspring's genotype (22, 23).

This research contributes to the emerging evidence of the impact of community health workers on coordinated systems of antenatal care. It may guide policymakers, practitioners, and administrators to target effectively. Resources and enrollment to potentially reduce the cost burden for health systems. In Arizona, this study provides strong evidence for the sustainability of investing in rural health worker home visits to ensure continuity of Maternal Child Health care and equity among geographically diverse women. Investment in Health should begin engaging with nulliparous young women (including adolescents) throughout the municipality. They could improve reproductive health planning and preconception Health and reduce unwanted pregnancies through adequate engagement with prenatal care (24).