27 Pregnancy and childbirth: From confirming pregnancy to discharge and paperwork

A Cochrane systematic review pooled 5 trials and 6708 births and rated the evidence high quality. Daily folic acid before and during pregnancy cut fetal neural tube defect risk to RR 0.31 (95% CI 0.17 to 0.58, the plausible range), about a seven-tenths reduction. For people who had already had a child with a neural tube defect, the risk of another affected child was RR 0.34 (95% CI 0.18 to 0.64), about one third of the original. By subgroup, 0.4 mg and higher doses did not differ in effect. Folic acid alone and a multivitamin did not differ either. The Ministry of Health’s 2010 folic acid supplementation program plan states that rural women preparing to conceive receive free folic acid, “taken from 3 months before pregnancy through the first 3 months of pregnancy,” as 0.4 mg tablets. The US Centers for Disease Control and Prevention notes that neural tube defects form in the first few weeks of pregnancy, often before you know you are pregnant

The third edition of the National Basic Public Health Service Standards outlines specific maternal health management services available to all permanent residents who are pregnant. These include one health checkup in early pregnancy, two in mid-pregnancy, two in late pregnancy, one postpartum home visit, and one 42-day postpartum checkup. Registration for the handbook must be completed before 13 weeks of pregnancy, at which point the first prenatal checkup is also done. The two mid-pregnancy checkups occur between 16–20 weeks and 21–24 weeks respectively, while the two late-pregnancy checkups are scheduled for 28–36 weeks and 37–40 weeks. Local service lists also include a full set of initial lab tests and postpartum depression screening.

Mother-to-child transmission means the disease passing from mother to child. The Work Specifications for Preventing Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B (2020 Edition) set requirements. At the first prenatal checkup, the hospital must give relevant information, “provide appropriate, standardized testing, and provide follow-up counseling based on the results.” If the status is still unclear before delivery, treat the person as infected in principle. The specifications require that pregnant women found to have syphilis “receive standardized penicillin treatment as early as possible,” and that the newborn get preventive penicillin right after birth. For pregnant women positive for hepatitis B surface antigen, those who meet the criteria may receive antiviral treatment after informed consent. A positive result is not a dead end. Article 23 of the Regulations on the Prevention and Control of HIV/AIDS states that people who voluntarily accept HIV counseling and testing are “provided free counseling and initial screening.” Article 44 requires free “treatment and counseling to prevent mother-to-child transmission of HIV” for pregnant women infected with HIV. Article 43 requires services such as blocking transmission (keeping the disease from the child), treatment, postpartum visits, and infant follow-up and testing. When the mother is positive for hepatitis B surface antigen, the newborn must receive hepatitis B vaccine and hepatitis B immunoglobulin at the same time at birth (see Section 20, item 2)

The US Centers for Disease Control and Prevention’s framing: smoking in pregnancy can leave a baby “born too small, even if full term” and “may lead to preterm birth.” It “doubles the risk of abnormal bleeding during pregnancy and delivery.” It raises the risk of birth defects such as cleft lip and cleft palate. It also “can damage a baby’s developing lungs and brain,” and “the damage can last into childhood.” Infants of mothers who smoked in pregnancy, and infants exposed to smoke after birth, have a higher risk of sudden infant death syndrome. Official advice is to “quit smoking before getting pregnant if you can, but quitting is still helpful if you are already pregnant” and “it is never too late to quit.” On alcohol, the CDC says there is “no known safe amount of alcohol use during pregnancy,” and no stage of pregnancy when drinking is safe. The baby’s brain develops through the whole pregnancy, so alcohol contact at any time may cause harm

The US Preventive Services Task Force gives this a Grade B recommendation: for people at high risk of preeclampsia, start low-dose aspirin (81 mg per day) after week 12 of pregnancy to prevent it. Preeclampsia is a hypertensive disorder of pregnancy. Combining many studies gives the results below; the 95% CI is the range of confidence. Preeclampsia: RR 0.85 (95% CI 0.75 to 0.95, 16 studies), about 15% lower. Premature birth: RR 0.80 (95% CI 0.67 to 0.95, 13 studies), about 20% lower. Perinatal death: RR 0.79 (95% CI 0.66 to 0.96, 11 studies), about 21% lower; perinatal death means death in the period around birth. Small for gestational age / intrauterine growth restriction: RR 0.82 (95% CI 0.68 to 0.99, 16 studies), about 18% lower; this means the fetus grows smaller than others of the same gestational age

The US Preventive Services Task Force gives a Grade B recommendation: screen pregnant people without symptoms (no felt discomfort) for gestational diabetes at 24 weeks or later. Gestational diabetes is high blood sugar that appears only after pregnancy begins. When only one screen is done, that one should be at 24 weeks or later. On screening before 24 weeks, the Task Force concludes that current evidence is insufficient to judge benefits and harms (Grade I). Untreated gestational diabetes raises the risks of macrosomia (a fetus that grows too large), difficult birth, cesarean, preeclampsia, and newborn hypoglycemia

These are all emergency warning signs during pregnancy and postpartum listed by the US Centers for Disease Control and Prevention. Persistent or worsening headaches, dizziness or fainting, changes in vision, a body temperature of 38°C or higher. Severe swelling of the hands or face, thoughts of harming yourself or your baby. Difficulty breathing, chest pain or a rapid heartbeat. Severe nausea and vomiting, unrelenting severe abdominal pain. Absence or significant reduction of fetal movement during pregnancy, vaginal bleeding or fluid leakage during pregnancy. Abnormal vaginal bleeding or discharge after childbirth. Severe swelling, redness, or pain in one arm or leg. These problems can all occur within the first year after childbirth. It is not the case that all is well once the postpartum month (月子) is over.

The Beijing Municipal Health Commission’s handling advice: after the water breaks, “immediately find a place to lie flat to stop the amniotic fluid from flowing out,” “do not walk around casually,” and “call 120 emergency services at once.” While waiting for the vehicle, tell family to bring things and meet at the hospital. Medical explainers add why: when a person stands, amniotic fluid is lost faster, and the baby’s umbilical cord may come out with it — cord prolapse, an emergency that threatens the fetus. So lie down, raise the hips; a left lateral position is fine

A Cochrane systematic review found that epidural analgesia is more effective than non-epidural methods at reducing labor pain and improving maternal satisfaction. Labor analgesia uses exactly this technique. The same review states that epidural analgesia has no effect on the risk of C-section or long-term back pain. Instrumental delivery — using tools to assist birth — shows no increased incidence in studies published after 2005. Starting in 2024, the National Healthcare Security Administration introduced separate pricing categories for “labor analgesia,” “doula-assisted childbirth,” and “family-member labor support,” precisely because previously there were no dedicated rates to motivate hospitals to offer these services.

WHO statement in 2015: when the cesarean rate in a population rises to about 10%, maternal and newborn deaths fall. Above 10%, there is no evidence that mortality improves further. WHO also stresses that every effort should be made to provide cesareans to women who need them, not to hit a particular rate

Article 54 of the Social Insurance Law: when the employer has paid maternity insurance premiums, the employee enjoys maternity insurance benefits. An unemployed spouse of the employee enjoys maternity medical expense benefits under national rules, paid from the maternity insurance fund. When the unit pays maternity insurance, the employee gets benefits, and medical costs when that unemployed spouse gives birth also come from the same fund. Maternity insurance benefits have two parts: maternity medical expenses — the medical costs of childbirth itself — and the maternity allowance — the money paid to you during maternity leave. Article 56 lists three situations for the allowance: female employees on maternity leave after birth, leave for family-planning procedures, and other situations set by laws and regulations. The maternity allowance is “paid according to the employer’s average monthly wage of employees in the previous year” — the unit’s prior-year average, not your own wage

Article 23 of the Maternal and Infant Health Care Law: medical and health-care institutions and persons engaged in home delivery issue a uniformly produced medical certificate of birth for the newborn under rules of the health administration under the State Council. This certificate is the prerequisite for everything that follows: hukou registration, insurance enrollment, a medical insurance card, and kindergarten or school all need it. The State Council General Office’s 2015 opinion on registering hukou for people without one states: for births inside a midwifery facility, apply to that facility for the Medical Certificate of Birth. For births outside a midwifery facility, first obtain a parentage test from a qualified appraisal body, then apply to the agency entrusted by the county-level health department

Article 3 of the Administrative Measures for Newborn Disease Screening: “National newborn disease screening covers neonatal inherited metabolic diseases such as congenital hypothyroidism and phenylketonuria, and hearing impairment.” These conditions share one point: early on there is no visible abnormality; once symptoms are obvious, intellectual damage is already irreversible. Early detection and early intervention work well — thyroid hormone replacement, special formula milk, hearing aids, or cochlear implants. Article 10 requires that when a screen is positive, the facility promptly notify the guardian to seek confirmatory diagnosis

According to the Chinese government website in 2024, “Newborns can enroll in yibao online using their birth certificate; household registration is not required first.” It also states that “after discharge, newborns can get medical expenses reimbursed immediately.” Previously, families had to complete household registration first, pay all hospital costs out of pocket, and then apply for reimbursement. The average processing time for enrollment has also dropped from 28.7 working days at the start of the year to just 6.4 working days now.

Article 7 of the Household Registration Regulations (《户口登记条例》): "Within one month after the infant is born, the household head, a relative, a caregiver, or a neighbor shall report the birth registration to the household registration authority at the infant's place of habitual residence." This is a deadline set by law, not advice. Hukou registration and vaccination are handled separately. The Vaccine Administration Law (《疫苗管理法》) requires that within one month after the child is born, you get a vaccination record at the vaccination site where you live or at the hospital where the child was born. These sites may not refuse. Vaccination is managed by place of residence, and the child does not need to be registered first. A child with no hukou must still be vaccinated promptly on the immunization schedule

Under maternal health management in the National Basic Public Health Service Standards (Third Edition), after birth there is 1 postpartum home visit and 1 health checkup at 42 days postpartum. On local published service lists, that visit includes lab tests (complete blood count, vaginal discharge exam) and 1 postpartum depression screen. The National Health Commission’s 2020 work plan for specialized depression prevention services asks pilot areas to “include perinatal depression screening in routine prenatal checkups and postpartum visit workflows.” So whether depression screening comes with the postpartum visit depends on whether the locality does this. Serious complications can still appear in the first year after birth. On the “go to the hospital immediately” list in Item 7, “thoughts of harming yourself or the child,” “postpartum vaginal bleeding or abnormal discharge,” and “severe swelling and pain in one limb” all belong to the postpartum period

The US Centers for Disease Control and Prevention says a first toxoplasma infection shortly before or during pregnancy can pass to the fetus. Most infected children have no symptoms at birth but may lose sight or develop intellectual disability later. A few are born with severe eye or brain damage. The UK National Health Service (NHS) says infection in pregnancy can cause miscarriage. A toxoplasmosis testing centre in Lyon, France, counted 603 women with infection confirmed in pregnancy, most of whom took antiparasitic drugs. Overall, 29% of infections passed to the fetus (95% CI 25 to 33, the plausible range). About 6% of infections at 13 weeks passed on, versus about 72% at 36 weeks. The earlier the infection, the more likely the child shows symptoms. Infection at 24 to 30 weeks carried the highest risk of early symptoms in the child, about 10%. A comparison across six European cities of newly infected and uninfected pregnant women found: living with a cat OR 1.0 (95% CI 0.7 to 1.5), no difference; cleaning the litter box yourself OR 1.3 (95% CI 0.8 to 2.1), a difference that may be chance; eating undercooked lamb OR 3.13 (95% CI 1.4 to 7.2), about 3 times the risk of not eating it; contact with soil OR 1.81 (95% CI 1.2 to 2.7), about 80% higher. Across the cities, 30% to 63% of infections could be tied to undercooked or cured meat, and 6% to 17% to soil. CDC advice for pregnant people: let someone else change the litter if possible; if no one can, wear disposable gloves and wash hands with soap and water afterward. Change litter daily, because the parasite in cat feces takes 1 to 5 days to become infectious to people. Do not get a new cat in pregnancy, and do not adopt or handle stray cats, especially kittens. Keep the cat indoors and feed only cat food or cooked food, never raw meat. Explainers from the Chinese CDC also say the father-to-be should take over the litter box when possible, and that with precautions in pregnancy the cat can stay. The NHS states that stroking or owning a cat does not give you toxoplasmosis

The WHO 2022 position paper pooled existing studies. Pregnant people with flu had about 7 times the hospitalization risk of people who were not pregnant (OR 6.8, 95% CI 6–7.7, the plausible range). A trial in Bangladesh randomized 340 pregnant women into two groups. One got inactivated influenza vaccine; the other got pneumococcal vaccine as a control, followed to 24 weeks after the child was born. In the flu-vaccine group there were 6 confirmed flu cases in children versus 16 in controls, vaccine efficacy 63% (95% CI 5–85). Mothers’ own fever plus respiratory illness fell 36% (95% CI 4–57). Two South African trials used placebo; neither doctors nor pregnant women knew which shot was which. Among pregnant women without HIV, confirmed flu fell from 3.6% to 1.8%, efficacy 50.4% (95% CI 14.5–71.2). Their children fell from 3.6% to 1.9%, efficacy 48.8% (95% CI 11.6–70.4). Pooling 4 trials and 3 observational studies, confirmed flu in children under 6 months was about 48% lower (95% CI 33–59). Four observational studies looking at child hospitalization for confirmed flu found about 72% lower (95% CI 39–87). Another pool of only two trials found confirmed flu 34% lower (95% CI 15–50). But children’s “influenza-like illness” did not differ — that is illness that looks like flu without lab confirmation. Pregnant people’s own hospitalizations were read from records in four countries from 2010 to 2016. Hospitalization for confirmed flu was about 40% lower among those vaccinated (95% CI 12–59). On safety, one pool took in 40 studies. Stillbirth after vaccination aOR 0.84 (0.65–1.08), congenital malformation 1.03 (0.99–1.07). Both differences sat within error. Preterm birth 0.87 (0.78–0.96), about 13% lower. The US checked three flu seasons from 2012 to 2015. Vaccination in the 28 days before miscarriage aOR 0.9 (0.6–1.5), no association. The Chinese CDC’s 2026–2027 season guideline lists pregnant people as a priority group. It says vaccination at any stage of pregnancy can protect infants under 6 months of age, with a better effect in late pregnancy. Live attenuated vaccine is forbidden in pregnancy

Stillbirth here means the baby dying in the womb after 28 weeks. One pool merged raw data from five studies. Four were in New Zealand, Australia, and the UK; one was an online international survey. There were 851 pregnant women with stillbirth and 2257 with a live child as controls. The method was to ask afterward how they had fallen asleep most recently. Versus falling asleep on the left, falling asleep on the back had stillbirth risk aOR 2.63 (95% CI 1.72–4.04, the plausible range), about 2.6 times. Falling asleep on the right aOR 1.04 (0.83–1.31), no difference from the left. The association was similar when the child was small, the pregnant person was obese, or smoked. The authors estimated that if all pregnant people after 28 weeks fell asleep on their side, stillbirths in that stage would fall by about 5.8% (3.2%–9.2%). The UK National Health Service (NHS) lists “do not fall asleep on your back after 28 weeks” among ways to lower stillbirth risk. It also says that waking up on your back is not a reason to worry — roll to the side and sleep on

The UK National Health Service (NHS) says you can conceive again as early as 3 weeks after birth, even while breastfeeding and before periods return. Unless you want another pregnancy right away, use contraception every time you have sex. Relying on breastfeeding is the lactational amenorrhea method; it needs all three at once: breast milk only, no period yet, and the child under 6 months. Done by the rules, it blocks over 99%. When that standard is not met, about 2 in every 100 people conceive within 6 months. Switch to another method if any of these appear: the child passes 6 months, formula or complementary food or a pacifier is introduced, a period returns (even light bleeding counts), night feeds stop, or feed frequency falls. One pool merged 67 studies and adjusted for maternal age and household circumstances. Using 18 to 23 months from prior birth to next conception as the reference, intervals under 6 months had preterm OR 1.40 (95% CI 1.24–1.58, the plausible range), about 40% higher; low birth weight 1.61 (1.39–1.86); child small for gestational age 1.26 (1.18–1.33). Intervals of 6 to 17 months and over 59 months were also higher on these three. A Canadian study of more than 148000 pregnancies compared a 6-month interval with an 18-month interval. For mothers 35 and older, death or serious illness was 0.62% versus 0.26%, aRR 2.39 (2.03–2.80), about 2.4 times. For mothers 20 to 34 there was no difference (0.92, 0.83–1.02). For children of mothers 20 to 34, combined stillbirth, death, extreme smallness, or extreme prematurity was 2.0% versus 1.4%, aRR 1.42 (1.36–1.47). A 2005 WHO expert meeting advised waiting at least 24 months after a live birth before trying the next pregnancy. Experts agreed that conception under 18 months should be avoided. After miscarriage or induced abortion, wait at least 6 months